What is dual diagnosis?
The term 'dual diagnosis' or 'dual disorders' has in recent years come to be used in  the  alcohol,  drug  and mental  health  fields  to  describe  a  particular  group  of people  who  have  both  a  diagnosed  mental  health  problem  together  with problems of alcohol and/or drug use.

Usually  this  focus has more often referred to a diagnosis of severe mental  illness, for example psychotic disorders such as schizophrenia  rather  than mood disorders such as anxiety and depression, and the combination of alcohol or drug problems.
There  is  however  a  wide  range  of  mental  health  problems,  including  mood disorders, which  in  combination with  alcohol  and  drug  use  can  result  in many varied  problems,  which  now more  commonly  is  referred  to  by  the  name  "co-morbidity"  (the  presentation  of  two  or more  problems  at  the  same  time  in  the same person).

This more accurately reflects the tremendous variety of problems people can experience, which in addition to medical problems can also include a wide variety of social and on occasions, legal problems.
The  terms  'dual  diagnosis',  'dual  disorders'  and  'co-morbidity'  are  often  used interchangeably.
The  focus  of  this  fact  sheet  will  be  on  severe  mental  health  problems  and substance abuse. 
Extent of co-morbidity
There are different views on how many people have co-morbidity and are likely to present  to  treatment  agencies. Most  studies  that  originate  from North America report very high  rates and suggest  that people with mental  illness have double the  possibility  of  having  an  alcohol  or  drug  problem  compared  to  the  general population.
In some of these North American studies it is reported that people with a severe mental  illness  have  a  rate  of  alcohol  or  drug  use  as  high  as  50%. 

It is further reported that people with an alcohol problem have a lifetime rate of experiencing any mental health problem of 37% and, with a drug problem, of 53%.

In Britain reports have indicated an average 30% of people with serious mental illness also misusing alcohol or drugs.
From the research findings to date, it can be generally assumed that a significant umber of people with mental  illness will also experience problems with alcohol or drug use.

In addition, many people with alcohol or drug problems are likely to have other forms of mental illness and both these groups are likely to present to alcohol and drug agencies.
The relationship between alcohol, drugs and mental health
Given  the  variety  of mental  health  problems  that  can  interact with  alcohol  and drug  use  and  vice-versa  it  is  obvious  that  no  single  explanation  exists  for  the development of these relationships.
Mental illness with developing substance misuse
People mainly present with a mental illness, but because of the symptoms of the illness or their attempts to cope with the effects of medication this can lead to the use  of  substances. 

This  self-medication  theory  has  been  very  popular  in explaining  the  increase  use  of  substances  in  the mentally  ill. 

However,  rather than use specific substances for the relief of particular symptoms, it is considered that people will use any substance  for general relief of distress.

The substances used by the mentally ill for the relief of tension would thus be determined more by availability  and  culture.  Indeed  some  studies  suggest  that  people  with  severe mental  illness  are  attracted  to  the  use  of  substances  because  of  social  and environmental factors, for example social acceptance.

People with mental health problems such as anxiety and depression are more likely to be influenced to use
substances for the relief of symptoms.
Substance use with developing mental illness
This  suggests mental  illness  can  be  a  consequence  of  people's  alcohol/  drug use.  This  would  include  transient  mental  illness  due  to  either  intoxication  or withdrawal  from  substances. 

Alcohol  withdrawal  can  display  hallucinations, paranoia, anxiety, depression and delirium. Heroin withdrawal can often result in depression,  apathy  and  irritability.   

Withdrawal  from  stimulants  can  cause depression and suicidal intentions. 
There are some studies that suggest that intoxication or short-term use of alcohol or  drugs  can  cause  lasting  and  enduring  mental  illness  in  some  people vulnerable  to mental  illness.

A  first presentation of mental  illness can  follow  the use of a variety of substances.  It  is known  that amphetamines and cocaine can cause psychotic symptoms like paranoia, if a large dose of the drug is taken on a single  occasion.

Cannabis,  LSD  and  ecstasy  are  thought  to  precipitate mental illness in some vulnerable people and can also greatly increase the symptoms of an existent mental health problem.
It  is  also  relevant  to  note  that  long-term  permanent  mental  illness  such  as Korsakoff's syndrome (dementia type syndrome linked to heavy drinking and low levels of thiamine B) and alcoholic dementia are both due to chronic alcohol use.

The long-term use of other substances can also result in enduring mental illness such as depression and anxiety.

Problems caused
There  is a complex  interaction between both problem areas where deteriorating mental  illness  can  increase  substance  abuse  and  continued  substance misuse can exacerbate mental illness.
If  alcohol  or  drugs  are  taken  in  combination with  prescribed medication  for  the treatment of mental health problems, this can result in the prescribed medication being ineffective or having an increased impotency.
Substance  abuse  in  people  with  severe  mental  illness  is  associated  with  a number of severe problems, some of which are  listed below but this list is by no means exhaustive:
*  Increased  crimes  of  violence,  with  a  recent  report  indicating  that substance  abuse  by  the mentally  ill  was  a major  factor  in  a  number  of homicides.

*  Increased  rates  of  attempted  suicide,  especially  with  people  having alcohol problems and depression.

*  Poor  medication  compliance,  which  results  in  a  worsening  of  mental illness.

*  Poor response to substance misuse treatment.

*  Homelessness and having problems such as neighbour disputes.

*  High  relapse  rate  in  both  conditions,  resulting  in  longer  periods  of hospitalisation.
Assessment considerations
Needless  to  say,  it  can  be  difficult  recognising  co-morbidity  as  often  the  signs, symptoms  and  presenting  problems  can  be mis-attributed  to  either  substance misuse or mental illness. There can be difficulty in establishing which comes first.

Symptoms of mental illness such as hallucinations may present in alcohol abuse as  part  of  a  withdrawal  state  and  this  can  be  difficult  to  differentiate  from hallucinations  as  expressed  in  a  psychotic  illness.  Similarly,  depression  as  a consequence  of  excessive  alcohol  use  may  be  indistinguishable  from  mental
The important point however is to address the person and their needs rather than attempting to dissect problem areas. 
There  is  however  a  number  of  indicators  which,  research  suggests,  are particularly pertinent to the person with co-morbidity:
*  History of violence
*  History of attempted suicide
*  High contact with criminal justice system
*  High relapse rate from psychiatric and substance abuse treatment
*  Poor response to substance abuse treatment
*  High rate of homelessness 
In assessing a person considered  to have symptoms of both mental  illness and substance misuse, the following points are important to note:
*  Limited insight into the nature of their problems. People with mental illness may  lack  understanding  of  the  effects  of  substances  and may  attribute them to mental illness or vice-versa

*  Memory difficulties can be common and present in both mental illness and substance abuse

*  If  presenting  in  an  acute  mental  state  a  client's  concentration  and understanding of  their condition will be poor. Remember, people  in acute mental distress can find interviews difficult to cope with. 

*  People can have poor motivation as a consequence of mental illness or as a side effect of medication

*  It  is necessary  to  take a very careful history of recent alcohol/drug use  to differentiate between symptoms of substance misuse and mental illness. 

*  Corroborative  information  is  very  important  from  relatives  or  other agencies. Do not rely on a single interview in making an assessment.
Implications for services/treatment
People with co-morbidity problems can present to agencies with a wide range of needs. The effect of substances on mental health can exacerbate acute mental health  symptoms  like paranoia,  hallucinations,  poor  concentration.

This  can  be overwhelming  to  workers  and,  with  the  possible  poor  treatment  contact  and outcomes, this group can sometimes be viewed as 'no hopers' or just too difficult. 

Needless  to  say,  these  are  factors  that mitigate  against  successful  treatment. However  a  number  of  studies  have  indicated  some  core  principles  that  are effective in working with this group of clients.
A  number  of  points  are  important  to  remember  in  the  management  of  co-morbidity:
*  A method of intervention that reflects the cycle of change model, namely a staged approach, is considered effective with this client group. 

*  Initially engaging the client involves sustaining contact by not making too many  demands.  It  may  require  not  insisting  on  an  immediate  goal  of abstinence  although  that  would  remain  the  ultimate  goal.  Offering  help with practical needs such as housing,  finances and benefits can  lead  to maintenance of close contact.
*  Very close contact and  inter-agency working  is vital when working with this  group.  They  can  easily  lose  contact  with  services  and  ideally  an integrated  service  that  addresses  both  mental  illness  and  substance abuse issues is considered the most promising approach. 

All areas of this complex problem need to be addressed. 

*  There is no quick fix solution with this client group and the contact with this group  is  likely  to  be  over  a  long  period  rather  than  a  few months.  It  is therefore necessary to have a long-term view of treatment.

*  A non-confrontational and empathic  approach with  this client group  is considered the best intervention. Motivational Interviewing type techniques have  shown  promise  in  some  studies. 

However  these  methods  require being adapted  to meet  the needs of clients  that have many symptoms of
mental  health  problems  such  as  poor  concentration  and  short-term memory.

*  Both  mental  illness  and  substance  abuse  are  known  for  high  relapse rates.  Remember,  the  co-morbidity  client  group  are  especially  prone  to high relapse rates, yet various research studies indicate that good contact with  services  results  in  a  good  outcome.  Relapse  prevention  strategies applied to substance misuse is also very relevant for this client group.
Further reading
*  Allan  C.A.  (1995)  Alcohol  Problems  and  Anxiety  Disorders  -  A  Critical Review, Alcohol and Alcoholism, 30, p145-151

*  Institute  for  the Study of Drug Dependence  (1999) Drug Abuse Briefing, Seventh Edition

*  MIND (1998) Understanding Dual Diagnosis, MIND Publications

*  Osher F and Kofoed L  (1989) Treatment of Patients with Psychiatric and Psychoactive  Substance  Abuse  Disorders,  Hospital  and  Community Psychiatry, 40, p 1025-1030

*  Rorstad P. and Checinski K. (1996) Dual Diagnosis: Facing the Challenge, Wynne Howard Books

*  Sokya  M.  (2000)  Alcohol  and  Schizophrenia,  Addictions  95.11,  p1613-1618

*  Ward  M.  and  Applin  C.  (1998)  The  Unlearned  Lesson  -  The  Role  of Alcohol and Drug Misuse in Homicides Perpetrated by People with Mental Health Problems, London, Wynne Howard Books
Useful Links
Institute for the Study of Drug Dependence www.isdd.co.uk
MIND (National Association for Mental Health) www.mind.org.uk
Scottish Association for Mental Health (SAMH) www.samh.org.uk

Alcohol Focus Scotland, 166 Buchanan Street Glasgow G1 2LW
Tel: 0141 572 6700
Email: enquiries@alcohol-focus-scotland.org.uk 
Web: www.alcohol-focus-scotland.org.uk
This handout  is  jointly owned by Alcohol Focus Scotland and  the authors. Many thanks to Mary Girvan and Archie Fulton.

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