As an alliance, we need to reconsider how to help patients who battle both mental illness and substance abuse problems.
The trouble with dual diagnosis according to Liz McCoy, Drug and Alcohol and Addictive Behaviours Lead for the Pennine Care NHS Foundation Trust, is that individuals living with alcohol and drug addiction and a co-existing mental health disorder easily slip through the system and, more often than not, don’t get the vital support they need.
Established as a concept over 30 years ago, dual diagnosis describes someone with both a mental illness and substance use disorder. In 2002, the Department of Health reported that supporting those with dual diagnosis was one of the biggest problems that frontline mental health services faced and highlighted that fragmented care leads to people falling between the cracks in services.
Liz, who is currently completing a PhD that explores the personal impact of these co-occurring conditions describes it as one of the biggest ongoing challenges faced by alcohol and drug services and mental health services; predominantly because each has its own, nationally driven set criteria, and patients who don’t fit in get lost in the system or drop out of care completely.
Mental health and drug and alcohol services are designed, commissioned, and provided almost entirely separately from each other at the moment in England. This has led to a disconnect between them which results in fragmentation and gaps.
Liz explains: “Alcohol and drug services may exclude people if their substance use doesn’t fit their commissioned ‘criteria’, and mental health services will exclude people if their problem is seen to be substance-related. So, people end up in a revolving door scenario with multiple A&E and psychiatric hospital admissions, contact with the police and a variety of other services, whilst still not receiving the support they so desperately need.
“The irony is that while struggling with a mental health disorder, substance use is not uncommon. There are many who struggle with alcohol or drug problems with mental health illness at the same time and it is not possible to identify whether alcohol and drug use causes mental health problems or vice versa.”
It is estimated that 86 percent of people who access treatment for alcohol use experience mental health problems, while 70 percent of people in treatment for drug use also have mental illness*.
Liz continues: “The squeeze on all services is significant. Among other issues, funding cuts means that they are stretched to nearly breaking point, so there is less leeway to give the right attention for those individuals who have high support needs for both substance use and mental health issues. This is compounded by high, aging caseloads of people with increasingly complex physical and mental health needs.”
People who live with both mental illness and substance use problems can have difficult and out of control lives, often have limited coping mechanisms, and are vulnerable to risks such as homelessness or exploitation. For many, using a substance is a way of masking mental health difficulties and asking them to stop means taking away their coping strategy. Without immediate support, it’s likely that they will return to using substances to cope with emotional and psychological distress.
This leads to the revolving-door scenario, where the patient asks for support from mental health services only to be told to stop using substances. If they can stop using substances but then can’t access support because of long waiting lists, they may end up reverting to substance use to cope.
“The squeeze on all services is significant. Among other issues, funding cuts means that they are stretched to nearly breaking point, so there is less leeway to give the right attention for those individuals who have high support needs for both substance use and mental health issues."
Writer and campaigner, Sam Thomas, knows all too well the barriers that those with dual diagnosis face when seeking support. Sam has a dual diagnosis and is in recovery from alcohol addiction and EUPD/CPTSD. “From the start I told mental health professionals that it was significant trauma that led me to drinking. However, due to the way services are set up they said I must quit drinking first before I could be referred to mental health community services.
"When I was seen at A&E on the third episode of serious withdrawal, my deteriorating mental health had reached a crisis point. I was told I needed to refer myself to the local substance use service to detox, which I did. What I discovered was the trauma I was trying to address with alcohol had led me to repeated relapses each time I detoxed.
“They say when you have both a mental health and substance use problem it’s a case of the ‘chicken and egg’ but, in reality, the trauma leads to the drinking and the drinking compounds the trauma. For many like me having a dual diagnosis is a catch 22, even more so when you risk serious and potentially deadly withdrawal symptoms.
“I had enough of the constant relapses, so I had to take charge of my recovery. But in order for me to begin the therapy I had to be sober. This was finally the beginning of my road to recovery and incentive to get well whatever it took.”
“They say when you have both a mental health and substance use problem it’s a case of the ‘chicken and egg’ but, in reality, the trauma leads to the drinking and the drinking compounds the trauma. For many like me having a dual diagnosis is a catch 22, even more so when you risk serious and potentially deadly withdrawal symptoms. "
Sam has recently launched a campaign; ‘See The Bigger Picture' which is a petition calling on the government for joint mental health and substance use assessments for improved treatment outcomes.
Unfortunately, Sam’s story is a common example of those with a dual diagnosis. So perhaps the challenge is to provide effective services to people with these high needs and instead of thinking of dual diagnosis patients as requiring two support services, acknowledging that it is the norm for these co-occurring conditions to happen together and that treating them as separate is a historic, political and funding decision rather than how people experience them in their lives. They have complex needs deeply linked with, and often extending beyond, their alcohol and drug use and mental health.
Consultant Psychiatrist and Vice Chair for the NHS Addictions Provider Alliance (APA), Dr Emily Finch, said: “We know what we have to do but, sadly, mental health and drug and alcohol services are not funded well enough to deliver. Therefore, we must get better at solving problems together and build good relationships with colleagues between services. It’s amazing what can be sorted out by picking up the phone to better understand the other person’s points of view and be able to build the best long-term therapeutic treatment plan for the patient.”
Liz concludes: “The issues are complex, many and long-standing, and opinions are polarised and largely unresolved. We need to open the debate and identify the issues that need resolving to reach an answer to develop the interventions that could drastically improve the outcomes for this very vulnerable group. Ultimately patients with a dual diagnosis deserve high-quality, focused, and integrated care and we must try harder to resolve this problem.
“After all, if we don’t help them who will?”