Interventions

  • Disorder: Depression
  • Type: Depression Uni-Polar
  • Severity: Moderate

Dual Diagnosis

Overview

Dual diagnosis is a term used to describe people who experience both severe mental health problems and substance misuse problems. Sometimes older people misuse substances, mainly alcohol, to cope better with their mental health problems. This can lead to an increased reliance on drug or alcohol and as a result, can cause psychological problems.

Our clinicians advise people who use drugs and/or alcohol on lifestyle choices and how this can potentially impact on physical well-being to enable the person to make informed choices about their future use.

When a person’s drug or alcohol use is more complex, the relationship between concurrent substance misuse and mental health problems can have a negative impact on the persons psychological, physical and social wellbeing, as well as increasing physical and psychiatric risks to self and/or other people.

The treatment of mental health and substance misuse problems must be addressed concurrently and in collaboration with the person, their mental health team and where appropriate a substance misuse service.

Although our Directorate services are unable to provide highly specialist substance misuse treatment for older people, such as planned/emergency detox and evidence based addiction treatment programmes, our clinical staff are trained in:

  • Detecting and assessing for substance misuse problems.
  • Engaging in collaborative conversations about a person’s substance use that explore what the person’s future goals are in relation to their use.
  • Providing advice on seeking the right specialist help at the right time for complex substance misuse issues.
  • Identifying how substance misuse risks could impact on the safety of the person and/or people around them.

When a person is admitted to the Directorate’s acute admissions wards with an acute phase of a mental health condition, physical detox for people experiencing dependence syndrome or opioid stabilisation will form part of the their treatment plan in line with the Maudsley Prescribing Guidelines.

Planned/emergency detox and opioid stabilisation are only available from specialist addiction services and not provided by the Mental Health Older Adults Directorate.

Who is responsible for care and treatment?

Phases of intervention

Assessment

All people assessed by Directorate services will be asked questions about their drug and alcohol use as part of the generic assessment process. Information about the type(s) of substance, frequency and patterns of use will be obtained by the allocated worker.

In addition to this, the worker will administer an alcohol assessment outcome tool called the AUDIT. The AUDIT consists of ten questions to determine whether the person’s alcohol use is harmful. The worker will directly feedback results of the AUDIT to the person being assessed in order to facilitate a collaborative discussion on what the results mean, what the person’s goals are in relation to their drinking and to identify what support is needed to help the person meet their goals.

Information about drug and alcohol use will be used as part of the person’s risk assessment to inform a risk formulation. This information is important to the development of a risk management plan, especially if the person’s substance misuse impacts on their risk to self and/or other people.

Sometimes blood investigations will be requested by the assessing clinician to understand if the person’s drug and/or alcohol use is impacting on their physical health. A common blood investigation is a Liver Function Test (LFT) to examine the impact of alcohol use.

Engagement

When a substance misuse issue is identified by health and social care professionals or someone close to the person, it could be that the person does not recognise that there is an issue or they could feel that their use is helping with managing their mental health problem.

The allocated workers will develop a trusting and collaborative relationship with person to provide a safe place to discuss their drug or alcohol use. For people with dual diagnosis it sometimes can take time and commitment from the allocated worker to develop a collaborative relationship to explore the impact of a person’s drug or alcohol use.

Persuasion

Once a collaborative relationship is developed between the person and the allocated worker, discussions will take place in order to explore the person’s perceptions of their drug and/or alcohol use in order for the person to identify future goals.

It is common for people with substance misuse problems to feel ambivalent about their drug or alcohol use and to be resistant to changing their behaviour around taking substances. It is particularly important that the worker’s approach is non-judgemental and sufficient time is provided to allow some insight into behavioural change.

Motivational interviewing will be used as a collaborative, goal-orientated approach to communicating with people with alcohol misuse problems. This approach can often be used to strengthen the person’s motivation toward establishing their own commitment toward setting future goals and the support and or/treatments available to achieve those goals.

Active Treatment

Once commitment to change is established and an action plan is developed active treatment will be delivered by the right service at the right time. Treatment could include working toward controlled use of the substance, incorporating techniques to minimise harm of continued use or abstinence. If a substance misuse issue is not complex it could be that an allocated worker from the Directorate can support the person toward this treatment goal.

However, if the complexity of the person’s use and its impact on their physical and mental wellbeing is significant, treatment will be agreed and planned for with the most appropriate specialist addictions service. The Directorate will work in partnerships with specialist services for people who remain open to their allocated team.

Relapse Prevention

On completing the agreed treatment or intervention, decision making about who will support the person in maintaining the changes they have made with their use will be made. For less complex substance misuse problems the support to prevent relapse, continue to minimise harm or maintain controlled use could be provided by the Directorate’s allocated worker.

For persons who have experienced more complex issues their support could be provided by a specialist addictions service, a voluntary sector treatment agency or a self-help organisation. The support could include structured relapse prevention, psychological therapies to treat the person mental health problems or on-going peer support.

Useful web resources

Alcoholics Anonymous

Support for families and carers

Al-Anon Family Groups

Local drug and alcohol services

Lambeth
Southwark
Lewisham
Croydon
Acute Assessment Unit, Maudsley Hospital

Alcohol and Health in Older People

Ref:252

What's next?

In order to ensure that the treatment and care we provide is effective we use a range of outcome tools to help us to assess the severity of a condition and monitor change over time.

Click Continue to Outcomes to view the tools we use for this disorder.

Continue to Outcomes