Chapter 14 - Dual diagnosis 'The expectation not the exception'
Over the last twenty years the number of people with mental
illness who also have a substance abuse disorder has been increasing. Service
providers now report dual diagnosis is the 'expectation not the exception' in
treated populations. Tragically,
many of those affected are young.
This chapter explores the experience of people with
co-occurring mental and substance abuse disorders and identifies some of the
obstacles to service provision for them. Reflecting on some of the good models
described or proposed during the inquiry, the chapter then suggests a better
and more comprehensive way of caring for this vulnerable, high prevalence
The nature of the problem
Dual diagnosis is a term that describes the situation
of a person experiencing two or more pathological or disease processes at the
same time. Other terms for this
are co-occurring disorders or co-morbidity.
There are two main clinical interpretations of the term
'dual diagnosis'. The first refers to the co-existence of intellectual,
developmental or physical disability with mental illness. The other describes the experience
of having a mental illness along with a substance abuse disorder. This latter
definition, which is the one applied in this report, has the longest history
and is most widely used in Australia.
People with dual diagnosis disorders are not a
homogeneous group—substantial diversity exists in the combinations of
disorders, in their severity and their individual treatment needs. Eastern Hume
Dual Diagnosis Service advises there are three basic categories used for
clinical assessment of co-occurring disorders:
substance use disorders co-occurring with
high-prevalence, low-impact mental health disorders (such as anxiety and
substance use disorders co-occurring with
low-prevalence, high-impact mental health disorders (such as psychosis and
major mood disorder); or
any mental health disorder co-occurring with
either substance abuse or substance dependence.
Substances used by people with dual diagnosis may
include prescription drugs or other substances, whether legal or illegal,
including alcohol, opiates, stimulants and cannabis. The most common form of
substance abuse disorder is alcohol dependence. Other legally available substances
are solvents and petrol, ingested by 'sniffing'.
Tobacco use, although frequent among people with mental
illness, is not treated as part of the dual diagnosis spectrum.
Self medication and dual diagnosis
Treatment of substance abuse and mental health disorders
is complicated by the fact that alcohol or drugs are often used by mental
health consumers to alleviate the stresses of their mental illness, including
psychotic systems, depression or to deal with the side effects of medication or
the stigma of being mentally ill.
The Jesuit Social Services Connexions program advised
that: 'Young people with mental illness take drugs for a multitude of reasons
including to treat their disorder, to reduce anxiety, peer group activity' and
to 'assume an identity as drunk or drugged rather than mad because this is
socially acceptable'. A Jesuit Connexions
case study reports:
Clients participating in group program for young people with
coexistent mental health and substance abuse misuse problems discussed the
perceptions they encountered with having dual diagnosis. They felt they were
commonly seen as criminals, junkies and worth less than others. One client said
he would prefer to be seen as drug affected than labelled a 'nutter'.
Professor Ian Webster advised that alcohol abuse can
alleviate the discomfort of deprivation and homelessness, making it difficult
to determine whether mental illness is the cause or the consequence of the
People with mental
illness drink alcohol to control their feelings and thoughts, alcohol “blots
our time” it “takes time away”, and it is not always the primary cause of
person’s circumstances. And when you have chronic pain from an early injury or
chronic disease, alcohol is not a bad analgesic when no one will refer you to a
pain clinic. If sleep is hard to get when living rough, or when trying to sleep
in a crowded dormitory—alcohol is a cheap sedative.
Australian Injecting and Illicit Drug Users League suggested that illicit drugs
are often used by people with severe psychotic disorders to control symptoms,
and to counteract the side effects of prescribed medications:
self-medicate by using illicit drugs to manage the symptoms of their mental
health problems. Anecdotal evidence suggests the effects of heroin and cannabis
are 'helpful' in peoples attempts to focus away from the distress and pain of
hearing voices (auditory hallucinations), and the effects of cocaine and
amphetamine in counteracting the extreme sedation and lethargy induced by anti
psychotic medications, and negative symptoms.
The Centre for Mental Health Studies commented on the high level of
substance abuse among people with depression:
People with depression often respond to everyday situations with
a negative interpretation. Symptoms of depression also include low mood, loss
of interest in activities, people or places and loss of energy which makes them
feel terrible about themselves and the world they live in. Many people then
turn to alcohol and drugs for temporary relief.
The medical contraindications of self-medication are
that dual diagnosis sufferers may be less compliant with prescribed treatment
regimes. Intravenous drug
injection makes people with co-morbid conditions more vulnerable to blood borne
infections such as AIDS and Hepatitis C.
Moreover, the 'drug cultures' surrounding illicit substance use often means
that sufferers, particularly dual diagnosis youth, are both less acceptable to,
and less inclined to access, standard support structures provided by mental
Involvement with illicit drugs also brings the
likelihood that people with dual diagnosis will engage in other illegal
activities to support drug habits, bringing them into contact with the criminal
Contact with the criminal justice system
Studies have shown that dual diagnosis sufferers come
into contact with the criminal justice system more often than people with a
mental health disorder only.
Police are the first point of contact with the criminal
justice system for people with dual diagnosis. The committee received strong
representation from the Police Federation of Australia that police officers are
inadequately prepared to deal with the high level of need exhibited by dual
diagnosis sufferers in the community. These people end up in custody, then
prison, rather than receive appropriate care.
The Drug Action Information Exchange (DAIE) reported on
the situation in the Illawarra:
Police within the Illawarra are continually confronted with
members of the public who are displaying severe symptoms of mental illness.
Police acting within the guidelines of the Mental Health
Act will transport the patient to a proclaimed hospital for assessment. On
numerous occasions the resulting assessment diagnoses a drug induced psychosis.
The end result is the patient being released and left with the Police to deal
with. Police do not have the training or resources to deal with those patients.
If left alone, they are a danger to themselves, if left with friends or
relatives similarly those people are now in danger. Police do not have access
to drugs which may be able to sedate the person and further do not have the
facilities to hold them for any length of time. The persons are inevitably
released out onto the street where they commit offences and then are criminally
Substance use has been identified as an important
contributor to the risk of mentally ill people engaging in violent crime. The Victorian Institute of Forensic Mental Health cited recent research that revealed:
Just as substance abuse alone is a significant risk factor for
violence, those who have both a substance abuse or dependence disorder and a
major mental illness (i.e., those with a so-called dual diagnosis) also have
been found to have an increased level of risk for violence. Dual diagnosis has
been associated with high rates of violence and criminal behaviour.
The rate of criminal conviction for persons with
schizophrenia with substances abuse problems was found to be 68.1 per cent, compared
to those without substance disorders at just 11.7 per cent.
Research conducted at the
Thomas Embling Forensic Hospital found that 74 per cent of mentally ill offenders have a
lifetime substance abuse disorder and 12 per cent have a current substance
abuse or dependence disorder. A
breakdown of offenders in the criminal justice system indicated that:
30 per cent of male prisoners and 50 per cent of
females had a diagnosable mental illness before entering the system;
around 40 per cent of women reported problems
with alcohol abuse prior to incarceration, and 60 per cent used illicit drugs;
illicit drug use for men was at the same rate
for women, but alcohol use had been higher, at 50 per cent.
disproportionately high number of these offenders are young. The Youth Mental Health Coalition reports that
over 30 per cent of the total prison population is under twenty five years of
age. Of these, four out of five have been incarcerated for offences relating to alcohol and other drug use; two in five meet
the diagnosis for personality disorder and one in five have attempted suicide.
The Centre of
Social Justice records that untreated mental illness and drug addiction are
also significant predictors of recidivism.
A study of Thomas Embling Hospital inmates confirmed that concurrence of mental illness and
substance abuse exponentially increased the risk of recidivism compared with
prisoners who had only one or the other disorder.
submitters contended that the combination of a 'tough on drugs' approach in law
enforcement and 'zero tolerance' treatment regimes with under-funded service
models for dual diagnosis is driving more people with mental illness into the
criminal justice system. Jesuit Social Services made a direct
correlation between the absence of adequate services, the growing incidence of
self-medication and this exponential growth:
Much of the recent
dramatic increase in the Australian prison population can be explained by the
relationship between untreated mental health needs, subsequent illegal use of
drugs as a form of self-medication, and the eventual intervention by
instrumentalities of the criminal justice system.
The Centre for Social
Justice noted that being in gaol significantly reduces any prosect for symptom
management and recovery. The 'zero tolerance' approach to alcohol and drugs in
the penal systems of most states means that prisoners are expected to go 'cold
turkey' without any assistance.
Moreover, prisoners have no access to Medicare. These factors contribute to poorer
treatment outcomes for prisoners with dual diagnosis.
The extent of the dual diagnosis problem
noted in the introduction, expert opinion is that dual diagnosis is the
'expectation not the exception' for people receiving treatment for either a
mental illness or a substance abuse disorder. Studies have shown that having
either a mental health or a substance use disorder substantially increases a
person's risk of developing the other disorder. Any
increase in mental health problems therefore reaps a related increase in
substance abuse disorders, and vice versa.
evidence confirms that substance abuse among those with mental health problems
is pervasive. Submissions cited
the findings of the 1997 Australian National Survey of Mental Health and Wellbeing (NSMHW), a household survey which assessed 10 641
respondents for symptoms of high prevalence mental health disorders, including
substance disorders. The survey found a high correlation between mental
illnesses and substance abuse disorders, so that in any 12 month period:
9.7 per cent of the population met criteria for
an anxiety disorder;
7.7 per cent met criteria for a substance use
5.8 per cent met criteria for an affective
The NSMHW concluded that one in four persons with an
anxiety, affective or substance use disorder also had at least one other mental
disorder, so that one in four of the persons with one of the disorders also had
one of the other disorders (such as an anxiety and affective disorder, or an
anxiety and a substance use disorder).
The study also found that those with low prevalence disorders, such as
schizophrenia, are most likely to have a substance abuse disorder. However, given
the high prevalence of anxiety and depression, the majority of cases of dual
diagnosis occur in people with these disorders.
The Black Dog Institute reported that the growing
incidence of both depression
(high prevalence) and bipolar disorder (low prevalence) has contributed
significantly to an overall increase in 'co-morbid' and secondary psychiatric
remains the most prevalent substance abuse disorder for males, but mental
disorders are more prevalent as a percentage among alcohol dependent women.
Figures overall indicate that alcohol dependent people are 4.5 times more
likely to have an affective or anxiety disorder than other Australians, whereas
cannabis dependent people are 4.3 times as likely to do so.
Since the late eighties, the age profile of
people experiencing dual diagnosis has undergone a significant shift.
Catholic Health Australia
reports that an accurate depiction of its client profile was once the
stereotypical one of the elderly alcoholic: usually male, isolated, dishevelled
and living in rundown accommodation or homeless on city streets. The submission
suggests that deinstitutionalisation has brought about a significant shift in
the age profile of the group. CHA's typical client is now a middle-aged male
between 35 and 60 years. His living conditions are the same but he may be reluctant
to access help because of the iatrogenic effects of past treatment:
Many people who had bad experiences in the past are now
reluctant to approach the mental health system for help because of this ongoing
fear. The style of treatment they experienced in the past may have been
traumatic and in many cases did not focus on educating people about their
mental illness. In these cases, people have no sense that there are other
options available for treatment and management of their illness.... In many
cases, people in this group have both chronic mental and physical health
conditions. Often, because of the difficult life they have led, they have
physically aged with chronic health conditions such as chest infections,
hepatitis, rotting teeth etc. In many cases they need just as much physical
care as would an older person in an aged care hostel or nursing home but their
age precludes them from eligibility for aged care services.
The emergence of the 'street kid' phenomenon has
also changed the profile of the dual diagnosis cohort. Dr Georgina Phillips advised that it is now 'mostly young, very
vulnerable, chaotic people' who suffer from dual diagnosis.
A disproportionate rise in dual diagnosis
presentation among young people appears to be an international trend. The
ORYGEN Research Centre cited recent results of United
Kingdom studies showing a clear increase,
particularly since 1986, in co-morbidity rates, along with conduct and
emotional disorders, among young people.
Drawing on Australian assessments, the Australian
Divisions of General Practice (ADGP) advised:
Co-morbidity is of particular concern for young people aged
15-24 years... the recent Australian burden of disease and injury study found
that nine out of the ten leading causes of burden in young males, and eight out
of ten leading causes in young females were substance use disorders or mental
disorders. Co-morbidity of these disorders is high with over 50 per cent having
The increased prevalence of bipolar disorder among
youth may be significant, given its frequent co-occurrence with substance
abuse. The Black Dog Institute has found a dramatic increase in Bipolar II
disorder among youth and adolescents over the last ten years. Consistent over decades at between
0.5 to 1 per cent, estimates now suggest that some five to six per cent of the
population might now experience Bipolar II over their lifetime.
A history of trauma and abuse, social dislocation and
distress is prominent in the life experiences of most people with dual
diagnosis. The personal account of the dual diagnosis survivor at the beginning of this chapter provides disturbing
confirmation of this fact, as do the many other personal stories the committee
Research confirms this relationship. Overseas studies
have found strong correlations between mental health problems and social
disadvantage. Children exposed to domestic violence, abuse or neglect or
community violence are at greater risk of mental and social dysfunction in
later life. Moreover, early trauma may significantly affect brain development
in children. Drug abuse by
parents creates generational problems in children who experience emotional,
cognitive, behavioural and other psychological problems.
Studies have also shown that foster children and other
young people in out-of-home care have a particularly high risk of mental illness,
and of drug and alcohol addiction. The Australian Government submission reports
a steady rise in the number of children and young people in out-of-home care, implying there may be an increase
in youth mental illness as this group grows in size.
The high incidence of dual diagnosis among Indigenous
Australians, who typically have experienced extremes of family and community
disintegration, makes a powerful statement about the role of social factors in
generation of co-occurring disorders.
Indigenous people experience poor diagnosis, higher rates of imprisonment and
substance abuse, self harm and suicide than the general population.
Recent studies have shown that the use of illicit drugs such as cannabis and the psycho stimulants,
amphetamines and cocaine is higher amongst young adults with severe mental
illness compared to either the general population or to other psychiatric
comparison groups. There was
some agreement in the evidence that intake of methamphetamines is increasing
the number of presentations of youth with drug-induced psychosis. Nevertheless, while there is a
clear correlation between substance abuse and mental illness, the causal relationship
between the two is not definite. Mr Gary Croton, Clinical Nurse Consultant at
Eastern Hume Dual Diagnosis Service advised that it is a case of the 'chicken
or the egg':
I think the wisdom at the moment is that there is a huge range
of possible relationships between the disorders depending upon the individual.
One disorder may be primary, one disorder may be secondary. The principle that
is really emerging strongly now is that, in terms of treatment, you often will
not be able to tease out what was the primary disorder and what was the
secondary disorder. It will come down to clinician judgement.
The Youth Substance Abuse Service (YSAS) reported that
the 'typical' young person accessing their dual diagnosis services have
experienced 'multiple adverse events', involving 'significant levels of trauma
and abuse during their childhood and adolescence'. Resulting distress manifests
in a range of self harming activities. YSAS explained:
Young people accessing the services provided by YSAS therefore
typically present with a multiplicity of mental health concerns such as
self-harm, eating disorders, anxiety and depression. While the behaviours may
vary from time to time, the cycles are similar – for example research and
practice wisdom demonstrate that substance abuse, bulimia and self-harm show a
tendency to occur in clearly patterned cycles of increasing tension, followed by bingeing/purging and then relief.
In most cases, emotional regulation is reported to be the primary intent of
Dual prisoners—doubly damaged
People with dual diagnosis in prison are typically from
among the most disadvantaged groups in society. The Probation and Community
Correction's Officers Association advises:
Typically young, male, single, with a history of conduct
disorder and family substance abuse, these are the people to whom are applied
such pessimistic terminology as 'falling through the gaps'.
As mentioned, women have a higher incidence of mental
illness than male inmates but equivalent histories of substance abuse:
Women prisoners are casualties from harmful early life
experiences and social deprivation showing mental health and other harms to a
very high degree. They are truly outsiders.
Sisters Inside records that over 50 per cent of women
in prison had been placed 'in care' as children and approximately one quarter
have been imprisoned in a juvenile detention centre. Further, prior to
incarceration, 98 per cent of women prisoners had experienced physical abuse
and 89 per cent had experienced sexual abuse. Sisters Inside reports that the
number of women in prison in Queensland
has being growing as a percentage relative to men, with a rise of 13 per cent
over five years to 2003 (up to 325).
The plight of Indigenous women within this spectrum has
been described as one of 'triple disadvantage'. Alcohol,
drug abuse and violence are endemic and more often lead to offending. With
lower levels of education and employment, Indigenous women also suffer from a
higher incidence of past physical and sexual abuse than other prisoners.
The service burden of dual diagnosis
People with a dual diagnosis have a higher level of
need than other mentally ill cohorts and a poorer prognosis compared with those
with either a mental or substance abuse disorder alone. This is in part because the
complex interrelationship of disorders creates obstacles to effective diagnosis
...the co-occurrence of mental health and substances disorders
cases influences the development and severity each condition, and affects the
individual's response to treatment and circumstances of relapse.
Co-occurring disorders are pervasive and have poor
The co-occurrence of drug dependence and mental health disorders
is widespread and is associated with higher levels of hospitalisation,
incarceration, suicide, homicide, housing instability and homelessness,
unemployment and financial difficulties, and lower treatment compliance
requiring more complex and more expensive care.
People with low prevalence disorders and dual diagnosis
experience the worst social and health outcomes:
experiencing more frequent relapse and
are more exposed to violence and exploitation,
both as victim and perpetrator;
are more likely to have a physical disorder;
a higher incidence of homelessness; and
more forensic involvement (as discussed above).
Clinical support services
The high needs of people with a dual diagnosis incur a
significant service burden with attendant costs. Eastern Hume Dual Diagnosis
Service reports that the overall treatment costs for persons with co-occurring
substance use disorders are twice those of people with other co-occurring
disorders. These costs are largely attributable to additional acute care needs.
The prevalence of physical illnesses and injury within
this group, consequent to the mental instability suffered, contributes
significantly to these costs:
Co-morbidity of substance use and severe mental disorders is
associated with an increased risk of illness and injury including self-harm and
suicide. Co-morbid disorders are more likely to become chronic and disabling,
and result in greater service utilisation and increased health care costs.
The inability of the public health system to deal
compassionately with threats of suicide and self harming behaviours among the
mentally ill has been discussed in other
chapters in this report. The record of failure is even more profound for
patients with dual diagnosis. Emergency departments are ill-prepared to deal
with repeated presentations of this type:
Patients with both
substance abuse and mental illness issues are particularly vulnerable to social
and medical risks, including accidental or deliberate self-harm. They are heavy
users of the emergency department and are extremely stressful for ED staff to
manage, not only because of acute behavioural disturbance but also because of
frequent re-presentations and a lack of willingness or capacity of either
mental health or drug and alcohol services to own the patient and direct their
care. These patients are too complex for the limitations of our current system,
yet they are at real risk of harm.
There can be great difficulty disentangling the
effects of drugs from the symptoms of mental illness when patients present at
emergency departments with psychosis. Some patients can enter and leave
hospital without proper diagnosis or treatment.
have shown that people with co-occurring psychotic and substance use disorders
are also at higher risk of experiencing certain physical disorders than people with
mental illness alone. These include diabetes, hypertension, heart disease,
asthma, gastrointestinal disorders, skin infections, malignant neoplasms and
acute respiratory disorders. The South Australian Division of
General Practice advised that these health needs are largely unaddressed by
overwhelmed emergency services and doctors who are disconnected from alcohol
and drugs services.
The absence of dedicated tertiary beds or hospital
wards to treat people with dual diagnosis, consequent to their closure under
deinstitutionalisation, was raised as an area of urgent unmet need. Professor
Kavanagh, of the Mental Health Centre at the Royal
noting extremely high rates of co-morbidity in inpatient wards and in younger
patients, warned that 'effective management of co-morbidity is likely to be
critical to the cost-effectiveness of [inpatient] services':
If these patients are
not effectively treated, this will have a substantial impact on the overall
effectiveness of the service. In practice, management of co-morbidity becomes
‘core business’ for the service, whether or not this is recognised.
Aged people with dual diagnosis have extremely poor access to drug
and alcohol services. Dr Roderick McKay of the Royal Australian and New Zealand College of
Psychiatrists noted that the national drug and alcohol plan has no policy
initiatives with regards to the elderly, and that the area seems to have been
overlooked as part of dementia services.
Another significant area of unmet need is in treatment
of those with anxiety or depression and substance abuse disorder. This is the
largest dual diagnosis cohort. As discussed elsewhere in the report, substance
abuse and depression are behind the high incidence of suicide recorded in Australia. Beyondblue
has identified this as a priority area in its programs promoting education
against stigma and General Practitioner (GP) access. This is discussed in Chapter 7.
Healthscope and the Australian Health Insurance
Association reported that the private sector currently provides care for some
high prevalence co-occurring disorders.
However, other submissions observed that options for this are limited for the
majority of the dual diagnosis cohort, because they typically have low income
levels. There is also a shortage of private psychiatrists able or willing to
work with people with dual diagnosis.
Healthscope identified potential to build care
capacity in rural areas through use of private providers. This depends, however, on ensuring
that health insurance fund cover remains accessible for mental health care, and
that health insurance portability is in place. This
is discussed in Chapter 12.
Community support services
Barriers to service provision for dual diagnosis youth in
the community include a lack of appropriate accommodation with suitable primary
care outreach, and of specialist and 'youth friendly' service models. The Mental Health
Coordinating Council (MHCC) submitted that the existence of these barriers contributes
to the high imprisonment rate of young
people with dual diagnosis:
Persons suffering co-morbidity, particularly young people, frequently
end up living on the streets, their needs unable to be met by the limits of the
existing services and the barriers to access due to risk management, inadequate
availability of professional clinical staff and suitable accommodation...[they] find
themselves involved in the criminal justice system as a result of inadequate mental
health and support services rather than inherent criminality.
Catholic Health Australia
indicated that current services do not address the needs of the broader cohort
of people with dual diagnosis, including the alienated aged and middle-aged
homeless who congregate in urban areas:
... there needs to be much better coordination between drug and
alcohol, mental health and disability services together with housing and
supported accommodation programs. Mental health services need to be tailored to
respond to the needs of inner city dwellers (often people who have a dual
diagnosis, are homeless and who have no family support).
People with co-morbid conditions experience high levels
of unemployment. At the same time, they are least able to meet Centrelink and
disability payment requirements, because these services do not comprehensively
assess or take into account the extent of the debilitation caused by behavioural
and mental disorders:
Very frequently the
homeless and other marginalised people are depressed, have great difficulty in
personal contact, and lack confidence in their own capacity to relate to other
people or indeed to initiate contact with them. The way income support
arrangements are implemented at this level does far more harm than the intended
good (namely encouraging people back to work).
The Australian government submission confirms that it
is not possible to assess how many people with co-morbid disorders access the
Disability Support Pension (DSP). Mental illness represents a major category of
disability condition under the Australian Government's DSP. However, the DSP statistics only
report the primary disability that qualifies the person for payment; the data
does not indicate how many people with co-morbidities, such as anxiety and
substance use, receive these payments.
Service delivery response—'service silos'
People with dual diagnosis have been characterised as
'the forgotten people' of the mental health system. They have more difficulty
accessing services than any other people experiencing mental illness and their
life circumstances reflect this.
Dr Andrew Gunn reported that stigma plays its part in
poor outcomes for people with co-morbid disorders. People with dual diagnosis and low
prevalence disorders in particular, are likely to be homeless or socially
isolated and in poor physical health. Hard to diagnose, hard to treat, and
often hard to motivate to attend available services in a system which relies on
voluntary participation, the dual diagnosis cohort are difficult and unreliable
However, while these factors are important, the main
problem for the dual diagnosis group is that they fall outside of the discrete
treatment spectrums of the mental health system on the one hand, and alcohol
and drugs services on the other. Professor Patrick McGorry
of ORYGEN Research Centre provides a concise summary of the situation: the
'service silos' are a 'recipe for fragmented care and very poor quality care'
of dual patients:
In the past, 20 years
ago, drug and alcohol services were run completely integrated with mental
health services, certainly in the two states I have worked in, New South Wales and Victoria. They have been separated off into two
separate systems of care. At the bureaucratic level, we have a state director
of mental health and we have a state director of drug and alcohol. On the
ground, they are separate service systems and separate cultures now. It makes
absolutely no sense for it to be like that. They are the same kinds of problems
and, quite often, it is the same people with different thresholds of mental
health or drug and alcohol problems. If you were to recommend that that be
addressed seriously, the territoriality would probably defeat it. But if it
were about patient care, you would bring those systems together tomorrow under
the same leadership and the same principles of service provision.
Mental health and alcohol and drug services—distinct and different
Historically, people with drug and alcohol addiction
were routinely incarcerated in mental institutions, sometimes indefinitely,
even though they may not have suffered mental illness. Modern health
legislation has been drafted to address this problem. Each state and territory
has legislation which provides that people with alcohol or drug addiction
cannot be subject to involuntary treatment by the mental health system, although
they can be detained for a short period.
While the legislation was drafted this way for
sound human rights reasons, the legal distinction underpins the development of
the now distinct and different service streams for mental health disorders as
against substance abuse disorders.
Evidence suggested that overwhelmed mental health service providers are now
using this distinction as a legal loophole to deny access to people with dual
Under current service criteria, people with
alcohol and drug problems can be turned away from mainstream mental health
systems, which are not required to treat substance affected people. Meanwhile
drug and alcohol services may also reject clients with mental health problems.
People with dual diagnosis are thus effectively excluded from both 'service
silos' and left to wander from provider to provider seeking treatment.
Submissions provided ample confirmation that the 'buck
passing' of high need dual diagnosis patients between the 'service silos' is
In the area of drug and alcohol services we still find that
people with a dual diagnosis involving mental illness and drug dependence almost
invariably fall “between the two stools”. People who get referred to Drug and Alcohol
services often get told that their mental health problem must be dealt with
first, while people with a drug or alcohol problem and a mental illness who are
referred to mental health get told the opposite ie that their drug or alcohol
problem needs to be dealt with first. This often results in neither disorder being
Distinct and different clinical perspectives inform the
two sectors, allowing people with coexisting disorders to 'slip through the
cracks' between both regimes. Dr Georgina Phillips advised: 'psychiatric illnesses
are seen as medical and the drug and alcohol problems are seen more as
Substance Abuse Service (YSAS) reported the consequence of these differences: 'Inconsistency
of concepts, language, and approach remain an obstacle to engagement,
retention, and compliance in dual treatments...and reduce capacity to effectively
assess both problems'. In particular:
...the AOD [Alcohol and Other
Drug] frameworks highlighted within dual diagnosis models have historically
been confrontational, disease based, 12-step approaches. It has been noted that
such approaches often sit in direct contradiction to mental health frameworks
that advocate pharmacological maintenance approaches to management of mental
health issues. It is thought such differences are hard to integrate when moving
between the two service systems, and can often lead to confusion over
appropriate treatment approaches for clients.
People with dual diagnosis are thus effectively
excluded from mainstream care in many states. Their care falls back on to an
overwhelmed non-government sector. Brotherhood of St Laurence advised:
Individuals who have a mental illness as well as a drug or
alcohol problem are even more limited in their access to services. Drug and
alcohol agencies are not set up to deal with issues of mental illness, and
mental health agencies often declare their work sites to be drug and alcohol
free. People with a dual disability find themselves in a bind. There are
services available that cater for them, but like most other organisations, they
are under resourced and over burdened.
The Gold Coast Drug Council reported that its drug and
alcohol service has been extended and transformed in recognition of the growing
burden of need, in absence of dedicated health services for its clients on the
Whilst we are primarily a service designed to treat people who
have a drug and/or alcohol problem, we are finding now—and have been finding
for many years—that in up to 80 per cent of cases there is a co-existing mental
health disorder. Consequently, we have had to expand our service delivery. I
suspect many other services have either had to expand or very soon will have to
do so, in order that we can treat mental health problems as well. So whilst
from the public’s perspective we are providing a drug and alcohol treatment
service, we are also providing a very comprehensive service to treat mental
health problems as well.
Non-government service providers maintained they are
overwhelmed by the extent of unmet need and must turn away many seeking help.
Evidence also provided many examples of the tragic human price that is being
exacted because of the failure to develop a proactive mainstream approach to
treatment of dual diagnosis. The White Wreath Association related this account:
One woman, who did not wish to be named, talked about her son
who died from a heroin overdose a year ago. She said her son, who was 27 when
he died and was a heroin addict from the age 14, developed a mental dysfunction
after trying to get off a methadone ‘cold turkey’ program. He spent several
months in a psychiatric ward, but she said the hospital did not treat his drug
problem. ‘It’s almost like you go to hospital with hospital with cancer and a
broken arm, and they treat your broken
arm but not your cancer,’ she said. ‘That’s what happened. They don’t liaise
with the drug counsellors, and its killing kids'.
The committee did hear about government and
non-government initiatives trying to bridge the gaps created by the divisions
between services, discussed below, but also about other gaps that were creating
problems for those seeking help.
Dedicated youth services—bridging
Access to adequate treatment for youth with dual
diagnosis is compounded by another 'silo' problem: the division between child
and adolescent services on the one hand and adult services on the other.
Stakeholders advised of the gaping service gap in this
area of most urgent need: the 16 to 24 year-old age dual diagnosis group:
Drug and alcohol service delivery for young people, especially
in their late teens and early adulthood are inadequate. Opportunities for
effective prevention programs (targeting early adolescence) have been poorly
realised nationally and effective early intervention programs are yet to be made
generally available in the community. This is a major gap. The significant
overlap of risk factors for drug and alcohol and mental health disorders in
young people suggest some potential synergies for prevention/early intervention
programs for children and adolescents.
Non-government organisations, under various funding
arrangements, step in to fill this gap. ORYGEN, which runs one of the few
targeted youth services of this type, reports there is nevertheless 'tremendous
resistance' among state and territory governments to a mainstream response to
this category of unmet need. Principal to the problem is that targeting 'youth'
as a cohort, would involve the adding of an additional youth to young adult tier to the existing
three age bracket system, comprising child and adolescents services, adult
services and aged services.
There are, nonetheless, methodological and socio-cultural
reasons to suggest that this should be a discrete group for service provision
As discussed in Chapter 15,
treatment within the adult mainstream services offers a depressing
introduction to life with a mental illness for the young and, incidentally, is an
indictment on adult services. One young person wrote to the committee:
Where I have felt like less of a person is within the adult
mental health system. There is a general atmosphere there that you have no
future, your illness means you can be ignored, spoken
to rudely, be made to feel like you are taking up too much time and you don't
deserve any patient respect because you are struggling with living.
Service providers report that the clinical model for
mental health services is particularly repellent to young people with dual
diagnosis, and not conducive to their accessing or continuing to engage with
available services. The Mental Health Legal
Centre advised that young people with
mental illness often rely on drug use to provide them with a peer group
which accepts their mental illness. They find that drug and alcohol services
are more respectful of these needs. The Centre recommended that service
agencies should address this by giving consumers options for self-management,
including in development of treatment plans and access to services.
A number of submissions referred to the services
provided by ORYGEN Youth Health services in Victoria
as meeting these criteria.
ORYGEN's model addresses the mix of clinical and social needs of the targeted
group, and received glowing endorsement by young clients who had found hope for
recovery and a sense of self-determination within its youth program. On the
basis of her experiences, Ms Jolan Tobias of the ORYGEN Youth Health Platform
We recommend that all young people who need a mental health service should be
able to access services that are specifically for young people, no matter where
they live. All mental health services should have group programs and do more
than just prescribe medicine. Social, vocational and emotional goals are
crucial to psychiatric recovery. We recommend that young people should be involved
in the design and delivery of mental health services for young people.
Dr Dan Lubman of ORYGEN explained that the success of
the approach relies on strong regional links between youth and the drug and
alcohol services. Other
submissions agreed that linkages must be built between local services to allow
for the integrated approach to service provision to the youth dual diagnosis
group, and this should include housing support, extended counselling
assistance, and mechanisms to better address health needs.
The ADGP suggested that adjustments should be made to
Better Outcomes requirements to allow co-location of GPs in environments
targeting dual youth needs, observing:
They require a different psycho-social approach to meet their
health needs which relies on good rapport with general practitioners and other
care providers and access to “youth friendly” systems. Marginalised young
people and those disconnected from family and school do not necessarily access
mainstream services such as general practice. There is a need for specialised
services to reach these young people, and for these services to have a strong
primary care interface so that discharge for recovery and rehabilitation in
primary care can occur...Better Outcomes needs to allow enrolled GPs to deliver
mental health care in settings where young people ‘hang out’ such as youth centres
and clinics. At present, this is not possible if the centre is not accredited.
The Gold Coast Drug Council endorsed these views,
noting that bulk-billing of GPs and psychiatric specialists is essential if
sustainable, integrated, community-based support is to be available for this
cohort. It recorded a definite
increase in dual diagnosis among amphetamine users, reporting that younger
clients are now seeking treatment earlier. This reinforces the need for
'holistic' service approaches to cater for the younger teenager through to the
young adult age group.
next section will consider some of the issues surrounding proposals for a more
integrated care model of public health services to better meet the complex care
needs of people with dual diagnosis.
Service integration—the state of play
There is a strong body of evidence which supports the
view that a more integrated approach to service provision for people with dual
diagnosis will not only improve outcomes for those affected but will be more
efficient and cost effective.
Dr Phillip Morris, Executive Director, Gold Coast
Institute of Mental Health, reported World
Health Organisation data that demonstrates that in countries where there had
been reform of drug and alcohol services along with mental health acts and
policies, there has been a fall in suicide rates. By
contrast ORYGEN Research Centre, commenting on the situation of Australia's
dual diagnosis youth, advised:
The lack of integration between
drug and alcohol and mental health services in Australia has significantly
contributed to the poor detection and treatment of mental illness amongst young
people with substance abuse. This results in waste of resources and long-term
psychiatric and substance use problems for individuals who could otherwise be
Nevertheless, some advances have been made in
individual states and territories. A number of stakeholders referred positively
to developments in Victoria,
which introduced a state-wide dual diagnosis initiative—the Victorian Dual
Diagnosis Initiative (VDDI)—in 2002. The initiative, jointly funded by both
mental health and drug services, was given $9 million in the Victorian state
2005-06 budget to improve service integration and workforce development over
four years. The VDDI aims to:
...support the development of better treatment practices and collaborative
relationships between drug treatment and mental health services. The key
activities of the initiative are the development of local networks; training,
consultation and modelling of good practice through direct clinical intervention,
and shared care arrangements.
Victorian-based Youth Substance Abuse Service (YSAS)
commented on the success of the model in its submission:
The development of dual diagnosis positions in each metropolitan
Department of Human Services (DHS) region, including the development of youth
focused dual diagnosis positions, appears to have improved cross-sector
knowledge around target populations, demand characteristics, service response
capacities, and the understanding of co-morbid substance use and mental health
Other states also reported progress on integration and
reform to better address the needs of people with dual diagnosis. Queensland
has undertaken a two year strategy of reform,
appointing nine new managers to head up an integrated mental health and alcohol,
tobacco and other drugs services department.
The Tasmanian Government told the committee of its appointment of two
co-morbidity executive positions to progress a memorandum of understanding
between mental health and drug and alcohol services. The MOU will cover a range
of initiatives to assist partnership and joint service delivery, and to link
services that will remain separate. The Minister has also announced the
establishment of an expert co-morbidity task force. Western
Australia has an integrated mental health and AOD service
operating in the Kimberley and
While these developments are commendable, there were
concerns that each state is progressing the issue without the benefit of a
consistent plan, or with any agreed theoretical direction, for implementation
of service integration.
Debate about integration models
There were different views about how integration of
services might be best achieved. Discussion of the Victorian model, which is
the most developed, revealed emerging criticisms of the approach in that state.
In particular, it was suggested that VDDI programs are
not resulting in the desired coordination of treatment between the two services
but may instead be developing a 'third tier' of 'niche' dual services. Jesuit
Social Services reported advice from its service providers:
Discussions with Connexions staff around the impact of dual
diagnosis teams in Victoria, considered positive outcomes to be the increased
capacity of drug and alcohol staff and mental health staff to recognise mental
health issue or substance use issues in their respective clients ... on the
negative side it was felt that the problem of staff in each sector not wanting
to work with dually diagnosed clients persists. They also expressed concerns
that dual diagnosis was in danger of becoming a niche market and services were
becoming more fragmented as organisations within different sectors establish
dual diagnosis specific services. Coordination was seen as a key component of
In its submission Eastern Hume Dual Diagnosis Service
warned that specialisation of skills in
a 'third tier', providing treatment only for those with co-occurring disorders,
may exacerbate rather than alleviate the likelihood of these individuals
'falling through the gaps'. The reason for this is that access to appropriate
treatment relies on staff being adequately trained to identify and assess
complex disorders, which they would not be inclined to do if dual diagnosis is
regarded as the domain of specialists.
Eastern Hume also predicted that treatment of people
with dual diagnosis in a third tier may generate a turf war among service
providers given that drug and alcohol services could lose between 30 and 70 per
cent of patients, which would be counter productive to development of a
Most stakeholders argued that it was preferable for existing
services to be utilised for any reformed dual diagnosis treatment, although
there were different opinions about whether drug and alcohol services or mental
health services should take primary responsibility for coordination of care for
dual diagnosis clients. YSAS for example, considered the ideal would be for AOD
services to provide integrated care for dual diagnosis clients in consultation
with mental health services, rather than simply referring them to a mental
health service. In contrast, the Western Australian Network of Alcohol
and Other Drug Agencies (WANADA) and St Vincent de Paul Society recommended
referrals be made to mental health services.
There was also debate about comparative models for
integrated care, such as whether a single agency or 'one-stop shop' would
better service the needs of the target group compared with the referral-based
service paradigms currently applied.
As noted, Eastern Hume warned against trends towards
specialisation in a distinct service tier. It also referred to United
States findings that specialisation of
skills in a particular agency, or in an individual within an agency, does not
develop the system's overall capacity to provide integrated care. By
contrast, Ms Nene Henry, a mental health case manager and registered nurse,
cited United Kingdom Department of Health studies which concluded that
integrated care, delivered by one team, appears to deliver better outcomes than
serial care (sequential referrals to different services) or parallel care (more
than one service engaging the client at the same time). Ms Henry recommended:
of an integrated model which provides the concurrent provision of both
psychiatric, and drug and alcohol interventions. This would require the same
staff member (or clinical team), working in a single setting, to provide
relevant psychiatric and substance misuse interventions in a co-coordinated
The single service model was also advocated in
particular for Indigenous dual diagnosis needs, with successful integrated
models in operation in South Australia. Indigenous
mental health needs are discussed in more detail in Chapter 16.
Whatever the service paradigm, it was agreed that
viable access points to services must be established for people with dual
diagnosis. As YSAS and others argued, a prime objective is to ensure that there
is a genuine 'equity of access' or a 'no wrong door' policy so that,
irrespective of which organisation or service system is initially engaged, the dual
diagnosis client can be accurately assessed and directed to an appropriate
service response for treatment.
To achieve this crucial objective it was agreed that
there must be a focus, both at national policy and service delivery level, on
systemic 'capacity building' to achieve the necessary linkages within and
across the mental health and drug and alcohol systems. Eastern Hume Diagnosis observed
that this could be achieved cost effectively if the approach is comprehensive:
International experience has demonstrated that rapid development
of a system’s recognition of and response to co-occurring disorders can occur
without the input of significant extra resources. Improving the system’s
recognition and response requires the strategically-planned, collaborative and
robust implementation of top-down and bottom-up strategies towards
well-defined, locally-grounded goals. Integrated strategic planning processes
and policy deployment are central to effecting enduring improvements to
systems’ recognition of and responses to co-occurring disorders.
The remainder of the chapter will explore the
requirements for 'capacity building' of integrated services for people with
The building blocks of service integration—'top-down'
The following 'top-down' strategies were advocated as
the building blocks of service integration:
national vision and appropriate policy levers,
including legislative requirements, to direct the system towards more effective
education and training strategies based on
national curricula, accreditation, competency standards and including modules
aimed at adjusting clinical attitudes;
improved diagnostic screening tools and
clinician focussed training manuals.
National policy levers
Progress on integrated service delivery requires that
dual diagnosis be recognised as 'core business' for mental health services.
This relies on strong leadership and commitment on the part of
Hume cited advances in the United Kingdom
on the government's announcement that dual diagnosis is 'a mainstream
responsibility for mental health services'. The publication of a mental health
policy implementation guide, the Dual
Diagnosis Good Practice Guide, had supported and reinforced progress.
government has also shown strong leadership, delivering an integrated approach
potentially useful to inform an Australian model. In the US, the improvement of treatment and services for
individuals with co-occurring disorders is one of the highest priorities for
the Federal Substance Abuse Mental Health
Services Administration (SAMHSA), which liaises with the Co-Occurring Centre
for Excellence, established to provide training and methodological direction
and linkages between SAMHSA and the states' communities and providers. The Comprehensive
Continuous Integrated System of Care (CCISC) is operational in a number of
states. It takes the position that dual diagnosis is an expectation of service,
and leverages substantial development of treatment largely within existing
14.108 However, it was contended that the
Australian Government, despite repeated strong rhetorical commitments to better
integrate mental health and drug and alcohol services, has failed to put in
place effective 'policy levers' to secure that objective. Submissions referred to the following
lack of articulation between key policy
documents and of supporting guidelines to direct comprehensive reform; and
lack of consultation mechanisms and centres of
research to assist and inform the process.
Providing leadership: policy
documents and guidelines
14.109 The Australian Government reports a range of
initiatives aimed at enhancing mental health service delivery for the dual
diagnosis cohort. The vision for integrated service is set out in two key
The National Mental Health
Plan 2003–2008, the third plan, aims to strengthen and consolidate the vision
of the second plan mental health services. It recognises the effect of mental
illnesses occurring together with drug and alcohol problems and other
The National Drug Strategy Australia’s
Integrated Framework 2004–2009, which aims to provide 'a framework for a
coordinated, integrated approach to drug issues in the Australian community'.
Despite this commitment
to interlinking services, Eastern Hume Dual Diagnosis Service notes that the National
Mental Health Plan undercuts the potential for connection
drug and alcohol problems are primarily the responsibility of the drug and
alcohol service system.
the key documents fail to provide advice on strategic directions for integrated
treatment of individuals with coexisting substance abuse and mental health
problems. Families and Friends for Drug
Law Reform observed:
These peak policy documents
fail in any meaningful way to address the links between mental health and
illicit drug substance abuse. The National Mental Health Plan 2003-2008 passes responsibility for
drug and alcohol problems to the national drug strategy. The National Drug Strategy:
Australia’s integrated framework 2004-2009 makes the
platitudinous point that there should be strong partnerships between the
treatment services. It also specifies that there should be integration of
policies and programs without indicating what this involves.
14.112 In this regard, Eastern Hume Dual Diagnosis noted
that the NMHP provides no advice on key implementation issues, such as the
relative efficacy of different integration models. It concluded: 'it is
difficult to discern at what points and in what manner the two strategies [alcohol
and drug, and mental health] are linked.
that the government exhibit strong leadership on integrated service reform. The
Australian Medical Association suggested that service integration might be better
advanced if mental health strategies were brought together with AOD as part of
the national chronic disease strategy initiative.
Another option is
the introduction of national guidelines and performance reporting to encourage
integration of services. It was noted that progress in the United Kingdom was underpinned by national mental health policy
implementation guidelines for treatment of dual
14.115 In the Australian context, where mental health legislation in
each state may vary treatment outcomes, such guidelines could be an important
means of promoting comprehensive and consistent service integration. National
guidelines could promote inter-agency cooperation and potentially promote, for
example, a broader recognition of the role of generic welfare services
in achieving good outcomes for people with dual diagnosis than current state
mental health legislation encourages.
They could also be used to establish inter-agency service agreements and memoranda
of understanding as well as agreed approaches to training and performance
delivery. At present a number of
states and some regions have initiated drafting or implementation of these
Mechanisms for coordination, consultation
overseas has also been due to the establishment of national vehicles for coordination, consultation and
research. A federally convened and funded forum or research body could assist
states and territories to agree on a service trajectory, in a 'whole of
government' approach. The Office of
the Public Advocate, Queensland, recommended:
approach to mental health policy and funding should emerge from the
Commonwealth, in order to see the same level of integration in the States’
delivery of services...resources could be better utilised if various silos of
government were to develop more effective collaborative arrangements.
Timothy Rolfe, Consultant Psychiatrist to Eastern Hume Dual Diagnosis Service
and Clinical Director to Southern Hume Diagnosis Service, advised the committee
that at present the states and territories have no opportunity to learn from
each other, nor any repository for shared knowledge:
I hesitate to comment on someone else’s system but it is
interesting that Western Australia, from the outside—from my perspective— devoted
a large amount of resources and expertise to putting an integrated response
together and now seems to have moved away from that. I would really like to
know from a national and Victorian perspective why that happened so that we can
learn from that. One of the things that happens is that people in different
states are doing different things and we are not learning from one another.
There is no capacity to be able to share experiences and to be able to learn
other than at the very informal level. There is no single centre or body of
people that holds this knowledge. That is a real difficulty, I think.
It was suggested that national initiatives such as the
National Co-morbidity Taskforce need to be reinstated. The Taskforce ceased to function as a co-morbidity specialist
forum twelve months ago, its functions being absorbed into the
intergovernmental task force on drugs.
Dr Timothy Rolfe, a member of the former Taskforce, took the view that the Australian Government should now
demonstrate leadership by funding a new national consultative body to foster
information exchange. The body could also coordinate funding and research to
build more cost effective and improved dual diagnosis service delivery:
It would be in a good place to coordinate such efforts of
collaboration. It should encourage collaboration between the states or
encourage collaboration through the distribution of research moneys and the
sharing of information about the effectiveness of services so that people are
not in the position of reinventing the wheel over and over.
The Eastern Hume Diagnosis Service submission suggested
that this centre should be like the US's Co-Occurring Disorders Centre of
Excellence, which works to identify and disseminate evidence-based practices,
develop training approaches and provide linkages between the states,
communities and providers.
Professional practice and skills
As discussed in Chapter 6,
mental health services are experiencing chronic skill shortages. The
erosion of the skills base among psychiatrists and nurses is in part a
consequence of the specialisation of service delivery into separate streams,
for example, mental health as against substance disorder services, and in part
due to systemic dysfunction since deinstitutionalisation. This has considerably reduced the
capacity of mental health services to respond flexibly to patient needs, in
particular to complex needs.
A national commitment to build skills among service
providers in both mental health and AOD services is vital if 'services silos'
are to be broken down. This would involve
investment in widespread upgrading of the skills base, with a focus on cross-skilling
of health professionals to support service integration. Specialist staff and
services could be developed within this framework, but should not dominate in a
third service tier:
NCOSS supports the need for cross-sector training and skilling
so that mental health workers and drug and alcohol workers can effectively
support people with a dual diagnosis of both mental illness and substance
dependence, no matter which service they are initially referred to. Maintaining
a separate work force for each area would only continue the effect of
"siloing" of service delivery and down skilling of staff, apart from
being non conducive to a holistic view of health, however NCOSS also supports a
limited network of specialist workers and specialist services for those who
have particularly complex needs.
The strongest message from health professionals was
that they do not have the competencies to deal with the growing number of
complex dual diagnosis cases.
The submission from the Association for Australian
Rural Nurses (AARN), the Australian and New Zealand College of Mental
Health Nurses (ANZCMHN) and the Royal College of Nursing
Australia (RCNA) reported that a lack of government commitment to training is affecting
rural staff retention and services:
The National Mental Health Strategy outlines integration of mental
health services with alcohol and drug services as a key objective. However,
there has been a lack of investment in initiatives to address training of staff
in dual diagnosis. Rural staff who work in districts without clinical alcohol
and drug services have often not had education in terms of dual diagnosis competency
development. This lack of training impacts on the ability to retain nursing
staff in the rural and remote setting, and has obvious negative connotations
for the services delivered.
14.124 In particular:
There are intense demands on acute mental health treatment
related to substance misuse. The input of the general community increase in
illicit substance misuse is seen impacted in the number of presentations of
first episode psychosis in young people and also in the increased levels of
violence concomitant to these presentations. North Queensland
(for example), which is viewed as a young overseas tourist destination, has a
higher than average increased use of potent methamphetamine. The increased
potential for violence associated with psychotic disorders for clients when
intoxicated impacts significantly on occupational health and safety issues for
staff and clients of health services.
14.125 The ADGP advised:
GPs encounter difficulties similar to those experienced by most
health care providers involved in the care of people with mental health and
substance use co-morbidity. Patients with co-morbidity are considered by GPs to
be problematic to work with, difficult to evaluate, and even harder to find
treatment for. These views are exacerbated by low levels of education and
training in co-morbidity issues and little access to clinical support or
supervision for GPs by specialists.
There are severe shortages of psychiatrists able to treat
people with dual diagnosis. Dr A
Gunn commented on professional prejudices among
Prosperity and pleasantness are common casualties of severe
mental illness. One would hope that psychiatrists, of all people, could accept this
but like most doctors, psychiatrists rarely show enthusiasm for, or understanding
of, patients who are neither cashed up nor personable. In a rural area, the
local psychiatrist once refused my referral of an actively suicidal patient
with major depression. She was drinking and he didn't see drinkers—but could a
psychotic depressive live in a rural Aboriginal community without drinking?
These problems call for a national action plan to
upgrade skills for assessment, referral and treatment of dual diagnosis.
Stakeholders recommended that this plan involve:
the development of national training competency
standards and training modules for dual diagnosis for undergraduate nurses and
other service providers in mental health and drug and alcohol services;
establishment of a national accreditation system
for training of psychiatrists, which
addresses clinical attitudes as well as knowledge and skill competencies;
incentive-based training opportunities for
doctors though the Better Outcomes Initiative to build knowledge of dual
training for all medical practitioners to better
recognise the relationship between physical and mental conditions, such as the
concurrence of depression, heart disease with substance abuse, including
Other training initiatives to promote integration could
targeted training strategies for state-employed
psychiatrists to lead the management of service integration;
provider training on how to implement protocols
and memorandums of understanding at a local level;
establishment of a network of specialist
co-occurring fieldworkers to assist in training development, delivery and
rotation of staff across agencies in the
different service sectors to promote cross-skilling; and
targeted strategies to increase numbers and
upgrade skills among Indigenous health care workers to address the complex
needs of Aboriginal and Torres Strait Islander communities.
Improved diagnostic tools
The development of appropriate diagnostic tools such as
screening processes, practitioner manuals and referral databases is important
to facilitate service integration. Submissions maintained that the development
and use of such tools will support other training initiatives and will improve
the capacity of professionals to accurately diagnose and refer people with dual
diagnosis to appropriate services.
Under the present service paradigm a different
diagnosis may exclude a person with co-occurring disorders from receiving
treatment or accessing an appropriate degree or type of service:
The opinion of one 19 year old female about mental health
services was "they don't help when you need them and they won't go away
when you don't want them". With a history of drug induced psychosis,
depression and abuse of heroin, cannabis, amphetamines, benzodiazepines and
alcohol, this young woman was an involuntary patient at age 15 and 17. She felt
that CAHMS [Child and Adolescent Mental Health Services] was too intrusive and
too quick to diagnose. The diagnosis of psychosis became a label that did not
fit. She was later diagnosed with depression and has been unable to access
mental health care though AMHS [Adult Mental Health Services].
practitioners are often the first point of contact for people experiencing
co-existing mental and substance abuse problems. However, surveys of unmet need in
2001 revealed that GPs did not recognise mental health disorders in 56 per cent
of cases and were less likely to do so if the disorder was common (such as
depression) or the client was less than 25 years old, male or not born in
address this problem it was considered vital that appropriate diagnostic
screening tools must be developed and applied in all service practice areas.
Eastern Hume recommended that, as a high priority, practical, user-friendly,
clinician-focused manuals (describing integrated screening, assessment and
treatment approaches) be developed for each of the mental health and AOD
members asked for specific screening mechanisms for youth with dual
The development of tools facilitating the identification,
screening, assessment, case planning, treatment and evaluation of outcomes related
to young people under 25 years of age presenting with co-morbid conditions
across all sectors of the service system, not just mental health services.
mechanisms in different languages could also be developed for CALD groups,
which experience difficulties accessing service due to lack of translation and
multilingual services. There is
also an urgent need to improve mechanisms for identification of mental health
disorders among Indigenous people, who record lower identification, but have
high incidence of behavioural and psychological disturbance by population percentage
than other groups.
Centre for Psychiatric Nursing Research and Practice reported that it is
leading the development of a multi-disciplinary project to examine the practice
screening for drug and alcohol use in in-patient mental health services
in metropolitan Melbourne and Rural Victoria:
It is intended that the findings from this study will be
utilized to identify, implement and evaluate strategies to enhance nurses’
preparedness and ability to routinely screen for drug and alcohol usage on
admission to mental health services. It is expected that training programs will
be developed to enhance the progress of this initiative.
Ms Janine Anderson, who manages a social recreation
program for adults with a mental illness, considers that the screening process
will aid holistic assessment and integrated treatment of all patient needs:
The integration of services requires staff to undertake training
so that each service has a better understanding of the other. Intake forms need
to have questions that will indicate any other areas of the consumer’s life [such
as whether they have children] that may need expert attention, so that
appropriate referrals and assistance can be given.
To underpin the implementation of this approach, the
National Drug and Alcohol Research Centre
recommended that any services which receive government funding should be
required to screen for co-morbid disorders and that accountability measures be
put in place to ensure best practice is implemented for both single disorder
and co-morbid conditions.
Capacity building in the community
Service integration cannot occur without a robust
network of interlinking agencies and service providers functioning at local and
Capacity for integrated service access should be grown from
the ground up. Submissions emphasised the importance of involving both
government and non-government agencies, along with consumers and carers, in
treatment models offering a mix of options to address the range of dual
disorder diagnoses. Dr Rolfe told the committee this is not just about access
to psychiatrists and specialists:
...it is a matter of having a whole-system approach where people
can access the level of expertise that is required according to their needs. It
is a matter of filtering people and building links between the various service
elements so that people can get the highly specialised care that they might
need—from a psychiatrist, for example—quickly and expediently through a process
of good communication through the network of agencies.
An integrated approach to community mental health
services also means more than breaking down the 'silos' of mental health and AOD
Such an approach should address relationships between mental
health services and the broader health service, as well as the links between
mental health and other government agencies such as Housing, Education,
Corrective Services, Juvenile Justice, Police and Transport.
Carers wanted more involvement in, and more integrated,
treatment regimes. Carers WA asked for opportunities to 'communicate between
all parties, staff, psychiatrists, social workers, case workers or community
nurses...and more integration with drug and alcohol services/psychologists for on
going maintenance of care and treatment'.
This vision is a giant step away from the acute care
paradigm presently followed by mental health services. It places emphasis on
early access and preventive care taking place in consumer friendly and
interconnected treatment environments. This relies on well developed local
referral systems and may be based on 'precinct' or accommodation based models.
Tertiary level beds for detoxification may be collocated, along with GP
services or support care by visiting or resident volunteers and professionals
may be offered.
These models will require significant commitment at
every level of service provision. Given the patient overload and under-funding
of mental health services, which evidence suggests are compounding the 'service
silo mentality', it is not to be assumed that top down initiatives will flower
without sustained work at ground level.
Integrated community service models—the vision
Integrated community service models rely on having a
developed methodology for agency referral, accountability mechanisms and
incentives to encourage agency partnerships. Of paramount importance is the
establishment of agreed treatment paradigms for the different disorders, so
that access to appropriate services is streamlined and automatic. This will
develop consumer, carer and service staff confidence, counteracting the sense
of hopelessness which currently pervades the mental health sector.
Building regional and local partnerships
Hume Dual Diagnosis Service has recommended the implementation of the CCISC
model adopted in the USA.
As already mentioned, this model requires that governments recognise dual
diagnosis as a mainstream mental health issue and set out ways in which existing
services can provide better treatment.
Eastern Hume submitted a template for improving the
capacity of the system to address complex needs by consolidating local
partnerships and regional links.
The model would provides both 'the carrot and the stick' necessary to secure
change. It would also facilitate information gathering, service networking,
education and leadership at a local level, by:
establishment of Regional Implementation Groups;
appointment of trained specialist co-occurring
disorder field workers; and
nomination of 'agency co-occurring
Implementation Groups—comprise mental health and drug treatment local
management, consumers, carers, clinicians from each agency, specialist co-occurring
disorders workers/portfolio holders. These groups would be policy advisers,
repositories of management advice and local knowledge. They could act as
coordinators of local partnership initiatives and generation of 'buy in' (local
ownership) by service providers into an integrated service model. Specific
tasks could include:
generation of Regional Profiles of co-occurring
issues, to map the extent and nature of local needs and identify service gaps;
generation of Regional Integrated Treatment
Plans, to identify specific local barriers to service, and generate statements
identifying which agency will treat specific co-occurring disorder cohorts,
interagency protocols, local education strategies, and plan review mechanisms;
development of mechanisms for cross-agency
treatment planning for complex clients.
co-occurring disorder fieldworkers—deliver training and education, clinical
supervisor, primary and secondary consultation (with orientation to co-occurring
disorders), tertiary consultation, protocol development and development of
worker competency standards. Eastern Dual Diagnosis Service considers that
these field workers could be a potent force for building local capacity for
integrated treatment as they will monitor and support implementation of central
policy directives to prioritise co-occurring disorders among middle management.
disorder champions—each agency would nominate a 'portfolio holder' of
information on co-occurring disorders accumulated in the agency to the Regional Implementation Group. The person would act
as a repository of agency knowledge about co-occurring disorders, mentor other
staff as well as evaluate the agency response to clients with co-occurring
Community care 'hubs' —user friendly services
Another proposal was collocation of services in the
same venue or area. This model was considered particularly effective for young
people. Professor McGorry of ORYGEN told the committee that the ideal for young
people was the development of youth 'precincts' offering a mix of services,
including vocational recovery and drug and alcohol services, as well as medium
The Gold Coast Drug Council proposed the establishment
of 'community-based hubs', some of which could target youth. These 'hubs' are
basically small scale step-up step-down housing arrangements, with a focus on
social integration and building of living skills rather than merely on
psychiatric treatment. An
advanced integrated recovery model of this type may reduce the burden on the
acute sector by enabling it to more adequately support the most complex
clients. The model would be characterised by:
development of psychiatric community-based hubs
which would provide an holistic approach to the treatment and support of
holistic treatment for clients including: disorder
specific clinical models for managing the symptoms of chemical dependence and of
mental and personality disorders; cognitive therapy for changing irrational
thoughts that drive the target problems; affective therapy for changing
unmanageable feelings that drive the target problem; behavioural therapy for
changing self-defeating behaviours that drive the target problem;
early identification and assessment of clients
with mental health problems through training of community organisations, public sector
services and GPs;
easy to access, prompt and accurate advice, and
support services for clients, families and friends, other agencies;
family support options for clients with families,
to avoid family separation and homelessness as a result of unemployment;
daily activity programs to address living skills,
employment, nutrition, social networks and training;
support officers to provide on-going support and
contact with clients living with ongoing mental health problems to prevent
relapse, these can be suitably skilled volunteers rather than specialist mental
development of appropriate supported accommodation
including 'step-down' support for those coming out of hospital;
development of specialist residential units to
provide holistic treatment and support for specific client groups—such as non-addicted
dual youth, aged etc; and
a career pathway for workers in the
mental health sector which provides training and development as well as
recognition for skills and experience.
Bulk billing of doctors and psychiatrists would be
essential and medical health services should be collocated with
multidisciplinary care teams. The 'hub' would function as an access point to a
range of other agencies including Centrelink and the departments for housing,
and families, and for education and training.
GCGC advises that an important role for federal and
state governments would be to ensure that medical health professionals,
especially doctors and psychiatrists find the model attractive. Options for
alternative models of employment and funding for GPs to encourage them into the
mental health sector, such as salaried positions, employment loadings and sessional
contracts could be considered.
Continuing care networks for dual diagnosis prisoners
The Australian Injecting and Illicit Drug Users League
developed a plan of action to provide more equitable treatment, and follow up
assistance, for people who have been in contact with the criminal justice
system. It recommended that
workforce development plans be developed to integrate mental health and AOD
services and other related services, and that:
harm reduction strategies be recognised as
valuable component of treatment for people living with co-morbidity;
prisons develop assessment and referral models
for when people leave prison and return to the community;
there be diversion to ethical and appropriate
treatment programs as an alternative to custody for people living with co-morbidity;
people living with co-morbidity be empowered to
retain a stronger advocacy role within the various sectors;
the role of peer education and support be
national initiatives such as the National Co-morbidity
Taskforce which has been disbanded need to be reinstated with appropriate
14.152 The Centre for Social Justice, Queensland, also suggested proposals to address the
special needs of Indigenous prisoners. It recommended:
prison officers be given cross-cultural
Aboriginal Liaison Officers be recruited with at
least one in every prison. These officers should liaise between prisoners,
their families and communities, the prison and the correctional department; and
Indigenous prisoners be given access to prison
release accommodation support which they are often denied on the basis that
accommodation applied for does not meet scheme criteria.
Leading by example —funding existing strengths
In the absence of a commitment to assist people with
dual diagnosis in public mental health systems, non-government organisations
have had to think and work hard to improve, adapt and expand their services. As
a consequence of this, many of the most innovative and successful treatment
models for people with dual diagnosis have been formulated by drug and alcohol
As discussed, people with dual diagnosis most commonly
present at drug and alcohol services for their clinical needs. These services are mainly provided
by non-government organisations which overwhelming rely on government grants
and project-based funding. This was not considered a good model for systemic
capacity building of existing service strengths.
Organisations that are the most innovative—offering the
most effective comprehensive and integrated treatment—are under the most
pressure. As mentioned, the Gold Coast Drug Council reported that it had
expanded and transformed its services to meet the needs of clients, some 80 per
cent of whom have dual diagnosis.
The GCDC provides a good case study of the challenges facing non-government
organisations of its type. The Mirikai Residential Therapeutic Community
Program is a prototype of the 'community hub' treatment model set out above. The
goal of the program is to enhance the capacity and commitment of some 40
residential clients, aged 16 to 29, to achieve and maintain an optimal level of
personal and social functioning free from harmful drug use. The program has
four stages with each stage taking six to eight weeks. Ms
Alcorn, GCDC Executive Director, describes the
process, citing a Mirikai success story:
A young woman—let us call her Jane—comes in from Robina. She has
been there for seven months, probably on an involuntary treatment order, having
an amphetamine issue diagnosed with bipolar and a psychotic disorder...Her mental
health worker comes and visits her once a week for 20 minutes...She would have
gone through the whole rehabilitation program; learnt lots of cognitive behavioural
therapy; learnt to swim; go for walks on the beach and do all the things that
people need to do; learned to take responsibility for her actions to manage her
disorder, her medication—and had education around medication. Most of all, she
was with a whole group of other young people, and that is a really healthy
thing to happen for you: to be able to mix again. From there, after six months
of that, she went into a training scheme funded through DET for landscaping.
She made a decision that she would like to go to TAFE, and she is currently
doing a diploma. She is in the halfway house and is about to move out.
The GCDC reported that, as result of the expertise
developed, the service is now experiencing the referral of the most complex
clients from mental health services as well as the wider community. This organisation, like ORYGEN and
equivalent service providers, is carrying the lion's share of the growing
service burden of dual diagnosis, without adequate recognition of that role:
The GCDC is supported by both State and Federal grants, but many
of these do not provide for cost increases year on year and all are fixed term
agreements. Recruiting and retaining staff in this environment is a continual
challenge. For example, the Youth Dual Diagnosis Worker position has been
filled by three different professionals since August 2004, as the salary
available for this position is not sufficient to compete with similar roles in
the public sector...In 2004/5 the Mirikai Residential Therapeutic Community
Programme bed cost was @ $21 000 p.a. Other States such as Victoria and New
South Wales have bench marked their costs for particular client beds, with the
cost of an equivalent bed in New South Wales and Victoria running @ $30 000 per
year, with this funding including a component related to complexity. Queensland
Health have repeatedly confirmed that they do not intend to benchmark costs for
specific services or to provide financial incentives for specific client
groups. Without financial recognition for the complexity of clients supported,
it may simply not be possible to provide the environment and staff to deliver
these services safely into the future.
with arguments that overall expenditure on mental health services should
reflect the extent of need, submissions maintained that as dual diagnosis has
the highest disease burden, it should be funded accordingly. It was also
considered that it is more cost effective to fund early prevention programs
than to carry the significant burden of self and societal harms generated if
these high needs are not met. ORYGEN made the point forcefully in its
Specialist interventions required by young people with serious
mental illness are often unavailable or inappropriate. Most young people in Australia
with serious mental illnesses will have access only to child or adult services
that are not designed to meet all of the unique challenges faced by young people.
Instead, they focus on the needs of younger children or chronically unwell
adults. Due to resource restrictions, ORYGEN is able to treat only 40 per cent
of the 2 000 young people referred to it each year. Even though research shows
ORYGEN correctly targets those ‘most in need’, a substantial number of very
unwell young people have to be turned away. Almost
two thirds of those not admitted to ORYGEN have at least one mental illness and
nearly one in four of this group have made a suicide attempt in the previous
Consistent with the model those services which most efficiently
service the cohort should be funded for continuous service; the expertise of
non-government organisations needs to be 'mainstreamed' in the process of
service integration, by being brought into core funding agreements.
To extend this model, the federal government should
also implement successful pilot programs nationally. Existing programs could be
trialled for longer term implementation in specific regions:
NCOSS supports the development of a number of funded trials on a
range of service types across NSW (rural, remote and metropolitan) that would
lead to an external evaluation of their effectiveness and the commitment to
implementation and ongoing funding of the best 'models' for each area. For
example, mental health peaks in discussion with NCOSS, raised an option of the
establishment of a small number of residential treatment services for people
with complex needs that would employ a number of different service models.
a national coordinating body in place, advanced models developed by state
agencies for all dual diagnosis cohorts could also be identified, trialled and
implemented nationally with federal support. The Public Advocate in South Australia reported that the state runs a very
successful Exceptional Needs Program for dual diagnosis clients. He regards the
program as a model of multi-sectoral intervention and recommends it for wider
South Australia is
one of a small number of states that offers a holistic resource stream to
clients deemed to live with exceptional needs. It provides a model of service
delivery that is genuinely holistic, dedicating resources to the individual person,
targeted to the key domains of their lives. Commonly, this combines issues of
housing, daily support, case management and therapy. The success of this
program is that it is well resourced, allows resources to follow needs rather than
diagnostic or multiple eligibility criteria and it’s commitment to clients is strong.
This stands in stark contrast to the more typical picture, where
housing, health and welfare services are discrete entities that create a degree
of inertia that can mitigate against positive outcomes for clients.
Acute care—community-based beds
Many operators of dual diagnosis services favoured collocation
or close location of detoxification beds to avoid possible iatrogenic effects
of hospitalisation and ensure consistent progression of a treatment plan. A
view consistently held was that the consolidation of collaborative
community-based care would reduce the need for dedicated acute care beds for
people with dual diagnosis. Dr Andrew Chanen of ORYGEN told the committee:
...an artefact of that coercive environment is, of course, that
there is an increased need for beds. There is a kind of sentimental attachment
to the old days when we had more beds, because we were more coercive and we
could utilise those beds. In a collaborative environment the need for beds
decreases, not increases.
However, it was agreed that deinstitutionalisation has
hit the dual diagnosis cohort particularly hard. The Health Services Union commented:
Closure of tertiary alcohol and drug services intervention beds
and competitive tendering has resulted in fragmentation of services as
providers were forced to compete and cut cost rather than work together
reaching cooperative benchmarks and industry service standards.
As indicated, community-based support is not adequately
funded to provide long stay detoxification beds. Consequently it was generally
There is an urgent need for more
resourcing and coordination of services on the full continuum of drug
prevention treatment, including medium intensive residential services for post
detox treatment and support.
As set out above, the policy of integrating people with
dual diagnosis into mainstream emergency wards has proven spectacularly
unsuccessful. Evidence also
suggested that integration of people with dual diagnosis into psychiatric wards
reduces treatment outcomes for all patients, as well as being difficult for
staff. Former psychiatric nurse Mr Jon Chesterson advised:
Many vulnerable patients who are treated for other psychiatric
or single disorders are frequently subjected to shared inpatient environments
where they feel unsafe, unprotected and threatened by other patients,
particularly by young males who may be acutely unwell during the initial phase
of treatment or detoxification, whether vicariously or planned. It is not
uncommon for patients with a dual diagnosis to continue using whilst receiving
inpatient treatment, and despite clear policies and procedures, it can be
extremely difficult and often compromises the therapeutic relationship and
environment, when nursing staff are expected to police these situations.
In recognition of this problem, the combined Queensland
Gold Coast Mental Health and the Alcohol,
Tobacco and Other Drugs Services (ATODS) has made a submission for the
establishment of a 24 bed inpatient facility for management of people with dual
diagnosis at the proposed new Gold Coast
Health Services District
Hospital. ATODS Director Dr Lynn
While patients with a mental illness are generally better
managed in MH [mental health] wards during the acute stage of psychosis, those
with co-occurring substance use problems who are non-acute, may often be better
managed in a detoxification ward where staff have the necessary training and
expertise, and where a safer and more secure environment can be provided for
With respect to the intersection between GCHSD Mental
Health Services and Alcohol,
Tobacco and Other Drug Services, we feel the best way of supporting mental
health services in its challenge to better manage co-occurring substance use
problems among its patients would be to establish a specialised alcohol and
other drugs detoxification ward here on the Gold Coast.
There is also potential to build services for dual
diagnosis in private settings, As discussed above, the model would require
guaranteed government funding, perhaps through a bed buying arrangement as
applied in Tasmania. Medical
insurance and Medicare bulk billing options would also be required to make it
affordable for this cohort.
14.166 Governments appear to have difficulty
engaging with the realities of dual diagnosis. This is reflected in the
declaration in the National Mental Health Plan that 'drug and alcohol
problems are primarily the responsibility of the drug and alcohol service
system'. The evidence before the committee clearly indicates that it is
counterproductive to separate out mental health and drug and alcohol services
in such a definite way.
14.167 Progress overseas has been achieved by
comprehensive review of both mental health and drug and alcohol policies.
Suicide rates have dropped. This is credited to reduced access to drug supplies
in combination with increased provision of integrated drug and alcohol and
mental health services.
14.168 It is doubtful that being 'tough on drugs'
without the existence of a robust well integrated service network to support
this vulnerable group will yield the desired results. People with dual
diagnosis—now the 'expectation rather than the exception' amongst those with
mental health problems—will remain 'forgotten people', and continue to fall
through the cracks, either into gaol or to their deaths.
14.169 The enormity of the problem suggests an
immediate response from government. Federal government must grasp the 'burning
brand' and lead the states on service integration. As potently argued in the
evidence there is an urgent need to build bridges by taking what's best and developing
on existing successful models.
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