North-South Perspectives Responding to the needs of people with co-existing issues of alcohol misuse and mental ill-health

1. Alcohol, Self Harm and Suicide
Southern Perspective
Dr Eamon Keenan
National Clinical Lead HSE Addiction
Services
03.05.17

2. National Policy
• Planning for the Future, 1984
- Approach to alcohol and drugs changed to prevention rather than treatment
• NACD, Dual Diagnosis, 2004
– Develop clinically effective service and treatment
• Vision for Change, 2006
- Addiction lies outside Mental Health
• National Drug Strategy 2009
- Highlighted issue of Alcohol
• National Substance Misuse Strategy 2012
- Challenged view outlined by ‘Vision’. Drinks industry at the table.
• National Drugs Strategy 2017 due to be published this
year

3. Vision for Change
• Most recent Mental health Strategy published by DOHC in
January 2006
• Provided template for development of Mental Health Services
over the next 10 years
• Follow up to ‘Planning for the Future’ in 1984
• Emphasises development of multidisciplinary Community
Mental Health Teams (CMHT) core elements of which are
psychiatry, nursing, social work, clinical psychology and OT
• Plan to close all mental hospitals
• Care for people with addiction lies outside the mental health
system. Now completely within Primary Care

4. Vision for Change - Addiction
• Addiction merits 3.5 pages in a 284 page report
• Expert group had been convened to make recommendations on
Addiction
• One specialist adult team per 300,000 of population to manage
complex severe substance misuse and mental disorder.
• One adolescent team per 1,000,000 of population.
• Addiction beds not for routine detoxification.
• No mention of development of alcohol services
• Recommendations of expert subgroup and all submissions on
subject were directly contradicted

5. Vision for Change - Developments
• National Substance Misuse Strategy 2012
highlights inconsistency and challenges ‘Vision’
• Faculty of Substance Misuse in College of
Psychiatrists calling to revisit document
• Otherwise asking for 20-25% of Mental Health
budget be diverted to the new Substance Misuse
service development
• No Transitional Investment provided no plan for
collaborative discussion
• Growing recognition of problem of ‘Dual
Diagnosis’

6. Rates of Admission to Psychiatric Hospitals with Alcohol related
diagnosis 2006-2013

9. Per Capita consumption 2016
• Provisional figures for 2016 indicate that per
capita consumption of pure alcohol was 11.46
litres per person aged 15+
• Increase of 4.8% from 2015
• Increases in all categories of alcohol
• Consumption of 11 litres of pure alcohol (taking
account that 20.6% of adult population abstain)
means the figures for those who consume alcohol
are 46 bottles of vodka or 130 bottles of wine or
498 pints of beer per year

10. Irish Suicide Rate-European Comparison
• Overall suicide rate is not high by European
comparison
• 11.1 per 100,000 population in 2013 was 11th
lowest of 31 countries reporting
• Among Young people aged 15-19 yrs, Ireland
is the 6th highest of 29 countries reporting

11. Suicide rates per 100,000 for males and females
2013

12. Suicide rates per 100,000 for males and females aged
15-19 yrs 2013

13. Number and Rates of suicide per 100,000 of
population and undetermined death 2013-2015
SUICIDE UNDETERMINED
Number Rate Number Rate
2015*
Males 375 16.4 51 2.2
Females 76 3.2 17 0.7
Total 451 9.7 68 1.5
2014*
Males 368 16.1 46 2.0
Females 91 3.9 16 0.7
Total 459 10.0 62 1.3
2013
Males 391 17.2 41 1.8
Females 96 4.1 15 0.6
Total 487 10.6 56 1.2

14. National Self Harm Registry
• Established 14 years ago by the National
Suicide Research Foundation in UCC
• Provides real time data on trends and high risk
groups
• Noted an increase of 67% in rates of self harm
in homeless people since 2007 assoc. with
substance misuse

16. Ireland’s National Strategy to Reduce Suicide 2015-2020
VISION: An Ireland where fewer lives are lost through suicide, and where
communities and individuals are empowered to improve their mental health
and wellbeing.

17. National Implementation Structure

18. Who are we going to support?
Health/mental health related groups: People with mental health problems of all ages, those who have engaged in
repeated acts of self-harm, people with alcohol and drug problems and people with chronic physical health
conditions
Minority groups: Members of the LGBT community, members of the Traveller community, people who are homeless,
people who come in contact with the criminal justice system (e.g. prisoners), people who have experienced domestic,
clerical, institutional, sexual or physical abuse, asylum seekers, refugees, migrants and sex workers
Demographic cohorts: Middle aged men and women, young people and economically disadvantaged people
Suicide related: People bereaved by suicide
Occupational groups: Healthcare professionals, professionals working in isolation, e.g. veterinarians, farmers

19. To improve the nation’s understanding of and attitudes to suicidal behaviour, mental
health and wellbeing
To support local communities’ capacity to prevent and respond to suicidal behaviour
To target approaches to reduce suicidal behaviour and improve mental health
among priority groups
To enhance accessibility, consistency and care pathways of services for people
vulnerable to suicidal behaviour
To ensure safe and high-quality services for people vulnerable to suicide
To reduce and restrict access to means of suicidal behaviour
To improve surveillance, evaluation and high-quality research relating to suicidal
behaviour
7 Strategic Goals

20. Outcomes of the Strategy
Reduced suicide rate in the whole
population and amongst specified
priority groups
Reduced rate of presentations of self-
harm in the whole population and
amongst specified priority groups

21. HSE Primary Care Commitments
HSE PRIMARY CARE – COMMITMENTS LIST Role Action
Build the link between alcohol/drug misuse and suicidal behaviour into all communication
campaigns.
Lead 1.1.4
Develop and implement a range of agency protocols and inter-agency protocols (including
protocols for sharing information) to assist organisations to work collaboratively in relation to
suicide prevention and the management of critical incidents.
Lead 3.1.2
Develop and deliver targeted initiatives and services at primary care level for priority groups. Lead 3.1.3
Continue the roll-out of programmes aimed at early intervention and prevention of alcohol
and drug misuse in conjunction with HSE Primary Care.
Lead 3.2.1
Deliver early intervention and psychological support service for young people at primary care
level.
Lead 3.3.6
Deliver, accessible, uniform evidence based psychological interventions including counselling
for mental health problems in both primary and secondary care levels.
Lead 4.2.1

22. Communications
• Build the link between alcohol/drug misuse
and suicidal behaviour into all communication
campaigns
• Askaboutalcohol.ie
• NPS campaign in conjunction with Union of
Students of Ireland

26. Priority Groups
• Develop and deliver targeted initiatives and
services at primary care level for priority
groups.
• STORM® training for Addiction services staff
and Traveller Health Unit staff being piloted in
2017 – Train the Trainer ongoing in CHO 4

27. Early Intervention
• Deliver early intervention/prevention for alcohol
and drug misuse plus psychological support
service for young people at primary care level
• Currently rolling out SAOR training model of
screening and brief intervention to targeted
groups and professionals
• Funding allocated to develop network of
Assistant Psychology posts to work in Primary
Care with support targeting adolescents and
young people including substance misuse issues

28. Dual Diagnosis
• Recognised as an issue in 2004 report of NACD
• Substance Misuse links with Mental health problems,
self harm and suicide rates becoming more evident
• Issue of NPS presenting to acute services has further
highlighted the issue (Ireland has highest rates of
NPS use among 15-24 yr age group in Europe)
• Vision for Change failing this cohort of patients

29. Extent of NPS Market:
2014 Flash Euro barometer
• Survey of 13,000 young adults age 15-24
• 8% had used NPS at least once
• Highest consumption- Ireland (22%)
• 3% had used NPS in the last year
• Highest use in last year- Ireland (9%)

30. Dual Diagnosis Response
• HSE Mental Health division in conjunction with the
College of Psychiatrists committed to setting up a
Clinical Programme (CP) - 2016
• ‘Co-morbid Mental Illness and Substance Misuse’
• Clinical Lead post (Consultant Psychiatrist) has been
recruited for a 1 yr period, awaiting backfill for 2 days
per week
• Programme Manager in place since Dec 2016
• Mapping of service has occurred highlighted
reduction in counselling provision

31. Dual Diagnosis Response
• CP develops a Model of Care, sets out National
Guidelines and Care pathways.
• Supports local implementation of Best Practice
• Develop joint policies with clear roles and
responsibilities for services
• Engages with relevant stakeholders within and
outside HSE including Service User group
• Ensures service delivery meets the needs of patients

32. CP Responsibility
• Convene National Working Group
• Design and develop an evidence based Model of Care for co-morbid
mental illness and substance misuse
• Work with Clinical Advisory Group from College of Psychiatrists
• Support and advise on the implementation of the Model of Care
Nationally
• Organise training and monitor implementation of Model of Care
• Development of Community Dual Diagnosis Teams with access to inpatient
drug treatment and rehabilitation units
• Two year time frame from establishment of CP to mainstream operation in
Mental Health Services

33. Challenges
• Collaborative working within Health services e.g.
Mental Health, Primary Care, Acute services
• Alcohol treatment has not received Transitional
funding since Vision for Change has been
published
• Fear from MH that the Dual Diagnosis CP will be
asked to provide primary alcohol tx
• Different models operating across the country
• Public Health (Alcohol) Bill v. slowly passing
through legislative process - ?attitudes to alcohol