18. People with co-occurring mental health conditions
How to support people with co-occurring mental health conditions and problem alcohol use, emphasising the 'everyone's job' and 'no wrong door' principles while outlining co-ordinated care across mental health and alcohol treatment services and evidence-based interventions.
Main principles: everyone’s job and no wrong door
Co-occurring mental health conditions and problem alcohol use are common among people attending mental health services and alcohol treatment services. But there is evidence that people with co-occurring conditions are often excluded from services and cannot access the care they need.
The 2 main principles for working with people who have co-occurring problem alcohol use and mental health conditions are ‘everyone’s job’ and ‘no wrong door’.
‘Everyone’s job’ means that commissioners and providers of mental health and alcohol treatment services should share responsibility and work together to commission and plan services for people with co-occurring conditions. They should:
- fully involve senior clinicians, people with lived experience and carers
- agree local treatment pathways and information sharing agreements
‘No wrong door’ does not mean that everyone should receive ongoing care at the service they first attend, but it does mean that all services and practitioners should be:
- proactive, flexible, compassionate and non-discriminatory in their response
- able to offer an initial assessment as soon as possible, refer the person onto a specialist service if needed and support their urgent physical and mental health needs
- active in planning longer term care with other services
Assessing people with co-occurring mental health conditions and problem alcohol use
When assessing a person, alcohol treatment practitioners and mental health practitioners should consider:
- the interrelationship of their mental health condition and problem alcohol use
- how this affects the choice or timing of interventions
- how it affects risk and risk management and safeguarding plans
Agreeing a care plan
When alcohol treatment services and mental health services are both working with a person, practitioners from both services and the person should agree and review a care plan that identifies:
- the treatment interventions for each condition
- who will deliver the interventions
- whether the interventions will be delivered at the same time or in sequence
The plan should also address other support needs, such as physical healthcare and social support.
Co-ordinating care
A named lead professional should co-ordinate care and act as the first point of contact for the person, their family or carer and other services. When the person has a severe mental health condition, they should be allocated a lead professional from the mental health service.
Where one service has appropriate expertise to provide treatment for both conditions, this provides consistency and continuity for the person.
Expertise across services varies. Alcohol treatment services should be able to work with people with non-severe common mental health conditions, but they can refer people to psychological therapies or mental health services to treat specific conditions if they do not have the expertise in their service.
Community mental health services will usually provide mental health care and alcohol treatment for people with severe mental health conditions but clinicians in alcohol treatment services can provide specialist input where necessary.
Training for staff in mental health settings
Staff across all mental health settings should be trained to:
- offer screening (identification) for alcohol use disorders (problem alcohol use) and offer brief advice
- arrange a rapid alcohol assessment if the person may be alcohol dependent or is drinking at harmful levels
Inpatient services: admission and discharge
When people with alcohol dependence are admitted to inpatient mental health services, it is vital that they are rapidly assessed for medically assisted withdrawal by someone with specialist alcohol treatment competence. As soon as possible, the clinician should provide the person with medically assisted withdrawal or where necessary refer them to a specialist inpatient medically assisted withdrawal unit or acute hospital.
Discharge planning from mental health crisis and inpatient settings should involve preparation and planning for alcohol treatment in community mental health teams. Where a person needs more specialist alcohol treatment input, then their discharge planning should also involve community alcohol treatment services.
Intoxication and exclusion
Intoxication increases a person’s risk of harm to themself and to others. It is often implicated in self-harm, including suicide. However, there is evidence some people in mental health crisis who are intoxicated are excluded from appropriate care. Practitioners in mental health services and alcohol treatment services should be able to manage episodes of intoxication and mental health crisis safely, making referrals to crisis or emergency care where necessary. See chapter 16 on acute hospital settings for guidance on managing a person in mental health crisis who is intoxicated.
Access to evidence-based interventions
People with co-occurring conditions should have access to evidence-based psychosocial and pharmacological interventions. There are several National Institute for Health and Care Excellence (NICE) evidence-based guidelines recommending interventions for:
- harmful or high risk drinking and alcohol dependence
- mental health conditions
- co-occurring mental health and problem substance use
This chapter describes principles and approaches to treatment and support for people who experience both problem alcohol use and mental health conditions.
18.2.1 Prevalence
Mental health conditions and problem alcohol use commonly occur together. Research on substance use and mental illness (Weaver and others, 2003) showed that up to:
- 85% of people in alcohol treatment had a psychiatric disorder in the past year
- 25.5% of patients in community mental health teams reported harmful alcohol use
- 9.2% of patients in community mental health teams reported severe alcohol use problems
More recently, research on depression, anxiety and substance use (Delgadillo and others, 2012) found 70% of a sample from community substance use treatment also met criteria for common mental health conditions.
The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) Annual report 2024: UK patient and general population data found that 47% of people in contact with UK mental health services who died by suicide between 2011 and 2021 used alcohol problematically. There is also evidence that intoxication is a risk factor for suicide (Kaplan and others, 2013; Ledden and others, 2022).
In addition, people with co-occurring mental health and problem alcohol or drug use as a group experience poor health and earlier death than the general population (Hayes and others, 2011).
18.2.2 Exclusion from services
Although co-occurring mental health conditions and problem alcohol use are common, those people are often excluded from services.
Some mental health services and psychological therapies services might exclude people because of their problem alcohol use and some alcohol treatment services might exclude people because of their mental health condition. People in mental health crisis are sometimes excluded from mental health crisis and emergency services because they are intoxicated. This should not happen because it is likely to make the crisis worse and increase risks to themself and others.
Commissioners and providers of mental health services and alcohol treatment services should work together to make sure that people with co-occurring mental health conditions and problem alcohol use are not excluded from services and can access the care they need when they need it.
The guidance in this section is for staff in mental health services and alcohol treatment services.
18.3.1 Main principles
The 2 main principles of care for working with people with co-occurring mental health conditions and problem alcohol use are:
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Everyone’s job: providers and commissioners of services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to reach shared solutions.
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No wrong door: alcohol treatment services, mental health services and other care services should have an open-door policy for people with co-occurring conditions and make every contact count (see section 18.3.3 on no wrong door: initial response and planning). Treatment for the co-occurring conditions should be available no matter which service they first contact.
18.3.2 Everyone’s job: partnership working
The way mental health services and alcohol treatment services are commissioned and planned varies across the UK, but the principle of partnership working applies to all areas.
Commissioners and providers of mental health and alcohol treatment services share responsibility for making sure that people with co-occurring conditions can access the help they need, when they need it, in an appropriate setting.
Commissioners, system leaders and senior service providers should work together to commission and plan services for people with co-occurring conditions, involving senior clinicians and people with lived experience and carers. They will also need to work closely with commissioners and providers of other relevant services, including:
- primary care
- acute physical health care
- social care and safeguarding
- criminal justice services
They could use existing partnership forums or create a specific forum to develop and monitor care for people with co-occurring mental health and problem alcohol use.
Commissioners and local health and social care system leaders should agree treatment pathways that enable people with co-occurring mental health conditions and problem alcohol use to access appropriate treatment and support for both conditions. All staff working in mental health services and alcohol treatment services should be aware of these treatment pathways. Commissioners and system leaders should make sure that services publicise the treatment pathways across health, social care, and community services and to the local population so that people know how to access the help they need. The partnership should monitor the effectiveness of agreed treatment pathways and address any problems.
People with co-occurring mental health conditions and problem alcohol use often have other needs including:
- other substance use needs
- physical health needs
- safeguarding needs
- social support needs
- housing needs
- criminal justice involvement needs
Treatment pathways should specify how people can access support from these services when they need it.
The partnership should develop local information-sharing agreements and (where possible) shared access to electronic patient records. This will involve agreements between NHS and third sector organisations in some local areas.
Developing and monitoring treatment pathways and information-sharing agreements, with strong and visible support from senior leaders, will encourage services and practitioners to work together to provide co-ordinated and integrated care tailored to individual need. There should be a mechanism for resolving any disagreements between services about their respective roles in providing appropriate care to individuals.
Healthcare Improvement Scotland’s National mental health and substance use protocol is an example protocol setting out how services should work together to provide more integrated care for people with co-occurring conditions. Some of the content will be relevant for other UK nations.
You can find more information on working together in section 18.5 on collaborative care planning.
18.3.3 No wrong door: initial response and planning
‘No wrong door’ does not mean that people must receive care at the first service they attend, but that all services should:
- be proactive, flexible, compassionate and non-discriminatory in their response
- offer an initial assessment as soon as possible and refer the person onto an appropriate specialist service if needed
- offer a person support for their urgent physical and mental health and social care needs, while also making plans for longer term care and support
- have a named lead professional who can co-ordinate care and comprehensive support from multiple services effectively, underpinned by clear communication reflected in case notes
- explore with people why they may have stopped using services in the past and agree a plan to help them stay engaged
When someone with a co-occurring severe mental health condition is accepted by secondary care mental health services, the person should be allocated a lead professional from within the mental health service. You can find more guidance on working with co-occurring conditions in secondary care mental health services in NICE guideline Coexisting severe mental illness and substance misuse: community health and social care services (NG58).
Practitioners in both alcohol treatment services and mental health services should be competent and supported to provide initial assessment and support for both conditions and work together to provide appropriate treatment.
An important part of the ‘no wrong door’ principle is that providers should be using the Making every contact count (MECC) approach. MECC helps promote health and healthy lifestyles by taking every opportunity to reduce health harms by offering advice and support to:
- stop smoking
- eat healthily
- maintain a healthy weight
- undertake the recommended amount of physical activity
- improve mental health and wellbeing
18.3.4 Broader principles of care
People with co-occurring mental health conditions and problem alcohol use, are stigmatised in society and sometimes within healthcare services. They have historically often been excluded from services or have had negative experiences of care. Chapter 2 on principles of care sets out principles that should underpin all treatment and help to provide a better experience of care for people who have been excluded and marginalised. These principles include prioritising:
- the therapeutic relationship
- reducing stigma
- trauma-informed care
- cultural competence
The guidance in this section is for staff in mental health services and alcohol treatment services.
Practitioners in both alcohol treatment and mental health services should be able to:
- identify mental health conditions and problem alcohol use
- offer initial assessment as soon as possible and initial support for urgent needs
- work together to plan and provide treatment for both conditions
Services should provide training, supervision, and procedures for escalating concerns about people with co-occurring conditions for immediate advice from the multidisciplinary team or senior clinicians so that practitioners are competent and supported to do this.
If the person is already attending a mental health service or an alcohol treatment service when they present at the other service, the assessor should involve the keyworker from the other service (with the person’s consent) in assessing and planning for the person’s needs.
Initial assessment should include consideration of the interrelationship between the person’s alcohol use and their mental health conditions, how they impact on one another and on risk formulation and risk management (safety) planning.
In some services there will be clinicians with the expertise to carry out a more comprehensive assessment and formulation of the person’s needs and offer interventions that address both conditions. Where this is possible, it offers the person more consistency and continuity. However, expertise varies across services and this will not always be possible.
Chapter 4 provides guidance on initial and comprehensive assessment, including risk assessment, for people with problem alcohol use. Section 4.9.9 of that chapter provides guidance on assessing mental health as part of that assessment.
The guidance in this section is for staff in mental health services and alcohol treatment services.
People with co-occurring conditions should be able to access the care they need, when they need it, provided in the setting most suitable to their needs.
Mental health services and alcohol treatment services should have an agreed protocol or written agreement to support practitioners in developing and reviewing collaborative care plans. The agreement should set out how organisations will collaborate, share responsibilities and ensure regular communication. It is helpful to have a mechanism for resolving disagreements about roles in collaborative care planning. The written agreement can also include other relevant services such as:
- primary care and secondary healthcare services
- social care and support services
- child and adult safeguarding
- criminal justice services
- other organisations like housing and employment services
- voluntary and community sector support services such as domestic abuse services
18.5.1 Agreeing a co-ordinated care plan
Practitioners from mental health services, alcohol treatment services and other relevant services should agree with the person how collaborative care will be provided based on the person’s individual needs and on locally agreed treatment pathways. The availability of suitably trained and competent staff will also determine what is available locally.
For each individual person, it may be appropriate to deliver interventions:
- addressing both conditions in one service
- from both services at the same time
- in sequence where one service leads to address a specific issue and then refers to the other for an additional unmet need
Where the mental health service and the alcohol treatment service will both provide care, they should agree a care plan (treatment and recovery plan). This will identify the treatment interventions for each condition, who will deliver them and whether they will be delivered at the same time or in sequence. The plan should address other support needs including physical healthcare, social support and safeguarding.
Personalised risk management (safety) planning should include strategies to manage risks related to mental health and to alcohol use. Services should share information and expertise on managing these risks. Where the person may be at risk or pose a risk to others, there should also be contingency and crisis plans for managing loss of contact or a deterioration in the person’s mental health (including increased suicide risk) or a relapse in their alcohol use.
Mental health and alcohol treatment services should work to one overall co-ordinated care plan. In some cases, they may have their own more detailed plans, which are aligned with the overall plan. The person should be fully involved in developing their care plan. This includes, as far as reasonably practicable, if they lack capacity to make the ‘decision in question’ (see glossary). Services should also ask family members or carers to be involved where this is appropriate and the person consents.
A named lead professional should co-ordinate care and act as the first point of contact for the person, their family or carer, and other services.
Practitioners from both services and the person should jointly regularly review the co-ordinated care plan including risk management (safety) plans and amend as appropriate. They should also agree arrangements for ongoing information sharing. The practitioners should communicate regularly and update one another if there are changes in the person’s situation or changes in risk to themselves or others. This should include sharing information on changes in the person’s pattern of alcohol use.
Services should work together to develop a shared plan for ongoing care with the person and where appropriate with family members before:
- a transition from one service to another (for example, between a young person’s service and an adult service)
- discharge from a service (for example, an inpatient service)
There are increased risks at both those times. You can find more guidance on this in NICE NG58.
There is further guidance on multi-agency treatment and recovery planning in section 4.10.4 of chapter 4 on assessment and treatment and recovery planning.
18.5.2 Safeguarding
Not all children of parents or carers with co-occurring mental health and problem alcohol use will experience harm, but they are at a greater risk of doing so. Both parental problem alcohol use and parental mental health conditions are common factors in child abuse, neglect and deaths.
There may also be adult safeguarding risks for people with co-occurring conditions or members of the family.
The safeguarding needs of all members of the family, both children and adults, should be considered as part of assessment. Any safeguarding needs should be built into the collaborative care plan and multi-agency working arrangements.
Practitioners in mental health services and alcohol treatment services must follow their national safeguarding guidance and local organisational procedures.
You can read guidance on working with parents in chapter 26 and guidance on pregnancy and perinatal care in chapter 24.
18.5.3 Collaborative care for people with severe mental health conditions
Mental health services should take the lead on delivering interventions to people with more severe mental health conditions and generally should address both conditions. Specialist clinicians from alcohol treatment services can provide input if the mental health service needs more specialist alcohol treatment expertise.
When alcohol treatment services are working with mental health services to provide treatment and support for people with co-occurring severe mental health and problem alcohol use, the mental health service should lead and co-ordinate care in line with national and local practice. The named lead professional should be from the mental health service.
Guidance for working with people with co-occurring drug and alcohol use and severe mental illness is set out in NICE NG58 and in NICE clinical guideline Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120).
18.5.4 Collaborative care planning for people with common less severe mental health conditions
Alcohol treatment services should be able to work with people with non-severe common mental health conditions, but they can refer people to psychological therapies services or mental health services to treat specific conditions if they do not have the expertise within their service.
Where people have a less severe mental health condition (non-severe anxiety or depression), alcohol treatment services should start treatment for the problem alcohol use as this may reduce the person’s psychological distress. However, once the person has reinstated control over their drinking or achieved abstinence and the mental health condition remains, the psychological therapies service or mental health service should treat the mental health condition if the alcohol treatment service does not have staff with appropriate expertise. The 2 services can then work together with the person to address both conditions. There is no evidence that delaying mental health treatment to monitor abstinence from alcohol for weeks or months is effective in helping people.
People with problem alcohol use with non-severe mental health conditions (anxiety and depression) can benefit from psychological therapies for those conditions, even while they are drinking problematically (see section 18.8.5) and care planning should take account for this.
18.5.5 Co-ordinating medically assisted withdrawal (detoxification)
Where mental health services and alcohol treatment services are both working with a person, medically assisted withdrawal (detoxification) should be carefully co-ordinated.
Some people may need medically assisted withdrawal but have longstanding or severe mental health conditions or have unstable mental health. They should have a mental health support package in place before they start withdrawal. Mental health services and alcohol treatment services should work together to arrange this support package to help the person through the process of medically assisted withdrawal and reduce their risk of relapse. A clinician with specialist alcohol treatment expertise should assess the person for medically assisted withdrawal and recommend whether a specialist inpatient setting would be the appropriate setting due to safety considerations.
Sections 10.3 and 10.4 of chapter 10 on pharmacological interventions provides guidance on medically assisted withdrawal. Section 10.6.5 in chapter 10 provides brief guidance on pharmacological interventions for people with co-occurring mental health conditions.
Section 10.2.4 of chapter 10 on pharmacological interventions provides guidance on criteria for deciding on the appropriate setting for medically assisted withdrawal based on safety considerations. Decisions about appropriate setting for medically assisted withdrawal should be based on individual assessment but where people have unstable mental health, specialist inpatient withdrawal is usually the appropriate setting.
18.5.6 When the person does not want to engage in alcohol treatment
If the person does not want to engage with specialist alcohol treatment, depending on the severity of the mental health condition and the risk assessment and formulation for the person, the mental health service will still need to remain engaged. In these circumstances, the care plan should include:
- ongoing monitoring of alcohol use
- ongoing monitoring of physical health, including access to liver screening (see NICE guideline Cirrhosis in over 16s: assessment and management (NG50) and section 19.5.2 of chapter 19 on liver disease screening and management)
- motivational work
- provision of harm reduction interventions, advice and information (see guidance on harm reduction in chapter 8)
The mental health service may need to work with primary care to manage the person’s problem alcohol use. There should be some staff in mental health services with alcohol specialist expertise. Specialist clinicians in alcohol treatment services can also share expertise with staff in mental health services if required.
The guidance in this section is for staff in mental health services and alcohol treatment services.
18.6.1 Risk factors for suicide and self-harm
Both problem alcohol use and mental health conditions put people at greater risk of suicide than the general population.
Research has shown that alcohol, both through intoxication and dependence, is a factor in a significant proportion of deaths by suicide (Kaplan and others, 2013; Ledden and others, 2022).
A NCISH national study on suicide by people in contact with drug and alcohol services found that between October 2021 and September 2022, 8% of all people who had died by suicide in England and Wales were people who had been in contact with drug and alcohol services within 12 months of their death. The study found that 48% of those people had been in contact with drug and alcohol treatment services for alcohol as the primary substance.
Since 2013, men aged 40 to 54 have had the highest suicide rate in the UK. According to the Office for National Statistics report Suicides in England and Wales: 2023 registrations, men are about 3 times more likely than women to die by suicide.
England, Scotland, Wales and Northern Ireland have national suicide prevention strategies, which are:
- Suicide prevention strategy for England: 2023 to 2028
- Scotland’s Creating hope together: suicide prevention strategy 2022 to 2032
- Wales’ Suicide prevention and self-harm: strategy and delivery plan
- Northern Ireland’s Protect life 2 - suicide prevention strategy
Services should be aligned with their national suicide prevention strategies which include information on risk factors for suicide.
People with mental health conditions and co-occurring problem alcohol use generally experience one or more additional risk factors for suicide which include but are not limited to:
- socioeconomic deprivation, financial difficulty and economic adversity
- a history of self-harm or suicide attempts
- long term physical health conditions
- gambling harm
- drug use
- domestic abuse
- social isolation and loneliness
- bereavement
- interpersonal difficulties
18.6.2 Identifying and responding to people with co-occurring conditions at risk of suicide
Having a policy for working with people with co-occurring mental health conditions and problem alcohol use can help to reduce suicide risk. A 2013 national inquiry into suicide and homicide by people with mental illness (PDF, 310KB) found that in England, there was a 25% fall in rates of suicide by patients in NHS trusts that had a policy on managing patients with co-morbid problem alcohol and drug use. When working to reduce the risk of suicide, mental health services and alcohol treatment services should work in line with:
- NICE guideline Self-harm: assessment, management and preventing re-occurrence (NG225)
- NICE NG58
Staff in mental health services and alcohol treatment services should:
- understand that both alcohol dependence and intoxication can increase risk of suicide
- understand that self-harm, suicidal thoughts, intentions or behaviour should always be taken seriously, regardless of whether the person is or was intoxicated at the time
- understand other risk factors for suicide
- be trained and supported by a multidisciplinary team to identify and respond to risk of self-harm and suicide, in line with organisational protocols and procedures
Mental health staff assessing risks should be trained to assess harmful drinking and alcohol dependence.
You can find guidance on assessing risk of self-harm and suicide in alcohol treatment services in section 4.9.9 of chapter 4 on assessment and treatment and recovery planning.
Services and practitioners should always personalise risk management (safety) plans and tailor them to the specific needs and risks of the person. NICE NG225 states that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment or who should be discharged. The guidelines recommend that risk assessment should focus on the person’s needs and how to support their immediate and long-term psychological and physical safety.
Risk assessment should include significant dates and anniversaries and online suicide-related activity which may then form part of safety planning.
18.6.3 Responding to immediate risk of suicide or self-harm
People presenting in a mental health crisis, self-harming or with suicidal intent should never be turned away from services, because this could increase risks to themselves or others. There is further guidance on this in section 18.7.
Services should have agreed pathways and procedures for managing people who are assessed as at immediate risk of suicide or self-harm. Staff should follow these procedures and seek support from the appropriate experienced clinician or clinical team. Where necessary, practitioners should arrange an assessment from an age-appropriate specialist mental health professional as soon as possible through local urgent and emergency mental health care pathways.
The practitioner should identify whether the person has access to the means of self-harm (for example, tablets) and discuss removing this or reducing other forms of immediate risk with the person.
Where appropriate, the practitioner should ask the person for consent to involve family members. If the person does not consent, the practitioner and multidisciplinary team (MDT) should follow organisational procedures on information-sharing and suicide prevention.
The assessor should also tell the person and if relevant their family member about local support that they can access in an emergency.
18.6.4 Ongoing support
Collaborative care plans for ongoing care should include arrangements for immediate information sharing with the lead professional and quick follow-up if a person at risk of suicide loses contact with a service.
Self-harm may indicate that the person has difficulty managing their emotions and they may need specialist treatment from a mental health service, such as dialectical behaviour therapy (a type of talking therapy). For people with ongoing problems with self-harm, suicide risk or a severe or significant mental health condition, the lead professional should be the mental health professional.
The guidance in this section is for staff in mental health services and for staff in alcohol treatment services.
People who are in mental health crisis, whether or not they are intoxicated or have problem alcohol use, should be managed by mental health crisis or emergency services. Alcohol treatment services are not equipped to manage mental health crises.
People in a mental health crisis can resort to alcohol to manage their distress. Their alcohol use can also lead to an escalation in symptoms of mental ill-health including psychosis, self-harm, suicidal intent or suicide attempts. They might present to emergency services, crisis services, inpatient mental health services or community services in a state of acute intoxication. The underlying problem alcohol use may reflect heavy episodic drinking or a severe dependence that requires rapid medical management.
Whatever the case, the immediate priority is to make sure any acutely intoxicated person is safe and not a risk to themselves or others. People presenting in a mental health crisis, self-harming or with suicidal intent should not be turned away from services, because this could increase risks to themselves or others. Staff should support them to access suitable care, including a place of safety where necessary, and monitor their safety.
There is guidance on managing and monitoring people who are intoxicated and in mental health crisis in an acute setting in section 16.7 of chapter 16 on alcohol care in acute hospital settings.
Staff in mental health services and alcohol treatment services should be able to identify the signs of intoxication and respond appropriately to the associated risks. In particular, these risks include:
- the person not being able to maintain their own safety (for example, being disorientated or losing motor co-ordination)
- physical risks (for example, accidents or alcohol poisoning)
- disinhibition (possibly enhancing feelings of distress, anger, self- harm or suicidal intent)
You can find guidance on intoxication and related risks in section 8.14.5 in chapter 8 on harm reduction.
If someone is at risk of self-harm, including suicide, or presents after an act of self-harm, services should work in line with NICE NG225. This provides detailed guidance on self-harm. NICE NG225 states that assessment should not be denied because the person is intoxicated or has been drinking.
Once the person is less intoxicated, a suitably competent clinician should reassess the severity of their alcohol dependence and their mental health. Staff responsible for treating or monitoring the person should provide harm reduction information relating to alcohol use and mental health. They should also refer the person to specialist alcohol treatment and the appropriate mental health service based on their assessment and follow up the referral to make sure they have engaged with the service.
The guidance in this section is for staff in mental health services.
18.8.1 Strategic leadership
There should be senior level commitment from mental health services to deliver appropriate interventions for people with co-occurring mental health and problem alcohol use. This could require a cultural shift in the organisation to understand that working with people with problem alcohol use is a core part of their role.
Mental health systems should work with primary care, community healthcare and secondary care to be part of a whole system approach to improve local outcomes for mental health and problem alcohol use.
Commissioners, system leaders and providers of mental health services should work with commissioners and providers of alcohol treatment to plan services and agree treatment pathways between mental health services and alcohol treatment services. Section 18.3.2 on partnership working provides guidance on this.
Senior mental health clinicians and senior alcohol treatment clinicians should be involved in the planning and commissioning of pathways between mental health and alcohol treatment services. A designated alcohol lead in the local partnership can help to make sure that mental health services offer effective interventions and pathways for the full range of problem alcohol use.
18.8.2 Identification (screening) of people with alcohol use disorders
Alcohol use disorders (problem alcohol use) are common among people with mental health conditions, so mental health services (community based, crisis and inpatient) should provide routine identification (screening) for alcohol use disorders. Staff should be trained to carry out identification using a simple validated tool such as the Alcohol use disorders identification test (AUDIT), the Alcohol use disorders identification test for consumption (AUDIT-C) or the adapted Alcohol, smoking and substance involvement screening tool (ASSIST-lite), and to offer brief advice. You can find guidance on identification (screening) and brief interventions in chapter 3 on alcohol brief interventions.
18.8.3 Specialist alcohol assessment and formulation in mental health services
Where people are identified as possibly alcohol dependent, their alcohol use is likely to be affecting their mental health condition or increasing risks to themselves and others. Staff should refer the person for a specialist alcohol assessment. This assessment can be carried out in the mental health service where there are trained staff with appropriate alcohol specialist competencies. Where practitioners with these competencies are not available, the mental health practitioner responsible for the person’s treatment should make a referral to the local specialist community alcohol treatment service.
Psychological therapists working in mental health services should have the competence to provide a psychological formulation that integrates the function of the alcohol use with an understanding of the presenting mental health need. You can find guidance on formulation in section 5.4 of chapter 5 on psychosocial interventions. Agreeing a formulation with the person will show that the clinician wants to understand them. It can also help the person to recognise their problems and enhance their motivation to seek specialist help.
18.8.4 Referral to alcohol treatment services and collaborative care planning
If staff in mental health services do not have the appropriate competencies to provide specialist alcohol treatment interventions, they can refer people to alcohol treatment services.
Section 18.3.2 on partnership working provides guidance on developing treatment pathways between mental health services and alcohol treatment services. Mental health services should make sure that staff are aware of local treatment pathways and that these pathways are clear, simple and clearly communicated to people identified as suitable for referral. Services should have information-sharing agreements and systems in place so that practitioners can share information about the person (with their consent), including information on risks. This also helps them to avoid having to tell their story repeatedly to different services. In some areas this will involve sharing information between NHS services and commissioned third sector alcohol treatment services.
Wherever possible, mental health practitioners should refer people for alcohol treatment by contacting alcohol treatment services. Relying on a person to self-refer is unlikely to be successful because many people find it difficult to approach alcohol treatment services. This may be because of stigma, the effects of trauma, previous poor experiences of services or their daily routine. If the alcohol treatment service receives a referral, they can contact the person and encourage them to come and attend another appointment if they miss the first one. The referrer should routinely follow up with the person and with the alcohol treatment service, so they know if the person is engaging with the service.
Following the referral to specialist alcohol treatment, the practitioners from the mental health service and alcohol treatment service will need to agree whether the person’s care will be handed over to the alcohol treatment service or whether the services will work together to provide care. You should follow the guidance in section 18.5 on collaborative care planning.
18.8.5 Working with people with problem alcohol use in psychological therapies services
People should not be excluded from psychological therapies based on problem alcohol use. There is evidence (Buckman and others, 2018) that people drinking at harmful levels can have equivalent psychological treatment outcomes to people who do not drink at harmful levels. But some people drinking at harmful levels may find accessing psychological therapies more difficult as they are more likely to drop out. The evidence suggests that the confidence and competence of staff to engage and work with people drinking at harmful levels may affect outcomes.
In England, the NHS talking therapies manual (formerly known as improving access to psychological therapies) includes a ‘bite-size positive practice guide’ for psychological therapists on working with people who use drugs and alcohol and a link to the full drug and alcohol positive practice guide (PDF, 406KB). Some of the guidance will also be useful to mental health and psychological therapies services across the UK.
18.8.6 Working with people with problem alcohol use in inpatient mental health services
The guidance in this chapter is relevant to all mental health services, but there are some additional considerations for inpatient settings.
Medically assisted withdrawal
When people who may be alcohol dependent are admitted to inpatient mental health services, it is vital that they are quickly assessed for medically assisted withdrawal by someone with specialist alcohol treatment competence. This is important because untreated withdrawal symptoms can lead to serious complications and can even be life threatening.
Staff involved in admissions and assessment processes should be able to identify that someone may be alcohol dependent and in need of medically assisted withdrawal. All inpatient mental health services should have local guidelines on delivering or providing access to medical assisted alcohol withdrawal. Staff involved in admissions and assessment processes should be able to arrange for the person to have a medically assisted withdrawal according to local guidelines, with support from specialist clinicians. The specialist clinician should provide the person with medically assisted withdrawal, or where necessary refer them to a specialist inpatient medically assisted withdrawal unit or acute hospital.
There is guidance on medically assisted withdrawal in sections 10.3 and 10.4 of chapter 10 on pharmacological interventions and guidance on appropriate settings for medically assisted withdrawal in section 10.2.4. There is guidance on prescribing for people with mental health conditions in section 10.6.5 of chapter 10 on pharmacological interventions.
Managing intoxication on the ward
Inpatient settings should have local protocols or guidelines for managing intoxication safely on the ward and should not exclude people who are intoxicated. Staff should be aware that intoxication increases a person’s risk of harm to themself and to others. See section 18.7 on managing episodes of intoxication safely.
Planning for discharge
Discharge planning from mental health crisis and inpatient services should involve preparation and planning for alcohol treatment with community mental health teams. Where specialist input is needed, the discharge planning should involve community alcohol treatment services. The transition from inpatient care to the community can be a vulnerable time when people are at increased risk of a return to problematic alcohol use. If the community mental health team has appropriate expertise, they should plan alcohol treatment interventions alongside mental health interventions before discharge. This is so the person has support during that high-risk transition.
If the plan needs input from community alcohol treatment services, the practitioner co-ordinating discharge planning should involve the alcohol treatment service in planning before discharge. This is so they can offer an appointment before or just after discharge and have the information they need to provide appropriate care. Visits from people with lived experience of co-occurring mental health conditions and problem alcohol use can also encourage people to engage with the alcohol treatment service.
The NICE guideline Transition between inpatient mental health settings and community or care home settings (NG53) provides more guidance on planning for discharge.
18.8.7 Training and skills for staff working in mental health
All practitioners working in mental health care settings should be trained and supported to:
- carry out routine identification (screening) and brief interventions
- make an initial assessment of alcohol and drug use and respond to urgent physical and mental health needs
- identify and make effective referrals to alcohol treatment services
- participate in collaborative care planning and co-ordination
- provide alcohol harm reduction advice and interventions (see chapter 8 on harm reduction)
- understand and identify additional risks or referrals (for example, a safeguarding referral or a housing referral)
- assess alcohol and drug use as factors for suicide risk and include actions to reduce or manage use as part of risk management (safety) planning
- safely manage episodes of intoxication
Additional skills and training will be necessary for staff working in crisis services and inpatient services. They should be able to:
- ensure a person who is acutely intoxicated and in mental health crisis is safely managed and monitored
- identify when a person requires medical management and medically assisted withdrawal
- safely provide a medically assisted withdrawal, according to local policy and procedures and these alcohol clinical guidelines (alcohol specialist members of the team only)
NICE clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends that staff responsible for assessing and managing medically assisted alcohol withdrawal should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms and the use of drug regimens appropriate to the setting (for example, inpatient or community) where the withdrawal is managed. This is important so staff can manage the process safely.
Mental health services are responsible for ensuring practitioners are suitably trained and supported. Mental health and alcohol treatment commissioners should support services to make sure the above alcohol-related skills become part of their standard workforce competencies.
The guidance in this section is for staff in alcohol treatment services.
For more on assessment and collaborative care planning, see section 18.5 on collaborative care planning.
You should also read section 4.9.9 of chapter 4 on assessment and treatment and recovery planning. This provides guidance on assessing mental health as part of a comprehensive alcohol assessment.
Alcohol treatment services should support people with common mental health conditions such as non-severe depression and anxiety if they are not accessing community mental health services. Practitioners should include any goals the person has around managing their mental health within their treatment and recovery plan.
Where alcohol treatment practitioners deliver psychosocial interventions to address common, less severe mental health conditions there should be a clinical governance structure, clinical supervision and input from a trained psychological therapist.
Alcohol treatment services should provide access to self-help resources (print or online) to address common mental health conditions and practitioners can also support people to work through these resources if they need help to do this.
Practitioners can provide psychoeducation on the mental health condition including the role of alcohol in maintaining this condition or making it worse. For example, while people may use alcohol as an attempt to manage depression, harmful or dependent alcohol use is likely to increase depression. Cognitive behavioural approaches to relapse prevention often include this kind of psychoeducation and coping strategies for managing anxiety and depression. See section 5.6.4 in chapter 5 on psychosocial interventions for more information on cognitive behavioural interventions.
If there are staff trained and supervised to deliver recommended evidence-based psychological treatments for specific mental health conditions, then these could be provided in the alcohol treatment setting. These interventions should follow the relevant NICE guideline (or equivalent national clinical guideline) for the condition (see section 18.10 below). If the alcohol treatment service does not have staff with appropriate training and supervision, they should refer the person to a psychological therapies service or a community mental health service for treatment for the condition.
Some psychological therapies services may wish to exclude people because of their problem alcohol use. In these situations, alcohol treatment staff and service commissioners may need to advocate for people with problem alcohol use and support people to engage.
The guidance in section is for staff in mental health services and alcohol treatment services who have the relevant competencies.
People with co-occurring mental health and problem alcohol use should have access to evidence-based interventions for both problem alcohol use and mental health conditions. You can find guidance on pharmacological interventions for problem alcohol use (harmful drinking and alcohol dependence) in chapter 10 and psychosocial interventions for people with problem alcohol use in chapter 5.
This section details several specific mental health conditions that commonly co-occur with problem alcohol use, although other mental health conditions not included here may also co-occur with problem alcohol use. Suitably trained and competent practitioners can provide evidence-based psychological treatments to address these conditions. Services should provide clinical supervision and oversight by psychological therapists trained in the relevant approach.
18.10.1 Assessment and formulation, and different approaches to psychological treatment
As with all psychological treatments, assessment and formulation are essential to understand the relationship between alcohol use and any mental health condition and to develop treatment that addresses both. There is guidance on formulation in section 5.4 in chapter 5 on psychosocial interventions.
There are different approaches to delivering effective treatments for people with co-occurring mental health conditions and problem alcohol use and the evidence for the best approach is still emerging.
Where more than one service is involved, they can agree one overarching care plan (treatment and recovery plan) together and each service may have their own more detailed care plan (treatment and recovery plan) that sets out the interventions they will provide. Best practice includes good communication between professionals about the care plans (treatment and recovery plans). The person should be fully involved in choosing the goals and interventions that are included in treatment and recovery plans.
Where there are suitably trained staff, it may be possible to treat both conditions as part of a single intervention. This is described as a dual-focused approach.
While research in this area is still limited, evidence shows that a dual-focused approach with a combination of psychological treatments can be effective for:
- depressive disorder (Delgadillo and others, 2015)
- bipolar disorder (Farren and McElroy, 2008; Weiss and others, 2009)
- post-traumatic stress disorder (Najavits, 2007)
A dual-focused approach could mean adapting a single treatment approach (for example, cognitive behavioural therapy) to address both conditions at the same time or blending 2 different evidenced-based treatments (such as cognitive behavioural therapy and motivational interviewing). A dual-focused approach may help to better engage people in treatment, because many people will not believe their alcohol use and mental health condition are easily separable. So, they might find addressing both issues in one setting makes more sense and is more convenient.
18.10.2 Depression
Primary mild or moderate depressive disorder is very common in alcohol treatment populations. Alcohol treatment services should use basic approaches to identify people who may have depressive disorder. For example, the NICE clinical guideline Common mental health problems: identification and pathways to care (CG123) suggests asking the following 2 questions.
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
Answering yes to either question indicates possible depressive disorder, so you should follow this with an assessment by an appropriately trained mental health practitioner, as set out in NICE CG123. However, practitioners should also be aware that people might experience depressed mood if they have recently used alcohol, been intoxicated or they are experiencing withdrawal. Their depressed mood may improve after reducing alcohol use or after a period of abstinence, although this will not always be the case.
Practitioners should provide guided self-help based on cognitive behavioural approaches as part of routine clinical care (for example during keyworking) for mild or moderate depressive disorders (one or two sessions).
Dual-focus treatments that combine cognitive (for example identifying and changing unhelpful patterns of thinking), behavioural (for example behavioural activation) and motivational (for example motivational interviewing) components generally have better outcomes at follow-up than offering separate treatments in different services. If there are staff in alcohol treatment services with appropriate competencies and trained in a psychological treatment for non-severe depression, the service could consider offering treatment for non-severe depression at the same time as alcohol treatment so the person can receive treatment in one place. You should only offer the treatment for depression in the alcohol treatment service if there are qualified practitioners trained in the approach and with the relevant governance structures, including clinical supervision.
To treat depression in adults, trained staff should use NICE guidelines on:
18.10.3 Anxiety disorders
Primary mild or moderate anxiety disorders (panic disorder, social anxiety, generalised anxiety disorder) are very common in alcohol treatment populations. Alcohol treatment services should identify people who may have anxiety disorders.
NICE CG123 suggests using the 2-item Generalised Anxiety Disorder scale (GAD-2) to ask the person about feelings of anxiety and their ability to stop or control worry.
For more information and the full GAD-2 scale see NICE CG123.
Sometimes, the person needs to be stable in their alcohol treatment before a healthcare professional can diagnose an anxiety disorder and plan treatment. Practitioners should give people advice on managing anxiety if it is indicated during assessment.
Specialist mental health services or alcohol treatment services (where staff are suitably trained and supervised) should use the standard interventions for treating and managing anxiety disorders when appropriate.
To treat anxiety disorders, trained staff with the necessary competences should use NICE guidelines on:
- Social anxiety disorder: recognition, assessment and treatment (CG159)
- Generalised anxiety disorder and panic disorder in adults: management (CG113)
18.10.4 Post-traumatic stress disorder and complex post-traumatic stress disorder
People in alcohol treatment have high rates of post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD), so services should be trauma-informed. Trauma-informed care requires services and practitioners to use an approach based on its core principles, which are set out in the Office for Health Improvement and Disparities guidance Working definition of trauma-informed practice. They should also be able to understand the impact of trauma and recognise the signs and symptoms of PTSD or CPTSD. This is different to providing specialist treatment for PTSD or CPTSD.
It is essential that all services can identify possible PTSD or CPTSD and can confirm the diagnosis or refer to a specialist team for assessment. The PTSD or CPTSD services and the alcohol service may need to work together to deliver treatment interventions.
Treatment for PTSD requires qualified staff with specialist training and supervision. An alcohol treatment service should only provide it where staff trained and supervised in the approach are available. In most circumstances, a high intensity psychological therapies service or a specialist mental health team will provide treatment.
Trauma-focused treatments with an exposure component, combined with interventions for substance misuse, have been shown to reduce PTSD severity (Roberts and others, 2022). Some people may need stabilisation interventions (for example, to reduce risky behaviours and increase emotional regulation skills) before they start trauma-focused treatment, to help prepare them and minimise the risk they drop out.
Treatment for PTSD requires a phase-based approach consisting of:
- an initial phase focusing on safety and stabilising symptoms (present-focused)
- a second phase focusing on processing traumatic memories (past-focused)
- a reintegration phase (future-focused)
Stabilising a person’s alcohol use can support this phased approach, although the specific role for alcohol treatment services in trauma treatment should be determined locally and will be dependent on the training and competencies of staff.
Where alcohol treatment services agree to provide the first phase focusing on safety and stabilising symptoms, this should be based on a recognised, evaluated manual. This work should be carried out by staff trained in the approach and supervised by psychological professionals. It is important that there is a clear local pathway through which people can access phase 2 work if they need it.
Trained staff should use NICE guideline Post-traumatic stress disorder (NG116).
18.10.5 Eating disorders
Eating disorders are common in alcohol treatment populations, although there is limited research in this area.
When identifying people with eating disorders, alcohol treatment practitioners should be aware of the range of indicators set out in the NICE guideline Eating disorders: recognition and treatment (NG69).
Mental health services should provide treatment for the co-occurring eating disorder with support from a specialist alcohol treatment service if required. Common components of treatment for both conditions can include psychoeducation, cognitive restructuring (identifying and changing unhelpful patterns of thinking) and teaching coping skills. Targeting psychological processes that are common to both conditions (for example, learning to manage emotions better) may be helpful for each condition.
You can find further information about treating eating disorders in NICE NG69.
18.10.6 Severe mental illness: psychosis and bipolar disorder
People with a severe mental illness need a care package co-ordinated by mental health services or a GP.
At present, there is not enough evidence to recommend dual-focused treatment to manage co-occurring psychosis and problem alcohol use. Services should offer patients specific interventions for each disorder as outlined in existing NICE guidance identified below.
For bipolar disorder, services (usually mental health services) should offer dual-focused treatments based on cognitive behavioural principles that are focused on bipolar disorder and alcohol use disorder (problem alcohol use) interactions. Evidence shows that these treatments are more effective for depressive, manic and substance use symptoms, compared to single treatment approaches (Farren and McElroy, 2008; Weiss and others, 2009).
Motivational interviewing (MI) offers a non-confrontational and person-centred approach to talk about alcohol use with people who have serious mental illness and co-occurring problem alcohol use. MI can be delivered as a brief intervention but can also be deployed over a longer period of time. MI could also help people with severe mental illness to engage with treatment. You can read more about MI in section 5.5.6 of chapter 5 on psychosocial interventions.
Services should provide harm reduction advice as well as information about how alcohol negatively affects mood, sleep and managing emotions. There is guidance on harm reduction information and advice in chapter 8.
To treat severe mental illness, trained staff should use the NICE guidelines on:
- Coexisting severe mental illness and substance misuse: community health and social care services (NG58)
- Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (CG120)
- Psychosis and schizophrenia in adults: prevention and management (CG178)
- Bipolar disorder: assessment and management (CG185)
18.10.7 Personality disorder
Mental health specialists will usually treat people with personality disorders, in line with current NICE guidelines, because this is a complex condition that requires specific training and supervision.
For people with co-occurring alcohol use disorders, their mental health treatment should include helping them gain insight and control over their alcohol use. Mental health services may work with alcohol treatment services where they do not have the relevant specialist expertise to provide alcohol treatment interventions in mental health services. Staff in alcohol treatment services will need support and supervision from the MDT or wider clinical team when working with people with personality disorders.
Systems and pathways for emergency psychiatric care should be available to assess and manage people with co-occurring personality disorder and alcohol or drug use who are experiencing a mental health crisis.
To treat personality disorders, trained staff should use NICE guidelines on:
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