People with substance use and mental health disorders being excluded from care

A new report from the Royal College of Psychiatrists warns that people who have a co-occurring substance use disorder and another mental health disorder – labelled CoSUM – are being failed by a system that is not designed or equipped to meet their complex needs.

CoSUM can refer to a range of different combinations of disorders, with examples including alcohol and depression; and cannabis and acute mental illness.

People with CoSUM experience poorer health, poorer engagement with work, and higher mortality and suicide rates than those who have an individual mental illness or substance use disorder.

Figures (between 2004 and 2014) showed that, in England 54% of patients treated by mental health services who died by suicide had a history of substance use problems, but of those (who died between 2012-2014) only 11% were in contact with substance use services.

Patients are often excluded from mental health and substance use services because these services typically work in silos and therefore don’t have the appropriately trained staff and resources needed to treat both conditions simultaneously.

Research suggests that up to 70% of people receiving community substance use treatment also experience a mental health disorder, while 44% of those receiving community mental health treatment reported problems with alcohol and/or drug use.

In England, this situation is exacerbated by the fact that substance use services are commissioned by local authorities outside of NHS structures, contributing to poor co-ordination of care and avoidable harms.

The report comes at a time when substance use and mental health services are under unprecedented pressure and facing a workforce crisis. The latest census figures (2023) show 24% of consultant addictions psychiatrist posts are vacant or filled by locums among the trusts and local health boards that responded in the UK.

Investment in adult substance use services in England has dropped by more than £200 million, after adjusting for inflation, since local authorities became responsible for commissioning substance use services in 2013/14.

“People with substance use issues often have a co-existing mental illness and it is not uncommon for people with mental illness to have a problem with alcohol or substance use,” Dr Lade Smith CBE, President of the Royal College of Psychiatrists, explains.

“A person might have an addiction to alcohol or ketamine that is linked to post-traumatic stress disorder. They are often bounced from one service to another, only being offered support for one condition at a time, as most services lack the specialist skills and resources needed to treat all their illnesses together.

“The consequence is that people only get sicker which is why we need trained and experienced staff who can provide care and treatment in one place.”

The Royal College of Psychiatrists is calling on the UK and Devolved Governments to provide substance use and mental health services with the training, staff and funding they need to address these difficulties. This includes implementing a co-ordinated approach in which patients are managed based on the severity of their illnesses and level of need, in England and NI.

The College is also calling on all health and local authority commissioners to ensure the number of people with CoSUM disorders, and their outcomes, are routinely monitored. This will help improve understanding the scale of the issue while supporting better resource allocation and strategic planning.

“We must move on from the current system of siloed care, which creates unnecessary barriers to access and generates further stigma. Instead, this group of people deserve a system which can co-ordinate their often complex treatment with the support of appropriately trained clinicians working collaboratively and compassionately,” Professor Owen Bowden-Jones, lead author of the report and Consultant in Addiction Psychiatry, said.

“This report, which reviews the situation across all four nations, provides practical advice and information for healthcare professionals while also making recommendations for governments, commissioners and standard setting bodies to improve services.

“Without improvements in staff training, clinical protocols, service pathways and performance monitoring, outcomes will remain unacceptable, and this most vulnerable group will continue to be stigmatised and forgotten.”