New report on Scotland’s crisis in mental ill health, alcohol and drug use – ending the exclusion

Scotland’s problems with alcohol and drugs are well known. Scotland has the highest level of deaths due to problem drug use in Europe, and the UK’s highest numbers of deaths due to problem alcohol use. 

The Mental Welfare Commission’s own data, and that of government and health authorities in Scotland, show rising rates of mental ill health. 

It is estimated that alcohol or drug misuse was a factor in between 48% - 56% of all suicides between 2008 and 2018 in Scotland.

A new report published today by the Mental Welfare Commission looks at the combination of mental illness and substance use, and asks if care, treatment and support are in place for people struggling with these issues. 

The Commission examined services across the country and heard from people with lived experience, families, GPs and health and care professionals.

Failure to implement guidance

The report finds that services are not meeting the needs of people who have both mental ill health and problems with substance use. Strategies, standards and guidelines are in place, but are not being translated into practice. 

Only 23% of NHS professionals agreed that adequate care and treatment is currently provided. 

Despite guidance on the importance of clear care plans, 77% of professionals said documented care planning did not happen or that they were unaware of it. 

Difficulties for GPs 

Ninety per cent of the 89 GPs who responded to the Commission had experienced difficulties in referring patients to both mental health services and addictions services, including when the patient presented in crisis. 

GPs also reported that referrals can be declined from community mental health services due to the person’s drug or alcohol use without any further assessment or signposting, leaving the GP to re-refer to other supports. 

Families excluded 

The Commission was keen to find out what support families had to help them cope, while also helping their family member. Their overriding message was the lack of support, care and treatment they feel is available to their relative and themselves. They describe patchy, inconsistent services who fail to properly engage. Their own input is frequently dismissed and they are often excluded from any care and treatment plan. The lack of crisis support, advocacy and rehabilitation services were also highlighted.

Drugs death task force 

Despite the medication-assisted treatment (MAT) standards introduced following the report of the Drugs Death Task Force, the Commission found little awareness of the task force standards on engagement and joined-up working so that people with a substance (drug or alcohol) use problem can access mental health care at the point of treatment. 

The Drugs Death Taskforce had called for an end to stigma as an essential element in Scotland’s fight against its high rate of drug deaths. Today’s report confirms that stigma is still preventing these issues being seen as the health problems that they are, and is compounding the suffering for individuals and their families and carers. 

Lack of continuity of care

People with lived experience, families/carers and professionals all highlighted the impact of staff shortages on delivering care and treatment and in the continuity of care. This results in people having to re-tell their stories to multiple professionals. Many have past trauma or adverse childhood experiences and it is upsetting to have to recount this repeatedly. This is not trauma-informed psychological care.

Dr Arun Chopra, medical director, Mental Welfare Commission, said:

“Our collective failure in dealing with this crisis is not for want of a lack of evidence or guidance on how to tackle it. There are abundant policies, guides and standards at a national level. 
“But we found a failure to implement them at local level. Despite guidance that emphasises the need for clear written protocols on joint working, the absence of, or lack of awareness of, protocols for joint working is somewhat hard to believe. 
“There is also a lack of recognition of the need to address substance use and mental illness concurrently. Whilst the substance use may be perpetuating the problem, without treatment of their mental ill health, it is likely that the person will struggle to stop using drugs or alcohol. 
 “We did find pockets of good practice, which we highlight, and a real desire to improve care and treatment.
“As a next, urgent step, rather than create new strategies, we call on services to deliver the strategies already in place, and on government to monitor this and report on progress in 12 months.”

Lack of physical health care

People with mental health conditions and substance use problems often also have physical health issues that should be monitored. Medications prescribed for the treatment of mental ill health and alcohol or drug use often also require monitoring. Only 13% of specialist staff stated that an agreed local protocol for the medical monitoring of patients with coexisting mental health conditions and problematic substance use exists in their area. 

Sixty seven per cent of the 77 families we heard from said the physical health of their relative was not a priority for health services. 

Recommendations for change

The Mental Welfare Commission report makes recommendations to health and social care partnerships (supported by their respective health boards and local authorities) and NHS Education for Scotland (NES). It makes one overarching recommendation to Scottish Government asking that they monitor the delivery from the others and address any barriers to that delivery over the next 12 months.

Background note

The relationship between mental health conditions and problem substance use is complex. For some people, problem substance use might lead to the emergence of a mental health condition. For others, the mental health condition might lead to the problem substance use as people use alcohol or drugs as a way of trying to cope with the distress of a mental health condition. For some people, a traumatic event or period or an adverse childhood experience can lead to these difficulties.