Editorial

Citation

Rao, R.(T). (2023), "Editorial", Advances in Dual Diagnosis, Vol. 16 No. 1, pp. 1-2. https://doi.org/10.1108/ADD-02-2023-051

Dual diagnosis and public health – a lost opportunity in prevention

The division between population and individual approaches to assessment, treatment and recovery for people living with substance use disorders can help to shape both policy and practice. However, the lines become blurred where wider implementation of what still justifiably be termed treatment can be a component of prevention (Crépault et al., 2023). In the case of alcohol use, this is carried out as part of screening, where accompanying brief intervention is treatment in itself through exploring motivation to change drinking behaviour and the provision of information and advice (Bien et al., 1993). Depending on risk, this can progress towards referral to other services, where more specialised pharmacological and psychosocial treatment can be offered. Similarly, public health interventions such as medication-assisted treatment and syringe exchange programmes for opioid use disorders plays a central role in harm reduction (Connery, 2015). For alcohol-related harm, we have come a long way from the dichotomy in the regulation of advertising, availability, accessibility, affordability and public education, all being separate entities from treatment when considered at a public health level.

Despite the above progress, we still know little comparatively less about primary prevention of dual diagnosis from public health interventions within primary care and other community settings (Connor et al., 2016; Crowley et al., 2015; Searby et al., 2022). Comparatively more is known about particularly around pharmacological and psychosocial approaches for relapse prevention for dual diagnosis provided in specialist settings (Subodh et al., 2018; Vitali et al., 2018).

Primary prevention has relevance to a range of populations, including the prevention of mental disorders in younger people (Spencer et al., 2021), prevention of foetal alcohol spectrum disorder in pregnancy (Roozen et al., 2016), prevention of alcohol-related cognitive impairment in older people (Rao et al., 2022) and prevention of intimate partner violence (Karakurt et al., 2019) in people at risk of alcohol use disorder, to name but a few. In the longer term, this has implications at a population level for the prevention of alcohol-related hospital admissions for mental and behavioural disorders and prevention of suicide associated with depression and alcohol use disorders.

For both primary and secondary prevention, psychosocial interventions are also key, as unmet needs such as social isolation and poor housing may lead to worsening mental health. In addition, primary prevention of substance use disorders in community settings can be achieved through psychological therapies and psychosocial support for families and carers. A focus on “upstream” interventions can help to reduce or modify drug and alcohol use; rather than reacting to a “downstream” problem requires acute treatment, and often crisis intervention for dual diagnosis. Such interventions include positive family relationships, improvement of educational attainment, positive adult role models and living in communities with lower levels of drug use.

Prevention of dual diagnosis is best viewed along a dynamic continuum that combines primary and secondary prevention measures across a broad range or populations at risk, be that for people with mental disorders at risk of substance use disorders or vice versa. Truly integrated care should address barriers to assessment and effective treatment such as stigma and skills in both the assessment of substance use and mental health problems in mental health and addiction services respectively, a “no wrong door” approach where such assessment is “everyone’s job”, making evert contact count and providing support for both families and carers (Public Health England, 2017). The provision of care for dual diagnosis that combines prevention and treatment is still few and far between, particularly where treatment for substance use and mental disorders are provided by different services. In this respect, the Australian model of care shows promise for improving health and social outcomes for people living with dual diagnosis (Foster et al., 2022).