Deputy Dessie Ellis: The definition of dual diagnosis according to the Royal College of Psychiatrists is the coexistence of mental health and substance misuse problems, including both drugs and alcohol. Each of these disorders is both chronic and relapsing and each has an independent course capable of influencing the other disorder. It is recognised by many notable psychiatrists that it is quite unusual for an individual to present to outpatient addiction services with addiction problems only. Many psychiatrists accept that those presenting in such circumstances would have a co-morbid disorder and that this would be the rule rather than the exception. 

There is, however, a complex relationship between these two scenarios in that an individual who presents may have what is termed a primary psychiatric disorder but also a secondary disorder of substance misuse. On the other hand, another presenting individual could have a primary substance misuse disorder with associated psychiatric complications. A third individual might have concurrent substance misuse and a psychiatric disorder. A final example would be an individual with an underlying traumatic or stressful experience causing a disorder such as post-traumatic stress disorder which results in substance misuse as well as mood disorders. 

According to figures from the European Monitoring Centre for Drugs and Drug Addiction, up to 80% of patients with drug dependency have a psychiatric disorder. The implications of dual diagnosis for an individual are extensive. For example, it can give rise to an acute increase in the severity of the symptoms or non-compliance by the individual with their treatment or medication plan. The individual could experience an increase in the relapse rate. There could be an increased risk of suicide, self-harm and homelessness. Furthermore, there could be a rejection of the individual by psychiatric and drug services and greater complexity in the diagnosis and assessment of the condition. 

Over recent years, there has been growing acceptance and recognition of the problem of dual diagnosis. However, this does not seem to be matched in actions taken. Some years ago, there was talk of a clinical lead in dual diagnosis having been appointed, but little was heard of this appointment after that. In 2019, in answer to a parliamentary question, Dr. Siobhán Ní Bhriain, the national clinical programme group lead, confirmed the post of clinical lead for the national clinical programme for dual diagnosis was vacant, not having been filled in a skills-matching process following national advertisements by the HSE and the College of Psychiatrists of Ireland. In October 2020, the HSE advertised the position again and the successful candidate was to take up the post in quarter 1 of 2021. Can the Minister of State advise us as to the position on that competition? 

I understand there are currently discussions on the development of a draft model of care. Can the Minister of State outline what provision is being made for those with comorbid mental illness and substance misuse? 

Dual diagnosis places an enormous strain on individuals, their families and health services. It should be the goal of the HSE to mainstream dual-diagnosis treatment in mental health services. Families and those suffering owing to a dual diagnosis, in addition to those in mental health services, are anxious that progress be made on this issue because the system has failed them over the past several years. We should not allow this to continue. 

Deputy Malcolm Noonan: I thank the Deputy for raising this. In the time I have, I will try to outline the response on behalf of my colleague Deputy Mary Butler, Minister of State at the Department of Health. 

Budget 2022 provided an unprecedented mental health budget of €1.149 billion, including €24 million for new developments. The new-development funding will allow further implementation of Sharing the Vision. Investment of €750,000 — the full year cost being €1 million — will enable the continued expansion of the specialist teams under the dual diagnosis clinical programme. Dual diagnosis is a particularly important area because service users living with both substance misuse and mental health difficulties are often the most vulnerable in society. The needs of people presenting with substance misuse and mental health difficulties are complex and may be coupled with other issues, such as poor physical health or homelessness. The complex nature of these needs makes it difficult to ensure that the treatment being given can capture all aspects of service users' needs. The HSE has recognised that there is a need to improve services for people with comorbid difficulties and that an integrated approach between mental health and addiction services is required. The HSE clinical programme for dual diagnosis was developed to respond to this need. 

The aim of the programme is to develop a standardised evidence-based approach to the identification, assessment and treatment of comorbid mental health difficulties and substance misuse. This includes increasing awareness of the frequent coexistence of mental health difficulties and substance misuse; ensuring a clear clinical pathway for management of people with such a dual diagnosis, including when they present to emergency departments; ensuring a standardised service is provided throughout the country; and ensuring adolescents are also included within the scope of this clinical programme. Work has already taken place on this aim. This includes the appointment of a national clinical lead and programme manager and the establishment of a national steering group. An integral part of the dual diagnosis programme is the development of a model of care that will ensure a clear clinical pathway for all adolescents and adults suspected of having a dual diagnosis, and access to a timely mental health service nationally. 

The model of care is being developed in collaboration with recovery agencies and advocacy groups that represent the experiences of service users. It will be delivered on a community health organisation, CHO, basis and provided in an integrated manner across the primary care division and the mental health service, with a close relationship with acute hospital groups. One of the key components of the model of care is the establishment of specialist teams to support individuals with a dual diagnosis. The first pilot site for a dual diagnosis team is in CHO 3 and received investment from 2021 new-development funding towards its development. In addition, the HSE and Mental Health Ireland have developed a resource for people affected by dual diagnosis. It is available at www.drugs.ie. The website advises people to look after their mental health during the crisis and includes information about accessing mental health and addiction services. Government policies, including Sharing the Vision and Reducing Harm, Supporting Recovery, set out clear commitments to improving services for people with a dual diagnosis. The high-level justice task force is also examining dual diagnosis among individuals who come into contact with the criminal justice system. 

The Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill, introduced in the Dáil in 2021 and sponsored by Deputy Ellis's colleagues Deputies Ward and Gould, seeks to define dual diagnosis and amend the Health Act 2004 to require a HSE service plan to include specific plans for dual diagnosis and care services. As I have outlined, these are now in train. With the appointment of a clinical lead, I believe we will see a considerable focus on this critical area over the coming years.

Deputy Dessie Ellis: For many years, the health services, particularly psychiatric services, have been struggling. Even before the pandemic, they were struggling. We were not recruiting staff although there was a commitment to do so. I have lost count over the years of the number of people who have been turned away from accident and emergency departments because of a dual diagnosis. In many cases, this resulted in fatalities.

The Minister of State referred to the specialist teams that have been set up, but this is all too slow. There is a pilot scheme in CHO 3 whereby specialist teams are brought in. I despair when I talk to people about some of the cases that have been raised with me in this regard. In each CHO area, we should have dedicated nurses trained in dual diagnosis. Also, psychiatrists in accident and emergency departments should be trained in dual diagnosis and have the ability to deal with it. We fought hard to get psychiatrists in accident and emergency departments — it took the Government a long time to concede on this — so it is not good enough that people are being turned away from accident and emergency departments.

I despair over recruitment in the mental health services. I have heard of people who interviewed successfully for jobs before Christmas but still have not got them. It is totally unacceptable that they are not being employed now.

Deputy Malcolm Noonan: I assure the Deputy that the expansion of the programme will occur on a CHO basis and in an integrated manner across mental health services in the primary care division and include a close relationship with the acute hospital groups. The point the Deputy made about people who present at accident and emergency departments and acute hospitals is critical.

In response to the Deputy's colleague Deputy Ward, Ms Niamh Wallis, the head of service of the mid-west mental health service, has stated that the national office, along with a consultant psychiatrist, is leading on the development of a model of care for dual diagnosis that will be used nationally. This is a positive development for the mid-west, the nation as a whole and the people who require the support and intervention of this team.

A clinical lead is in place. The pilot programme is in place in the mid-west, with anticipation and funding in place to roll out this programme nationally. I agree wholeheartedly with the Deputy that it is a critically important area for people who present with complex assessments and needs in dual diagnoses. As we have outlined, the response to date has been co-ordinated and there is significant movement happening on this.