- ‘Dual diagnosis’
- Psychosis, drugs and alcohol
- Treatment and care for two problems
- Treatment for drug and alcohol misuse
- Physical tests
- Treatment for physical health problems
- Support for family members
A person who has been given a ‘dual diagnosis’ has two distinct diagnoses because they have two co-existing conditions or illnesses that are different.
In mental health services, however, ‘dual diagnosis’ refers to those who have experience of psychosis and who also use alcohol and/or drugs detrimentally. The use of alcohol and drugs is labelled ‘substance misuse’ by professionals.
Around 40% of those who have experience of psychosis misuse alcohol or drugs at some point in their lives. This number is more than double the number of those with no psychosis experience.
When talking about ‘substance misuse’, we are referring to street drugs like cocaine, cannabis, heroin and crack cocaine, for example, prescribed drugs like diazepam or over-the-counter medicines like codeine. The most common street drug used by those who have experience of psychosis is cannabis.
People with a mental illness diagnosis like schizophrenia often say that they drink alcohol or take drugs to help them cope with their illness and its symptoms or to counter side effects of their medication. Even a small amount of alcohol or drugs, however, can make psychosis symptoms worse and can make a person’s treatment less effective – the alcohol or drugs might stop their antipsychotic medication from working as it should.
Studies have also shown that those with a schizophrenia-like mental illness that misuse alcohol and/or drugs will be more likely to have a relapse and be admitted to a hospital ward. They are also less likely to take their prescribed medication and will be more likely not to continue with their treatment, losing touch with their mental health workers. Additionally, they are more likely to try to take their own lives and more likely to become involved in activities that are illegal or violent.
A study from Sweden highlighted those people with a schizophrenia diagnosis that misuse substances were more around four times more likely to end up with a conviction for a violent crime than the general public or people with schizophrenia that does misuse alcohol or drugs.
People with a mental illness that misuse alcohol or drugs have a higher risk of being homeless or having more problems with their housing. They are less likely to be on good terms with their family. People with illnesses like schizophrenia who misuse substances are socially excluded often.
People might also have physical health problems because of their misuse of drugs and alcohol. Drinking alcohol excessively causes pancreatitis, which means the pancreas becomes inflamed. It also causes cirrhosis of the liver, high blood pressure, some cancers and heart disease. Misusing drugs can also cause problems with the lungs. People also have a higher risk of getting blood-borne viruses like HIV and hepatitis and often overdose accidentally.
People with experience of psychosis that drink alcohol and use drugs hazardously might need help for many different problems. The different services needed are often organised by different sectors, which means that a lot of people do not get a comprehensive support package.
There doesn’t exist a treatment that is specifically for people with experience of psychosis alongside alcohol or drug misuse and up to now, there hasn’t been a lot of research into treatments for those who have schizophrenia-like illnesses who also have alcohol and drug problems.
Most of the research studies tend to focus on single conditions. So psychosis research usually excludes those who also have a problem with substances. Secondly, research studies about treatment for alcohol and drug misuse will exclude those that also have a mental illness.
Substance misuse services and mental health services, however, often have different organisations running them although they are sometimes separate parts of one organisation. Unfortunately, therefore, people are ‘bounced’ from services sometimes or don’t get the right care. Mental health professionals might not have the necessary skills to help their patients who also misuse substances and those who work in services for substance misuse might not have the right skills to support those with mental illnesses like schizophrenia.
NICE says that the two services should work in unison to ensure treatment and care is coordinated properly. Mental health specialists that support those with experience of psychosis should seek advice from specialist alcohol and drug professionals to arrange collaboration of their services. Those working in alcohol and drug specialisms should take part in planning care for patients with mental illnesses. For example, they should attend meetings for the Care Programme Approach.
Some individuals with mental illnesses don’t consider their alcohol and drug use to be causing them any problems and so they might not want to seek support from services designed to help them stop. Some services like assertive outreach teams actively attempt to encourage patients to accept treatment for substance misuse alongside their mental health conditions. In some areas, however, these teams are being disbanded.
Additionally, research teams across the globe are working on and testing services and treatments specifically designed for those who have psychosis as well as alcohol and/or drug misuse. A research trial in the UK, for example, examined whether CBT combined with motivational interviewing helped those with a schizophrenia diagnosis to reduce their alcohol and/or drugs consumption. American studies have tested ‘family therapy for dual diagnosis’ and research teams are seeking to gain a better understanding as to why people who have had psychotic episodes drink alcohol or use drugs hazardously with a view to designing new treatments.
Most substance misuse treatments happen through services based in the community so that people do not have to be taken into hospital. Sometimes, however, people might need hospitalisation for their alcohol and/or drug misuse.
The treatment for misuse of drugs depends on what has been used. Treatments can include taking drug substitutes (methadone, for heroin addicts, for example), detoxification or an incentives programme that encourages patients to stop taking drugs by rewarding them with vouchers, for example. Treatments also include withdrawal symptom management via medication if a person has developed a dependency as well as CBT or motivational interviewing talking therapies. The aim of treatments is to help patients deal with withdrawal symptoms and prevent a relapse as well as helping them to stop.
Alcohol misuse treatments can include detoxification for people to stop their alcohol consumption in a safe way with the help of medication to manage their withdrawal symptoms if they have a physical dependency as well as talking therapies.
NICE has published two guidelines for treating alcohol misuse. These are Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence and Alcohol use disorders: Diagnosis and management of physical complications. There are summaries of the guidelines for the public here: Harmful drinking and alcohol dependence and Physical health problems caused by drinking alcohol.
The guidance by NICE on co-existing psychosis and substance abuse states that patients need to be assessed properly in order for professionals to plan appropriate treatment.
Physical or biological tests for substance misuse – blood tests, urine tests and hair analysis – are available to help assess and treat people for misuse of substances. These can only be given with consent, however, and they should be as a part of and agreed treatment plan.
The guidelines say that physical and biological testing should not be used routinely to screen for substance misuse in those who have a mental illness like schizophrenia.
People with a mental health condition such as schizophrenia alongside co-existing substance abuse might also require treatment for associated physical health problems.
People with a mental illness should have their physical well-being monitored by their family doctor annually, if not more frequently. If people are heavy drinkers or use drugs heavily, they should have physical check-ups more frequently.
It is very hard to support or live with a person who has a mental health condition like schizophrenia as well as an alcohol or drug problem. Family members can support their loved one in their battle against substance abuse but will also need information and support from health professionals to do so.
NICE says that family members need to have access to information regarding substance misuse and psychosis as well as information about their treatments.
If a patient agrees for family members to be involved in his/her treatment, family members should be told about their care plan and how they can support their loved one. Families should be involved in their relative’s assessment as they can often give vital information to health professionals. Relatives could also be involved in the development of advance statements and advance decisions that express the person’s wishes regarding treatment if they were to become seriously ill in the future. Family members should also be offered support by health professionals and should be put in touch with groups for carers, for example.