A new report from the Royal College of Psychiatrists warns that people with substance use disorder and another mental illness (CoSUM) are being failed by a system that is not equipped to meet their complex needs
CoSUM refers to the co-occurrence of a substance use disorder and a mental health disorder in the same individual, such as alcohol and depression. 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.
New research from the Royal College of Psychiatrists (RCPsych) looks at how patients experiencing both a substance use disorder and a mental illness are suffering harm and premature death after being excluded from care.
54% of patients with mental illness who died by suicide had a history of substance use
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.
Figures reveal that up to 70% of people receiving community substance use treatment also experience a mental health disorder. In comparison, 44% of those receiving community mental health treatment reported problems with alcohol and/or drug use.
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.”
Substance use and mental health services are facing a workforce crisis
In England, substance use services are commissioned by local authorities outside of NHS structures, contributing to poor coordination of care and avoidable harm.
However, Scotland and Wales both have unified local health boards, and local authorities still have responsibility for social care.
In Northern Ireland, mental health and substance use services are primarily commissioned by the Health and Social Care (HSC), although gaps in services remain.
Currently, substance use and mental health services are facing unprecedented pressure and a workforce crisis. The latest census figures (2023) show that 24% of consultant addiction psychiatrist posts are vacant or filled by locums among the trusts and local health boards that responded in the UK.
Figures indicate that investment in adult substance use services in England has dropped by over £200m, after adjusting for inflation, since local authorities became responsible for commissioning substance use services in 2013/14.
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 coordinated approach in England and NI that manages patients based on the severity of their illnesses and level of need.
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 deserves a system that can coordinate their often complex treatment with the support of appropriately trained clinicians who work 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.”
