This is part 1 of a series of posts in relation to dual diagnosis, an issue that has long been part of national dialogue when it comes to mental health practice. Witnesses gave evidence in Ireland’s national parliament in advance of the launch of a new clinical model of care. First up, Mad in Ireland’s Dr. Liam MacGabhann, associate professor in mental health practice, from Dublin City University.
I have been involved in or have been leading out, or both, on dual diagnosis service development, education, research and community capacity building since 1999 in another jurisdiction and since 2004 in Ireland.
I led the first and, to date, only national study on dual diagnosis management in 2004 and have been researching and developing practitioner and community capacity in this area to the present day. With the Dublin North, North East Recovery College and community partners, we have been actively developing community capacity to respond to dual diagnosis since 2019. I am on the national dual diagnosis clinical programme subcommittees for capacity building and evaluation. I have submitted a brief overview to the committee.
In Sharing the Vision, dual diagnosis is defined as “the coexistence of mental health problems and significant substance – drug and alcohol – misuse problems in an individual”. This broad definition is helpful and in keeping with international evidence on how to encompass and respond to all the people who experience these issues. There are other narrower definitions that are not useful regarding service development or service user experiences and that have historically been used divisively to deny effective systemic treatment to this client group and service users, serving only to double-stigmatise them. However, the narrower medical definition can be helpful where access to specialist services warrants specified criteria. Internationally, the number of people warranting specialist integrated dual diagnosis care is minimal, at around 10% of those needing intervention for substance use and mental health problems combined.
We finally have a policy mandate in Sharing the Vision to respond to people with identified complex needs associated with their dual diagnoses. I would like to note a couple of points in this regard. Approximately 90% of clients will not need, or be able to avail of, specialist services identified in the model of care. They will require their needs to be met by generic statutory addiction and mental health teams and community organisations. The clients requiring dual diagnosis interventions will not be new; there will not be a new avalanche. They are already clients of our services, only not yet receiving the care they need. We now have a policy mandate, though non-mental health governed services may now attempt to absolve themselves of responsibility, as we have seen before.
We have known the challenges for dual diagnosis and the solutions for many years, and there is no new evidence to suggest otherwise. In this statement, I purposely allude to Irish publications to demonstrate we have home-grown evidence commensurable with international evidence. Interestingly, as can be seen from the three sample reports, namely, the Health Research Board report, the mental health reform report and our research involving the communities of Finglas and Cabra, there is consensus on what we have to do if, conservatively, 50% of clients using our mental health, community health and addiction services are to begin to have their needs met. As an example and reminder, members will see the illustrated diagram in their briefing statement. We have seen that we will now have a national clinical programme. We have seen that there is now a joined-up policy, which is, in relation to the Government response, very helpful. We have seen communities respond. The statutory services are slow to respond to the mandate and the required evidence base.
We can see where policy has responded. The dual diagnosis model of care has been developed and the clinical programme is about to be piloted. We can see where non-statutory community organisations with attempts to engage statutory services have started to collaborate and engage in capacity building to enable community responses to dual diagnosis, though there has been little else as yet.
There are three pilot sites where the clinical programme is to be implemented, and much of the focus at these sites is on the recruitment of the specialist teams for the 10% of people – a minor part of the required systemic response to dual diagnosis. There is a danger that services will wait for outcomes from the pilot sites in a couple of years and wait for funding etc. Neither is necessary. Indeed, to wait is to perpetuate the problem of unmet needs for 50% of our service users when we know already what we have to do. We have already developed, and in some cases are still providing, evidence-based dual diagnosis services. Community networks are already engaging in basic dual diagnosis awareness programmes. We now need all relevant services to engage in systemic preparation, for example, following the training needs analysis by the national programme for dual diagnosis, and to ensure all relevant stakeholders now have access to the required learning processes so they are all equipped to provide an open door with joined-up signposting to the required integrated service provision. “No wrong door” does not mean a one-stop shop. It means that wherever a person in a community presents with complex substance use, mental health and other needs, this door will open the way to integrated care.
There are significant structural, cultural, territorial and educational barriers to overcome. These can all be overcome through engaging in the initial capacity-generating possibilities for all relevant service providers. That will take time.
The model of care does not need to wait for pilot sites to report back, remembering we already know what needs to happen. The solutions are already beginning to happen, though they need bolstering. Statutory services need to engage more. The resources to respond to 90% of people with dual diagnosis are not insurmountable, given that many of the requirements are to capitalise on whatever is already established and free up interagency collaboration.
The committee is hearing from a person who knows what they need, from a community service that already provides dual diagnosis response and a service that provides the international gold standard approach – case management-dual diagnosis co-ordination – to ensure a systemic response can meet inevitable complex needs. I hope I have been able to signpost with an overview that the solution is already at hand, though needs a push if we are to respond now effectively to dual diagnosis in this land.