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Dual diagnosis: Integrating a fractured service 

By Paul Mulholland - 14th Aug 2023

A national model of care for dual diagnosis was recently launched, but the task of improving services will not be straightforward. Paul Mulholland reports

There are different definitions of dual diagnosis (DD). However, it commonly refers to the presence of co-existing mental health and substance use disorders. 

In Ireland, the development of services for people with DD has been slow due to several factors, including lack of funding. 

An initial national working group for the HSE Dual Diagnosis National Clinical Programme was established and convened between 2016 and 2018. The work of the group was paused in 2018 due to the absence of a Clinical Lead. 

In June 2021 Dr Narayanan Subramanian was appointed Clinical Lead and a second working group was established the following month. In partnership with HSE Social Inclusion, HSE Health and Wellbeing and the HSE National Office for Suicide Prevention, as well as voluntary bodies, a model of care for dual diagnosis was developed. Feedback from service users also informed the development of the model, which was approved by the HSE in April 2022 and subsequently endorsed by the College of Psychiatrists of Ireland. 

The model of care was officially launched in May 2023 and will be rolled out in two phases, with phase one currently being implemented. It includes the Seeking Safety Programme, which was established through the Dual Diagnosis National Clinical Programme in November 2022. Funded by the Department of Health, through the Women’s Health Fund, the Seeking Safety Programme has supported 157 women with DD and a history of trauma since its establishment. 

In the second phase of implementation it is planned to include behavioural addiction, such as gambling and gaming disorders, as part of DD service provision. However, this will be dependent on the initial development of supports for these disorders within addiction services.  

Strategic change

The previous mental health strategy, A Vision for Change, published in 2006, recommended that general community mental health teams (CMHTs) include counsellors skilled in working with addiction issues. It called for the development of specialist adult and adolescent DD mental health teams to manage complex and severe substance abuse and mental health difficulties. 

However, it also stated that specialist mental health services should support only individuals “whose primary difficulty is mental health”. The new mental health strategy, Sharing the Vision, published in 2020, posits a different approach.

“Individuals with co-existing mental health difficulties and addiction to either alcohol or drugs should not be prevented from accessing mental health services,” according to the current strategy. 

“Consequently, it will not be necessary to establish whether a mental health difficulty is ‘primary’ for an individual to access the support of a mental health team. A shared case management approach may be required for particularly complex patients.”

In May 2022, Mental Health Reform (MHR) published a report examining existing services for people with DD. 

The findings of this report were in line with research that showed individuals with DD have found themselves “largely rejected by services” due to their concurrent difficulties. As some people with DD may also experience homelessness, they can be “at the extreme end of social exclusion” and experience “multi-stigmatisation”. 

“Long waiting lists for access to mental health services, coupled with poor understanding of the interaction between mental-ill health and [substance use disorder/alcohol use disorder], has led to a number of organisations developing their own dual diagnosis service,” according to the report. 

The MHR report pointed to the development of the model of care as offering a way forward. 

Speaking to the Medical Independent (MI), Ms Ber Grogan, Policy and Research Manager with MHR, said the issue has been raised “consistently” by stakeholders and service users for a number of years. 

Ms Grogan pointed out that people with DD are often in an extremely vulnerable financial position. They may be homeless or without health insurance, which makes it difficult for them to avail of services in the independent/private sector such as the well-recognised DD programme offered by St Patrick’s University Hospital in Dublin. Meanwhile, she explained the services in the public and voluntary sector are often fragmented and unintegrated. 

“People were falling between the cracks,” Ms Grogan said. “If you had a mental health difficulty and addiction you were being turned away from both services. Addiction service providers would say, ‘we can’t deal with your mental health difficulty’, and mental health teams would say, ‘we can’t see you if you have an addiction’. There was a clear gap in services. And that was really acknowledged in the fact that it was a specific recommendation in Sharing the Vision. That was why we conducted our research, to get a better understanding of the problem.”

The lack of adequate services for people with DD has also been on the agenda of the College of Psychiatrists of Ireland.

“The current model is that if you present to the mental health service and there is an active drug or alcohol use problem, the tendency would be for people to be advised to address that problem first and then to return,” Dr Mike Scully, Consultant Addictions Psychiatrist and member of the College’s Faculty of Addictions Psychiatry, told MI.

“And then if you present to addiction services with a drug/alcohol problem and a mental health problem, they will correspondingly advise you to see a mental health service first. So, it is a very difficult place for patients, families, and carers.”

Dr Scully referred to how services are not consistently spread across the country.

“Some catchment areas and some services will do quite a bit,” he said. “Other services will do very little and historically have done very little. So, you are then in a position where if you have health insurance you potentially have access to resources that are not available locally within the HSE services. But you still have no guarantee of access.”

Care levels

Most of the initial contacts for people with DD are at ‘level one’. This is where the service user attends their GP, the regional drug and alcohol service in the HSE, or a voluntary and non-statutory agency. This includes the section 39 agencies that offer addiction support services and, in some cases, mental health support services in the community. Often, the service user also ends up directly in ‘level two’ services when they are in crisis, leading to attendance in an emergency department. In many cases where the service user has DD, staff from the liaison psychiatry department would be involved.

‘Level three’ involves CMHTs. People with DD are referred through their GPs or after an earlier crisis presentation in an acute hospital setting. HSE drug and alcohol services may provide level three care, in addition to services at level one. 

Specialist DD teams, involving ‘level four’ services, “virtually do not exist in the HSE”, according to the new model of care document. As a result, those who need specialist services end up either with level three CMHTs or addiction services or both. 

“Since addiction services and CMHTs in most cases lack appropriately skilled professionals and have inadequate resources for catering to those with DD, the service users often end up falling between the different levels, leading to inadequate service provision,” the document states.

“A significant limiting factor has also been the lack of access to inpatient beds (‘level five’) for those with dual diagnosis in many cases, and in particular to specialised DD rehabilitation inpatient beds, in addition to inpatient detoxification and stabilisation beds. It is envisaged that specialist DD teams will minimise barriers to service users accessing the appropriate service.”

Multidisciplinary 

Under the model of care, DD services will be a tertiary level resource providing support to CMHTs; community child and adolescent mental health teams; acute inpatient psychiatric units for both adults and adolescents; HSE addiction services; and community, voluntary and HSE-funded organisations including section 39 agencies. As envisaged in the Sharing the Vision recommendation for DD, an integrated approach will be adopted. Resources such as staff, training, and premises will be shared between the service partners. Primarily it will come under the clinical governance of HSE mental health and in some cases will be shared with HSE addiction services.

Twelve adult DD teams are recommended to cover the nine Community Healthcare Organisations (CHOs). They will cater to the age group of 18-to-64 years and cover an approximate catchment area population of 300,000 (“appropriate support” will be provided to services accessed by people aged 65 years and above).

Each team will be multidisciplinary in nature and consist of 13 whole time equivalents (WTEs) led by a consultant psychiatrist.

A total of four ‘hub’ adolescent DD teams are recommended. These teams will provide services for those in the age group of 10-to-17 years. They will follow a ‘hub-and-spoke’ model. The four ‘hub’ teams will be multidisciplinary in nature and will also include outreach workers and family therapists. Each ‘spoke’ adolescent DD service will have clinical nurse specialists and addiction counsellors.


In the present climate, that is a major ask given the number of consultant posts that are unfilled across all specialties, but particularly within psychiatry

Dr Aoife O’Sullivan, ICGP/HSE Primary Care Lead for Mental Health, noted that under the new model GPs cannot refer directly to the DD teams. Instead, they are to continue to refer to either addiction services or to an appropriate CMHT.

“The patients will be triaged and referred onwards to the new teams if indicated,” Dr O’Sullivan told MI. She added that “GPs are not mentioned in the integrated model for DD teams”. Dr O’Sullivan highlighted that GPs are the first “port of call for most mental health presentations” and manage 90 per cent of mental health issues in the community.

Beds

It is envisaged under the model that consultant psychiatrists in DD teams will have access to one-to-two inpatient acute psychiatric unit beds in their catchment area for planned admissions only. This will be subject to the outcome of the review of bed capacity in acute inpatient psychiatric units, which is currently being undertaken by the HSE. Additional beds have been requested by the DD clinical programme as part of this process. 

“In the interim, local arrangements can be considered,” according to the document.

“This shall include dual diagnosis teams having direct access to inpatient unit beds depending on bed capacity and also consideration for access to beds in partnership with the HSE addiction services.”

With regard to inpatient rehabilitation, it is recommended that an “appropriately staffed” 10-to-16 bedded inpatient HSE national DD rehabilitation centre should be established, preferably in Dublin. 

Progress

The estimated cost of resourcing 13 WTEs for each team is approximately €1.03 million. The funding is dependent on the sharing of resources with other HSE divisions, such as  HSE Social Inclusion, in addition to the cost of other ancillary services.

Resources have been released this year for teams in some CHOs. However, roll-out of the model of care is experiencing “a minor delay”, according to the Sharing the Vision implementation report for the first quarter of 2023. While “significant progress” has been made in the recruitment of members for the CHO 3 adult DD team, which covers the mid-west, the commencement of its work will depend on the refurbishment of the building that will house the service. Regarding the adult DD team for CHO 4, which covers the Cork/Kerry area, the report said there were no applications for the consultant post. As a result, an executive search internationally was necessary through the Public Appointments Service. Other team members were still in the process of being recruited.

In addition, three posts approved for the adolescent DD team in CHO 9 (north Dublin) were being recruited.

When asked for an update on these posts, a HSE spokesperson said the CHO 3 team is expected to be operational by the end of 2023/early 2024. The team in CHO 4 will be operational around the same time “subject to the recruitment of a consultant”.   

“The Dublin north city and county adolescent team will be operational when all the WTEs are recruited,” according to
the spokesperson. 

MI can reveal that the Keltoi centre at St Mary’s Hospital in Phoenix Park, Dublin, has been earmarked to serve as the national DD rehabilitation centre. The building had previously been a drug rehabilitation centre, but was closed in March 2020 to serve as a Covid-19 isolation facility. The building, which is managed by HSE Primary Care (Social Inclusion), is currently being refurbished, according to the HSE’s spokesperson. 

“Discussions are at an early stage with different stakeholders for this building to be used as the national referral centre for service users who require dual diagnosis rehabilitation. Depending on this process, it’s expected there will be a gradual implementation of services at this centre.”

Funding 

Inadequate funding has been a problem in general mental health and addiction services for years and there are concerns it could hamper the implementation of the model of care. Ms Grogan said “real-time feedback” needs to be produced by the HSE on how people are accessing the service as the model is rolled out. She stressed it is very positive the model has been developed, “but whether sufficient resources are available to the teams on the ground to actually provide the services, that is what we are unsure about.”

“We can have these great models of care, but if people can’t actually access services on the ground, what difference will they make?”

Dr Scully also strongly welcomed the model of care to allow for much-needed service integration. However, he stated that “without funding you go nowhere”.

“The difficulty after that is to recruit relevant clinical specialists to create the teams,” he said.

“In the present climate, that is a major ask given the number of consultant posts that are unfilled across all specialties, but particularly within psychiatry.”

MI asked Dr Subramanian, National Clinical Lead, if he is confident that the model will be funded and implemented. He said: “I am pretty confident.”

“We have three teams already on the way. And we are hopeful we will get more funding as we expand. There is a big need out there. There is no question about whether it will be implemented or not. It is being implemented already. People have been given employment contracts. It is happening as we speak.”

He admitted developing services for people with DD is “challenging” given its complexity and the different sectors involved. “That is one of the reasons why it has taken this long,” Dr Subramanian said. 

“It is not a straightforward case of getting someone into rehab and ‘it is all well and good’. A lot of people struggle with homelessness; a lot of people struggle with unemployment; a lot of them have issues with domestic abuse…. It is very complex. We cannot do it on our own. We need our partners in the voluntary bodies. We need our partners in the different areas of the HSE. That is the only way we can make it successful and benefit service users and their families.”

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