On December 5, the Council of the European Union approved recommendations to improve the approach and treatment of people in whom addictions and other mental disorders come together.
The document was prepared and presented by the Government of Spain within the framework of the Spanish presidency of the European institution and was approved after six months of intense deliberations among the member countries.
“In Spain, during our presidency, we chose the issue of mental health as the axis because it is a national priority,” Elena Álvarez Martín, deputy director general of Institutional Relations of the National Plan on Drugs, who chaired the Horizontal Drug Group, explains to EL PAÍS. the one in which the document was approved.
“In this case, we believed that comorbidity between drug use disorders and other mental disorders is an issue on which there is a lot of scientific information that deserved to be elevated to a more political level.
The topic was very well received within Europe, which means that it is interesting,” she adds.
Álvarez Martín points out that it was necessary to tread very carefully in the use of terminology, since there is no unanimity when it comes to naming this clinical condition (
dual disorders
in English and dual pathology in Spanish are the most used concepts, although in the document , for example, we talk about comorbidity or dual disorders).
In any case, what does not deserve discussion, as the document reflects, is that the coexistence of addictions and other mental disorders is a reality that constitutes "an important challenge for mental health and drug services and policies."
Not in vain, it is estimated that between six and seven out of every ten people who are treated in the addiction care network also have another mental disorder;
while approximately 30% of the people who are treated in the mental health network also have an addiction, a figure that rises to almost 80% if the tobacco use disorder is taken into account.
“This is a very important recognition because it means moving this problem to a political level, so it is to be optimistic.
It is no longer a scientific society that asks for research and funding, but rather it is the European Union that, within its mental health policy, aims to improve care for people with dual pathology.
It is going one step further,” reflects psychiatrist Marta Torrens, coordinator of the addictions working group at the Hospital del Mar Research Institute in Barcelona, who participated in drafting the document.
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In it, among other considerations, the European Council emphasizes many of the historical demands of scientific societies and patient associations.
Among them, the need to see dual pathology as the norm and not the exception.
Or the importance of those affected receiving a comprehensive and integrated treatment that avoids what is known as wrong door syndrome, by which these patients are forced into a kind of ping-pong game, going from the mental health network to the of addictions and vice versa without ever receiving comprehensive treatment that jointly responds to all their mental disorders.
The Spanish Society of Dual Pathology (SEPD) considers that the document constitutes “a great step forward and at the same time a challenge” for policy makers, managers and clinicians.
“For historical reasons, addictions, despite their consideration as mental disorders and, therefore, as disorders of the human brain in all international classifications, have been valued only as behavioral disorders.
The document from the Council of the European Union takes for the first time a step that leaves behind so many institutions that have denied dual pathology or relegated it to a secondary role of simple coincidence," defends Néstor Szerman, psychiatrist at the Institute of Psychiatry. and Mental Health of the Gregorio Marañón Hospital in Madrid and president of the Dual Pathology Foundation of the SEPD.
“It is necessary to take steps towards an integration between mental health and addictions, gathering the best of both networks for the benefit of patients and families.
Professionals' knowledge must be updated so that patients can receive the treatment they deserve based on scientific evidence,” adds Szerman.
The expert considers that the existence of two networks, "still in force in the majority of the Autonomous Communities, increases the risk of greater stigma and, what is even more serious, discrimination against people with dual pathology."
For the Government delegate for the National Plan on Drugs, Joan Villalbí, it is true that there are countries in which the addiction assistance network is more developed and integrated into their health system, and countries in which, on the contrary, , is less or equally developed, but very far from the core of the health system.
“That is where it seemed to us that we could intervene to, in the same way that we are following in Spain a long process that is leading addiction services towards greater integration with the entire public health system, stimulate that same process in the rest of the countries of the European Union,” he says.
Villabí considers that this integration of the addictions network “is already very well done” in some Autonomous Communities such as the Basque Country, the Valencian Community (more integrated in Primary Care) or Castilla y León (more integrated with Social Services).
“Rather than postulating that it has to be integrated in this or that way, the important thing is that the network works;
and can work well with many organizational models, as demonstrated in Spain.
Are there patients who have many difficulties because they are being treated in a center that is not able to see that the patient has more than one problem?
It is possible, but I would say that in general professionals strive to provide integrated care and the approach is quite integrated,” he maintains.
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María Asunción Zubia is president of the Spanish Federation of Relatives and People Affected by Dual Pathology (FEDEPADUAL).
His 37-year-old nephew, whom he has raised since he was born, began to show mental health problems since childhood - he is currently diagnosed with borderline personality disorder - which were later complicated by the appearance of several addictions. starting from adolescence, including alcohol and gambling.
“Today I can tell you that things are much better, but not thanks to the Basque health system or the resources we have been able to receive.
He is better despite that, especially because I have been on top of him his whole life, something that other families cannot afford.
Families feel helpless,” she denounces.
Zubia believes that the recommendations of the European Council will not only benefit patients and their families, “but also health professionals” who, in his opinion, “many times want to offer answers, but they lack knowledge, resources, supports, tools and greater coordination between services.”
“The situation in Spain is common to the situation in most of the countries around us, which does not mean that we are fine.
Everything can be improved a lot," says Marta Torrens, who recognizes that more and more Autonomous Communities are making the integration plan for mental health and addictions, "but what is said on paper is one thing and reality is another. "That's what patients tell you."
“The objective now is for what the paper says to be a reality and for that to happen, all agents must be involved, starting with the training of professionals from both networks,” adds the psychiatrist, who believes that after the difficulty in integrating the mental health and addiction networks, one often finds the “reluctance” of both networks: “Sometimes there is a reluctance on the part of the psychiatry network to care for these patients with substance addiction, while other times the addiction network fears that this integration undermines some specificities of substance use disorders—such as the diagnosis of HIV—and that patient care worsens in some aspects.”
“We are children of history,” says Joan Villalbí, who remembers that in the seventies, when the heroin epidemic took place, there were no addiction services in Spain and the mental health service was asylums.
“We come from this.
When the heroin problem arrived, mental health services in general did not integrate addiction treatment and, therefore, Spain was equipped with three parallel networks: a general network (primary and specialized), the mental health network ( which went from the asylum model to psychiatric services in hospitals and more community mental health centers) and the addiction network, created by city councils, autonomous communities and NGOs," explains the Government delegate for the National Plan on Drugs. .
Now, as the document states, the objective is to move towards greater coordination and integration of these networks.
“In Spain, in this sense, things are much better today than they were years ago, but there is still room for improvement because there are many differences between territories.
That is also why the 12 recommendations for improvement that are included in the document,” Villalbí concludes.
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