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Dual Diagnosis

News and presentations from today’s conference focusing on improving the management of severe mental illness and substance misuse.
Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide to commissioners and service providers
Professor David Kingdon
, Co-Chair, Guidance Sub-Group, Better care for people with co-occurring mental health and alcohol/drug use conditions: A guide for commissioners and service providers, Clinical Service Director, Southampton, and Professor of Mental Health Care Delivery, University of Southampton.

Prof Kingdon commented; 
“Are we really meeting the NICE standards we should be meeting”
“Many people have been depressed or anxious first before substance misuse has become involved and this is an important factor to consider when we are thinking about prevention”
“Working together is so important. There are people who are in between services and people are not receiving treatment. I think there is a big gap in primary care mental health services”

‘Dual diagnosis’ or ‘co-morbidity’ covers a broad spectrum of mental health conditions and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex. Possible mechanisms include:- 

  • A primary psychiatric illness precipitating or leading to substance misuse 
  • Substance misuse worsening or altering the course of psychiatric illness 
  • Intoxication and/or substance dependence leading to psychiatric symptoms or illness (e.g. Acute or residual psychosis after substance misuse – F1*.7)

Substance use does not inevitably lead to deterioration in mental health problems and may be used to cope with anxiety, hallucinations and sedation from medication with mixed effects. Assessment of individual responses, both positive and negative, is necessary for effective engagement and management. 

Principle 1 – Providers in alcohol and drug, mental health and other services should have an open door policy for individuals with co-existing alcohol and drug misuse and mental health issues, and should make every contact count. Service users can access screening, advice and comprehensive assessment which address alcohol and drug and mental health issues, and other presenting needs in both alcohol and drug and mental health services. 

The risk assessment process should explore the presence of different risk factors across a range of indicators and cover the dual issues of mental health and drug alcohol use (DH, 2007)

Factors associated with the increased likelihood of particular risks include:- 

  • Poor compliance with medication regimes 
  • Increased rates of inpatient admissions 
  • Homelessness 
  • Social exclusion 
  • Offending behaviour 
  • HIV or other BBV or physical health concerns 
  • Disengagement from services 
  • Suicidal ideation and actions 

People presenting in crisis frequently have dual diagnosis and management can present complex problems. Presentations can be to the Emergency Department, Police, Ambulance or Acute and Community Mental Health Teams and Substance misuse services. Safety issues often arise in terms of risk to self or others especially when the individual is intoxicated. 

MDT care of frequent attenders at ED or presenting to emergency services can be usefully supported by area High Intensity User Groups including mental health and substance misuse lead practitioners: MyCrisisPlan

Principle 2 - Providers of substance misuse and mental health services have a joint responsibility to meet the needs of individuals with co-existing substance misuse and mental health issues 

Service design

  • Dual diagnosis ‘champions’ can be selected in CMHT’s, AMHT, Inpatients
  • Local Dual Diagnosis Pathway groups:  AMH managers, clinicians and ‘champions’, SA providers incl clinicians, LA, homeless, hostels, commissioners, etc
  • Area  ‘oversight’ committees to coordinate care and commissioning

Training should be available at different levels to all staff in both Adult Mental Health and Substance Misuse Services, who routinely come into contact with people with dual diagnosis and will seek to involve reciprocal training from partner agencies. 


  • Dual diagnosis is common and can be complex and risky to manage 
  • Relationships between organisations and teams are key: responsibilities need to be defined and joint working considered
  • Preventative work e.g. Making Every Contact Count, is simple to do
  • Treatment involves effective care coordination but evidence for specific interventions is limited: always consider involving families 

Full PowerPoint Presentation

Creating coordinate service to support people living with multiple and complex needs
Richy Cunningham, 
Systems Broker, Fulfilling Lives Newcastle & Gateshead

Pre-Conference Abstract:

Richy has been working as a Systems Broker for Fulfilling Lives Newcastle Gateshead, one of 12 Big Lottery national programmes, since 2014.  Employed by Oasis Aquila Housing, one of the core partnership with Changing Lives and Mental Health Concern, his role, alongside a team of service navigators, involves brokering between criminal justice, substance use, mental health and housing systems across Newcastle and Gateshead. The focus of the Fulfilling Lives programme is to achieve sustainable system change for people dealing with multiple and complex needs. Within this, Richy’s key area of focus is to improve access to secondary mental health services for this client group and he has a particular passion and expertise around improving services for people experiencing co-existing mental health and substance use issues. Richy brings over 15 years’ experience of working within the substance use and criminal justice field from both statutory and third sector organisations, including the National Probation Service, Phoenix Futures, Turning Point and HM Prison Service

Useful links:

Future related events: 

Improving Psychological Therapies For Mental Health Trauma National Summit 2017
Friday 8 December 2017 
De Vere West One Conference Centre, London

Smoking Cessation in Mental Health
Monday 29 January 2018 
De Vere West One, London

Implementing the 2017 Quality standard on Transition between Mental Health Settings
Monday 5 February 2018 
De Vere West One Conference Centre, London

Transforming Mental Health Services for Children & Young Adults
Monday 26 February 2018 
De Vere West One Conference Centre, London

Psychological Therapies in the NHS
Wednesday 21 March 2018 — Thursday 22 March 
Millenium Conference Centre, London

Masterclass: Assessment, Diagnosis, Treatment & Management of Eating Disorders
Friday 20 April 2018 
De Vere West One Conference Centre, London

Preventing Suicide in Young People & Children
Monday 23 April 2018 
De Vere West One Conference Centre, London

Depression in adults: treatment and management
Friday 27 April 2018 
De Vere West One Conference Centre, London

1 December 2017


    Partner Organisations

    The Tavistock and Portman NHS Foundation TrustInPracticeClinical Audit Support CentrePlayoutJust For Nurses
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