Abstract
A.R. MacQueen, Orange, NSW:
From a public health perspective, gaining access to a group who suffer up to 10 times more psychiatric illness than the general population should be seen as a triumph. I fear, though, that the work of Callaly et al. [1] will go unnoticed since their patients, people receiving methadone maintenance, have, over the years, suffered ongoing disenfranchisement, if not demonization. I offer some history, gained from 18 years of methadone prescribing in 3 states of Australia, and a challenge to psychiatrists to take the problems of people on methadone seriously.
A 28-year-old man was noted by the methadone dispensing staff to be flat. They felt he was at risk of suicide. The mental health team assessed him and felt he was safe, despite the concerns of staff who had known him for 4 months, on a daily basis. He gassed himself in his car that weekend. Some months later, the same team reviewed a woman who was intoxicated with benzodiazepines and distressed after a personal crisis. Again the staff who knew her well and felt this was not her usual state were concerned for her safety. After a brief interview, she was sent home, and was found hanging in the kitchen next day. At another site, I reviewed a man who was new to the unit, and realized there was more to him than opiate use problems. After 3 reviews, he asked if he could be seen by a psychiatrist, a triumph of gentle counselling, I felt. He lasted less than 5 minutes with the psychiatrist who insisted on reading the riot act first since he was a drug user. A week later he was admitted after attempting to strangle his father who, our patient felt, had been controlling his mind. The diagnosis was paranoid schizophrenia, albeit well guarded.
In these and many other cases, two problems lead to mismanagement and tragedy. Firstly, there is little recognition by mental health workers, including psychiatrists, that people on long-term methadone have many problems including a high rate of affective and anxiety disorder [1]. We should not have to say that the mental health problem often came first, with the implication this makes a claim to be helped more legitimate [2]. Secondly, advice from methadone unit staff is usually ignored, despite them often having spoken with a person daily for some time, even years. Commonly, we hear after a brief assessment that our patient is ‘just a personality disorder’, a view rarely shared by experienced methadone unit staff and one explicitly cautioned against by Parker and Roy [2].
Coexisting mental health and drug use problem has been documented in the recent National Survey of Mental Health and Wellbeing [3] which supports the intuitive view that those with more problems are more likely to seek treatment, as they are more distressed. The national comorbidity project has produced a report [4] while New South Wales Health has responded by publishing a discussion paper and service guidelines [5]. Despite this, the experience of most alcohol and other drug workers is that the mental health system will look after people with ‘dual diagnosis’ problems, that is ‘legitimate’ mental health problems like schizophrenia with a substance use disorder, but will fail to address the needs of the other 95% with comorbid problems such as those with anxiety disorders and alcohol or benzodiazepine use, and of course, opiate users with an affective or anxiety disorder.
I issue this challenge – can psychiatrists take seriously the issues raised by Callaly et al. [1] or explain why they will not or cannot. Green and Bloch [6] have reminded us of the Code of Ethics of the Royal Australian and New Zealand College of Psychiatrists with its Principle 10, annotation 1 that ‘Psychiatrists shall promote the improvement of mental health services recognizing that psychiatric patients may be disenfranchised and unable to assert themselves’. Patients receiving methadone often assert themselves by drug use, or violence to themselves, but it would surely be more appropriate to help them, to be assertive in gaining control of their mental health and improving their quality of life. It is not only possible but also rewarding.