Intended for healthcare professionals


Moving beyond single and dual diagnosis in general practice

BMJ 2003; 326 doi: (Published 08 March 2003) Cite this as: BMJ 2003;326:512

Many patients have multiple morbidities, and their needs have to be addressed

  1. Nat Wright (, general practitioner consultant in substance misuse and homelessness,
  2. Liam Smeeth (, clinical lecturer,
  3. Iona Heath the Royal College of General Practitioners Health Inequalities Standing Group (, general practitioner
  1. No Fixed Abode Health Centre for Homeless People, Leeds LS9 8AA
  2. Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  3. Caversham Group Practice, London NW5 2UP

    The awkward phrase “multiple morbidity” describes the common predicament of the many patients who have more than one health problem. Such patients are disproportionately represented among populations that are socioeconomically deprived and elderly.1 A socioeconomic gradient exists in the incidence and prevalence of almost all major categories of disease, meaning that individuals and families who are socioeconomically disadvantaged are at risk of a compounding multiplicity of health and social problems.2 This multiple morbidity, coupled with the fact that the population of the United Kingdom is ageing,3 poses challenges to the delivery of effective health care that have received almost no official attention.

    Examples from mental health show that provision of service in this field has been slow to move from single diagnosis to dual diagnosis.4 Dual diagnosis applies to patients who have a mental health problem and problematic substance or alcohol use. A recent report on dual diagnosis from the Department of Health highlighted the role that primary care had in ensuring adequate care pathways for patients with mental health problems, drug problems, and related physical problems such as infection with hepatitis B or C virus or HIV.2 The report highlighting the issue of dual diagnosis did not use the term “multiple morbidity” to describe these patients. We believe, however, that such a term accurately describes the multitude of health need. It is our purpose to highlight this need so that effective policy measures can be taken to ensure adequate service provision for this complex group of patients.

    Effect of specialisation

    In the …

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