« Previous | Contents | Next »
Listen
Chapter 1: Introduction
Overview
The research described in this report investigated the nature, extent and impact of existing service provision across Scotland for people with co-morbid mental health and substance use problems. It was commissioned by the Effective Interventions Unit ( EIU) at the Scottish Executive to address perceived gaps in information on the nature and provision of care for this client group and help inform the development of the co-morbidity agenda in Scotland.
The study aimed to:
- identify the broad range of health and social care needs of people with co-morbid mental health and substance use issues in Scotland
- explore service users' experiences of accessing and receiving services from health, social care and independent organisations
- review the quality of current provision and organisation of health, social care and the independent sectors in meeting the needs of co-morbid individuals
- identify common factors that impede provision and organisation of health, social care and independent services for people with co-morbidity
- examine how different services relate to one another through informal and formal arrangements or protocols
- identify examples of good practice.
The researchers interviewed three groups of people, commissioners, service providers and service users to obtain a range of perspectives on these key issues. As decision makers and future planners, the commissioners helped to establish local strategic and bureaucratic contexts. Providers from the independent and statutory sectors gave the research an operational perspective. The views of service users on the services they utilised, their expectations and experiences, provided valuable new insights and made a unique contribution to the project.
The research fits within the wider strategic context in the UK, complementing other initiatives or strategies, such as the National Service Framework recommendations for people with dual diagnosis, the Mind the Gaps report of the SACAM/ SACDM Working Group, the Health Advisory Service publication on Standards for Mental Health Services, the Royal College of Psychiatrists information manual on co-morbidity and the Department of Health Mental Health Policy Implementation Guide for Dual Diagnosis.
Research and policy context
Chapter 1 defines co-morbidity and looks at the consequences for those with the condition and for society at large. It covers current models of service delivery and treatment interventions and examines the policy framework and measures being taken in Scotland to manage co-morbidity more effectively.
Defining co-morbidity
Co-morbidity is a complex phenomenon with a range of definitions.
In the field of mental health the term may be used narrowly or broadly. For example, it can be used to describe the co-occurrence of two (or more) different disorders such as the presence of substance misuse disorders (e.g. alcohol or other drug abuse or dependence) and psychotic disorders (e.g. bipolar disorders or schizophrenia).
A distinction is often made between concurrent and successive co-morbidity. Concurrent means two (or more) disorders are present at the same time. Successive co-morbidity is when disorders occur at different times during a person's life. It is unfortunate that the term co-morbidity sometimes blurs rather than clarifies the complicated diagnostic problems that clinicians have to understand and treat.
Another term used extensively is dual diagnosis. The World Health Organisation ( WHO 1994) and the United Nations Office on Drugs and Crime ( UNODC) define dual diagnosis as a 'person diagnosed as having an alcohol or drug abuse problem in addition to some other diagnosis, usually psychiatric such as mood disorder or schizophrenia'. The European Monitoring Centre in Drug Dependence and Alcohol ( EMCDDA 2004) refers to co-morbidity or dual diagnosis as a situation when there is a 'temporal co-existence of two or more psychiatric or personality disorders as defined by the International Classification Diagnostic System ( ICD), one of which is problematic substance use.
Since the interrelationship is complex, it is important to appreciate that co-morbidity can present in several ways (Crome 1999). Psychiatric syndromes or symptoms may result from substance use, and psychiatric or psychological symptoms may be triggered by harmful use, dependence, intoxication or withdrawal. Psychological morbidity not amounting to a disorder may precipitate substance use, and primary psychiatric disorder may lead to or precipitate a substance use disorder which may, in turn, lead to psychiatric syndromes.
This report uses the broader definition of co-morbidity/dual diagnosis as that of a co-existing mental health and substance misuse problem as defined by its bio-psycho-social context.
Brief historical background
Mental health and substance misuse problems are a major public health issue (World Development Report 1993).
Increased pressures on providers of mental health services have resulted in attempts to limit the remit of different providers and the development of case-mix to determine the resources made available for interventions (Farrell et al 2003). These developments have given rise to a greater focus on diagnostic groupings in some health care settings. There has been a tendency in some specialist services to disown the problems of these different groupings (i.e. the seriously mentally ill with problematic substance misuse within general psychiatric services and those with personality and other psychiatric disorders within addiction services). This has been further complicated by an assumption that each population belongs to the counterpart service. The result is that people with co-morbidity are left in 'No Man's Land' or fall 'between the cracks' (Abou-Saleh 2004).
Prevalence
International research points to co-morbidity being not only an issue among clinical populations but also in the general population in many countries (Regier et al 1990; Hall et al 2002; Frisher et al 2004; Abou-Saleh and Samet et al 2004). One population based co-morbidity study, The Netherlands Mental Health Survey and Incidence Study (Bilj et al 1998), found that one percent of both males and females in the Netherlands met criteria for combined 12 month mood, anxiety and substance use disorder. Another study, The UK Psychiatric Morbidity Study on adults living in private households (Singleton et al 2002), showed that 12% of males and 6% of females had some form of drug dependence combined with a current neurotic disorder.
Consequences of co-morbidity
Poor prognosis
Patients with co-morbidity have a poorer prognosis. The most consistent predictor of a poor treatment outcome for clients in treatment for substance misuse is the presence of psychopathology (McLellan et al 1983; Rounsaville et al 1987). Similarly, substance misuse is a predictor of poor treatment outcome for mentally ill patients (Drake and Wallach 1989; Carey et al 1991). Research evidence suggests that drug treatment outcomes improve if mental disorders are treated (e.g. Woody et al 1985).
Self harm, suicide and early mortality
Self-destructive and antisocial behaviours may develop in extreme situations, leading to homelessness, disengagement from family and community, and the presentation of high-risk behaviours such as offending, intravenous drug use, needle-sharing, suicide attempts, unsafe sex, and binge consumption (Murray et al 1999). There is also an increased risk of early mortality (Evans and Willey 2000).
Psychological problems
Increases in impulsive, aggressive and uninhibited behaviours, as well as increases in anxiety, depression and self-harms have been associated with the co-existence of substance use and mental health problems (Evans and Willey 2000).
General consequences
Co-morbidity is associated with a range of negative factors. These include higher rates of relapse (Swofford et al 1996) and rehospitalisation (Linszen et al 1994); hospitalisation (Haywood et al 1995); violence (Cuffell et al 1994); arrest and imprisonment (Clark et al 1999); homelessness (Caton et al 1994) and poorer housing stability (Osher et al 1994); and serious infections such as HIV and hepatitis (Rosenburgh et al 2001).
Social and economic cost
Those with a co-morbid condition place a heavy burden on a range of public services (Hall 1996). Severe psychotic disorder and substance misuse may be accompanied by a range of social issues, such as homelessness, poverty, criminality, unemployment and marginalisation. A particular strain is placed on acute psychiatric services (Regier et al 1990; Kivlahan et al 1991). The costs of providing treatment for those with co-morbidity are disproportionately higher than for those with psychiatric disorders that do not misuse substances; this is also true of those with substance use disorder ( SUD) alone (Hoff and Rosenheck 1998).
Models of service delivery
The international literature describes three service delivery models for the treatment of co-morbidity (Drake et al 1998):
- Sequential or serial treatment: Psychiatric/mental health and substance disorders are treated consecutively and there is little communication between the services. Follow up studies underline low success rate (Cuffel and Chase 1994; Bartels et al 1995 and Drake et al 1998)
- Parallel treatment: Treatment of the two different disorders is undertaken at the same time, with drug and mental health services liaising to provide concurrent services. In this model the medical model of psychiatry may conflict with the psychosocial approach to drug-related issues.
- Integrated treatment: Treatment is provided within a mental health or a substance misuse service or in a special co-morbidity programme or service. This is seen as the model of excellence ( SAMSHA 1997, 1998; DH 2002).
In practice the different models of care (sequential, parallel and integrated) often co-exist with little being known about what actually works and for whom (Drake et al 1998). No standard instrument exists for describing social and health care systems and pathways through care for people with co-morbidities. Comparing systems in different areas or in different national contexts is consequently difficult.
Service delivery infrastructures often cannot respond to geographical dispersal of the client group. In addition, the lack of specialised training opportunities for staff, problems in continuity of care with other health providers and stigmatisation issues in the wider community further challenge already fragmented service provision to this population (Larson et al 1993)
Treatment interventions and best practice
The UK Good Practice Guidance to Dual Diagnosis (DoH, 2002) provides the ingredients to help identify and develop an effective and efficient treatment approach individuals with co-morbid mental health and substance misuse problems.
Integrated Care for Drug Users: Principles and Practice ( EIU 2001) sets out the evidence base for integrated care. Part of this programme includes a fact sheet and guidance on the management of the co-morbid treatment-seeking population ( EIU 2004).
The European wide project on co-morbidity ( ISADORA Project) is designed to describe service provision for individuals with dual diagnosis in seven European psychiatric settings (including Scotland). The forthcoming publication of the European Monograph on Co-morbidity: policy and practice will provide the framework to identify not only the population but also the interventions provided in a European context to individuals with co-morbidity accessing treatment at all levels of the health and social care continuum.
Policy framework
There has been growing public and governmental concern about the consequences of mental and substance misuse disorders - both for the individuals concerned, their families and carers and for the impact on wider society.
Such concerns have been evident since the early 1990s, e.g. the introduction in 1991 of the Care Programme Approach to provide a framework for the care of mentally ill people ( HMSO 1994); the Department of Health's Confidential Inquiry into homicides and suicides by mentally ill people (Appleby et al 2001); the development in 1995 of a national drugs strategy and subsequent updates ( HMSO 1995; Home Office 2002).
Other countries have also developed similar approaches. In Australia, for example, the issue of co-morbidity is included in both the National Drug Strategic Framework (1998/9 - 2002/3) and the Second National Mental Health Plan (1998-2003) (McCabe and Holmwood 2003). The European Monitoring Centre for Drugs and Drug Addiction included a special section on co-morbidity in its annual report for 2004 and issued a policy briefing on the subject in the 20 official EU languages and Norwegian ( EMCDDA 2004, 2005).
The report from the joint working group between the Scottish Advisory Committee on Drug Misuse ( SACDM) and the Scottish Advisory Committee on Alcohol Misuse ( SACAM), Mind the Gaps: Meeting the Needs of People with Co-occurring Substance Misuse and Mental Health Problems, was published by the Scottish Executive in 2003. It makes a number of recommendations aimed at improving the well-being, support and general outlook of people with co-occurring substance misuse and mental health problems ( SACDM/ SACAM 2002).
This is part of a wider Scottish public health initiative to improve the mental health of the population. The current policy on the organisation of mental health services is set out in A Framework for Mental Health Services in Scotland (Scottish Office 1997), Our National Health (Scottish Executive 2000(1)), Partnership in Care (Scottish Executive 2003 (1)) and Delivering for Health (Scottish Executive 2000 (1)).
Taken together, these documents describe how the Scottish Executive, working with statutory agencies, the voluntary and independent sectors and others, have and plan to introduce and develop a range of policies and initiatives to identify the population in need, improve the planning and delivery of accessible and meaningful services, improve outcomes and provide a governance structure which upholds ethical and accountable frameworks of good quality mental health and addiction services. Multi-agency working and communication of good quality and meaningful information is the core driver in the current Scottish Drug/Alcohol misuse and mental health agendas. Several Scottish based agencies have either been set up (Mental Health and Wellbeing Support Groups and Mental Health Services Improvement Network) and others reorganised ( NHS Quality Improvement Scotland, Chief Scientist Office, NES Scotland) to maximise resources and respond in a clinically meaningful and responsive manner.
A number of Action Plans and other documents have been published by the Scottish Executive, aimed at tackling various aspects of alcohol and drug-related problems. These include:
- Framework for Alcohol Problems Support and Treatment Services (2003)
- Tackling drugs in Scotland, Action in Partnership (1999)
- Drug Action Plan: Protecting our Future (2000) which sets out the strategic framework for meeting the needs of drug misusers in Scotland. The drug strategy has been updated more recently with the Treatment and Rehabilitation review (2004), the Criminal Justice Plan (2004) and Hidden Harm (Scottish Executive 2003) which examines the Executive's action to help children and young people in families affected by drug misuse.
- Plan for Action on Alcohol Problems (2002) which sets out the strategic framework for reducing alcohol-related harm in Scotland.
Closely-related Scottish policy initiatives that impact on the Scottish response to co-morbidity include the Health and Homelessness Guidance aimed at improving the health of homeless people (Scottish Executive 2001), Joint Future Agenda aimed at better outcomes through an integrated approach (Scottish Executive 2000(3)), Beyond Trauma (Nelson 2001), aimed at understanding the views and experiences of survivors of trauma (including childhood sexual abuse) and Choose Life: A National Strategy and Action Plan (Scottish Executive 2002(2)) aimed at addressing the rising rate of suicide in Scotland. The Clinical Standards Board (now part of NHS Quality Improvement Scotland) published its Standards in Schizophrenia ( CSBS 2001) and subsequent programmes ( CSBS 2002) which aim to monitor and identify gaps in services and potential lack of access to specialised services.
« Previous | Contents | Next »