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No wrong door: the case for holistic approaches to alcohol, other drugs and mental health

Introduction by Croakey: Though robust evidence remains limited, the coronavirus pandemic appears to have driven shifts in alcohol and other drug use, with a recent report from the Australian Institute of Health and Welfare suggesting alcohol consumption has increased  — particularly for women — while illicit substance use has fallen off, partly due to issues around access and supply.

The AIHW report summarising what has been gleaned so far about the impact of COVID-19 on AOD patterns of use shows spending on alcohol is up on the same period last year, with declines in pub and club earnings more than offset by increased revenues to bottle shops, and a number of surveys reporting increased consumption. By contrast, use of other drugs appears to have declined according to the AIHW report, which was published in September.

(We have published several pieces on the pandemic and alcohol including this, another here, and here).

In recognition of the impact COVID-19 was expected have on use of alcohol and other substances, Health Minister Greg Hunt pledged $6 million to online and telephone services earlier in the pandemic.

Professor Nicole Lee from the National Drug Research Centre has warned that changes in use have been complex and are likely to have affected different groups in different ways, with the pandemic limiting access to treatment for those who need it.

In this piece for Croakey, Lee presents the findings of a new report showing integration of alcohol and other drug services with mental health needs a fundamental rethink.


Nicole Lee writes:

High rates of co-occurring mental health and alcohol and other drug problems have resulted in calls for the two sectors to join together in order to meet the needs of people with multiple issues.

Now our new research, undertaken with my colleague at the National Drug Research Institute, Professor Steve Allsop, calls for a rethink of this approach.

Our report, Exploring the place of alcohol and other drug services in the mental health system, presented to the National Mental Health Commission, looked at the state of the evidence on responding to complex problems and consulted with 18 key experts in Australia.

We explain why integrating services hasn’t worked in the past and why it is not the solution for the future.

Working with complexity

There is no doubt that there is a high co-occurrence of alcohol and other drug use and mental health problems in the Australian community, sometimes referred to as ‘comorbidity’.

Around 18 percent of people in the community with a mood disorder and 12 percent of people with an anxiety disorder also had a substance use disorder. For people in treatment, comorbidity is even higher.

We note in our submission to the recent Productivity Commission Inquiry into Mental Health that around half of the people seeking treatment for psychosis in Australia have a lifetime history of alcohol or other drug issues, most commonly alcohol dependence.

For people seeking alcohol and other drug treatment, the rate of comorbidity is even higher. Between 70 and 90 percent of people in these services meet diagnostic criteria for at least one mental health disorder.

Having more than one disorder can result in more severe symptoms and higher rates of relapse, and can also make treatment more complex and longer.

The call for integration

People with complex alcohol and other drug and mental health problems often ‘fall through the gaps’ in our health system. Many have trouble accessing help due to stigma. Clients and their families often report that they feel like they are ‘bounced around’ between different service providers with little continuity of care.

Up until now, the go-to solution to bridge these gaps has been to combine or ‘integrate’ alcohol and other drug and mental health services to provide a ‘one stop shop’. Many government inquiries and reviews of the service sectors, including the recent Productivity Commission Inquiry, have called for integration of services.

The problem is that, because the two areas are so different, this approach typically ends in failure. These failures mean a radical rethink of alcohol and other drug and mental health services is needed.

Is alcohol and other drug use a mental health disorder?

For some people, alcohol and other drug use might be considered a mental health problem, impacting on mood, wellbeing and cognitive functioning.

But alcohol and other drug use is not the same as a problem. Many people use alcohol or other drugs without significant negative impacts.

Use exists on a continuum from recreational to dependent use, and it’s only really at the dependent end of that continuum that we might consider it a mental health condition.

Source: 360Edge

So integrating alcohol and other drug with clinical mental health services only accounts for a relatively small piece of the alcohol and other drug sector, leaving the important areas of prevention, harm reduction, and early intervention out of the equation. 

In our report, we note that the call to integrate alcohol and other drug and mental health services is well meaning, but like many approaches in these areas, it has unintended consequences. It can reduce the overall quality of care provided to people with both disorders and reduce the specialist care that both sectors offer.

There is a very distinct culture and philosophy, workforce, and intervention approach between the two sectors, and service providers want to maintain their uniqueness.

There is very little research evidence to support the integration approach, and our key experts told us of attempts in the past that left the alcohol and other drug sector, in particular, with less funding and reduced capacity to respond.

As one of our key experts said: “Integrating alcohol and other drugs into mental health is like integrating Australia in the USA.”

Source: 360Edge

Our key experts also noted that many people with alcohol and other drug and mental health problems have a range of other issues, including physical health problems, child protection and legal issues, and family violence issues. We can’t integrate all these sectors together.

Ultimately, our report found that integrating sectors causes more problems than it solves. So the question is, then, how to make sure that people who need help with more than one problem can get all their needs met without having to join services together.

Collaboration, not integration

The bulk of the evidence supports well-funded and distinct alcohol and other drug and mental health services that collaborate, rather than integrate, to meet the needs of people with complex problems.

And while the research shows that integrated treatment (treating both disorders together) can be effective, it is probably not more effective than parallel or sequential treatment. So, integration of services is neither necessary or universally helpful.

What is required is holistic wrap-around services within each sector that address a person’s physical health, mental health, alcohol and other drug, and other needs. It’s sometimes referred to as ‘no wrong door’.

People are treated holistically in the service that they present to, and only referred to another specialist service under specific circumstances.

We know that co-location, in which multiple services are geographically located together, can facilitate working relationships and referral pathways, and improve outcomes for people with complex presentations. We also know that improving collaboration between different health services is key to ensure continuity of care.

Source: 360Edge

So the solution?

Providing holistic care within specialist sectors; co-location of services and formal structures for collaboration between services; improving relationships between agencies and encouraging collaboration in the form of structured discussions and planning; agreements on how services will collaborate; and co-location of professionals can all improve responses, without the need for major structural or cultural change.

Source: 360Edge

Of course, all of this needs to be funded adequately to be effective. Service providers need professional development and guidance to ensure that they have the skills to make this approach work. It also takes more time to provide holistic treatment.

The mental health sector is chronically underfunded. And the alcohol and other drug sector fares even worse, funded at about one-tenth of mental health services.

But we know that treatment is effective and we know that every dollar spent on alcohol and other drug treatment returns $7 to the community, so it is worth the investment.

Professor Nicole Lee is the is Chief Executive at leading drug and alcohol consultancy 360Edge, Adjunct Professor at the National Drug Research Institute and a member of the Australian National Advisory Council on Alcohol and other Drugs (ANACAD)

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Closing the Credibility Gap 2013
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