Alicia was 19, doing well in civil engineering at university, enjoying social pot more and more. But the affect began to flatten, her quick, cognitive function slowed and she became aggressive to her friends. Her first paranoid psychotic episode had begun and, fortunately, she received good psychiatric care, including medication. She took this for three months, but the side effects proved intolerable and she reverted to using non-prescription drugs and alcohol. Her car left the road at high speed on a bend at 2am one morning.
Dutch (or scotch) courage
People with mental pain naturally seek relief and escape. Drugs and alcohol are close at hand, and often seem more attractive than prescribed medications. Health care workers commonly encounter clients with both mental illness and drug or alcohol addiction; especially young people, sliding down the social scale to homelessness and dereliction.
Not for Service, the explosive report of the Mental Health Council of Australia, strongly recommends ‘that funding to support integrated drug and alcohol and mental health services become a high priority’.
At present mental health services are so stretched they are mostly consumed with providing short-term crisis care. Most drug and alcohol services deal with those problems exclusively and have little space for clients who are patently mentally ill.
Patients who are both mentally ill and have a drug and/or alcohol dependency double-slip, rather than double-dip: they fall between two hassled services with no time or energy for their care.
Why the disconnect?
Mental health workers see this weird disconnect between drug and alcohol services on one hand, and psychiatric services on the other, as a disaster. One former psychiatric nurse puts it this way:
Around the time of moving patients out into the community [when the Richmond Report was implemented in NSW], most of the chronic patients were middle aged and old. Now, with this pot-meds-drugs and alcohol problem, the chronically mentally ill are getting younger and younger. It’s just plain bloody tragic and utterly socially irresponsible.
Here’s the story of another person whose life was affected by these comorbid conditions:
Michael began suffering with mental illness when he was 18. He suffered from lengthy episodes of depression and anxiety over fifteen years. He was prescribed many anti-depressants but each time he ceased the medication, his depression and anxiety returned. He began to think that he would be on medication for the rest of his life.
Michael coped with his mental illness through alcohol and drank very heavily most nights of the week. Because of his anxiety, he felt comfortable in social situations only if he was drinking. The counsellors, psychiatrists and doctors that he had seen had not picked up on his alcohol problem.
It was not until he was 33 that an astute counsellor grasped the full extent of Michael’s alcoholism and convinced him to seek help. He decided to try being alcohol free for one month, then progressing month by month. Michael has now been alcohol free for over five years and his depression and anxiety, while still present, do not need to be treated with medication and instead, can be managed with counselling and cognitive behavioural therapy.
We do not know accurately the number of patients with both mental illnesses and drug and/or alcohol dependencies in Australia: estimates range widely from 20 per cent to 90 per cent of psychiatric sufferers. In Victoria in 2003-2004, just under 50 per cent of clients accessing public mental health services had a drug and alcohol problem as well.
The problem is greater outside metropolitan areas, where the incidence of illicit drug-induced psychotic illness is increasing. In the Northern Territory and in Indigenous communities, the burdens of mental illness and alcohol dependency is immense (Bansemer Report; RANZCP).
When drug, alcohol and mental health disorders coexist, problems multiply. Patients with both disorders have a poorer prognosis. They are more likely to be aggressive, harm themselves and try to commit suicide. Many self-medicate with drugs and alcohol to counter the side effects of prescribed anti-psychotic drugs.
Victorian research found that 67 per cent of those diagnosed with schizophrenia and a drug and alcohol problem have committed an offence. When this happens, the police become the crisis management team, for which they are often not professionally equipped (though many provide humane support under heroic conditions).
Thanks to Bill Leak
Problems with current services
Living with comorbidity [mental illness alongside a D and A problem] actually means being pushed from one service provider to another, not being understood, self-medicating and experiencing a poorer quality of life.
– Australian Illicit and Injecting Drug Users League.
Sorry, no medecins sans frontiers here!
Mental health services are ill-equipped to deal with people with drug and alcohol dependencies; there is a shortage of staff and skill. Drug and alcohol services are also unable to cope easily with the mentally ill. Indeed, sometimes those with mental illness who also have dependencies are actively discriminated against by mental health services.
The Brotherhood of St Laurence states that many mental health agencies declare their services to be ‘drug and alcohol free’! Those coping with dependencies and mental illness therefore often find that they may be treated for either their dependency or their mental illness, but not for both. In consequence, their risk of relapse of either is high.
Under these conditions, it is inevitable that they become non-participatory members of society.
The difficulties are even greater in rural and regional areas where there is an urgent need for supported accommodation. Often there is no safe haven anywhere. Supported accommodation services close on weekends, leaving care to family or other ill-equipped community-based voluntary housing services.
Even when supported accommodation services are available, they are often terribly inadequate. They are filled with people eking out miserable, alcohol-soaked existences in crumby boarding houses, surrounded by others sharing their desperation.
What kind of a society confers this fate on some of its most vulnerable and unfortunate members? If a hurricane were to sweep away their appalling accommodation, as Katrina did in New Orleans, and reveal them in their vulnerability, we would see the same social desperation and neglect as we saw among the American underclass.
So are there policy responses that might clear up this mess?
Drug and alcohol services work in isolation from each other and the drug and alcohol treatment skills of mental health workers are not sufficiently developed. A capacity to work with drug and alcohol issues should be part of a mental health worker’s core skills. Currently it is not.
– Health Services Union
Mental health services should be able to effectively treat comorbid conditions, both at a societal and individual level. Although successive reports have recommended greater coordination between mental health and drug and alcohol services, this has not yet been translated into effective policy.
Co-operation does occur, but usually it is ad hoc and depends on the good will of health workers who are prepared to step out of the boxes created for them by current policy. Governments of both political stripes and at all levels have run away from devising effective policy responses. Instead they commission more reports. Reports, however, rarely lead to action.
So what is the story?
Many problems stop mental health and drug and alcohol services from integrating. Some of these relate to the perceptions and attitudes of different health care professional groups.
For example, each service operates with very different philosophies, affecting the way issues are conceptualised, the language used and the treatment paths followed. It means that patients with comorbid conditions are left, at the point of maximum vulnerability, to chart their own path through the labyrinthine system (or, most frequently, out of it).
The Royal Australian College of General Practitioners commented in their submission to the Senate Select Committee on Mental Health last year that general practitioners are well placed to recognise and manage these problems. That may be true for simpler cases – indeed, in rural areas there is often no one else to deal with them, and responsibility falls solely to the GP.
In order to do this effectively, however, general practitioners need to be equipped with the skills of dual diagnosis and the treatment of mental illness and drug and alcohol dependency. These are areas that are currently absent in the education of all health professionals. Many general practitioners feel they are unable to provide their patients with appropriate care, one commenting:
I am very limited by what I can do for mentally ill patients – I cannot even diagnose schizophrenia for someone that is clearly suffering from this problem. Diagnosis must be done by a psychiatrist, but when I try to refer such patients on, I find that most of the available psychiatrists in this area have closed their books and are not seeing new patients. What can I do? I have to wait until this person reaches a crisis point and only then can I admit them into a hospital. This is a terrible situation to be put in – for both of us.
Late last year, health ministers across Australia used the report, Not for Service, as an occasion for ritual breast-beating and buck-shifting, but have studiously avoided any commitment. Most lobby groups however, recognise that leadership by the federal government is necessary to make progress in mental health. On present indications, they will be waiting a long time for any tangible improvements.
The AMA believes that to spearhead the integration of mental health, drug and alcohol services, they should be brought together as part of the national chronic disease strategy.
This initiative (broad almost beyond imagining when one considers the sweep of chronic disease) would help coordinate education, encourage joint training, and channel research funding towards the problem. Whether mental health would get a fair go in such an arrangement is anyone’s guess.
Australia’s attitude to the mentally ill is pathetic, the kind of response which might be expected from an economically disadvantaged nation where development is a serious challenge. Most Australians have achieved John Howard’s goals, set at the commencement of his prime ministership, of being relaxed and comfortable. Whether the nation has any brain or heart left is a moot question. We might commence our recovery toward becoming a compassionate nation by attending to the needs of one of our most vulnerable groups – those who are mentally ill and drug and alcohol dependent.
Recommendation 1: That firm figures of the numbers of people affected by comorbid drug, alcohol and mental health disorders be devised so that the problem can adequately be treated by services.
Recommendation 2: That mental health services and drug and alcohol services work more closely together and that joint services are made more readily available.
Recommendation 3: That funding to support integrated drug and alcohol and mental health services become a high priority as recommended in Not for Service, the recent report from the Mental Health Council of Australia.
Recommendation 4: That the supported accommodation services available in rural and regional areas be accessible 24 hours a day, seven days a week.
That appropriate accommodation services for those with comorbid conditions be adequately funded and administered.
Recommendation 5: That, as part of their training, general practitioners are trained to deal with the complex issues surrounding comorbidity of drug and alcohol dependency and mental illness.