24. Dual diagnosis

Matter for discussion submitted by the RCN Mental Health Forum

That RCN Congress discusses the challenges faced by nurses working across all health care sectors in managing people with dual diagnosis

Progress reports

Submitted by: Mental Health Forum
Council lead and committee assigned: Andrew McGovern, Nursing Practice and Policy Committee
Committee decision: Existing work addresses this issue
Members involved: Cris Allen, Chair of the RCN Mental Health Forum and Brighton and Hove Branch, Anna- Marie Felice, RCN Mental Health Forum steering committee member and Hertfordshire Branch, Peter Kelly, North West London Inner Branch and Ellie Gordon, Scunthorpe Branch, both expert reference group members

Final summary update at May 2012

While this item did not call for specific actions, the RCN has undertaken related work.
A substance abuse nurse has been appointed to the RCN Mental Health Forum steering committee, ensuring the clinical area of substance misuse and the issue of co-morbidity is factored in to the forum’s work.

The RCN has also spoken to the Association of Nurses in Substance Abuse (ANSA) around revising their guidance documents for all nurses. The need for this resource was highlighted by the Congress debate.

A RCN Learning Zone resource entitled “Substance misuse nursing for non-experts” has been launched at Congress this year. This was developed in conjunction with an expert reference group of substance misuse nurses drawn from ANSA and the RCN.

The RCN continues to work with the Royal College of Psychiatry and General Practice and the British Psychological Society on the substance misuse agenda and has had meetings with the Department of Health (DH) and the Ministry of Justice to discuss issues specifically related to clients with dual diagnoses and complex needs and their welfare in the current commissioning environment.

The RCN has regular meetings with the DH to discuss the broader substance misuse agenda and is represented by members who are clinical experts in the field.

Update at November 2011

Norman Young, chair of the RCN Mental Health Forum and staff lead Ian Hulatt, RCN Mental Health Adviser met following Congress on the 22 June 2011. It was agreed to appoint a substance misuse nurse to the steering committee to ensure that the clinical area of substance misuse and the issue of co-morbidity was factored in to the ongoing work of the RCN Mental Health Forum.

It was also agreed that the ongoing discussions with the Association of Nurses in Substance Abuse (ANSA), around the revision and re launch of their guidance documents for nurses in all fields to assist meeting the needs of this client group, would continue. It was felt that the Congress debate had increased not only the impetus to achieve this but also demonstrated its need.

There has been progress in two areas:

The process of seeking nominations for the position on the steering committee of the Mental Health Forum for a substance misuse nurse has commenced with adverts in RCN Bulletin and on the RCN website
The renewed resource on the care of people with substance misuse issues was the subject of ANSA’s Executive meeting in July 2011.

Debate report

Chris Holley of the RCN Mental Health Forum opened this matter of discussion by highlighting the difficulty that patients with dual diagnosis face in accessing services. “Dual diagnosis creates system-wide challenges for the nursing workforce,” she said.

Thomas Murray of Devon Branch was keen to point out that although being older is not a diagnosis itself, the further along the pathway people get the more likely they are to have physical and mantal health components in their diagnosis.

Debaters raised the issue of mental health services claiming to be unable to start their work until substance abuse services had completed theirs and vice versa as a barrier to treatment programmes.

In closing Chris Holley acknowledged that dual diagnosis had a vast impact for nurses and that whilst there are community services, nurses are expected to know it all and do it all.

Individuals with a dual diagnosis – coexisting mental health and alcohol and drug problems – generally experience poorer outcomes with regard to their mental health, and their engagement with services and treatment compliance may also be compromised. Meanwhile, individuals with substance misuse issues risk deterioration of their mental health and the emerging presence of serious mental illness. Either way, the physical health of individuals in both groups may deteriorate, necessitating access to physical health services – often for the treatment of trauma (either as victims of violence or for self-inflicted injuries).

Given the broad spectrum of mental health disorders and types of substances used – ranging from severe and enduring mental health disorders like bi-polar or schizophrenia and heroin or ‘crack’ cocaine misuse, through to the so-called milder mental health disorders such as anxiety and personality disorders and alcohol and cannabis misuse - assessing which condition is the ‘primary’ and which the ‘secondary’ diagnosis may be possible. But all too often these act a barrier to accessing treatment.

Individuals with a mental illness and a substance misuse issue may find themselves not accepted into substance misuse services because they have a mental health problem. These individuals may also find it difficult to access mental health services as they have a substance misuse issue and there are not the skills present in the mental health team to assist them.

The level of preparation for nurses and health care support workers to enable them to engage effectively with this challenging group varies widely. The presence of dual diagnosis labelled clients in both mental health and acute hospital settings provides a system-wide challenge to the nursing workforce.

In Scotland the two agendas for improving mental health - Delivering for mental health (Scottish Government, 2006a) and integrated care pathways – include measures to improve service provision for people with both mental health and substance misuse problems. In December 2010 the Scottish Government and Convention of Scottish Local Authorities (CoSLA) published a joint statement to support the development of the workforce to deal with challenges posed by alcohol and drug misuse; one element of the work going forward will be the setting out of learning priorities, which may include skills to deal with the challenges posed by people with a dual diagnosis.

In Northern Ireland the principles of co-morbidity were defined through the Bamford Review (which published a separate report on alcohol and substance misuse in 2005), which determined people with co-existing substance misuse and mental health problems should be treated using an integrated treatment model within a single service (either mental health services or substance misuse services, depending on the nature of the diagnosis). Effective systems of liaison between the two services should exist to ensure people with dual diagnosis have access to the full range of appropriate treatment services, and there should be locally agreed care pathways for dual diagnosis.

In Wales, the Welsh Assembly Government has addressed the issue in its Service framework to meet the needs of people with co-occurring substance misuse and mental health problems (2005).

References and further reading

Department of Health (2002) Mental health policy implementation guide: dual diagnosis good practice guide. London: DH. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009058 (Accessed 04/02/11) (Web)

NHS Quality Improvement Scotland (2007) Standards for integrated care pathways for mental health, Edinburgh: NHS Quality Improvement Scotland. Available at: http://www.nhshealthquality.org/nhsqis/files/mentalhealth_standardsforICP_DEC07.pdf (Accessed 04/02/11) (Web)

Phillips P, McKeown O and Sandford T (editors) (2010) Dual diagnosis practice in context, Chichester; Wiley-Blackwell.