Approximately 30% to 50% of individuals facing severe mental illness (SMI) also encounter concurrent alcohol or drug use (Weaver et al., 2001). Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) exacerbates the challenges faced by these individuals, as it leads to poorer treatment outcomes, reduced treatment retention and increased morbidity (Amodeo et al., 2008; Cornelius et al., 1995; Hayes et al., 2011). Treatment of patients with COSMHAD requires an integrated service including psychiatric, substance dependence and medical treatments. In fact, a previous blog outlines how certain pharmacotherapies are successful in treating both anxiety and coexisting alcohol dependence.

In the UK, due to the mainstreaming of services, people’s COSMHAD needs are usually addressed through mental health services. However, putting mainstreaming into action in this country has proven more challenging than expected; mental health services have been inconsistent and slowed down by lack of funding due to budget cuts, competition in finding services, and drug and alcohol treatment not being part of the main healthcare budget (Cummins, 2018).

Currently, there is uncertainty about how best to provide care to individuals with COSMHAD, and under what context the UK’s strategy is effective. As such, Harris et al (2023) conducted a realist synthesis to investigate how context influences the mechanisms through which UK service models for COSMHAD work.

Methods

A realist synthesis is a type of review methodology that primarily aims to answer the question of “what works? for whom? under what circumstances?” (Pawson et al., 2004). These typically involve forming initial program theories (IPTs) that evaluate the program’s context, mechanisms, and outcomes to guide the review.

In the study by Harris et al (2023). The initial program theories were developed by combining findings from research articles about Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) services in the UK, important UK policies, and a 2-hour online workshop involving clinicians, policymakers, managers, and academic experts that described the status of COSMHAD service provision.

Results

Based on the initial program theories, 132 studies were included in the final review. 11 theories were grouped into three main themes comprising Leadership, Workforce, and Service Delivery based on the Sustainable Integrated Chronic Care Models for multimorbidity (SELFIE) framework (Leijten et al., 2018). SELFIE is an international classification system that outlines effective integrated care approaches for individuals with comorbidities.

The 11 theories were grouped into three main themes summarised in the table below.

Leadership and governance	Workforce	Service delivery
Encouraging collaborative case management Continuous workforce development Opinion leaders Coordinated care pathways Evaluation and quality improvement Recruiting and retaining talented staff	Staff attitudes Continuous exposure from undergraduate level	First contact and assessment Formalised networking opportunities Mental health-led services

Leadership theories

Most of the programme theories (N=6) highlighted supportive leadership as the backbone for providing good integrated care. The synthesis revealed that leaders with strong Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) service visions, who were proactive with developing procedures and processes, helped staff feel supported in taking an individualised approach to care, leading to better patient outcomes.

Notable outcomes of supportive leadership included improved care coordination and consistency which encouraged collaborative case management. This ensured a consistent approach to care which is of utmost importance when treating individuals with COSMHADs. Additionally, supportive leadership also encouraged better staff outcomes like continuous workforce development, improved recruitment, and retention of skilled staff. All of this taken together led to improved therapeutic relationships with patients and allowed patients to achieve their treatment goals.

Workforce theories

Two of the program theories related to the workforce, surround making integrated care for individuals with COSMHAD a standard and routine part of healthcare. The synthesis demonstrated diverse perspectives among healthcare professionals regarding the treatment of COSMHAD.

Imagine undergoing treatment, and each time you interact with different healthcare professionals they bring entirely different approaches or attitudes to the table. It can be confusing, frustrating, and potentially detrimental to the quality of care you receive!

These disparities revolve around varying understandings of pharmacotherapies, divergent ontological views of health, distinct beliefs about COSMHAD causes, diverse symptom classification frameworks, and differing opinions on client autonomy. These differences ultimately shape how substance use and mental health services are organised and define treatment outcomes.

The synthesis suggests that specialised training programs aimed at fostering a more accepting attitude among staff towards integrating COSMHAD care into routine healthcare are essential. Additionally, ongoing supervised experience in working with individuals having COSMHAD as part of both pre- and post-qualification training is crucial. These measures are vital in ensuring that individuals with COSMHADs receive consistent and non-judgemental care. Overall, based on this review, addressing staff attitudes and values was found to improve outcomes regarding increased empathy towards individuals with COSMHAD and better therapeutic relationships.

Service delivery theories

Three program theories concerning service delivery were identified. These theories highlighted the importance of well-organised initial contact, formal networking among staff across services and the prioritisation of mental health clinicians leading care planning. The synthesis highlighted that when healthcare professionals are unsure about comorbidity, it can affect how they assess and interact with patients. Therefore, to ensure a positive initial interaction, it is important to educate staff about COSMHAD as part of routine care, with a focus on mental health, and to use suitable assessments and screening tools. Furthermore, offering formal networking opportunities to staff for them to meet, communicate, and establish relationships, enables teams and services to collaborate effectively when treating individuals with comorbidities. Formal COSMHAD networking was found to foster peer support and a collaborative ethos among disciplines, leading to better-integrated care delivery.

Conclusions

Overall, the paper highlights the complex challenges in providing integrated care for Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) services in the UK. One of the key takeaways from the paper is that healthcare staff’s readiness to care for individuals with COSMHAD can vary widely. As such, the major recommendation of the review includes improving leadership and staff commitment to providing integrated care. This would require implementing extensive workforce training, supervision, and dialogue. Nonetheless, merely changing staff behaviour is not enough. The authors also highlight the importance of a broader cultural shift towards compassionate leadership and system delivery in truly improving healthcare outcomes for individuals with COSMHAD.

Strengths and limitations

The study had many methodological strengths including:

• The authors used realist methodology, which provides insights into how an intervention works and the specific contexts that make it effective. This approach is beneficial to both policymakers and practitioners, as it considers the essential mechanisms needed for an intervention to work, unlike systematic reviews that solely examine what works without exploring why it works.
• The systematic search was conducted across 7 major databases by a team of 3 authors. The review adhered to PRISMA guidelines, ensuring transparency in both the search process and reporting, thus minimising bias.
• The review gathered global evidence on COSMHAD service models, extending beyond the UK, to uncover novel and diverse approaches for the successful integration of COSMHAD services.

However, this review was limited in a few ways:

• The review excluded non-English studies and those in specialised environments (like the criminal justice system or HIV-focused settings). Comorbid substance abuse with serious mental illness (e.g., non-affective psychosis and depression) is up to 20 times more common in prison populations than in the general community (Baranyi et al., 2022). Therefore, excluding these groups could restrict the applicability of the findings to all individuals with COSMHAD.
• The review focused on COSMHAD service providers, not those receiving the services. Therefore, it didn’t explore why individuals with COSMHAD might personally decide not to use integrated services. Future studies should investigate how personal experiences affect these choices when it comes to accessing integrated services.
• Realist reviews do not include a formal quality appraisal. As such, the quality of the studies included in this review has not been assessed fully which may limit the applicability of the results. Given that NICE guidance has identified a scarcity of strong evidence regarding the effective implementation of staff training for COSMHAD (NICE, 2016), it’s possible that some of the reported outcomes from the included studies may not be generalisable.

Implications for practice

Overall, the UK policy goal of mainstreaming care for Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) individuals means that healthcare professionals need to be equipped with the training and skills to provide treatment that tackles both mental health and substance use at the same time. Many integrated services in the UK have not undergone thorough evaluations of their methods and organisational structures.

This review offers an evaluative framework to assess the effectiveness and standards of existing integrated service practices. Furthermore, the findings of this review bear substantial implications for reshaping the structure and functioning of these integrated services, with a particular focus on aspects like leadership, workforce development, and top-down service delivery.

Additionally, this review holds important implications for shaping the structure and organisation of these integrated services, particularly in areas such as leadership, workforce enhancement, and service delivery from a top-down perspective. It also provides a valuable framework for future planning of integrated mental health services.

Statement of interest

AN is interested in substance misuse and addiction, but she had no involvement with the paper summarised in this blog and has no conflicts of interest to declare.

Primary Paper

Harris, J., Dalkin, S., Jones, L., Ainscough, T., Maden, M., Bate, A., Copello, A., Gilchrist, G., Griffith, E., Mitcheson, L., Sumnall, H., & Hughes, E. (2023). Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions. The Lancet Psychiatry, 10(8), 632–643.

Other references

Amodeo, M., Chassler, D., Oettinger, C., Labiosa, W., & Lundgren, L. M. (2008). Client retention in residential drug treatment for Latinos. Evaluation and Program Planning,31, 102–112.

Cornelius, J. R., Salloum, I. M., Mezzich, J., Cornelius, M. D., Fabrega, H., Ehler, J. G., & Mann, J. J. (1995). Disproportionate suicidality in patients with comorbid major depression and alcoholism. The American Journal of Psychiatry,152, 358–364.

Hayes, R. D., Chang, C. K., Fernandes, A., Broadbent, M., Lee, W., Hotopf, M., & Stewart, R. (2011). Associations between substance use disorder sub-groups, life expectancy and all-cause mortality in a large British specialist mental healthcare service. Drug and alcohol dependence, 118(1), 56–61.

National Institute for Health and Care Excellence (2016). Coexisting severe mental illness and substance misuse: community health and social care services (NG58). London: National Institute for Health and Care Excellence.

Cummins I (2018). The impact of austerity on mental health service provision: a UK perspective. Int J Environ Res Public Health

Greenhalgh, T., Harvey, G., & Walshe, K. (2004). Realist synthesis: an introduction Ray Pawson.

Leijten, F. R. M., Struckmann, V., van Ginneken, E., Czypionka, T., Kraus, M., Reiss, M., Tsiachristas, A., Boland, M., de Bont, A., Bal, R., Busse, R., Rutten-van Mölken, M., & SELFIE consortium (2018). The SELFIE framework for integrated care for multi-morbidity: Development and description. Health policy (Amsterdam, Netherlands), 122(1), 12–22

Baranyi, G. et al. (2022) ‘The prevalence of comorbid serious mental illnesses and substance use disorders in prison populations: A systematic review and meta-analysis’, The Lancet Public Health, 7(6). doi:10.1016/s2468-2667(22)00093-7.

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