Table 1 Risks and consequences associated with mortality for tobacco, alcohol and drug use in SMDs
Tobacco | Alcohol | Drugs |
|---|---|---|
Systemic factors | ||
Lack of data- so that scale of problem in some countries is unclear- allowing the issue to be ignored [47, 48] | ||
Lack of/ or limited funding for healthcare service provision [49] | ||
Mental health provision or tackling service provision for dual diagnoses populations is a low priority for government [49] | ||
Low levels of service provision for people with SMDs to be able to access interventions [48] | ||
Lack of training/ capacity building- impacting on ability to deliver interventions, particularly in lower resourced settings [49] | ||
Vertical approaches to healthcare delivery which lead to ‘silos’ in service provision (mental health and physical health provision not well integrated, or health and social care poorly integrated) [49, 50] | ||
| Â | Â | Criminal justice (instead of public health) to address people with substance use disorders |
Beliefs/ Awareness | ||
Healthcare provider belief that smoking cessation may exacerbate mental state or concerns about pharmacotherapy interactions- leading to lower levels of cessation advice and intervention being offered [51]. | Beliefs that alcohol and/or drugs are helpful as self-treatment for depression and other mental health conditions | |
Healthcare provider belief of futility- that patients will not benefit- leading to lower levels of intervention offered | ||
Healthcare provider- Lack of awareness or knowledge relating to evidence-based interventions and application of these | ||
| Â | Lack of awareness (on part of healthcare provider or service user) of treatment need for substance use disorders [48] | |
‘Culture’ of smoking in services for people with SMDs which may increase the risk of smoking initiation [52] |  | |
Inequalities | ||
In the general population, a social class gradient is observed for tobacco use. May be reflected in people with SMDs who are also more likely to ‘drift’ into lower socioeconomic position | Complex bidirectional associations with unemployment, lower socioeconomic position and other indicators of poverty and exclusion (e.g. homelessness) associated with usage and with poorer physical health and excess mortality | |
Social exclusion | ||
|  | Higher risk of social exclusion and ‘extreme inequalities’ for dual diagnosis populations- directly impacting on reduced or delayed access to mental/ physical healthcare [50], also reflected in exclusion from research [39]. | |
Mental state impact | ||
| Â | Impact on mental state- comorbid substance use impacts on severity and remission, increasing the risk of onset, recurrence and reducing chances of recovery. Impact on adherence to treatments. | |
Physical health impact | ||
Respiratory disorders, e.g. COPD leading to pneumonia | Alcohol withdrawal, delirium tremens | Overdose (opioids and other drugs) |
Cancers e.g. Lung, other | Acute alcohol/ drug intoxication Exacerbation of mental state, death through indirect pathways | |
Increased susceptibility to infection e.g. TB | Alcoholic hepatitis, pancreatitis, ulcer (gastric, duodenal) | Â |
| Â | Increased risk-taking behaviours as a result of intoxication with impact on physical health (e.g. infectious diseases, increased risk of STDs) | |
| Â | Increased risk of accidents- leading to trauma/ head injury (subdural haemorrhage) | Injecting drug use- Infections including HIV, hepatitis (A, B, C) |
Modifiable risk factor for dementia in later life [53] | Neurological sequelae and impact on cognition- Wernicke Korsakof’s syndrome, alcohol-related brain damage |  |
| Â | Malnutrition | |
| Â | Increased risk of range of infections- chest infection, TB, HIV, hepatitis- through multifactorial causes | |
| Â | Self-harm/ suicidal behaviours secondary to intoxication/ withdrawal | |