Written evidence submitted by Dr Laura Goodwin (Senior Lecturer in Mental Health at Lancaster University); Professor Stephen Jones (Professor of Clinical Psychology at Lancaster University); Dr Jasper Palmier-Claus (Senior Lecturer in Clinical Psychology at Lancaster University); Mr Neil Caton (Service User Researcher at Lancaster University) (CMH0204)
Evidence submitted by Professor Steven Jones, Dr Laura Goodwin, Dr Jasper Palmier-Claus and Mr Neil Caton. Spectrum Centre for Mental Health Research at Lancaster University.
Community Mental Health Services Call for Evidence. Health and Social Care Committee.
We are submitting this evidence on Community Mental Health services as researchers from the Spectrum Centre for Mental Health Research at Lancaster University, a research centre which specialises in translational research into the understanding and psychological treatment of bipolar disorder and other mental health conditions. We welcome the opportunity to present our evidence in person to the committee.
We are submitting evidence because we have conducted research that is relevant to the future of Community Mental Health (CMH) services in guiding treatment recommendations for people experiencing bipolar and our work provides an understanding of people’s wider health and social needs, for example in relation to co-occurring alcohol use disorders and physical health needs.
We have specific expertise in understanding treatment for people with bipolar disorder and have contributed to treatment guidance, such as serving on the NICE Clinical guideline development group for the 2014 Bipolar Guidance and leading the team that developed the British Psychology Society’s Understanding Bipolar Disorder report. We are providing our evidence in the context that many people experiencing severe mental health conditions are not getting the support through mental health services that they require. Using the example of bipolar disorder, we know from the most recent Adult Psychiatric Morbidity Survey that approximately 2% of the population in England meet criteria for this condition, but 60% are not receiving any treatment and of those who do, the majority receive treatment through their GP (Marwaha, Sal & Bebbington, 2016). The findings of the recent Bipolar Commission identified that people are often waiting up to a decade for an accurate diagnosis of bipolar disorder (Bipolar UK, 2021).
In summary of the details provided below, our research has identified:
What does high-quality care look like for adults with severe mental illness and their families/carers?
As NICE and BPS Guidance highlight, a crucial element of high-quality care is access to evidence based psychological support that is matched to an individual’s needs(Jones, Lobban and Cooke 2010, NICE 2014). Actual provision of such care is uncertain across CMH services currently, but can be offered by appropriately trained clinicians as has been highlighted by severe mental health problem demonstration site data(Jones, Akers et al. 2018). This needs to include integrated psychological support for comorbid difficulties and approaches that enhance personal recovery so that people can live well alongside their mental health challenges. Our research has again demonstrated that such approaches are feasible and safe (Jones, Smith et al. 2015, Jones, Riste et al. 2018).
How could the service user journey be improved both within community mental health services and in accessing support provided by other services/agencies?
We conducted a consultation of the most important issues affecting service users in Lancashire and South Cumbria between March and December 2024. We will share a summary of the most common themes from people who used CMH services:
It was felt that there was a lack of crisis support, with people finding it difficult to access care when they needed it, particularly at weekends. Some people reported that when they rang crisis home treatment teams they either got an answerphone or no one answered. People in rural areas were particularly disadvantaged if they were told to attend A and E in a crisis, sometimes having to travel over an hour to the nearest hospital and then having to wait several hours before they were seen.
Many people reported a lack of early intervention by CMH services with people having to reach crisis with their mental health before they received support. Some people spoke of being accepted into CMH services but not being allocated a care coordinator for prolonged periods.
Lack of access to psychological therapies was a common theme, with people often having to wait long periods on waiting lists and then travelling long distances to see their therapist (sometimes in neighbouring towns). People discussed a lack of choice in psychological therapies, with people most typically only offered CBT and if that didn’t meet their needs there was a lack of access to alternatives. People felt that services relied too heavily on medication and that this did not get to the root of their problems.
People with substance misuse issues alongside mental health issues found that there was a lack of support from mental health services if they were still misusing substances. They reported that building trust with mental health services gave them hope that they could develop other ways of coping with their mental health in order to reduce or stop using substances.
How can community mental health services work with social care, the third sector and local government to better address service users’ health and wider social needs that are wider determinants of mental health outcomes?
Co-occurring severe mental health and alcohol use disorders:
Our research has shown that people with severe mental health problems, such as bipolar disorder, are more likely to have an alcohol use disorder than people without, but. For example, people with bipolar disorder are more likely to meet criteria for an alcohol use disorder compared to those without bipolar ( 17% vs 3%, ref). Current CMH provision does not reflect this high level of co-occurrence and there is a need for better integration of care across CMHs and specialist drug/alcohol services, (Home Office, 2021).
We recently conducted a systematic review to understand the extent to which current UK guidance for the treatment of co-occurring substance use and mental health problems (PHE, 2017; NICE, 2016) is being implemented in practice and we found many examples in which it is not (Swithenbank, in preparation). For example, the guidance suggests that there should be ‘no wrong doors’ approach, but our systematic review identified many examples of ‘wrong doors’ and of people being turned away from community mental health services as a result of their heavy alcohol use. This also meant that people were sometimes left without any mental health support, often in times of crisis and when they may be more at risk of self-harm and suicidal thoughts in relation to their alcohol use (Swithenbank, in preparation).
One way to improve care for people with co-occurring mental health and alcohol use disorders in CMH services is to improve identification. Our recent work in CMH services in the North West has shown that whilst there are validated alcohol assessment tools recommended for this context (e.g. Alcohol Use Disorders Identification Test (AUDIT)), that these were rarely used (recorded in less than 5% of records) (Puddephatt, in preparation). Qualitative interviews identified particular issues which deterred staff from having these conversations, relating to trust and understanding service users’ fear of disclosure, which means that problems are commonly left untreated due to a lack of referral. These issues are particularly compounded for service users from racial and ethnic minority backgrounds, as there are greater risks around disclosure and increased stigma (Puddephatt, in preparation). This work has highlighted the need for improved staff training in CMH services around alcohol and drug use and a move towards more systematic and regular alcohol screening. However there needs to be guidance around how to conduct screening, for example, thinking about whether other people are present (e.g. family members, translators) when screening is conducted and making clear to the individual what the outcomes of screening are likely to be and who the information could be shared with ( to reassure someone that it wouldn't be passed, for example, to their social worker, employer etc).
There is more evidence required on how eligibility for starting psychological therapies could be made more flexible so that people who have an alcohol or substance problem may still be able to engage, without a requirement that they are fully abstinent. This may require better evidence on whether people using alcohol or drugs at a low level can engage and benefit from therapy, but the current practice may be too exclusionary and prevents people from receiving the treatment that they need, e.g. trauma focused therapy.
Oral health in people with severe mental health problems:
People with severe mental illness (e.g. bipolar disorder, psychosis) experience extremely poor oral health compared to the general population (Kisely, Baghaie, Lalloo, et al. (2015)). They are more likely to have decayed, missing or filled teeth, and gum disease. It can affect people’s quality of life, making it harder to them to eat, drink, and talk. Dentists can prevent and treat oral health problems. However, our recent review suggests that people with severe mental illness are less likely to access routine dental care (Turner, Berry, Aggarwal et al., 2022). Indeed, people with severe mental illness experience multiple barriers to attendance, including financial barriers and transport difficulties. Psychiatric symptoms, like low motivation and anxiety, can sometimes make visiting a dentist harder. Unfortunately, existing dental interventions have not addressed these issues. They have not enabled people with severe mental illness to attend the dentist. Our research focuses on empowering and enabling people with severe mental illness to see a dentist to address inequities and inequalities in this area (Hilton, Morris, Burnside et al., (2023)). We are particularly interested in using link workers to bridge and navigate the gap between mental health and dental services.
References:
Bipolar UK (2021). Bipolar Diagnosis Matters. London, Bipolar UK
Hilton, C., Morris, A., Burnside, G., Harris, R., Aggarwal, V. R., Procter, S., ... & Palmier-Claus, J. (2023). A two-arm, randomised feasibility trial using link workers to improve dental visiting in people with severe mental illness: a protocol paper. Pilot and Feasibility Studies, 9(1), 157.
Home Office (2021). Independent review of drugs by Dame Carol Black. Department of Health and Social Care. Accessed December 2, 2024. https://www.gov.uk/government/collections/independent-review-of-drugs-by-professor-dame-carol-black
Jones, S. H., Lobban, F., & Cooke, A. (2010). Understanding bipolar disorder : why some people experience extreme mood states and what can help. British Psychological Society.
Jones, S. H., Smith, G., Mulligan, L. D., Lobban, F., Law, H., Dunn, G., … Morrison, A. P. (2015). Recovery-focused cognitive–behavioural therapy for recent-onset bipolar disorder: Randomised controlled pilot trial. British Journal of Psychiatry, 206(1), 58–66. doi:10.1192/bjp.bp.113.141259
Jones, S. H., Akers, N., Eaton, J., Tyler, E., Gatherer, A., Brabban, A., Long, R., & Lobban, F. (2018). Improving access to psychological therapies (IAPT) for people with bipolar disorder: Summary of outcomes from the IAPT demonstration site. Behaviour research and therapy, 111, 27–35. https://doi.org/10.1016/j.brat.2018.09.006
Jones S, Riste L, Barrowclough C, Bartlett P, Clements C, Davies L, et al. Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme. Programme Grants Appl Res 2018;6(6). https://doi.org/10.3310/pgfar06060
Kisely, S., Baghaie, H., Lalloo, R., Siskind, D., & Johnson, N. W. (2015). A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosomatic medicine, 77(1), 83-92.
Marwaha S, Sal N, Bebbington P. (2016) ‘Chapter 9: Bipolar disorder’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.
National Institute for Health Care Excellence (NICE) (2016). Coexisting severe mental illness and substance misuse: community health and social care services. National Institute for Health Care Excellence. https://www.nice.org.uk/guidance/ng58
Puddephatt, J. A., Jones, A., Gage, S. H., Fear, N. T., Field, M., McManus, S., McBride, O., & Goodwin, L. (2021). Associations of alcohol use, mental health and socioeconomic status in England: Findings from a representative population survey. Drug and alcohol dependence, 219, 108463. https://doi.org/10.1016/j.drugalcdep.2020.108463
Puddephatt, J., Marshall, P., Swiffen, D., Onwumere, J., Das-Munshi, J., Ross Coomber, R. & Goodwin. L. (2025). A rapid appraisal of how alcohol is screened and treated among minoritised ethnic service users within community mental health settings [Manuscript in preparation]. Division of Health Research, Lancaster University.
Public Health England (2017). Better care for people with co-occurring mental health, and alcohol and drug use conditions. GOV.UK: Public Health England. https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf
Swithenbank, S., Irizar, P., Halsall, L., Lobban, F. & Goodwin, L. (2025). The implementation of current UK guidance for the treatment of co-occurring substance use and mental health problems in research and practice: a mixed methods systematic review and thematic synthesis [Manuscript in preparation]. Division of Health Research, Lancaster University.
Turner, E., Berry, K., Aggarwal, V. R., Quinlivan, L., Villanueva, T., & Palmier‐Claus, J. (2022). Oral health self‐care behaviours in serious mental illness: A systematic review and meta‐analysis. Acta Psychiatrica Scandinavica, 145(1), 29-41.
February 2025