What is dual diagnosis

Do you know what dual diagnosis is?

Colour image, yellow background with coloured tablet forming a question mark
Dual Diagnosis —Anna Shvets @ Pixels.com

The Recovery Village explains that dual diagnosis is where “a person has been diagnosed with a substance abuse disorder (SUD) and another mental health disorder.”

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

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

What comes first?

Coloured image of two chicks and a broken egg
Chicken or the egg — image by Anja @ Pixabay.com

Evidence shows that SUD is quite common among individuals with severe mental illness and vice versa. So, what came first?

Mental illness first, or SUD? In fact, they often go hand-in-hand. People either develop mental illness in response to their SUD or self-medicate untreated mental illnesses through substance abuse. Patients report that substance use helps relieve their anxiety, or voices and other symptoms of mental illness.

Moreover, it’s known that some youngsters who experience mental illness use alcohol/drugs to fit in with their peers. They prefer being seen as drunk or on drugs rather than being mad, because this is more socially acceptable.

Working with dual diagnosis

Spoon holding white powder and a needle - depicting drugs and Dual Diagnosis
Dual Diagnosis — image by
Reno Beranger @ Pixabay.com

From personal experience, both nurses and psychiatrists found it extremely draining working with patients who had a dual diagnosis. 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. It was seen as time-consuming and a never-ending task. Nurses didn’t have time to contact and engage with the many and varied services required to support dual diagnosis patients.

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, and were confused and frustrated by the system. As were nurses, because these patients’ needs were complex, and created a heck of a lot more work.

Complex needs of someone with a dual diagnosis

Coloured image young female wearing black bra, two tattoos on her arm, smoking a joint
Photo by Ike louie Natividad from Pexels

A person with ‘complex needs’ is someone with two or more needs affecting their physical, mental, social or financial wellbeing. Such needs typically interact with and exacerbate one another leading to individuals experiencing several problems simultaneously (The All Party Parliamentary Group, APPG, 2013).

Someone with complex needs will generally have two or more of the following:

  • mental health issues
  • substance misuse issues
  • dual diagnosis of mental health and substance misuse issues
  • a learning disability
  • a physical disability
  • a physical health condition
  • employment problems
  • relationship or family difficulties
  • social isolation
  • poverty
  • domestic violence
  • history of offending
Prison bars and guard behind - Dual Diagnosis and criminal justice system
Dual diagnosis in UK prisons —
Getty Images

Studies have shown that those with dual diagnosis come into contact with the criminal justice system more often than people with a mental health disorder only. It’s estimated that a large proportion of prisoners have both mental health and substance misuse problems (Brooker et al., 2002). Moreover, a large percentage of people with dual diagnosis are also homeless, adding to their already very complex needs.

Treatment for dual diagnosis

The complex needs of dual diagnosis contribute to a huge health burden, which reduces the health care system’s capacity to adequately treat patients. Knowing how to respond or who should respond is a huge worry for both the drug and alcohol services and mental health services. Who is responsible for coordinating care of patients? Should it be mental health services or the substance abuse teams?

The components needed in the treatment of dual diagnosis are many and varied:

  • case management and assessment by dual diagnosis a trained professional i.e. a mental health nurse, social worker or support worker)
  • individual counselling
  • group interventions by i.e. occupational therapist, mental health nurse, social worker or support worker
  • family psychoeducation
  • vocational rehabilitation
  • medication management
  • money management
  • housing
  • and close working with local safeguarding for children and vulnerable adults.

Research suggests that these components be integrated with all other aspects of mental health services, rather than isolated as a discrete substance abuse treatment intervention (Drake et al. 1993a).:

Services

Public Health England wrote A guide for commissioners and service providers (2017) which states:

Scruffy looking man lying in a doorway - dual diagnosis and homelessness
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, “

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.

Over to you

Big red question mark with little white caricature man leaning against it
Clipart.com

What’s your thoughts on dual diagnosis? How best do you think they can be supported? Or do you think, like many nurses, that people with a SUD are a waste of time and money?

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

Other posts you might find interesting:

  • Dual diagnosis – Substance abuse plus underlying mental health issues (1)
  • Living with someone else’s mental illness/addiction (2)


Sources:

  • What are co-occurring disorders? The Recovery Village Columbus (2020)
  • Severe mental illness and substance misuse (dual diagnosis) – community health and social care services, NICE Guidelines, Draft for consultation, 2016
  • The All Party Parliamentary Group on Complex Needs (2013)
  • 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.
  • Drake, R.E.; Bartels, S.B.; Teague, G.B.; Noordsy, D.L.; and Clark, R.E. Treatment of substance use disorders in severely mentally ill patients. Journal of Nervous and Mental Disease, 181:606-611, 1993a.
  • Drake, R.E. and Mueser, K.T (2000) Psychosocial Approaches to Dual Diagnosis Schizophrenia Bulletin, Vol. 26, No. 1, 2000
  • Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide for commissioners and service providers, Public Health England (2017)

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.

29 thoughts on “What is 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. 🙁

    1. It’s an odd one Dual Diagnosis as many are not actually diagnosed as having a mental illness and vice versa.

      I tried alcohol but it just made me sick. And my aunt was an alcoholic, park drinker and it terrified me cos I never wanted to end up like that. I stopped drinking totally for 5 years, until I actually felt more mentally stable – it didn’t do great things for me.

      Glad you resolved yours too Mio x

  9. I think people abuse substances for the same reason as people self harm or develop eating disorders or any maladaptive behaviour pattern. It gives them a handle on the world.

    1. True. And as I mentioned to another blogging pal, I tried alcohol but it just made me more paranoid and then literally sick. Gave that up lol. I do drink wine now occasionally 🙂

  10. Hi Carol, just testing if your notifications are working. If the problem insists please edit this post by adding a word somewhere and update it. This may take care of the issue. Btw, feel free to delete this message.

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