MENTAL HEALTH and SUBSTANCE MISUSE Peter Rice, Consultant Psychiatrist, NHS Tayside and Chair, Mental Health and Substance Misuse Group, Scottish Government.

THE MENTAL HEALTH AND SUBSTANCE MISUSE GROUP - 2007 –  To improve the awareness of co-occurring mental health and substance misuse problems and   –  To improve support and service provision for people who have both mental health and substance misuse problems. Our goal is to enable individuals to improve their life chances and live to their potential. So what’s the problem ?

Psychiatric Disorder Rates in UK Addictions Treatment Population ---------- N = 216 Drug Misuse and Dependence – UK Health Depts 2007

SUBSTANCE MISUSE IN CMHT PATIENTS 282 CMHT pts. London, Nottingham, Sheffield Alcohol 25% Harmful use Any use Problematic Use Cannabis 26% 13% Stimulants 16% 7% Benzodiazepines 7% 2% Opiates 5% 2%

WHAT’S DIFFERENT ABOUT THIS CLIENT GROUP ? Retrospective case control study of 400 MH and 190 SM pts Measured uptake by attendance patterns. No difference in attendance rates for single and dual diag pts in Subs Misuse service. More drop out in dual diag pts with CMHT. Suggests that Substance Misuse, not comorbidity, is the factor determining service uptake .

THE UNMET NEED FOR ALCOHOL SERVICES IN THE UK PREVALENCE to SERVICE UTILISATION RATIO (PSUR) INTERNATIONAL NORMS High Access 1:5 Low Access 1:10 UK PERFORMANCE England 1:18 Scotland 1:12

THE NATURE OF 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 2006) and “ 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)

RATES OF ALCOHOL AND DRUG PROBLEMS IN SUICIDE ENQUIRY CASES Scotland England and Wales Alcohol Dependence 17% 8% Drug Dependence 9% 3% Alcohol Misuse 58% 44% Drug Misuse 39% 30% Confidential Enquiry 2008

“It is likely that alcohol and drugs lie behind Scotland’s higher rates of suicide and homicide.” “Our findings support the view that alcohol and drugs are the most pressing mental health problems in Scotland”

Priority Areas Early Years Later life Communities Working life and employment Suicide, self harm and common mental health problems Quality of life for those with mental illness

Focus of Activity Improving the outcomes for those with mental illness (recovery, social inclusion, discrimination, physical health, stigma) Reducing the likelihood of common mental health problems (mental health literacy, responding effectively to depression, anxiety and stress, work on alcohol, suicide) Promoting wellbeing (public health work, early years resilience, wider social change)

Scottish NHS Performance HEAT Targets Health Improvement Efficiency and Governenance Improvement Access to Services Treatment Appropriate to Individuals.

HEALTH IMPROVEMENT Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines by 2010/11. Reduce suicide rate between 2002 and 2013 by 20%, supported by 50% of key frontline staff in mental health and substance misuse services, primary care, and accident and emergency being educated and trained in using suicide assessment tools/ suicide prevention training programmes by 2010. Through smoking cessation services, support 8% of your Board's smoking population in successfully quitting (at one month post quit) over the period 2008/9 - 2010/11.

ACCESS TO TREATMENT 4 week referral to treatment for Drug Services by December 2010 and 3 weeks by 2013. Alcohol target to be set this year.

TREATMENT Reduce the annual rate of increase of defined daily dose per capita of anti-depressants to zero by 2009/10/ Access target to Psychological Therapies. Reduce the number of psychiatric readmissions. Each NHS Board will achieve agreed improvements in the early diagnosis and management of patients with a dementia. To support shifting the balance of care, NHS Boards will achieve agreed reductions in the rates of attendance at A&E. By 2010/11, NHS Boards will reduce the emergency inpatient bed days for people aged 65 and over, by 10% compared with 2004/05.

SINGLE OUTCOME AGREEMENTS Concordat between National and Local Government. ECONOMIC OUTCOMES % of working age population economically active Percentage of working age people in receipt of out of work benefits. CHILDREN’S OUTCOMES Reduce pregnancies among under 16 year olds Increase life expectancy at birth

Scottish Drug Policy Support aspirations of users to become drug free Maintain harm reduction approach where it is necessary and effective Have recovery concepts at the heart of drug treatment Drug policy and practice linked to Improving Mental Health and to Early years strategies.

TARGETED OR WHOLE POPULATION ? Scottish Strategy 2008

TARGETED OR WHOLE POPULATION ? Alcohol Harm Reduction Strategy for England – Cabinet Office 2004

SCOTTISH MENTAL HEALTH and SUBSTANCE MISUSE POLICY Substance Misuse issues will be important in future MH Delivery plans Links to wide range of Health Targets and Local Govt Outcome agreements Expansion of Psychological Therapies, including Substance Misuse services Primary Care target for Alcohol Brief Interventions as part of whole population approach. 3 week waiting times for drug and alcohol treatment, which will include those services dealing with common mental health problems. More holisitic Drug treatment. Dementia strategy in preparation

THE SCOTTISH APPROACH Issues with Dual Diagnosis reflect generic issues in Services. Improvement in quantity and quality of Substance Misuse (esp Alcohol Services) will help Improvement in the quality of Mental Health, especially Psychological Therapy Services will help. Effective Prevention will help. We’re not convinced about specialist Dual Diagnosis services.