Dealing with dual diagnosis patients 'is a problem'

Substance abuse can be more dangerous than people think since apart from leading to addiction it may cause or catalyse psychiatric problems.

Mental health professionals, caregivers and families well know the complexities of treatment required by patients diagnosed with a dual diagnosis - the coexisting diagnosis of substance abuse and other mental illness.

Programmes that treat individuals with mental disorders do not treat those with substance abuse problems and programmes for substance abuse do not cater for people with mental illness. So who is responsible for these patients?

The director of psychiatric services, Joe Saliba, and consultant psychiatrist Anton Grech recognise that there is a problem on how to manage such patients even in Malta.

Dr Saliba and Dr Grech explained that the treatment depends on the level of care required. Patients are generally cared for on an outpatients level at the detox centre where they are treated for their substance abuse problem and visited by one of three psychiatrists designated such responsibilities.

If patients require admission for a psychiatric problem they are sent to Mount Carmel Hospital where they are followed up by addiction services such as Sedqa or Caritas.

They went on to explain how whereas in the past patients with a dual diagnosis were kept in male or female ward one, which are acute admission wards, as from June this year males suffering from the condition could be transferred to the dual diagnosis ward - a six-bed unit at Mount Carmel Hospital.

Dr Grech explained that, due to the lack of resources, a choice had to be made between opening a male or female dual diagnosis ward. Since the ratio of males to females suffering from the condition is seven to one, the male ward was opened.

Due to the highly vulnerable nature of the group it is difficult to manage a group of mixed sexes. The opening of the female ward, they said, is being discussed.

Sedqa's clinical director George Grech noted the need for a continuum of services to monitor such patients. "The lack of a continuum of services leads to what is known as the 'revolving door syndrome', that is, the same individual is attending different departments, clinics and hospitals because nobody is primarily responsible for him".

He agreed that a more tailored treatment for patients with a dual diagnosis was needed and explained that since the outpatients system was set up at the detox centre the number of patients at Mount Carmel Hospital has reduced dramatically.

"One of the biggest challenges of such patients is that some stop taking their treatment and that's when they regress... By having a good outpatients service we have much better control over patients," Dr Grech said.

Speaking about the dual diagnosis unit he explained that this service had to be community based. "The challenge is to keep them in the community and therefore the stay in the six-bed unit is not a long one so that patients won't get stuck there.

"Once released from the unit, they are moved on to the other services and this is where the continuum fits in. For this reason, apart from the unit we need a good outreach service to ensure that they are still in contact with the services and taking their treatment," he said.

Asked which of the problems came first Dr Saliba and Dr Anton Grech explained that both could lead to each other. "Drugs do not have the same effect on everyone. Some people will try drugs and not get addicted while in others it will cause not only addiction but also serious psychiatric problems.

"A normal person who abuses alcohol for a long time, for example, may start suffering from depression or eventually even dementia. On the other hand if someone is predisposed to schizophrenia using cannabis could increase the chances of schizophrenia... So the prolonged use of substances can lead to psychiatric illness and a psychiatric illness itself can lead to substance abuse," they said.

They added that it is important that people with a dual diagnosis or their families overcome the social stigma surrounding drug addiction and seek treatment.