The RECO study: Realist Evaluation of service models and systems for CO- existing serious mental health and substance use conditions



Approximately 30%-50% of people with serious mental health problems (SMI) have a co-existing alcohol/drug condition. In alcohol and drug treatment services, 70-80% of serve users have co-morbid mental health problems, and these tend to be depression, anxiety and personality disorders with SMI less prevalent. Co-Occurring Serious Mental Health problems and Alcohol/Drug use (COSMHAD) is associated with a significant impact on health and social outcomes such as increased risk of suicide and self-harm, violence perpetration and victimisation; contact with the criminal justice system and forensic mental health services, mental health and substance use treatment recidivism; high use of crisis services; higher overall service costs than those with single diagnoses; co-morbid physical health problems, and social problems such as homelessness.

Services for people with co-existing serious mental health and alcohol/drug conditions are complex systems with outcomes that could be affected by numerous compounding factors such as the type and severity of the mental health or alcohol/drug condition, the interplay between the two conditions, peoples’ age, gender and ethnicity, as well as previous experiences of seeking help. Realist approach generates and tests programme theories which are used to understand complex interventions by synthesising relevant literature and/or analysing relevant data. Applying realist approaches will offer the potential to describe why interventions or services for COSMHAD, are successful or unsuccessful, within complex social systems through focusing on ‘what works, for who, in which circumstances’.

Overall aim

The overall aim is to generate a programme theory using realist methods to identify and describe the contexts and associated mechanisms by which engagement and other health outcomes are achieved for people with co-occurring mental health and drug/alcohol use. 

Research plan

The two year study has 3 interconnecting work-packages: realist review, service mapping and stakeholder consultation leading to a final synthesis and programme theory.

Study procedure 

Work package 1: Evidence synthesis: We will explore the literature based on two approaches: (i) to purposively identify, map and describe the literature on the types of provision; and (ii) using a realist logic of analysis that develops, tests and refines programme theories.

Work package 2: Mapping of national service systems: An initial search for services specifically targeting COSMAD will be commenced as soon as the study starts. We will use a snowballing method via our contacts and networks (such as PROGRESS, NHS SMPA, Public Health England, NHS England, social media, NHS mental health Nurse Director’s forum) to identify the range of services that provide dedicated services, models, interventions or care pathways for COSMHAD. An audit template will be developed from the outcomes of WP1 to map and capture details of provision across the United Kingdom (England, Scotland, Wales and Northern Ireland). This will be informed by the emerging findings of WP1. As each service is identified, they will be sent an online survey (audit template) that will be supplemented with brief telephone interviews with key informants (such as a lead COSMHAD clinician). We will also request any service specifications and protocols.

Work package 3: Consultation with providers and service users and carers: This WP comprises two components: stakeholder focus groups (WP3a), and individual interviews (WP3b) with a purposive sample of people currently experiencing co-existing severe mental health and alcohol/drug conditions. This will take place in South East London, Birmingham, Merseyside, Scotland, West Yorkshire, and Avon and Wiltshire.

The workpackages will overlap and each will inform the next, with the programme theory being developed in WP1 and refined by data collected in WP2 and 3. 

The findings of the study will inform a set of recommendations and guidelines for practice and research. Everything we do will be co-produced by people with lived experience, their carers, service providers and commissioners within the wider advisory groups for the RECO project. 

If you are interested in finding out more please contact Elizabeth Hughes and follow us on Twitter @aostudyRec.