Substance use and mental health concerns - The Way Ahead: rapid review recommendations
A set of independent recommendations to the Scottish Government on how to improve care for people with co-occurring mental health and substance use conditions. It forms part of a wider rapid review of co-occurring substance use and mental health concerns in Scotland.
The current focus on co-occurring mental health conditions and substance use disorders in Scotland is welcome as it is a problematic area of practice that requires urgent attention. The concern as to how to best help people with such co-occurring problems has been around now for several decades. There are strong indications that it has worsened as a day-to-day clinical issue in the last ten years, with data showing an increase in drug-related admissions to general hospitals with "mental and behavioural disorders" (Public Health Scotland, 2021). In part this is due to many new mind-altering drugs becoming available. Such drugs are also highly relevant to psychiatric and emergency medicine practice (e.g., see recent research on the relevance to psychiatric admissions of Novel Psychoactive Substances at the Royal Edinburgh Hospital. (Mogford et al, 2019)).
However, even before this expansion in the types and amounts of drugs available, such comorbidity was already an area of immediate concern in Scotland with high levels of co-occurrence between both problematic licit and illicit drug use and mental health conditions. Often the co-occurrence was talked of as "Dual Diagnosis." This high level of concern led to the "Mind the Gaps" (2003) and "Closing the Gaps" (2007) reports. These reports, however, did not have the impact on clinical practice that had been hoped for at the time. Mental Health Services and Substance Use Services still need to find better ways of working together for the benefit of their patients as evidenced by the recent inquiries in Tayside (Dundee Drug Commission ,2018; The Independent Inquiry into Mental Health Services in Tayside, 2020). Scotland is again examining the issue of co-occurrence at this time and we can also draw on recent reports from England (Public Health England, 2018) and Northern Ireland (Northern Ireland Assembly, 2021) which focussed on this topic.
The current task, then, for all practitioners and managers, is to ensure a shift in culture in this area and to bring about better integrated care within mental health and substance use services for the benefit of all patients with co-occurring disorders. This is the context for this Rapid Review, commissioned by the Minister for Drugs Policy and the Minister for Mental Wellbeing and Social Care.
Our report has aimed to be complementary to the recent Mental Welfare Commission (MWC) for Scotland report on the same issue – Ending the Exclusion: Care, treatment and support for people with mental ill health and problem substance use in Scotland (MWC, 2022).We are aware that the Mental Welfare Commission report has captured views from patients and their families, from primary care services and from secondary care practitioners, in both mental health and substance use services. Our own time-limited review has aimed to add to this but due to the limited time we were unable to consult as widely as we would have wished. The Mental Welfare Commission report has strong representation from people with Lived and Living Experience and from the relatives of those with co-occurring disorders and their voice shows that we need to strive harder to improve services for those with co-occurring disorders.
This document is the final part of a suite of three reports, and we cross reference where relevant to the other two documents. We also draw on a series of consultations and discussions with some key stakeholders over the past six months in coming to our recommendations. These were mainly professionals who share the goal of bringing about change in this area of work. The other two documents in our suite are 1) a literature review, based on search terms that we provided and 2) a research survey of addiction services which we also helped design. These other two documents are hopefully self-explanatory around methodology and findings. We draw on these findings in setting out our recommendations here.
The literature review suggests that building formal and informal service integration and networks around co-occurring disorders will be of benefit (e.g. Anderson et al,2013). It is hoped that the five Health Improvement Scotland Pathfinder projects represent a significant step in this direction and may function as a role model for the other Health Boards that are not included in this initiative. The HIS Pathfinder projects are being implemented in NHS Tayside, NHS Grampian, NHS Lothian, NHS Lanarkshire and NHS Greater Glasgow and Clyde. They are designed to improve services for those with co-occurring disorders.
We would also strongly support the roll out of the NHS Education for Scotland TURAS learning modules on motivational interviewing for substance use disorders to mental health services to help increase the skills of mental health practitioners in relation to substance use screening and intervention. This would include training on how drug screening tests and blood tests/alcohol biomarkers can help in detecting hidden substance use that may be relevant to the mental health issue.
Similarly, there should be parallel training for addiction workers around mental health screening and treatment. Both workforces should come together at a local level for training around co-occurring Mental Health Conditions and Substance Use Disorders and training on how best to respond to the needs of this client group. Rotation of staff and shadowing between the services would also help with such learning and aid integration.
A key point in all of this training is to give practitioners a more complex understanding of the issues of co-occurrence such that they will keep an open mind in each case about the relationship between the substance use and the mental health condition in relation to issues of cause and effect. In reviewing this whole area, we have considered substance induced mental health problems as being part of co-occurrence. The training should also reinforce the philosophies of "No Wrong Door" and "Everybody's Job" in relation to the Four Quadrant model.
Given our remit was to consider alcohol as well as drugs in relation to mental health care it is worth reminding ourselves as to the links between population alcohol consumption, depressive illness, and suicide rate (unlike in Closing The Gaps we were not asked to look at Alcohol Related Brain Damage in our review).
In the past six decades, alcohol consumption in Scotland gradually rose to such levels that patients with alcohol use disorders were increasingly presenting in psychiatric clinics and in medical and psychiatric wards with alcohol-induced mood disorders and suicidal crises. This association between alcohol use disorders and depression and anxiety has been well described (Schuckit,1994; Schuckit and Hesslebrock, 1994). Consideration of problematic use of alcohol, along with that of drugs, needs to be embedded in the Scottish national mental health and suicide prevention strategies. We are aware this is being addressed at this time.
The recent updated NICE Guideline on Self Harm (NG 225) should also be mentioned here as this does consider alcohol and drug use in relation to self-harming behaviours (NICE, 2022).
A particular concern that needs to be addressed in local interface protocols between mental health services and substance use services is how to respond to people with co-occurring disorders presenting in crisis if they are not admitted to inpatient care. Mental health crisis teams have seven day coverage where substance use services often do not have such coverage. Follow up at a weekend may be necessary in some cases and local protocols should address how this is realised.
Adequate provision of services for emergency detoxification from alcohol and emergency stabilisation for drug use should be considered to deal with patients presenting with a suicidal crisis. This often entails admission to general medical and psychiatric care, and we would strongly argue this is a legitimate use of psychiatric beds. Alcohol and drug-induced major depression is one of the commonest comorbidities. An expansion of inpatient stabilisation provision for drug users in crisis should also be considered, in relation to the goal of reducing drug deaths, where stabilisation in the community is felt to entail undue risk. Unstable drug use is particularly associated with mental and behavioural disorders.
We have made seven recommendations in our executive summary, and we will now explain below the rationale of these recommendations. We intend to assist the Scottish Government in developing an implementation plan for these recommendations.
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