CitationDownload as .RIS
Emerald Group Publishing Limited
The unlearned lesson
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 8, Issue 4.
The recent publication by the Office of National Statistics (ONS) on drug-related deaths is of great concern to those of us who work in the field of substance use and mental health (Office of National Statistics, 2015). In the UK, drug-related deaths have increased according to data published on the 3 September 2015. There were 3,346 drug poisoning deaths registered in England and Wales in 2014 (the highest since records began in 1993). Of these, 67 per cent were drug misuse deaths involving illegal drugs. This seems to be affecting men more than women with males over 2.5 times more likely to die from drug misuse than females. The highest mortality rate was in the 40-49-age group, followed by 30-39. Deaths involving heroin and/or morphine increased by almost two-thirds between 2012 and 2014, from 579 to 952 deaths, and deaths involving cocaine increased sharply to 247 in 2014 – up from 169 deaths in 2013. The northeast of England (also one of the most deprived areas of the country) had the highest rate for the second year running. (All figures presented in this bulletin are based on deaths registered in a particular calendar year. Out of the 3,346 drug-related deaths registered in 2014, half (1,682) occurred in years before 2014.)
The key message of the report is that drug-related deaths are rising. In addition, in July this year, the National Confidential Inquiry into Suicide and Homicide (NCISH, University of Manchester) published their annual report into suicides and homicides by people with mental illness (NCISH, 2015). Overall, suicide rates by people known to have contact with mental health services in the previous 12 months is continuing to increase. Whilst deaths in inpatient settings have fallen, there is a rise in deaths whilst people are under the care of crisis/home treatment teams. Suicide in men is rising and alcohol use is often a co-occurring issue. The main cause of death by suicide was by opiate overdose, resulting in 141 deaths in 2013. This can be broken down as: heroin/morphine (58, 38 per cent), methadone (33, 21 per cent) and tramadol (31, 20 per cent). People who died of opiate overdose were more likely to have a chronic physical illness, be female and have an affective disorder as well. The report makes many recommendations for clinical services. In relation to substance use, the report calls for attention to be paid to young men with mental health problems especially with co-occuring alcohol use, as well as care to be taken around the prescribing of opiate-based pain-killers for people who also have depression.
So, drug-related deaths are increasing, and opiate overdose are the main cause of death in people with mental health problems. Taken together this indicates a serious system failure for people who are substance users.
Any untimely death is a tragedy no matter what the cause. It is a loss to the family and friends, and a loss of future potential. There is a prevailing stigma related to those who use drugs (and alcohol); and with people with additional mental health, the stigma is compounded. I am not sure that the general public care too much about deaths related to substance use. It is perceived as a lifestyle choice and if people choose to use, then they should take responsibility regarding the risks. However, conversely, public attitude then shifts when substance use is implicated in harm to others, and there is an outcry; for example: transmission of blood borne virus transmission, drug-related crime and violence. There is nothing new here, the link between substance use, mental illness and risk of harm to self or others has been known for decades. Yet we do not seem to have been able to use this as an argument to push for better care pathways. The blame seems to rest with the person themselves, yet I would argue that there is a collective blame in health and social care policy, service commissioning and service provision. We are failing people with co-morbid substance use and mental health problems.
I have been working in the field long enough to be able to reflect on progress (or lack of progress) in the recognition of the vulnerability of people who use substances (and often also have mental health problems. In 1998, The Unlearned Lesson Report (Applin and Ward, 1998) highlighted how failure to provide an integrated and comprehensive service for people with mental health and substance use issues was implicated as a factor in a number of homicides. Applin and Ward analysed a set of inquiries into homicides committed by people with co-occurring mental health problems. Of 17 studies, 14 showed marked drug or alcohol component. They made five recommendations:
1. that there should be further work to research the contribution of alcohol and drugs in homicides by people with mental health problems;
2. inquiries should have a standard term of reference for the consideration of drugs and alcohol;
3. inquiry reports should make recommendations about the care related to the substance use;
4. alcohol and drug services should be routinely circulated with inquiry reports and should consider lessons for their services; and
5. mental health and substance use at a national and local level should collaborate to develop better services to this service user group.
Do these recommendations seen familiar? They were written 17 years ago. So, we learnt the lessons yet? With the figures on drug-related deaths, as well as suicide and homicide by people known to mental health services, I am concerned that instead of "learning the lessons" we repeatedly fail to provide a comprehensive approach to people with substance use and mental health problems. This journal is dedicated to highlighting the range of multiple needs that people experience in relation to substance use and mental health. We all have a duty to recognise that people with multi-morbidities need more comprehensive care not less, and are the people that will fall through the gaps in our very separate services.
In this issue we have a diverse set of papers, yet they all draw attention to the importance of being able to offer holistic care. Hamilton and colleagues write a commentary on a topic that can cause a huge amount of suffering and loss of quality of life, yet often is avoided by clinicians: sexual dysfunction as a consequence of prescribed medication. They note that there is limited information to guide prescribers about sexual dysfunction in relation to people with co-occuring mental health and substance use, but recommend more assessment of sexual dysfunction in practice, and appropriate adjustments to medication and psychoeducation about the potential impact of substance use and prescribed medications.
Fielder and colleagues report on a trial of a self-directed booklet based on cognitive behavioural therapy for anxiety in people who are in treatment for alcohol problems. They found that anxiety levels at baseline were significantly higher than expected in the general population, however, there was no difference in anxiety at follow-up as both groups reduced their anxiety (control and booklet groups). The conclusions are that the self-help model without support may not be sufficient in itself, and a future study should obtain a sample to be able to have sufficient power to detect differences.
Martin-Santos and colleagues have written a paper giving an overview of the issues associated with chronic hepatitis C, depression and gender. They highlight the gender differences in route of transmission, disease progression and risk factors, as well as the issues around association of hepatitis C and depression. Contrary to accepted belief, the newer drugs used to treat hepatitis C cause less neuropsychiatric side-effects, depression at start of treatment should not exclude anti-viral treatment and that prescribing an antidepressant is recommended.
Applin, C. and Ward, M. (1998), The Unlearned Lesson: The Role of Alcohol and Drug Misuse in Homicides Perpetrated by People with Mental Health Problems; A Study of Seventeen Reports of Inquiries into Homicides by Mentally Ill People, Wynn Howard Publishing, London
National Confidential Enquiry into Suicides and Homicdes (NCISH) (2015), "Annual report 2015", available at: www.bbmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/NCISHReport2015bookmarked.pdf (accessed 20 October 2015)
Office of National Statistics (2015), Drug Related Deaths Report, September, available at: www.ons.gov.uk/ons/taxonomy/index.html?nscl=Drug-related+Deaths