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A 10-year strategy for mental health research which ignores drug use
Following a recommendation made by the Mental Health Task Force in 2016, the UK Department of Health has published a strategy for mental health research (The Mental Health Task Force, 2016, Department of Health, 2017). The ambition is to direct mental health research over the next decade.
Mental health and substance use dominate the top ten global causes of non-communicable diseases (Delgadillo and Kay-Lambkin, 2016). Both issues are important in their own right but there is also significant overlap between drug use and mental health. So any ambition to improve our understanding of mental health through research must include the issue of drug use. However, this new strategy mentions drugs only twice. The first relates to physical and mental health, with a recommendation that the connection between the two are strengthened in research, at this point a brief reference to addiction is made:
Research which spans physical and mental health such as: understanding mechanisms behind the mortality gap in severe mental illness; side-effects of medication; ethnicity; immunology and mental health; addictions/compulsive disorders and physical health.
The only other mention of drugs, including alcohol, is a section summarising population mental health problems in the UK. Bizarrely, this points to significant overlap between mental health and substance use which the rest of the strategy then ignores:
Alcohol and/or drug misuse often co-exist with mental health problems. It has been estimated that 75% of users of drug services and 85% of users of alcohol services experience mental health problems. People with co-existing substance use and mental health problems face significant barriers in accessing mental health and or drug and alcohol services, sometimes requiring both services simultaneously.
Ten recommendations (Table I) are made to improve the impact of mental health research and as drug use is ignored, Table I takes each of these recommendations in turn and provides examples of why drug use should have been considered in the strategy.
Unfortunately, the strategy amplifies problems with the way policy and research is organised and managed in the UK.
Policy and research
Despite individuals having combined problems of mental health and drug use, the government and research in the UK is organised in ways that views these issues as distinct. The Home Office continues to lead on drugs as this is viewed as a criminal matter while the Department of Health leads on mental health, this leaves Public Health England trying to respond to the real needs of people who have problems with drugs and their mental health. Given the significant budget cuts imposed on Public Health England this severely restricts their ability to influence policy and practice (Drummond et al., 2017).
Research faces its own challenges, despite increasing recognition of the relationship between drug use and mental health this is not an easy topic to investigate. The loss to follow up of participants with a dual diagnosis in trials can discourage researchers from investigating novel treatment methods. There is also a lack of replication of pilot trials to test novel treatments (Delgadillo and Kay-Lambkin, 2016). The recommendations made in the new mental health research strategy, which aim to promote greater interdisciplinary collaboration, patient involvement and capacity building could be promoted for the field of dual diagnosis by a commissioned call from research funders such as the National Institute of Health Research or the Economic and Social Research Council.
The health secretary responded to the launch of the research strategy by saying “We’re investing in mental health more than ever before and have started one of the biggest expansions of mental health services in Europe but we know when it comes to research, we can and should do better” – perhaps the Health Secretary could lead by example and agree to take over responsibility for drug policy from the Home Office sending a clear message that the government recognises this as a health issue and not a criminal one, it would be a good start.
|Strategy recommendation||Examples of why drug use should have been considered|
|(1) Life-course approach||Substance use often precedes and can exacerbate existing mental health problems (Hartz et al., 2014). But there is still more to understand about the relationship between drugs and mental health|
|(2) Patient and public involvement||Involving service users who have experience of dual diagnosis would improve our understanding of their needs and the support they would benefit from (Wells et al., 2008). This remains an ambition rather than a reality|
|(3) Mental and physical health||Drug use impacts on physical and mental health, capturing this in research outcomes measurement is critical (Robson et al., 2008)|
|(4) Co-ordination and infrastructure||Dual diagnosis does not fit the aim or scope of many major research funding bodies despite the potential for applied research|
|(5) Data, informatics and virtual populations||Improved data reporting at a population level must include drug use given the incidence and prevalence of dual diagnosis (Lai et al., 2015)|
|(6) Flexible funding||Collaboration between researchers in mental health and addiction is critical but structurally impeded, see point 4 (Sellman, 2010)|
|(7) Emerging interventions and alternative settings||Investigating dual diagnosis beyond the treatment setting would provide intelligence that could inform prevention strategies and interventions (Gore et al., 2015)|
|(8) Industry engagement||Insufficient information is available about the way medication benefits or presents risks to people with a dual diagnosis. Drug use excludes potential participants from trials in mental health and vice versa (Hamilton and Pringle, 2013)|
|(9) Regulation, ethics and governance||Research ethics committees should also have people who understand the association between drugs and mental health|
|(10) Capacity building||Multi-disciplinary research must include professionals and service users from the field of addiction if the ambition of applied research is to be realised (Fonseca et al., 2012)|
Delgadillo, J. and Kay-Lambkin, F. (2016), “Closing the science-practice gap: introduction to the special issue on psychological interventions for comorbid addictions and mental health problems”, Advances in Dual Diagnosis, Vol. 9 Nos 2/3, pp. 2-3.
Department of Health (2017), “A framework for mental health research”, Department of Health, London.
Drummond, C., Day, E. and Strang, J. (2017), “Return failing drug and alcohol detoxification services to NHS control”, British Medical Journal, available at: http://blogs.bmj.com/bmj/2017/11/30/return-failing-drug-and-alcohol-detoxification-services-to-nhs-control/
Fonseca, F., Gilchrist, G. and Torrens, M. (2012), “Integrating addiction and mental health networks to improve access to treatment for people with alcohol and drug-related problems: a qualitative study”, Advances in Dual Diagnosis, Vol. 5 No. 1, pp. 5-14.
Gore, S., Mendoza, J. and Delgadillo, J. (2015), “Multiple obstacles to psychological care from the viewpoint of addiction service users”, Advances in Dual Diagnosis, Vol. 8 No. 3, pp. 129-40.
Hamilton, I. and Pringle, R. (2013), “Drug interactions and dual diagnosis”, Advances in Dual Diagnosis, Vol. 6 No. 3, pp. 145-50.
Hartz, S.M., Pato, C.N., Medeiros, H., Cavazos-Rehg, P., Sobell, J.L., Knowles, J.A., Bierut, L.J. and Pato, M.T. (2014), “Comorbidity of severe psychotic disorders with measures of substance use”, JAMA Psychiatry, Vol. 71 No. 3, pp. 248-54.
Lai, H.M.X., Cleary, M., Sitharthan, T. and Hunt, G.E. (2015), “Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990-2014: a systematic review and meta-analysis”, Drug and Alcohol Dependence, Vol. 154, September, pp. 1-13.
Robson, D., Keen, S. and Mauro, P. (2008), “Physical health and dual diagnosis”, Advances in Dual Diagnosis, Vol. 1 No. 1, pp. 27-32.
Sellman, D. (2010), “The 10 most important things known about addiction”, Addiction, Vol. 105 No. 1, pp. 6-13.
The Mental Health Task Force (2016), “The five year forward view for mental health. A report from the independent Mental Health Taskforce to the NHS in England”, The Mental Health Task Force, London.
Wells, H., Davy, B. and Chuttoo, V. (2008), “Service user involvement: more than a token gesture”, Advances in Dual Diagnosis, Vol. 1 No. 2, pp. 23-7.
About the author
Ian Hamilton is a Lecturer at the Department of Health Sciences, University of York, York, UK.