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Co-existing substance misuse with mental health issues (CESMMHI) – proposed new guidance Luke Mitcheson, PHE Alcohol, Drugs and Tobacco Division Contexts Mental Health Intelligence Network – Coexisting Substance Misuse and Mental health Issues ERG Crisis Care Concordat (Norman Lamb) – recognition from government that MH has been neglected Our service users are significantly represented in crisis response / pathways (Liaison and diversion in police cells, A&E ) DH 2002 guidelines “archived” New bits of guidance (NICE, Orange) Fragmentation in commissioning structures Ongoing need to be addressed 2 Presentation title - edit in Header and Footer The Imperial College Co-morbidity Study (Weaver et al 2002) To estimate prevalence of co-morbidity among current patients of mental health and substance misuse services. Drug Treatment Population Mental Health Population Psychotic disorder 7.9% Problem drug use 30.9% Personality disorder 37% Drug dependence 16.7% Severe depression 58% Alcohol Misuse 25.5% Minor depression 87% Severe anxiety 41% One or more disorder 74% DH 2002 Guidelines Focused on psychosis / severe MH Key ideas: Mainstreaming (MH lead) Four quadrants: High / Low addiction severity and mental health need 4 Presentation title - edit in Header and Footer Current guidance: NICE Adult Mental Health Alcohol Drugs Tobacco • Psychosis with coexisting substance misuse: Assessment and management in adults and young people (CG120) March 2011 • Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115) February 2011 • Drug misuse – psychosocial interventions (CG51) July 2007 • Brief interventions and referral for smoking cessation (PH1) 2006 • Psychosis and schizophrenia in adults: treatment and management (CG178) February 2014 • Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care (CG185) Sept 2014 5 Presentation title - edit in Header and Footer • Methadone and buprenorphine for the management of opioid dependence (TA 114) January 2007 • Naltrexone for the management of opioid dependence (TA115) January 2007 • Smoking cessation services (PH10) 2008 • Tobacco: harmreduction approaches to smoking (PH45) June 2013 • Smoking cessation in secondary care: acute, maternity and mental health services (PH48) Nov 2013 NICE guidance – CESMMHI? Alcohol: Tobacco: •for co-morbid depression/anxiety treat the alcohol use first •smoking prevention/cessation in secure mental health settings /secondary care (inc. mental health) •Tailor treatment goals (abstinence/moderation) to take account of co-morbidity Psychosis: Drugs: •ask about CESMMHI routinely •Psychosocial guideline does not specifically cover dual diagnoses •Consider specialist advice from/joint working relationships with specialist SM services •Staff in mental health institutions should ask routinely about drugs use •Health professionals in SM services competent to recognise psychosis •No exclusion on the basis of diagnoses 6 Presentation title - edit in Header and Footer Drug Misuse and Dependence: UK guidelines on clinical management (2007) “…there is still a need for more collaborative planning, delivery and accountability of services for people with comorbidity, including those with mild-to-moderate mental ill-health, early traumatic experiences, and personality traits and Disorders. Further concerns are of the lack of specified core competencies, inadequate assessment and communication between services, and the need for greater integrated care” “The guiding principle should be to match the needs of the patient to the clinical team and its competencies, minimise multiple referrals and movements within multiple teams, and prevent exclusion from services (Raistrick et al., 2006)” 7 Presentation title - edit in Header and Footer CESMMHI – guidance update 2002 Target audience - aimed at commissioners and providers Local definition of CESMMHI, care pathways, interagency protocols Lead clinician/lead commissioner roles promoted Implementation models: SM/AMH develop agreed care pathways supported by liaison worker roles Each sector to provide training input/support to the other 2015 Definition/scope - ‘co-existing’ to include Tobacco and CMI not just severe MHI Landscape - commissioning landscape has changed Terminology – ‘dual diagnosis’ replaced with ‘co-existing substance misuse and mental health issues’ Increased focus on staff competency - mental health services should be competent to respond to presenting substance misuse and vice versa Move away from exclusion by diagnosis and focus on competency to treat – individual should still be offered support for other issues and/or to access appropriate care elsewhere Increased focus on responses to crisis care ‘Collaborative care’? 8 Presentation title - edit in Header and Footer Implications for Addictions providers Involvement at local level in strategic partnership with MH (Commissioner led) Service governance structures that can enable MH needs to be identified and appropriately care-planned Consultation, advice and training to MH providers on substance misuse Staff competent: To assess and identify mental health problems To know when to refer to MH in line with NICE guidance To monitor MH on an ongoing basis To deliver psychological therapies for common mental health problems where addiction severity would be a barrier to accessing IAPT services 9 Presentation title - edit in Header and Footer