Guest editorial

Rahul (Tony) Rao (Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK)

Advances in Dual Diagnosis

ISSN: 1757-0972

Article publication date: 13 July 2021

Issue publication date: 22 July 2021



Rao, R.(T). (2021), "Guest editorial", Advances in Dual Diagnosis, Vol. 14 No. 2, pp. 33-35.



Emerald Publishing Limited

Copyright © 2021, Emerald Publishing Limited

Older people and dual diagnosis: building better lives Since the first themed issue on older people in Advances in Dual Diagnosis was published 10 years ago, the area of dual diagnosis in older people has flourished. The most remarkable achievement is that it has reached across several domains, including research, policy, workforce development and public education. But this veritable blossom of activity has not been confined to the UK. There is now a growing body of academics, practitioners, educationalists and policymakers who have helped make this endeavour achievable to improve the health and social outcomes of older people living with dual diagnosis. Older people of the “baby boomer” generation now represent the age group with the fastest rise in substance use and misuse. Using Disability Adjusted Life Years (DALYs) as a marker of population morbidity, alcohol use rose from the 14th to 5th highest place in ranking for people aged 50–69 in England between 1990 and 2017. For drug use, the rise was from 25th to 13th place. In people aged 70 and over, alcohol use rose from the 61st to 18th highest risk factor (Institute of Health Metrics and Evaluation, 2019). It is this age group of people now aged 55 and older, who will remain the focus of global attention in the coming decades.

Alcohol and dual diagnosis

One of the most significant landmarks in harm reduction around alcohol misuse has come from an update of Our Invisible Addicts (Royal College of Psychiatrists, 2018) which reiterated guidance from its first report of 2011, where it recommended that “low risk” drinking for people aged 65 and over be defined as drinking no more than 12 UK units per week, or an average of 1.75 UK units per day.

These limits are not dissimilar to the current UK guidelines for low risk drinking of no more than 14 UK units of alcohol per week across all age groups (Department of Health, 2016). This low risk drinking guidance has been supported by a look at the wider evidence base which shows that when total disease burden is considered, an even lower level of between zero and 1 unit of alcohol per week has been shown to minimise harm across all health outcomes (Griswold et al., 2018).

As a consequence of the Our Invisible Addicts report, all GP practices are now required to offer an NHS health check to patients aged between 40 and 74 (NHS England, 2019). All primary care practices in England are also now required to identify all newly registered patients drinking alcohol at increasing or higher risk levels. This includes the offer to assess and screen patients for anxiety and/or depression and offer advice and treatment that includes referral to mental health services (NHS Employers, 2015).

Such public health intervention have been supplemented by the first programme to improve health and social outcomes in older people with alcohol misuse – the UK Drink Wise Age Well programme aimed at increasing health awareness; tackling public stigma, providing information and advice; training and skills development; increasing resilience and providing structured support for people over 50 experiencing alcohol problems (Wadd et al., 2017). The impact of this five-year project for older people living with dual diagnosis is eagerly awaited.

Integrated care for dual diagnosis

Older people with substance use have multiple needs and complex physical co-morbidities, which is likely to mean frequent contact with primary care, medical, addictions, old age psychiatry and geriatric medicine services (Rao and Shanks, 2011). In view of this, the publication of an Information Guide (Royal College of Psychiatrists, 2015) was another milestone in policy change – designed to assist clinician decision making and improve health and social outcomes that included dual diagnosis.

The recent coexisting severe mental illness and substance misuse Quality Standard (National Institute of Health and Care Excellence, 2019) represents another step forward in the assessment of people living with dual diagnosis. These guidelines recommend that all older people with mental illness should be asked about their use of alcohol. But perhaps the largest step, if not leap, of all is the inclusion of older people with dual diagnosis in the Community Mental Health Framework for Adults and Older Adults (National Collaborating Centre for Mental Health (2019).

But there is still a long way to go for an evidence based around the prevention and treatment of areas such as alcohol-related cognitive impairment (Kelly et al., 2019; Cabelleria et al., 2020), as well as for depression (Stankov et al., 2019) and bipolar affective disorder (Canham et al., 2018) in older people. There is also a huge mountain to climb in our knowledge around interventions for older people living with drug misuse and dual diagnosis (Bhattia et al., 2015).

This issue of Advances in Dual Diagnosis heralds the publication of a regular annual themed issue on older people. With wider global participation in research, practice and policy, it promises a new dawn for improving the assessment, treatment and recovery of older people living with dual diagnosis. Substance use and ageing both remain very much 21st century problems (McKee et al., 2021) that will need better integration for better care.


Canham, S.L., Mahmood, A., Stalman, M.N., King, D. and O'Rourke, N. (2018), “Personal theories of substance use among Middle-aged and older adults with bipolar disorder”, Aging & Mental Health, Vol. 22 No. 6, pp. 813-818.

Department of Health (2016), UK Chief Medical Officers’ Low Risk Drinking Guidelines, Department of Health, London.

Griswold, M.G., Fullman, N., Hawley, C., Arian, N., Zimsen, S.R., Tymeson, H.D. and Farioli, A. (2018), “Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016”, The Lancet, Vol. 392 No. 10152, pp. 1015-1035.

McKee, M., Dunnell, K., Anderson, M., Brayne, C., Charlesworth, A., Johnston-Webber, C. and Watt, R.G. (2021), “The changing health needs of the UK population”, The Lancet, Vol. 397 No. 10288, available at:

National Collaborating Centre for Mental Health (2019), The Community Mental Health Framework for Adults and Older Adults, NCCMH, London.

National Institute of Health and Care Excellence (2019), Improving Care for Older People with co-Existing Mental Disorders and Alcohol Misuse, NICE, London.

NHS Employers (2015), 2015/16 General Medical Services (GMS) contract NHS Employers, London.

NHS England (2019), NHS Health Check, NHS England, London.

Rao, R. and Shanks, (2011), “Development and implementation of a dual diagnosis strategy for older people in southeast London”, Advances in Dual Diagnosis, Vol. 4 No. 1, pp. 28-35.

Royal College of Psychiatrists (2015), Substance Misuse in Older People: An Information Guide, Royal College of Psychiatrists, London.

Royal College of Psychiatrists (2018), “Our invisible addicts. Second report of the older persons’ substance misuse working group of the royal college of psychiatrists”, College Report CR211, Royal College of Psychiatrists, London.

Stankov, I., Yang, Y., Langellier, B.A., Purtle, J., Nelson, K.L. and Roux, A.V.D. (2019), “Depression and alcohol misuse among older adults: exploring mechanisms and policy impacts using agent-based modelling”, Social Psychiatry and Psychiatric Epidemiology, Vol. 54 No. 10, pp. 1243-1253.

Wadd, S., Breslin, J., McDougall, G., Elliott, L., Madoc-Jones, I., Whittaker, A. and Donnelly, M. (2017), “Drink wise age well: a UK-wide multilevel programme to reduce alcohol-related harm in older adults”, Innovation in Aging, Vol. 1 No. suppl_1, pp. 309-309.

Further reading

Bhatia, U., Nadkarni, A., Murthy, P., Rao, R. and Crome, I. (2015), “Recent advances in treatment for older people with substance use problems: an updated systematic and narrative review”, European Geriatric Medicine, Vol. 6 No. 6, pp. 580-586.

Caballeria, E., Oliveras, C., Nuño, L., Balcells-Oliveró, M., Gual, A. and López-Pelayo, H. (2020), “A systematic review of treatments for alcohol-related cognitive impairment: lessons from the past and gaps for future interventions”, Psychological Medicine, Vol. 50 No. 13, pp. 2113-2127.

Kelly, S., Olanrewaju, O., Cowan, A., Brayne, C. and Lafortune, L. (2018), “Interventions to prevent and reduce excessive alcohol consumption in older people: a systematic review and meta-analysis”, Age and Ageing, Vol. 47 No. 2, pp. 175-184.

About the author

Rahul (Tony) Rao is based at Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Related articles