A 'dual diagnosis' community psychiatric nurse service in Lanarkshire: service innovation

AIMS AND METHOD

We established two ‘dual diagnosis’ community psychiatricnurse posts within community mental health teams in Lanarkshireto improve the service care for individuals with comorbidity.A questionnaire-based evaluation of the service over a 2-yearperiod was conducted.

RESULTS

Comorbidity was under-reported by community mental health teamsand under-referred to specialist addiction services. The presenceof new specialist nurses enhanced the detection of comorbidity,improved staff perceptions of working with patients that misusesubstances, and was associated with a clinical and functionalimprovement in patients over 2 years.

CLINICAL IMPLICATIONS

Our findings support the recent trend to provide integratedcare for comorbid service users within main-stream mental healthservices, and suggest a model of service delivery that mightbe more widely developed to address the concern that such users‘fall through the gaps’ between services.

Introduction

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Introduction

It is widely accepted that severe mental health disorder andsubstance misuse are strongly associated in community and serviceuser populations. This view is supported by studies in boththe USA and the UK. Regier et al (1990) found that 47% of peoplewith schizophrenia and 32% with bipolar disorder misuse drugsor alcohol. Substance misuse was found by Menezes et al (1996)in 36% of psychotic service users, and by Cantwell et al (1999)in 37% of those with first-episode schizophrenia.

Individuals with comorbidity in general are more likely thanthose with mental health disorder alone to show violent orsuicidal behaviour (Swanson et al, 1999), be homeless (Drakeet al, 1989), be admitted to hospital and make greater useof emergency services (Bartels et al, 1993). They may be moredifficult to treat due to chaotic lifestyles and poor compliancewith medication (Cantwell & Harrison, 1996) and may tendto ‘fall between the cracks’ of treatment and care (el-Guebaly, 2004).

Several national guidance documents have highlighted the serviceneeds of individuals with ‘severe or enduring mentalhealth problems’ who misuse drugs or alcohol (National Health Service Scotland, 1997; Clinical Standards Board for Scotland, 2001; The Scottish Government, 2003).Currently, because of boundary issues between different services,and busy case-loads, these people can face rejection by services,or be passed between services repeatedly with what has beencalled ‘the ping pong effect’. Mental health servicesmay see substance misuse as more salient than comorbid mentalhealth problems and pass such individuals on to addiction services.On the other hand, addiction services may feel disconcertedby their coexisting mental disorder, deskilled and unqualifiedto take them on.

This discontinuity in care has been widely discussed and a consensusis emerging across the UK regarding best practice in caringfor individuals with mental health and comorbid substance misuseproblems. Two national reports have recommended a ‘mainstreamresponsibility’ for mental health services (Department of Health, 1999;Appleby et al, 2001). Three main patterns of treatment constitutethe sequence of care by mental health services and addictionservices (el-Guebaly, 2004). These are: (a) sequential treatment,(b) parallel treatment, and (c) integrated treatment. The lastone provides the unified and comprehensive treatment programmeswithin one service for individuals with concurrent disorders.We believe that integrated treatment may be best suited tothe needs of people with comorbid substance misuse and severemental disorder.

Setting up the service

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Setting up the service

We describe the setting up of an integrated service and theevaluation of its impact on staff and service users in twoof the eight community mental health teams (CMHTs) in Lanarkshire(Hamilton and Cumbernauld). A specialised dual diagnosis communitypsychiatrist nurse post was positioned within each of theseteams to provide a service for individuals with substance misuseand comorbid ‘severe or enduring mental health problems’(almost all had established psychotic illness). The experiencedcommunity psychiatrist nurses appointed were already servingat G grade level within the Hamilton and Cumbernauld teams.They received training in addiction studies at diploma level.Their remit included:

providing a clinical service within their own multidisciplinaryCMHTs
conducting assessment of needs throughout Lanarkshire
helping to conduct an evaluation of the impact of their serviceon colleagues and staff within their own CMHTs.

Clinical service (Hamilton and Cumbernauld)

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Clinical service (Hamilton and...

Main responsibilities of dual diagnosis community psychiatristnurses included (in ascending order of their clinical involvement):

signposting colleagues to existing resources to help them withtheir clinical work
providing consultation on ongoing cases
providing assessment of service users followed by appropriateadvice on clinical management
time-limited joint work withCMHT colleagues
taking over care of very complex cases.

Needs assessment (Lanarkshire-wide)

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Needs assessment (Lanarkshire...

Our clinical impressions prior to the study were that addictionteams were not engaging many individuals with comorbid severemental disorder, and that CMHTs were under-reporting or under-referringsubstance misuse problems among their service users. To testthese impressions, National Health Service addiction teamsacross Lanarkshire (predominantly trained psychiatric nurses) were asked by questionnaire to estimate the prevalence of majorpsychiatric diagnoses among their service users. Also, staffin the six Lanarkshire CMHTs not hosting a dual diagnosis communitypsychiatrist nurse were asked by questionnaire to estimatethe number of their ‘severe or enduring’ serviceusers with coexisting alcohol or drug misuse, and the numberthat would benefit (in their opinion) from referral to specialistaddiction services. They were also asked about the proportionof individuals they had actually referred to such services,and about potential barriers to referral (they could choosefrom among four barriers provided in the questionnaire).

Evaluation (Hamilton and Cumbernauld)

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Evaluation (Hamilton and...

Locally in the Hamilton and Cumbernauld CMHTs (served by thedual diagnosis community psychiatric nurses), the same groupof staff was asked to identify service users with problem substancemisuse in 2004 and again in 2006, to determine if any personsnot identified in 2004 (and still on case-load) were identified2 years later. New discharges and new referrals since 2004 were excluded. Therefore, the comparison involved the same serviceuser cohort across 2 years.

Staff perceptions of working with individuals misusing alcoholand drug were assessed using two validated instruments: theAlcohol and Alcohol Problems Perception Questionnaire, andthe Drugs and Drug Users Problems Perception Questionnaire.These instruments break down perceptions into seven domains(Tables 1 and 2). Baseline data were collected in 2004 andquestionnaires were repeated in 2006, to detect any changesin staff perceptions coinciding with the presence of dual diagnosis community psychiatric nurses in their teams.

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Table 1. Alcohol and Alcohol Problems Perception Questionnaire results

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Table 2. Drug and Drug Users Problems Perception Questionnaire results

Improvement in the measures above would mean little if serviceusers did not also benefit. To gauge this, the clinical statusof Hamilton and Cumbernauld service users was assessed in 2004and again in 2006 using the validated Christo Inventory forSubstance misuse Services. This scale measures substance misuseand social functioning. Individuals whose clinical care was taken over at any stage by the dual diagnosis nurse were excluded,the intention being to detect clinical improvement achievedvia their impact on staff colleagues. The results would reflectthe key worker’s own assessment of change in their patients.A reduced score represents a clinical improvement; the samecohort (n=65) were assessed in 2004 and again in 2006.

Results

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Results

Needs assessment (Lanarkshire-wide)
Lanarkshire addiction teams had 1212 service users on case-loadin 2004. Of those, 19 (1.6%) were reported to have schizophreniaor other psychoses, and 7 (0.6%) bipolar affective disorder.

Lanarkshire CMHTs not hosting dual diagnosis community psychiatricnurses had 804 service users with ‘severe or enduring’mental health problems in 2004. Of these, 156 (19%) were deemedto have a substance misuse problem but it was thought thatonly 108 (13%) ‘would benefit’ from referral tospecialist addiction services. However, only 73 (9%) had actuallybeen referred. Community mental health team staff were presentedwith four potential barriers to referral and asked to comment(in general) on the relevance of each for their patients. Ofthe 33 staff questioned, 21 (64%) agreed that ‘some individualsrefuse to consider referral,’ 24 (73%) that ‘someindividuals would be unlikely to engage with addiction services,’19 (58%) that ‘some individuals are unable or unwilling to acknowledge their substance misuse problems,’ and12 (36%) agreed that ‘the addiction team model wouldbe unlikely to provide the kind of input needed.’

Evaluation (Hamilton and Cumberland)
Within Hamilton and Cumbernauld CMHTs (hosting community psychiatric nurses) there was a striking increase over the 2-year periodin the number of individuals with comorbid mental health andsubstance misuse problems identified. Combining results forboth teams, of the 453 users in 2004 who were still in contactwith the CMHTs in 2006, 71(16%) were initially deemed by theirkey workers to have ‘dual diagnosis’. From thissame group, an additional 33 users had been further identifiedby 2006, representing an increase in identifications by 46.5%.

Tables 1 and 2 show changes in CMHT staff perceptions overthe 2-year period of their work with service users misusing alcohol and drugs (in Hamilton and Cumbernauld). A lower scorerepresents an improvement in the staff member’s perceptionsof working with substance misusers. For working with problemdrinkers, there were significant changes in the domains of‘role adequacy’ (P=0.025), ‘role legitimacy’(P=0.019), ‘role support’ (P=0.001), and in totalscore (P=0.002). For problem drug users, there was a significantchange in the domain of ‘role support’ (P=0.000)and in total score (P=0.006).

Table 3 Shows the Christo Inventory results for 2004 and 2006.There was a significant improvement in service users’clinical assessment results over this period (P=0.001).

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Table 3. Christo Inventory for Substance misuse Services results

Discussion

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Discussion

The main limitation of the evaluation was the lack of controlgroups for service users and staff. Community mental healthteam service users reported on here included only those with‘severe or enduring mental health problems’. Inview of comorbidity levels reported in the literature, it islikely that people with major psychiatric disorder were underrepresentedon addiction service case-loads across Lanarkshire.

It is likely that CMHT staff are underreporting alcohol anddrug misuse problems among their service users. Even if identified,such people are often not referred to specialist addictionservices for a variety of reasons. Community mental healthteam staff in Hamilton and Cumbernauld improved their performancein detecting these problems in their patients during the period when they were supported by the dual diagnosis community psychiatricnurses. If we speculate that the other Lanarkshire CMHTs mightsimilarly improve in their detection of comorbidity, the discrepancybetween the number of their service users with comorbidityand the number referred for specialist treatment would be evenwider than those reported (19% and 9%, respectively). In Cumbernauldand Hamilton, CMHT staff perceptions of working with people with comorbidity had significantly improved over the 2-yearperiod. Also, there was evidence of a general clinical improvementamong service users with comorbidity in the same period, whichwas achieved indirectly via the dual diagnosis nurses’impact on staff colleagues (since their own direct clinicalwork was excluded from the evaluation).

Overall, dual diagnosis community psychiatric nurses were successfulin improving the quality of care for complex and vulnerableindividuals and their full integration within the CMHTs wascrucial in providing the necessary level of staff trust andsupport. By not positioning posts externally (for example withinaddiction teams), unnecessary cross-boundary tensions and theso-called ‘ping pong effect’ could be avoided.We would argue that the outcomes reported here support the‘mainstream’ approach to service provision forindividuals with comorbidity.

Acknowledgments

We thank Andrew McAuley of Lanarkshire Alcohol and Drug ActionTeam for his assistance in preparing the statistical tablesfor presentation, and Scott Lees and Susan Hughes, CMHT teamleaders in Cumbernauld and Hamilton respectively, for theirsupport for the project.

References

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