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Treatment Of Patients With A Dual Diagnosis Social Work Essay

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Dual diagnosis is the term used when a person has a mood disorder such as depression or bipolar disorder (also known as manic depression) and a problem with alcohol or drugs. A person who has a dual diagnosis has two separate illnesses, and each illness needs its own treatment plan.

A mental health nurses perspective of the issues surrounding the treatment of patients with a dual diagnosis of psychiatric disorder and learning disabilities in mainstream mental health units. This essay is going to explore from a mental health nurses perspective the issues surrounding the treatment of patients with a dual diagnosis of psychiatric disorder and learning disabilities in mainstream mental health units.

Knowing the symptoms of mood disorders can help you decide to seek help. You can't diagnose yourself. Only a health care professional can diagnose and treat a mood disorder. When a person's mood switches between depression and mania, it is called bipolar disorder (also known as manic depression).

Including a discussion around prevalence, provision of services, access to services, government policy and whether staff in mainstream mental health units have the knowledge and skills necessary to provide effective care for this potentially vulnerable service user group.
She then started substance abuse classes and one-on-one therapy was treated for both substance abuse and depression. They put her on medication she continues after care substance abuse classes and sees a therapist. She has remained alcohol and drug free for almost a year with treatment and continues Narcotics Anonymous (NA) group meetings twice a week. Christy’s* treatment was effective because she was ready to leave drugs and alcohol alone. She was also fortunate enough to have a therapist that realized she suffered from depression and substance abuse. Her psychiatrist and her therapist worked together to treat her with antidepressants and individual therapy to deal with her poor self-esteem and her continuing abandonment issues. Christy* attends 2 meetings a week in aftercare substance abuse classes; and she also attends NA group meetings 2 nights a week. She takes on-line classes with Liberty University and is engaged to be married. She has a bright future because of the up-to-date dual diagnoses and treatment.

The contemporary concept of learning disabilities focuses on the physical and social difficulties that can occur as a consequence of being labelled a person with a learning disability and how any impairments a person may have affect them (Swain et al, 2004) however it neglects to identify the mental health issues people with learning disabilities regularly and more commonly face

If people who meet the diagnostic criteria for borderline learning disability are included the prevalence of learning disabilities in the UK equates to 12 % of the population or around 8 million people (Hassiotis et al, 2008)

It is generally recognised that people with a learning disability have a higher rate of psychiatric disorder compared with the general population with the prevalence estimated at 40 - 50 % (Raghavan and Patel, 2005).

In comparison to 10 - 20 % of the general population (The Office for National Statistics, 2000) Various factors have been cited as being contributory towards this vulnerability including brain damage, sensory impairment, chronic physical ill health, epilepsy, repeated loss or separation issues, poor self-image, coping mechanisms and social skills, communication difficulties and family problems (Fraser & Nolan 1995, Hardy et al, 2007)

Mental health nurses are specifically trained to treat a diverse group of people including children and young people, working age adults, the elderly and new mothers all with mental health problems.

Experiences from clinical practice demonstrate an increase in the number of people with learning disabilities admitted to general acute mental health hospitals and the increasing incidence of complications that can often come along with the care of this group of people.
The most of people who enter treatment programs have a “dual diagnosis” or an accompanying mental disorder, such as depression, anxiety, or bipolar disorder, along with a substance abuse problem (Treatment Centers). One study found that over 70 percent of the clients had dual diagnosis issues, of which 54 percent were properly diagnosed, and only 23 percent got appropriate treatment for them (Treatment Centers). Dual diagnoses services integrate assistance for each condition helping the client recover from both conditions at once; if not they are at high risk of treatment drop out (Medline).

These include problems with assessment and treatment, usually stemming from communication difficulties, behavioural issues and barriers to collaborative working between the learning disabilities and mental health teams.
Christy* was diagnosed with depression at the age of 6; she had childhood issues of abandonment. She stayed back and forth between her dad and grandparents house. At the age of 13 she was raped; she became promiscuous after being raped and began to drink alcohol then began self -mutilation. She followed the older kid’s crowd and when the alcohol was not enough she began to smoke weed at 14. She began working with her aunt at the age of 15. Her grades stayed low throughout high school, during this time she was only smoking weed. She began to see a therapist again at the age of 16 up until she was 18 she then stopped because she no longer had the money. She did graduate with summer school class. At the age of 19 she began to drink heavily which caused her to lose job and caused problems at home. She continued to drink and smoke weed because she felt like it took the edge of the depressive symptoms.

They can often lead to an increase in length of stay in hospital and inappropriate or inadequate care being delivered.

Problems arise for the most part when a person with a learning disability develops a psychiatric disorder to the extent that requires acute psychiatric admission.

People with severe mental disorders also experience a co-occurring substance abuse problem; approximately 50% of individuals with a mental disorder are also affected by substance abuse; 37% are alcohol abusers, 53% drug abusers (Medline). This is also called dual diagnosis which is when someone has a mental disorder and alcohol or drug dependence (Medline). It occurs with depression, anxiety, schizophrenia, or personality disorders (Medline). The interviewee for this paper has been dually diagnosed with depression and has a history of alcohol/l drug abuse.

It is now more common to find that they are being admitted to general psychiatric beds under the care of general adult psychiatrists and mental health nurses, many of whom have had little training in the assessment and treatment of mental illness in this group.
According to research done by Sciacca, there were several programs instated in the early 1980s around the US that were working to treat the dually diagnosed patient. The programs tried what most mental health care professionals believe is best for Dual Diagnosis individuals, which is to treat both of their illnesses simultaneously rather than have the patient attend one 12-Step program and psychiatric therapy at the same or different times. One person with two problems does not mean two different treatments; the whole person needs to be treated at the same time. Although these types of patients are not often heard of in mainstream society, Sciacca cites an article in TIME Magazine in the 1980s that a reporter wrote after hearing about one the new treatment programs being developed. That, Sciacca says, was the first time Dual Diagnosis was mentioned on a national level in the popular media. (3)

The communication difficulties people with a learning disability may face can make assessment extremely complex. People with learning disabilities often require a longer stay and may also be vulnerable (ie. Abuse and exploitation) without additional support on the ward.
The problem with Dual Diagnosis patients, however, is the fact that they typically seek treatment for one problem and not the other. What makes things more difficult is that most substance abusers and alcoholics do not seek help at all. For the Dual Diagnosis patients that do seek treatment for alcoholism, let's say, do not then get treated for another underlying illness like depression. Doctors, psychiatrists and other mental health care professionals are hard at work in implementing effective treatment programs for these special patients, which I will discuss later. (1)

People with a learning disability may also have unusual presentations of common mental disorders due to brain injury or other long standing conditions such as epilepsy leading to difficulty in diagnosis and an idiosyncratic response to treatment.
The difficulty of living with a mental illness is extreme, as is the difficulty of living with a chemical dependency. Both problems are diseases with both biological and psychological causes and symptoms. Treatment is more difficult if an individual is dually diagnosed with both problems. But treatment is possible. From models developed by Kathleen Sciacca and other mental health care professionals, simultaneous treatment of both disorders appears to be the best method for recovery as a Dual Diagnosis individual. For a condition that applies to so many millions of people in the United States alone, it is a wonder that more outreach and treatment programs have not been established to help such patients. But with more awareness of the disorder by the general population, it will become easier to identify multiple problems in an individual family member or friend, and aid them in seeking treatment.

Furthermore, people with learning disabilities represent a diverse group with a varied range of complex mental health needs, which mainstream staff may feel ill-equipped to meet. Boundary disputes between general adult and learning disability services frequently lead to a reduced quality of care for people with complex needs

Death by Indifference (Mencap, 2007) highlighted alleged care failings in general hospitals and primary care settings It led to the establishment of an independent government inquiry in England.

As I conducted research on the World Wide Web on Dual Diagnosis, almost every site I visited on the subject had a link to a page authored by Kathleen Sciacca, M.A. Sciacca is both founder and director of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction and Alcoholism (MIDAA), based in New York. Among other accomplishments, Sciacca has written books and articles (many of which are available her website), is a touring lecturer, and leader in the development of effective treatment programs for individuals with Dual Diagnosis. She began her work in the 1980s and helps to train other mental health care workers in treating these special patients. (3)

The inquiry unfortunately did not extend to mental health services It found that there is little evidence concerning the quality of care received by people with learning disabilities in these settings but anecdotal evidence from practice has indicated that it is reasonable to believe mental health services face the same kind of problems as general medical care.
It can be seen from the review of the theoretical work on dualdiagnosis that the picture is extremely complicated. Causal mechanismsare hypothesised in a number of directions with a consequentproliferation of different treatment ideas. Perhaps the only conclusionthat can be drawn with confidence from this literature is that anattempt should be made to treat every patient individually. Theprevalence of dually diagnosed patients in prisons is clearly atworrying levels, however, as can be seen from the policy documentsreviewed here, there is little mention of prisons and prisoners.Generally, prisoners are mentioned in passing, and mental health andsubstance misuse services are encouraged to integrate prisons intotheir scheme, but no particular emphasis is placed on them - indeedtheir mention is surprisingly scarce. The policy directions that arerecommended in the documents reviewed here point to an increase in theuse of integrated care pathways. It seems, from reviewing the evidence,that there is some support from studies carried out in the US that thismethod of working is beneficial to the patient with a dual diagnosis.Aside from integrated pathways a number of different treatmentmodalities have been investigated with varying degrees of success. Thisis indicative of the extremely wide and variable nature of a dualdiagnosis itself. It can only be hoped that major improvements to thetreatment of prisoners with a dual diagnosis will be made in the nearfuture.

It seems pertinent to tackle these issues head on in order to meet the needs of this client group who have a diverse range of needs that can span across all branches of nursing and whose care can suffer as they seem to be regularly forgotten or pushed to the bottom of the pile

Until 20 years ago, people with learning disabilities did not normally come into contact with mainstream services.

The early treatment programs took "A "non-confrontational" approach to denial and resistance, involving acceptance of all symptoms [of the patient]...." (3) Not being confrontational or accusatory of patients with alcohol or substance abuse problems especially is key to effectively reaching out to these patients. With so many stigmas in society about drug and alcohol abusers, and the lack of knowledge in general about chemical abuse as a disease and not just a 'problem' or choice, makes most patients feel like seeking treatment means admitting they are wrong or bad. Sciacca explains that many mental health care workers also do not understand and recognize alcoholism and chemical dependency as a disease, and this hinders treatment of such patients. Therefore a comprehensive treatment program for Dual Diagnosis individuals must recognize both diagnoses as diseases that the patient does not have control over. (3, 1)

Most people with a learning disability who had complex needs including mental illness, were cared for in specialist mental handicap hospitals, and all medical and psychiatric care was provided on site.
Some components of the Sciacca's model for treatment include, day programs in clinics, residential programs, and support/therapeutic group work. She cites that many patients find discussing their chemical abuse and mental illness problems in a group setting with others who share similar problems, helps a Dual Diagnosis individual to see in others what is going on inside of them. Another component of the program is incorporating Alcoholics Anonymous and other such groups into the treatment. Most Dual Diagnosis patients find that programs like AA are ineffective for them. However, Sciacca has found that brining in speakers from groups like AA to join group therapy discussions is very effective and helpful to patients. Through group discussion, one on one time with a therapist, and other activities in the program, a patient comes to understand his or herself as having multiple problems that can be treated simultaneously. Sciacca also stresses communication between all therapists and psychiatrists working with a given patient in order that comprehensive treatment will occur. (3)

Deinstitutionalisation has transformed their care and now this group can live in the community and access mainstream health services, regardless of the degree of their disabilities. This process has been guided by the principle of normalisation since the early 1970s, which is a philosophy that remains influential today.
It is important that a person with dual diagnosis get treated for both their alcohol and drug dependence along with their mental disorder to give them a better chance of recovery (Medline). At times the mental disorder comes first which leads to people to drink or use drugs to self-medicate. The alcohol or drugs gives the person a temporary feeling of relief which is a confused feeling associated with their mental disorder. When the substance dependence comes first it can lead to emotional and mental disorders while the person is dealing with the consequences of their drug usage.

Normalisation represents a fundamental statement of human rights stating that patterns of life and everyday living which are as close as possible to the regular circumstances of society should be made available to all mentally ill and learning disabled people (Nirje, 1976).
It can be seen that a high level of integrated communication andworking patterns is recommended by the document, particularly inrelation to those in prison. Those in prisons are recognised by thedocument to be at greater risk. The guidelines encourage thecommunication between different agencies including the primary careteam and prisons. They also encourage establishing partnership with thecriminal justice system, partly by creating 'in-reach' programmes todeliver these services to prisoners. The document states that as forthe treatment that is recommended for these patients, there has been noresearch in the UK into what is effective, the authors therefore turnto evidence from the US which, they claim, suggests the importance ofintegrated treatment, motivational interventions and individualcounselling.

Closely associated with the principal of normalisation is the concept of mainstreaming, which advocates the use of standard rather than specialised services, for example, schools,

Employment and health care it is now a firmly established principle and features heavily in government policy which supports the use of mainstream services and the interrogation of the learning disabled population back into society but also recognises the need in some cases for specialist services.

Christy* began to have a very poor appetite, didn’t want to get out the bed, and was very withdrawn from family and normal activities. She had her first child at 21 shortly after she tried cocaine. After she had her second child she began drinking heavily and smoking on occasion. She did a lot of moving around during this time was drinking smoking and using cocaine. She eventually lost her kids to DFACS; she later did what she had to do to get her children back. She then sent her kids with their dad, but later fell into a deep depression. Which caused her to drink and use heavily she was what you call a functioning addict. She continued to work and carry on daily activities despite her addiction. Later she was arrested for possession of cocaine was bonded out after 5 days of sitting in jail. She filed her income tax she spent 85% of her refund on drugs and alcohol. Once the money was gone, she realized she needed help so she called behavior health.

(The Department of Health, 1992) stated that: "wherever possible people with learning disabilities should be enabled to use ordinary health services as well as specialist assessment and treatment services".

Advocates of normalisation generally support the mainstream approach; they may argue that specialised services lead to labelling, stigmatisation and negative professional attitudes.

Dual Diagnosis patients are more prone to relapse of either their substance abuse problem or their mental illness and they are also more prone to commit suicide and be violent. (1) Relapse often occurs because both problems the individual is suffering from were not treated in a manner that addresses both problems simultaneously. This is also something that I will examine later on. Studies have also found that Dual Diagnosis individuals have a high rate of sexual abuse experience as well (as either victim or perpetrator). (5)

The argument for this approach at first glance appears sound and is supported widely by literature. It is, for example, current policy in the UK and USA. However, in practice mainstream community mental health and inpatient teams have found it increasingly difficult to meet the needs of people with learning disabilities and psychiatric disorders (US Public Health Service, 2002).
Before reviewing the evidence, it is necessary to be aware of some of the limitations in this type of research. Mueser et al. (1998) are careful to explain that they do not assume that the models are mutually exclusive, in fact they hypothesise that each will explain different individuals under a variety of circumstances. There are, also, a numbe rof other difficulties with this type of research that are identified byMueser et al. (1998). They cite the work of Hambrecht and H & aumlfner (1996) who have investigated whether alcohol abuse precedes schizophrenia orthe other way around. In their study they found that, in general, it was the alcohol abuse that came first, although actually this came after the first symptoms of schizophrenia were noticeable. Needless t osay, this is a very confusing finding. A further difficulty that ismentioned by Mueser et al. (1998) is the general presumption in psychiatry that the biological basis of disorders is paramount. Psychosocial effects tend to be minimised and treated as secondary - a view that has been challenged by a significant body of research.

Each of the four UK countries has its own policy structure addressing how the needs of people with learning disabilities should be met in a mental health environment. England's policy is set out in the following reports.

In the past two decades doctors have discovered that at least 50 percent of mental ill individuals in this country also suffer from either alcoholism or substance abuse. (4) Some studies indicate that this percentage translates to 7.2 million individuals between the ages of 18 and 54 are suffering from both a substance abuse problem and a mental illness. (2) These numbers are simply staggering. Many of these numbers apply to the adolescent demographic in particular, who the National Alliance for the Mentally Ill (NAMI) say are most prone to having a mental illness "...that may in fact lead to self-medicating with street drugs and alcohol." (1) NAMI's fact sheet on Dual Diagnosis also states that mental health professionals are discovering Dual Diagnosis in such high rates that they have come to expect that individuals with a substance abuse problem will also have a previously undiagnosed mental illness. These mental illnesses range from Attention Deficit Disorder to Bipolar Disorder and everything in between. (1)

Valuing People: A new strategy for learning disability in the 21st century (Department of health, 2001), Health Services for People with Learning Disabilities (Department of Health, 1992) and Mental Health: National Service Framework, (Department of Health, 1999), The common themes and issues that underpin this policy structure, include: promoting collaborative working between mainstream mental health services and specialist learning disability services; allowing people with learning disabilities to access mainstream mental health services wherever possible but creating small specialist inpatient services for those whose needs cannot be met by mainstream services, implementing a changing role for specialist learning disability services to providing support and facilitation for mainstream services including providing mainstream mental health and care staff with adequate training on the needs of people with learning disability; applying a care programme approach for people with learning disability and mental health problems and creating mental health promotion materials which are made accessible for people with a learning disability.

Advice is available to help care providers and staff support people with learning disabilities in accessing mainstream mental health care settings (Hardy et al, 2006).

Mainstreaming refers to avoiding moving patients from one service toanother as this may lead to them leaving treatment completely. In orderthat mainstreaming should be effective, this document makes a number ofpolicy recommendations. These include specialist dual diagnosisworkers, a clear definition of what dual diagnosis means, an adequatenumber of staff available in areas like community mental health teamsand early stage intervention.

The Green light toolkit (Foundation for People with learning disabilities et al, 2004) is one example of a guidance document that demonstrates how policy structure and specific policies are being implemented in practice.
What emerges, then, from the theoretical perspectives is that there isa lot of confusion and a proliferation of different approaches. So, howdo public services attempting to deal with dual diagnosis? TheDepartment of Health's (2002a) Mental Health Policy ImplementationGuide: Dual Diagnosis Good Practice Guide provides policy informationabout how services should be targeted at dual diagnosis patients.Reviewing the history of how dual diagnosis patients have been treatedin the past the guide points out that there has generally been littleintegration. In the past, drug and alcohol services have remained quiteseparate from mental health agencies. This guide puts into place a newpolicy that aims to reverse this trend. Mental health services areencouraged to provide similar sorts of treatment to that alreadyprovided by drug and alcohol services. The drug and alcohol servicesare encouraged to see themselves as consultancies to other agencies,particularly mental health services, in order to provide'mainstreaming'.

It is used throughout England as an audit tool to measure how the National Service Framework for mental health (Department of Health, 1999) is being implemented for people with learning disabilities. The toolkit provides a gold standard that can be used by local mainstream mental health services to measure services against.
In the delivery of interventions, the integrated care pathway hasbecome the mantra of healthcare managers. This is because it is oftenseen that different services have different philosophies (as suggestedby Weaver et al., 1999), and patients should not be expected to shuttlebetween them. Drake & Mueser (2000) describe the attributes of adual diagnosis system as including the patient receiving treatment fromthe same clinicians who are trained in both substance misuse disordersand mental health disorders. There is a much greater emphasis inintegrated treatment of not immediately confronting the patient andchallenging them to become abstinent quickly. Instead the integratedapproach focuses on a gradual and long-term strategy of harm reduction.The emphasis here is on, for example, motivational interviewing whichprovides encouragement rather than chastisement. Another innovation isthe use of 12-step programmes for alcohol abuse only in those patientswho believe they can benefit from it rather than its mandatory use.Having described some of the differences, it is nevertheless clear thatthe integrated approach does share some commonalities with moretraditional parallel approaches. For example some assessments andinterventions are still the same as are psychosocial andpsychopharmacological approaches.

It offers a traffic light scoring system and provides guidance on how services can be improved, covering areas such as local partnerships, planning, accessing services, care planning and workforce planning.
The Models of Care (DoH, 2002b) report describes the prison-basedtreatment of those with substance misuse problems. CounsellingAssessment Referral Advice and Throughcare (CARAT) services providethat treatment and support. The staff who provide this service are notmembers of the prison service and their function is to cover a numberof areas. These include the initial assessment of the prisoner,liaising with a variety of other agencies, input into different reportsthat are required for sentencing or probation and either group orindividual counselling that aims to ameliorate the misuse problem. TheCARAT services also look to the prisoner's welfare after their sentenceis complete by providing training before they leave and assessing theirrequirements for post-prison treatment. One of the most surprisingomissions of the CARAT scheme is that it excludes alcohol misuse, whichis one of the most common substance misuse disorders (O'Grady, 2001).

After a green light toolkit assessment, each local area should develop an improvement plan from the action points identified and have a time frame to implement the necessary changes. Anecdotal evidence from observations in practice suggest that the green light tool kit is still being used in practice today but similar areas for improvement are identified time and time again such as access to health promotional materials in understandable formats.
Overall, while acknowledging that prisoners are at high risk of dualdiagnosis, there is little mention of them in this document. Weaver,Renton & Stimson (1999), in anticipation of some of therecommendation of this document, make some salient criticisms. Theyblame the way in which separate services have developed for those whohave a dual diagnosis on political ideology and point out that researchevidence has had little sway. The psychosocial model on which substancemisuse services are based, as the name suggests, tend to emphasise theimportance of psychological and social causes and remedies. Incontrast, mental health service tend to be based on the medical modelwhich is normally biologically based and encourages the diagnosis ofproblems as well as the attendant implications of compulsoryincarceration within institutions. These two groups of people approachthe world in different ways and it will, Weaver et al. (1999) suggest,be difficult for them to communicate effectively with each other.

This would suggest that although assessments of services are being undertaken the outcomes of these assessments and action points are not being carried forward into practice. The Disability Rights Commission (Disability rights commission, 2006) supports this view by saying that previous guidance documents intended to help people with learning disabilities gain access to mainstream health services have had limited effect.
Sometimes people may use alcohol or drugs to help cover up or mask symptoms of a mood disorder. For example, if a person's mind is racing because of mania, a drink of alcohol may slow it down. If a person has intense sadness or hopelessness because of depression, a drug may help him or her feel happy or hopeful for a period of time. This "self-medication" may appear to help, but it actually makes things worse. After the temporary effects of the alcohol or drugs wear off, a person's symptoms are often worse than ever. Self-medication can cause a person's mood disorder to stay undiagnosed for a long time.

A working group from the royal collage of psychiatrists (Royal College of Psychiatrists, 1996) acknowledged that enabling people with learning disabilities to access mainstream mental health services can be a complex and demanding task requiring input from specialists in the psychiatry of learning disability.

Many other different types of treatment modalities have been examined,such as in-patient versus outpatient treatment, persuasion groups,social skills training and self-help groups (Abou-Saleh, 2004), but howmuch of the available services do dual diagnosis patients use? Studiesin the US have shown higher rates than those with a single disorder(Narrow, Reiger, Rae, Manderscheid & Locke, 1993). Other morespecific studies, such as Wu, Kouzis & Leaf (1999), have foundlittle difference between alcohol misusers with other comorbid mentalhealth problems and those without the comorbid disorders. Still, theevidence shows that the use of services by dually diagnosed patients isat least as high as other comparable groups.

To respond to this statement they have advocated two principles for the mental health nursing of people with learning disabilities: joint working between mental health and learning disability teams with the use of Mainstream psychiatric facilities at every possible opportunity as well as stressing that provisions for specialist services are still to be available if needed.
The Department of Health (2002) review some of the evidence onintegrated care pathways. It seems there has been mixed evidence of abeneficial effect on the mental health outcomes of dual diagnosispatients with the use of integrated care pathways. Much of the workthat has evaluated this approach has been carried out in the US.Hellerstein, Rosenthal & Milner (1995) carried out a study in theUS on schizophrenic patients who also had substance misuse disorders.This compared the integrated with non-integrated pathways and foundlittle difference between them in the outcomes measured. This researchdoes not, however, take into account all the possible factors involved.Other research, such as that reviewed by Drake & Mueser (2000), hasfound advantages. Similar findings are reported by Drake, Yovetich,Bebout, Harris & McHugo (1997) who argue that an integratedapproach is effective in providing housing stability, reduced alcoholintake compared to the parallel approach that has been in use in the USand the UK.

The independent government inquiry instigated by Death by Indifference (Mencap, 2007), while not extending to mental health services, promoted research into the experiences reported by people with learning disabilities of acute mental health units.

Wu, L-T., Kouzis, A. C., Leaf, P. J. (1999) Influence of comorbidalcohol and psychiatric disorders on utilisation of mental healthservices in the National Comorbidity Survey, American Journal ofPsychiatry, 156, 1230-1236.

This provides a mixed picture. The negative experiences are similar to concerns expressed by other patients. These include: lack of control and information; theft of property; intimidating multi disciplinary meetings; poor food and poor care.
The secondary substance use disorder models can, according to Mueser etal. (1998) be divided into psychosocial risk factor models andbiological sensitivity models. The psychosocial model is againsubdivided by Mueser et al. (1998), but the authors report the modelwith the most empirical support is the multi-factorial model. Thefactors involved include, for example, bad interpersonal skills, socialisolation, lack of structured daily activities. The second category oftheory is that of biological sensitivity. The biological sensitivity ofschizophrenic patients has certainly been shown to be greater inamphetamine use - this contributes to a 'revolving door' effect forthese patients (Haywood, Kravitz, Grossman, Cavanaugh, Davis, &Lewis, 1995). Both of these sub-groups within this group of dualdiagnosis theories has some evidence to back it up.

However the presence of learning disabilities may alter their significance for example, service users with learning disabilities may find it harder to understand information about their admission and treatment, unless it is shared in a format which is appropriate to their cognitive and communication skills.
So far, very generalised factors of dual diagnosis have been addressed,but it should be made clear that many interventions will be heavilyreliant on the individual needs of the patient. Research studies haveshown that treatment must take into account which dual diagnosis thepatient receives. For example, a study in the UK, Barrowclough,Haddock, Tarrier, Lewis, Moring, O'Brien, Schofield & McGovern(2001), found that when measuring days of abstinence, symptoms andgeneral functioning, a combination of cognitive, motivationalinterviewing and a family intervention was more effective in dualdiagnosis for psychosis than the standard treatment. By contrast, forbipolar disorder with substance misuse, integrated group therapy wasfound to be effective by a US study (Weiss, Griffin, Greenfield,Najavits, Wyner, Soto & Hennen, 2000).

Psychotropic medication may further impair already poor cognitive functioning and may represent an additional limitation on individuals' capacity to understand and take an active part in their treatment.
This paper reflects the research and thoughts of a student at the time the paper was written for a course at Bryn Mawr College. Like other materials on Serendip, it is not intended to be "authoritative" but rather to help others further develop their own explorations. Web links were active as of the time the paper was posted but are not updated.

Relatives and paid carers are likely to have a much more significant and long-standing role in supporting the service user than would be the case with other adults with mental health problems, Often a person with a learning disability has specific routines that only someone close like a carer would know and following these routines can make nursing them much easier.
At its most basic, the idea of dual diagnosis, that of the co-occurrence of mental health problems with substance misuse problems, covers a broad range of factors, the interaction of which has been analysed by Krausz (1996) as falling into four categories. Firstly, theprimary diagnosis of mental health problems is followed by secondary problems of substance misuse then leading back in a circular fashion,into further mental health problems. Secondly substance misuse is seenas the primary diagnosis and this is followed by mental health problems, which are seen as secondary. Thirdly, the mental health problems are seen concurrently with substance misuse. Finally, there is a traumatic event which results in both mental health problems, such as a personality disorder, as well as substance misuse. These four different categories represent different lines of causation that are postulated between mental health and substance misuse.

this is something to which mainstream services in particular seem to pay little attention. Not stressing involvement with carers in particular with a client from this group can lead to either a lack of support for carers or carers feeling pushed away by services and left without a role which in itself can lead to the presentation of depression and low mood in the carer.
This analysis of Krausz represents one theory of how substance abusemight interact with mental health problems - but these theories have proliferated. Mueser, Drake & Bellack (1998) provide an in depth analysis of the different types of theories surrounding dual diagnoses.Mueser et al. (1998) organise their review of the theories of comorbidity into four categories. These are, firstly, common factor models, which suppose that there are common factors that cause both substance misuse and mental health problems. Secondly, there are secondary substance use disorder models - so that mental illness causes substance misuse. Thirdly, there are secondary psychiatric disorder models which essentially propose the opposite of the last category. Finally, there are bidirectional models that do not cede primacy toeither of the disorders.

(Scior and Longo, 2005) Finally, the risk that signs and symptoms of mental health problems will be misattributed to a person's learning disability (diagnostic overshadowing) is specific to this group. These issues need to be considered by practitioners however, evidence indicates that healthcare professionals often lack the knowledge, skills and experience necessary to meet the healthcare needs of people with learning disabilities.
Another complicating issue Dual Diagnosis individuals face is the fact that often the patient will use one disorder to mask the other from his or herself as well as their friends, families, co-workers, and health care providers. This causes some difficulty in diagnosing someone as having two disorders. There is also the specific issue of diagnosing the teenage population. Most people are keenly aware of the fact that teenagers are hard to figure out due to their fluctuating moods and hormones. "How can [we] separate the normal mood variations of a fifteen year old teenager from certain Bi-polar disorders? When substance use or abuse is present, with resulting mood fluctuation, the variables become staggering," says a counselor in an article for About.com. (5)

(Fraser, 1999)

The Royal College of Nursing (Royal College of Nursing, 2008) commented that the recent development of an expectation of the mainstream mental health services to respond to the needs of the majority of people with learning disabilities and co-morbid mental illness has often proved an unrealistic goal for the mental health nurse.

In recent years, alcoholism and substance abuse have been labeled as diseases because of new research findings that doctors have discovered regarding the biological and psychological factors causing someone to become an alcoholic or a substance abuser. Anyone who has a friend of family member who suffers from any form of substance abuse knows the extreme difficulty of helping the suffering individual seek help and recover. The same goes for individuals suffering from a mental illness.

It has been proven that special expertise and training as well as the use of specialist mental health teams are required for the assessment, diagnosis and treatment of mental illness in the learning disabled population.

The Mental Health Policy Implementation document provides an overviewof aims and objectives for dual diagnosis patients, however The Modelsof Care (DoH, 2002b) takes a closer look at the way in which treatmentcan be delivered. The Models of Care (DoH, 2002b) report does notitself cover the treatment in prisons in any detail but, as the authorsclaim, it does have a general relevance. In particular, though, it doesdescribe the care pathway for prisoners as being through a prison-basedreferral scheme.

Although it is theoretically possible to train staff in mainstream settings, the small number of cases gives little opportunity for staff in the various disciplines to gain the necessary skills. Additionally, mainstream mental health staff often feel that caring for this group of vulnerable people is not part of their role, and the resources of adult mental health services are already stretched (Day, 1988).
Narrow, W. E., Reiger, D. A., Rae, D. S., Manderscheid, R. W., Locke,B. Z. (1993) Use of services by persons with mental and addictivedisorders, Archives of General Psychiatry, 50, 95&ndash107.

The funding implications that arose from such a massive shift in service responsibility that came out of the implementation of the mainstreaming approach never seem to have been adequately addressed (Bouras et al, 1995)

Collaborative working between professional groups in healthcare is vital across the board for improving standards of care for patients and their carers (Pollard,2004).

One important treatment factor in the integrated pathway is the use ofmotivational interviewing. This is used to try and encourage a moreco-operational approach between patient and clinician. It ishypothesised that this will help encourage patients to return tooutpatient clinics to continue their treatment. US research on this hasprovided some supportive evidence for this approach. Swanson, Pantalon& Cohen (1999) compared motivational interviewing with the standardtreatment to the standard treatment alone. They found a statisticallysignificant difference in the group that had comorbid disorders.

In relation to this professional rivalries between mental health and learning disabilities teams are common and the understanding of each other's role is poor leading to mainly ineffective collaborative working (Bouras et al, 1995) There has also been no apparent or definitive negotiation between the two service teams in the UK to develop clear local operational policies or service agreements and only vague definitions of who is entitled to access which service exist, which can sometimes lead to a patient receiving inappropriate treatment, being bounced between services or, in rare cases, even being denied care altogether as neither team is willing to take responsibility for that patients care.

Distinguishing between psychiatric disorders and behavioural issues in people with learning disabilities is not always a straightforward process.

Secondary psychiatric disorder models which give primacy to substancemisuse have proved controversial. Perhaps this is chiefly becausealcohol is the substance most often abused and there is little evidenceof its relationship with the specific diagnoses of bipolar disorder orschizophrenia. Indeed, there is even evidence that it contributestowards covering up the onset of the condition (Bernadt & Murray,1986). Despite this, there is evidence from some studies that certaindrugs are associated with psychosis. LSD has been associated withpsychotic outbreaks (Bowers, 1972). Andréasson, Allebeck, Engstrom,andRydberg (1987) found a link between cannabis use and schizophrenia,with heavier users showing a quicker onset of symptoms. Overall,though, Mueser et al. (1998) state that it is difficult to show astrong connection across a variety of different drugs as the evidencesimply does not exist.

Both empirical and conceptual issues relating to the nature of such behavioural disorders question both the validity and reliability of a diagnosis of mental illness in a person who has a learning disability (Krose et al, 2000) This raises the question what does a nurse treat first? As with dual diagnosis of a drug addiction and mental illness, in many cases the drug problem needs to be tackled first before the full extent of the mental illness can be seen (Drake,2007).
Further, of those with substance misuse problems, theco-morbidity with mental disorders is 79%. With these figures in mind,the importance of the service, delivery and treatment of prisoners presenting with co-morbid mental disorders can be clearly seen. This essay will first examine the theory of dual diagnosis and what theevidence can tell us about its nature and how the different factors interact. Then the policy guidelines for the service and delivery oftreatments will be examined. Finally the treatment options currentlybeing used will be surveyed and assessed critically.

However, with a learning disability this is not a possibility as a learning disability is a long standing condition that cannot be treated. The question is therefore, is the behaviour being exhibited by a patient due to their mental health problems or the learning disability?

When a person with a learning disability requires admission to hospital due to a psychiatric illness, the first objective is to agree on whether the general or learning disability psychiatrist acts as the responsible clinician.

Bowers, M. B. (1972). Acute psychosis induced by psychotomimetic drugabuse: Clinical findings. Archives of General Psychiatry, 27, 437&ndash440.

The admission of a person with learning disability often happens as a last resort in response to an emergency that cannot be managed elsewhere such as in the community or via the use or respite services.
In this day in age, there are many diseases that one can contract. Sometimes a person contracts a disease because it was contagious, and others because they are genetically prone to it. Still others contract diseases and disorders in ways that are not clear to doctors and medical researchers.

The community learning disability team should be able to offer some training to nursing staff or even carry out specific pieces of work directly with the patient.

The allocation of a named nurse is extremely important and, if available, someone with special skills or interest should be appointed in order to develop a more effective therapeutic alliance with the patient.

The publication does report on changes introduced by a new drugstrategy. This new strategy aims to introduce new interventions thatare available from arrest through to sentencing. The primary aim willbe to get drug misusers into treatment at the earliest opportunity andemphasise the importance of integrated care pathways. The guidelineslaid out in the Models of Care (DoH, 2002b) maintains that the causesof patient's problems will often be multifactorial and change overtime. These implicitly acknowledge some of the findings from the reviewof the theoretical literature. For this reason, it is important thatcare plans are updated over time to take into account the latestcircumstances of the patient.

The increased vulnerability of people with learning disabilities to abuse even during admission should be considered and protection from this potential risk given. This may need to be in the form of separation from 'high-risk' patients or an increased level of nursing observation such as is policy with under 18s admitted to adult acute psychiatric units.
Haywood, T. W. Kravitz, H. M., Grossman, L. S., Cavanaugh, J. L., Jr.,Davis, J. M., Lewis, D. A. (1995). Predicting the &ldquorevolving door&rdquophenomenon among patients with schizophrenic, schizoaffective, andaffective disorders. American Journal of Psychiatry, 152, 856&ndash861.

In all cases, the importance of collaboration with the learning disability team should be stressed. This becomes particularly important during discharge planning. In the scenario of an admission under a Mental Health Section, people with learning disability and mental health problems are entitled to all the provisions of the Care Programme Approach and Section 117 after-care.
The term 'dual diagnosis' refers to patients with co-existing mental health and substance misuse disorders. The importance of the treatment of both mental health problems and substance misuse problems in prisons is addressed by the Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide (DoH, 2002a). Statistics quoted here state that at least half of prisoners on remand have substance misuse problems, with 10% being classed as moderate and 40% classed as severe.

It is also essential that mental health nurses have a good working knowledge of mental health law and legislation. Experiences from clinical practice have demonstrated that often mental health legislation is misused or disregarded for people with co morbid learning disabilities which denies them the safeguards and protection of the law that legislation such as the mental health act was designed to put in place (Mental Health Act, 1983).

When a person has five or more of the following symptoms, including feelings of sadness or loss of interest or pleasure, or if these symptoms interfere with a person's life, s/he may have major (clinical) depression and should see a health care professional.

The relevant legislation should be applied to this group of people if and when it is appropriate to do so and the same categories of detention used as for other individuals experiencing mental ill health.
It is hard to understand the policy implications, treatment methods orservice delivery standards without first having a basic knowledge of the difficulties that researchers have had in understanding what a dual diagnosis is and how it arises. This discussion is just as relevant forthose inside and outside of the criminal justice system.

Although it is important to note that a person with a learning disability can still be sectioned if it is deemed they behave abnormally aggressively or seriously irresponsibly, without any signs of mental illness it is therefore important to determine that that there be actual mental health problems present if a person is admitted under section to a mainstream mental health hospital.
Mueser, K. T., Drake, R. E., Ackerson, T. H., Alterman, A. I., Miles,K. M., Noordsy, D. L. (1997). Antisocial personality disorder, conductdisorder, and substance abuse in schizophrenia. Journal of AbnormalPsychology, 106, 473&ndash477.

Assessment is a specific part of the nursing process where mental health nurses can struggle when dealing with people with learning disabilities For example, The Mental State Examination, which constitutes an essential component of the formulation process and is essential for assessing risk and formulating a treatment plan, may be problematic.

Mood disorders and alcohol/drug problems are both treatable illnesses. They are not moral weaknesses or character flaws. They can affect anyone, regardless of age, ethnicity or economic background. Studies have shown that more than half of the people who have depression or bipolar disorder also use alcohol and/or drugs.

This could be for a number of reasons, including high rates of compliance or an eagerness to please in certain interview situations (Sigelman et al, 1982). Moss argues that people with learning disabilities are also less likely to complain or approach members of staff to ask for help which may further complicate the Assessment and risk management process.
Finally, in Mueser et al.'s (1998) review, the authors state that thebidirectional model has not been empirically tested. Overall, while theplethora of theoretical models have some evidence bases, none of themprovide particularly strong explanations of reality. This serves tounderline the complexity of dual diagnosis.

(Moss,1999) Simple language and direct questioning including communication and in depth discussion with carers could be a way to overcome this difficulty. Higher levels of nursing observation may also be useful, not only in ensuring a person's safety on the ward but also in giving vital information regarding a person's mental state (Appleby,1999)

(Gibson, 2007) highlighted some key factors that nurses without specialist training may find complicate effective assessment and intervention The two main factors that affect mental health nurses are: intellectual distortion, which may result from cognitive deficits in areas such as memory and concentration which can make comprehension and communication of thoughts and feelings difficult; and Cognitive disintegration, which can occur in situations where the person is overwhelmed by the anxiety of the demands being placed on them, resulting in an inability to martial thoughts and bizarre behaviour

Communication is central to making a sound and accurate assessment.

Swanson, A. J., Pantalon, M. V., Cohen, K. R. (1999) Motivationalinterviewing and treatment adherence among psychiatric and duallydiagnosed patients, The Journal of Nervous and Mental Disease, 187,630-635.

It is estimated that upwards of 50% of people with learning disabilities have significant communication difficulties (Matson, 1998) A nurse needs to address the particular communication needs of each individual as each will vary in their abilities, This is another point in which collaborative working becomes very important as if the person is involved with a learning disabilities team, that team may be able to provide the nurse with accurate information about the levels of a person's communication and how best to manage these issues.
Depression affects about 20 million people in the U. S. Depression is not the blues, it continues and interferes with everyday life (Medline). The symptoms include: sadness; loss of interest or pleasure in things previously enjoyed; weight loss or gain; sleeping too much or too little; lack of energy; feelings of worthlessness; and finally if the depression they may entertain thoughts of suicide (Medline).

Many of the problems in relation to management of people with learning disability by mental health nurses relate to the lack of knowledge skills and training (Lennox & Chaplin, 1995). Evidence suggests that qualified nurses regularly feel out of their depth and unsupported when dealing with this client group and observations in practice indicate a certain amount of avoidance tactics from mental health nurses when it comes to volunteering for the named nurse roll which could be due to a lack of confidence in this area.

Weiss, R. D., Griffin, M. L., Greenfield, S. F., Najavits, L. M.,Wyner, D., Soto, J. A., Hennen, J. A. (2000) Group therapy for patientswith bipolar disorder and substance dependence: results of a pilotstudy. Journal of Clinical Psychiatry, 61, 361&ndash367.

The current pre-registration nurse education programme for mental health nurses was originally validated by the English National Board (English National Board ,2000), and the curriculum follows the Nursing and Midwifery Councils' Fitness For Practice Guidelines (United Kingdom Central Council for Nursing, Midwifery and Health Visiting ,1999), which states that students undertaking pre-registration programmes must have certain other specialities included.

Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B. Schulenberg,J., Anthony, J. C. (1997). Lifetime co-occurrence of DSM-III-R alcoholabuse and dependence with other psychiatric disorders in the NationalComorbidity Survey. Archives of General Psychiatry, 54, 313&ndash321.

However, learning disability, as either a practical or theoretical component of the branch programme, is not one of them. With government policy (Department of Health, 2001) stating that people with learning disabilities should wherever possible access generic services, there would appear to be the need for a more specific and in-depth approach to learning disability education for all students throughout their pre-registration education.

Experiences from local preregistration nurse education show that currently nursing education provides a 12- month common foundation programme for nurses who intend to train in all areas of nursing including Adult, Mental health, Midwifery, child and learning disability nursing.

Drake, R.E., Yovetich, N.A., Bebout, R. R., Harris, M., McHugo, G. J.(1997) Integrated treatment for dually diagnosed homeless adults. TheJournal of Nervous and Mental Disease 185, 298-305.

Although not required by the NM, Learning disability theory is taught but placements in this area are not common. After common foundation period of training, student nurse education in mental health has little or no further opportunities to gain learning disability experience.

Comparisons with learning disabilities mental health can be made to both child and adolescent mental health, as well as to older people's psychiatry in that they are both specialist groups with their own issues and mental health nurses are expected to study these client groups in detail during their branch training in order to become familiar with the complexities of this type of mental health nursing.

Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S. W. Moring, J.,O'Brien, R. Schofield, N., McGovern, J. (2001) Randomized controlledtrial of motivational interviewing, cognitive behavior therapy, andfamily intervention for patients with comorbid schizophrenia andsubstance use disorders. American Journal of Psychiatry, 158,1706&ndash1713.

As these areas are mandatory specialities in order to meet the requirements of qualification as a mental health nurse (English National Board, 2000) and, coupled with the government's policy for people with learning disabilities to access generic mental health services, it would appear essential that mental health nurses address the speciality of people who have learning disabilities and additional mental health problems during their pre-registration education as they do with other specific patient groups.
Krausz, M. (1996) &lsquoOld problems &ndash new perspectives', European Addiction Research, 2, 1&ndash2.

Many senior mental health nurses have received no learning disability training at all. This lack of training may result in problems with communication and understanding, as well as negative attitudes toward people with learning disability. On the flip side, nurses in learning disability have similarly limited training in the area of mental health, although there are newly available post-registration courses. One such course gives an experienced nurse from either branch a six month secondment to the other nursing discipline which is backed up by 2 modules of theory.

Substance abuse is usually defined as a “pattern of harmful use of any substance for mood-altering purposes” or “the use of illicit drugs or the abuse of prescription or over-the-counter drugs for purposes other than those for which they were prescribed (Medline).

Anecdotal evidence gained from speaking to a mental health nurse who has recently completed this course has shown that general nursing skills that every nurse should be competent in upon qualification can be transferred across the board to other branches of nursing. The feeling of this nurse is that currently, mental health mainstream services see only those with mild or borderline learning disabilities coming into the service and the assessment and treatment process for these people is not much different to that of non learning disabled people.
Hellerstein D. J., Rosenthal, R. N., Milner, C. R. (1995) A prospectivestudy of integrated outpatient treatment for substance-abusingschizophrenic patients, American Journal on Addictions, 4(1) pp. 33&ndash42.

Currently specialist services provide the majority of care for the patients with more complex needs. (Scior and Longo, 2005)

In conclusion the evidence presented in this essay suggests a number of issues that need to be addressed if mental health nurses are to meet the needs of their clients with a co morbid learning disability effectively. There are: pre and Post registration training for mental health nurses, collaborative working between the mental health and learning disability teams and provision and access to services.

It seems that specialist learning disability in-patient units with a mental health focus offer a more positive experience for the patient than mainstream mental health units, and therefore should be developed further(Scior and Longo, 2005). However, realistically mainstream services are highly likely to continue to provide care for this group, if only because of the resource limitations in specialist services and the fact that 30% of NHS trusts provide no specialist admission facilities (Bailey & Cooper, 1997). There seems a need now for major changes to be made to the structures and day-to-day practices in these services. Such changes should include initiatives to promote more positive attitudes and behaviour towards individuals with learning disabilities through training and regular input from specialist learning disabilities services. Closer attention must be paid to the need to make information about diagnosis and treatments accessible, in media such as leaflets using simple language videos and audio information (Forster et al, 2001) and the need for stronger involvement of and co-operation with service users' regular carers.

Mueser, K. Drake, R. Bellack, A. (1998) Dual Diagnosis: A Review of Etiological Theories. Addictive Behaviours. 23(6), 717-734.

Current practice experience has shown however that in the most part mental health services in this area only seem to come into contact with patients who have a borderline or mild learning disability as there is a bountiful supply of specialist beds.

If you or someone you know has thoughts of death or suicide, contact a medical professional, clergy member, loved one, friend or crisis line such as 1-800-273-8255 (TALK)immediately, or go to your nearest hospital emergency room.

Currently only in rare cases would mainstream mental health units be admitting a person with severe or profound learning disabilities whereby small alterations to practice and transferable nursing skills would not be enough to give that patient the best care available.

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Appleby L (1999) National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Department of Health

Bailey NM & Cooper SA (1997) The current provision of specialist health services to people with learning disabilities in England and Wales. Journal of Intellectual Disability Research 41 52-9.

Bouras,N., Holt,G. & Gravestock,S. (1995) Community care for people with learning disabilities : deficits and future plans. Psychiatric bulletin, 19, 134-137.

Drake, R.E., Mueser, K.T., (2000) Psychosocial Approaches to dual diagnosis, Schizophrenia Bulletin 26, 105-118.

Day, K. (1988) Services for psychiatrically disordered mentally handicapped adults. Australia and New Zealand Journal of Developmental Disabilities, 14,19-25.

Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century. The Stationery Office, London.

Department of Health (1999) mental health: national service framework, The Stationery Office, London.

Department of Health (1992) Health Services for People with Learning Disabilities (Mental Handicap). HSG(92)42. London: Department of Health.

Disability Rights Commission (2006) Equal Treatment: Closing the Gap. Final Report of a Formal Investigation into Health Inequalities. DRC, London.

Drake, R E, 2007. Dual diagnosis of major mental illness and substance disorder: An overview. New Directions for Mental Health Services, [Online]. 50, 3-12. Available at: http://onlinelibrary.wiley.com/doi/10.1002/yd.23319915003/abstract [Accessed 20 November 2010].

English National Board (ENB) (2000) Education in Focus. Strengthening Pre-registration Nursing and Midwifery Education.Curriculum Guidence. Part 13 of the Professional Register. ENB, London.

Forster M, Wilkie B, Strydom A, Edwards C & Hall I (2001) Medication Information Leaflets. London: Elfrida Press.

Foundation for people with learning disabilities, valuing people support team and national institute for mental health in England (2004) Green light: how good are your mental health services for people with learning disabilities? A service improvement toolkit, London: Foundation for people with learning disabilities

Fraser, B. (1999) Psychopharmacology and people with learning disability. Advances in Psychiatric Treatment, 5, 471-477.

Andréasson, S., Allebeck, P., Rydberg, U. (1989). Schizophrenia inusers and nonusers of cannabis: A longitudinal study in StockholmCounty. Acta Psychiatrica Scandinavica, 79, 505&ndash510.

Fraser W. & Nolan M. (1995) Psychiatric disorders in mental retardation. In: Mental Health in Mental Retardation; Recent Advances and Practices (ed Bouras, N), pp. 79-92. Cambridge University Press, Cambridge.

Gibson, T, 2007. People with learning disabilities in mental health settings. Mental Health Practice, 12/7, 30-33.

Hardy S, Chaplin E, Woodward P (2007) Mental Health Nursing of Adults with Learning Disabilities. Royal College of Nursing, London.

Hardy S, Woodward P, Woolard P et al (2006) Meeting the Health Needs of People with Learning Disabilities. Royal College of Nursing, London.

Hassiotis A, Strydom A, Hall I et al (2008) Psychiatric morbidity and social functioning among adults with borderline intelligence living in private households.

Bernadt, M. W., Murray, R. M. (1986). Psychiatric disorder, drinkingand alcoholism: What are the links? British Journal of Psychiatry, 148,393&ndash400.

Journal of Intellectual Disability Research. 52, 2, 95-1-6.

Krose B., Dewhurst D. & Holmes G. (2000) Diagnosis and drugs: help or hinderance when people with learning disabilities have psychological problems? British Journal of Learning Disabilities 29, 26-33.

Lennox, N. & Chaplin, R. H. (1995). Intellectual disability: the views of psychiatric trainees. Australian and New Zealand Journal of Psychiatry, 29, 632-637.

Matson,JL. and Bamburg,J. reliability of the assessment of dual diagnosis (ADD), research in developmental disabilities 20,89-95

Mencap (2007) Death by Indifference. Mencap, London.

Moss S. (1999) Assessment of mental health problems. Tizard Learning Disability Review 42, 14-19.

Government of England (1983) The Mental Health Act. Stationary Office, London.

Nirje, B. (1976) The normalisation principle and its human management implications. In Normalisation, Social Integration and Community Services (eds R J. Flynn & K. E. Nitsch). Baltimore, MD: University Park Press.

Pollard, KC, 2004. Collaborative learning for collaborative working? Initial findings from a longitudinal study of health and social care students. Health & Social Care in the Community, 12,4, 346-358.

Raghavan R, Patel P (2005) Learning Disabilities and Mental Health. A Nursing Perspective. Blackwell Publishing, Oxford.

Royal Collage Of Nursing , 2008. Mental health nursing of adults with learning disabilities: RCN Guidelines . London : South London and Maudsley NHS Foundation Trust

Royal College of Psychiatrists (1996) Meeting the Mental Health Needs of People with Learning Disability. Council Report CR56. London: Royal College of Psychiatrists.

Scior K, Longo S (2005) Inpatient psychiatric care: what can we learn from people with learning disabilities and their carers? Learning Disability Review. 10, 3, 22-33.

Sigelman C.K., Budd E.C., Winer J.L., et al. (1982) Evaluating alternative techniques of questioning mentally retarded persons. American Journal of Mental Deficiency 86, 511-518.

Swain J, French S, Barnes C et al (2004) Disabling Barriers, Enabling Environments. Second edition. Sage, London.

The Office for National Statistics. 2000. Psychiatric Morbidity among Adults living in Private Households. [ONLINE] Available at: . [Accessed 16 November 2010]

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US Public Health Service (2002) Closing the Gap: A National Blueprint for Improving the Health of Individuals with Mental Retardation. Report of the Surgeon General's Conference on Health Disparities and Mental Retardation. Washington, DC:US Department of Health and Human Services.

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