1. Managing alcohol to support recovery in Mental Health: How big is the problem locally Dr Chris Daly Consultant Addiction Psychiatrist GMW

2. Alcohol related death rates per 100,000 population males and females regions of England 2010 Male (Confidence Intervals) Female (Confidence Intervals North East22.6 (20.1-25.0)10.2 (8.6-11.9) North West21.3 (19.8-22.8)11.7 (10.6-12.8) Yorks and Humber16.5 (15.0-18.0)7.4 (6.4-8.4) East Midlands16.3 (14.7-17.8)6.8 (5.8-7.8) West Midlands18.6 (17.0-20.2)9.4 (8.4-10.5 East of England11.7 (10.5-12.9)5.5 (4.7-6.2) London15.3 (14.0-16.6)6.4 (5.6-7.2) South East13.0 (12.0-14.1)6.0 (5.3-6.7) South West14.3 (12.9-15.6)6.0 (5.2-6.9)

3. Number of alcohol related deaths by country and region of England 2000-2010

4. Number of female alcohol related deaths by county and region 2000-2010

5. Comorbidity alcohol or drug use in Community mental health team Illicit non prescribed use in the past year Number ( percentage) Total= 282 Any drug use87 (31) Cannabis71 (25) Sedative21 (7.4) Crack cocaine16 (5.7) Heroin11 (3.9) MMDA (ecstacy)11(3.9) Cocaine8 (2.8) Opiate substitute4 (1.4) Alcohol harmful use72 (25.5) Harmful alcohol or drug use124 (44) Weaver et al. 2003

6. Comorbidity psychiatric illness in people with drug or alcohol problems Number ( percent) total = 62 (alcohol) Non substance induced psychotic disorder12(19) Personality disorder33 (53) Severe depression21 (34) Mild depression29 (47) Severe anxiety20 (32) Psychiatric disorder present53 (85) Weaver et al. 2003 Psychiatric disorders are common in people with alcohol problems

7. COSMIC Rates of dual diagnosis in CMHT/ SMS in London, Sheffield and Nottingham. Detection of alcohol misuse by CMHT and psychiatric illness in SMS poor (sensitivity 20-38%). Prevalence co-morbidity higher in alcohol than drug using patients. 21% CMHT with alcohol problems had been seen by alcohol services in previous 1/12 Similar proportion D&A patients seen for their co-morbid mental health condition Alcohol service users rates of psychosis 24x general population rates Conditions untreated e.g personality disorder Overall rates co-morbidity 44% across CMHT/ SMS

8. Dual Diagnosis in Manchester (Schulte and Holland 2008) Practitioners perception of prevalence Of patients in treatment proportion with dual diagnosis as follows: Assertive outreach team 71% Substance Misuse Services 56% Psychiatric Inpatients 56% CMHT 28% Overall 46% across all services higher than other data sets

9. Theories on co-occurrence. Self-medication – little support – of psychiatric symptoms: psychosis, dysphoria, negative symptoms – of prescribed drug side effects: motor side effects (extrapyramidal) – of illicit drug effects Stress model – Neurobiological vulnerability interacts with environmental stressor (substance misuse) Accumulative risk factor – People with scz have risk factors for SUD e.g. poor cognitive, social, vocational function, poverty ‘ comorbid addiction vulnerability’ i.e. dysfunction in reward circuitry – abuse substances because they find them rewarding and fail to anticipate or respond to the negative consequences

10. 11 Effect on Course Suicide rates Violence / Aggression Early Onset, early hospitalization Prolonged course more frequent admissions Treatment non compliance Poor clinical outcome –once abstinent have a better prognosis than other frequently hospitalized patients with SMI Bipolar patients with SUD more likely to have mixed manic/ rapid cycling Secondary alcohol problem more likely to stop drinking or episodic drinking Increasing physical/ social problems

11. s Hunt et al 2002 Schiz Res 54:253

12. Local Data: Length of Stay (Holland et al ) All Trust Wards Drugs & Alcohol Care PlanNo Drugs & Alcohol Care Plan Mean Length Of Stay99.350.4 Median Length Of Stay30.515 All Adult Wards (including Safire, PICU, Anderson, Rehab) Drugs & Alcohol Care PlanNo Drugs & Alcohol Care Plan Mean Length Of Stay102.341.3 Median Length Of Stay28.57

13. JAMA, 2004

14. Challenges in Systems Commissioning in bunkers. Lack of specialist clinical input in some commissioned SMS. Failure to consider gaps in provision explicit roles in relation to dual diagnosis for SM/MH services. Busy work-loads and increased exclusion criteria retreat from mainstreaming. Common mental health problems in dual diagnosis excluded from treatment services.

15. Dual Diagnosis Good Practice Guide Mainstream responsibility mental health services Specialist teams / workers coworking with other services ACT all trained in dual diagnosis Adequate numbers of staff in inpatient,CMHT Crisis services Mapping local need, project teams, definitions CPA and care pathways Local policies eg inpatients, training needs

16. Dual Diagnosis Manchester Mainstreaming meet NHS LA Standard 1 Dual diagnosis link workers increasing coverage Adult Care Group confirmed aim full recruitment and development of roles in adult services Clinical practice leads inpatient services N/C/S Old age services Maureen Rackshi lead Screening and Brief Intervention

17. Dual Diagnosis Manchester Substance Misuse Services BHU, MDS, CAT all developed dual diagnosis capacity MI CBT training Dual Diagnosis Service Mark Holland, Ian Wilson, Maureen Brannan 7 clinics per week, training and support as well as strategic function Public Health Information office Liz Burns, Ian Tyre Specialist Inpatient provision- Chapman Barker Unit