Dual Diagnosis

Dual diagnosis is the term used to describe patients with both severe mental illness (mainly psychotic disorders) and problematic drug and/or alcohol use. Personality disorder may also co-exist with psychiatric illness and/or substance misuse. The term originated from the US in the 1980s and has been adopted in the UK more recently. The nature of the relationship between the two conditions is complex and sometimes controversial:^1,2

• A primary psychiatric illness may precipitate or lead to substance misuse. Patients may feel anxious, lonely, bored, have difficulty sleeping or may want to 'block out' symptoms or medication side effects.³
• Substance misuse may worsen or alter the path of a psychiatric illness.
• Intoxication and/or substance dependence may lead to psychological symptoms.
• Substance misuse and/or withdrawal may lead to psychiatric symptoms or illness. It may act as a trigger in those who are predisposed.³

People with dual diagnosis have complex needs relating to health, social, economic and emotional stressors or circumstances which can often be exacerbated by their substance misuse.² Professor Louis Appleby, in his 2004 report to the Secretary of State for Health on the implementation of the National Service Framework for Mental Health, stated that 'services for people with dual diagnosis - mental illness and substance misuse - are the most challenging clinical problem that we face.⁴'

A report was published in 2004 by the Rethink Dual Diagnosis Research Group. This highlighted a lack of support services for those with dual diagnosis and their carers. It made a number of recommendations including:⁵

• Training to increase awareness of dual diagnosis and to provide specialist dual diagnosis workers and services.
• Development of services for carers.
• Development of health promotion activities in workplaces, schools and community settings to increase public awareness of the condition.

In the UK, it is thought that the number of people with a potential dual diagnosis is high and possibly rising.¹

• About a third to a half of those with severe mental health problems will also have substance misuse problems.⁶
• About half of patients in drug and alcohol services have a mental health problem, most commonly depression or personality disorder.⁷
• Alcohol misuse is the most common type of substance misuse and where drug misuse occurs, it tends also to co-exist with alcohol misuse.
• Between 22 and 44% of adult psychiatric inpatients also have problematic drug or alcohol use, up to half being drug dependent.⁸

Community Mental Health Trusts typically report 8-15% of their clients have dual diagnosis problems but rates are higher in inner cities. One survey showed that 36% of clients seen by an inner London psychiatric service were dependent on alcohol and/or drugs.⁹ Substance misuse is usual rather than exceptional amongst those with severe mental health problems.¹

The symptoms of drug or alcohol misuse can be very similar to the symptoms of mental illness and vice versa and they frequently co-exist.¹⁰ This can make it difficult to make a confident dual diagnosis. When differentiating between a primary psychotic and a substance-induced disorder, consider:

• Did psychosis precede the onset of substance abuse?
• Does psychosis persist for longer than one month after acute withdrawal or severe intoxication?
• Are the psychotic symptoms consistent with the substance used?
• Is there a history of psychotic symptoms during periods of abstinence?
• Is there a personal or family history of a non-substance-induced psychotic disorder?

Substance-induced psychotic symptoms resulting from substance misuse include:

• Cannabis intoxication can induce a transient, self limiting psychotic disorder characterised by hallucinations and agitation.
• Psycho stimulants such as amphetamines when used over prolonged periods can produce a psychotic picture similar to schizophrenia.
• Hallucinogen-induced psychosis is usually transient but can persist with sustained use.
• Heavy alcohol use is associated with morbid jealousy and alcoholic hallucinations. Withdrawal from alcohol may also provoke psychotic symptoms.

A framework for practice around dual diagnosis has been produced by the Department of Health: Dual Diagnosis Good Practice Guide.¹ This summarises current policy and good practice in the provision of mental health services to people with severe mental health problems and problematic substance misuse.

The Royal College of Psychiatrists Research Group was also commissioned by the Department of Health to produce an information manual for practitioners working in the field of dual diagnosis in 2002.⁷

The Department of Health also issued guidance in 2006 on the assessment and management of patients in mental health inpatient and day hospital settings who have mental ill-health and substance use problems.⁸ It covers information on service planning and needs assessment, clinical management (assessment, care and treatment, discharge and follow-up), as well as organisation and management of services.

The Dual Diagnosis Good Practice Handbook has been developed by Turning Point (the UK's leading social care organisation), based on the Department of Health Good Practice Guide. Its purpose is to help practitioners to plan, organise and deliver services for people with dual diagnosis.¹¹ It contains case studies from services working with people with a dual diagnosis in a range of settings and localities, offering practical help for those wanting to establish dual diagnosis services.

• Screen all patients with psychosis for substance misuse.^1,10
• Determine the severity of use and associated risk-taking behaviours.
• Exclude organic illness or physical complications of substance misuse (including any possible medication and substance interactions).
• Seek collateral history from family or close supports wherever possible.
• Consider carer needs.
• Determine the individual's expectation of treatment and the degree of motivation for change.
• Do a risk assessment to include risk of self-harm, self-neglect, risk of violence to others and risks from others including exploitation.⁶

Models of integrated mental health services and substance misuse services are the way forward and have begun to be implemented in the UK.² Primary care has a responsibility to assess the needs of those with mental health problems and help them to access appropriate services.¹² Physical health needs should also be considered fully.

There has been a tendency in the past to find appropriate referral difficult, as those with dual diagnosis may 'fall between the two stools' of psychiatric services and drug and alcohol agencies, but the need for better coordination and clearer care pathways is strongly advocated.¹ The Department of Health 2002 guidance stated that treatment for dual diagnosis should be delivered within mental health services, known as 'mainstreaming'.¹ The suggestions the guidance makes include the following key points:

• Local services must be developed according to need with care pathways and clinical governance guidelines drawn up.
• Specialist dual diagnosis workers should provide support to mainstream mental health services where they exist.
• There should be adequate staff training around dual diagnosis.
• A Care Programme Approach (CPA), including the concept of a keyworker, and full risk assessment should be used in clients with dual diagnosis.

In some areas, specialist teams already exist to tackle the specific needs of those with dual diagnosis. They usually adopt an outreach working model as well as supporting mainstream mental health services. In other areas where this is not the case, the aim should be to mainstream the care of those with dual diagnosis. Often those doing crisis resolution, early intervention and assertive outreach work have the most contact with the dually diagnosed and should receive specific training. The approach should be non-judgemental and service users, carers and families should be involved in treatment where possible. Services should also be culturally appropriate.

Stages in treatment⁶

• Engagement
• Persuasion (working towards change)
• Active treatment
• Relapse prevention including identification of triggers for relapse and development of alternative coping strategies

Treatment aims⁶

• Harm reduction: supervised consumption, needle exchanges, looking at wider health needs (e.g. hepatitis and HIV exposure)
• Stabilising consumption: establishing treatment programmes (detoxification, substitute prescribing, counselling and psychological treatments)
• Education: improving awareness of risk taking behaviour, explaining how to find support
• Addressing social care needs including possible triggers for substance misuse
• Treatment of mental health problems: drug treatment, psychosocial therapy, complementary therapies

Dual diagnosis is associated with:^1,10,2

• Worsening psychiatric symptoms
• More frequent re-hospitalisation
• Poor medicine adherence
• Homelessness and poverty
• Increased risk of HIV infection
• Poor social outcome (including impact on family, carers and employment)
• Financial pressures³
• Increased risk of violence¹³ and contact with the criminal justice system
• Increased risk of suicide
  Isolation and social withdrawal

Dual diagnosis continues to be a challenging field. Progress is being made but there is still unmet need. Areas/groups that have been particularly highlighted as needing further development include: services for women, services for young people, services for black and minority ethnic communities, services for people in the criminal justice system and also support that is provided through primary care.⁸