Psych · Addiction psychiatry — dual diagnosis and integrated care
Dual diagnosis and integrated care
Also known as Dual diagnosis · Co-occurring disorders · Dual disorders · Comorbid mental illness and substance use · Integrated Dual Disorder Treatment · IDDT · Coexisting severe mental illness and substance misuse · NICE CG120 · NICE NG58 · Sequential parallel integrated care
Exam-exhaustive fellowship reference on dual diagnosis (co-occurring mental illness and substance use): etiological models, sequential/parallel/integrated care, stages of change, motivational interviewing, common comorbidity pairs, systems barriers, NICE/RANZCP-style principles, recovery. FRANZCP-primary, globally tagged.
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Red flags
- Refusing mental health treatment until perfect abstinence when both disorders are active — historical sequential error that worsens outcomes
- Active suicidal intent, overdose risk (opioids plus sedatives), or severe withdrawal (alcohol/benzodiazepines) — medical stabilisation and same-day senior review
- Psychosis with ongoing high-THC cannabis or methamphetamine — dual formulation and concurrent care; do not withhold antipsychotics for mythical abstinence first
- Ping-pong between mental health and alcohol/other drug services (eligibility exclusion) — activate no-wrong-door shared plan
- Child at risk, homelessness with high vulnerability, or forensic risk without coordinated dual plan
- Iatrogenic benzodiazepine dependence layered on anxiety/alcohol dual presentation
Meet the patient
A 24-year-old with schizophrenia is discharged from the psychiatric ward on Tuesday. He is referred to the drug service, who write back that he is "too unwell for our programme". He is referred back to mental health, who write that he is "primarily a substance issue".[4][6]
He smokes high-potency cannabis every night, has stopped his antipsychotic, and has been sleeping at his cousin's since February. He does not want to stop smoking. He does want to stop hearing the voices.[14][15]
Nobody has done anything wrong on either side of that correspondence, and he is still untreated by both. The examinable question is not which diagnosis is primary — it is why he is standing between two buildings.[6][17]
References20ShowHide
- [1]Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study JAMA, 1990.PMID 2232018
- [2]Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication Arch Gen Psychiatry, 2005.PMID 15939839
- [3]Mueser KT, Drake RE, Wallach MA Dual diagnosis: a review of etiological theories Addict Behav, 1998.PMID 9801712
- [4]Drake RE, Mercer-McFadden C, Mueser KT, et al. Review of integrated mental health and substance abuse treatment for patients with dual disorders Schizophr Bull, 1998.PMID 9853791
- [5]Minkoff K An integrated treatment model for dual diagnosis of psychosis and addiction Hosp Community Psychiatry, 1989.PMID 2807203
- [6]Drake RE, Mueser KT, Brunette MF Management of persons with co-occurring severe mental illness and substance use disorder: program implications World Psychiatry, 2007.PMID 18188429
- [7]Drake RE, Mueser KT, Brunette MF, et al. A review of treatments for people with severe mental illnesses and co-occurring substance use disorders Psychiatr Rehabil J, 2004.PMID 15222148
- [8]Drake RE, McHugo GJ, Xie H, et al. Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders Schizophr Bull, 2006.PMID 16525088
- [9]Hunt GE, Siegfried N, Morley K, et al. Psychosocial interventions for people with both severe mental illness and substance misuse Cochrane Database Syst Rev, 2019.PMID 31829430
- [10]Prochaska JO, DiClemente CC Stages and processes of self-change of smoking: toward an integrative model of change J Consult Clin Psychol, 1983.PMID 6863699
- [11]Hettema J, Steele J, Miller WR Motivational interviewing Annu Rev Clin Psychol, 2005.PMID 17716083
- [12]Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials Patient Educ Couns, 2013.PMID 24001658
- [13]Brunette MF, Mueser KT Psychosocial interventions for the long-term management of patients with severe mental illness and co-occurring substance use disorder J Clin Psychiatry, 2006.PMID 16961419
- [14]Di Forti M, Quattrone D, Freeman TP, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study Lancet Psychiatry, 2019.PMID 30902669
- [15]Schoeler T, Petros N, Di Forti M, et al. Effects of continuation, frequency, and type of cannabis use on relapse in the first 2 years after onset of psychosis: an observational study Lancet Psychiatry, 2016.PMID 27567467
- [16]Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders Aust N Z J Psychiatry, 2016.PMID 27106681
- [17]Minkoff K, Cline CA Changing the world: the design and implementation of comprehensive continuous integrated systems of care for individuals with co-occurring disorders Psychiatr Clin North Am, 2004.PMID 15550290
- [18]McHugo GJ, Drake RE, Teague GB, et al. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study Psychiatr Serv, 1999.PMID 10375153
- [19]Eddie D, Hoffman L, Vilsaint C, et al. Lived Experience in New Models of Care for Substance Use Disorder: A Systematic Review of Peer Recovery Support Services and Recovery Coaching Front Psychol, 2019.PMID 31263434
- [20]Saitz R Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking Drug Alcohol Rev, 2010.PMID 20973848