a service framework to meet the needs of people with a co … · 2007. 9. 21. · 2 programmes requ...

A Service Framework to Meet the Needs of People with a Co-occurring Substance Misuse and Mental Health Problem

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Foreword

The del�very of appropr�ate treatment to persons who have mental health and substance m�suse d�sorders �s of �ncreas�ng concern to the publ�c, cl�n�c�ans and pol�cy makers.

Ev�dence now suggests that drug and/or alcohol m�suse among pat�ents w�th mental d�sorders must be cons�dered as commonplace rather than except�onal. However, �t �s w�dely acknowledged that the prov�s�on for mental health and substance m�suse co-morb�d�ty �n Wales �s, at present, not sat�sfactory.

The �mportance of the development of qual�ty serv�ces for people w�th co-morb�d�ty cannot be stressed too strongly. Research shows, amongst other th�ngs, that treatment for substance m�suse problems often amel�orates psych�atr�c and mental health problems. Substance m�suse treatment �s also assoc�ated w�th decrease �n substance use, decreased �nject�ng behav�our and thus a reduct�on of the r�sk of HIV and hepat�t�s transm�ss�on, and �mprovements �n other related forens�c, psycholog�cal and phys�cal problems. Intervent�ons for people w�th co-morb�d�ty are also l�kely to be cost-effect�ve: the healthcare costs of untreated cases areh�gher than for those treated.

Desp�te the ava�lab�l�ty of effect�ve treatments, most �nd�v�duals who have co-occurr�ng mental health and substance use problems are not rece�v�ng effect�ve treatment. Efforts to �mprove the care prov�ded to persons who have co-occurr�ng d�sorders should focus on protocols that �ncrease the del�very of effect�ve treatment and ensure a seamless pathway.

Dr Brian Gibbons Edwina Hart MBEM�n�ster for M�n�ster for Soc�al Just�ce and Local Government Health and Soc�al Serv�ces

July 2007

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A Service Framework to Meet the Needs of People with a Co-occurring Substance Misuse and Mental Health Problem

1.0 Overview

1.1 Definition(drawnfromScottishAdvisoryCommitteeonDrugsMisuse&ScottishAdvisoryCommitteeonAlcoholMisusedocumentMindtheGaps)

Substance m�suse refers to the problem use of prescr�bed or �ll�c�t drugs, and/or alcohol.

Dual d�agnos�s or co-morb�d�ty refers spec�f�cally to the co-ex�stence of d�agnosed mental health problems (�rrespect�ve of sever�ty) and substance m�suse but also a range of other cond�t�ons.

Co-occurr�ng substance use and mental health problems �s used more generally to acknowledge that not all mental health problems have been d�agnosed, nor are all forms of substance use cons�dered to be problemat�c.

Co-occurr�ng substance m�suse and mental health problems has therefore been adopted for use �n the development of these serv�ce standards. Taken together these problems g�ve r�se to s�gn�f�cant �mpa�rment and d�sab�l�ty for wh�ch people affected need adv�ce, support and serv�ces, �n order to follow a more �ntegrated l�fe course. The sever�ty and nature of a person’s problem are l�able to change over t�me. Each problem, however, would be s�gn�f�cant enough to mer�t planned care on �ts own.

The intention of this framework is therefore to address the broad spectrum of mental health and substance misuse problems from mild/moderate to severe. Inev�tably serv�ces w�ll have to pr�or�t�se those �n greatest need and �n order to fac�l�tate th�s the framework w�ll be augmented w�th �nclus�on cr�ter�a and thresholds.

Because of the complex needs of people w�th a co-occurr�ng substance m�suse and mental health problem, a co-ord�nated approach from a range of pr�mary and secondary serv�ces �s essent�al. These serv�ces w�ll need to be prov�ded �n both statutory and non-statutory sett�ngs. Wh�lst the key serv�ce prov�ders are adult mental health and spec�al�st substance m�suse teams �nput from non spec�al�st prov�ders such as hous�ng agenc�es �s also v�tal �n order to del�ver a comprehens�ve range of serv�ces. In the absence of an �ntegrated approach from the prov�ders of the d�fferent serv�ce components, �nd�v�duals w�th a co-occurr�ng substance m�suse and mental health problem are potent�ally at r�sk of fall�ng between stools and hav�ng an �ncreased r�sk of substance m�suse relapse. Th�s �s of part�cular concern g�ven that th�s cl�ent group has an �ncreased r�sk of su�c�de and/or hom�c�de.

In order to del�ver effect�ve care, serv�ces have to be co-ord�nated w�th clear treatment protocols and care pathways. The complex�ty of the care


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programmes requ�red to meet these needs has g�ven r�se to �ncreas�ng challenges �n both the del�very of mental health and substance m�suse serv�ces. The purpose of th�s document �s to prov�de a serv�ce framework for the del�very of treatment and care to those w�th a co-occurr�ng substance m�suse and mental health problem �n Wales. It w�ll establ�sh a framework based on current ev�dence base for co-occurr�ng substance m�suse and mental health problems aga�nst wh�ch health and soc�al care agenc�es can be assessed.

The emphas�s w�th�n the framework �s co-occurr�ng mental health and substance m�suse problems. However �t �s w�dely recogn�sed that many people may have add�t�onal problems �nclud�ng one or more of the follow�ng:

• a personal�ty d�sorder

• a phys�cal d�sab�l�ty

• a learn�ng d�sab�l�ty

• a phys�cal health problem sensory �mpa�rment

• problems assoc�ated w�th old age.

Where people have mult�ple problems a range of responses from agenc�es �n d�fferent sett�ngs w�ll be requ�red. Th�s shall be del�vered �n l�ne w�th the requ�rements of the Un�f�ed Assessment Process (UAP) and/or the Care Programme Approach (CPA) or where substance m�suse �s the predom�nant problem the Wales Integrated In-depth Substance M�suse Assessment Tool (WIISMAT). Cons�derat�on was g�ven to the �ntroduct�on of serv�ce thresholds due to the need to pr�or�t�se serv�ce prov�s�on. However, �t was cons�dered that th�s should best be ach�eved by means of the appropr�ate use of CPA or WIISMAT �n cases of co-occurr�ng mental health and substance m�suse problems.

2.0 Context

Mental Health �s one of the top three cl�n�cal pr�or�t�es of the Welsh Assembly Government. In September 200� the strategy document "Adult Mental Health Serv�ces for Wales ‘Equ�ty, Empowerment, Effect�veness, Eff�c�ency’" was publ�shed, sett�ng out a ten year strategy for the development of mental health serv�ces �n Wales. The strategy was supported by the publ�cat�on �n Apr�l 2002 of "Adult Mental Health Serv�ces ‘A Nat�onal Serv�ce Framework for Wales’" and the rev�sed Nat�onal Serv�ce Framework and Act�on plan “Ra�s�ng the Standard” October 2005. All of these documents �dent�fy the need for close collaborat�on between serv�ces.

The strategy emphas�ses the �mportance of unamb�guous cl�n�cal respons�b�l�ty for �nd�v�duals w�th a dual d�agnos�s and appropr�ate access to the serv�ces they need. The strategy also notes the need for general adult mental health serv�ces to recogn�se that those w�th alcohol and drug problems can also develop mental �llnesses that requ�re treatment. It further


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reaff�rms that mental �llness serv�ce users who m�suse drugs or alcohol are a part�cularly vulnerable and h�gh-r�sk group. The strategy c�tes the "Safer Serv�ces" report, wh�ch recommends that alcohol and drug serv�ces work much more closely w�th general adult mental health serv�ces. A po�nt re �terated �n “Avo�dable Deaths” F�ve year report �nto su�c�de and hom�c�de by people w�th mental �llness (Dec 2006). Avo�dable Deaths �dent�f�es that �659 (27%) of su�c�des and 72 (�6%) of hom�c�des �ncluded �n the report were cases of dual d�agnos�s. Furthermore �t stresses that “Safer Serv�ces” recommended the development of dual d�agnos�s serv�ces but notes that th�s �s the recommendat�on w�th the least take up. It stresses that serv�ces to those w�th a dual d�agnos�s should be central to the prov�s�on of modern mental health care and that these serv�ces should �nclude:

• Staff tra�n�ng �n substance m�suse management

• Jo�nt work�ng w�th drug and alcohol teams

• Local cl�n�cal leadersh�p

• Use of enhanced CPA for those w�th severe mental �llness and a destab�l�s�ng substance m�suse problem

In order to clar�fy respons�b�l�ty, the strategy makes �t expl�c�t that �f a serv�ce user has a psychot�c �llness or severe mental �llness (SMI) that adult mental health serv�ces should be the "lead" serv�ce. In any event mental �llness symptoms shall be treated by mental health serv�ces.

The substance m�suse strategy "Tackl�ng Substance M�suse �n Wales - A partnersh�p approach", (2000), �dent�f�es the need for the development of serv�ces for those w�th a dual d�agnos�s of substance m�suse and severe mental health problems. Co-ord�nated and effect�ve cl�n�cal and soc�al care follow�ng on from assessed needs �s cruc�al to th�s process.

Cl�n�c�ans work�ng �n th�s area were h�ghl�ghted by the Aud�t Comm�ss�on (2002) as report�ng a lack of co-ord�nat�on �n approach to pat�ents w�th a dual d�agnos�s. Th�s lack of co-ord�nat�on was further ev�dent at the strateg�c plann�ng stage level �n the Comm�ss�on’s analys�s.

The "Dual D�agnos�s Good Pract�ce Gu�de", (2002), suggests that all health and soc�al care econom�es conduct a local mapp�ng exerc�se to determ�ne the local level of need �n dual d�agnos�s.

In adopt�ng the def�n�t�on co-occurr�ng substance m�suse and mental health problems �t shall be used to meet the pol�cy object�ves set out �n strateg�es where the term dual d�agnos�s has prev�ously been used.

The major strateg�c a�ms l�nked to successful care co-ord�nat�on for th�s pat�ent populat�on are an �mprovement �n treatment outcomes, a reduct�on �n the rate of su�c�de, homelessness and v�olence and an �mprovement �n the w�der publ�c health.

They are also l�kely to ass�st �n meet�ng the mental health ga�n target (HGT) "To reduce the European Age Standard�sed Rate from su�c�de (�nclud�ng undeterm�ned deaths) for all ages by at least �0 per cent by 20�2".


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Model of treatment Description Issues for Consideration

�. Jo�nt l�a�son/ The care of pat�ents �s • Jo�nt work�ng requ�red collaborat�ve jo�ntly managed by between mental health approach both serv�ces and substance m�suse serv�ces

• Jo�nt respons�b�l�ty

• Ensures the sk�lls and expert�se of both spheres of health care �s ut�l�sed

2. Parallel Substance m�suse and • Pat�ents are shunted mental health serv�ces between two serv�ces establ�sh a l�a�son to • Health problems are prov�de the two serv�ces treated as separate ent�tles concurrently • Med�cal respons�b�l�ty �s not clearly def�ned • Pat�ents have to go through the�r deta�ls tw�ce and bu�ld up relat�onsh�ps w�th two sets of profess�onals • Pat�ents have to negot�ate two d�ferent systems

�. Integrated There �s concurrent • Isolated from prov�s�on of both ma�nstream serv�ces psych�atr�c and substance • V�ews dual d�agnos�s m�suse �ntervent�ons by as a stat�c cond�t�on the same cl�n�cal team • Expens�ve serv�ce (des�gnated serv�ce) prov�s�on

�. Ser�al or Psych�atr�c and • Pat�ents are shunted consecut�ve substance-use d�sorders between two serv�ces are treated consecut�vely • Health problems w�th l�ttle commun�cat�on treated as separate ent�t�es between substance • L�m�ted commun�cat�on m�suse and psych�atr�c between the serv�ces. serv�ces • Pat�ents have to go through the�r deta�ls tw�ce and bu�lt up relat�onsh�ps w�th two sets of profes�onals • Pat�ents have to negot�ate two d�fferent systems

3.0 The Development of Models of Care in Wales

Four models of care have evolved �n wh�ch the del�very of serv�ces to people w�th a co-occurr�ng substance m�suse and mental health problem can potent�ally be del�vered these are set out �n table � overleaf.


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Abstracted from NTASM (200�, p.�)

Models 2 & � above are not cons�dered acceptable models for the del�very of effect�ve care. Model � would be l�kely to del�ver effect�ve care but does not f�t comfortably w�th the mental health and substance m�suse strateg�es w�th�n Wales. It �s recommended therefore that model �, the jo�nt l�a�son or collaborat�ve approach should be adopted as the preferred model for the del�very of care to people w�th a co-occurr�ng substance m�suse and mental health problem. The application of the model will require local interpretation reflecting local geographic, demographic and service configuration issues. Th�s w�ll be part�cularly relevant �n relat�on to the locally adopted model of serv�ce collaborat�on. Where l�nk workers are �ntroduced cons�derat�on w�ll also need to be g�ven to the�r deployment.

3.1 LiaisonandCollaboration

The prec�se nature of l�a�son and collaborat�on w�ll be determ�ned by local serv�ce conf�gurat�on and ult�mately by the requ�rements of each �nd�v�dual case. However l�a�son and collaborat�on should �nclude arrangements for:

• Jo�nt tra�n�ng

• The clar�f�cat�on of cl�n�cal leadersh�p

• The ava�lab�l�ty of a l�nk worker or su�table alternat�ve

• Consultancy

• Adv�ce

• Formal jo�nt work�ng and shared care

• The use of UAP and CPA and WIISMAT to assess and plan care

• The use of comprehens�ve assessment w�th CPA for those people w�th mult�ple pathology

• A s�ngle and where appropr�ate �ntegrated care plan.

4.0 Service Aims and Objectives

Wh�chever model of prov�s�on �s adopted, mental health and substance m�suse serv�ces need to agree clear a�ms and object�ves for dual d�agnos�s serv�ces. These should ensure:

• That a comprehens�ve staged approach to recovery �nclud�ng, where appropr�ate, assert�ve outreach, mot�vat�onal �ntervent�ons and prov�s�on of help to cl�ents us�ng sk�lls to manage both mental health and substance m�suse problems


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• That people are managed at a level of care; pr�mary or secondary, appropr�ate to the�r need

• That serv�ces are del�vered by the statutory or non-statutory serv�ces or both where appropr�ate

• That Appropr�ate l�nkage to the cr�m�nal just�ce serv�ces �nclud�ng the pol�ce courts pr�son and probat�on serv�ces �s �n place

• cultural sens�t�v�ty and competence

• the ava�lab�l�ty of early �ntervent�ons

• rap�d access to serv�ces that should be flex�ble and appropr�ate to �nd�v�dual need

• broadly based �ntervent�ons that �nclude soc�al, hous�ng, educat�on and employment components

• advocacy, w�th key workers help�ng serv�ce users through the care processes

• pos�t�ve expectat�ons of what can be ach�eved through treatment

• effect�ve jo�nt work�ng protocols between mental health and substance m�suse serv�ces

• jo�nt plann�ng

• the prov�s�on of �n-reach to acute �npat�ent and detox�f�cat�on fac�l�t�es.

4.1 ServiceStandards

Comm�ss�on�ng and prov�der agenc�es need to establ�sh effect�ve serv�ce standards for the�r locally developed co-occurr�ng substance m�suse and mental health problem serv�ces. These should �nclude as a m�n�mum:

• The ma�ntenance of a clear l�ne of cl�n�cal respons�b�l�ty for the pat�ent

• A clear and agreed local def�n�t�on of co-occurr�ng substance m�suse and mental health problem

• Clear and agreed care pathways

• Tra�n�ng plans to ensure the del�very of tra�n�ng and superv�s�on at a suff�c�ently sen�or level, �n substance m�suse treatment for all members of the psych�atr�c serv�ce and equ�valent tra�n�ng �n mental health �ssues for substance m�suse workers

• The prov�s�on of a l�a�son funct�on between serv�ces. Th�s may �nclude where appropr�ate a l�nk worker spec�al�s�ng �n substance m�suse and mental health problems to augment ex�st�ng commun�ty mental health and substance m�suse teams


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• The prov�s�on of a s�ngle co-ord�nat�on po�nt w�th�n mental health and alcohol and drug serv�ces ensur�ng access to serv�ces outs�de normal off�ce hours

• The use of compat�ble models and conceptual frameworks for both cond�t�on

• The use of UAP and where appropr�ate CPA

• Clear def�n�t�ons of wh�ch pat�ents w�ll be treated

• User �nvolvement at all stages

• Common referral cr�ter�a and process

• Where appropr�ate comprehens�ve mult�d�sc�pl�nary assessment

• Access to out-reach serv�ces, commun�ty treatment, home v�s�ts, outpat�ent treatment, �npat�ent treatment and day care prov�s�on

• Involvement w�th pat�ent’s GP

• Retent�on of cl�ents �n act�ve treatment

• Prov�de �ntervent�ons that fac�l�tate mot�vat�on to change

• Access to relapse prevent�on serv�ces

• Fac�l�tat�on of re�ntegrat�on �nto the commun�ty.

5.0 Unified Assessment Process (UAP) and Care Programme Approach

Because of the complex needs of people w�th a co-occurr�ng substance m�suse and mental health problem, care and treatment approaches need to be broad-based and flex�ble. As each person w�ll need to be assessed �nd�v�dually there �s no spec�f�c treatment approach. However as w�th all serv�ce user groups people w�th a co-occurr�ng mental health and substance m�suse problem w�ll be subject to the requ�rements of UAP. Where appropr�ate the�r care needs shall be assessed and planned us�ng th�s methodology. It �s l�kely however due to the level of complex�ty assoc�ated w�th the needs of people w�th mental health problems who also m�suse substances that they w�ll be subject to the Care Programme Approach (CPA) or WIISMAT. CPA became fully operat�onal across Welsh mental health serv�ces �n December 200�.

CPA requ�res a full need and r�sk assessment that addresses the follow�ng �ssues:

• Ident�f�cat�on and response plann�ng to urgent or acute problems


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• Assessment of patterns of substance m�suse and degree of dependence

• Assessment of phys�cal, soc�al and mental health problems

• Assessment of needs of dependent ch�ldren and not�f�cat�on to appropr�ate serv�ces

• Cons�derat�on of the relat�onsh�p between substance m�suse and mental health problems

• Cons�derat�on of any �nteract�on between med�cat�on and other substances

• Assessment of carer �nvolvement and need

• Assessment of knowledge of harm m�n�m�sat�on �n relat�on to substance m�suse

• Assessment of treatment h�story

• Determ�nat�ons of �nd�v�dual’s expectat�on of treatment and the�r degree of mot�vat�on for change

• The need for pharmacotherapy for substance m�suse

• Not�f�cat�on to the Nat�onal Drug Treatment Mon�tor�ng System.

All cl�ents w�ll also have a copy of the�r care plan deta�l�ng the range of serv�ces ava�lable to ass�st the�r recovery.

Clients who are parents or carers may have a particular need for support to enable them to fulfil their responsibilities. Client’s children may be acting in a caring capacity or may need support and in some cases the clients may pose a risk to the children or adults in their care. Referral should be made to children’s or adult social services in such cases.

6.0 Groups with specific needs

Key stakeholders w�ll need to cons�der the need of part�cular target groups as h�ghl�ghted by The Health Adv�sory Serv�ce (200�). These target groups �nclude:

• Older people (mental health serv�ces should expl�c�tly address the �ssue of alcohol and tranqu�ll�ser m�suse)

• Young people (the�r needs should be addressed by ch�ld centred serv�ces)

• Homeless people


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• Black and m�nor�ty ethn�c groups (mental health assessments should take �nto account culture and ethn�c�ty) �n l�ne w�th the Race Relat�ons (Amendment) Act 2000

• Refugees and asylum seekers

• Those w�th gender spec�f�c �ssues (assessment and care should �nclude eat�ng d�sorders, self harm, su�c�de attempts and low self- esteem)

• Pr�soners both wh�lst �n detent�on and dur�ng trans�t�on upon release �n l�ne w�th the requ�rements of the pr�son mental health pathway

• People w�th a personal�ty d�sorder

• Poly-drug users w�th a mental health problem

• People w�th a learn�ng d�sab�l�ty

• Parents and carers of vulnerable adult.

7.0 Needs Assessment and Service Planning

Local Health Boards (LHBs) and Local Author�t�es (LAs), through the�r Commun�ty Safety Partnersh�ps, need to be aware of the nature and the scale of co-occurr�ng substance m�suse and mental health problems w�th�n the�r local populat�on. Th�s w�ll allow serv�ces to be targeted appropr�ately. Gaps �n current serv�ce prov�s�on need to be �dent�f�ed and the voluntary sector should be resourced to play a key role �n both the plann�ng and del�very of care to th�s cl�ent group.

Data on co-occurr�ng substance m�suse and mental health problems are currently poor. Serv�ces should therefore be prov�ded on the bas�s of perce�ved need �ncorporat�ng what data �s ava�lable. However, �mproved data collect�on methods should be pursued w�th partner organ�sat�ons to enable future accurate needs assessments to be undertaken.

The Mental Health Strategy and NSF requ�re that each LHB/LA w�ll have a Local Mental Health Strateg�c Plann�ng Group. They w�ll also have a Substance M�suse Act�on Team respons�ble to the Commun�ty Safety Partnersh�p. These groups have respons�b�l�ty for develop�ng Health Soc�al Care and Well-Be�ng Strateg�es to meet the needs of those people w�th�n the�r local populat�on. In order to ensure a co-ord�nated approach to prov�s�on, the plann�ng groups must l�ase, share and reconc�le these strateg�es and act�on plans.


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8.0 Training and Qualifications

Staff, whether �n mental health or substance m�suse serv�ces, need to develop the sk�lls necessary to �dent�fy and understand cl�ents w�th co-occurr�ng problems, to develop the conf�dence to deal w�th them and to be g�ven the capac�ty to cope. Effect�ve staff superv�s�on, both cl�n�cal and manager�al, �s equally �mportant. Support structures should be �n place for staff of all levels to help them cope w�th th�s challeng�ng cl�ent group.

Tra�n�ng and cont�nuous profess�onal development (CPD) �s therefore v�tal �n the development and susta�n�ng of effect�ve serv�ces. Tra�n�ng and CPD should �nclude as a m�n�mum:

• development of assessment sk�lls based upon substance m�suse and mental health assessment frameworks bas�c tra�n�ng �n substance m�suse management for staff �n mental health �npat�ent and commun�ty serv�ces

• bas�c tra�n�ng �n substance m�suse and mental health �nclud�ng self harm for staff work�ng �n Acc�dent and Emergency and targeted general med�cal sett�ngs

• knowledge of drug and alcohol trends for those w�th mental health problems

• effect�ve work�ng w�th a range of mental health �ntervent�ons and treatment approaches

• The DANOS module on co-occurr�ng substance m�suse and mental health problems

Jo�nt tra�n�ng should �nclude mental health substance m�suse and targeted staff from w�th�n the Cr�m�nal Just�ce Serv�ce.

It �s essent�al that tra�n�ng for deal�ng w�th cl�ents �n spec�al needs groups �s undertaken by all staff. Part�cularly to �dent�fy�ng potent�al r�sks when a cl�ent �s a parent or carer.

Each local area should develop a tra�n�ng strategy to ensure all staff work�ng �n statutory and voluntary organ�sat�ons have formal tra�n�ng �n co-occurr�ng substance m�suse and mental health problems.


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9. Care Pathway for Co-occurring Mental health and substance Misuse Problems

Person �dent�f�ed w�th a potent�al substancem�suse and mental health problem andreferral made v�a UAP contact assessment

UAP Overv�ew Assessment completed

Pr�mary level care assessed as appropr�ate for management and superv�s�on e.g. GP,Soc�al Serv�ces or Voluntary Sector

Obta�n formal UAP spec�al�st assessmentdeterm�n�ng mental health, substance m�suseand other serv�ce �nputs

L�a�son between local mental health andsubstance m�suse statutory and non statutoryserv�ces

Cl�n�cal respons�b�l�ty mutually agreed w�th�nCMHT or substance m�suse serv�ce

Cl�ent accepts serv�ces

Arrange CPA meet�ng to develop the carepackage w�th cl�ent, relevant profess�onals,formal and �nformal care prov�ders. Ident�fya lead agency to co-ord�nate care

Allocate a named care co-ord�nator and setup a l�st of all care prov�ders �nvolved w�th the cl�ent for a support and commun�cat�onnetwork

Agree a culturally sens�t�ve care package and�dent�fy the role of each care prov�der. Prov�de cl�ent and all agenc�es �nclud�ng pr�mary care w�th a copy of the care plan

Agree mon�tor�ng system between allagenc�es, cl�ent and carer

Arrange formal CPA rev�ew w�th cl�ent carerand all part�es

No

No

Is cl�ent cons�dered r�sk to healthor safety of self or others?

No Yes

Cons�derassert�veoutreach and�nform pr�marycare team

Obtra�n formalassessment underMHA �9��

Need to cons�der referral andthe potent�al need for support to enable them tofulf�l the�r respons�b�l�t�esas parents or carers

Yes No

Referral to ch�ld Protect�onor Ch�ldren �n Need serv�ces,or vulnerable adult serv�ces

Yes

Case managed w�th�n pr�mary level care unless deter�orat�onrequ�res referral tospec�al�st serv�ces

Need for statutory�ntervent�on

Yes

No Yes


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Annex A

"Good Practice Checklist"

MINIMUM ESSENTIAL CRITERIA FOR SERVICES TO PEOPLE WITH A CO-OCCURING MENTAL HEALTH AND SUBSTANCE MISUSE PROBLEM IN WALES

�. Clear l�ne of cl�n�cal respons�b�l�ty at all t�mes wh�le �n treatment.

2. Involvement of general pract�t�oners �n the care and management of pat�ents.

�. Clear locally agreed def�n�t�on of dual d�agnos�s supported by clear care pathways.

�. Prov�s�on of �nformat�on on local serv�ces, wh�ch �s read�ly ava�lable �n a su�table format to users, the�r relat�ves and referr�ng agenc�es.

5. A jo�nt protocol between mental health and substance m�suse teams.

6. Pat�ent allocated to a named key worker w�th respons�b�l�ty for co-ord�nat�ng both mental health and substance m�suse serv�ces.

7. Advocacy serv�ces becom�ng �ntegral to the care plans.

�. Su�tably tra�ned l�nk-workers or su�table alternat�ve prov�ded from Adult Mental Health Teams.

9. A s�ngle co-ord�nat�on po�nt w�th�n mental health and substance m�suse serv�ces ensur�ng access to serv�ces outs�de normal off�ce hours.

�0. Pathways fac�l�tat�ng prompt referral between serv�ces to those w�th a co-occurrence of a mental health and substance m�suse problem. Ch�ldren’s and vulnerable adult serv�ces need to be �n place.

��. Local Health Boards and Local Author�t�es, through Commun�ty Safety Partnersh�ps, undertake a regular mapp�ng exerc�se to determ�ne the local level of need based upon agreed def�n�t�ons.

�2. Compat�ble models, conceptual frameworks and a common language for both cond�t�ons.

��. Rap�d access to serv�ces wh�ch must be flex�ble and appropr�ate to the �nd�v�dual.

��. Broad-based �ntervent�ons that �nclude soc�al, hous�ng, educat�on and employment.


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�5. Emphas�s on pos�t�ve expectat�ons of what can be ach�eved through treatment.

�6. All stakeholders, �nclud�ng the cl�ent, consulted and l�stened to.

�7. Access to outreach serv�ces.

��. Appl�cat�on of the Un�f�ed Assessment Process/Care Programme Approach.

�9. Local tra�n�ng plans for all staff work�ng �n mental health and substance m�suse.

20. Effect�ve superv�s�on and support for all staff work�ng w�th people w�th dual d�agnos�s.

2�. Assessment of the needs of dependent ch�ldren and referral to appropr�ate agenc�es �f requ�red.


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Annex B

Dual Diagnosis Framework Supporting Technical Document

Definition

There �s no s�ngle agreed def�n�t�on of the term dual d�agnos�s, wh�ch refers to two concurrent d�sorders. For the purposes of th�s document a broad, unrestr�cted def�n�t�on w�ll be used that encompasses the co-occurrence of drug and/or alcohol problems and a w�de range of mental health problems. NTASM (2003).

Th�s approach recogn�ses the fact that not all mental health problems have been d�agnosed at the t�me of cl�n�cal presentat�on.

(Krauts (1996) and Abdulrahim (2001) placed dual d�agnos�s w�th�n four categor�es:

• A pr�mary d�agnos�s of a major mental �llness w�th a subsequent d�agnos�s of substance m�suse wh�ch adversely affects mental health

• A pr�mary d�agnos�s of drug dependence w�th psych�atr�c compl�cat�ons lead�ng to mental �llness

• A concurrent substance m�suse and psych�atr�c d�sorder

• An underly�ng trauma exper�ence result�ng �n both substance m�suse and mood d�sorders.

Ident�f�cat�on of the pr�mary d�agnos�s may be problemat�c because of the s�m�lar s�gns and symptoms of mental �llness w�th �nd�cators of �ntox�cat�on and w�thdrawal from substances. Th�s can lead to m�sd�agnos�s. It �s therefore necessary to �nterpret the symptoms accord�ng to a part�cular class�f�cat�on system such as the Internat�onal Class�f�cat�on for D�seases, (ICD �0). NTASM (2003).

Mental Illness Needs Ind�ces (MINI) scores are h�gh �n Wales as are rates of substance m�suse. As a result the prevalence of dual d�agnos�s �n Wales �s s�gn�f�cant.

1. Epidemiology

1.1 Prevalence

Dual d�agnos�s �s recogn�sed as a complex area of health and soc�al care and �t �s hard to assess the exact levels of substance m�suse �n both the general populat�on and �n those w�th mental health problems. The ex�st�ng ev�dence base �s pr�mar�ly der�ved from stud�es undertaken �n Amer�ca �t �s therefore an area requ�r�ng further research �n the UK.


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Stud�es �n the UK �n �9�� found that:

• �0% of psych�atr�c �npat�ents had an alcohol problem

• �0% of those w�th alcohol problems had a dual d�agnos�s.

NTASM (2003).

The most robust source of �nformat�on on the prevalence of co-occurr�ng mental �llness and substance m�suse �n the UK �s the survey of "Psych�atr�c Morb�d�ty Among Adults �n Br�t�sh Households 2000".

The data �nd�cate that:

• less than �% of the populat�on are class�f�ed as be�ng moderately or severely dependent on alcohol

• th�s f�gure �ncreases to 2% for people w�th a neurot�c d�sorder,

• 5% among those w�th a phob�a

• 6% among those w�th two or more neurot�c d�sorders.

SACDM (2003, p. 25).

Further UK data from a nat�onal survey and local stud�es reveal:

• Up to � �n � drug us�ng cl�ents have been reported as hav�ng mental health problems. SACDM (2003, p.12)

• Over half of people w�th substance m�suse problems are also d�agnosed w�th a mental d�sorder at some po�nt. Drake and Essock (2001) and Little (2001, p.27)

• Alcohol �s the most common substance m�sused. DOH (2002, p. 7)

• Where drug m�suse occurs �t often coex�sts w�th alcohol m�suse DOH (2002, p. 7)

• Homelessness �s assoc�ated w�th substance m�suse. DOH (2002, p.7)

• CMHT’s report that �-�5% of the�r cl�ents have dual d�agnos�s. DOH (2002, p.7)

• Pr�son populat�ons have a h�gh prevalence of dual d�agnos�s. DOH (2002, p.7)

• Co-morb�d�ty �n general pract�ce �n England has r�sen by 62% between �99� and �99�. SACDM (2003, p.12).


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1.2 EvidenceinWales

Data on �nc�dence and prevalence of those w�th dual d�agnos�s �s not read�ly ava�lable �n Wales, though �t �s poss�ble to est�mate prevalence from data collected separately on mental �llness and substance m�suse.

Tackl�ng Substance M�suse �n Wales (2000), descr�bes the nature and extent of drug m�suse �n Wales, part�cularly the m�suse of �llegal drugs and alcohol. Us�ng data from the Welsh Youth Health Survey �t reports:

• �n �99�, �2% of �5 and �6 year olds reported ever hav�ng used some k�nd of �ll�c�t drug

• �n �99�, ��% of �� year olds drank alcohol at least weekly, r�s�ng to 5�% amongst �5 and �6 year olds.

In Wales, one �n n�ne people suffer from mental health problems and one �n two hundred has a severe mental �llness, wh�ch may requ�re substant�al health and soc�al care. The Welsh Health Survey (�99�) produced the follow�ng data:

• there was �ncreased prevalence �n mental �llness �n Wales from �995 to �99�

• across Wales, ��% of adults reported a mental or nervous �llness

• mental �ll health prevalence for the adult populat�on across Wales �s ��.6% or �05,�65 �nd�v�duals

• 22% of adults �n Merthyr Tydf�l reported a mental �llness, the h�ghest �n Wales

• the prevalence of sch�zophren�a �n Wales �s about 0.2% or �,�� nd�v�duals.

W�th�n Wales, Merthyr Tydf�l, Blaenau Gwent, and Rhondda Cynon Taff tend to have h�gher mental �llness needs �nd�ces than other parts of Wales. However, the rural areas �n Wales tend to have h�gher than average su�c�de rates. There were 2�0 male and 52 female deaths recorded as due to su�c�de and self �nfl�cted �njury �n Wales �n �996. (Better Health, Better Wales (1998).

2. Clinical Implications

Substance m�suse among those w�th severe mental �llness has been assoc�ated w�th s�gn�f�cantly poorer outcomes, Todd et al (2002, p.792), �nclud�ng:

• worsen�ng psych�atr�c symptoms DOH (2002, p.9)

• m�sd�agnos�s due to d�ff�cult�es �n evaluat�on Howland (1990, p. 1134)

• �ncreased use of �nst�tut�onal serv�ces DOH (2002, p.9)


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• poor med�cat�on adherence DOH (2002, p.9) and Rubinstein (1990, p.98)

• �ncreased r�sk of HIV �nfect�on DOH (2002, p.9) and Drake et al (2001)

• �ncreased r�sk of su�c�de and v�olence NTASM (2003)

• be�ng less respons�ve to treatment. Howland (1990, p.1134) and Rubinstein (1990, p.98).

There are other a�lments that can affect people that abuse substances. For example, �ntravenous drug m�suse can cause venous or arter�al thrombos�s and card�ac d�sease. Furthermore, where hypoderm�cs are shared the r�sk of HIV or Hepat�t�s B and C are �ncreased, Drake et al (2001). Smok�ng substances can result �n resp�ratory d�seases and long term alcohol use can result �n extremes �n Korsakoff’s syndrome, del�r�um and se�zures. To overlook or neglect substance m�suse �n the course of mental health treatment w�ll result �n poor treatment outcomes, Drake et al (2001). Psych�atr�c symptoms can tr�gger the urge to dr�nk or use drugs to self med�cate. NTASM (2003) and Philip and Johnson (2001) and Rubinstein (1990, p.100).

3. Public Health Implications

Soc�al env�ronment and l�fe exper�ences are l�kely to be factors �n the development of substance m�suse by those who are ser�ously mentally �ll but there �s a dearth of emp�r�cal ev�dence to support th�s, Ph�l�p and Johnson (200�). However, drug cho�ce �s correlated w�th the pattern of amb�ent drug use �n the commun�ty, D�xon, (�999). There are a number of �ssues that can affect publ�c health where those w�th dual d�agnos�s are res�dent �n the commun�ty:

• those w�th dual d�agnos�s �n the commun�ty can be d�ff�cult ne�ghbours

• l�v�ng w�th some one w�th dual d�agnos�s can cause stress and a dra�n on the energy and resources of carers and fam�ly. Rub�nste�n (�990, p.�00)

• �ncreased contact w�th the cr�m�nal just�ce system. DOH (2002, p.9)

• a th�rd of people w�th dual d�agnos�s w�ll be sero-pos�t�ve for HIV, Hepat�t�s B or Hepat�t�s C. DOH (2002, p.9 and p.14)

• �ncreased rates of v�olence and su�c�dal behav�our are assoc�ated w�th dual d�agnos�s. A study of �7 reports of �nqu�r�es �nto hom�c�des by mentally �ll people concluded that alcohol and drug m�suse was a s�gn�f�cant factor. Ward and Applin (1998, p. 1) and Greenfield (1996)

• those w�th dual d�agnos�s frequently use emergency serv�ces. Howland (1990, p.1134) and Rubinstein (1990, p.100).


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4. Current Service Provision in Wales

4.1 GapsinServiceProvision

A rev�ew of purchas�ng requ�rements for drug and alcohol treatment fac�l�t�es conducted �n �99� �dent�f�ed that there �s a lack of serv�ces for some groups �nclud�ng those w�th dual d�agnos�s. NAW (2000, p.22).

The language of care and of strategy d�ffers markedly between local author�ty, health and voluntary sector serv�ces, often lead�ng to m�sunderstand�ng and subsequent d�ff�culty �n serv�ce prov�s�on. Those forms of work�ng that depend upon profess�onal or organ�sat�onal �dent�ty are l�kely to result �n a pathway of care, wh�ch �s less effect�ve than those, wh�ch work jo�ntly. SACDM (2003, p.49).

Serv�ce users nat�onally �dent�f�ed the follow�ng gaps �n current serv�ces and part�cularly �n cont�nu�ng support for cl�ents, DOH (2002, p.2�):

• access to mental health serv�ces and adv�ce �n �nformal sett�ngs

• access to spec�al�st serv�ces w�th�n general day support serv�ces

• longer stay res�dent�al serv�ces

• day support both dry and wet ava�lable 7 days per week

• someone to talk to

• hous�ng support

• res�dent�al rehab�l�tat�on places that accept people w�th dual d�agnos�s.

In Wales, a basel�ne rev�ew of dual d�agnos�s serv�ce prov�s�on was undertaken �n November 200� us�ng a telephone quest�onna�re. Th�s snapshot of serv�ces revealed that wh�le most of the Trusts prov�ded both mental health serv�ces and substance m�suse serv�ces, the major�ty of Trusts d�d not prov�de spec�f�c �npat�ent dual d�agnos�s beds. The major�ty of Trusts had no staff cons�dered as dual d�agnos�s spec�al�sts work�ng w�th�n the Commun�ty Mental Health Teams and only half the Trusts had shared care management w�th pr�mary care for dual d�agnosed pat�ents.

In most Trust catchment areas there was voluntary sector prov�s�on. However, the extent of th�s coverage and the nature of th�s prov�s�on were not reported.

F�nally, most Trusts had no spec�f�c strateg�c Serv�ce Plan for dual d�agnos�s. In add�t�on, there was a lack of formal protocols or agreements w�th any partner agenc�es about serv�ce prov�s�on, �nev�tably leav�ng gaps �n serv�ce. However, four of the Trusts reported that work on plans and a protocol was �n progress.


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Eleven Local Health Boards fa�led to prov�de data for the basel�ne serv�ce rev�ew, a quest�onna�re hav�ng been c�rculated to them electron�cally. However, from those who d�d respond �t was apparent that few were aware of any networks or collaborat�ons w�th�n the�r boundary that had dual d�agnos�s as part of the�r rem�t. The local plann�ng arrangements for dual d�agnos�s are usually the rem�t of the Substance M�suse Act�on Team and the Mental Health Steer�ng Group wh�ch meet separately. Several of the Boards �dent�f�ed the need for these separate pathways to be co-ord�nated v�a a jo�nt plann�ng mechan�sm.

4.2 ServiceUtilisation

Stud�es �n the US have found that people w�th a dual d�agnos�s seek treatment more frequently than those w�th one d�sorder. However �t �s apparent that there are a w�de var�ety of barr�ers that �mpede the del�very of opt�mal care rang�ng from access to the serv�ce to the att�tudes of �nd�v�dual cl�n�c�ans. Todd et al (2002, p.792).

The prov�s�on of psych�atr�c serv�ces by therap�sts w�th m�n�mal formal tra�n�ng or exper�ence �n the treatment of substance abuse has also been c�ted as a barr�er, Howland (1990, p.1134). Research has shown that remov�ng the barr�ers to the serv�ces s�gn�f�cantly �ncreases the consumers’ qual�ty of l�fe, Hays and Andrews (2003). Other barr�ers relate to the structure and organ�sat�on of serv�ces w�th�n wh�ch treatment �s del�vered and that there �s poor commun�cat�on between the agenc�es �nvolved. Those w�th dual d�agnos�s are frequently referred from mental health serv�ces to an alcohol and drug serv�ce and back aga�n result�ng �n no serv�ce be�ng prov�ded at all. DOH (2002, p.14) and Sims et al (2003, p.112).

Little data exists to set out a Welsh context. Consideration needs to be given as to whether there is a need to develop a specific data set for dual diagnosis


2�

Co-occurring Mental Health and Substance Misuse

Bibliography

• Abdulrah�m (200�) Substance M�suse and Mental Health Co-Morb�d�ty (Dual D�agnos�s) Standards for Mental Health Serv�ces

• Appleby, L. Safer Serv�ces Nat�onal Conf�dent�al Inqu�ry �nto Su�c�de and Hom�c�de by People w�th Mental Illness. London: The Stat�onery Off�ce �999

• Appleby, L. Avo�dable Deaths: F�ve year report of the Nat�onal Conf�dent�al Inqu�ry �nto su�c�de and hom�c�de by people w�th mental �llness Manchester Un�vers�ty 2006

• The Aud�t Comm�ss�on Chang�ng Hab�ts: The Comm�ss�on�ng and Management of Commun�ty Drug Treatment Serv�ces for Adults Report 2002

• Department of Health (2002) Dual d�agnos�s good pract�ce gu�de, London: Department of Health.

• D�xon Dual D�agnos�s of Substance Abuse �n Sch�zophren�a: prevalence and �mpact on outcomes (�999)

• Drake and Essock (200�) Implement�ng dual d�agnos�s serv�ces for cl�ents w�th severe mental �llness

• Drake et al (200�) Implement�ng dual d�agnos�s serv�ces for cl�ents w�th severe mental �llness

• Hays RA et al Serv�ce enhancement to a dual d�agnos�s populat�on mental �llness/substance abuse Qual�ty Management �n Healthcare (200�)

• Howland RH "Barr�ers to commun�ty Treatment of pat�ents w�th dual d�agnoses." Hosp�tal and Commun�ty Psych�atry (�990, p.��)

• Krauts, M. (�996) ‘Old problems - new perspect�ves’, European Add�ct�on Research, 2:� -2

• L�ttle J. Treatment of dually d�agnosed Cl�ents Journal of Psychoact�ve drugs Vol ��(� ) Jan-March 200� 27-��

• NAW (2000, p. 22) Tackl�ng Substance M�suse �n Wales A partnersh�p Approach

• NTASM (2002) Models of care for the treatment of Drug m�susers

• Ph�l�ps P and Johnson S (200�) How does drug and alcohol m�suse develop among people w�th a psychot�c �llness? A l�terature Rev�ew Soc�al Psych�atry and Psych�atr�c Ep�dem�ology �6 269-276


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• SACDM (200� p.�2) "M�nd The Gaps" ‘Meet�ng the needs of people w�th Co-occurr�ng substance m�suse and mental health Problems’

• SACDM (200�, p.�9) "M�nd The Gaps" ‘Meet�ng the needs of people w�th Co-occurr�ng substance m�suse and mental health Problems’

• S�ms et al The tr�angular treatment parad�gm �n dual d�agnos�s cl�ents w�th a mental �llness Journal of substance m�suse (200� , p.��2)

• Todd et al Barr�ers to opt�mal care for pat�ents w�th coex�st�ng substance use and mental health d�sorders Austral�an and New Zealand Journal of Psych�atry �6:6 (2002, p.792)

• Ward M and Appl�n C (�99� p.� ) The Unlearned Lesson. London Wynne Howard Books

• Welsh Assembly Government: Adult Mental Health Serv�ces for Wales Equ�ty, Empowerment, Effect�veness, Eff�c�ency Strategy Document (200�)

• Welsh Assembly Government: Wales, In-depth Integrated Substance M�suse Assessment Toolk�t (WIISMAT) consultat�on module (2006)

• Welsh Assembly Government: Creat�ng a Un�f�ed and Fa�r System for Assess�ng and Manag�ng Care (200�)

• The Care Programme Approach for Mental Health Serv�ce Users a Un�f�ed and Fa�r System for Assess�ng and Manag�ng Care Mental Health Pol�cy Gu�dance (200�)

• Welsh Assembly Government: Adult Mental Health Serv�ces Ra�s�ng the Standard The Rev�sed Adult Mental Health Nat�onal Serv�ce Framework and Act�on Plan for Wales (2005)

• Welsh Assembly Government: Pr�son Mental Health Pathway (2006)


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