Mental Health and Substance Use Nature & Extent Derek Tobin Team Manager COMPASS Programme

1. Mental Health and Substance Use Nature & Extent Derek Tobin Team Manager COMPASS Programme COMPASS Programme

2. Definitions • Dual Diagnosis • Combined mental health and substance use problems • More than “dual problems”- likely to have complex health and social needs • Wide range of people with varying degrees of need- need individualised treatment

3. Table 1

4. Policy Drivers and related Documents • Dual Diagnosis Good Practice Guide (2002) • Inpatient Dual Diagnosis Guidance (2006) • Standards for Better Health • NIMHE Suicide Toolkit • NSF 5 Years On • Health Care Commission • Themed review in dual diagnosis • The management of Dual Diagnosis in prisons (2009)

5. Prevalence • Cantwell (1999) Nottingham first episode psychosis 37% (1 year) • Weaver (2001) Inner London Community mental health and substance use services 24% (recent-last 30 days) • Phillips (2003) Inner London (in-patient setting) 49% (last 6 months) • Graham (2001) Birmingham (MH and SU services) identified 24% SMI problems with drugs/alcohol • More likely to be using at impairment/dependence level • More likely to be in AOT (26-45% of case-loads depending on location) • Over representation of African-Caribbean in AOT (46%) • Priebe et al (2003) London AOT 29% misused at least 1 type of substance(last 6 months) • 20% misused/dependent on drugs • 16% misused/ dependent on alcohol • Most common street drug was cannabis (23%), followed by cocaine (7.4%) On track: Helping People Get Better

6. Forensic Units • Studies have shown prevalence of use toward upper end of range in both medium and high security patients (Steele et al, 2003; Da Silva et al, 2003, Madden et al, 1999; Beck et al 2002) • Isherwood et al (2001) found 57% of consecutive referrals to a forensic psychiatric service in London had an ICD 10 diagnosis of substance misuse • In a national review of MSU’s, Melzer et al (2000) found that 58% of patients had social or health problems related to substance misuse

7. Consequences of Dual Diagnosis • Increased likelihood of self-harm and violence • Poor physical health (including HIV, hep B and C) • Frequent relapse and re-hospitalisation • Higher rates compulsory detention • Forensic mental health care and criminal justice system • Higher overall risk of untoward incidents • Difficulty getting access to appropriate aftercare • Poor medication adherence • Family problems • Homelessness • Higher overall service costs • Higher levels of social exclusion

8. CLINICAL CORRELATES Specific consequences depend on individual and type of substance used but broadly alcohol/drug use can affect on 3 levels: • Symptoms • Social • Treatment Outcome See Drake, R.E., McLaughlin, P., Pepper, B . And Minkoff, K. )1994) Dual Diagnosis of Major Mental Illness and Substance Disorder; An Overview. In K. Minkoff and R.E. F Drake. Dual Diagnosis of Major Mental Illness and Substance Disorder. NY; Jossey-Bass Inc. On track: Helping People Get Better

9. CLINICAL CORRELATES continued Specific consequences depend on individual and type of substance used but broadly alcohol/drug use can impact upon 3 areas There is a higher likelihood of the following in those individuals with co-existing SU and SMI problems than those with SMI alone… • Symptoms • Earlier onset and more severe • symptoms • Violence and aggressive behaviour • Exacerbation of symptoms • Depression and suicidal behaviour • Other health consequences • Social • Poor social functioning • Family discord • Housing instability • Financial problems • Risky sexual behaviour • Imprisonment • Treatment Outcome • Non-engagement in treatment • Increased hospitalisations • Poor prognosis • Medication non-adherence • Higher service costs • Fall between services In summary… Clients with psychosis and substance misuse problems have poorer outcomes than those with either disorder alone (Drake et al.,1989).

10. Reasons for use • Why do people with mental health problems use drugs/alcohol?

11. REASONS FOR SUBSTANCE USE • Socialisation Substance use in social situations Substance use with peers Desire to be with other people Limited other social opportunities To feel “normal” and “accepted” by others Cultural norms

12. REASONS FOR SUBSTANCE USE • Coping With persistent, distressing symptoms (e.g. hallucinations, negative symptoms). Severe depression or anxiety Medication side effects Loneliness

13. REASONS FOR SUBSTANCE USE • Pleasure Enhancement Substance use for enjoyment Limited other leisure activities Lack of close relationships Boredom Not working NB. Reasons for starting substance use may be different from reasons that maintain it. From Mueser, K.T. and Gingerich, S. (1994). Coping with Schizophrenia; A Guide for Families. Oakland, CA; New Harbinger Pubs Inc. Chapter 12, pp 245-272

14. ALCOHOL: Effect on mental health and some interactions withcommonly used psychotropic medications: Alcohol is a central nervous system (CNS) depressant. • Exacerbates depression • Disinhibiting effect, suicide attempts more likely (15% people with serious drinking problems kill themselves and most who do so are depressed) • Sedative effects of antidepressants exacerbated and action impaired • Exacerbates mania – increases likelihood and level of disinhibited behaviour • Increases sedative effects of anti-psychotic medication • Psychotic symptoms common as part of alcohol withdrawal syndrome Long term delusional disorders and dementias noted with prolonged and heavy use Georgiou (1999) ISDN (1999)

15. CANNABIS: Effect on mental health and some interactions with commonly used psychotropic medications: Cannabis is an hallucinogenic and all rounder. • THC (Tetrahydrocannabinols) effects some dopamine receptors; therefore heavy use has been shown to increase frequency and severity of relapsefor those with psychosis. • Disorientates to time and space • Exacerbates paranoid delusions • Depression/A motivational syndrome noted •  Cannabis use is an independent risk factor for more psychotic relapses and aggravation of psychotic and disorganization symptoms (D Linszel et al 2004) • Can increase anxiety levels and be a trigger for panic attacks leading to an increase/complications for people with depression • In mania, paranoia can manifest as grandiosity Georgiou (1999) ISDN (1999)

16. COCAINE/CRACK COCAINE & AMPHETAMINES: Effect on mental health and some interactions with commonly used psychotropic medications: • These drugs are CNS stimulants. • Exacerbates psychotic symptoms for those with diagnosedpsychosis • Drug precipitated/induced psychosis • Opposes action of anti-psychotic medication • Will initially induce euphoria/lift mood but mood will lowerfollowing use of drug: use will exacerbate depression • Will exaggerate delusional elements of mania and hypomania Georgiou (1999) ISDN (1999)

17. RISKS OF NON-DETECTION • Misdiagnosis • Inadequate treatment planning - Suboptimal pharmacological treatment for both - Neglect of interventions for substance misuse - Inappropriate referrals • Poor treatment outcomes e.g. - relapse - rehospitalisations • Economic/service costs • Poor experience of services

18. Training and Development • Dual Diagnosis training is advocated by most policy documents • Staff should be appropriately recruited and trained for the work they do • Gap around sustaining capabilities after training • Need to consider the retention of learning by the use of specialist supervision and support, forums/interest groups

19. Dual Diagnosis Good practice Guide 2002 • Mainstreaming • Doesn’t advocate a separate DD services, but advocates services that can support mainstreaming • Mental health services should take primary responsibility for those with serious mental health problems (like schizophrenia) and substance use • AOT likely to provide care for those with dual diagnosis as typically hard to engage and chaotic users of services • Substance use services should take primary responsibility for those with primary substance problems and common mental health problems (anxiety, depression) • However mental health and substance use services should work together and support each other

20. The COMPASS Programme ModelCognitive behavioural Integrated Treatment (C-BIT) • Based on a shared care integrated approach with a target service user group based on local need.Prevalence (Graham et al 2001) & Training & support needs surveys (Graham & Maslin 2002). • Evidence based interventions Cognitive Behavioural Integrated Treatment (published Wiley & Sons 2004) • Training and clinical input to teams • Harm reduction/abstinence Philosophy.

21. COMPASS Interventions • Intensive Input to Assertive Outreach Teams / Homeless Team / EIS • Train teams + Support to deliver integrated treatment approach (C-BIT) • COMPASS clinician based one day per week in the above teams • Consultation-Liaison Service • Offered to clients outside of AOR etc, for e.g., PCL, R&R, inpatients, CDTs etc • Screening/assessment + brief intervention over 12-weeks Evaluation: before & follow-up measures • Training - Staff within inpatient units trained in ‘how to run groups’ for their clients. • Drug and alcohol awareness Training • C-BIT Training

22. Principles of C-BIT Approach & Integrated Treatment • Harm reduction/abstinence approach • Flexible, but structured approach • Stage-wise treatment • Collaborative relationship • Guided discovery • Integration of substance use and mental health treatment • Flexibility and specialisation of clinicians

23. Service users No Fall Between services Not duplicating Assessment Complex needs addressed concurrently. Enhanced engagement and retention in treatment Access to interventions for cannabis use Teams Enhanced skills Consistency Ownership of client group Clearly identified roles/responsibilities Support to deliver structured interventions Comprehensive services. Consistent approach. Achievement of Integrated treatment in mainstream mental health teams.

24. C-BIT Outcomes • Significant Improvement in Confidence andSkills • Improvement in staff ability to implement components of C-BIT • Integrated treatment could be achieved • Managers reported significant changes Teams • Evidence of reduction in units of alcohol and substance related beliefs. • Service user Study (Research)

25. COMPASS Programme Contact Details • Derek Tobin • derek.tobin@bsmhft.nhs.uk • Tel 0121 301 1750