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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.

The aim of this study was to explore young people's experiences of the role and the processes underpinning the use of alcohol and/or other substances in attempts to end their life. Seven young people, aged 16-25 years old, were interviewed using in-depth, semi-structured interviews. Interpretative Phenomenological Analysis was used to analyse these interviews and develop an understanding of how young people understand their attempted suicide in the context of alcohol and/or other substance use. The analysis identified four superordinate themes reflecting young people's experiences across the seven interviews. Superordinate themes included: i) The complexity of relationships; ii) The double-edged sword of alcohol and substance use; iii) The straw that broke the camel's back; and iv) Reflecting on the on-going processes of recovery. The results of this study highlight the complex and multifaceted functions of the consumption of alcohol, and other drugs, in the experiences of young people attempting suicide. Young people described a number of inter and intrapersonal factors which impact upon their suicidal experiences including suicidal ideation and attempts. Participants reported using alcohol and substances as methods of coping with distress, low mood, hearing voices, anxiety and mania. However they also reflected on the impact that this has on their own suicidal ideation and attempts., Competing Interests: The authors have declared that no competing interests exist.

Young people in care have a four-fold increased risk of drug and alcohol use compared to their peers. The SOLID study aimed to deliver two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol) and improve mental health in young people in care. The study was carried out in 6 local authorities in the North East of England. Young people in care aged 12-20 years, who self-reported substance use within the previous 12 months were randomised to Motivational Enhancement Therapy, Social Behaviour and Network Therapy or control. In-depth 1:1 interviews and focus groups were used with young people in care, foster carers, residential workers, social workers and drug and alcohol practitioners to explore the key lessons from implementing the interventions. The Consolidated Framework of Implementation Research framed the analysis. Findings illustrated that the everyday interaction between individuals, service level dynamics and external policy related factors influenced the implementation of these new interventions at scale. We concluded that unless interventions are delivered in a way that can accommodate the often-complex lives of young people in care and align with the drug and alcohol practitioners' and social workers priorities, it is unlikely to be successfully implemented and become part of routine practice.

Background: Young people in state care, often due to abuse or neglect, have a four-fold increased risk of drug and alcohol use compared to their peers., Aim: The SOLID study aimed to investigate the feasibility of a definitive randomised controlled trial, comparing two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol), and improve mental health, in young people in care., Methods: We recruited young people in care aged 12-20 years, self-reporting substance use within the previous 12 months and residing in 1 of 6 participating local authority sites in the North East of England. Participants were randomised to either i. Motivational Enhancement Therapy (MET), ii. Social Behaviour and Network Therapy (SBNT) or iii. Control (usual care). All interventions were delivered by trained drug and alcohol workers. Follow-up data were collected 12 months post recruitment. Feasibility for trial progression was compared to pre-specified stop: go criteria (recruitment of 60% of eligible participants, 80% of participants attending 60% of offered sessions and retention of 70% of participants at 12 month follow up)., Results: Of 1450 eligible participants, 860 (59%) were screened for drug and alcohol use by social workers, 211 (24.5%) met inclusion criteria for the trial and 112 young people (7.7%) consented and were randomised. Sixty of these 112 participants (54%) completed 12-month follow-up questionnaires. Only 15 out of the 76 (20%) participants allocated to an intervention arm attended any of the offered MET or SBNT sessions., Conclusion: By reference to pre-specified stop: go criteria it is not feasible to conduct a definitive trial for SOLID in its current format. Despite co-designing procedures with staff and young people in care, the screening, referral and treatment pathway did not work here. Future work may require dedicated clinically embedded research resource to evaluate effectiveness of new interventions in services., Competing Interests: The authors have declared that no competing interests exist.

Background: Looked after children and care leavers have an increased risk of drug and alcohol use compared to their non-LAC peers. Despite high prevalence rates within this population, looked after children are reported to show low levels of engagement in services resulting in unmet needs emerging from substance use. This paper reports on the initial formative phase of a pilot feasibility randomised controlled trial; SOLID (Supporting Looked After Children and Care Leavers In Decreasing Drugs, and Alcohol) that aimed to adapt two evidence-based psychosocial interventions, Motivational Enhancement Therapy and Social Behaviour and Network Therapy, which will aim to reduce substance misuse by looked after children., Methods: We conducted qualitative semi-structured interviews and focus groups with 19 looked after children aged 12 to 20 years old, 16 carers and 14 professionals across four local authorities in the North East of England. The data gathered were analysed and then presented within co-production workshops inclusive of 13 young people and 14 professionals (drug and alcohol practitioners and social workers). Findings were used to adapt and refine the interventions prior to the trial., Results: Overall findings suggested that whilst original components of both interventions were feasible to deliver and acceptable, specific process areas were highlighted including: increased emphasis upon therapeutic relationships, the benefits of using creative non-traditional methods of engagement and identification of treatment goals wider than those narrowly focused on substance misuse., Conclusion: This paper provides an example of methods used to collect multiple perspectives to refine and co-develop interventions to reduce drug and alcohol use in the specific population of looked after children., Trial Registration: ISRCTN80786829 (first registered 06.06.2016- prospectively registered).

Conventional practice within the United Kingdom and beyond is to conduct economic evaluations with "health" as evaluative space and "health maximization" as the decision-making rule. However, there is increasing recognition that this evaluative framework may not always be appropriate, and this is particularly the case within public health and social care contexts. This article presents a methodological case study designed to explore the impact of changing the evaluative space within an economic evaluation from health to capability well-being and the decision-making rule from health maximization to the maximization of sufficient capability. Capability well-being is an evaluative space grounded on Amartya Sen's capability approach and assesses well-being based on individuals' ability to do and be the things they value in life. Sufficient capability is an egalitarian approach to decision making that aims to ensure everyone in society achieves a normatively sufficient level of capability well-being. The case study is treatment for drug addiction, and the cost-effectiveness of 2 psychological interventions relative to usual care is assessed using data from a pilot trial. Analyses are undertaken from a health care and a government perspective. For the purpose of the study, quality-adjusted life years (measured using the EQ-5D-5L) and years of full capability equivalent and years of sufficient capability equivalent (both measured using the ICECAP-A [ICEpop CAPability measure for Adults]) are estimated. The study concludes that different evaluative spaces and decision-making rules have the potential to offer opposing treatment recommendations. The implications for policy makers are discussed.

Background: Family interventions appear to be effective at treating young people's substance misuse. However, implementation of family approaches in UK services is low. This study aimed to demonstrate the feasibility of recruiting young people to an intervention based on an adaptation of adult social behaviour and network therapy. It also sought to involve young people with experience of using substance misuse services in the research process., Objectives: To demonstrate the feasibility of recruiting young people to family and social network therapy and to explore ways in which young people with experience of using substance misuse services could be involved in a study of this nature., Design: A pragmatic, two-armed, randomised controlled open feasibility trial., Setting: Two UK-based treatment services for young people with substance use problems, with recruitment taking place from May to November 2014., Participants: Young people aged 12-18 years, newly referred and accepted for structured interventions for drug and/or alcohol problems., Interventions: A remote, web-based computer randomisation system allocated young people to adapted youth social behaviour and network therapy (Y-SBNT) or treatment as usual (TAU). Y-SBNT participants were intended to receive up to six 50-minute sessions over a maximum of 12 weeks. TAU participants continued to receive usual care delivered by their service., Main Outcome Measures: Feasibility was measured by recruitment rates, retention in treatment and follow-up completion rates. The main clinical outcome was the proportion of days on which the main problem substance was used in the preceding 90-day period as captured by the Timeline Follow-Back interview at 3 and 12 months., Results: In total, 53 young people were randomised (Y-SBNT, n  = 26; TAU, n  = 27) against a target of 60 (88.3%). Forty-two young people attended at least one treatment session [Y-SBNT 22/26 (84.6%); TAU 20/27 (74.1%)]; follow-up rates were 77.4% at month 3 and 73.6% at month 12. Data for nine young people were missing at both months 3 and 12, so the main clinical outcome analysis was based on 24 young people (92.3%) in the Y-SBNT group and 20 young people (74.1%) in the TAU group. At month 12, the average proportion of days that the main problem substance was used in the preceding 90 days was higher in the Y-SBNT group than in the TAU group (0.54 vs. 0.41; adjusted mean difference 0.13, 95% confidence interval -0.12 to 0.39; p  = 0.30). No adverse events were reported. Seventeen young people with experience of substance misuse services were actively involved throughout the study. They informed key elements of the intervention and research process, ensuring that the intervention was acceptable and relevant to our target groups; contributing to the design of key trial documents, ideas for a new model of public involvement and this report. Two parents were also involved., Conclusions: The adapted intervention could be delivered in young people's services, and qualitative interviews found that Y-SBNT was acceptable to young people, family members and staff. Engagement of family and network members proved difficult within the intervention and research aspects. The study proved the feasibility of this work in routine services but outcome measurement based on narrow substance use variables may be limited and may fail to capture other important changes in wider areas of functioning for young people. Validation of the EuroQol-5 Dimensions for young people aged 12-18 years should be considered and flexible models for involvement of young people in research are required to achieve inclusive representation throughout all aspects of the research process. Although recommendation of a full trial of the Y-SBNT intervention compared with TAU is not supported, this study can inform future intervention development and UK research within routine addiction services., Trial Registration: Current Controlled Trials ISRCTN93446265., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 21, No. 15. See the NIHR Journals Library website for further project information.

Background: The psychological difficulties and emotional impacts resulting from the substance use of close relatives constitute a large, underestimated and frequently unidentified health burden. The development of primary care mental health services in response to the Improving Access to Psychological Therapies initiative provides an opportunity to investigate this in more depth., Aims: A preliminary exploration of prevalence of IAPT service-users being treated for moderate-severe depression and/or anxiety who report that they have relatives with alcohol and/or drug problems. To explore the characteristics of the sample including comparison with those without a substance misusing relative., Method: One hundred service users completed a brief questionnaire. Routine data on depression and anxiety symptoms were accessed for the full consenting sample. Descriptive statistics were used to explore the family members of substance users and differences to the rest of the sample., Results: Twenty-two of the 100 IAPT service users reported having a close relative whose use of substances was of concern to them. The group with a relative who used substances were more depressed at the beginning of treatment than the rest of the sample., Conclusions: A significant number of people seeking psychological help for depression and anxiety within IAPT services reported being concerned about a close relative who misuses substances. They may be more distressed than those without a relative who misuses substances. Further exploration is warranted but preliminary findings indicate that this is an important research area with significant clinical implications.

Background: Worldwide, there are an estimated 15 million individuals with drug use disorders and over five times as many with alcohol use disorders (WHO 1:2, 2005). Most individuals with substance misuse have families who are affected. Initial scoping searches identified an expanse of broad and disparate studies and reviews on the family interventions for substance misuse. This systematic review of systematic reviews aims to bring together the expanse of research on the effectiveness of family-based interventions in substance misuse.Initial scoping searches identified an expanse of broad and disparate studies and reviews on the family interventions for substance misuse. This systematic review of systematic reviews aims to bring together the expanse of research on the effectiveness of family-based interventions in substance misuse., Methods: Extensive electronic and manual searches will be undertaken. Screening, data extraction and quality assessment will be undertaken by two reviewers with disagreements resolved through discussion.The inclusion criteria will be that the study is a systematically undertaken review, the population is individuals with substance misuse problems and the interventions include a family-focused component. Reviews that focus on prevention rather than treatment will be excluded. The reviews will be assessed for quality and relevance. The evidence from included systematic reviews will be mapped by focus of intervention (promoting engagement of user into treatment/joint involvement in treatment of user/treating family member in own right) for both adults and adolescents for drug and/or alcohol misusers to allow assessment of the density of available evidence. The higher-quality, up-to-date evidence for each domain will be identified and described, and conclusions will be drawn with limitations of the evidence highlighted., Discussion: This systematic review of systematic reviews will be an efficient and robust way of looking at the current state of the evidence in the field of family-based interventions for substance misuse. It will evaluate all the available systematic-review-level literature to report on the effectiveness of family-based psychological interventions in improving substance-related outcomes and improving health and wellbeing of substance misusers and/or their families. This will inform future treatment policies and commissioning decisions.In addition, it will identify areas of poor quality, inconsistency and gaps in the evidence base for family-based psychological interventions in substance misuse with respect to secondary evidence in order to inform future research., Systematic Review Registration: PROSPERO CRD42014006834.

Background: Substance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention., Methods/design: This randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention., Discussion: This pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care., Trial Registration: ISRCTN43548483 Date of ISRCTN assignation: 4/17/2014.

Background: Convergent research reveals heterogeneity in substance use disorders (SUD). The Addiction Dimensions for Assessment and Personalised Treatment (ADAPT) is designed to help clinicians tailor therapies., Methods: Multicentre study in 21 SUD clinics in London, Birmingham (England) and Adelaide (Australia). 132 clinicians rated their caseload on a beta version with 16 ordinal indicators of addiction severity, health and social problem complexity, and recovery strengths constructs. In Birmingham, two in-treatment outcomes were recorded after 15-months: 28-day drug use (Treatment Outcome Profile; n=703) and Global Assessment of Functioning (GAF; DSM-IV Axis V; n=695). Following item-level screening (inter-rater reliability [IRR]; n=388), exploratory structural equation models (ESEM), latent profile analysis (LPA), and mixed-effects regression evaluated construct, concurrent and predictive validity characteristics, respectively., Results: 2467 patients rated (majority opioid or stimulant dependent, enrolled in opioid medication assisted or psychological treatment). IRR-screening removed two items and ESEM models identified and recalibrated remaining indicators (root mean square error of approximation 0.066 [90% confidence interval 0.055-0.064]). Following minor re-specification and satisfactory measurement invariance evaluation, ADAPT factor scores discriminated patients by sample, addiction therapy and drug use. LPA identified three patient sub-types: Class 1 (moderate severity, moderate complexity, high strengths profile; 46.9%); Class 2 (low severity, low complexity, high strengths; 25.4%) and Class 3 (high severity, high complexity, low strengths; 27.7%). Class 2 had higher GAF (z=4.30). Class 3 predicted follow-up drug use (z=2.02) and lower GAF (z=3.51)., Conclusion: The ADAPT is a valid instrument for SUD treatment planning, clinical review and outcome evaluation. Scoring and application are discussed., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: A randomized trial to compare two levels of an intervention (full versus brief) for use by primary health-care professionals with family members affected by the problematic drug or alcohol use of a close relative., Design: A prospective cluster randomized comparative trial of the two interventions., Setting: A total of 136 primary care practices in two study areas within the West Midlands and the South West regions of England., Participants: A total of 143 family members affected by the alcohol or drug problem of a relative were recruited into the study by primary health-care professionals. All recruited family members were seen on at least one occasion by the professional delivering the intervention and 129 (90 %) were followed-up at 12 weeks., Main Outcome Measures: Two validated and standardized self-completion questionnaires measuring physical and psychological symptoms of stress (Symptom Rating Test) and behavioural coping (Coping Questionnaire) experienced by the family members. It was predicted that the full intervention would show increased reduction in both symptoms and coping when compared to the brief intervention., Results: The primary analysis adjusted for clustering, baseline symptoms and stratifying variables (location and professional group) showed that there were no significant differences between the two trial arms. The symptom score at follow-up was 0.23 [95% confidence interval (CI): -3.65, +4.06] higher in the full intervention arm than in the brief intervention arm, and the coping score at follow-up was 0.12 (95% CI: -5.12, +5.36) higher in the full intervention arm than in the brief intervention arm., Conclusions: A well-constructed self-help manual delivered by a primary care professional may be as effective for family members as several face-to-face sessions with the professional.

Purpose of Review: Recent developments in research and practice have highlighted the effectiveness of family interventions in substance misuse treatment. The present paper will critically review studies of family approaches published over the past 12 months, assess the current state of this field and suggest future directions., Recent Findings: Family interventions lead to positive outcomes for both misusers and family members. Some recent interventions have widened the focus also to include other members of the user's social networks and have focused on a range of treatment goals., Summary: An increasingly robust evidence base supports family-focused and social network-focused interventions in substance misuse treatment. Recent studies have continued to show that family and network approaches either match or improve outcomes when compared with individual interventions. Research needs (and is starting) to consider a broader set of outcomes relevant to family and network interventions, besides simply making an impact on substance use. The major challenge involves implementation of family approaches in routine service provision; interventions with most evidence supporting them are not used routinely in practice. Research studies and policy initiatives need to focus on dissemination of family approaches and their integration into treatment services.

This paper reports on the implementation and preliminary evaluation of Social Behaviour and Network Therapy (SBNT) within drug treatment services. SBNT was initially developed and evaluated as part of a trial for alcohol treatment in the UK (UKATT). For the study reported in this paper SBNT was adapted for application with drug users. Therapists (N=20) from community drug services in Birmingham, UK, were trained to deliver the intervention. Training methods were supported by a treatment manual and included a two-day workshop followed by video supervision and monitoring. Following training therapists were asked to implement the treatment within the services in which they worked. Twelve of the therapists that were trained delivered SBNT to 24 clients within the study period of 8 months. Baseline and 3-month follow-up measures were administered using both quantitative and qualitative methods. This paper reports the quantitative results including drug use, levels of dependence, drug users' social network variables and family environment. Results suggest that it was feasible to train a number of therapists to deliver SBNT, and preliminary outcome results are encouraging. Further evaluation is needed in order to continue developing this promising social intervention.

Aims: To describe a set of standard questionnaire measures for the assessment of the needs of family members of relatives with alcohol, drug or gambling problems, and to present evidence of their reliability and validity from a series of related studies., Design: Includes cross-sectional and repeated-measurement studies., Setting and Participants: Family members affected by and concerned about the problem drinking or drug-taking of close relatives in treatment and non-treatment samples in the United Kingdom (white and Sikh) and Mexico City; family members of untreated heavy drinkers; and family members of problem gamblers., Measurements: Four measures derived from a stress-strain-coping-support model of alcohol, drugs and gambling problems and the family: Family Member Impact scale (FMI), Symptom Rating Test (SRT), Coping Questionnaire (CQ), and Hopefulness-Hopelessness scale (HOPE). FMI, SRT and CQ assess stress, strain and coping, respectively. The exact role of HOPE in the model remains to be determined. The support component remains unmeasured., Findings: Results from a number of studies support the internal reliability, discriminant and construct validity and sensitivity to change of the SRT and its two constituent scales (psychological and physical symptoms) and at least two subscales of the CQ (engaged and tolerant-inactive coping). Although showing evidence of satisfactory reliability and some evidence of discriminant validity, further work may be required on the CQ withdrawal coping subscale. Evidence suggests that the FMI is reliable and valid and may have a factor structure that will support future research (distinguishing worrying behaviour from active disturbance). HOPE is a new measure showing promising characteristics., Conclusions: A set of standard measures is available for helping to assess the needs of concerned and affected family members, derived from an explicit model of the family in relation to excessive drinking, drug taking or gambling. It may have a role to play in correcting the current neglect of the needs of such family members, estimated to be in the region of nearly a million adults in Britain alone.

The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young people's taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people.

Background: Use of illicit drugs, particularly cannabis, by young people is widespread and is associated with several types of psychological and social harm. These relations might not be causal. Causal relations would suggest that recreational drug use is a substantial public health problem. Non-causal relations would suggest that harm-reduction policy based on prevention of drug use is unlikely to produce improvements in public health. Cross-sectional evidence cannot clarify questions of causality; longitudinal or interventional evidence is needed. Past reviews have generally been non-systematic, have often included cross-sectional data, and have underappreciated the extent of methodological problems associated with interpretation., Methods: We did a systematic review of general population longitudinal studies reporting associations between illicit drug use by young people and psychosocial harm., Findings: We identified 48 relevant studies, of which 16 were of higher quality and provided the most robust evidence. Fairly consistent associations were noted between cannabis use and both lower educational attainment and increased reported use of other illicit drugs. Less consistent associations were noted between cannabis use and both psychological health problems and problematic behaviour. All these associations seemed to be explicable in terms of non-causal mechanisms., Interpretation: Available evidence does not strongly support an important causal relation between cannabis use by young people and psychosocial harm, but cannot exclude the possibility that such a relation exists. The lack of evidence of robust causal relations prevents the attribution of public health detriments to illicit drug use. In view of the extent of illicit drug use, better evidence is needed.