Talking about severe addiction and mental illness

March is severe addiction and mental illness (SAMI) awareness month on BLOOM. We caught up with Dr. Anna S. Nazif MD, FRCPC, medical director, Emergency Psychiatry at St. Paul’s Hospital to speak with her about her experience working with SAMI patients and the stigma that continues to plague them.

Q: Tell me a little bit about the patient population in the ER at St. Paul’s Hospital.

A: At SPH we see all kind of patients because of our downtown location. Families and working professionals from Yaletown, individuals from the LGBTQIA-rich West End, professionals who work or commute downtown, people who come to enjoy the amenities of the city centre, and people from other hospital catchments who come here because they have been appreciative of the previous care they have received or who have heard good things about the work we do. Many of our patients also come from the shelters and low-income housing of the Downtown Eastside (DTES) where our vulnerable, complex patients with concurrent disorders often reside.

Patients come to us in a variety of ways: they walk in on their own, are brought by family and friends, are sent in by community agencies, family doctors or allied health workers, come via EHS or are brought by police or sheriffs. Of the hospitals within Vancouver Coastal Health region, we have the highest number of patients brought in by police.

Q: What is a section 28 arrest?

A: If the police have reason to believe a patient has a mental disorder and may be a risk to themselves or others, they have the authority to issue a Section 28 and transport the patient to hospital for evaluation by a physician.

Q: Tell me about the patients we see with combined addiction and mental illness problems.

A: The SAMI group is a very complex and heterogeneous population. Some people have mental illness before they start using substances, others use substances and then develop mental illness as a result of the effects of drug misuse, intoxication or withdrawal – this can include mood and anxiety disorders as well as psychotic disorders.

Q: Have you seen an increase in the number of SAMI patients presenting to the emergency department?

A: Since 2009 we’ve seen a 63 percent increase in the number of SAMI patients presenting to our emergency department as well as an 89 percent increase in the number of patients with addictions. Other hospitals across Metro Vancouver have also seen increases, though St. Paul’s Hospital’s are disproportionately high.

Q: How do you feel stigma plays a roll in the lives of SAMI patients?

A: Unfortunately, mental illness still carries significant stigma in general. It is becoming more acceptable to talk about depression, anxiety and even bipolar illness, but psychotic illnesses are still mostly unknown or misunderstood by lay people. Add into this unknown entity the use of illicit substances, which many people think is totally volitional, and there is a lot of fear and misunderstanding of what these patients are all about. Another issue is that many of these patients either don’t have families or have lost touch with them as a result of their illnesses. As a result, they do not have vocal supports to advocate for them within the community and health system.

Q: What is the most challenging thing about working with the SAMI population?

A: Many of our patients have not made the connection between their addictions and worsening mental health. They are often ‘precontemplative’ (not yet thinking) about reducing or ceasing their drug use. I have even seen patients who call crystal meth or another drug their “medicine”, thinking it makes them better.

Another issue is that individuals in this population are often homeless or tenuously housed in areas of high drug use (especially the DTES). Even if we can get them stabilized and treated in hospital and they are interested in stopping their drug use, when we have to discharge them back to a shelter or single room occupancy hotel where everyone is using and offering them drugs, or there are ‘triggers’ for their use all around them, the chance that they will remain abstinent is very low.

Q: Prior to crystal meth, what substances were you seeing SAMI patients using? And was it easier to treat those addictions compared to crystal meth?

A: Even now our SAMI population uses a variety of substances: alcohol is still very prevalent and problematic; we see patients using cannabis, crack, opiates and crystal meth every day. Before crystal meth became so common, patients were using more crack and heroin (but these are still very prevalent). The difference is that the psychosis and functional impairments caused by crystal meth seem to cause really significant problems more quickly after a shorter duration of use, and even with abstinence from crystal meth, once patients have these impairments they are less likely to regain their pre-morbid level of functioning. The psychosis can be permanent or very long lasting, and so can the functional impairments or problems with executive functioning (ability to plan, sequence and prioritize things they need to do in daily life).

Q: There has been a lot of effort to try and reduce stigma for people with mental health and addiction. Do you feel this has changed?

A: There have been positive strides made in tackling the stigma of more main stream mental health issues as public education and awareness rises. However, I would say that our concurrent disorders population still faces a lot of stigma. This is partially because people see drug use as entirely volitional whereas in mental health we see it as a true psychiatric disorder in its own right. Addictions are disorders with both genetic and environmental factors contributing to their expression. If we want to treat these disorders we need to alter environments to maximize patients’ abilities to recover, but even then there may be some people for whom battling an addiction will be hard because of their genetics. Conversely, some patients will have had such adverse environmental conditions during their developmental years that they may not have the same neurologic and emotional resilience and ability to recover from addictions.

The important message for us to spread in the community is that with specialized treatment like that which we strive to provide at St. Paul’s (and which our community partners provide outside of the hospital) these patients can see significant improvements or remission in their illness. Our patients are amazing people, each with their own life stories; they are unique and resilient human beings and it is a privilege to work with them every day.

As you may know, we are opening a new Acute Behavioural Stabilization Unit (ABSU) at St. Paul’s this month and celebrating the start of our collaboration with a new community program the Assertive Outreach Team (AOT) to help transition our SAMI patients from hospital to community care. It is the recognition that we need these types of specialized services to provide excellent care to our complex patient population that provides the proof that the hospital staff, health region and government are committed to working against this stigma and giving these worthy patients the best chance at recovery.