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Listen
MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems
CHAPTER 3: THE NATURE AND EXTENT OF THEPROBLEM
This Chapter:
Evidence regarding the nature and scale of the problem
3.1 The evidence comes from a variety of sources including routinely collected national datasets, general population surveys, and research studies. Scottish data has been supplemented by information from other parts of the UK and around the world. The evidence highlights the ways that people who experience co-existing substance misuse and mental health often have other complex, inter-related, serious problems. For example, there is evidence that those who experience unemployment, homelessness, violence and childhood trauma are also more likely to experience mental health/substance misuse problems.
A complex and dynamic picture
3.2 Co-morbidity brings with it a number of complex and variable features. First, there are continuums between severe and mild mental illness, severe and mild drug misuse, and severe and mild alcohol misuse. However, within each of these three major spheres (mental health, drugs and alcohol) there are also continuums that relate to different types and severities of mental illness, of illicit drug use and of alcohol misuse. The high prevalence of polydrug use further complicates the review task. Another dimension is the different pictures of co-morbidity which result from snap-shots or following people over time. Lastly there are a range of possible relationships between substance misuse and mental health:
primary mental health disorder may lead to substance misuse;
substance misuse may worsen mental health disorder;
substance misuse (intoxication/dependence) may lead to mental health problems;
withdrawal from substance use often leads to mental health problems; and
substance misuse and mental health problems may develop concurrently.
3.3 Estimating prevalence from large general population studies is likely to underestimate the true picture. Conversely, estimation from research in specialist services can overestimate prevalence in the general population. What is certain is that those who experience co-morbidity are not a homogenous group and that individuals' problems are likely to change over time.
3.4 It is possible to group existing evidence into four broad categories:
information on the prevalence of mental health problems, drug and alcohol misuse in Scotland;
information gathered from those whose primary problem is identified as a substance misuse problem;
information gathered from those whose primary problem is identified as a mental health problem; and
information from the general or other populations on co-existing substance misuse and mental health problems.
Prevalence of alcohol problems in Scotland
3.5 Alcohol problems, that is, hazardous and harmful levels and patterns of drinking and their consequences, are a major concern for Scotland. In general, men are more likely than women to have problems with alcohol and younger age groups are more likely to drink to excess. Seven percent of men and 3% of women continue to drink at a level which is thought to pose a potentially serious risk to health (Scottish Health Survey 1998). Trends suggest that alcohol use is increasing, particularly for young women. Of concern is the concurrent trend in alcohol related harm, such as the rise in alcohol related deaths. Vulnerable populations such as those in prison, homeless or less affluent groups have higher rates of alcohol problems. Alcohol problems account for a considerable use of health service resources. It is estimated that alcohol problems cost Scotland at least 1 billion each year.
Prevalence of Drug Problems in Scotland
3.6 As with alcohol, drug misuse is a major problem for the Scottish population. One in 20 adults report having used drugs in the previous month, with higher use reported by males and younger age groups. Trends suggest that drug use is tailing off from a peak in the mid nineties. However, drug related deaths continue to show an upward trend. As with alcohol, drug misuse is higher in vulnerable populations such as prisoners and those living in less affluent areas.
Prevalence of Mental Health Problems in Scotland
3.7 In Scotland, far more profound even than both alcohol and drug problems is the burden of mental health problems. In contrast to both drugs and alcohol problems, these are more likely in women and in the middle years. Trends have been more difficult to determine due to changing service delivery (from hospital to community settings) where information collection has not been as developed and lack of long term community surveys on mental health. Of great concern has been the rise in suicide rates particularly in young men where substance misuse (both drugs and alcohol) is a known risk factor.
3.8 There is a perception from service providers in Scotland that the co-morbidity client group appears to be growing and presenting in large numbers to both addiction and mental health services. What evidence there is for this, particularly in Scotland, is set out below.
People with substance misuse problems with associated mental health problems
3.9 The Scottish Drug Misuse Database (SDMD) was set up in 1990 to collect information on individuals who seek treatment for problem drug use. Information is collected on each new client, defined as those who are seeking treatment for the first time, or who are seeking treatment after an interval of at least six months. Contributors to the database include specialist addiction services and a number of GPs. Alcohol misuse is only recorded when it is used in conjunction with illicit drugs.
3.10 Data from the SDMD shows that between April 2001 and March 2002, over 40% of individuals who sought treatment for problem drug use (3,236 out of a total of 10,798 individuals) reported that their mental health was one of the issues which led them to seek treatment (see Figure 1 below). It is likely that data on mental health in SDMD may not necessarily be complete or consistent across Scotland. In a recent study in England by Weaver, 75% of drug misusers attending treatment were found to have one or more psychiatric disorders. A large study in the USA (the Epidemiologic Catchment Area (ECA) Study) found 64% of those being treated for drug disorders had an associated mental health disorder (Regier et al 1990). What is clear is the high prevalence of mental health problems in those presenting to drug treatment services.
Figure 1 Individuals attending drug treatment services with mental health problems, April 2001 - March 2002, by age and sex, n=7,752.
Source: Scottish Drugs Misuse Database
3.11 There is no equivalent national database for specialist alcohol services. Data are collected from people attending Local Councils on Alcohol, voluntary alcohol counselling services present in every local area in Scotland. However, the presence of co-occurring mental health problems are currently not recorded. The ECA study also found that 55% of those attending for treatment of an alcohol disorder had a co-morbid mental health disorder (Regier et al 1990). An English study which screened patients attending a community alcohol service found high prevalence of history of childhood sexual abuse, adult sexual abuse or assault (Moncrieff 1996).
3.12 Evidence from a nationally representative sample of Scottish general practices provides further evidence of an association between substance misuse and mental health problems. A third (35.2%) of consultations with drug misusing and half (51%) of consultations for alcohol misusing patients were found to relate to either mood or anxiety-related disorders. In comparison, fewer than a fifth (17.6%) of patients who do not misuse drugs or alcohol consulted their GPs for these problems.
3.13 Data from the National Treatment Outcomes Research Study (NTORS) in England and Wales, a prospective study of addiction treatment outcomes, has revealed that a fifth of all NTORS clients received treatment for a psychiatric illness prior to seeking treatment for their drug misuse problem (Gossop
et al 2002), and polydrug use was particularly related to psychiatric problems (Marsden
et al 2000). This same study found increased levels of psychological problems, including those with psychotic and paranoid features, among drug users who were also dependent on alcohol. Women drug users were found to be significantly more likely than men to report suicidal thoughts in the three months prior to seeking help for their drug use (Marsden
et al 2000). A similar study Drug Outcomes Research in Scotland (DORIS) is underway, but results are not yet available.
3.14 The ECA study found, in the general population, the commonest mental health disorders for those with both alcohol and drug disorders were anxiety disorders (19.4% and 28.3% respectively) (Regier
et al 1990). Many clients with drug and alcohol problems are diagnosed additionally with personality disorder, a condition frequently considered to complicate mainstream psychiatric interventions. A recent review of studies estimating prevalence of personality disorder in those with substance misuse problems found a median prevalence of 56.5%. However, these studies may have a bias towards higher prevalence as they are largely based on those attending specialist addiction services. What is also evident is that personality disorders, although more prevalent than in the general population, appear less prevalent in people with alcohol problems compared to those with drug problems (Welsh 2002).
3.15 Smaller scale local research highlights an association between social disadvantage, mental health and drug/alcohol misuse. A study by Gilchrist of female drug users attending a crisis centre, a drop-in and a methadone clinic in Glasgow found that 71% (184/260) had a lifetime experience of emotional abuse, 65% (168/260) had been physically abused, and 50% (129/259) had a history of sexual abuse (Gilchrist 2002). High incidences of traumatic experiences among women drug users are further supported by evidence from the USA and Australia (Broom 1994; Russell S and Wilsnack S 1991; Boyd 1993).
3.16 Our knowledge about young people, substance misuse and mental health in Scotland is limited. However, data from the Scottish component of the 1997/98 Health Behaviour in School-Aged Children (HBSC): World Health Organisation (WHO) Cross-National Survey showed that 15-year-olds who report drinking alcohol at least once a week were significantly more likely than their peers to report feeling low, feeling irritable and having sleep problems. Similar results were found among 15-year-olds who reported using drugs at least once a month.
People with mental health problems and associated substance misuse
3.17 The form SMR 04 contains information across Scotland about all patients leaving a psychiatric hospital. In the period April 2000-March 2001, there were 33,962 patient episodes of which 14.2% (4812) had an alcohol related diagnosis and 5.2% a drug related diagnosis. For those with an alcohol related diagnosis, the most common mental health diagnosis was depression (12%) whereas for people with a drug related diagnosis, schizophrenia was the most common diagnosis (14.8%). These data are likely to over-represent those with a severe or acute mental health problem (as these people are more likely to be admitted to hospital). They may also under-record substance misuse. Weaver's study (Weaver
in press) also examined those attending mental health services in England and found that 44% had problem drug and/or alcohol use. There is no national data collection from community mental health services in Scotland. The ECA study found that 20% of those with mental health problems seen in a service setting had a substance misuse disorder (Regier
et al 1990).
3.18 SMR 01 reports are returned for all patients leaving an acute hospital. The most common mental health diagnosis in those with either an alcohol or drug related diagnosis was of poisoning (accidental or intentional) and self harm (ISD).
3.19 Substance using behaviour has been shown to be an important factor in deaths from suicide. In 2001 alone, one-quarter (25.9%) of drug-related deaths in Scotland were attributed to intentional self-poisoning or poisoning with undetermined intent (General Records Office Scotland (GROS) 2001). Moreover, of all Scottish suicides between 1997-2001, of people who had previously been in contact with mental health services, over half (56%) had a history of alcohol misuse and over a third (37%) had a history of drug misuse. One in five of these individuals (19%) had a primary diagnosis of alcohol dependence; one in ten (10%) had a primary diagnosis of drug dependence (Appleby
et al 2001).
Co-occurring mental health and substance misuse in population studies
3.20 The most robust UK wide source of information on the prevalence of co-occurring mental illness and substance misuse (alcohol and illicit drugs) is the survey of Psychiatric Morbidity Among Adults in British Households. The most recent survey in 2000 (Coulthard
et al 2002) of a representative sample of 16-74 year olds living in private households, found important differences in levels of substance misuse between men and women and between people with different types of mental health problems. The results show that people who report obsessive compulsive disorders have particularly high rates of hazardous drinking, as well as alcohol and drug dependence. Individuals are also more likely to misuse substances if they report
any form of neurotic disorder compared to those who do not report these problems. For example, less than 1% of the population are classified as being moderately or severely dependent on alcohol, but this figure rises to 2% for people with a neurotic disorder, 5% among those with a phobia and to 6% among those with two or more neurotic disorders (Coulthard
et al, 2002, p. 53). The above survey includes a Scottish sample of 919 which reports Scotland has slightly higher rates of alcohol dependence and markedly higher rates of drug dependence.
3.21 In relation to gender differences, women were found to be more likely than men to report a form of neurotic disorder (20% of women compared to 14% of men) (Singleton
et al 2001), but men with any form of neurotic disorder were more likely than women to engage in hazardous drinking
, to be dependent on alcohol, to be more
heavily dependent on alcohol, and to use and be dependent on illicit drugs.
3.22 In the USA, the ECA population survey (Regier
et al 1990) found that just under 1 in 3 (29%) of people with a mental disorder had a lifetime experience of a substance use disorder (22% an alcohol disorder and 15% a drug disorder), just over 1 in 3 (37%) of those with an alcohol disorder had a lifetime experience of a mental health disorder and 1 in 2 (53%) of those with a drug disorder had experienced a mental health disorder.
3.23 A national epidemiological study in England, due to report shortly, has assessed the patterns and prevalence of co-occurring of substance misuse and mental health problems in general practice (Frischer 2003
in press). Co-morbidity increased by 62% between 1993 and 1998 from a rate of 50/100,000 to 81/100,000. The average practice sees four co-morbid cases per year.
3.24 The UK wide Psychiatric Morbidity Among Adults survey is household based and is likely to under-report the relationships between mental health and substance misuse for people living in residential, hospital and custodial settings. The evidence suggests that these populations experience the most severe forms of mental illness and substance misuse problems. Office for Population Census and Survey (OPCS) survey data relating to relatively large samples of people living in institutional settings and the homeless and roofless populations provide important insights. In an institutional sample (n=755) 10% reported ever using illicit drugs (for those who experienced schizophrenia, delusional or schizo-affective disorders this figure was 7%, 18 % for those with affective disorders and 22% for those with neurotic disorders). In comparison, 28% of the homeless sample and 46% of those attending night shelters (total sample n= 1061) reported drug use. Eight per cent of the homeless population reported having injected drugs but this figure rose to 14% among night shelter attendees (Farrell
et al 1998).
3.25 In Glasgow, a survey of over 200 homeless people (Kershaw
et al 2000) reported that 44% met the criteria for at least one mental health diagnosis (excluding substance misuse). The most common disorders were generalised anxiety disorder (21%), mixed anxiety and depressive disorder (13%) and depressive episode (11%). A quarter of the sample reported a level of neurotic symptoms likely to need treatment. Overall 25 % showed evidence of drug dependence but in the 25-34 year age range this rose to 70 %. Eighteen per cent of the sample was heroin dependent. In relation to alcohol consumption, hazardous patterns of drinking were higher in men than women (60% compared to 16%). However, of the total sample 54% reported hazardous consumption, with this figure rising to 63% for those over 55 years.
3.26 Similarly in the USA, high prevalence rates of co-morbidity are found in institutional settings, with a lifetime prevalence of 71.9%, more than twice that found in the community population (Regier
et al 1990).
3.27 Recent discussions with voluntary sector providers in Glasgow have identified that mild to moderate mental health problems are extremely common in homeless people, appear to be linked to experience of trauma such as sexual, physical and emotional abuse and often appear in tandem with drug or alcohol abuse. Post-traumatic stress disorder was thought to be under diagnosed whereas mild to moderate mental health problems were thought to be over attributed to a diagnosis of personality disorder.
Information gaps and developments
3.28 Much of the above evidence comes from continuously collected national datasets, national surveys and research studies. There are, however, key services from which there are no current national databases. Services such as community mental health, police and A & E could also potentially collect information on those with co-occurring substance misuse and mental health problems.
3.29 What is also apparent on reviewing the evidence is that there is a need to enhance data collection on co-occurring substance misuse and mental health within current national datasets (including surveys). With the implementation of initiatives such as Joint Future and
Integrated Care for Drug Users there is the opportunity to develop collection and collation of information that is person centred and covers the full range of their needs.
3.30 There is a wealth of information collected locally as part of patient/client care. A variety of local data collection systems are in place in health, social and voluntary care, addiction and mental health services. The more generalist services such as general practice, generic social work, the police also have local systems. The Improving Mental Health Information Project at ISD Scotland has been conducting an audit of information systems in use by the NHS throughout Scotland for mental health services. A similar exercise for social work information systems was carried out by the Scottish Social Care Data Standards project (SCDS) (2003). All 32 local councils have (or are acquiring) a computerised main social care client information system. These however vary considerably in functionality including support for joint working such as through the Joint Future Agenda.
3.31 There are currently no national data standards for either mental health or addiction information collection to support these local initiatives. An example of a local information system in the addiction field is the Ayrshire and Arran Common Addictions database which has been developed to collect client/patient information on those presenting to addiction services in Ayrshire and Arran. Details of the mental health profile are collected both through the completion of an assessment tool and the SMR24. Further details are also collected on those referred to the dual diagnosis service. The database will be able to interface to a central information store to allow exchange of information between Joint Future partners.
Conclusion
3.32 People at risk of social exclusion are more likely to experience ill health (World Health Organisation (WHO) 1998). The focus of this report is the provision of services for people who experience co-occurring substance misuse and mental health problems. Accordingly, this chapter has documented the evidence of these problems in Scotland.
3.33 Co-occurring problems are present for many of those seeking care from both addiction and mental health services as well as for the wider population. It is striking that people who experience co-occurring substance misuse and mental health problems also often experience other complex social problems. For example, there is evidence that those who experience unemployment, homelessness, violence and childhood trauma, are also more likely to experience mental health and substance abuse.
3.34 At this point, the research base does not allow us to identify precise elements of social disadvantage, or to make statements relating to causal pathways. However, it is important to acknowledge that people who experience co-occurring substance misuse and mental health problems also often simultaneously experience multiple other forms of deprivation over long periods of time. It is also the case that clients seek help from services with combinations of needs other then just solely substance misuse or mental problems or combinations of these two.
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