No one's land

Dual diagnosis is the co-existence of mental health problems and substance misuse. It is a very grey area because nobody can tell for sure whether the mental health problem started as a consequence of substance misuse or the mental health problem lead to substance misuse.  In a classic example of what came first the chicken or the egg people with this diagnosis suffer from all adversities of mental health and drug services. The reasons are very easy to understand mental health professionals usually demand their clients to stop taking any substance if they want to continue or start treatment while drug professionals in many cases do not have the knowledge to deal with mental health distress.

To this it must also be added that dual diagnoses affects people’s lives not only from the medical perspective but also from the social point of view as much of the problems adjacent to it such as inability to work, access to housing, problems with the law and continuous referrals to the welfare system and primary and secondary mental health care usually leave patients with the impression that they are being blamed for their lifestyles instead of finding the right support. This in other words means that dual diagnosis equals to the double stigmatization of adding up the consequences of drug taking and being a mental health patient.

One of the most common cause people why people get trapped in this situation is due to the false impression that self-medication is good and that consuming prescribed or illicit drugs can help to alleviate difficult states of mind. Alcohol consumption is perhaps the clearest example as people start enjoying a drink to forget the problems or simply pursuing a brief moment of euphoria that normally leads to mood deterioration once it is over. Nevertheless people prefer to drink rather than telling their problems to a professional and giving the first step seeking advice. In other occasions when the patients are prescribed medication its side effects produce dizziness, tiredness and other physical reactions altering the normal body functions and as consequence patients need an extra quick to feel normal and perform to what they think are normal standards. 

More than often returning to the normal activity prior to the crisis is very difficult because of the changes and sequels that the breakdown infers in people. So the willingness to get back on track, the prescribed medication, the therapy and the substance misuse creates a vicious circle and a dependency aimed at looking for a way out of the problems. The major problem with substance misuse is that it covers the mental health problem or even worsens it. Cannabis for instance can trigger psychotic episodes in people prone to suffer from manic-depression or schizophrenia while alcohol abuse increases depression. On the other hand, all the symptoms common to substance misuse (i.e.  Needing to increase the amount taken to get the same effect, feelings of dependency or fear of stopping, loss of motivation. poor performance in work or education, financial difficulties) can deteriorate mental health problems worsening their origins.


Figures for dual diagnosis are quite shocking and some sources estimate that it may affect between 30 and 70 per cent of those presenting to health and social care settings. According Mind’s website between 22 to 44 per cent of inpatients in psychiatric hospitals also have problems with drug or alcohol use, and up to half of these is dependent on street drugs. The information also stresses the idea that between 60 and 80 per cent of people admitted to secure hospitals have existing problems with drug or alcohol use at the same time that indicates the possibility that as many as a half to two-thirds of people who come into contact with drug or alcohol treatment services may also have some kind of mental health problem, although they will not necessarily have contact with mental health services. There are many reasons for the increase of dual diagnosis but mainly the de-institutionalisation of mental patients and the increasing substance misuse in the communities are the most significant.



Dual diagnosis is not a homogeneous field where every patient receives equal treatment due to their personal circumstances. People may be referred during an episode of intoxication or withdrawal; they may be dependent on one or more substances and may suffer from more than one psychiatric symptom. The situation, therefore, requires to assess what comes first in order to provide an effective treatment. However, looking for the main cause disregards the need to understand the complexity of the patient’s problem. Health and drug service tend to revolve around their areas of knowledge paying little attention to each other. As a result it is not unusual that the specific disorders of each individual get isolated diluting the whole nature of the problem. This is clear in the different approaches and philosophies that different services have when dealing with patients. The clearest example is perhaps the negative of some recovery centres for mental health patients to engage with drug users due to the lack of knowledge and training while some substance misuse practitioners advocate for harm reduction approaches.


Continuing with this miscommunication between services in 2006 the Department of Health published a paper for inpatients and day hospital settings affirming that most people with dual diagnoses simply required interventions rather than specialist substance misuse input. The guidance argued that with appropriate development strategies and ongoing support staff in mental health could develop the necessary skills to develop dual diagnosis interventions. These skills would be based on formal training, provision of information, shadowing and ongoing support and guidance from staff skilled in dual diagnosis approaches. From a critical point of view it could be argue that the omission of substance misuse professionals could impose the medical model over the social one that most mental health activist prefer to follow. On the other hand, the mental health charity Rethink in its information booklet advocates for a more holistic approach of recovering arguing that the mental health team should make contact with the person, provide social support, and involve families and carers if appropriate. At the same time counselling skills can be used to help motivate the person to make changes and prevent relapses



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