New NICE guidance on dual diagnosis: sterile or infectious?

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Mental health and substance use dominate the top ten global causes of non-communicable diseases (Delgadillo et al, 2016). In combination they can have a hugely debilitating effect on individuals, but unlike many other areas of healthcare we still don’t know how many people have a combined mental health and substance use problem; frequently referred to as dual diagnosis (Schulte et al, 2008).

Doing a head count is difficult when definitions vary. Should we think about dual diagnosis as applying only to people with the most severe problems? Or should we consider any combination of a mental health problem with substance use as the definition? New guidance from NICE recognises the problem and the varied ways in which providers define dual diagnosis, if they do at all (NICE, 2016).

The Dual Diagnosis Good Practice Guide of 2002, (a sort of Policy Implementation Guide, known as PIGs back then) was produced to address shortfalls in care and treatment of people with co-existing mental illness and substance misuse (Department of Health, 2002). It was part of a new era that complemented a wide range of PIGs stemming from the National Service Frameworks that Frank Dobson, the then Minister for Health under Tony Blair produced.

Health funding was abundant compared to previous governments and compared to today’s austerity the funding in 2002 would appear recklessly generous. But did it make any difference to people with a dual diagnosis of mental illness and substance misuse?

A quick reminisce with the 2002 Good Practice Guide and an examination of the new 2016 guidance tells us not much has changed. It’s all about working together, being inclusive and holistic. There is little to separate the two documents. Fourteen years and the issue of dual diagnosis specialist teams or workers are the only differences.

NICE 2016 guidance states:

Do not create a specialist ‘dual diagnosis’ service.

Whereas the DH 2002 Good Practice Guide recommended:

Specialist teams of dual diagnosis workers should provide support to mainstream mental health services.

The last decade has produced a large quantity of research into co-existing mental health and substance use problems. It has revealed the effectiveness of harm reduction, an approach that was previously viewed as condoning substance use. With the emphasis now firmly placed on recovery not retention in substance misuse services, there’s a strong suggestion that harm reduction will again become viewed as negative.

14 years separate the 2002 DH Good Practice Guide from this new NICE guidance, but little has changed.

14 years separate the 2002 DH Good Practice Guide from this new NICE guidance, but little has changed.

Assertive versus passive

The new guidance recognises that services can be ‘fragmented’ and ‘inflexible’ for this client group. This is compounded by differing ways of providing care, with mental health services providing more assertive outreach and community type contact compared with mainly clinic-based substance misuse services. The philosophies underpinning the two are very different too, in mental health a more paternal approach applies where the individual is deemed in need of help. Contrast this with the prevailing philosophy in substance misuse, where you seek help when you are ready and willing. For an individual with a combined problem, the approach taken by these two service models must seem at odds.

Flexibility is lost when services face drastic cuts, as both mental health and substance misuse services have. In effect, this fosters an environment where exclusion criteria are used to preserve core business (Hamilton, 2015). The reality is that mental health services will exclude people with a primary drug or alcohol problem and substance use services return the compliment by excluding people who have a primary mental health problem; leaving the client stranded.

Between a rock and a hard place. Dual diagnosis clients are excluded from both mental health services and substance misuse services.

Catch-22: Dual diagnosis clients are excluded from both mental health services and substance misuse services.

Strengths

Some strengths of the guidance include:

  • Recognises the frequent physical problems this client group face and the inadequate service response
  • Acknowledges that staff often stigmatise people with a dual diagnosis
  • Having separate funding streams for the commissioning of mental health services and substance misuse hampers integration of these services
  • Attempted economic evaluation, but with several limitations.

Limitations

This guidance is focussed on severe mental health problems and substance use which rightly needs attention, but the most common mental health problem for people in substance misuse services is anxiety and depression (Delgadillo et al, 2012). The most commonly used substances by people who have a mental health problem are tobacco, alcohol and cannabis. This guidance does not focus on the problems that the majority of clients who present to either mental or substance use services experience.

For many practitioners, clients and carers, providing integrated care between mental health and substance misuse seems intuitively the right thing to do. But as the NICE guidance points out, there is insufficient evidence to support this type of care currently. However, that doesn’t mean to say that integrated care is ineffective, rather it is a reflection of the lack of research funding available to test these types of treatment. Only one study to date has been funded in the UK by the Medical Research Council (Barrowclough et al, 2010).

Many people with a mental health problem are prescribed medication. They are also more likely than not to be using a substance such as alcohol, cannabis and other drugs (Hamilton, 2013). Understanding how these drugs interact with each other is important, but unfortunately is not given any attention in these guidelines. The absence of any information on this issue compounds the problem, which warrants appropriate assessments and advice for people who experience adverse reactions as a result of drug interactions.

Although not unique in healthcare, the NICE guidance recognises there is insufficient evidence to support the cost effectiveness for many of its recommendations. This is a serious problem when across the health and social care sector there is increasing demand accompanied by rationing. Being able to make an economic argument for a client group is vital. The case looks fragile when there is no evidence of cost effectiveness.

The greatest demand in the dual diagnosis world is for evidence on common conditions (anxiety and depression) and common substances (tobacco, alcohol and cannabis).

The greatest demand in the dual diagnosis world is for evidence on common conditions (anxiety and depression) and common substances (tobacco, alcohol and cannabis).

Summary

This new NICE guidance infers values and actions that are determined by inclusiveness, fairness and equity. However, the guidance itself is sterile and uninspiring.

Substance use is a choice. Of course we can accept that addictive processes (both physical and psychological) are often in place, but the behaviour of taking a substance is ultimately volitional. Yes of course there’s the fact that for many Chem Sex, sex work and exploitation, escaping traumas and so forth question that choice exists and changes the nature of that volition. However, the value-based beliefs around people who use substances and the prejudice around mental health problems endemic in the general population are present in the health and social care system. The sterility of the NICE guidance is a reflection of the problem for dual diagnosis service users and why they’ve had problems of access for many years. The system-led practice changes detailed in the NICE guidance need to be nourished with values, fed with humanity and spread with passion.

People with substance use and mental health problems miss out because they don’t readily fit in.

The guidance is good, but it needs to instil more than willingness on the part of services to implement its recommendations. Ultimately, the problems are less technical and more human. Evidence needs to inspire practitioners. Are you feeling inspired and incentivised to act?

People with substance use and mental health problems miss out because they don’t readily fit in.

People with substance use and mental health problems miss out because they don’t readily fit in.

Links

Primary paper

NICE (2016) Severe mental illness and substance misuse (dual diagnosis) – community health and social care services. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/indevelopment/gid-phg87

Other references

Delgadillo J, Kay-Lambkin F. (2016) Closing the science-practice gap: introduction to the special issue on psychological interventions for comorbid addictions and mental health problems. Advances in Dual Diagnosis 2016 9:2/3

Schulte S, Holland M. (2008) Dual diagnosis in Manchester, UK: practitioners’ estimates of prevalence rates in mental health and substance misuse services. Mental Health And Substance Use Vol. 1 , Iss. 2, 2008 [Abstract]

Department of Health (2002) Mental health policy implementation guide: Dual diagnosis good practice guide.

Hamilton I. (2015) Why addiction treatment is in need of a fix. The Conversation, 2 Jul 2015.

Delgadillo J. et al (2012) Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment. Drug & Alcohol Dependence , Volume 125 , Issue 1 , 37 – 42. [Abstract]

Barrowclough C, Haddock G, Wykes T, Beardmore R, Conrod P, Craig T. et al (2010) Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial.

Hamilton I, Pringle R. (2013) Drug interactions and dual diagnosis. Advances in Dual Diagnosis 2013 6:3 , 145-150. [Abstract]

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Ian Hamilton

Ian is a lecturer in mental health in the Department of Health Sciences at York University, with an interest in the relationship between substance use and mental health (Dual Diagnosis). Ian trained and worked as a mental health nurse in South London, working with people who had a severe mental health problems and used drugs or alcohol problematically. He joined the Department in 2004 as a lecturer. His interest in this client group has continued through his work with teams who come into contact with such clients, and also facilitating sessions in this area.

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Mark Holland

Mark is a registered general and mental health nurse. He has specialised in co-existing mental health and substance use for two decades. His research provides evidence of effectiveness of both harm reduction and recovery oriented intervention for people with a ‘dual diagnosis’. He works as a consultant nurse in Manchester.

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