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. 2024 Oct;28(67):1–100. doi: 10.3310/JTNT0476

Care models for coexisting serious mental health and alcohol/drug conditions: the RECO realist evidence synthesis and case study evaluation.

Elizabeth Hughes, Jane Harris, Tom Ainscough, Angela Bate, Alex Copello, Sonia Dalkin, Gail Gilchrist, Emma Griffith, Lisa Jones, Michelle Maden, Luke Mitcheson, Harry Sumnall, Charlotte Walker
PMCID: PMC11491988  PMID: 39400110

Abstract

BACKGROUND

People with severe mental illness who experience co-occurring substance use experience poor outcome including suicide, violence, relapses and use of crisis services. They struggle to access care and treatment due to a lack of an integrated and co-ordinated approach which means that some people can fall between services. Despite these concerns, there is limited evidence as to what works for this population.

OBJECTIVES

To undertake a realist evaluation of service models in order to identify and refine programme theories of what works under what contexts for this population.

DESIGN

Realist synthesis and evaluation using published literature and case study data.

SETTING

Mental health, substance use and related services that had some form of service provision in six locations in the United Kingdom (five in England and one in Northern Ireland).

PARTICIPANTS

People with lived experience of severe mental illness and co-occurring substance use, carers and staff who work in the specialist roles as well as staff in mental health and substance use services.

RESULTS

Eleven initial programme theories were generated by the evidence synthesis and in conjunction with stakeholders. These theories were refined through focus groups and interviews with 58 staff, 25 service users and 12 carers across the 6 case study areas. We identified three forms of service provision (network, consultancy and lead and link worker); however, all offered broadly similar interventions. Evidence was identified to support most of the 11 programme theories. Theories clustered around effective leadership, workforce development and collaborative integrated care pathways. Outcomes that are meaningful for service users and staff were identified, including the importance of engagement.

LIMITATIONS

The requirement for online data collection (due to the COVID-19 pandemic) worked well for staff data but worked less well for service users and carers. Consequently, this may have reduced the involvement of those without access to information technology equipment.

CONCLUSION

The realist evaluation co-occurring study provides details on how and in what circumstances integrated care can work better for people with co-occurring severe mental health and alcohol/drug conditions. This requires joined-up policy at government level and local integration of services. We have also identified the value of expert clinicians who can support the workforce in sustaining this programme of work. People with co-occurring severe mental health and alcohol/drug conditions have complex and multifaceted needs which require a comprehensive and long-term integrated approach. The shift to integrated health and social care is promising but will require local support (local expert leaders, network opportunities and clarity of roles).

FUTURE WORK

Further work should evaluate the effectiveness and cost-effectiveness of service models for this group.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020168667.

FUNDING

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128128) and is published in full in Health Technology Assessment; Vol. 28, No. 67. See the NIHR Funding and Awards website for further award information.

Plain language summary

There are very few services in the United Kingdom that currently provide a service for people with co-occurring severe mental health and alcohol/drug conditions. We identified a set of factors that are likely to promote better outcomes for people with co-occurring severe mental health and alcohol/drug conditions including commitment from leaders across organisations to address this issue and support staff training. A local expert clinical leader was seen to be important in enabling closer working between mental health and substance use. Service users and carers recognised that when care was co-ordinated, and staff demonstrated empathy and compassion, they were more likely to engage in treatment. Further work will be needed to evaluate how helpful some of the aspects of the models of care are in helping people in their recovery goals.

Full text of this article can be found in Bookshelf.

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