substance use treatment. Death by suicide is also common, with a history of alcohol or drug use being recorded in 54 % of all suicides in people experiencing mental health problems.( Public Health England guide, 2017.)
Jenny’ s tragic story left me with many questions – what were the underlying causes of mental illness? What spurred the spiral into addiction? Why did individuals turn to substance use? – that, even after six years as a mental health social worker working in prisons and psychiatric hospitals, I had neither the knowledge nor experience to answer. Talking to colleagues did not resolve them, so I sought answers by returning to academia alongside my day job.
A postgraduate diploma helped me better understand the theories of mental health from neuroscientific, psychiatric and pharmacological perspectives. But above all, I realised that many of the people I was now encountering in my new role, working in a crisis home treatment team( a community-based team set up to support people experiencing severe mental health issues), would never get better. Rather, they would just keep coming back with a new crisis.
And for a large majority of them( around four in five), substances ranging from highly addictive narcotics to potent, mind-altering chemicals would be a key part of their daily lives in addition to, or as an alternative for, their prescribed psychiatric medication.
Roger was one of many people I met who relied on Spice, a synthetic cannabinoid designed to mimic the effects of naturally occurring THC.( In addition to consumption by smoking, there are increasing reports of synthetic cannabinoids being used in e-cigarettes or vapes.)
Nonetheless, Roger told me Spice was the“ only thing that would help sort my head out”. And, after listening to a lecture from me about the dangers of these substances, he responded:
I know how much to take – I know when I’ ve taken too much or not enough. I use it in doses now. Why would I stop if it’ s the only thing that works?
It was clear that Roger knew much more about the effects of Spice than I did. Interactions like this ignited a desire in me for deeper knowledge – not from books or universities, but directly from people with coexisting mental health and addiction problems.
Perhaps surprisingly, in the UK we don’ t know how many people are living in this combined state. Estimates have tended to focus only on people with severe mental health problems and problematic substance use. For example, a 2002 Department of Health guide suggested that 8-15 % of its patients had a dual diagnosis – while acknowledging that it is difficult to assess exact levels of substance use, both in the general population and among those with mental health problems.
A decade earlier, US research had identified that for people with schizophrenia, substance use( nonprescribed drugs) was a significant problem relative to the general population. More recently, a 2023 global review of evidence identified that the prevalence of co-existing mental health and substance use among children and adolescents treated for psychiatric conditions ranged between 18.3 % and 54 %.
But what I found particularly interesting was an analysis of the writings of Thomas De Quincey from more than 200 years ago. In his 2009 article Lessons From an English Opium Eater: Thomas De Quincey Reconsidered, leading clinical academic, John Strang, highlighted that issues raised by De Quincey in 1821 remain causes for concern some two centuries later.
De Quincey was arguably the first person to document his own use of substances, in particular opium. His writing shows that he self-medicated to manage pain, including“ excruciating rheumatic pains of the head and face”:
It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet … In an hour, oh Heavens! What an upheaving, from its lowest depths, of the inner spirit!
De Quincey’ s use of non-prescribed drugs mirrors that of John, Jenny, Roger and so many other people I have met as a social worker. Clearly, we’ ve known about the close relationship between mental illness and substance abuse for hundreds of years, yet are still wrestling with how best to respond.
Official guidance almost always advocates for a“ no wrong door” policy, meaning that those with dual addiction and mental health issues will get help whichever service encounters them first. But from what people with lived experience were telling me, this was not the case.
I sent freedom of information requests to 54 mental health trusts across England, to try to discern any patterns of variation in the way their patients were being measured and treated. Some 90 % of the trusts responded, of which a majority( 58 %) recognised the dual occurrence of mental illness and substance use. However, the estimated prevalence of this dual diagnosis varied widely – from only nine to around 1,200 patients per trust.
What I found most alarming was that less than 30 % of the mental health trusts said they have a specialised service for addiction which accepts referrals for dual diagnosis patients. In other words, throughout England, a lot of these patients are not being appropriately supported.
‘ When I say I use heroin, people change’ I started using when I was around 18. Things weren’ t good in my life at the time, and I got in with a crowd who offered me heroin. It was the most amazing experience; all my worries disappeared better than the antidepressants I had been taking. But the more I used, the more I needed it. Now I use it in stages, just before I go to work and at night.
Carl had been using heroin for more than ten years when I interviewed him. When I asked if he wanted to stop, he shrugged and said no, explaining:
I’ ve tried so many times – I’ ve been on methadone but that was worse, especially coming off it. I know how much to take, and no one knows I use gear – so, no. But, as soon as you tell a professional you take heroin, their whole attitude changes. I’ ve seen it many
Official guidance almost always advocates for a“ no wrong door” policy, meaning that those with dual addiction and mental health issues will get help whichever service encounters them first.
GlobalHealthAsiaPacific. com ISSUE 1 | 2025
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