The extent and nature of mental health issues among problem drug users and issues in treatment.

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1 The extent and nature of mental health issues among problem drug users and issues in treatment.

2 Well, that rules out a coalition

3 DIAGNOSIS? Diagnosis implies identifiable clinical picture Often associated with complex social problems Problems with concept of mental disorder Concept may oversimplify need Many different indicators but none equivalent to the concept Heavy drinking, opioid injecting male with antisocial personality disorder who develops major depression in the context of chronic pain secondary to diabetic neuropathy Diagnosis does not equal need

4 DIAGNOSIS? (2) No assumption of discrete boundaries Tailored by clinical judgment Categories rather than dimensions Problems when applied to communities e.g. high prevalence rates in ECA Diagnosis does not equal need Failure to measure Functionality

5 FUNCTIONALITY

6 OMNIMORBIDITY 26 yr. old man - single - 2 children, no access o Psychotic episodes for >10 years o Homeless, unemployed, poor literacy o Chaotic drug use 37 yr. old woman - 3 children - no regular partner o On Methadone Px. - tops up o Various other downers o Heavy Alcohol intake o Depression, poor anger control, cutting 76 yr. old man - lives with wife of 48 years o Admitted through A & E o Confused - evidence of repeated falls o Alcohol problem + cocktail of Prescription drugs o Demented / Depressed / Intoxicated?

7 SCALE OF PROBLEM - 1 Continuums - severe/mild drug abuse - severe/mild alcohol misuse - severe/mild mental illness Continuums - types of drug/alcohol use - types of mental illness

8 QUADRANT MODEL Severe Substance misuse problem Mild Less Severe Mild Mental health problem Severe

9 SCALE OF PROBLEM - 2 Primary mental health problems may worsen substance misuse Substance misuse may worsen mental health problems Substance misuse may lead to mental illness Withdrawal may produce mental health problems Concurrent development of substance misuse and mental health problems Heterogeneous group with dynamic problems

10 SCALE OF PROBLEM - 3 SDMD - 40% of individuals reported that mental health was a problem area. Weaver - 75% 1st time attendees had mental health problem. Epidemiologic Catchment Area (ECA) Study - 64% drug clinic attendees had associated mental health disorder. ECA - 55% alcohol clinic attendees had associated mental health problem.

11 SCALE OF PROBLEM - 4 ECA - Anxiety disorders commonest (19% alcohol + 28% drugs) Welsh (2002) - meta-analysis found 57% had personality disorder! (less in alcohol than drugs) Gilchrist (2002) - Female drug users at crisis centre and methadone clinic % history of emotional abuse - 65% history of physical abuse - 50% history of sexual abuse

12 SCALE OF PROBLEM - 5 SAFER SERVICES (2001) % suicides had history of alcohol misuse - 37% suicides history of drug misuse - 20% primary diagnosis of alcohol misuse - 10% primary diagnosis of drug misuse Commonest diagnoses -Depression, Personality disorder, Substance misuse 1/2 had co-morbid diagnosis High rates of alcohol and drug misuse 1/2 had history of self harm and substance misuse 10% did not have care plan altered because of personality or substance problems

13 SCALE OF PROBLEM - summary 3 in 4 drug using clients reported as having mental health problems 1 in 2 people with alcohol problems reported as having mental health problems 2 in 5 people with mental health problems likely to have substance use problems

14 EXISTING SERVICE PROVISION - 1 Planning, delivery, and accountability of integrated service poor Different planning processes for mental health and substance use services Service provision for personality disorders and for childhood trauma patchy with no consensus

15 EXISTING SERVICE PROVISION - 2 Lack of operational communication between specialisms Lack of willingness to work with this client group with inappropriate onward referral or no service Poor planning of aftercare as integral part of service Poor voluntary partnerships

16 SAFER SERVICES - RECOMMENDATIONS Promote services for people with mental illness who also misuse alcohol and drugs Resource determination should reflect level of risk (rates of co-morbidity) Staff training in General Psychiatry to include management of substance misuse Services for those with severe mental illness and substance misuse should be part of mainstream mental health services

17 PLANNING and PROVISION Person-centred best practice Training in integrated assessment methods Training in broad range of interventions Supervision essential both clinical and managerial Good quality information transfer essential Voluntary sector has a key role - Partnership for care Raise expectations of positive treatment outcomes amongst staff and clients Ensure access to advocacy, peer support and mutual aid groups

18 ASPIRATIONS Shared understanding of types and sequencing of appropriate care Flexible application Diverse enough skill mixing to allow rapid response to need Confident specialist workers Confident generic workers Understanding by commissioners of service

19 RECOVERY -difficulties Both fields recognising high co-occurrence Research suggests best results if fully integrated Integration been difficult Political, structural, attitudinal differences hard to overcome Focus on aetiology, nature and treatments causes difficulty Role of behavioural change different (can choose not to use, can t choose not to experience symptoms of mental illness. Can only choose response). Addiction and mental health problems very different when seen through a diagnostic manual

20 RECOVERY -possibilities Integration might be achieved by focussing on processes of recovery, healing and community inclusion Identifying and building on strengths might be better than attending to dysfunction Process of recovery in addictions and mental health problems might be very similar and interwoven Personal process of growth with multiple pathways People in recovery from both often describe both transformational and incremental change People are active agents of change not passive recipients of care

21 RECOVERY -possibilities Recovery stories full of new insights, decisions taken and finding unexpected healing resources Emphasis on importance of family and peers Both forms of recovery need promotion of hope Want to manage or eliminate symptoms Want to embrace purpose and meaning Want to be in enhanced social roles and relationships Want to give back to their communities These are all commonalities that can facilitate effective integration

22 RECOVERY -principles Recovery looks different for different people Long term outlook and appropriate intervention matching Nonlinear a process not an outcome Importance of family and peer involvement Services need to encourage and support these and instil hope of positive change to health and wellness These similar for addictions and mental health services Beyond this efforts needed to change environment over which people have no control poverty, unemployment, poor housing, discrimination Services need to be political

23 Social Inclusion Mental Health Substance Use School nonattendance Early criminality Experience of LA care Unemployment as cultural norm Experience of homelessness Exclusion Problems Problems Heavy, early use of legal drugs Personal experience of mental health problem Parents actively criminal with history of substance misuse Disruption of family unit

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