‘Dual Diagnosis’ Refers to Patients With Co-Existing Mental Health and Substance Misuse Disorders

The term ‘dual diagnosis’ refers to patients with co-existing mental health and substance misuse disorders. The importance of the treatment of both mental health problems and substance misuse problems in prisons is addressed by the Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide (DoH, 2002a). Statistics quoted here state that at least half of prisoners on remand have substance misuse problems, with 10% being classed as moderate and 40% classed as severe.

Further, of those with substance misuse problems, theco-morbidity with mental disorders is 79%. With these figures in mind, the importance of the service, delivery and treatment of prisoners presenting with co-morbid mental disorders can be clearly seen. This essay will first examine the theory of dual diagnosis and what the evidence can tell us about its nature and how the different factors interact. Then the policy guidelines for the service and delivery of treatments will be examined. Finally the treatment options currently being used will be surveyed and assessed critically.

Theories of Dual Diagnosis

It is hard to understand the policy implications, treatment methods or service delivery standards without first having a basic knowledge of the difficulties that researchers have had in understanding what a dual diagnosis is and how it arises. This discussion is just as relevant for those inside and outside of the criminal justice system.

At its most basic, the idea of dual diagnosis, that of the co-occurrence of mental health problems with substance misuse problems, covers a broad range of factors, the interaction of which has been analysed by Krausz (1996) as falling into four categories. Firstly, the primary diagnosis of mental health problems is followed by secondary problems of substance misuse then leading back in a circular fashion,into further mental health problems. Secondly substance misuse is seen as the primary diagnosis and this is followed by mental health problems, which are seen as secondary. Thirdly, the mental health problems are seen concurrently with substance misuse. Finally, there is a traumatic event which results in both mental health problems, such as a personality disorder, as well as substance misuse. These four different categories represent different lines of causation that are postulated between mental health and substance misuse.

This analysis of Krausz represents one theory of how substance abuse might interact with mental health problems – but these theories have proliferated. Mueser, Drake & Bellack (1998) provide an in depth analysis of the different types of theories surrounding dual diagnoses. Mueser et al. (1998) organise their review of the theories of comorbidity into four categories. These are, firstly, common factor models, which suppose that there are common factors that cause both substance misuse and mental health problems. Secondly, there are secondary substance use disorder models – so that mental illness causes substance misuse. Thirdly, there are secondary psychiatric disorder models which essentially propose the opposite of the last category. Finally, there are bidirectional models that do not cede primacy toeither of the disorders.

Before reviewing the evidence, it is necessary to be aware of some of the limitations in this type of research. Mueser et al. (1998) are careful to explain that they do not assume that the models are mutually exclusive, in fact they hypothesise that each will explain different individuals under a variety of circumstances. There are, also, a number of other difficulties with this type of research that are identified by Mueser et al. (1998). They cite the work of Hambrecht and H & Aumlfner (1996) who have investigated whether alcohol abuse precedes schizophrenia or the other way around. In their study they found that, in general, it was the alcohol abuse that came first, although actually this came after the first symptoms of schizophrenia were noticeable. Needless to say, this is a very confusing finding. A further difficulty that is mentioned by Mueser et al. (1998) is the general presumption in psychiatry that the biological basis of disorders is paramount. Psychosocial effects tend to be minimised and treated as secondary – a view that has been challenged by a significant body of research.

Looking first, then, at common factor models, Mueser et al. (1998)divide the research into genetic factors and antisocial personality disorder. While there is evidence of a genetic link (for example Tsuang, Simpson & Kronfol, 1982), there is also evidence that has not found a link. Kendler (1985), for example, did not find a difference in the incidence of schizophrenia and alcoholism between monozygotic and dizygotic twins – the importance of this being that monozygotic twins generally share the same environment and all the same genes while dizygotic twins only share half their genes. Their findings in this research tend to downplay the importance of a genetic link.There is a considerable weight of research that has looked at the link between antisocial personality disorder and substance misuse, Kessler, Crum, Warner, Nelson, Schulenberg & Anthony (1997), for example,found a strong link. Mueser, Drake, Ackerson, Alterman, Miles & Noordsy (1997) also found an association between the personality disorder and more severe forms of substance misuse. In analysing this connection Mueser et al. (1998) call on a criticism that is widespread in the personality disorders and in psychiatric diagnoses generally,that the measures used to ascertain this diagnosis are not valid and reliable. Validity in psychology refers to whether a construct actually measures what it purports to measure. Part of showing a construct’s validity involves showing that it is just measuring one thing rather than overlapping, in the case of antisocial personality disorder, with simple criminality. The labelling of a person with a personality disorder may hide the fact that, for example, they are the victim of circumstance, or perhaps social and economic conditions. This becomes conflated with the idea that a person is intrinsically mentally ill.

The secondary substance use disorder models can, according to Mueser etal. (1998) be divided into psychosocial risk factor models and biological sensitivity models. The psychosocial model is again subdivided by Mueser et al. (1998), but the authors report the model with the most empirical support is the multi-factorial model. Thefactors involved include, for example, bad interpersonal skills, social isolation, lack of structured daily activities. The second category of theory is that of biological sensitivity. The biological sensitivity of schizophrenic patients has certainly been shown to be greater in amphetamine use – this contributes to a ‘revolving door’ effect for these patients (Haywood, Kravitz, Grossman, Cavanaugh, Davis, &Lewis, 1995). Both of these sub-groups within this group of dual diagnosis theories has some evidence to back it up.

Secondary psychiatric disorder models which give primacy to substance misuse have proved controversial. Perhaps this is chiefly because alcohol is the substance most often abused and there is little evidence of its relationship with the specific diagnoses of bipolar disorder or schizophrenia. Indeed, there is even evidence that it contributes towards covering up the onset of the condition (Bernadt & Murray,1986). Despite this, there is evidence from some studies that certain drugs are associated with psychosis. LSD has been associated with psychotic outbreaks (Bowers, 1972). Andréasson, Allebeck, Engstrom, and Rydberg (1987) found a link between cannabis use and schizophrenia,with heavier users showing a quicker onset of symptoms. Overall,though, Mueser et al. (1998) state that it is difficult to show a strong connection across a variety of different drugs as the evidence simply does not exist.

Finally, in Mueser et al.’s (1998) review, the authors state that the bidirectional model has not been empirically tested. Overall, while the plethora of theoretical models have some evidence bases, none of them provide particularly strong explanations of reality. This serves to underline the complexity of dual diagnosis.

Service and Delivery: Mental Health Policy Implementation

What emerges, then, from the theoretical perspectives is that there isa lot of confusion and a proliferation of different approaches. So, how do public services attempting to deal with dual diagnosis? The Department of Health’s (2002a) Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide provides policy information about how services should be targeted at dual diagnosis patients.Reviewing the history of how dual diagnosis patients have been treated in the past the guide points out that there has generally been little integration. In the past, drug and alcohol services have remained quite separate from mental health agencies. This guide puts into place a new policy that aims to reverse this trend. Mental health services are encouraged to provide similar sorts of treatment to that already provided by drug and alcohol services. The drug and alcohol services are encouraged to see themselves as consultancies to other agencies,particularly mental health services, in order to provide’mainstreaming’.

Mainstreaming refers to avoiding moving patients from one service to another as this may lead to them leaving treatment completely. In order that mainstreaming should be effective, this document makes a number of policy recommendations. These include specialist dual diagnosis workers, a clear definition of what dual diagnosis means, an adequate number of staff available in areas like community mental health teams and early stage intervention.

It can be seen that a high level of integrated communication and working patterns is recommended by the document, particularly in relation to those in prison. Those in prisons are recognised by the document to be at greater risk. The guidelines encourage the communication between different agencies including the primary care team and prisons. They also encourage establishing partnership with the criminal justice system, partly by creating ‘in-reach’ programmes to deliver these services to prisoners. The document states that as for the treatment that is recommended for these patients, there has been no research in the UK into what is effective, the authors therefore turn to evidence from the US which, they claim, suggests the importance of integrated treatment, motivational interventions and individual counselling.

Overall, while acknowledging that prisoners are at high risk of dual diagnosis, there is little mention of them in this document. Weaver, Renton & Stimson (1999), in anticipation of some of there commendation of this document, make some salient criticisms. They blame the way in which separate services have developed for those who have a dual diagnosis on political ideology and point out that research evidence has had little sway. The psychosocial model on which substance misuse services are based, as the name suggests, tend to emphasise the importance of psychological and social causes and remedies. In contrast, mental health service tend to be based on the medical model which is normally biologically based and encourages the diagnosis of problems as well as the attendant implications of compulsory incarceration within institutions. These two groups of people approach the world in different ways and it will, Weaver et al. (1999) suggest,be difficult for them to communicate effectively with each other.

Service and Delivery: Models of Care

The Mental Health Policy Implementation document provides an overview of aims and objectives for dual diagnosis patients, however The Models of Care (DoH, 2002b) takes a closer look at the way in which treatment can be delivered. The Models of Care (DoH, 2002b) report does not itself cover the treatment in prisons in any detail but, as the authors claim, it does have a general relevance. In particular, though, it does describe the care pathway for prisoners as being through a prison-based referral scheme.

The Models of Care (DoH, 2002b) report describes the prison-based treatment of those with substance misuse problems. Counselling Assessment Referral Advice and Through care (CARAT) services provide that treatment and support. The staff who provide this service are not members of the prison service and their function is to cover a number of areas. These include the initial assessment of the prisoner,liaising with a variety of other agencies, input into different reports that are required for sentencing or probation and either group or individual counselling that aims to ameliorate the misuse problem. The CARAT services also look to the prisoner’s welfare after their sentence is complete by providing training before they leave and assessing their requirements for post-prison treatment. One of the most surprising omissions of the CARAT scheme is that it excludes alcohol misuse, which is one of the most common substance misuse disorders (O’Grady, 2001).

The publication does report on changes introduced by a new drug strategy. This new strategy aims to introduce new interventions that are available from arrest through to sentencing. The primary aim will be to get drug misusers into treatment at the earliest opportunity and emphasise the importance of integrated care pathways. The guidelines laid out in the Models of Care (DoH, 2002b) maintains that the causes of patient’s problems will often be multifactorial and change overtime. These implicitly acknowledge some of the findings from the review of the theoretical literature. For this reason, it is important that care plans are updated over time to take into account the latest circumstances of the patient.

Treatment of Dual Diagnosis

In the delivery of interventions, the integrated care pathway has become the mantra of healthcare managers. This is because it is often seen that different services have different philosophies (as suggested by Weaver et al., 1999), and patients should not be expected to shuttle between them. Drake & Mueser (2000) describe the attributes of a dual diagnosis system as including the patient receiving treatment from the same clinicians who are trained in both substance misuse disorders and mental health disorders. There is a much greater emphasis in integrated treatment of not immediately confronting the patient and challenging them to become abstinent quickly. Instead the integrated approach focuses on a gradual and long-term strategy of harm reduction.The emphasis here is on, for example, motivational interviewing which provides encouragement rather than chastisement. Another innovation is the use of 12-step programmes for alcohol abuse only in those patients who believe they can benefit from it rather than its mandatory use.Having described some of the differences, it is nevertheless clear that the integrated approach does share some commonalities with more traditional parallel approaches. For example some assessments and interventions are still the same as are psychosocial and psychopharmacological approaches.

The Department of Health (2002) review some of the evidence on integrated care pathways. It seems there has been mixed evidence of a beneficial effect on the mental health outcomes of dual diagnosis patients with the use of integrated care pathways. Much of the work that has evaluated this approach has been carried out in the US.Hellerstein, Rosenthal & Milner (1995) carried out a study in the US on schizophrenic patients who also had substance misuse disorders.This compared the integrated with non-integrated pathways and found little difference between them in the outcomes measured. This research does not, however, take into account all the possible factors involved.Other research, such as that reviewed by Drake & Mueser (2000), has found advantages. Similar findings are reported by Drake, Yovetich, Bebout, Harris & McHugo (1997) who argue that an integrated approach is effective in providing housing stability, reduced alcohol intake compared to the parallel approach that has been in use in the US and the UK.

One important treatment factor in the integrated pathway is the use of motivational interviewing. This is used to try and encourage a more co-operational approach between patient and clinician. It is hypothesised that this will help encourage patients to return to outpatient clinics to continue their treatment. US research on this has provided some supportive evidence for this approach. Swanson, Pantalon & Cohen (1999) compared motivational interviewing with the standard treatment to the standard treatment alone. They found a statistically significant difference in the group that had comorbid disorders.

So far, very generalised factors of dual diagnosis have been addressed,but it should be made clear that many interventions will be heavily reliant on the individual needs of the patient. Research studies have shown that treatment must take into account which dual diagnosis the patient receives. For example, a study in the UK, Barrowclough, Haddock, Tarrier, Lewis, Moring, O’Brien, Schofield & McGovern(2001), found that when measuring days of abstinence, symptoms and general functioning, a combination of cognitive, motivational interviewing and a family intervention was more effective in dual diagnosis for psychosis than the standard treatment. By contrast, for bipolar disorder with substance misuse, integrated group therapy was found to be effective by a US study (Weiss, Griffin, Greenfield, Najavits, Wyner, Soto & Hennen, 2000).

Many other different types of treatment modalities have been examined,such as in-patient versus outpatient treatment, persuasion groups,social skills training and self-help groups (Abou-Saleh, 2004), but how much of the available services do dual diagnosis patients use? Studies in the US have shown higher rates than those with a single disorder(Narrow, Reiger, Rae, Manderscheid & Locke, 1993). Other more specific studies, such as Wu, Kouzis & Leaf (1999), have found little difference between alcohol misusers with other comorbid mental health problems and those without the comorbid disorders. Still, the evidence shows that the use of services by dually diagnosed patients is at least as high as other comparable groups.

Conclusion

It can be seen from the review of the theoretical work on dual diagnosis that the picture is extremely complicated. Causal mechanisms are hypothesised in a number of directions with a consequent proliferation of different treatment ideas. Perhaps the only conclusion that can be drawn with confidence from this literature is that an attempt should be made to treat every patient individually. The prevalence of dually diagnosed patients in prisons is clearly at worrying levels, however, as can be seen from the policy documents reviewed here, there is little mention of prisons and prisoners.Generally, prisoners are mentioned in passing, and mental health and substance misuse services are encouraged to integrate prisons into their scheme, but no particular emphasis is placed on them – indeed their mention is surprisingly scarce. The policy directions that are recommended in the documents reviewed here point to an increase in the use of integrated care pathways. It seems, from reviewing the evidence,that there is some support from studies carried out in the US that this method of working is beneficial to the patient with a dual diagnosis.Aside from integrated pathways a number of different treatment modalities have been investigated with varying degrees of success. This is indicative of the extremely wide and variable nature of a dual diagnosis itself. It can only be hoped that major improvements to the treatment of prisoners with a dual diagnosis will be made in the near future.

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