Combined drug and mental health teams promised  

Long-awaited services for people with dual diagnosis — with both mental health and drug issues — have been announced, but questions remain on implementation

Patients and their families are told by mental health services that an addiction needs to be treated first — and by addiction services that psychiatric issues need to be addressed first.

John was hearing voices of his dead friends telling him to join them.

His friends had been fellow drug users and he was very close to them.

John (not his real name) had gone to a hospital emergency department twice, with significant suicidal ideation, cutting himself, and one attempt to jump off a high building.

He was a heroin user, and had taken methadone, but had stopped this before he began to hear the voices.

John was also a regular user of cannabis and drank every day.

He did not have secure accommodation.

He was discharged each time from the the hospital A&E with drug-induced psychotic disorder and put on a short course of Olanzapine.

John was advised to stay away from drugs and was not given any follow-up by other services.

His story is one of many that pepper a detailed study by HSE experts on the need to set up a specialist national service that would treat people who have both serious mental health needs and addiction problems — referred to as dual diagnosis.

The Model of Care for Dual Diagnosis report, published this week, promises the establishment of 12 adult dual diagnosis teams and four adolescent teams across the country — although funding for nine of them has yet to be found.

Again and again, individuals and their families tell of their experiences of being told by mental health services that the addiction would need to be treated first — and by addiction services that the psychiatric issue would need to be seen to first.

“I found it very difficult to access mental health services while I was active in my substance use,” said one person.  "The mental health place couldn’t keep me, they said, because I was using at the time.”

One parent said: “It wasn’t easy trying to get help for him. He was told he couldn’t be helped by the mental health services because of his addiction issues. I remember feeling very frustrated by the lack of information.”

Another parent told researchers: “The answer I kept getting back from services, whether it was in the hospital or from the health professionals, was that the addiction has to be addressed first, before they can even look at possibly diagnosing any underlying psychiatric condition.”

The exhausting process is taking a heavy toll on both the person seeking help and their parents and siblings.

“My relationship with my husband has recently ended due to all the stress and wear and tear of dealing with our son,” one mother said. “Families and supportive people and structures need to be brought into the care.”

This is not a new problem and families and advocacy groups, and indeed professionals, have been highlighting it for years, decades even.

Official reports going back almost 20 years have highlighted the need for it.

In 2004, the now-defunct National Advisory Committee on Drugs found gaps in policy and practice in relation to the management of dually diagnosed people among service providers in both the mental health and addiction fields.

In 2006, the landmark health document, A Vision for Change, recommended the establishment of a network of specialist teams to deal with severe mental health disorder and substance misuse — but these teams were never formed. The Steering Group Report on a National Substance Misuse Strategy, 2012, called on HSE Mental Health to develop an integrated approach to dual diagnosis (DD).

The National Drugs Strategy, Reducing Harm, Supporting Recovery 2017-2025, echoed these calls, as did the Sharing the Vision strategy of 2021.

The Model of Care report said the HSE set up a national working group for the HSE Dual Diagnosis National Clinical Programme in 2016. It ran until 2018, but then went nowhere for the next three years, due to the absence of a clinical lead.

A second working group was formed in July 2021, leading to the drafting and publication of the 141-page report this week.

The report said that international research indicated that between 30-50% of people with severe mental illness had co-existing substance misuse problems.

Separate studies indicated between 75-85% of people attending an alcohol or drug service reported suffering from a psychiatric disorder in the previous year.

Research has found that people with DD had increased rate of risky behaviour, and higher rates of unemployment, homelessness, and criminal behaviour.

The HSE report said dual diagnosis had been described as a “major issue” in the prison population.

It said two reports by the Irish Probation Service in 2021 identified the extent of mental health and substance abuse issues and called for the different services to collaborate to address the complex needs of the prison population.

One mother quoted in the HSE report said: 'My relationship with my husband has recently ended due to all the stress and wear and tear of dealing with our son. Families and supportive people and structures need to be brought into the care. Stock picture

The Model of Care report said international research indicated that people with dual diagnosis were more prone to risk of overdosing, using multiple substances and had an increased risk of suicide.

The report said that feedback from people with DD indicated “high levels” of stigma when they said they used drugs or were in recovery.

Their families spoke of the “everyday stress and strain”. The report said family members were both agents of change in recovery care and “service users in their own right”.

It said there was a third group, who, in addition to having DD, had also experienced trauma in their lives, including adverse childhood experiences.

The report also said that, in time, the teams will also include people with behavioural addictions, such as gambling and gaming disorders.

The report recommended a network of 12 adult teams and four adolescent teams along with a national dual diagnosis rehabilitation centre.

Campaign groups, including Mental Health Reform, have welcomed the published plan and comments made by Minister of State for Mental Health Mary Butler and Minister of State for Drugs Hildegarde Naughton.

But there is understandable concern at the implementation, particularly given the repeated references that the setting up of at least nine of the teams, and the national centre, depended on
resources being found.

The report itself is silent on the timeframe for implementation, save for references to two phases:

• Phase 1 is the initial phase, with DD services “gradually rolled out” across the nine health regions;
• Phase 2 will commence when HSE Addiction Services have “adequate resources” to manage behavioural addiction

The only indication of actual implementation comes from the launch of the report and comments from Narayanan Subramanian, HSE national clinical lead for dual diagnosis.

Dr Subramanian said the initial Adult DD teams were expected to commence in the Mid-West region, based in Co Clare, in addition to another team in Cork.

He said the first adolescent DD team was planned for North Dublin.

The establishment of the remaining nine teams would be based on “available resources in the future”.

The report points out that the existing adolescent team in North Dublin only had 40% of its staffing levels and that additional staff and resources would be required.

Given the current staffing shortages across medicine, psychology, social work, and related professions, it is unclear how the teams will be established, and when.