An increasing number of people are given a dual diagnosis of severe mental illness and substance misuse. The prevalence of substance abuse in most US community samples of individuals with psychotic illnesses falls between 30% and 50% . The frequency of dual diagnosis in other countries is likely to vary, mainly in response to different cultural attitudes to substances of potential abuse. Dual diagnosis is associated with greater inpatient service use, poorer adherence to treatment, more frequent violent behaviour and probably more severe clinical and social problems than psychotic illness alone [113,114].
Seeking effective ways of developing services for this group of patients has been one of the major tasks undertaken by service planners and health service researchers in the USA in the last 15 years . A range of service models has been developed. Research on dual diagnosis is recent and relatively rare on the eastern side of the Atlantic, and there are as yet very few specific services addressing this combination of problems.
The options for management of individuals with dual diagnosis within conventional mental health service configurations are as follows: (a) treatment provided exclusively by generic CMHTs; (b) treatment provided exclusively by addiction services; (c) joint management by generic adult and addiction services, either concurrently or sequentially.
However, various impediments to effective care may arise with each of these strategies [116, 117]. Thus, workers in the CMHTs may lack training, experience and confidence in helping people with addictions. Staff responses may be punitive rather than therapeutic, with the substance abuse conceptualized as difficult behaviour rather than as a disabling problem for which treatment is needed. Finding residential places for individuals with dual diagnosis is particularly difficult.
On the other hand, staff in addiction services may sometimes lack confidence in working with individuals with psychotic illnesses, especially where they have active symptoms such as delusions and hallucinations. Conventional addiction treatments may be inappropriate for individuals with severe mental illnesses, especially where the approach is relatively confrontational, where there are strict limits on tolerance of relapse, and those who do not achieve abstinence are ejected from the service, or where the emotional temperature in treatment sessions tends to run high. Some non-statutory addiction services may not permit clients to be on any form of medication, making them inappropriate for many with psychotic illnesses.
However, joint management by addiction services and generic mental health services has its own problems. Many individuals with dual diagnosis lead relatively chaotic lives, are ambivalent about engaging with services, and tend not to adhere to treatment. Thus continuity of care and engagement are already difficult to maintain for this group, and the difficulties may be worse if two distinct services are involved and clients are expected to keep two distinct sets of appointments.
The literature on dual diagnosis services in the USA indicates a number of central principles common to many services. In order to minimize barriers to obtaining treatments and maximize continuity of care, treatment for severe mental illness and that for addictions are closely integrated, with both delivered by the same team. Training and supervision are provided so that individual workers have some skill and confidence in the management both of psychotic illnesses and of addictions. Community dual diagnosis services often adopt the main principles of assertive outreach teams, with small case-loads, a team approach, and intensive attention to engaging clients. In the initial phase of treatment, there may in fact be very little active work on the substance abuse, with efforts directed primarily towards establishing a relationship with clients and persuading them to accept contact with services.
Addiction techniques, such as motivational interviewing education about the effects of substance abuse and relapse prevention, are used. Attention is directed towards the social skills required to maintain abstinence. For example, if clients are not assertive enough to refuse drugs offered by their peers, staff may focus on developing the skills required for them to do so. Staff aim to identify and address the reasons for substance misuse. These may include self-medication of distressing symptoms, escape from boredom and social isolation, or difficulties in coping with stressful social situations or relationships. Addiction treatments are modified so that the problem is confronted in a gentle manner, and clients who have difficulty in attaining abstinence or who relapse very frequently are not ejected from the services. Staff help clients to find activities and social networks that do not involve substance misuse, and ensure that basic needs for housing, food and money are met.
Well-known examples of specialist dual diagnosis services in the USA include the "continuous treatment teams'' which have been established throughout New Hampshire by Drake et al. [116-118]. These teams have a case-load consisting exclusively of individuals with dual diagnosis, for whom they have 24-hour responsibility. Case-loads are small, at around 12 clients per case manager. A combination of group and individual interventions is used. For many clients, the initial phase of treatment is a "persuasion'' phase, in which the aim is gradually to raise their awareness of the problems caused by their substance misuse. Once some motivation for work on substance abuse is established, an "active treatment'' phase follows, in which more intensive and explicit substance abuse interventions are employed.
Descriptions of a variety of models for specialist dual diagnosis treatment have been published, including the outpatient group therapy programme described by Kofoed et al.  and the intensive dual diagnosis treatment programme based on an inpatient ward described by Franco et al. . These accounts provide some evidence of success in engaging clients in treatment and may have improved their short-term outcome. However, as yet, relatively few researchers have published more methodologically robust studies with appropriate comparison groups, longer follow-up periods and substantial numbers of subjects.
Jerrell and Ridgeley  followed up 146 subjects over two years, comparing three different approaches to dual diagnosis, one based on behavioural skills training, one on intensive case management and one on an Alcoholics Anonymous (AA) model. Over the two-year study period, the sample as a whole showed improvements in drug and alcohol-related symptoms, reductions in service use and costs, and a trend towards better social adjustment. Outcomes were better in the groups receiving behavioural skills training and intensive case management than for the AA-based programme. In Washington, an integrated programme combining mental health, substance abuse and housing interventions was compared with standard management for homeless individuals with dual diagnosis . There was some evidence of benefit from the integrated programme, with fewer days in institutions, more stable housing and greater improvement in alcohol problems. Differences between the programmes in degree of recovery from drug problems and in changes in psychiatric symptoms, social functioning and quality of life were unremarkable.
A large randomized controlled trial of "continuous treatment teams" has been carried out in New Hampshire. The results have not yet been published in full, but preliminary reports are promising, with reductions in hospitalization, improvements in functioning, and almost half the teams' clients achieving a degree of abstinence after three years .
Some specialist North American dual diagnosis services do seem largely to have failed. For example, in the community-based programme described by Lehman et al. , very few people with dual diagnoses cooperated with an attempt to initiate intensive treatment for them on a day-patient basis. The likeliest reason for this was the absence of an initial phase during which the main focus was on engaging clients and increasing their motivation. Similarly, Bartels and Drake  found no evidence of benefit from an intensive residential programme for dual diagnosis, and concluded that successful treatment needs long-term work within the clients' usual social environment and with great attention to engagement.
Thus in North America some interesting and promising models for management of individuals with dual diagnosis have been developed, although the evidence base for them is as yet not wholly satisfactory. Are we at a stage where it would be beneficial to transplant such American models to other countries? Particular local factors have a bearing on this. First, the separation between mental health and addiction treatment systems may not always be as radical as in the USA, where training and funding are generally wholly distinct for the two specialties. Thus, for example, in the UK many workers have some basic training in both areas, so there will be a stronger basis for developing good practice for dual diagnosis clients within existing service structures. Secondly, in many Western countries, services are principally sector-based, and CMHTs, where they exist, are usually generic, providing a full range of services to the severely mentally ill population of a small geographical catchment area. Specialist dual diagnosis teams serving larger catchment areas might struggle to achieve close integration with other services in their catchment areas, such as primary care and social services. Moreover, specialist services with no obligation to accept everyone from a particular catchment area might develop barriers to taking on the most complex and difficult-to-engage clients. The success of the US specialist teams in engaging clients in treatment may also be related to the avail ability of coercive methods. Discharges from hospital may be conditional on acceptance of treatment, and representative payeeships allow mental health professionals to take close control of the finances of clients known to be spending state benefits on drugs and alcohol . Such methods might not necessarily find acceptance elsewhere, and could, for example, fall foul of the European Convention on Human Rights.
In our current state of knowledge, it might be worth listing the possible options for increasing expertise in the management of dual diagnosis patients: (a) developing closer links between generic mental health and addictions services; (b) providing training and supervision in addictions techniques for all community mental health staff; (c) attaching specialist dual diagnosis key workers to community mental health teams; (d) developing specialist dual diagnosis teams; (e) developing a specific dual diagnosis programme within an assertive outreach team.
Sub-groups among those with dual diagnoses may be best served by different models, so that a combination of the above strategies may be appropriate. Thus, there may be a group who are relatively compliant with services and whose needs might be met by improving links between addiction services and CMHTs, and offering appointments with workers from each. For less compliant individuals whose substance misuse is not yet very severe, it may be appropriate to train CMHT workers so that they are better able to detect substance misuse and have some basic skills in managing it. Specialist dual diagnosis teams or specialist workers within assertive outreach teams might then be reserved for the most challenging of the dual diagnosis clients.
In many countries, dual diagnosis is a clinically significant problem that may not be adequately addressed in current service planning. More comprehensive assessment is required of the overall needs for the care of people with dual diagnoses, together with rigorous evaluation of the costs and outcomes of the various strategies that might be used to provide them with integrated care.
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