22 December 2016

Help from all sides By Dr Luke Mitcheson, consultant clinical psychologist, South London & Maudsley NHS Foundation Trust

Luke highlights the issues people with co-occurring mental illness and substance use face when they try to seek help.

Alcohol and drugs are commonly used by people with severe mental health problems.

Drinking or taking drugs may be a way of avoiding emotional pain or a means to cope with difficult thoughts and feelings. The fact that drugs and alcohol worsen a mental state or lead to addiction may be of little concern to the person.

Severe mental illness has a dreadful impact on people’s health. They are more likely to suffer with ill health and disability, and they die prematurely compared to the general population. Problem substance use only perpetuates and adds to these difficulties.

Yet, despite this recognition of the extent of the problem and its consequences, services for this group of people can be patchy. Changes brought about by the 2012 Health and Social Care Act have meant that that Local Authorities are responsible for substance use services and Clinical Commissioning Groups look after mental health.

This fragmentation poses a risk as commissioners and staff may decide that someone is not their responsibility if they also have issues not directly related to their service.

People with co-occurring mental illness and substance use are often actively excluded from services. You will hear many excuses; “too intoxicated to assess”, “suffering from drug-induced psychosis” or “too complex for our drug-rehab”. 

Those who are able to access services may find that they are treated based on what is considered their primary need, be that alcohol use, mental ill health or offending rather than as a set of related and interconnected issues.

NICE’s key message is that helping severely mentally ill people cope with substance use problems should be the business of any NHS and social care staff they come across.

Wherever people end up there are a few standard things that should be done. For example routine screening for any associated health problems. Or checks to see that their care plan is one they are happy with and able to stick to.

Although the guideline emphasises that mental health staff should take the lead on assessing each individual’s needs, it also says they should coordinate this with other staff. This could be doctors, nurses, occupational therapists or housing officers. Anyone involved in delivering part of a person’s treatment should consider whether substance abuse and mental health problems are at the root of their problems.

I believe a clear and unambiguous message about this has the potential to change existing service provision and I hope that providers will review their working processes with this in mind.

My hope for the new NICE guideline is that it will shine a light on the wider health and social care needs of this highly marginalised and stigmatised group. So that people with complex health and social care needs will get the all-inclusive care that they need.


  • Such an important piece of work. This should make a big difference to sufferers.

  • Thanks Dr. Mitcheson, you've stated exactly how it is here in Perth Western Australia. Lots of talkfests/forums/conferences ad nauseam of what is needed but a baffling lack of action. Sincerity and ACTION at the top of the pyramid, with those who have the clout to progress evidenced based change, is what is required.

  • This just won’t happen!
    All over the country apart from the Maudsley in London are not investing in up to date treatments.
    The Maudsley and Kings should be the leaders in treatment and their procedures and care should be the standards set across all England.
    If a hospital fails to follow their guidance on how to treat and medicate each patient then they should lose funding until they educate themselves and adhere to Maudsley treatments and standards.
    The treatments across the UK are so substandard as to be dangerous and I despair for anyone becoming seriously mentally ill!

  • Hi Sally, thank you for your comment. Please do drop us a line on nice@nice.org.uk as we can then signpost some examples where groups are implementing our guidance to make a change.

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