As far back as 2002, research was showing that 70 per cent of people in drug services and 86 per cent in alcohol services had described or reported severe mental health problems in the previous year, said Dr Hauwa Onifade, a forensic psychologist at Turning Point involved in developing services with an integrated approach to co-existing mental health difficulties and substance use. Far too many in this client group were still failing to access the support they needed, she said.
Despite efforts to integrate services, there were ongoing barriers to bridging the gap. In many services there was ‘sequential delivery’, with clients told to address their substance issues before they could access mental health support, or parallel delivery – clients accessing both, but with difficulties in joining them up. Years of diminishing investment had taken its toll, while the transfer of public health functions to local authorities had also led to an ‘accountability gap’ across substance and mental health providers. ‘And of course COVID hasn’t made any of this any easier.’
Turning Point had developed a substance use and mental health (SUMH) toolkit for professionals, condensing research and guidelines from PHE, NICE and elsewhere, she said. The organisation had also been working in Leicester, Leicestershire and Rutland on developing an integrated team, with a pilot launching during the COVID period following an audit of more than 3,000 clients. This had identified two significant groups where there were gaps in accessing treatment – populations involved in injecting drug use who were ‘frequent flyers’ at local hospitals and also presented with high levels of risk around mental health, including self-harm and suicide, and longer-term clients who, although there was little risk of self-harm or suicide, were in high levels of distress and unable to make changes in their substance use as a result.
‘We tend to focus on high-risk populations, almost to the detriment of the other group,’ she said. ‘And even with the high-risk populations we’re not necessarily working with them long-term, so they tend to fall into that pattern of re-presenting to services. A lot of services were involved in their care and a lot of people were aware of their difficulties, but they weren’t necessarily in treatment for very long.’
No Wrong Door
Turning Point’s integrated team had tried to implement the ‘no wrong door’ concept – that all services should have a fully open-door policy – along with a ‘huge focus on engagement and retention’, she told the seminar. There was also a need to focus on client needs rather than just diagnosis – ‘we found that when we focused on diagnosis alone we excluded a high number of clients who were struggling and in distress’.
Turning Point had also conducted a mapping exercise of all the services in the area that could meet the clients’ treatment needs. It found that specialist services for domestic violence, for example, would also work with people who had experienced those issues in the past, allowing the building of links to provide support while clients were on a waiting list. ‘Establishing those networks and looking at the wider availability of resources is really key,’ she said. ‘It’s astounding the number of peer support groups available’, and even organisations like Age UK could address issues of loneliness and provide interim support while clients waited to access other services. ‘So really broadening our idea of what intervention looks like for these client groups, which means we’re able to filter in a lot more options.’
Focusing on being able to deliver genuinely trauma-informed services was vital, alongside breaking down both stigma and professionals’ anxiety around their skill sets. Lack of clinical psychologists in third sector addiction services was a crucial issue, however – ‘I’m astounded by the number of services that don’t have psychologist input’ – and proper support for staff was also a key consideration. ‘If you’re working with people with those high levels of risk, as a professional you’ll likely need some support as well. Without that full structure and that supervision and training element, teams such as this would likely fall apart.’
But barriers didn’t just exist when it came to accessing treatment for co-existing conditions. There were also the legal barriers that prevented the use of substances that could provide potentially life-changing help for depression, anxiety, PTSD and other mental health issues.
‘It was the first great revolution in psychiatry,’ said professor of neuropsychopharmacology at Imperial College London, David Nutt, of the widespread use of LSD therapy in the US in the 1950s and ’60s. There had been an ‘enormous clinical interest’ in LSD, and to a lesser extent psilocybin, with around 1,000 clinical papers and ‘overwhelmingly positive’ results describing safe and effective treatments.
For researchers and psychiatrists, psychedelics offered the opportunity to ‘ask questions of the brain that hadn’t been asked before, and potentially change brain function in a very positive way’, he said, and it was ‘remarkable’ how few adverse effects there had been. ‘Lower than you’d imagine for untreated populations at the time and certainly better than any treatment they were getting, which was essentially just barbiturates.’
It constituted a ‘remarkable period of enormous enthusiasm’, he stated. ‘But we don’t use them now, because in 1967 the US government decided to ban psychedelics because they thought they were encouraging the anti-Vietnam war movement.’ And – as ‘we’d always done in drug policy exactly what the US told us’ – the UK followed suit, as did the UN.
This meant an end to research, as it was almost always funded by governments, with even those researchers who could access funding from philanthropists unable to get hold of the drugs. It added up to ‘a genuine attempt by the US government and UN to eliminate all knowledge and almost all memory of the drugs, because they were seen as being so challenging to the status quo’.
In 2012, however, money finally became available from the Medical Research Council to study the use of psilocybin in treatment-resistant depression, dependent on an initial safety study. ‘But even that was easier than getting hold of the drug,’ said Nutt. ‘In the end, 32 months of our 36-month grant were spent on bureaucracy, which is all about protecting society from the dangers of magic mushrooms. It’s completely absurd.’
The study finally went ahead, involving 20 patients who had all failed to benefit from anti-depressants and CBT. ‘We gave them one dose, one trip of 25mg, and saw a halving of depression scores within a day.’ Even at six months there were still ‘huge’ effects, with some patients in remission after eight years. ‘It opened up the whole field, and now there are 40 different companies working in the field of psilocybin for depression.’
Psilocybin ‘changes the way people think’, he said, helping to remove the ‘pessimism bias’ involved in perpetuating depression. A subsequent ‘head-to-head trial’ of psilocybin versus the widely used SSRI antidepressant escitalopram found that psilocybin was ‘at least as good, and probably better’ on most measures, with ‘remarkably higher’ remission rates (www.drinkanddrugsnews.com/magic-mushrooms-may-be-as-effective-as-antidepressants).
While SSRIs worked by enhancing serotonin in the limbic system – ‘they are to depression what a plaster cast is to a broken leg’ – psychedelics worked in a different part of the brain by disrupting cortical thinking. This helped to break down negative thought patterns and increase wellbeing, without the blunting effect on the emotions that sometimes came with SSRIs.
Studies had now been widened to include areas like anorexia, OCD and pain syndromes, he said. These were ‘internalising disorders where people get locked into thinking patterns they can’t escape, and psychedelics can help them do that’. The drugs also worked well in treating addiction, he stressed, in that they helped to ‘break down the circuits that drive addictive thinking and habit behaviour’, and he was now involved in work looking at whether ketamine could be effective for behavioural addictions such as gambling or pornography.
MDMA was now likely to become approved therapy for PTSD in the US from the end of next year, he said. ‘They’ve done one phase 3 study, and the second one’s on its way – if it’s as good as the first I’m pretty sure it’ll get a licence, and hopefully we’ll then be able to use it in Britain. And maybe in the next three years we’ll be able to have psilocybin in the UK, depending on how the next phase 3 trial comes out.’ Psychotherapeutic support provided around the psilocybin dosing was essential, however. ‘I like the idea that we can bring psychotherapy and pharmacology together to maximise the benefits for people.’
‘As George Bernard Shaw said, “Those who cannot change their minds cannot change anything”, and I think what’s pretty clear is that psychedelics can change the minds of our patients. I’m hoping this research can also change the public’s and politicians’ minds about psychedelics and bring them back into medical practice, because it was absurd that they were taken from it. It’s actually the worst censorship of research and clinical practice in the history of the world. And we should rectify it now.’ DDN
The SUMH resource pack – working with people with coexisting substance use and mental health issues at www.turning-point.co.uk/reports