Do you know what dual diagnosis is?
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?
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
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
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
- domestic violence
- history of offending
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
- 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).:
Public Health England wrote A guide for commissioners and service providers (2017) which states:
“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
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 Contacts’ list 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)
- 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)