There is an apparent belief that more emphasis on and investment in crisis response services, assertive outreach teams and 24-hour staffed accommodation will reduce the number of homicides committed by people with a serious mental illness. There is some merit in this belief, and the injection of new resources will be welcome.
But there must be a suspicion that significant investment in 24-hour staffed accommodation will be an attractive political proposition that will soon consume the lion's share of these resources, and will do so without dealing with the underlying policy problem.
The assumption that the provision of additional staffed accommodation will meet the needs of service users with chaotic lives seems to neglect the fact that these people do not want to live together, and there is currently no legislation to compel them to do so.
To argue that an approach based on massive investment in residential schemes is flawed is not to suggest that the system does not require more supported accommodation. Rather, it is to put forward a case for a solution that addresses the real needs of the people with serious mental illness who are most likely to harm fellow members of society.
In common with the majority of violent assailants in our community, the priority is to deal with their dependence on, or abuse of, legal and illegal drugs - there is clear evidence that people with severe mental illness who misuse substances are much more likely to be hostile or aggressive than those with a severe mental illness alone.1
A recent study showed that in a sample of inquiry reports into homicides by people with a mental illness, misuse of substances was a major factor, either in the homicide or in the life of the perpetrator (or both), in over half of the cases.2
Furthermore, the report argued that the presence of abuse was constantly underplayed in inquiry recommendations. It could be argued that the problem of public safety posed by this group is as much a product of the overall high rates of drug and alcohol abuse as it is a product of a failure of mental health policy.
Compounding the oversight in inquiry reports, the recent white paper on drug misuse also largely overlooked this connection. Given the links between mental illness, substance abuse and homicide, it is regrettable that specific objectives are not set in this area and that the targeting on this group of treatments known to be effective is not a priority.
If the aim is to protect communities from drug-related crime, then a major opportunity to connect assertive outreach with active assessment of, and treatment for, substance misuse for people with serious mental illness has been missed.
The traditional divide of clinical responsibility between community mental health teams and substance misuse services has to be bridged. Given that up to 50 per cent of people referred to community mental health teams have significant problems with legal or illegal substances, the policy imperative must be to ensure that those services have the expertise and experience to assess and intervene.
The forthcoming national service framework must seek to build those bridges. If such integration is achieved, then the government will succeed in improving the lives of people with serious mental illness while making a significant contribution to reducing the danger to the public from one group - one among many within our society - who abuse drugs and alcohol.
Centre for mental health services development
King's College London
1 Scott H, Johson S et al. Substance Misuse and the Risk of Aggression and Offending among the Severely Mentally Ill. Brit J of Psychiatry 1998. 172; 345-350.
2 Ward M, Applin C. The Unlearned Lesson. Wynne Howard Books. 1998.