This is Ellie's story which I hope highlights the need for changes in the way we help people who are using alcohol or other drugs and who also have significant mental health issues.
As well as running a Suicide Crisis Centre, I manage a separate Trauma Centre where we provide support for people who have experienced recent or historic trauma. The focus there is on early intervention - supporting people to help prevent a crisis. There may be a wait for NHS psychological therapy and we support a lot of people in that intervening period.
Ellie attended regular appointments at our Trauma Centre. She was also under the care of secondary mental health services and alcohol services. She had reduced her alcohol intake and was drinking very little at the time. I recall the day that this changed. She had been to a local alcohol support group and described how distressed she was after what she had heard shared in the group. It had been traumatic to hear about another group member's past experiences. She had gone home after the alcohol support group meeting and drunk a significant amount.
What she had heard in the group seemed to re-trigger memories of her own traumatic past. Over the weeks that followed she described experiencing "night terrors" - dreams so terrifying and realistic that she would awake believing that she was back in the traumatic situation. It was unbearable for her and she started to drink particularly heavily at night to block out the frightening dreams.
As she began to drink more heavily, she stopped coming in to our Centre so we went out to see her regularly. Eventually she was drinking so much that she couldn't leave home at all. This meant that alcohol services couldn't provide regular support any more. They came to her home a couple of times but couldn't do regular home visits.
Our local mental services made a decision to temporarily stop providing care. They told her that her mental health care would resume when she had been free of alcohol for a month. They felt this would be an incentive to stop drinking. But she was devastated by their decision. "It cut me like a scythe," she told us. She felt abandoned.
I contacted all the services involved in her care to express my concerns that we were now the only organisation supporting her regularly and that, whilst we could provide crisis support, we couldn't treat her alcohol addiction nor provide the psychological intervention which she needed for PTSD.
Her situation deteriorated rapidly. On two occasions when we visited her home, she had sustained injuries as a result of a fall and we had to call emergency services.
She wanted to go into residential rehab, specifically to a place where they would treat not just her alcohol dependency but also her PTSD - the underlying reason why she was drinking. She was told that she needed to show that she could engage with alcohol services in the community first. She needed to demonstrate that she could attend appointments and that she could reduce her alcohol intake.
At home, alone, and plagued by images of her traumatic past, she simply wasn't able to reduce her alcohol intake. She needed support to do so.
Ten days before she died she spoke to me on the phone and said: "Joy, I'm fading fast." I contacted all the statutory services previously involved in her care to express my concern that she would die if urgent care wasn't put in place. We were devastated when we heard that the prediction had proved to be accurate.
Ellie died of pancreatitis. I attended her funeral and overheard a neighbour say "There are some people who cannot be helped". I profoundly disagree. Ellie wanted to be helped. She wanted and needed a type of help that doesn't seem to exist at present for people who are alcohol dependent, who also have significant mental health issues, and who reach such a point of crisis that they need urgent, intensive care - probably residential care.
If you experience a mental health crisis, you can access crisis care and home treatment teams and if necessary psychiatric hospital. You do not have to demonstrate engagement in the community to access psychiatric hospital. Indeed, an inability to engage in the community makes it more likely that you will be offered inpatient care. We need a similar level of care for a combined addiction/mental health crisis.
I recall being told by Ellie's GP that it was her choice to continue to drink. I replied: "She is on anti-depressants so you acknowledge that she is clinically depressed. She is describing severe post-traumatic symptoms. Her depression and PTSD are impacting upon her ability to make decisions at present."
Surely there comes a point where we intervene and say "This is now a crisis situation where there is a significant risk to life. We need to act to preserve life and either provide intensive home treatment or admit the person to a residential unit."
Ellie's is not an isolated case. Again and again we see clients at our Suicide Crisis Centre and our Trauma Centre who are discharged from mental health services because they are alcohol dependent or who are refused these services in the first place because of dependency. They are referred to separate addiction services, despite the fact that they may be using alcohol or other drugs to suppress the symptoms of their mental health condition.
The recommendations now are that addiction and mental illness are treated at the same time (1) and yet, in reality, this isn't happening. We are seeing new clients who have been directed only to addiction services.
We are now in regular contact with the former carer of a young man who has reached crisis point. He has a mental health diagnosis for which he is not being treated. When he cuts down on his substance intake, the memories of his traumatic past resurface, and so he starts to use more again. He has just been made homeless. His carer tells me that she awakes every morning expecting to receive a call informing her of his death. She is distraught and cannot understand why there is no form of crisis intervention at this point, and neither can we.
I do not want to see another client die in the same manner as Ellie. It is simply too painful. We watched a bright, intelligent, caring, creative individual deteriorate before our eyes over a period of months. We cared about her and we feel her loss. We need to urgently review the way in which statutory services help people who reach such a crisis point.
Turning Point, the substance misuse charity, has just produced a report "Dual Dilemma: The impact of living with mental health issues combined with drug and alcohol misuse"(1) which confirms that current service provision is inadequate, and that co-existing disorders are still usually treated sequentially rather than simultaneously.
New NICE guidelines for the treatment of dual diagnosis are expected to be published in November 2016.
Information about the charity Suicide Crisis and the Suicide Crisis Centre can be found at http://www.suicidecrisis.co.uk
Ellie is not our client's real name.
Draft NICE guideline: severe mental illness and substance misuse (dual diagnosis). First contact 1.1.2 "Ensure the person is referred to secondary care mental health services for assessment and care planning."
US Department of Health Substance Abuse & Mental Health Services Administration (SAMHSA). Overarching Principles To Address The Needs of Persons With Co-Occurring Disorders, principle 8: "Within the treatment context, both co-occurring disorders are considered primary.... It is a disservice to the person with COD to emphasise attention to one disorder at the expense of another."
PTSD and Co-Occurring Substance Use Disorders: Advances In Assessment and Treatment. Jenna L McCauley 2012. "Conclusion: Integrated treatments have demonstrated the ability to significantly reduce symptoms of PTSD, Substance Abuse Disorder and associated pathology such as depression."
Turning Point Report: http://www.turning-point.co.uk/media/1138757/dual_dilemma.pdf