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Developing guidance for those who experience mental illness through drug misuse

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Mark Holland was a finalist in NT’s 2007 Chief Nursing Officer award category for his submission of “Out of your head guides for people who use drugs and experience mental illness”, which talks about developing good practice in the field of co-morbid mental illness and substance misuse.

Co-morbidity or dual diagnosis of substance misuse and mental illness is common. Why wouldn’t it be when the Office of National Statistics records that, of the adult population in the UK, 26% drink alcohol beyond the safe drinking levels and 11% are using illicit drugs? In addition, mental illness prevalence is approximately 20%. So, the prevalence of singular diagnoses is quite startling and I’m not including people who feel low or anxious who have yet to be diagnosed.


Consider also how psychologically aware society has become. The concept of unwinding or coping with stress by having a drink is well established. It is unsurprising then that an acceptable unwind/stress management/coping strategy can develop into a problem. This is what psychologists refer to as a mal-adaptive coping mechanism.


Most people appreciate that emotional distress is part of being mentally ill. Emotional distress – be it tension, anxiety, sadness, fear or panic – is difficult to cope with, particularly when it’s sustained over a long period of time.


People with a mental illness have three things that don’t help:


  • Firstly their mental health problems are often long-term and therefore distress and misery accumulates until they get really desperate for some form of relief. They try things they might not ordinarily have considered
  • Secondly, their mental illness symptoms become more marked in response to social and psychological stress, like being out of work, being isolated, lonely or criticised; common consequences of mental illness
  • Finally, they are extremely vulnerable to the chemical effects of substances. They appear to be more likely to get paranoid, depressed or more anxious as an adverse side-effect. After all, substances are all psychoactive so it stands to reason that their existing mental health symptoms will be amplified, not alleviated, when taking drugs.

I am a mental health nurse and see a lot of clients with both mental health and substance-related problems. Almost half of all people with a mental illness use drugs or alcohol to cope at some point in their lives. They usually take the drugs, not to get high or derive great pleasure, but to numb their pain, their distress or to alleviate their social circumstances. Poor housing, social isolation and downward socio-economic drift are aspects of mental illness that frequently go underestimated.


I often found myself in therapeutic sessions giving out advice or information materials about medication, sleep, panic, low mood, hearing voices, improving communication with relatives, even benefits. I had little idea what to do or say about substance misuse. And since the substance misuse was often a big issue for them, their families and other services, it seemed logical to match my repertoire of mainstream mental health interventions with something around substances.


Herein lies the tale of good practice. The need as I have described was obvious. I needed to learn about substance misuse and find some material that clients could take away and digest.


The idea I had in mind was to search for literature both academic and user-orientated for my own learning and to give to clients. Unfortunately, despite the former being useful, information for people with a dual diagnosis was very general in content and did not say much other than ‘don’t take drugs, they’ll make you worse’.


At this stage I had learnt quite a lot about substance misuse through reading and applying the new knowledge. Where the knowledge made less sense I enrolled on workshops and the odd longer course such as a BSc in Addictions. At the end of the degree I still could find little material for my growing band of dual diagnosis clients or their carers. It is significant that many clients do not want to give up their drugs or drink and so intervention / education about harmful substance use would also benefit carers. They are often positioned well to deliver information. They also need information to help them understand what’s going on too.


I asked around in my NHS trust what I should do. I asked senior nurses including my executive director of nursing. I asked some helpful psychiatrists and psychologists, and occupational therapy and social work colleagues what they thought of this gap in user-orientated information. They all said with the growing prevalence of co-morbidity something should be written, and quick.


After collaborating at this stage with some influential people in the organisation I was therefore confident that they’d support any coherent proposal to develop material myself. The proposal was produced highlighting the area of need, how it matched related government policy (DH 2002) and how inexpensive it would prove to (i) release me for a few hours a week, (ii) pay some academic fees through my professional development entitlement and (iii) reap some benefit for clients and their carers. The latter aim was assisted by support from local user and carer forums.


Developing the information materials for users was straightforward research and development (MHP 2007). Publishing them and achieving additional publicity through media and successful award applications encouraged dissemination (MHP 2007). They need to be evaluated to complete the cycle of course.


Currently the material for dual diagnosis clients and their carers can be viewed at



DH (2002). Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. Department of Health.


MHP (2007) Interview: Out of Your head Guides. Mental Health Practice 10 (7) 36-37


ONS (2002). Psychiatric morbidity: tobacco, alcohol and drug use and mental health. Survey of Psychiatric Morbidity among Adults in Great Britain. Office of National Statistics. HMSO. London

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