Mental Health and Drugs: the whole “Dual Diagnosis" question.

The interface between mental health, drugs and alcohol is highly complex and not necessarily well understood. The debates over the nature of the relationship between cannabis and psychotic illness are filling the UK press at the moment and creating a lot of fear and anxiety.
Section 4.3 of the NTA's  Models of Care, Psychiatric co-morbidity (dual diagnosis) in talking about this difficult inter-relationship quotes Crome(1996)saying;
  • substance use (even one dose) and withdrawal from substances may lead to psychiatric syndromes or symptoms
  • intoxication and dependence may produce psychological symptoms
  • substance use may exacerbate or alter the course of a pre-existing mental disorder
  • primary mental disorder may precipitate substance use disorder which in itself may lead to psychiatric syndromes.
To which can be added issues to do with medication prescribed for mental health conditions interacting with non-prescribed drugs.

Prevalence

Many clients who report to drugs and alcohol services have some kind of mental health issue.
  • Some 74.5% of users of drug services and 85.5% of users of alcohol services experienced mental health problems.
  • Most had affective disorders (depression) and anxiety disorders. A relatively high rate of psychosis was also observed.
  • Almost 30% of the drug treatment population and over 50% of those in treatment for alcohol problems experienced ‘multiple’ morbidity (co-occurrence of a number of psychiatric disorders or substance misuse problems).
  • Some 38.5% of drug users with a psychiatric disorder were receiving no treatment for their mental health problem.
  • Some 44% of mental health service users reported drug use and/or were assessed to have used alcohol at hazardous or harmful levels in the past year. 

Mind the Gaps the Scottish Executive’s Practice Guidance states that
  • up to 3 in 4 drug using clients have been reported as having mental health problems;
  • up to 1 in 2 patients with alcohol problems may also have a mental health problem;
  • up to 2 in 5 people with mental health problems may have a drug and/or alcohol problems; and
  • co-morbidity in general practice in England has risen by 62% between 1993 and 1998.

Dual diagnosis or complex needs

Dual Diagnosis is a wide term and there is no particular agreement about what it means. Alcohol Concern in its Fact Sheet on Alcohol and Mental Health  discusses two basic definitions.
  • The co-existence of an alcohol and/or drug misuse or dependence problem and a range of mental health problems or behavioural disorders (a broad unrestricted definition) or
  • The co-existence of an alcohol and/ or drug misuse or dependence problem and a ’severe and enduring mental illness’ (a restricted definition)  
A severe and enduing mental health problem refers to the kind of symptoms described in DSM IV (Diagnostic and Statistical Manual fourth edition). This is the American Psychiatric Association set of diagnostic criteria for mental health problems.  It is hugely influential in the notoriously difficult and inaccurate business of diagnosis. The breadth of the definition matters - a narrow definition restricts the ability of clients to get services.
Rather than dual diagnosis two terms used often are;
  • co-morbidity and
  • complex need.
These both reflect the truth that almost anyone who has worked which everyone has worked with clients will know; that very few people who come in contact with services have only one need. For most people  many things are going on - physical and mental health, housing, legal and financial things will be going on as well.
Models of Care, quotes Krausz (1996) who suggests that there are four categories of ‘dual diagnosis’:
  • a primary diagnosis of a major mental illness with a subsequent (secondary diagnosis) of substance misuse which adversely affects mental health
  • a primary diagnosis of drug dependence with psychiatric complications leading to mental illness
  • a concurrent substance misuse and psychiatric disorder
  • an underlying traumatic experience resulting in both substance misuse and mood disorders e.g. post-traumatic stress disorder.

Issues with how services respond

The Scottish Executive summarises the major service provision problems as
  • some mental health services working on too narrow a model of assessment and care;
  • general lack of communication at both operational and planning levels between addiction and mental health services;
  • lack of clarity in defining clients with co-occurring mental and substance misuse problems (‘multi-problematic’, as opposed to ‘dual diagnosis’), with poor assessment by generic workers and primary diagnosis often reflecting source of referral rather than causation;
  • lack of specified core competencies, and thus training for staff in generic and front-line services;
  • lack of willingness to work with this client group, and stigmatisation associated with their problem; this sometimes results in treatment not being offered and inappropriate and rapid referrals on to other services when their significance is not clear;
  • the need for aftercare support to be planned as an integral part of treatment to prevent recurrence; and
  • the need for better partnership with the voluntary sector in delivering services to this client group.
In a research summary of a report by Strathdee et all (2002)  it was noted that:
“Most substance misuse clients would not have sufficient mental health problems for eligibility at community mental health teams which prioritise those with severe and enduring mental illness. It is recommended that the majority with mild and moderate mental health problems should be managed by specialist substance misuse services and or primary care or by counselling services. Staff training may be required”
The implication of this may be that most people with types of distress who do not fit into the diagnostic criteria drawn up by mental health services will not be seen by them. If primary care, counselling and drugs/ alcohol services are expected to pick up all the people who deal with often highly disturbed people then some training may indeed be required.
The training need
Mind the Gaps the Scottish Executive’s Practice Guidance states three specific training needs. These are;
  • development of assessment skills based upon substance misuse and mental health assessment frameworks;
  • integration of knowledge of drug and alcohol trends for individuals with mental health problems, into practice; and
  • effective working with a range of mental health interventions and treatment modalities.