For Those With Both Substance-Use and Mental-Health Issues, a Lack of Services

Valerie Farragher turned to drink to get through the day when she was depressed and quickly developed a serious problem.

For ten years she went to Alcoholics Anonymous (AA) and tried to cope. She says she was in hospital approximately 30 times during that decade, but was never offered psychiatric treatment.

Finally, following a suicide attempt, a psychiatrist diagnosed her with post-natal depression. She had had it since since the birth of her fourth child, 10 years earlier.

“It was only when I got into the mental-health services that things started to come together for me,” she says.

The psychiatrist prescribed an anti-depressant called Lexipro, she says. “What it did was calm down that galloping brain.”

Farragher left AA, and began attending Aware, a support group for people with depression. Today she works to support other women with drink problems.

Most addicts are using substances to self-medicate for underlying mental and emotional problems, she says. “People of sound mind don’t get up and go on the piss every day.”

Ireland’s health-care system is not well-equipped to help people like these who are dealing with both mental-health issues and substance-use issues.

Some say that needs to change, especially as research shows that many people who have substance-use issues also have underlying psychiatric conditions.

And there are hopeful signs that the government is working on a new service for such “dual-diagnosis” patients.

Valerie’s Story

A mother of five, Valerie Farragher felt incredible guilt that she couldn’t stop drinking.

Believing she would never recover, and feeling like a burden on her family, she tried to take her own life, and ended up in hospital.

On previous admissions, she had always been admitted for detox, she says, where staff normally just recommended that she return to AA.

But this time, after she was treated for her physical injuries, she got a referral to see a psychiatrist as an outpatient. He diagnosed her with post-natal depression, and prescribed medication.

He also told her to stop going to AA, and she started attending Aware. “The message in Aware was, ‘Empower yourself, you are fine, your drinking is in the past, forget about it,’” she says.

She now works to support other women who have turned to drink as a coping mechanism for trauma or pain. She says that women drink for emotional reasons.

A lot of these are women who start to drink later in life, in their 40s and 50s, and she thinks she has spotted a pattern in this age cohort.

“Every single one of them has lost a baby,” she says. Those who lost babies through adoption, or who had abortions may also have feelings of shame that they need to work through.

What all these women need is a good counsellor to look at the grief, shame or trauma they have experienced, she says.

“As they are figuring it out, and getting stronger, the drinking just stops on its own,” she says.

Suicide and Substances

A combination of mental-health and substance-use issues caused Valerie Farragher to try to take her own life. She is not alone in this.

Last week, the Irish Independent independent.ie/irish-news/teen-18-rescued-from-river-by-garda-then-turned-away-from-busy-hospital-35733660.html”>reported that a girl of 18 who had tried kill herself, was turned away from the University College Hospital, Galway because she was “intoxicated”.

The off-duty garda who saved the girl took her to a Garda station and looked after her until her father arrived.

Her father brought her back to the hospital and begged them to admit her, says the report, but they refused.

Tony Duffin, who is CEO of the Ana Liffey Project in Dublin, which works with people with serious mental-health and substance-use problems, says this refusal of services is the normal procedure for hospitals.

“In our experience, mental-health services do not assess, and therefore cannot admit, persons when intoxicated. We can’t think of any exception to this,” he says.

Yet substances, particularly alcohol, are known to greatly increase the risk of suicide.

A University College, Cork study of 121 suicides revealed that in 80 percent of suicides studied, substances were present in the blood at the time of death

“Alcohol consumption may exacerbate depression and depressive symptoms,” says the study. “It increases disinhibiting thoughts and behaviour and depressive symptoms, impacting on the other risk factors for suicide.”

So why aren’t there more dual-diagnosis services, which can help people like this Farragher and this girl in Galway, who may show up drunk, and need help with that, but also with underlying mental-health issues?

The HSE did not respond by the time this was published to a series of questions about the lack of dual-diagnosis services.

Dual Diagnosis

Neither the mental-health services nor residential rehabs are structured to deal with people with dual diagnoses, says Carol Moore, of the organisation Dual Diagnosis Ireland.

“Vision for Change, which is the government’s policy for mental health, is fundamentally flawed because it is says addiction is not a mental-health issue,” she says.

But research has demonstrated that providing a dual-diagnosis service is more effective than treating mental-health and substance-use issues separately, says Moore.

“If you provide integrated care, all the evidence shows it is cheaper in the long run … because the person gets better quicker,” she says.

Says Duffin, of Ana Liffey: “Dual diagnosis is a complex problem to address. There are no dedicated dual-diagnosis services for the most vulnerable people on the streets of Dublin.”

Addictions treatment often fails because the underlying mental-health problem has not been successfully treated, says Duffin. “This can be damaging to the person, their family and the community.”

“Treating dual-diagnosis issues in tandem would appear to be a good use of scarce resources,” he says.

Turned Away

Mark Kennedy of Merchants Quay Ireland, which runs a community detox unit, says that those with serious psychiatric illnesses need to be detoxed in hospital.

“The more complex the case, the more resources you need there on site,” he says. “More  doctors, nurses, psychiatry, which builds up the cost of a service.”

There are only about 40 medical detox beds nationwide, he says.

Of course, not detoxing people is also a risk, as they may die from substance use. “You have to have a service for those people,” he says.

Kennedy says a specialised medical detox unit is required for the most complex cases, people who are poly-drug users, and have severe mental-health problems.

Duffin, of Ana Liffey, also pointed to a shortage of services for people with dual diagnoses.

“[We] work with people with complex and multiple needs,” he said. “All are poly-drug users and many people present to us with mental-health issues.

“There is an absence of accessible residential drug-stabilisation/detox services for this very vulnerable cohort of people.”

Francis Doherty, of the Peter McVerry Trust, says his organisation routinely raises the lack of dual-diagnosis services, as their clients are regularly turned away from mental-health services due to their drug use.

Peter McVerry Trust runs a small community-based rehab funded by the HSE, but there isn’t a doctor there all the times, so they can’t accept people with severe psychiatric illnesses, he says.

“People with complex needs would go to the hospital with the full suite of staff, in case of any issues,” he says.

However, Aoife Mulhall of Simon Community says her organisation’s detox  is aimed at those who are usually excluded from other services.

“We work with people with mental-health issues, and once we are clear on the risks associated – for example withdrawal and exacerbation of psychotic symptoms – we can mitigate against those risks provided it is safe for the client,” says Mulhall.

Integrated Services

Says Duffin: “In the past, I have worked directly with people who have had their underlying mental-health issue properly treated in tandem to their drug use issue, and the outcome has been successful.”

Moore, of Dual Diagnosis Ireland, says that treatment should be person-centred and evidence-based. All services should be regulated and results audited.

The HSE recently wrote to Dual Diagnosis Ireland outlining  details of a new dual-diagnosis service they are planning.

The aim of this will be to “develop a standardised evidence-based approach to the identification, assessment and treatment of co-morbid mental illness and substance misuse,” says the letter written on behalf of Minister of State for Mental Health and Older People Helen McEntee.

A programme manager has been identified, the letter says. The service will be aimed at those with moderate to severe mental-health problems and substance-use issues.

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