A HEALTH TEAM in Cork is seeing a huge impact in the progress experienced by patients with addiction issues due to a collaboration between services with different areas of expertise.
There have long been calls for greater integration between services within the health system, and one addiction expert said the results in Cork show the real-life impact this approach can have.
Andrew Fiddow said that when a patient with a dual diagnosis (a mental health condition and a substance issue) is referred from one team to another, “very often they’re lost in transit between services”.
Fiddow, who has over 20 years of experience in the addiction and homelessness sectors, started to work with the RISE team in 2021.
RISE provides early intervention for people who experience psychosis. As well as Fiddow, the multidisciplinary team includes a psychiatrist, a psychologist, a nurse who specialises in psychosis, and an employment support worker.
Just over 100 people are currently engaging with RISE, about 10% of whom need support related to substance use.
Since Fiddow started to work with RISE, he has seen a high success rate in terms of helping people stop or reduce their substance use.
For example, of the 69 referrals in 2022, 20 people stopped using drugs and alcohol (29.4%), 18 significantly reduced their use (26.5%), and six (8.8%) engaged in residential treatment.
It’s a relatively small sample size, but Fiddow said these figures are double what he would typically achieve before joining RISE.
The holistic approach provided by the team is making a massive difference in people’s lives, Fiddow told The Journal.
The numbers that I achieved in the first year in terms of abstinence, reduction, disengagement, residential treatment – without a doubt, in the 15 years I was working in the community, I’ve never reached those numbers. The statistics speak for themselves.
People “working in isolation”, even with “all the best intentions”, simply cannot achieve those results, he said.
It’s hoped that the RISE model can be replicated by other psychosis teams around the country.
Cannabis and alcohol are typically the most common substances people are using, but other drugs like cocaine sometimes feature too.
When Fiddow first meets a person who has been referred to the RISE team, he rarely brings up the topic of addiction.
He told us: “Very often, I won’t even mention drugs in the first meeting. I think developing a therapeutic relationship – finding out where that person’s at, where that person was before their drug use, what interests they have, what their personality is like, what they were like in school – is vitally important.
“I’m obviously trying to get that person engaged and coming back, getting them to commit to engagement and an assessment, motivating change.”
As well as one-on-one meetings, Fiddow runs regular peer support groups and wellbeing sessions. He said working alongside a clinical nurse practitioner, who is specialist in psychosis, has been “invaluable”.
One parent whose son was treated by RISE said the integration of addiction and mental health services “played a key role in [his] healing and recovery”.
It felt like a more holistic approach to a complex issue. I am also grateful for the support that was given to us as a family which also played a big part in his healing journey.
Cathal*, another patient who was referred to RISE, said the fact he received a range of supports – therapy, medication, and addiction and employment support – was vital in his recovery.
He experienced an intense psychotic episode last year which he believes was brought on by smoking HHC, a semisynthetic cannabinoid. He is doing much better now and has returned to work.
“You need support, you need people to help you through… Everyone should be able to get those supports,” he previously told The Journal.
Dr Karen O’Connor, RISE’s consultant psychiatrist, said it has been “brilliant” to have an addiction worker on the team.
O’Connor noted that some people don’t want to talk to a psychiatrist, feeling they are “lecturing” them about substance use, but are more comfortable talking to an addiction specialist.
“We see a massive benefit as a team,” she said.
O’Connor said there is “absolutely” a need to integrate services better across the health system, adding that “some people fall through the cracks, there’s no doubt about it”.
“It’s a really frustrating, challenging aspect of the way our health services work.”
O’Connor is the HSE’s National Clinical Lead on early intervention in psychosis (EIP). She said investing in these services would save lives, keep people out of hospitals and homeless shelters, and save money long-term.
However, even though the long-term benefits of early intervention have been proven in Cork and elsewhere, the Government has been slow to fund certain services.
From 2015 to 2022 €3.68 million was invested in EIP services, but no new funding was granted last year or to date in 2024. As previously reported by The Journal, at the current rate of investment, it could take over 60 years to set up the required number of EIP teams.
There are five adult EIP teams in Ireland at present, including RISE, but not all fully staffed.
These multidisciplinary teams typically consist of a key worker, a psychiatrist, a psychologist, specialised therapists, employment support, and support services for the patient’s family.
The HSE estimates that an additional 20 teams are required “to ensure everyone presenting for the first time with psychosis” gets access to EIP services.
It would cost around €2.5 million to set up a fully-staffed EIP team in an urban area, with a high incidence of psychosis providing care to a population of 200,000 people aged 14 to 64 years, the HSE said. However, smaller teams would cost less to get up and running.
The country’s first CAMHS EIP team recently started to see child and adolescent patients. They have carried out 20 assessments to date. All staff members are in place on this team bar the consultant psychiatrist, who is due to start by June.
A spokesperson for the Department of Health said the Government “remains firmly committed to enhancing all aspects of mental health services, including for specialist mental health services such as early intervention psychosis (EIP)”.
They acknowledged that, in the absence of an EIP service, “access to treatment can often be in crisis and limited to medication”.
An additional €10 million for the national mental health budget was announced in January. The department’s spokesperson said some of this funding may cover posts to support EIP services, adding that the “details are currently being finalised”.
The main symptoms associated with a psychotic episode are hallucinations and disturbed thoughts.
Some people have a one-off psychotic episode, but don’t develop a related condition. However, every year in Ireland around 1,500 people develop a psychotic disorder such as schizophrenia, which is treatable but not curable.
The age range varies, but people typically experience their first psychotic episode in their late teens or early 20s.
If psychosis is treated quickly, a person can fully recover and lead a healthy life. However, delayed treatment can impact their quality of life for decades - and costs a lot more money in the long run.
People develop psychosis for a variety of different reasons, including genetics, exposure to trauma, and substance use.
More research on the topic is needed but it’s believed that living in urban and socially-deprived areas can also play a role due to high levels of poverty and isolation.
People with psychotic disorders who don’t receive timely access to services often end up in hospital for prolonged periods or, in some cases, homeless.
O’Connor said investing in EIP services could prevent this from happening.
“You’re changing the trajectory of young people’s lives, you’re reducing suffering, reducing the risk of suicide,” she explained.
You retain people in work, you keep people out of needing sheltered accommodation, there’s reduced admissions in hospitals.
Aside from the primary goal of saving and improving lives, investing in EIP services also makes economic sense.
The HSE estimates that every €1 invested in EIP results in an €18 saving to the economy because it prevents costs related to a person needing prolonged hospital stays and support such as unemployment benefits.
A 2020 report by the Mental Health Commission found that of the 116 patients classed as long-stay residents in mental health units around the country at the time (i.e. those there for six months or longer), 60% (70 people) had a primary diagnosis of schizophrenia.
“What we’re trying to do is prevent people ending up in that situation,” O’Connor told The Journal. It costs around €50 million a year to keep patients in these beds for six months or longer, she said.
“We added up the number of bed days for people in for at least six months and those in for at least one year.”
She said this is a “conservative” estimate of €950 per bed per night, so the actual cost is possibly even higher.
Explaining how EIP teams work, O’Connor said that a lot of time is spent on developing the relationship with the person seeking support.
“You’ve got someone coming through the door, it’s psychosis, then this person will be picked up by a key worker who will be their key contact person for the next three years. They’ll coordinate their care, they’ll develop a relationship with them.
“The first six months is often spent on just developing the relationship, understanding where the person is coming from. Some people, their episode will have a very sudden onset and then will ease off very quickly. Other people may build up slowly.
“People vary in how comfortable they are talking to us, engaging with us, so a lot of time is put into understanding the person.
Where are they coming from? What are their particular set of problems? What are their particular set of concerns? Are they worried about stigma? All of those things.
Another big element of EIP teams is family engagement.
“Family intervention is really important,” O’Connor explained. “It’s about trying to involve families or others, whoever is a supportive person in your life, really early on.”
The patient has a say in what details are shared with their family, but providing practical advice and support for relatives is often vital in a person’s recovery.
Family members are also offered courses on topics such as psychoeducation (which combines elements of therapy and education) and communication (advising them how to talk to a loved one who needs support).
O’Connor told us: “More recently in our team in Cork, we have someone who is a dedicated family person. If you’re a mother or sister or brother, they’ll contact you and say, ‘Do you want to meet me and talk?’
“Obviously we have to respect confidentiality but confidentiality doesn’t stop us from providing information, providing support to families.”
As well as therapeutic support, a person living with psychosis often needs to take antipsychotic and antidepressant medication. As part of the EIP team, an employment specialist also works with the person to help keep them in work or get them back into employment.
If extra EIP teams were funded, it “would make a huge difference”, O’Connor said.
The new CAMHS EIP team, which has just started to see patients under 18, is linked to the DETECT EIP team in Dublin. More CAMHS teams could be linked to adult EIP services, O’Connor said.
“What we would really like to do is to extend the existing other [EIP] teams into CAMHS as well. It makes more sense to build on what you have than to start new things – and they could do that reasonably easily because the expertise is already there.”
The sticking point, as ever, is money.
“There are just so many competing demands [in mental health] and really those types of decisions are outside of our control. It’s a political decision, it’s a Department of Health decision,” O’Connor said.
However, she added that the lack of investment in EIP – which has been proven to save lives and money here and abroad – simply doesn’t make sense.
“We’re now a rich, western country but, for some reason, there are still people that we’re leaving behind. It’s just hard to get your head around it.”
*Name changed at interviewee’s request
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Read more articles in this series >>
FALLING THROUGH THE CRACKS
How are inadequate services impacting young people with psychosis?
By Órla Ryan
The Journal and Noteworthy are exploring access to services for people with psychosis and/or schizophrenia as part of a wider series called Falling Through the Cracks.
We would like to hear from teenagers and young adults – or their parents / guardians – who have been impacted by the lack of services available to them. Please email orla@thejournal.ie to share your story.
Supported by the Rosalynn Carter Fellowship for Mental Health Journalism in the Republic of Ireland in partnership with Headline, a Shine programme.
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If you have been affected by any of the issues mentioned in this article, you can reach out for support through the following helplines. These organisations also put people in touch with long-term supports:
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