Things were going really badly for me; I was getting very
depressed and started drinking to numb my feelings. In the
end, I couldn't tell whether I was drinking because I was
depressed or I was depressed because I was drinking. But now I'm getting help from a support group, both problems are beginning to be sorted out.
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What is dual diagnosis?
How common is it?
What are the symptoms?
Drugs that can directly cause mental health problems
Drugs that can aggravate mental health problems
Drugs that people use to relieve mental health problems
Do psychiatric drugs and street drugs affect each other?
Downers
Uppers
Hallucinogens
What about withdrawal?
What help is available?
References
Useful organisations
Further reading
The term 'dual diagnosis' refers to people diagnosed with mental
health problems, who also use alcohol or street drugs (illegally
produced drugs or illegally obtained prescription medicines). It may,
for instance, include someone diagnosed with a psychotic illness
who uses cannabis; or someone who is depressed and drinking
heavily or using stimulant drugs (such as amphetamine or cocaine)
in order to feel more socially confident.
Health professionals sometimes disagree about when to apply the term. Some believe that any substance use by people with mental health problems is likely to lead to increased symptoms, and is therefore problematic. Others accept that drinking and drug use is more common amongst people with mental illness than it used to be, and are more flexible about it.
There is no standardised treatment for dual diagnosis, largely because it ranges across such a large number of problems and involves both substance misuse services and mental health services.
People with this combination of problems often have a lot of additional difficulties, which aren’t solely medical, psychological or psychiatric. They are more likely to come into contact with mental health services, in crisis, with problems relate to social, legal, housing, welfare and ‘lifestyle’ matters. Medically orientated services can’t always help with multiple non-medical problems like these, which often reflect the social stigma that people with dual diagnosis face. They are not only drug users, but also mentally ill: two of the most stigmatised groups in society.
In a move away from medical definitions, the term 'complex needs' is often used when people have these complicated social and lifestyle problems. To tackle these complex needs, successfully, often requires a more holistic, joined up approach, from several different directions at once.
It is very common for both mental health services and drug
and alcohol treatment services to encounter people with dual
diagnosis. Research suggests that between 22 to 44 per cent of
inpatients in psychiatric hospitals also have problems with drug
or alcohol use, and up to half of these is dependent on street
drugs. The numbers are higher in cities than in rural areas.
Between 60 and 80 per cent of people admitted to secure
hospitals have existing problems with drug or alcohol use.
It's possible that as many as a half to two-thirds of people who
come into contact with drug or alcohol treatment services may
also have some kind of mental health problem, although they
will not necessarily have contact with mental health services.
It can be very difficult to separate out the symptoms into those caused by a mental health problem and those relating directly to drinking or illegal drug use. There are many reasons why individuals start and continue to use alcohol or street drugs. Each person will have their own reasons, and their background, age, class and ethnicity will influence this.
The drugs can be split into three groups:
Stimulant drugs, such as amphetamine (speed) and cocaine (charlie or crack), are most commonly associated with causing psychotic illness, especially if they are used for a long time. They can cause hallucinations, paranoia, restlessness, agitation and very distressing, unpleasant thoughts.
Some mental health workers believe that the symptoms linked to schizophrenia are associated with high or very changeable levels of the brain chemical dopamine. Amphetamines increase the dopamine levels, and research has demonstrated, beyond doubt, that taking amphetamines produces these symptoms in some people. A drug-induced psychosis usually responds very quickly once the drug is stopped, though sometimes appropriate treatment is necessary. It’s possible that drug use could trigger a longer-lasting mental illness, such as schizophrenia, if a person is vulnerable to the illness. In this case, treatment may take longer to work and may need to be continued indefinitely.
There is a long-standing debate about the relationship between
mental ill health and taking cannabis (skunk, pot, dope, hash or
marijuana). Although many people take cannabis with no ill
effects, there is evidence that heavy and frequent use can cause
psychosis in vulnerable people. (This is especially true of people
who use skunk, a form of cannabis bred to have high levels of
THC (tetrahydrocannabinol) - the ingredient of cannabis that
causes the psychotic effects.) In some cases this may be the
start of a long-term problem which continues after cannabis is no
longer used and may lead to a diagnosis of schizophrenia. Young
people may be especially vulnerable. Some people become
dependent, and some tend to become lethargic and unmotivated.
Alcohol can also cause the symptoms of psychosis, particularly hallucinations and paranoia. It’s also linked to low moods and physical problems with withdrawing.
Many people who use analgesic drugs, such as opium or heroin, describe themselves as being depressed. It's not clear whether the drug itself causes the depression. It could equally relate to the difficulties in their daily lives that many drug-users face. These problems may be to do with lack of money, work and housing, or to contact with the police or the justice system.
Cannabis, LSD, stimulants and ecstasy (MDMA) can all intensify a person’s mood when they take it. If they are already feeling low, paranoid or anxious, the drugs may make this worse, although this will depend on their environment and the quantity involved. But it's also true that these drugs can lift someone’s mood. On balance, however, someone who has a mental health problem and who misuses drugs or alcohol may well worsen the symptoms of their illness.
Opiates (including opium, heroin, methadone, dihydrocodeine and buprenorphine) belong to the only family of drugs that appears always to have a calming (anxiolytic) effect. However, the user is likely to become 'tolerant' of the drug, which means they need to take more of it to achieve the same effect.
Some people suggest that there are certain combinations of drugs or alcohol that may relieve mental health problems. This self medication may be for symptoms of distress, or may sometimes help relieve the unpleasant effects of prescribed medication. Mental health services do not support self-medication, and most agree that illicit drugs or alcohol generally cause or worsen mental health problems.
Research has confirmed that drug or alcohol use can lead to people being mistakenly diagnosed with schizophrenia. Recent reports also suggest that African-Caribbean people are more likely to receive an inappropriate diagnosis of schizophrenia in these circumstances.
Some people may have physical health problems associated with drug misuse, such as alcoholic liver disease, hepatitis B or C, or HIV. Sometimes criminal activity may arise, such as theft to support an illegal drug habit, or disordered behaviour while under the influence of drugs or alcohol. In addition to the illegal behaviour itself, this may make someone less likely to keep appointments or engage with health services.
When two or more drugs are taken at the same time, they may interact with one another; one drug changing the effect of the other. One or both of them may become toxic, or their effects may be decreased or increased. A person’s age, weight, genetic makeup, general health and liver or kidney function will make a difference to the way the drugs impact, but it is possible to predict what the interactions are likely to be. (For more information, see 'Further reading'.)
'Street drugs’ are drugs that are illegal or not taken under medical instruction. Some of them are pharmaceuticals (legally produced medicines) available on prescription (for example, diazepam). Others are produced illegally (street heroin, cannabis or ecstasy, for example). Taking street drugs is always potentially dangerous. It's especially risky if the person is on another prescription medicine, or if they already have health problems. It may interfere with treatment or make the illness worse. The following is a very brief overview of some of the possible interactions. (Most hospitals have pharmacists who can provide more information.)
Downers include opiates, such as heroin, methadone, dihydrocodeine and buprenorphine, and benzodiazepines, such as diazepam, temazepam and nitrazepam. Some of these are available on prescription, but may also be obtained illegally. Cannabis and alcohol are also downers.
These drugs are sedatives, which slow down the working of the central nervous system. They are sought-after as a means of escape, and users describe having fuzzy feelings and a sense of euphoria, although occasionally, benzodiazepines may have the opposite effect and make someone feel agitated, hostile and aggressive. People may become dependent on downers, and develop withdrawal effects if they stop taking them. These drugs can affect breathing and make people feel drowsy.
In certain combinations, downers may increase the effects of prescribed sedatives, making people even drowsier. In severe cases, users may become confused and shaky, and their breathing may be adversely affected.
Other psychiatric drugs that can cause sedation include antipsychotics, such as chlorpromazine, haloperidol, clozapine and risperidone, and sedating antidepressants, such as amitriptyline, dothiepin and trazodone. As a general rule, the higher the dose, the greater the sedation.
In one study, some people on prescribed methadone were given the antidepressant fluvoxamine, and showed raised levels of methadone in their bloodstream afterwards. It may therefore be especially dangerous to take these two drugs in combination, without medical supervision.
Uppers include amphetamines, cocaine and ecstasy (MDMA). These drugs speed up the central nervous system, stimulating the mind and body. Users seek feelings of wellbeing, increased confidence, energy, stamina and alertness.
There have been reports of amphetamines causing psychosis after prolonged use, and even after a single dose. This may be more likely to happen to people who are prone to mental health problems. People sometimes become depressed after coming down from a drug-induced high. This makes the drugs especially risky for anyone who has once been diagnosed with a depressive, bipolar, or psychotic illness.
Uppers can be potentially fatal if they are taken with monoamine oxidase inhibiting antidepressants (MAOIs), such as phenelzine, isocarboxazid or tranylcypromine. The signs include high blood pressure, chest pain, neck stiffness, rigid muscles, flushing, vomiting and severe headache. It’s possible that the antidepressant moclobemide (a reversible MAOI) could also interact with uppers. If chlorpromazine is taken together with amphetamines, the effects of one or both can be reduced. There are isolated reports of lithium and carbamazepine reducing the effects of cocaine, and of lithium opposing the effects of amphetamines.
LSD, magic mushrooms, mescaline, ketamine and phencyclidine cause changes in perceptions, which may include visual illusions, distorted sensory experiences, or 'out-of-body' experiences. The effects vary from person to person and depend also on their mood and surroundings. ‘Bad trips', can lead to panic attacks, acute depression and psychosis. It’s thought that people who already tend towards these problems are more likely to experience them when they take hallucinogens.
There are very few known cases of hallucinogens interacting with psychiatric drugs. However, ketamine and phencyclidine are anaesthetics, which have sedative properties. Ketamine reduces respiration rates at very high doses, and this effect will increase if it is taken with other sedatives.
The effects of withdrawing from many illicit drugs can produce, or mimic, symptoms of mental ill health. This is one of the reasons why it’s important to assess someone’s drug and alcohol intake when they first have contact with mental health services.
Alcohol withdrawal can cause anxiety, insomnia, hallucinations (commonly visual), and clouded thinking. Coming off stimulants often results in confusion, irritability and low mood. It sometimes makes people feel suicidal, and may even provoke an attempt.
Withdrawing from opiates can cause unpleasant physical effects. People may feel very low, apathetic, irritable, and isolated. Opiates and tranquillisers can sometimes mask intense emotions, which may emerge once people stop taking them. (For more information, see Understanding the psychological effects of street drugs.)
There’s been much debate in both mental health and drug treatment services about how best to help people with mental health problems, who use illicit drugs and alcohol. They have, traditionally, been regarded as difficult to treat, unresponsive and chaotic, and many workers feel less than confident about caring for such clients. The usual treatment strategies for drug and psychiatric problems are not always effective for patients with dual diagnosis, for a variety of reasons.
Substance misuse services and mental health services have very different philosophies and therapies, and these are reflected in their approach both to the problems they deal with and to training. Staff may have little experience of each other’s fields.
For example, a psychiatric service worker may have little sympathy with or understanding of the drug culture and drug users’ experience. This can reinforce existing stereotypes and a negative view of drug users. Standard psychiatric practice often requires drug users with mental health problems to stop using street drugs altogether, in order to ‘recover’. At the same time, they may wish to treat them with psychiatric medicines, which frequently have unpleasant side effects, and they may not give sufficient consideration to social, financial and other practical problems. Mental health services which take a user-led approach are likely to be more flexible and more successful in treating people with a dual diagnosis. A service’s willingness to help with basic practical concerns, such as housing, food, or child care, is likely to make a lot of difference to a client’s motivation to make use of the more conventional aspects of treatment for their mental health and drug or alcohol problems.
People who work in the drug treatment field, on the other hand, often have personal experience of drug use. This knowledge and their ability to identify with patients can be extremely important in the treatment process. But they often have limited expertise or experience in recognising and working with drug users who have mental health problems.
Drug users who have mental health problems have often been excluded from mental health care. This is because staff in psychiatric units assume that the main problem is the addiction. This can mean the person receives no help, while drug services and mental health services argue about which is the primary problem, and who should therefore have responsibility for the patient. The reality is that it's not essential to establish, at the start, which problem is primary, as long as the person receives the necessary help. The situation is beginning to change with current guidance, and mental health services have started to accept that they are often the first and most appropriate port of call for people with this combination of problems, especially if they are diagnosed with a psychotic illness.
The Dual diagnosis good practice guide produced by the Department of Health (see 'References') states that for people with severe mental health problems and problematic substance misuse, the primary responsibility for treatment should lie with mental health services. Mental health teams and substance misuse services should each provide training and support for the other, and should aim to work together in providing treatment for everyone with a dual diagnosis.
Providing an effective service for people in this position needs coordination, partnership and shared care arrangements between all the different agencies involved. These should encompass drug and alcohol and mental health services, and also housing agencies, criminal justice systems, welfare departments, social services, leisure facilities and community care.
One of the biggest problems for people with a dual diagnosis is finding somewhere to live. Many housing agencies and supported housing trusts will not accept drug users. More recently, however, a number of housing associations and trusts are starting to open suitable supported schemes. (See 'Useful organisations'.)
People also need assistance with welfare and benefits. They may need legal advice and general health care. It's important to put these in order of priority. There's little benefit in dealing with psychological issues until basic human needs have been met and the person is in a safe environment.
On the positive side, there are a number of treatment approaches that have benefited people with a dual diagnosis. There is a form of cognitive behaviour therapy called motivational interviewing, which has been used successfully. It can help those with drug problems to make changes to their drug-using patterns, and create new social networks in which drug use is controlled. Family therapy and 12-step approaches to drug and alcohol use (as used by organisations such as Alcoholics Anonymous) may be helpful in some cases. Counselling, in its various forms, can also help people with a dual diagnosis. It provides a safe environment in which both drug use and mental health problems can be explored. (For more information about these talking treatments, see 'Useful organisations' and 'Further reading'.)
In some instances, drug treatment can be of assistance. For example, methadone could be prescribed as a substitute for those with opiate dependency. These drugs should always be given alongside other forms of treatment not involving medication. The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on the use of methadone and buprenorphine for people with opioid dependence.
For the time being, there is still nothing to suggest one form of treatment is more effective than another, although research is still going on. Assessments of this client group tend to focus on the negative aspects of their lives. The practical toolkit produced by Turning Point and Rethink (see 'References') emphasises the need to encourage them to engage with services and to build their self-esteem, by focusing on their needs and interests, and emphasising fulfilling activities and positive achievements.
Dual diagnosis toolkit: mental health and substance misuse (A guide for professionals and practitioners), Caroline Hawkings and Helen Gilburt (Turning Point and Rethink 2004)
Dual Diagnosis Themed Review Report 2007/8 (Care Services
Improvement Partnership)
Mental health policy implementation guide: dual diagnosis good
practice guide (Department of Health 2002)
Methadone and buprenorphine for managing opioid
dependence (National Institute for Health and Clinical Excellence
(NICE) 2007)
Adfam National
tel. 020 7553 7640, web: www.adfam.org.uk
Support and information for relatives, families and friends of those with drug problems
Alcoholics Anonymous
PO Box 1, 10 Toft Green, York YO1 7ND
tel. 0845 769 7555
web: www.alcoholics-anonymous.org.uk
Support group
British Association for Behavioural and Cognitive
Psychotherapies (BABCP)
tel. 0161 797 4484, web: www.babcp.com
Can provide details of accredited therapists
British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300 (general enquiries)
tel. 01455 883 316 (to find a therapist)
web: www.bacp.co.uk
See website for details of local practitioners
Lifeline
web: www.lifeline.org.uk
Advice for drug users and their families and friends, visit their website for local telephone numbers.
Talk to Frank
freephone: 0800 77 66 00 web: www.talktofrank.com
For young people and their parents
Phoenix Futures
tel. 020 7234 9740, web: www.phoenix-futures.org.uk
Services for drug and alcohol users across the UK, including residential treatment centres
Release
helpline: 0845 4500 215, web: www.release.org.uk
Specialist services for drug users, families, friends and professionals, including the law and human rights
Shelter
helpline: 0808 800 4444, web: www.shelter.org.uk
National campaign for homeless people
Turning Point
tel. 020 7481 7600, web: www.turning-point.co.uk
Social care in the areas of drug and alcohol misuse
www.spdirectory.org.uk
Search for housing and support services in your area
www.nice.org.uk
Provides guidelines for promoting better health
How to help someone who is suicidal (Mind 2008)
Making sense of antidepressants (Mind 2008)
Making sense of antipsychotics (major tranquillisers) (Mind 2007)
Making sense of cognitive behaviour therapy (CBT) (Mind 2009)
Making sense of coming off psychiatric drugs, (Mind 2005)
Making sense of lithium and other mood stabilisers (Mind 2009)
Making sense of psychotherapy and psychoanalysis (Mind 2004)
Making sense of sleeping pills and minor tranquillisers (Mind 2008)
The Mind guide to advocacy (Mind 2006)
Mind rights guide 1: civil admission to hospital (Mind 2009)
Mind rights guide 2: mental health and the police (Mind 2008)
Mind rights guide 3: consent to medical treatment (Mind 2009)
Mind rights guide 4: discharge from hospital (Mind 2008)
Mind rights guide 5: mental health and the courts (Mind 2008)
Pillar to post: a film about dual diagnosis (DVD or VHS) (Mind in Croydon 2001)
Understanding addiction and dependency (Mind 2007)
Understanding borderline personality disorder (Mind 2007)
Understanding dissociative disorders (Mind 2009)
Understanding mental illness (Mind 2007)
Understanding paranoia (Mind 2007)
Understanding personality disorders (Mind 2007)
Understanding psychotic experiences (Mind 2009)
Understanding the psychological effects of street drugs (Mind 2007)
Understanding schizoaffective disorder (Mind 2003)
Understanding schizophrenia (Mind 2008)
Understanding talking treatments (Mind 2009)
For a catalogue of publications from Mind, send an A4 SAE to:
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email: publications@mind.org.uk
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This booklet was written by Prashant Phillips and Joanne Labrow. Revised by K. Darton
First published by Mind 1998. Revised edition © Mind 2009
ISBN 978-1-874690-80-1
No reproduction without permission