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/