Clinical Audit

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					             Clinical Audit

Substance Misuse & Dual Diagnosis Service


    North Lee Mental Health Service


             Sharon Bailey

The Substance Misuse and Dual Diagnosis Service has been
available in North Lee Mental Health Service since 2005. The
service was developed to provide counselling and support to
clients experiencing both mental health problems and
problems with addiction.

Prior to the development of this service, clients’ issues were
treated as two separate entities and by two separate
organizations, with the mental health issue being managed by
the mental health service and the addiction being managed by
the addiction services. The problems with this scenario were
that clients often ended up falling between the two and were
lost until either problem reached crisis point again.

The second problem with this was that in Munster the only
form of treatment available to clients was a Twelve Step
Programme (ie. total abstinence). This meant that the
treatment centres wouldn’t admit people on any form of mood
altering medication which included anti-depressants, mood
stabilizers or anti-psychotics. Clients needed these forms of
medication for their mental health so therefore they either
couldn’t avail of the service or risked a relapse in their mental
health condition.

Audit History:

Teesson & Gallagher (1999) in their study of a treatment
programme for serious mental illness and substance misuse
found that “people with co-occurring drug and alcohol
problems and mental disorders often fail to access treatment or
are poorly treated by the current health systems”(pg 19). They
also found that despite the common occurrence of these
disorders, service delivery systems did not adequately meet the
needs of this group. Our substance misuse and dual diagnosis
service was put in place to meet the very complex and unique
needs of this client group.

Objectives of Audit:

  • This audit presents data from all attendances in a four
    month period to the substance misuse and dual diagnosis
  • This is the first audit done in this area. It is being carried
    out to form a baseline from which future audits can be
    compared and improved upon.
  • The aims are to look at the number of clients, the
    substances of misuse and the psychiatric diagnosis of
    those being referred to the substance misuse service.

Audit Questions:

  • What are the numbers of attendances per month?

  • What is the addiction being treated?

  • What is the psychiatric diagnosis of the clients?
Literature review:

The literature review looked at health policies and the mental
health legislation and various recommendations made in them
in relation to the treatment of substance misuse in the Mental
Health Service in Ireland. Information was obtained from the
Mental Treatment Act of 1945, through Planning for the Future
(Department of Health, 1984), the new Mental Health Act
(2001) and finally A Vision for Change (DoHC, 2006).

The recommendations have changed dramatically from there
being specific provisions for both the voluntary and
involuntary admission of ‘addicts’, in the 1945 Mental
Treatment Act, to the recommendation in A Vision for Change
that mental health services ought not be responsible for
addiction – only for co morbidity/dual diagnosis.


  • The information was manually taken from monthly
    statistics in relation to client numbers and substance.
  • The psychiatric diagnosis was obtained by going through
    client referral forms and medical notes.


Findings - No. of Attendances:
Month     Number of Clients      Number of Attendances
Dec ’11      23                     22
Jan ’12      23                     34
Feb ’12      20                     33
March ’12    19                     36
Findings – Addiction being treated:
Month        Alcohol         Drugs   Polysubstance   Gambling   Total
Dec          14              2            5          1          22
Jan          22              2            8          2          34
Feb          21              2            8          2          33
March        22              0            13         1          36

Findings - Psychiatric diagnosis:
Month      Dep. Dep/Anx. Schiz.          P.D.   MBD   Un        Total
Dec         16    3      2                 1    1     0         23
Jan         16    3      2                 1    1     0         23
Feb         14    3      1                 1    1     0         20
March       10    3      1                 1    2     1         18

Glossary of abbreviations:

•     Dep. = Depression
•     Dep/Anx. = Depression & Anxiety
•     Schiz. = Schizophrenia
•     P.D. = Personality Disorder
•     MBD = Mental Behavioral Disorder
•     Un = Unspecified

Summary of findings – Addiction :

    • It is clear from the findings that alcohol is the most
      common substance of abuse in this catchment area with
      between 61% and 63% of all attendances presenting for
      alcohol misuse problems alone.
    • Polysubstance misuse is significantly less with between
      22% and 36% of attendances presenting with both
      alcohol and drug misuse.
    • Attendances for drug misuse are considerably lower at
      between 0 and 9% on the four months studied.
  • While gambling brings up the rear with between 2.7%
    and 6%.

Summary of findings – Psychiatric Diagnosis:

  • Depression is obviously the most common diagnosis
    amongst those presenting for help with addiction
    problems with on average 66.2% of clients also treated
    for depression.
  • Combined Depression & Anxiety is the next largest
    category with an average of 14.4%.
  • Schizophrenia was the average recorded diagnosis for 7%
    of those being treated.
  • Personality Disorder was the diagnostic grouping for
    4.8% clients on average.
  • Mental Behavioral Disorder was the diagnostic category
    for a monthly average of 6.2% of clients
  • And just 1 client had an unspecified diagnosis.

Recommendations for future Audit:

  • A repeat of the same audit every four to six months.
  • Drug use could be looked at in terms of illegal misuse and
    prescribed/over the counter misuse.
  • Since the findings show that the biggest problems for
    clients are alcohol misuse and depression it suggests that
    any future psycho-education groups should focus largely
    on these areas.

   Department of Health and Children (2006). A vision for
    change: report of the Expert Group on Mental Health
    Policy. Dublin: Government Publications Office.
   Department of Health. (1984). The psychiatric services -
    planning for the future. Dublin: Stationery Office.
   Mental Health Act (2001). Dublin: Stationery Office
   Mental Treatment Act (1945). Dublin: Stationery Office.
   Teesson, M. & Gallagher, J. (1999) Evaluation of a
    treatment programme for serious mental illness and
    substance use in an inner city area. Journal of Mental
    Health, Vol 8(1), Feb,. pp. 19-28.

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