In 2006 an Advisory Group was established to review and update available guidance on care and support for people with co-occurring substance misuse and mental health problems and to make practical recommendations for improvement in the prevention, care and recovery services for this care group, their carers and their families.
Membership of the Group was drawn from both mental health and substance misuse backgrounds and services and placed the interests of service users and carers at the centre and whose interests were particularly represented through the Voices of Experience ( VOX) and Al Anon representation on the Group. The full membership is at Annex A.
The Group remit was to translate the principles and recommendations of Mind the Gaps and A Fuller Life reports into practical advice on action needed to move the joint agenda forward and support joined-up local delivery to improve the awareness, support and service provision for people who have both mental health and substance misuse problems by the end of 2007. This undertaking addresses the 2006 published commitment 13 for mental health.
This work is now complete and it has been used to inform the development of this publication.
The aims of this publication are:
- to improve the awareness of co-occurring mental health and substance misuse problems;
- to improve support and service provision for people who have both mental health and substance misuse problems (and their carers); and
- to reduce stigma and influence positively attitudes towards this care group.
The previously published Mind The Gaps - Meeting the Needs of People with Co-occurring Substance Misuse and Mental Health Problems, was commissioned by the Ministerial Advisory Committees on Alcohol and Drug Misuse in 2003, and A Fuller Life - Report of the Expert Group on Alcohol Related Brain Damage, was co-ordinated by the Dementia Services Development Centre in 2004. The policy context of A Fuller Life was part of the forward Plan for Action on Alcohol Problems.
Both reports were well received, but there is little evidence (2007) of their recommendations being implemented. The Centre for Addiction Research and Education Scotland ( CARES) report on Co-morbid Mental Health and Substance Misuse in Scotland showed individuals still falling through the gaps in services.
This research and other UK work (Department of Health 2004, McNeill 2007) have helped to explain the nature of the gap in services, suggesting that these reflected generic issues in the nature of substance misuse and mental health services.
During consultation for this report, service users said that:
- Stigma is a major issue in the area of co-occurring problems. This stigma is also seen in staff whose attitudes are sometimes perceived to be negative;
- Care needs to be person centred and to be recovery orientated;
- There are inconsistencies round Scotland in treatment approaches;
- Agencies need to work together better; and
- General Practitioners and Primary Health Care have an important role to play.
The diversity of this client group and their carers must be recognised. The Group took the approach that the needs of all age groups, all types of mental health problems and all types of substance misuse should be considered, specifically:
- Of the 44% of mental health service users misusing substances, less than 5% satisfied eligibility criteria for drug treatment programmes in their area. The substance misuse services were set up to deal with opiate dependence, the drugs misused were predominately alcohol, cannabis, sedatives and stimulants.
- The majority of the mental health problems among substance misusers were diagnosed as personality disorder, and mild/moderate depression and anxiety which were judged "low potential for referral" to mental health services.
Carers of those with co-occurring mental health and substance misuse problems can experience similar difficulties in having their needs recognised and in accessing appropriate support. Unpaid carers play a vital role in the treatment and recovery of those with co-occurring substance misuse and mental health problems, providing emotional and practical support and supporting treatment at home where possible.
Under the Community Care and Health (Scotland) Act 2002, NHS Boards have an obligation to develop and implement a Carer Information Strategy. These Strategies will improve carer identification, information and training, including those caring for people with co-occurring mental health and substance misuse problems. GPs also have a register of carers within their population.
Just how big is the problem?
The UK Psychiatric Morbidity Study on adults living in private households showed that 12% of males and 6% of females had some form of substance dependence combined with a current psychiatric illness.
The Continuous Morbidity Register, supplied with data by a representative group of GPs nationwide, found that half of the consultations for alcohol problems were found to relate to either mood or anxiety disorders (as opposed to one-fifth of those patients not misusing alcohol).
Over 40% of patients in Scotland seeking treatment for their drug-related problem between April 2001 and March 2002 for the first time or after a period of 6 months absence did so due to mental health reasons. The UK wide National Treatment Outcome Research Study ( NTORS) found that a fifth of clients received treatment for a psychiatric illness prior to seeking treatment for their drug misuse problems.
About 50% of suicides since 1997 have had a history of alcohol misuse and about 37% a history of drug misuse, while 20% had a primary diagnosis of alcohol dependence and 10% a primary diagnosis of drug dependence.
In 1997, The Office for National Statistics undertook a survey of psychiatric morbidity among 3000 remand and sentenced prisoners aged 16-64 in England and Wales. Of those on remand 81% of males and 13% of females had two or more of the five mental disorders considered (personality disorder, psychosis, neurosis, alcohol misuse, and drug dependence); the proportions for sentenced prisoners were 72% and 71% respectively for males and females. Those with anti-social personality disorder were more than six times more likely than others to report drug dependence in the year before coming to prison.
A study of female drug users attending a crisis centre, a drop in and a methadone clinic in Glasgow found that 71% had a lifetime experience of emotional abuse and 65% had been physically abused, with 20% having a history of sexual abuse. (Gilchrist, Gruer and Atkinson 2005).
Rates of substance use were found to be low in minority ethnic populations in a Glasgow study (Heim et al 2004.). However culture and attitudes are changing and substance use, misuse and mental health may change too. There was no consensus among participants about whether service provision should be specialist or mainstream.
There are high rates of homelessness and unemployment in people with either substance dependence or a psychiatric illness. For those with co-occurring problems these factors present even bigger barriers to recovery.
In 2006, a survey of 4,200 Scottish carers for the Care 21 Report found 24% of carers saying the person they looked suffered from a mental illness, with only 2% of carers giving their primary reason for looking after someone as addiction to drugs or alcohol.
There is evidence that carers of people with unpredictable behaviour, such as those with co-occurring mental illness and substance misuse, are particularly vulnerable to stress and poor health.
The overall intention behind this guidance is to improve and refine the approaches made individually and collectively by all agencies, ( NHS, local authority, voluntary sector and others) in designing and ensuring better, more responsive, timely and accessible prevention, care, and recovery services and approaches for those with a mental illness and substance misuse issues.
Connection to published targets for Mental Health
The targets and commitments for Mental Health published in 2006 set a vision for mental health services in Scotland and also underpinned the Scottish Government's vision for a healthier, more successful Scotland. They reinforced the need to undertake this work and made a commitment to -
"….translate the principles of Mind the Gaps and A Fuller Life into practical measures and advice on what action needs to be taken to move the joint agenda forward and support joined-up local delivery by the end of 2007".
This commitment is consistent with the Plan for Action on Alcohol Problems' intention to strengthen links between the alcohol and mental health fields, and the commitment to partnership working in the National Quality Standards for Substance Misuse Services.
It is important to achieve a balance and to have clear links between health promotion, illness prevention, care, treatment and rehabilitation/recovery. Each complements and supports the other.
The promotion of good mental health will have direct and indirect benefits on the prevention of mental illness and on substance misuse. With this in mind an emphasis on substance misuse in mental health promotion activities should be supported. It is also important to advance health promotion and illness prevention action aimed at populations and not just at individuals.
We have attempted to focus on recommendations which we think will help to deliver better outcomes for this population through the structure of services that need to be in place to deliver good outcomes. Rigid structures can lead to a reduction in innovation and are not always appropriate for the changing population they service. It is designed to inform change, focusing on the key aspects that need to be in place at each point in a journey of care so that agencies, staff, service users and carers can be clear about what needs to be delivered, how it is to be delivered, where, when and by whom.
As with responses to other identified service needs, delivery requires a clear view and agreement on what is in place, on what is required and local and wider discussion and agreement on how any identified gaps in provision are to be addressed, and by what timetable.
Delivery on many of the mental health targets published in 2006 will particularly benefit those with co-occurring mental health and substance misuse and we need to build on them and the performance management arrangements around them to help to deliver this agenda. An example of such a commitment is "to improve the physical health of those with severe and enduring mental health problems by ensuring a physical health assessment every 15 months where possible and appropriate (published Commitment 5).
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