Positive approaches to dual diagnosis

Transcription

1 Positive approaches to dual diagnosis QNI: Improving mental healthcare for people who are homeless Dr Cheryl Kipping Consultant nurse dual diagnosis 27 th Jan 2016

2 Overview Dual diagnosis: concepts, scope, prevalence Effects of substance use on health Challenges of working with people with dual diagnosis Positive approaches for moving forward Questions/discussion

3 Dual diagnosis the concurrent existence of a substance misuse problem and one or more mental disorders Mental disorder Dual diagnosis Substance use disorder

4 Dual diagnosis v complex needs Homelessness Legal/criminal justice issues Physical health: acute & chronic eg abscesses, withdrawal seizures, blood borne viruses, liver disease Past trauma Financial problems Mental disorder Dual diagnosis Substance use disorder Impact on education/ work Relationship difficulties/ breakdown Safeguarding: children, at risk adult

5 Multiple exclusion homelessness People have experienced MEH if they have been homeless (including temporary/unsuitable accommodation as well as sleeping rough) and have also experienced one or more other domains of deep social exclusion : - institutional care: prison, local authority care, mental health hospitals - substance misuse: drug, alcohol, solvent or gas - participation in 'street culture activities : begging, street drinking, 'survival' shoplifting or sex work MEAM Making Every Adult Matter (CLINKS, Homeless Link, Mind)

6 Life sequence of people with multiple needs Substance misuse Experiences of abusing solvents/glue/gas; leaving home or care; using hard drugs; developing a problematic relationship with alcohol and/or street drinking. Transition to street lifestyle Confirmed street lifestyle Official homeless -ness Becoming anxious or depressed; survival shoplifting; survival sex work; being victim of violent crime; sofa-surfing; time in prison; being made redundant. Sleeping rough; begging; injecting drug use. Being admitted to hospital with a mental health issue; becoming bankrupt and getting divorced. Applying to the council as homeless, staying in hostels/other temporary accommodation; being evicted or repossessed; death of a partner. Mental health & substance use usually precede homelessness.

7 Scope of coexistent MH & SM disorder Severity of substance misuse High eg dependent drinker who experiences low mood and anxiety eg person with schizophrenia using cannabis and crack on a daily basis Low Severity of mental illness eg recreational ecstasy use who has begun to experience low mood after weekend use High eg person with bipolar disorder whose occasional binge drinking destabilises his mental health Low

8 Prevalence of coexistent MH & SM disorder Severity of substance misuse High eg dependent drinker who experiences Prevalence low mood and anxiety Low 70%+ Severity of mental illness eg recreational ecstasy use who has begun to experience low mood after weekend use eg person with schizophrenia using cannabis and crack on a daily basis Prevalence 30-50% High eg person with bipolar disorder whose occasional binge drinking destabilises his mental health Low

9 Facts and figures Homeless Link (2014) national audit n= areas across England most in hostels/supported accommodation 80% reported mental health issue 45% diagnosed with mental health issue 39% taking drugs or recovering from drug problem 27% drinking or recovering from alcohol problem 41% used alcohol and/or drugs to help with MH issues 2/3 drink more than recommended lower risk level of alcohol each time they drink

10 Fact and figures 92% of people with co-occurring substance use, homelessness and criminal justice issues also have a mental health issue over 55% diagnosis by a professional Bramley et al 2015

11 Facts and figures Substance use Had a period in life when had six or more alcoholic drinks on a daily basis 63% Used hard drugs 44% Injected drugs 27% Abused solvents, gas or glue 23% Mental Health Admitted to hospital because of mental health issue 29% Had a period in life when very anxious or depressed 79% Attempted suicide 38% Deliberately self-harmed 30% Kirkpatrick et al (2012)

12 Facts and figures Self-reported MH symptoms 73% Stressed 65% Anxious 39% Panic attacks 67% Depressed 64% Difficulty sleeping 32% Suicidal thoughts Substances used Cannabis 64% Heroin 27% Prescription drugs not prescribed for them 29% Benzodiazepines 18% Amphetamine 17% 32% Self harm 18% Hear voices Homeless Link (2014)

13 Facts and figures A&E Homeless Link (2014) 35% had attended in the past 6 months Average cost of A&E attendance % admitted to hospital in past 6 months Average cost of hospital inpatient episode 1779 Lewisham DD frequent attenders: - 9/10 housing issues - 9/10 not engaged with SM service 10% of people with DD that had attended 5+ times in past year had died

14 Toxic combination People with mental illness die years younger than the general population Lifestyle factors Unnatural deaths Effects of medication Poorer access to healthcare Chesney et al (2014), Thornicroft (2011) Substance use Mental health Homeless -ness Average age of death of homeless people is 47 (general population is 77) Drug and alcohol use common cause Suicide 9x more common than general population Crisis (2012)

15 Which substances? Heroin alcohol Cannabis New psychoactive substances Crack/cocaine

16 Alcohol effects Wernicke s encephalopathy Involvement with criminal justice Cancer of throat & mouth Withdrawal seizures Delerium tremens* Foetal abnormalities Alcoholic hallucinosis* Aggression/violence Depression* Unsafe sex Falls Anxiety* Suicide* Accidents Self neglect Cognitive problems/memory* loss/brain damage/black outs Oesophageal varices Heart disease Breast cancer Ulcers Pancreatitis Liver disease High blood pressure Impotence Peripheral neuritis/ nerve damage: tingling, numbness Interactions with medications* and other substances

17 Cannabis - effects Depression* Trigger anxiety/paranoia/ psychosis/relapse (THC)* Short term memory problems Lung problems coughing, wheezing Anti-psychotic effects* (CBD)? Amotivational syndrome Impaired thinking and coordination - Accidents Impact on IQ? Nausea/vomiting Low birth weight babies? Helpful for pain eg in MS

18 Stimulants - effects Psychosis, mental health relapse* Agitation, irritability* Come down low mood/depression, lethargy* Loss of weight Poor appetite Self-neglect Violence Seizures/fits Involvement in criminal justice system Poor sleep Damage to nose septum Heart problems: abnormal rhythm, heart attack, stroke Lung problems: coughing, wheezing, crack lung If injecting vein damage, abscesses, blood borne viruses, septicaemia etc Liver damage Risks to unborn child High blood pressure Unsafe sex sex to fund use

19 Relationships between MH and SM often complex substance use or withdrawal can produce psychiatric symptoms or illness dependence, intoxication or withdrawal can produce psychological symptoms psychiatric disorder can lead to substance misuse disorder substance misuse may exacerbate a preexisting psychiatric disorder

20 Associated risks/difficulties higher rates of homelessness increased rates of suicidal behaviour worsening of psychiatric symptoms poorer adherence with medication increased rates of HIV and hepatitis greater contact with criminal justice system greater use of institutional services

21 The challenges: Individual Difficult to find/engage Don t see substance use as problem/may see as helpful Don t recognise that they have mental health problem Multiple problems where to start Disentangling mental health and substance misuse Stigma double/triple whammy

22 The challenges: the system(s) Service thresholds high Exclusion criteria Multiple agencies involved Standardised treatment pathways (eg self-referral, predetox groups) Lack of staff knowledge/confidence Commissioning gaps provision for people that want to continue to drink, alcohol related brain injury/dementia Many homeless people with MH and/or SM problems were either not getting support at all or would have liked more (Homeless Link 2014)

23 Dual diagnosis treatment models Serial Parallel Integrated

24 Treatment models Serial: one problem treated after the other people with MNE are often characterised by ineffective contact with services most are designed to deal with one problem at a time DD often restricts homeless people from accessing support, as services are unable or unwilling to provide support around MH while still using drugs or alcohol Homeless Link

25 Treatment models Parallel: both treated at same time but by different services

26 Treatment models Integrated: mental health and substance misuse issues are treated at the same time, in one setting, by one team Dual diagnosis is everyone s business

27 Facing multiple problems that exacerbate each other, and lacking effective support from services, people easily end up in a downward spiral of mental ill health, drug and alcohol problems, crime and homelessness. MEAM

28 The Way Forward There are no magic wands!

29 Positive approaches: working with partners

30 Services leading care provision: integrated treatment Severity of substance misuse High Low eg dependent drinker who experiences low mood and anxiety Severity of mental illness eg recreational ecstasy use who has begun to experience low mood after weekend use eg person with schizophrenia using cannabis and crack on a daily basis High eg person with bipolar disorder whose occasional binge drinking destabilises his mental health Low

31 Working with partners Build relationships with your partner agencies - get to know people, especially people that work well with this group have a go to person/advocate - understand how they work/what they can (and can t) do - invite them to spend time with you/your service Develop joint working protocols/guidance that all have contributed to and are signed up to Develop informal/practical tips on working together Identify team dual diagnosis champions/leads Get commissioners on board support, understanding gaps

32 The MEAM* Approach Helping areas design and deliver co-ordinated services *Making Every Adult Matter

33 MEAM approach Establish partnership of the right people and understand local need (consider Joint Strategic Needs Assessments) Consistency in client identification/referral Co-ordination for clients and services Plan flexible responses from partner services Identify and fill service gaps Measure success clients and local public sector economy Embed change in the system so that improvement are permanent/sustainable

34 Communities of Practice (King s College London, Revolving Doors) CoP - a group of people who share a concern, set of problems, or passion about a topic and want to deepen their knowledge and expertise by interacting on an ongoing basis. Focus on frontline practitioners rather than managers or commissioners. 6 CoPs established, each 6-10 participants from across agencies and a knowledge broker (to provide information about relevant research and policy) Met minimum of 6 times for two hours Focus on clinical discussion

35 Communities of Practice Aims build networks and improve and sustain relationships between different agencies and professions improve front line responses through knowledge brokerage and interdisciplinary learning provide space for reflective practice and interdisciplinary group supervision with opportunities for mutual support.

36 Communities of Practice 90% reported that: - their networks and contacts increased - knowledge of the role and function of other agencies increased - skills in working with people with multiple needs and exclusions improved. Demonstrating hard change outcomes was difficult.

37 Positive approaches: working with individuals

38 Stages of change/ treatment Contemplation - some acceptance of problem - no commitment to change Building motivation/ persuasion Pre-contemplation - use not seen as a problem, see no reason to change Decision/preparation - to address substance misuse Relapse - return to prechange behaviour Action -steps taken to change Active treatment Prochaska & Di Clemente (1996) Maintenance -work to maintain gains and prevent return to past behaviours Osher and Kofoed (1989) Relapse prevention

39 Engagement..take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism...use a flexible and motivational approach (NICE 2011) Focus on person s agenda, typically practical issues eg housing, benefits, food; be flexible (time, place), regular contact

40 Spirit of motivational interviewing (way of being with people) Partnership/collaboration Acceptance - absolute worth (unconditional positive regard) - accurate empathy - autonomy support - affirmation acknowledge strengths Compassion Evocation - drawing out from person own views/perspectives/ideas

41 Assessment Know the person, understand his/her mental health experiences and the role alcohol/drugs play in person s life Draw on: - QNI Health Assessment Tool (2015) - NICE (2011) Psychosis with coexisting substance misuse (full guideline chapter 5) Risk assessment is crucial: mental health, substance use Share information with other agencies

42 Risk management/patient safety Need to be alert to physical, psychological and social risks associated with mental health and substance use and know what action to take A&E physical health (eg withdrawal seizures, delirium tremens, Wernicke's encephalopathy, accidental overdose) - mental health (eg suicidality, psychosis if immediate risk to self/others) psychiatric liaison Mental health team urgent referral to assessment team Street triage (in collaboration with police) Local authority safeguarding children, at risk adults Check your local Crisis Care Concordat action plan

43 Harm reduction/minimisation Acknowledges some people are unwilling or unable to stop use Policies and programmes that aim to reduce the health, social and economic consequences associated with the use of mood altering substances to individuals, their families, wider community/ society Dual diagnosis take a wider perspective Having a safe, stable & affordable home is critical for promoting positive mental health and well being and for enabling individuals with complex and multiple needs to move on positively with their lives. MEAM Naloxone can be available in hostels

44 Selfactualisation Maslow s hierarchy of needs Esteem - self and from others Belonging eg affection Safety eg shelter Physiological eg food, sleep

45 Routine/non-emergency mental health provision Know you local service and pathways - assessment service GP referral may be required/useful Consider wider range of options than statutory provision: - for mental health eg MIND - for developing more structured, purposeful life eg gardening, football, art, faith groups etc

46 Making changes involving substance misuse services Formal services - increasingly provided by voluntary/3 rd sector agencies - rarely commissioned to provide any mental health treatment - limited number of staff with mental health background Know about what they can offer, their referral pathways - outreach/engagement provision Self-help/mutual aid eg Alcoholics Anonymous, Narcotics Anonymous, Dual Recovery Anonymous, SMART recovery

47 Conclusion: It s good to talk and listen

48 Questions/discussion

49 References/resources Bramley G, Fitzpatrick (2015) Hard Edges: Mapping severe and multiple disadvantage The Lankelly Chase Foundation SMD-2015.pdf Chesney et al (2014) Risks of all-cause and suicide mortality in mental disorders: a meta-review Cornes et al (2013) Little Miracles: Using Communities of Practice to improve front line collaborative responses to multiple needs and exclusions King s College London, Revolving Doors Agency Department of Health (2002) Mental Health Policy Implementation Guide: Dual diagnosis good practice guide, DH, London Department of Health (2014) The Mental Health Crisis Care Concordat Improving outcomes for people experiencing mental health crisis Fitzpatrick, Bramley and Johnsen (2012) Multiple Exclusion Homelessness in the UK: An Overview of Key Findings, Briefing Paper No 1

50 Homeless Link (2014) The Unhealthy State of Homelessness: Health audit results 2014, Homeless Link, London The%20unhealthy%20state%20of%20homelessness%20FINAL.pdf Kipping C, Simpson L (2010) Contrasting maintenance and recovery approaches to the care and people with dual diagnosis Advances in Dual Diagnosis 3(1):15-18 Maslow (1943) A theory of human motivation Psychological Review 50: National Institute for Health and Clinical Excellence (2011) Psychosis with Coexisting Substance Misuse. NICE clinical guideline 120 (full guideline), British Psychological Society and Royal College of Psychiatrists, London Queen s Nursing Institute (2015) Assessing the Health of People Who Are Homeless QNI, London Thomas B (2012) Homelessness Kills University of Sheffield/Crisis, London %20Executive%20Summary.pdf Thornicroft G (2011) Physical health disparities and mental illness: the scandal of premature mortality (Editorial) British Journal of Psychiatry 199: