Dual diagnosis calls for joined-up solutions

Can nursing education fulfil the needs of mental health service users with dual diagnosis? Yes, providing it is willing to change, says Cliff Roberts

Dual diagnosis refers to the use of drugs by an individual who is also suffering from a mental health disorder (Minkoff 1995). The provision of care for patients suffering from dual diagnosis of severe mental health problems and substance abuse is of major importance to nursing as the incidence of drug use is increasing (Sandford 1995).

The most commonly used substances are alcohol and cannabis (Smith and Hucker 1994), often taken to relieve anxiety, depression, difficult social interactions (Miller and Tannenbaum 1989) or induced extra-pyramidal side-effects from psychotic medication. In-patient populations and primary health care are not yet fully able to support these client groups and are lacking in nursing specialism and collaboration. Educational initiatives aimed at the provision of clinical care within these settings are essential to redress this imbalance. The nursing literature over the last few years has been debating a case for just such an educational development (Gournay et al 1996).

What is required is an educational programme that is a clinically based nursing initiative, focused on research. This direction also fulfils the requirements of the NHS Plan in terms of educational provision. There exists an ideal opportunity for the nursing profession to take a lead in what appears to be a delay in the appreciation of need in the seriously mentally ill client group. But the term "seriously mentally ill" is misleading and does cause some confusion, having become associated with schizophrenia, mostly through the public's interpretation of media coverage. Therefore patients with mental health disorders such as depression, personality and eating disorders may not be regarded as seriously ill. This confusion does not aid the plight of this client group and only adds to delay and uncertainty among health care professions.

The significance of evidence-based nursing interventions, supported by outcome measures, may provide a powerful denominator in promoting change. Currently these outcome measures are developed and evaluated by the commissioning bodies set up by trusts to audit the managed market. They are standards by which the NHS Executive evaluates policy and monitors performance. Nursing practice/specialism outcome measures could be used to the same end.

Two main possibilities for the clinical specialist area are suggested (Gournay et al 1995):

each area could develop a specialist dual-diagnosis team, where all workers would receive specialist education and clinical support/supervision, with this service becoming the central vehicle for delivery
specialist workers could be educated and placed in generic services, and thus dual diagnosis expertise could be spread throughout.

These possibilities are focused on dual diagnosis, but equally could be aimed at any client group suffering from mental illness.

Four central themes have been suggested regarding approaches to case management (Drake and Noordsy 1994):

engagement
persuasion
active treatment
relapse prevention.

Engagement may come from any area within mental health services to primary health care sources not necessarily set up for the support of these individuals. Lack of alliance to medicines and failure to attend clinics means that mental health outreach needs to be a key initiative in community and primary health care. A working knowledge of mental health assessment is essential during this stage.

Persuasion using motivational interviewing and explanation of the consequences of dual diagnosis on physical and mental health is essential in this stage. It may not be until this stage that a useful and meaningful assessment can be made. Mental health nurses and those with no traditional background in mental health need the knowledge and skills (achievable in a clinically based programme), to enable this stage to succeed.

Active treatment in this country revolves mostly around pharmacological and cognitive behavioural therapy or both. This includes support of the family. Knowledge of pharmacology, symptoms (both positive and negative), education and behavioural therapy is essential for case management at this stage.

Relapse prevention can be minimised by clinical skills and knowledge required to support the patient in the active treatment stage. Management is centred on exploring the factors leading up to relapse and supporting the patient through what should be seen as a learning process.

At present the education and clinical support discussed above does not exist cohesively within any generic educational programme in the UK, although the Institute of Psychiatry and the Sainsbury Centre are working on the development of educational programmes in dual diagnosis.

Barker (1996) suggests provision should be made in the following areas:

developing existing relationships with colleagues in primary health care
networking and liaison with health visitors, district nurses, community workers, social services departments and schools
working directly with families at an earlier stage of distress.

There is a need for a diversity of nursing roles within primary health care, and these roles require support from academic institutions which must be able to respond by providing clinically based courses. It is imperative and increasingly urgent that courses of this nature are developed if we are to fulfil requirements of the NHS Plan.

From the discussion above it is suggested that a clinically based course be developed amalgamating the suggestions of Gourney et al, Drake and Noordsy, and Barker. The Thorn initiative may be a useful model to use for the development of a programme or pilot modules. Thorn provides a model for practice that incorporates a problem-centred approach to the delivery of psycho-social intervention. Barker's suggestion spreads the net of professional incorporation wider within the field of primary health care nursing. The Thorn initiative contains some very enterprising and innovative approaches to the care of the seriously mentally ill and the problem of dual diagnosis is a prominent feature within this client group. Perhaps what is required is an innovative hybrid of the Thorn initiative, which would cater for primary health care nurses with or without a mental health care background. This would meet the needs of the seriously mentally ill, their families, nurses working with this client group, and the needs of many RCN members.

Cliff Roberts is Senior Lecturer, Clinical Neurosciences, RCN Development Centre, South Bank University. Email: cliff.roberts190@btinternet.com

References

Barker P, Jackson S (1997) Mental health nursing: making it a primary concern. Nursing Standard. 11, 17, 39-41.

Department of Health (1995) Clinical Standards Advisory Group Report on Schizophrenia. London, HMSO.

Drake R, Noordsky D (1994) Case management for people with co-existing severe mental disorder and substance misuse disorder. Psychiatric Annals. 24, 8, 427-431.

Gournay K, Sandford T, Jackson S et al (1996) Double bind. Nursing Times. 92, 28, 28-29.

Miller F, Tannenbaum J. (1989) Substance misuse in schizophrenia. Hospital and Community Psychiatry. 40, 847-849.

Minkoff K (1995) An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry. 40, 1031-1036.

Sandford T (1995) Drug use is increasing. Nursing Standard. 9, 38,16-17.

Smith J, Hucker S (1994) Schizophrenia and substance misuse. British Journal of Psychiatry. 165, 1, 13-21