Dual Diagnosis. Dr John Dunn Associate Clinical Director for Substance Misuse & Forensic Services Camden & Islington NHS Foundation Trust

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1 Dual Diagnosis Dr John Dunn Associate Clinical Director for Substance Misuse & Forensic Services Camden & Islington NHS Foundation Trust

2 Past, Present & Future The ghost of dual diagnosis past The ghost of dual diagnosis present The ghost of dual diagnosis future

3 Dual Diagnosis Past Dual Diagnosis Good Practice Guide (DH, 2002) - Mainstreaming - Substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex. Individuals with these dual problems deserve high quality, patient focused and integrated care. This should be delivered within mental health services. This policy is referred to as mainstreaming.

4 Manage in substance misuse services Jointly manage in mental health and substance misuse Severity of mental illness Manage in primary care/iapt Manage in mental health service Severity of substance misuse

5 Barriers to implementation Acceptance of role appropriateness of working with DD clients Disagreement on the model of delivery specialist DD teams, specialist workers in a team, full-team training, closer integration between mental health and substance misuse Service-led referral criteria rather than pathway or commissioner-led Specialist staff move on Lack of effective leadership and commitment Training too focused on class-room teaching and not on clinical supervision and work-based assessments

6 Overcoming barriers and innovation the example of IAPT When first set up, many IAPT services excluded clients who used alcohol or drugs. Then IAPT team at DH & NTA issued new guidance 2012 there is no evidence that substance misuse per se makes the usual psychological therapies ineffective (NICE, 2007). IAPT services now being commissioned to provide brief interventions and stepped care for harmful and hazardous alcohol misuse and non-dependent drug use E.g. Down Your Drink developed by Stuart Linke and e- Health unit at UCL

7 Dual diagnosis present NICE guideline psychosis with coexisting substance misuse (2010) Engage Flexible approach and MI skills Beware of stigma Assess type, amount, frequency, route Training Pathways and referral criteria Coordinated care with SMS for those with dependence SMS services need competencies in MH

8 Dual Diagnosis Present BAP guidelines (Lingford-Hughes et al, 2012) Little evidence of superiority of any one pharmacological agent in treatment psychiatric problems in patients with dual diagnosis Category D evidence that: In bipolar disorder Li + combined with Valproate may be more effective In schizophrenia Clozapine may be more effective In depression mixed Serotinergic/Noradrenergic antidepressants may be more effective Concomitant treatment of the substance use disorder is important

9 Dual diagnosis present Fragmentation of care pathways for substance misusers In SMS pooled treatment budgets already allow NHS commissioners to award services to third sector and private sector in SMS the future is already here and has been for a while Third sector not closely aligned to mainstream mental health services or primary care May not employ psychiatrists, mental health nurses or social workers although increasingly they do May be less experienced at managing clients with complex needs both physical and psychiatric

10 Dual diagnosis the future Dual diagnosis: a challenge for the reformed NHS and Public Health England (UKDPC, 2012) The new Health and Social Care Act: Mental health services will be commissioned by Clinical Commissioning Groups Whilst substance misuse services will be commissioned by Health & Well Being Boards Prison services to be commissioned by NHS Commissioning Board A challenge to providing joined-up and integrated care to dual diagnosis clients Opening up of mental health service provision to the private and third sector could lead to further fragmentation Will substance misuse be a priority for H&W Boards? Potential of pooled health and social care budgets and joint commissioning

11 Dual diagnosis the future A move away from secondary care provision to community-based services Integrated clinical care pathways with the commissioning of clinical pathways rather than diagnosis specific services Payment by results in substance misuse focused on getting drug-free, reducing offending, getting into work improving health and well-being, but not on making the care pathway work

12 Dual Diagnosis and Integrated Care Barnet, et al Lancet 2012 multi-morbidity and implications for health care Supporting generalists to provide personalised care Continuity of care A move away from single-disease framework of health care A move away from secondary care to primary care A more holistic approach focus on multi-morbidity not just Dual Diagnosis, e.g. physical health problems such as hepatitis C, smoking, metabolic disorders, cardiovascular disorders Darsi-style poly-clinics or community-based integrated care clinics.

13 Summary In the 10 years since the Good Practice Guide published progress made but still some way to go The importance of good assessment, MH and SM competencies and integrated and collaborative care Uncertainty following the Health & Social Care Act, 2012 But potential through clinical care pathway commissioning, pooled budgets and joint commissioning