A new report1 from the Royal College of Psychiatrists warns that people who have a co-occurring substance use disorder and another mental health disorder (CoSUM) are being failed by a system that is not designed or equipped to meet their complex needs.
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.2 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.
CoSUM refers to a range of different combinations of disorders, with examples including [see clinical case write-ups on each in the report]:
- alcohol and depression
- cannabis and acute mental illness
- ketamine and post-traumatic stress disorder
- methamphetamine and psychotic disorders
- opioids and a range of mental health disorders.
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.3
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.
While Scotland and Wales both have unified local health boards, local authorities still have responsibility for social care. In Scotland, the Medically Assisted Treatment (MAT) standards aim to address the challenges affecting services, although they can be difficult to implement due to the pressure that services are under. In Wales, the co-occurring framework and approach is already working well in some areas, with spread and scale for the rest of the country being looked at.
In Northern Ireland, mental health and substance use services are primarily commissioned by the Health and Social Care (HSC) although gaps in services remain.
This 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.4
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 2013/14.5
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.
Dr Lade Smith CBE, President of the Royal College of Psychiatrists, said:
“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.
“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.”
Professor Owen Bowden-Jones, lead author of the report and Consultant in Addiction Psychiatry, said:
“People experiencing both mental health and substance use disorders are some of the most vulnerable in society and have the poorest outcomes and greatest treatment need. They also constitute a significant proportion of people receiving substance use and mental health treatment making their needs a high priority.
“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.
“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.”
Dr Emily Finch, co-author of the report and Chair of the Royal College of Psychiatrists Addictions Faculty, said:
“Anyone can develop an addiction, but no one chooses to. It’s vital that we shift from a culture of blame to one of compassion.
“People who struggle with alcohol and drug misuse often have underlying trauma and suffering that makes it difficult to cope with their thoughts and emotions. This can be connected to a range of experiences from bullying and abuse to poverty, discrimination and loneliness and lead to mental health problems
“It takes tremendous courage to seek help and accessing services should not be a barrier to care. I’ve seen firsthand how beneficial joined up support can be, and we must ensure nobody is excluded from the care they need.”
The College’s report is aimed at helping the general public, healthcare professionals and commissioners to better understand CoSUM and has recommendations for how people can be better cared for. It includes detailed information about these illnesses, how they can be treated and shares accounts from people who have personally experienced them.
Footnotes
Please find a copy of the report here: Co-occurring substance use and mental health disorders (CoSUM)
The report also identifies that new and expectant mothers, people who experience homelessness and neurodivergent people are particularly at risk and more likely to need additional support.
Substance use services treat people who have an addiction, but they also treat a range of people who use substances harmfully and not dependently.
RCPsych Mental Health Watch: Spending on adult substance misuse services
For further information, please contact:
- Email: press@rcpsych.ac.uk
- Twitter: @rcpsych
- Out-of-hours contact number: 07860 755896
