VOL: 99, ISSUE: 27, PAGE NO: 34
Lorna Saunder, BSc, RMN, is lecturer/practitioner in substance misuse and mental health, City University, London
Initially, the term ‘dual diagnosis’ was used to describe an individual who had a learning disability and mental health difficulties, but it has been redefined to signify mental health and substance misuse issues (Banerjee et al, 2002). Even so, the term can be misleading because most people in this category have more than two problems and often present with complex needs.
Although commonly referred to by mental health care professionals, dual diagnosis does not exist as a formal diagnosis. In addition, the severity and degree of mental health and substance misuse problems can be vast. These factors make it difficult to provide appropriate and timely health care and frequently these patients fail to have their needs met.
Historically, patients with a dual diagnosis found themselves bounced between mental health and substance misuse services. Typically, the substance misuse services felt unable to treat these individuals until the mental health issue had been addressed, and the mental health services felt unable to address the mental health difficulties until the individual was ‘clean’ and sober. As a result, the risk of the patient disengaging from services, which is high in this group anyway, was increased further.
The provision of care for people with a dual diagnosis is currently receiving a lot of attention, both at a national and local level. Last year, the Department of Health published a Dual Diagnosis Good Practice Guide (DoH, 2002), which clearly outlines the need for the care of patients with a dual diagnosis to be integrated into mainstream mental health services. This implies a shift away from the traditional model, whereby care was provided either simultaneously by mental health and substance misuse services or in a serial fashion, and a move towards a model of integrated care.
The integrated care model requires mental health and substance misuse services to work together to provide a seamless service. However, this means that mental health services are now responsible for patients with a dual diagnosis, while the substance misuse services provide specialist input on a joint working basis.
Incorporating patients with a dual diagnosis into mainstream mental health services is likely to cause some difficulties for mental health services, not least because of nurses’ perceived lack of knowledge. A study by Gafoor and Rassool (1998) showed some nurses either lacked the confidence to ask patients about their substance misuse or had pessimistic views regarding treatment.
Substance misuse training
Traditionally, specific substance misuse training has only played a nominal role in education programmes for mental health nurses and some nurses report having had only one or two sessions on the subject. However, this is now beginning to change. At City University, for example, mental health students are taught about dual diagnosis as soon as they enter their specialty and the subject is revisited throughout the course.
Many mental health nurses feel ill equipped to address the substance misuse needs of patients who have a dual diagnosis. Colleagues have also reported that they feel that their basic drug awareness is inadequate and they do not know how to approach the care of this patient group.
A feeling of ineffectiveness is often worsened by an adherence to the belief that complete abstinence is the only appropriate goal when planning interventions. Although abstinence is likely to be the only way to determine the effect that a substance has upon a patient’s mental health, it is likely to be the least acceptable option to the patients themselves.
Harm reduction model
The Dual Diagnosis Good Practice Guide recommends using a harm reduction model (DoH, 2002). Harm reduction acknowledges that totally eradicating drug abuse is impossible, but advocates using every effort to minimise the harmful consequences of drug abuse (Ghodse, 1995).
The Dual Diagnosis Good Practice Guide proposes that if it is unrealistic to aim for abstinence then it may be more appropriate to consider intermediate goals that will reduce the harm sustained from drug and alcohol misuse (DoH, 2002).
A steering group at East London and the City NHS Trust has been set up to improve the services provided for patients with a dual diagnosis. The group includes representatives from mental health services, substance misuse services, social services and City University, as well as representatives from all three boroughs of Newham, Tower Hamlets and Hackney.
The group has identified a need for nurses, particularly within acute mental health inpatient settings, to undergo training on dual diagnosis and its management. It is envisaged that dual diagnosis training within the trust will become a compulsory part of the continuing professional development of mental health nurses, in the same way as basic life support and risk assessment.
The need for ward-based staff to receive dual diagnosis training is also supported at a national level by the Models of Care document (National Treatment Agency for Substance Misuse, 2002), which has taken its lead from the Health Advisory Service’s Standards for Substance Misuse and Mental Health Co-morbidity (Abdulrahim, 2001). This document specifies that mental health services must ensure that members of staff have access to substance misuse training once they are in post.
A two-day training course has been developed at the Newham Centre for Mental Health based on the recommendations in the Dual Diagnosis Good Practice Guide (DoH, 2002). The course covers:
- Basic drug and alcohol awareness;
- The link between substance misuse and mental health;
- Drug-induced psychosis;
- Harm reduction;
- The process of change;
- Brief interventions;
- Locally available services.
The training programme is open to all disciplines within the centre and, so far, has been attended by both nursing staff and occupational therapy staff.
Setting the standards
As with all training there is always the risk that education will not be put into practice, so it was decided that the interventions provided to patients with a dual diagnosis should be audited.
Using the Dual Diagnosis Good Practice Guide and the local illicit drugs and alcohol policy the following standards were set and then audited:
- All patients should be advised of trust policy regarding the prohibition of all illicit drugs and alcohol on trust premises, and this should be documented;
- All patients with an identified substance misuse issue require a urine drug screen;
- All patients with an identified substance misuse issue need to have an assessment of their substance misuse using a locally agreed tool;
- All patients with an identified substance misuse issue should have a care plan specific to this;
- All patients with an identified substance misuse issue should be provided with health education;
- All patients with an identified substance misuse issue should be offered referral to a relevant specialist service.
It is essential to inform all patients about the trust’s policy regarding the prohibition of all illicit drugs, alcohol and non-prescribed substances. The prevalence of illicit substance use in psychiatric units is of particular concern and is well known to most psychiatric services.
Ideally, all individuals admitted to a mental health unit should have a urine drug screen to determine exactly what substances (if any) they have used recently and whether any are still present in their bloodstream. Urine drug screens should also form part of the ongoing treatment so that any changes in mental state can be linked either to substance misuse or to the person’s mental health problem.
This is not as simple as it may seem because many patients use substances without any negative impact on their mental health. This relationship was highlighted in a report by Phillips (2002) who found that a worsening of symptoms and illness occurred in some individuals with a diagnosis of schizophrenia who were using cannabis, while others found that cannabis relieved negative symptoms, unpleasant affective states and the side-effects of anti-psychotic medicines.
Assessment is essential when working with patients with a dual diagnosis. Not only does it provide a picture of what is being used, in what pattern and some of the reasons for the development of the problem, it also helps the individual increase his or her own understanding of the problem. In their seminal work Miller and Rollnick (1991) identified assessment as having a key role in enhancing a patient’s motivation to change. They found that the very process of conducting a thorough assessment provided the patient with an opportunity to reflect in detail upon his or her situation.
A care plan specific to substance misuse, health education and referral to an appropriate specialist service are key elements in providing a comprehensive treatment plan for patients with a dual diagnosis.
The notes of the current inpatients on four acute wards at the Newham Centre for Mental Health were audited. These notes focused on the initial assessment, care plan and progress of the patients and were mainly completed by nursing staff.
For the first audit, 58 sets of notes were analysed and of the nursing staff who compiled the notes, three had completed the training programme. After the first audit, each member of the nursing staff was provided with an individual report that outlined suggestions for interventions to improve care in line with local standards.
The audit was repeated one month later and 69 sets of notes were analysed. On this occasion four nurses had undergone training.
In the first audit, of the 58 patients analysed, 15 (25.6 per cent) were identified as having a substance misuse issue. The results of the initial audit were as expected, considering the mental health nurses’ lack of specific training (Fig 1).
In the second audit, of the 69 patients looked at, 10 (14 per cent) were identified as having a substance misuse issue. The increased number of notes audited was a result of the differing numbers of patients admitted at any one time. The results from the second audit are shown in Fig 1 (see p36).
The results show that there has been an improvement in the standard of the notes completed. Without further study it is difficult to say if patient care has improved, and it would be interesting to investigate the patients’ perception of the care they have received.
Some of the notes included in the second audit had been previously audited and some of the nurses involved in the first audit had been given detailed advice as to what standards of care should be achieved. These factors may have contributed to the improvements in care witnessed in the second audit. It must be remembered that this is a very small sample and without further statistical analysis it is difficult to determine whether the results are statistically significant.
As with all training programmes, the staff evaluated the usefulness of the training and made recommendations. Overall, the training has been well received and staff generally feel more confident when working with patients with a dual diagnosis.
A number of staff members have also revealed that some of their less positive attitudes towards patients with a dual diagnosis have been challenged. Their willingness to learn and their commitment to the patients have been essential in building the momentum to keep this initiative going. It is hoped that some of the resistance to working with patients with a dual diagnosis can be reduced.
Local substance misuse services have been involved in the delivery of the training by discussing what their services do and how they can be accessed. It is hoped that this will promote joint working by raising the profile of local substance misuse services among ward-based staff. The trust is currently working on formalising joint working protocols between substance misuse services and mental health services to further this work.
The low level of self-reported substance misuse among the patients is also extremely interesting. Because Menezes et al (1996) found that rates of concurrent substance misuse among psychiatric populations in south London were 30-50 per cent, similar levels were expected in this study. However, the results show that 14 per cent of mental health inpatients have a concurrent substance misuse problem. This could be an anomaly and may be shown not to be the case by future audits. Alternatively, this result may indicate under-reporting of substance misuse. If true, the reasons patients feel unable to report substance misuse and whether patients are receiving the correct and appropriate treatment, if they are under-reporting, should be determined.
This result has implications at a local level. The Newham Centre for Mental Health has only recently received urine-testing kits that can be used on the wards, and patients are currently not being screened as often as they should be. It is likely that the numbers of patients shown to be using substances will increase if urine screening is carried out more widely.
This project has begun to demonstrate the need for more training in substance misuse and dual diagnosis. By setting clearly defined, basic standards of care attached to a tailor-made training package, our audit has gone some way towards addressing this issue.
The Dual Diagnosis Good Practice Guide (DoH, 2002) has clearly outlined the need for mental health services to tackle the issue of dual diagnosis, but to do this effectively nurses must be offered suitable education. At present, many nurses feel ill equipped to offer interventions to this group of patients, which is exacerbated by an overall lack of UK-based research into the subject.
This highlights a need for substance misuse and mental health services to be working jointly in a way that shares information and expertise. Within East London and the City NHS Trust a number of projects have been set up to take this forward.
In order to validate this audit properly, a study into the patients’ experience is also vital. We need to know what they find effective and acceptable, otherwise it simply becomes a paper exercise meeting our own needs but not those of our patients.