Briefing - Mental health and substance misuse

DrugScope has produced this briefing ahead of a debate on mental health being held in the House of Lords today.

There is a close relationship between mental ill health and problems with drugs and alcohol.
Where these issues co-exist (often referred to as ‘dual diagnosis’) people experience poorer outcomes – including high rates of relapse, hospitalisation and completed suicide.

A 2002 study found that:

• 75% of users of drug and 85% of alcohol services experienced mental health problems
• Conversely, 44% of mental health service users reported drug use or harmful alcohol use
• 38% of drug users with a psychiatric disorder were receiving no treatment for it

The Department of Health issued guidance that year establishing that mental health services should lead on providing integrated care, working closely with substance misuse services to establish appropriate processes and training. Progress to date has been limited and inconsistent.

Through its member organisations on the frontline, DrugScope has learned that:

• People are frequently denied access to mental health services on the grounds that their substance use is the cause of their mental ill health or will make treatment impossible
• Raised thresholds for statutory mental health services often mean that people are unable to access mental health care and support until they are close to or actually in crisis
• People experiencing a mental health crisis while intoxicated are often excluded from health-based ‘places of safety’, which may result in being placed in a police cell
• People with drug and alcohol problems have struggled to get appropriate support through the Improving Access to Psychological Therapy (IAPT) programme
• Drug/alcohol treatment providers have repeatedly voiced concern about their clients’ access to appropriate mental health support, and see this as worsening

This is of concern given that a number of international studies suggest that substance misuse can account for the increased risk of violence amongst those accessing mental health services.

What’s more, a recent investigation by the Lancet highlighted concern about adequate funding and training for addiction psychiatrists.

There are specific issues in the prison population, where 70% of prisoners suffer from two or more psychiatric disorders with 75% experiencing dual diagnosis. Lord Bradley’s 2009 report found services are organised in a way that ‘positively disadvantages’ this group. These concerns were again highlighted in Lord Patel's report on drug related crime and offender rehabilitation.

Reviews of the use of Section 135 and 136 of the Mental Health Act have highlighted the problem of intoxication in assessing the mental health of those believed to need a 'place of safety'. In a survey carried out by the Care Quality Commission about half of the providers said that people who were intoxicated would be excluded from the places of safety in their local area. Similar findings are reported by the Centre for Mental Health who say:

This issue of intoxication was a problem for most areas, and some emergency departments (EDs) and most 136 suites would reportedly not accept a person whom they deemed too incapacitated to assess.

Recently, there have been some positive developments:

• The Department of Health is currently engaging with this issue, which is, for example, highlighted in the 'Mental Health Crisis Care Concordat'. This work includes the development of tools and resources to support practitioners and a review of the 2002 guidance on dual diagnosis
• The introduction of Health and Wellbeing Boards provides an opportunity to join up mental health and substance misuse care (which are currently commissioned separately)
• The continued roll-out of the Liaison and Diversion schemes will place mental health professionals in police stations and courts, covering half the population from April 2015. These have been particularly championed by Lord Bradley, who observes in his report that “no approach to diverting offenders with mental health problems from prison and/or the criminal justice system would be effective unless it addressed drug and alcohol misuse”.
• The government’s review of the operation of sections 135 and 136 of the Mental Health Act 1983 has made constructive recommendations on health-based places of safety

While promising, it is not sure that all of these developments will be sustainable and provide the systemic change needed. This is particularly difficult given the division of funding at a local level – with separate budgets for mental health through Clinical Commissioning Groups and substance misuse through Public Health allocations.

It is vital that the opportunities we have to improve support for this particularly vulnerable group are not missed.

Further reading on this topic on DrugScope's website.

Download this briefing as a PDF from here.