Mental health articles

OF mental health care and mentally ill

dual diagnosis services

Despite growing concern about dual diagnosis, services have been slow to respond. Two main reasons have been identified for this. First, the way in which mental health and substance misuse services have traditionally operated. They have been separate parts of organizational structures and had different expectations and ways of working with clients. Second, staff in both types of service lack the knowledge and skills for working with people with a dual diagnosis. People in mental health services lack the knowledge and skills for working with people with substance misuse problems and vice versa. Three service models have been identified for working with people with a dual diagnosis: serial, parallel and integrated. The serial model, where mental health and substance misuse disorders are treated consecutively by different services, has been discredited. Each service has expected the client to deal with the other ‘problem’ first and as a consequence people have fallen through the net of care provision. Rorstad and Checkinski describe the experience of one client. ‘I was pushed around like a tennis ball. The alcohol people said I had a mental illness and the mental illness group said I had a drink problem. Neither of them did very much for me’.

In the parallel model, mental health and substance misuse interventions are provided by the two services concurrently. While this model has its critics  some projects in the UK have developed services in this way and appear to have provided benefits to clients. In the USA, services have developed using an integrated model, where mental health and substance misuse interventions are provided concurrently in the same setting by one specialist team. There has been considerable enthusiasm for this approach. Ley et al., however, following a systematic review of studies evaluating programmes designed to meet the needs of people with a severe mental illness and a substance misuse problem, concluded that there was no clear evidence supporting one approach over another.

Policy guidance from the Department of Health has now set the agenda for the development of UK services. For people with a severe mental illness and a substance misuse problem an integrated approach to care provision is to be provided within mainstream mental health services. It is likely that people with less severe mental disorders and substance misuse problems will be the responsibility of substance misuse and/or primary care services. However, many different services are likely to be involved and f inding ways of working together across traditional boundaries will be essential if the diverse and complex needs of people with a dual diagnosis are to be met.

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