Post-its from Practice:
Double check for dual diagnosis: Don't forget mental health in people who drink (Mar 2012)
A very upset colleague of mine called Ruth, was in my room saying, "What have I done? How could this have happened, I did all they told me to do? I hope John will be OK!" I got her to sit down and tell me what was going on. It turned out that she had sent John; a patient of hers to see the psychiatrist to get an opinion, as he was getting more depressed and had marked suicidal ideation.
John was 56 years old, single, had worked all his life in the building trade and had drunk between 60-100units/week for most of the past 30 years. He had detoxed on a number of occasions, but had not "felt right" when he wasn't drinking. He had been helped by fluoxetine for the past 3 years but his mood had deteriorated after the death of his mother several months ago, and Ruth explained to me that, she was reluctant to change his anti-depressants without specialist advice. She had also wanted psychological support for John, but the local community IAPT service will not see people with drug or alcohol problems, so she could only access counseling for John through the mental health services.
Ruth recalled that it had taken a few weeks to get John assessed by a psychiatrist, who then said it was a) impossible to "help" him until he stopped drinking and b) anyhow his depression would probably go away if he stopped drinking. Although both John and Ruth were anxious about this course of action, they were both keen to get help and so agreed. John was lucky (sic) and got a place in detox quickly, due to a cancellation. Physically he coped well, but his mood got worse. On completion he was discharged back into the community.
When I spoke to Ruth last week, John had been discharged from detox for just four days. She had just been rung by the local hospital to say he had been admitted the previous night after trying to hang himself and he was now going to be transferred under section to the psychiatric unit.
Ruth and I discussed what other approaches could have been used. She felt she had failed him and I first reassured her that she had acted well. She had treated John properly and had worked to her level of competence and confidence, with compassion. She had asked for help when she needed it - and for me this was when the mistakes started happening. Firstly, for it to take weeks to get an appointment for someone that the GP is worried about because they are suicidal and then to say they can't offer anything until the patient stops drinking, I feel is simply wrong, and it seems as if this is based on opinion rather than evidence.
We know that psychiatric illness can precipitate, as well as worsen; drug and/or alcohol problems and drug and/or alcohol use can lead to psychiatric symptoms. Over the last 20 years we have recognised higher levels of dual diagnosis and there is now strong research evidence that shows the rate of substance misuse is substantially higher in the mentally ill than in the general population, ranging from 35% to 60%. These rates are even higher in in-patient and emergency settings.
Also, nearly 75% of Drug Treatment Population and over 85% of the Alcohol Treatment Population were found to have mental health problems; mostly depression and anxiety disorders as well as psychosis.
As drug and/or alcohol use is therefore usual rather than exceptional in the mentally ill, the provision for dual diagnosis should be central to mental health care and the drug and alcohol interventions required by this group should be integrated or "mainstreamed" into mental health services, and not dismissed as this psychiatrist seemed to do.
We will never know what would have happened if John had been given bereavement counselling, a change of antidepressant and on-going help from the mental health services after his primary assessment, but I suspect he would be in a better state than he is now. And don't forget, even if linked to payment, never to force people into a detox they don't feel they can do, always be aware of patients' underlying mental health when they undertake one by choice, and be ready for a problem that may emerge when reducing.