More joined-up work needed across services in the UK

The nature and prevalence of co-occurring alcohol problems and mental health problems is increasing within mental health and substance misuse services across the UK. The problems for individuals, families and communities are becoming ever more complex and the absence of a joined-up way of working in some regions of the UK is having a significant negative impact on those seeking help. Staff working in psychiatric and addiction service settings are faced with the challenges involved in treating patients whilst at the same time balancing risks and providing people with difficult and sometimes confusing choices about their care.

It is difficult to define the many and varied combinations of mental health problems and co-occurring alcohol problems. The term ‘dual diagnosis’ indicates that there are only two problem areas, when in fact there are usually several, all of which are specific to the individual and are clearly seen in many and multiple combinations. These may include a range of other factors, which impact on people’s lives; for example, personal and family issues, physical health concerns, emotional health, involvement in the criminal justice system and accommodation needs.

Therefore, it may be more useful to think about people as having ‘complex needs’ and consider ways of working which are flexible and tailored to the needs of the individual, and their family or carers. It is also apparent that treatment of dual diagnosis involving alcohol use may have traditionally been associated with more severe and enduring mental illnesses, for example schizophrenia and bipolar disorders. However, there has been an increase in the number of people who are struggling with anxiety and depression because of their alcohol use. In order to try to address these problems, research shows that more people are turning to alcohol to try to block out their mental health symptoms, trauma or physical pain.

From the evidence, it is clear that alcohol-related harms and associated problems have increased in the majority of the four nations in the UK.

In England, there were 337,870 hospital admissions due to alcohol in 2017/18. This figure has not changed greatly since 2016/17 although over a ten-year period, it is 15% higher than 2007/2008 figures. In addition, there were 5,483 alcohol specific deaths, 6% higher than in 2016.

Figures from Wales show that in 2017/18, hospital admissions for alcohol-specific conditions were 2.4 times higher than for illicit drug use. There were also 540 alcohol deaths in 2017, which represents an increase of 7% from 2016.

Scottish statistics indicate that there were 1,265 alcohol-related deaths in 2016, an increase of 10% in comparison with 2015. Furthermore, there were 36,235 alcohol-related hospital admissions in 2016/17.

In order to respond to the range and depth of problems caused by alcohol and mental health problems, a number of service models have been developed in the UK and on an international basis. The majority of models of service delivery can be categorised as serial (separate care from different services), parallel (provided at the same time from different service providers) or integrated (both services provided together in the same unit) with the latter viewed as the most beneficial for service users and patients.

Across the UK, the policy framework that addresses both alcohol misuse and mental health is fragmented or in some cases absent. In England, the last comprehensive guide to policy and practice was published by the Department of Health in 2002. In Northern Ireland, there has been a gap in policy guidance for alcohol misuse and mental health problems since 2005. However, the Welsh government produced a recent practical policy framework, which addresses the needs of people with alcohol and mental health problems in 2015. Similarly, Scotland may not have a recent specific policy framework document related to alcohol use and mental health but it does discuss both problems in a number of mental health and alcohol policy frameworks.

According to the research and guidelines [1-5] levels of assessment and care planning in working with both alcohol and mental health must be tailored to the individual needs of the service user (and carers where appropriate). They must also be developed in full partnership with the service user (where possible) and founded on a non-judgemental, empathic and person-centred approach. ‘Shunting’ people from one service provider to another is commonplace in some regions in the UK and this inevitably leads to poor support and care for those people who are most in need. It is crucial that changes are made at structural levels to facilitate a national move to an integrated treatment system within a four-nation framework. This will help to save lives, safeguarding those from the vulnerabilities caused by the complex and high-risk marriage of mental health and substance use problems.

[1] Public Health England, (PHE) (2017). Better care for people with co-occurring mental health and alcohol/drug use conditions A guide for commissioners and service providers.

[2] North East London NHS, (2009). Dual Diagnosis Strategy: an implementation plan for delivering good practice in working with service users with a dual diagnosis (mental illness and substance misuse).

[3] NICE, (2011). Alcohol-use disorders: The NICE guideline on diagnosis, assessment and management of harmful drinking and alcohol dependence. Clinical guideline.

[4] Ness, O., Borg, M., & Davidson, L. (2014). Facilitators and barriers in dual recovery: a literature review of first-person perspectives. Advances in Dual Diagnosis, 7(3), pp.107-117.

[5] Muser, K.T., Noordsy, D.L., Drake, R.E. & Fox, L. (2003). ‘Research on integrated dual disorder treatment Integrated Treatment for Dual Disorders: A Guide to Effective Practice’, London. Guildford Press.