Let’s break down dual diagnosis

What is dual diagnosis?

Now, bear with me for a moment here.

Dual Diagnosis — image by

The Recovery Village Columbus, for our friends in the USA, explains that “a person with a co-occurring disorder has been diagnosed with a substance abuse disorder and another mental health disorder.”

The World Health Organization defines it as “the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder”.

Confused? I would be too, if I hadn’t already come across the different terminology while studying and in my work as a mental health nurse.

I think the UK National Institute for Health and Care Excellence (NICE) offers a clear explanation, referring to dual diagnosis as “young people and adults with severe mental illness who misuse substances.”

The dilemmas and challenges of dual diagnosis

With a huge proportion of their patients experiencing mental health problems, knowing how to respond or who should respond is a huge worry for both the UK’s drug and alcohol services and mental health services. So who is responsible for coordinating these patients’ care? Should it be mental health services or the substance abuse teams? And who should pay?

Nurse management of Dual Diagnosis — Sam Abraham at Researchgate.net

I know from personal experience both psychiatrists and nurses found that working with mental health patients, who also had a dual diagnosis, was a significant problem. Most nurses neither had the skills and knowledge or the patience to work with this group of patients. Many saw it as a patient’s choice (they could just stop using drugs or alcohol). Some lacked the empathy and compassion needed to support our more challenging patients. Others just saw them as a bloody nuisance or a waste of space.

As much as I found working with patients with a dual diagnosis trying at times, my heart went out to them. They were tired of being pushed from one service to another, they were confused and frustrated by the system. As were nurses because these patients needs were complex, which created a lot of work for nurses i.e. contacting and interacting with the various services required to support patients with dual diagnosis.

So what came first, the chicken or the egg?

It’s well documented that chronic use of alcohol and/or certain drugs can cause both short and long-term changes in the brain, which can in fact lead to depression, anxiety, sleeplessness, anger or aggression, paranoia and other mental health disorders.

Research also shows that many mental health patients use alcohol or drugs, sometimes as a way of self-medicating. Patients often said that the drink or drugs (or both) helped to calm them down, helped them ‘get out of it‘, to get away from it all, to blot things out, to relieve the anxiety, their voices or the stigma of mental illness.

More than this, I’ve read and believe that some youngsters who experience mental illness use alcohol/drugs perhaps to fit in with their peers or to assume an identity as drunk or drugged rather than mad because this is more socially acceptable.

Dual diagnosis in UK prisons —
Getty Images

Studies have shown that dual diagnosis sufferers come into contact with the criminal justice system more often than people with a mental health disorder only. It is estimated that a large proportion of prisoners have both mental health and substance misuse problems (Brooker et al., 2002).

Moreover, in the UK, a large percentage of people with dual diagnosis are also homeless which adds to their already very complex needs.

There appears to be great concern about the UK’s fragmented mental health service delivery. Particularly for those who are dually diagnosed homeless people, and consternation that such a fragmented service will adversely affect access to services.

With all these issues in mind, Public Health England wrote A guide for commissioners and service providers (2017) which states:

Dual diagnosis and homelessness- Darren Listicle SovCal.com

“Reaching these populations may require local and innovative strategies and service models. Services should be built around the specific needs, and work to overcome potential issues of stigma, mistrust based on poor past experiences or other barriers preventing access.”

The Guide goes on to say “They need to be able to respond to a range of presenting needs, including: alcohol and drug use, mental and physical health issues, and other vulnerabilities such as homelessness and domestic violence. This will require collaboration with a wide range of other services, and close working with local safeguarding for children and vulnerable adults.”

It’s a huge ask.

I’d say good luck with that and I’ll be interested to read their results after the alloted five year time span.

What’s your thoughts on people who have a dual diagnosis? How best do you think they can be supported? Do you know what services are available in your area?

If you or someone you know has a dual diagnosis and needs support, you may find this ‘Useful Mental Health Contactslist helpful. However, in the first instance (and where possible), please seek support from your GP.

Other posts you might find interesting:


  • Brooker, C., Repper, J., Beverley, C., Ferriter, M. & Brewer, N.l. (2002) Mental Health Services and Prisoners: A Review. Commissioned by Prison Healthcare Taskforce, Department of Health / Home Office. Sheffield: ScHARR, University of Sheffield.
  • Public Health England (2017) Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide for commissioners and service providers
  • The Recovery Village Columbus (2020) What are co-occurring disorders. https://www.columbusrecoverycenter.com/treatment-programs/co-occurring-disorders/

Author: mentalhealth360.uk

Mum to two amazing sons. Following recovery from a lengthy psychotic episode, depression, anxiety and anorexia, I decided to train as a Mental Health Nurse and worked successfully in various settings before becoming a Ward Manager. I am a Mental Health First Aid Instructor and a Mental Health Awareness Trainer, Mental Health First Aid Youth and Mental Health Armed Forces Instructor. Just started my mental health from the other side blog.

23 thoughts on “Let’s break down dual diagnosis”

  1. Accept it, embrace it, learn about it because it is there and it’s not going away. We have some wards here who are for dual diagnosis. Though when I worked there it were people with a mental problem who used some substances. The mental problem was the biggest reason that they were there. Some people can smoke weed and drink and it doesn’t worsen their condition. When it did, we talked about it and tried to find solution. The addictive problems didn’t became that bad overnight and won’t go away with a quick fix. I kinda liked working there, it was always fun.

    1. No, it’s certainly not going away, particularly in diverse over-populated areas in big cities. Unfortunately, we had a large Afro-Caribbean community who saw it as culturally okay to smoke weed and while cannabis doesn’t ’cause’ schizophrenia, if someone is already vulnerable towards mental health problems, the cannabis will exaccerbate this. I loved working with the young lads, explaining their illness, their drug use, the impact and effects on not only them, but their families. It often took 2-3 times on Section 3 of the Mental Health Act (for up to six months) for them to realise that the weed really does make their symptoms worse. Many stopped using but of course, many didn’t. And this was what I found so frustrating.

      1. It’s a process where you need to stick like glue to them but not always of course. We had those people too, the weed and all the problems that went with it. But you know, if I had those voices, honestly the only reason that I don’t smoke weed is because I need the control. I can’t let go. But I think sometimes, you need to escape and go through that process with the ups and the downs. And like you said very well, sometimes it’s easier for such a young man or woman to be a ‘smoker’, ‘a dopehead’ than ‘really’ crazy. It must be so frightening to live with some voices all the time. Can you blame them? And in some communities it is ok like you said but the quality of the weed isn’t anymore what it was in the sixties either. It’s much more chemical now, like a hard drug. They don’t sell the nice plants from Jamaica anymore. It’s just so fascinating isn’t it? I just love thinking and talking about it. I’m glad I found your blog!

      2. It’s great having you as someone to bounce ideas off too Kacha. We find the mind fascinating and the wonder of people never ceases to amaze us both 🙂 We both appear to have this unquenchable thirst for knowledge. So reading personal accounts and stuff written at my level is great. Easy to read but well written and informative 🙂

  2. It’s unfortunate that there’s not more integrated treatment options available. If someone is sent to two different treatment teams they’re probably going to be a lot less likely to actually access treatment.

    1. I know, this is what’s so frustrating for patients, mental health services and drug/alcohol services. We didn’t have a ward specifically for dual diagnosis so when someone was discharged from our m.h. in-patient wards, they were then referred to drug/alcohol services and seen as out-patients.

      I’m confused and frustrated — so how must dual diagnosi patients feel?

  3. Where I am in the states, addiction is considered a comorbid diagnosis for those who also have a mental health diagnosis. But the treatment is very split-a doctor for the mental health disorder, then there is a team who specialize in treatment of addiction and aid in recovery.
    Unless you have really good insurance and can seek a more urban area, a comorbid diagnosis here can be the death knoll. There is no coordination so you can imagine how ineffective it ends up being.

    1. I know it must be much worse in the States because you need insurance. I often feel that our NHS system is abused and understand how mental health teams become frustrated with ‘revolving-door’ patients (as they’re called). I believe we need fully integrated systems and in-patient wards to work solely with dial diagnosis. Otherwise, the current system remains fragmented.

      1. Agreed. Everyone wants to talk big about equal care for physical and mental health but it could not be a less equal situation. Mind and body need to be healthy to exist together and function properly.

  4. It is interesting because we were told by CAMHS that once somebody was diagnosed with one disorder, they never even bothered trying to find a second. This between five and eight or nine years ago. Putting my neck on the line, but I can’t see that anything will have improved!

  5. This article is spot on. For a endless amount of years I suffered from severe mental health and a drug addiction. It took me a long time to realize that these were two separate diseases. Also to help me deal with both diseases I need to recognize for me that both diseases are a literime

  6. I was on Netflix the other day looking for documentaries. I stumble across a documentary entitled ‘Voyeur’. The voyeur owned a motel and set up the motel so he could look into rooms. A book was written about the voyeur by Gay Talese who is a very prominent journalist in the US. The voyeur spends every waking moment voyeuring. I watched about a third but the voyeur was incredibly uninteresting . All addictions on some level seem about the same. There are incredible compulsions not backed up by much thought. The question I have is why some individuals choose one addiction over another. I would guess that the milieu of the addiction is all important. The point you make that many mentally ill individuals prefer to be viewed as party people rather than as mentally ill is an excellent point. I am wondering if one addiction could be substituted for another, a less harmful addiction for a harmful addiction. Could an all consuming hobby be an answer to an addiction? The difficulty is that the milieu would be different. Drug addicts might look very unfavorably on the recommendation that model trains be built rather than opioids scored. In a sense 12 step programs substitute a beneficial addiction, group meetings, for harmful addictions. The milieu of 12 step programs can substitute for much more dangerous milieus

    1. Thank you for all your comments Thomas. I’m not quite sure why people choose one addiction or another. I suppose, in the beginning say if you started smoking (through peer pressure), it’s only later that the addiction starts. I laughed at your model trains 🙂 And like you, I don’t think taking up knitting would be the answer. It might keep your hands busy but you’ll still want the ciggies.

      I’m not certain that you could switch addications either. If you’re a smoker, then switching to gambling isn’t going to reduce the need for nicotine.

      You’ve made me think and my brain’s gone into overdrive tonight 🙂

  7. What a complex issue.

    I didn’t know the term dual diagnosis before reading this, but I’ve often thought about the “chicken or the egg” question in the case of substance abuse and a psychiatric disorder.

    My uneducated intuition was that it went something along the lines of “anxiety/depression/other leads to self-medicating, which leads to brain changes, which makes the initial disorder more severe, etc.”

    There are people in my life that I’ve so, so wanted to know the answer to the “chicken or the egg” question about.

  8. Whichever one leads to the other, I’m sure they quickly become a vicious cycle. Not having much experience with addiction, I don’t think I’m qualified to recommend any solution. Still, what accounts I’ve read from people going through addiction recovery make me think treating the mental health side as much as possible first might be a good start. If a person is struggling with a severe mental illness, why would they want to be fully in that struggle if they could help it?

    1. Sometimes people with severe mental illness lack insight and don’t actually think there is a problem. And sometimes, their mental state can be stabilised so they think it’s okay to stop taking medication – the same as the general population. We stop taking antibiotics before the 7 days are up cos we feel better. 🙁

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.