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4. Introduction
In 2006 Scottish Executive Ministers established an Advisory Group to review and update available guidance on care and support for people with co-occurring substance misuse and mental health problems and make practical recommendations for improvement in the prevention, care and recovery services for this care group and their families.
The Extent Of 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). A study in England and Wales showed that the prevalence of co-morbidity in Primary care almost doubled in the period 1993-99 (ref Fischer et al)
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.
The study by Gilchrist et al 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.
Policy Context
The Executive had previously published Mind The Gaps - Meeting the Needs of People with Co-occurring Substance Misuse and Mental Health Problems, 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, co-ordinated by the Dementia Services Development Centre in 2004. The policy context of A Fuller Life was part of the Executive's Plan for Action on Alcohol Problems.
Both reports were well received, but there is little evidence of their recommendations being implemented and so the problems of poor health, social exclusion and inadequate and patchy service responses which led to these reports being commissioned persist. The Centre for Addiction Research and Education Scotland ( CARES) report on Co-morbid Mental Health and Substance Misuse in Scotland (ref) showed individuals still falling through the gap.
- "Individuals with substance misuse-related issues often did not have sufficiently severe mental health problems to be eligible for attention from community mental health teams which prioritised severe and enduring mental illness." ( CARES report)
- "Despite high prevalence rates of drug misuse, only a small number (less than 5%) of mental health patients exhibited patterns of drug use that would have been likely to satisfy eligibility criteria for statutory drug treatment programmes in their areas mainly because they were not opiate users." (Department of Health 2004).
The CARES research found that a major issue is the exclusion from services. It is important to distinguish where this exclusion is due to local operational policy, for instance of substance misusers from mental health crisis services, or to the general under development of services, for instance for younger people with brain damage, sexual abuse survivors or alcohol problems where the access difficulties of those with co-occurring problems are the same as those of other people.
Since Mind the Gaps and A Fuller Life there have been a series of reports from Scotland and elsewhere in the UK and Europe. Some of these are listed at the end of this report. A consistent message is shown throughout these reports that co-occurring mental health and substance misuse is associated with more severe problems, poorer outcomes from interventions and higher rates of dropout. This applies in different models of service within Scotland, the UK and internationally. The challenges of working together to help and support this group though early identification and intervention, integrated care and supported recovery are among the most pressing currently facing services in Scotland. The wide range of interests and care networks that can potentially be involved means that clarity of responsibilities and co-ordination of care is essential.
During consultation for this report, service users said that:
- Stigma is a major issue in the area of co-occurring problems. This stigma is seen in staff whose attitudes are sometimes perceived to be negative.
- Their 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.
- General Practitioners and Primary Health Care have an important role to play.
A reason for poor implementation may be that the previous reports had their origins within the Substance Misuse field. The recognition of the importance of co-occurring problems, and the impact of substance misuse on mental health in Delivering for Mental Health ( add ref) represents an important step forward in driving forward service delivery in both mental health and substance misuse services.
The diversity of this client group 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. This is of considerable importance as UK research (Dept of Health 2004) has shown the range and effectiveness of services on offer vary widely depending on the nature of the mental health or substance problem.
- 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.
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