NICE guidance on dual diagnosis 2016

This is not the first time that Dual Diagnosis has been discussed on this blog (you can read them all here).  However we now have official guidance from the National Institute of Clinical Excellence (NICE) on the issue.

My lovely friend Libby Ranzetta did an excellent synopsis that garnered praise on Twitter from the NICE guidelines chair themselves no less! 🙂

Over to her summary detailed over at Alcohol Policy UK:

New NICE guidance on dual diagnosis was released in November 2016: Coexisting severe mental illness and substance misuse: community health and social care services.

The guidance and supporting tools and resources sets out how services for those dually diagnosed aged 14 and above should be improved to ‘provide a range of coordinated services that address people’s wider health and social care needs, as well as other issues such as employment and housing.’

NICE has also produced a guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings.

Context and definitions

NICE contextualises the guidance by stating that adults and young people with coexisting severe mental illness and substance misuse have some of the worst health, wellbeing and social outcomes (details here). It is not clear how many people in the UK experience dual diagnosis issues, partly because some people in this group do not use services or get relevant care or treatment (see previous post).

The Department of Health’s Refocusing the Care Programme Approach identifies people with dual diagnosis as one of the groups in need of an enhanced Care Programme Approach. That is because they are not being identified consistently and services are sometimes failing to provide the support they need. The policy highlights the need for a whole systems approach to their care, involving a range of services and organisations working together. This guideline, NICE claims, aims to address this need.

In announcing the guidance, Professor Alan Maryon-Davis, chair of the guideline committee, spoke frankly about the challenges coexisting substance misuse and mental health problems pose for patients and practitioners alike.

“People with dual diagnosis almost always have multiple needs – often with physical health and social issues as well as their dual mental health and substance problem. They are often unemployed or struggling to hold onto a job. They may be in debt, homeless or poorly housed. They could even be in an abusive relationship.

To add to their woes, they are also more likely to be stereotyped and stigmatised. They are often regarded as unreliable, feckless, difficult to engage, aggressive or abusive.

As a result, they tend to get shunted around the various services they need support from with no-one wanting to take responsibility for them. This can all too easily lead to a downward spiral and sooner or later a crisis – perhaps forcing them into A&E, or on the streets. They may even find themselves in the magistrate’s court.

This is why our NICE guideline is so desperately needed.”

For Guideline 58 the age cut-off for young people has been set at 14 to reflect the small numbers affected below this age and the fact that many early intervention services usually start at age 14. ‘Substance misuse’ refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage.

‘Severe mental illness’ includes a clinical diagnosis of:

  • schizophrenia, schizotypal and delusional disorders, or
  • bipolar affective disorder, or
  • severe depressive episodes with or without psychotic episodes.

NICE Recommendations

The guideline is arranged as series of detailed recommendations on the following:

  • first contact with services
  • referral to secondary care mental health services
  • the care plan: multi-agency approach to address physical health, social care, housing and other support needs
  • partnership working between specialist services, health, social care and other support services and commissioners
  • improving service delivery
  • maintaining contact between services and people with coexisting severe mental illness and substance misuse who use them

Drug and Alcohol Findings Bank has provided a summary of the key recommendations here.

Professor Maryon-Davis summed up two main messages from the recommendations:

“First, there has to be much wider recognition that this group of people, despite their complexities, have as much right to dedicated care and support as anyone else. They should not be turned away or left to flounder. Every effort should be made to help them benefit from the services they so badly need. Crucial to this is a non-judgmental, empathetic approach and the building up of mutual respect and trust.

And secondly, good communication is key! Staff working in mental health, substance misuse, primary care, social care, housing, employment, benefits, criminal justice and the voluntary sector need to have strong leadership to ensure that they are all working together as best they can. We recommend that this can be best achieved by having a dedicated care coordinators.”

What happens next

Substance misuse practitioners could be forgiven for saying they have heard these messages before; messages which have not made much difference to the way mental health services respond to dual diagnosis. Last year the Recovery Partnership’s Review of Alcohol Treatment Services found a clear failure of services to meet the needs of people with dual diagnosis, summarising the policy context for such failure as follows:

“National guidance on the management of this [dual diagnosis] group was first published by the Department of Health in 2002. NICE published further guidance on psychosis with coexisting substance misuse in 2011.

However, the… situation has not improved and may be worsening because budgets have been cut in mental health services, and because mental health services are now commissioned by a separate body (Clinical Commissioning Groups) from alcohol services (Public Health). This represents a real blockage in the pathway of care for problem drinkers (and drug users), a blockage that cannot be easily resolved at the local level.”

Other questions may relate to possible missed opportunities to address low level mental health problems and substance misuse. For instance Improving Access to Psychological Therapies (IAPT) services – which exist for those mild to moderate mental health difficulties, such as depression, anxiety and phobias – are not mentioned within the guidance. IAPT though may be considered an ideal setting for brief intervention given the link between alcohol misuse and problems such as anxiety and depression, yet few IAPT services appear to routinely deliver IBA (although guidance was released for IAPT roles in 2012).

In 2014 an analysis suggested cognitive based therapy (CBT) and/or motivational interviewing (MI) for comorbid alcohol use disorder and major depressive disorder produced small but robust beneficial effects on both depression and alcohol consumption – regardless of whether delivered by mental health or subtance misuse roles.

Commissioners and service providers though will now be expected to use Guideline 58 to improve the quality of care given to people with dual diagnosis involving severe mental health problems. The Care Quality Commission (CQC) use NICE guidelines and quality standards as evidence for inspections, to inform the award of good and outstanding ratings. CQC’s inspection regime and associated powers may well provide the impetus needed for real change to happen this time.