Lesson 6 - Substance Misuse and Mental Health
Substance Misuse and Mental Health
1. Introduction
Substance misuse and mental health are closely interconnected.
For some people, alcohol or drugs are used as a way of coping with distressing thoughts, anxiety, low mood, trauma, loneliness or difficult life circumstances. For others, substance use may contribute to the development or worsening of mental health symptoms. Often, the relationship works in both directions.
This means that when supporting someone experiencing mental health difficulties, it is rarely enough to think about their mental health symptoms without also considering alcohol and drug use.
A person may tell you that cannabis helps them relax, while at the same time experiencing worsening paranoia. Someone may use alcohol every night because it helps them fall asleep, yet gradually develop poorer-quality sleep, increased anxiety and dependence. Another person may use stimulants recreationally and begin experiencing agitation, insomnia and suspiciousness.
These situations are rarely straightforward.
The role of the case worker is not to diagnose substance dependence, provide detoxification or act as an addiction specialist. Instead, the case worker should be able to ask about substance use comfortably, recognise when it may be affecting someone's mental or physical health, understand important risks, support engagement with appropriate services and escalate concerns when necessary.
NICE emphasises that people experiencing both severe mental illness and substance misuse should not be excluded from mental health services because they use substances, nor excluded from substance misuse services because they have a mental illness. Care should instead be coordinated around the person's combined needs.
This principle is fundamental to good case work.
A person should not become "too complicated" for support simply because more than one problem is occurring at the same time.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Explain the relationship between substance misuse and mental health.
Ask sensitively and non-judgementally about alcohol and drug use.
Recognise common ways in which alcohol and drugs can affect mental health, behaviour and risk.
Understand the difference between substance use, harmful use, dependence, intoxication and withdrawal at a practical level.
Recognise important risks associated with particular patterns of substance use.
Support people to engage with appropriate mental health and substance misuse services.
Recognise situations requiring urgent clinical or emergency escalation.
3. The Lecture
3.1 Understanding the Relationship Between Substance Use and Mental Health
When substance misuse and mental illness occur together, you may hear terms such as co-occurring conditions, comorbidity or dual diagnosis.
The terminology matters less than understanding the person in front of you.
Consider someone experiencing severe anxiety.
They discover that drinking several glasses of wine in the evening temporarily reduces their anxiety. Initially, this feels helpful. Over time, they begin drinking earlier in the day and require more alcohol to achieve the same effect. Their sleep deteriorates and they become increasingly anxious in the mornings. They begin cancelling appointments because they feel unwell.
Which came first: the anxiety or the alcohol problem?
In practice, this question may be less useful than understanding how the two are now maintaining one another.
The relationship may look something like this:
Psychological distress → substance use for short-term relief → temporary reduction in distress → longer-term physical, psychological and social consequences → increased distress → further substance use
This is one of the most important patterns to understand.
People usually use substances because the substance is doing something for them.
That does not mean that the behaviour is safe or beneficial overall. It means that if we want to understand why someone continues to use a substance despite negative consequences, we need to understand the role it plays in their life.
3.2 Why Do People Use Alcohol or Drugs?
Substance use occurs for many different reasons.
Some people drink alcohol socially and never develop significant problems. Others may begin using substances recreationally but gradually increase their use.
For people experiencing mental health difficulties, substances may also serve particular psychological functions.
Someone experiencing social anxiety may drink before social situations because it makes conversation easier. Someone who has experienced trauma may use cannabis because they feel it helps them switch off intrusive memories. Someone experiencing depression may use stimulants because they temporarily increase energy. Someone experiencing emotional instability may use alcohol when distressed because intoxication temporarily reduces uncomfortable emotions.
This is why simply asking:
"Why don't you stop?"
is often not very helpful.
A more useful question is:
"What does using it do for you?"
The answer can tell us a great deal.
If someone says:
"It's the only thing that stops me thinking at night,"
then simply removing the substance without addressing their distress leaves an important problem unresolved.
Good substance misuse work therefore involves understanding both the costs of the substance and the function it serves.
3.3 Substance Use Exists on a Spectrum
Not everyone who uses alcohol or drugs has an addiction.
It is useful to think about substance use along a spectrum rather than dividing people into two categories of "addicted" and "not addicted".
At one end, someone may use alcohol or another substance occasionally without obvious harm.
Further along the spectrum, use may become increasingly risky. The person might use more frequently, consume larger quantities or begin using in situations where it creates danger.
Harmful use occurs when substance use is already having adverse consequences.
These might include deterioration in physical health, worsening mental health, relationship breakdown, financial problems, loss of employment, unsafe behaviour or difficulties caring for children.
At the more severe end of the spectrum, dependence can develop.
A dependent person may experience a strong compulsion to use the substance, increasing difficulty controlling their consumption, withdrawal symptoms, tolerance and continued use despite increasingly serious consequences.
The purpose of this distinction for a case worker is not to diagnose precisely where someone falls on the spectrum.
Instead, it helps you recognise that the question:
"Do you use drugs?"
is only the beginning of an assessment.
You also need to understand how much, how often, in what circumstances and with what consequences.
3.4 Asking About Substance Use
People may feel ashamed, frightened or defensive when discussing alcohol and drugs.
Some may worry they will be judged. Others may fear involvement from the police, social services or other authorities. Some may worry that mental health professionals will stop treating them if they disclose drug use.
NICE therefore recommends a direct but flexible and motivational approach, taking into account the stigma associated with both mental illness and substance misuse.
Your tone matters enormously.
Compare these two questions:
"You're not using drugs, are you?"
and:
"Lots of people use alcohol or drugs when they're struggling. Can I ask whether you're using anything at the moment?"
The first question communicates that there is a preferred answer.
The second makes disclosure easier.
What do we actually need to know?
If someone reports substance use, gradually establish:
what substances they are using
approximately how much
how often they use them
whether their use is increasing
how they take the substance
whether they use several substances together
whether they experience problems when they stop
what effect the substance has on their mood and behaviour
whether it has led to physical, financial, relationship or legal difficulties.
NICE recommends asking specifically about the substance used, quantity, frequency, pattern of use, route of administration and duration of the current pattern.
You do not need to conduct an interrogation.
Often this information emerges naturally through a conversation.
3.5 Alcohol and Mental Health
Alcohol deserves particular attention because it is legal, socially accepted and widely available.
This can sometimes make harmful drinking less obvious.
A person who would be concerned about using an illicit drug every evening may consider drinking half a bottle of spirits every evening entirely normal.
Alcohol is a depressant of the central nervous system. Although it can initially produce relaxation or increased sociability, regular heavy use can contribute to a range of mental health difficulties.
These may include:
depressed mood
increased anxiety
irritability
poor sleep
impulsivity
aggression
memory problems
impaired judgement
suicidal behaviour.
Alcohol can also make existing mental health conditions more difficult to manage.
A person experiencing depression may become considerably more impulsive when intoxicated. Someone who would not act on suicidal thoughts when sober may do so after drinking heavily.
That is why alcohol use should be considered whenever risk changes unexpectedly.
3.6 Alcohol and Sleep: A Common Misunderstanding
One of the most common reasons people give for drinking in the evening is:
"It helps me sleep."
In one sense, they may be correct.
Alcohol can make someone feel sleepy and may reduce the time it takes them to fall asleep.
The problem is that it generally produces poorer-quality sleep later in the night.
People may wake frequently, experience fragmented sleep and feel less refreshed the next morning.
They may then become anxious or irritable during the day and drink again that evening.
This creates another reinforcing cycle:
Poor sleep → alcohol to help sleep → disrupted sleep quality → fatigue and anxiety → continued alcohol use
Understanding this cycle can be more helpful than simply telling someone that drinking is bad for them.
3.7 Alcohol Dependence and Withdrawal
One of the most important safety issues for case workers is understanding that someone who is physically dependent on alcohol should not necessarily stop drinking suddenly without medical advice.
This can sound counterintuitive.
You might reasonably assume that if alcohol is causing harm, stopping immediately must always be safest.
For a person who is dependent, however, abrupt cessation can lead to withdrawal.
Symptoms may initially include:
sweating
shaking
anxiety
nausea
insomnia
agitation
rapid pulse.
Severe alcohol withdrawal can result in seizures, severe confusion and delirium tremens, which can be life-threatening.
Planned assisted alcohol withdrawal should therefore be clinically managed. NICE guidance describes medically assisted withdrawal as a structured treatment process, and NICE guidance on coexisting psychosis and substance misuse specifically identifies withdrawal seizures and delirium tremens as significant physical risks.
What should the case worker do?
If someone who drinks heavily every day says:
"I've had enough. I'm going to stop completely tonight,"
do not simply congratulate them and send them home.
Establish whether they may be dependent and seek appropriate clinical advice.
You are not diagnosing alcohol withdrawal.
You are recognising that sudden cessation in a potentially dependent drinker can require medical supervision.
3.8 Cannabis and Mental Health
Cannabis is particularly relevant in mental health services.
People may use cannabis for relaxation, sleep, emotional distress or recreation.
However, cannabis can also contribute to anxiety, panic, altered perceptions and paranoid thinking. In people vulnerable to psychosis, cannabis use can be particularly problematic.
This does not mean that every person who uses cannabis will develop psychosis.
Nor does it mean that every person experiencing psychosis who uses cannabis has psychosis because of cannabis.
The relationship is more complex.
What matters for case workers is recognising patterns.
Suppose someone with a history of psychosis says:
"Cannabis calms me down."
You might then discover that they are smoking cannabis every evening and that their paranoia has gradually increased over the same period.
Rather than arguing:
"Cannabis is causing your psychosis,"
a more constructive approach may be:
"You've said it helps you relax, but you've also noticed the paranoia has been worse recently. Do you think there could be any connection?"
This invites reflection rather than confrontation.
NICE notes that even levels of substance use that might not ordinarily appear particularly harmful can have a significant effect on people experiencing psychosis.
3.9 Stimulants
Stimulant drugs include substances such as cocaine, amphetamine and methamphetamine.
Their effects vary depending on the substance, dose, frequency and individual, but they may produce increased energy, confidence, alertness and wakefulness.
At higher doses or with repeated use, they may contribute to:
severe anxiety
agitation
irritability
insomnia
impulsive behaviour
aggression
suspiciousness
paranoia
hallucinations or other psychotic symptoms.
This can create difficult clinical situations.
A person may present extremely agitated and paranoid after prolonged stimulant use.
From the case worker's perspective, the immediate priority is not to decide whether this represents a primary psychotic illness or a substance-induced presentation.
The priority is:
Is this person safe, and do they require urgent assessment?
Diagnostic questions can be resolved later by appropriately qualified clinicians.
3.10 Opioids
Opioids include heroin and a range of prescribed and non-prescribed opioid medications.
The most important acute risk associated with opioids is overdose.
Opioids can suppress breathing. In an overdose, someone may become extremely drowsy or unconscious and their breathing can become dangerously slow or stop altogether.
A person suspected of opioid overdose requires emergency medical attention.
Naloxone is a medication that can temporarily reverse the effects of opioid overdose. NHS England identifies take-home naloxone as an important harm-reduction intervention for people at risk of opioid overdose.
Where local substance misuse services provide naloxone, people using opioids and those close to them may be encouraged to carry it and receive appropriate training.
Again, the case worker's role is not to become an addiction prescriber.
It is to understand that opioid overdose is potentially fatal and time-critical.
3.11 Mixing Substances
Using several substances together can considerably increase risk.
People may not describe this as "mixing drugs".
They may say:
"I only had a few drinks and then took my tablets."
or:
"I had some cocaine but then took something to help me sleep."
One particularly concerning combination involves substances that depress the central nervous system.
For example, alcohol combined with opioids or sedating medications can increase the risk of excessive sedation, impaired consciousness and respiratory depression.
Substances may also interact unpredictably with prescribed psychiatric medication.
Case workers should therefore routinely consider:
What else has the person taken?
This is particularly important if someone appears unexpectedly drowsy, confused, agitated or physically unwell.
3.12 Substance Use and Prescribed Medication
People sometimes use substances deliberately to modify the effects of prescribed medication.
Someone may use stimulants because their medication makes them feel tired.
Someone may use cannabis because they feel medication makes them restless.
Someone may use alcohol because they cannot sleep.
NICE specifically recommends discussing the potential dangers of using alcohol or non-prescribed substances to counteract the effects or side effects of prescribed medication.
For case workers, discovering this can be clinically important.
Imagine someone tells you:
"My antipsychotic knocks me out, so I use cocaine during the day to keep going."
The correct response is not simply:
"You need to stop taking cocaine."
The prescriber also needs to know that the person is experiencing significant sedation from medication.
The substance use and the medication problem may need to be addressed together.
3.13 Intoxication, Withdrawal and Mental Illness
One of the challenges of working with substance misuse is that intoxication and withdrawal can both change someone's mental state.
Someone may appear:
confused
irritable
frightened
agitated
depressed
euphoric
suspicious
impulsive
unusually drowsy.
The question is not always:
"Is this their mental illness?"
Sometimes the safer question is:
"Could substances be contributing to what I am seeing?"
This does not mean assuming that everything is caused by drugs.
That would simply be another form of diagnostic overshadowing.
Instead, mental health symptoms and substance use should be considered together.
3.14 Substance Use and Risk
Substance use can change risk very quickly.
NICE advises clinicians to consider how substance misuse affects risks including:
self-harm
suicide
self-neglect
accidental overdose
accidental injury
violence
exploitation
abuse
offending behaviour
physical illness
interactions with medication.
Recent NHS England guidance also emphasises the importance of recognising co-occurring substance use when assessing safety and risk in people experiencing severe mental health problems.
The important point is not that people who misuse substances are inherently dangerous.
They are not.
Rather, intoxication, withdrawal and particular substances can affect judgement, impulse control, perception and vulnerability.
3.15 Suicide and Substance Use
Substance use deserves particular attention when someone is experiencing suicidal thoughts.
Alcohol and drugs can increase impulsivity and reduce inhibition.
Imagine someone tells you:
"Sometimes I think everyone would be better off without me, but I would never actually do anything."
That information matters.
Now imagine they add:
"Although when I've been drinking I don't really know what I'm doing."
The risk picture has changed.
NHS England notes a substantial overlap between alcohol or drug problems and suicide among people receiving mental health care.
When assessing or escalating concerns about suicide, always consider whether alcohol or drugs may increase the person's likelihood of acting impulsively.
3.16 Asking Without Judging
A case worker's attitude can determine whether a person continues talking.
Suppose someone tells you:
"I've started using cocaine again."
Responses such as:
"Why would you do that?"
or:
"After everything that's happened, you should know better."
may shut down the conversation.
A more useful response might be:
"Thanks for telling me. When did it start again?"
That does not mean approving of the behaviour.
It means prioritising understanding.
NICE guidance for both alcohol and drug misuse emphasises supportive, respectful and non-judgemental care.
People are more likely to disclose risk when they expect curiosity rather than criticism.
3.17 Understanding Motivation to Change
People do not always want to stop using substances.
This can be difficult for professionals.
You may be able to see clearly that alcohol or drugs are damaging someone's health, relationships and mental state.
The person may nevertheless say:
"I don't want to stop."
Arguing usually achieves very little.
A useful way of thinking about change is that people may move through different stages.
Someone may initially see no problem with their substance use. Later, they may begin wondering whether it is causing harm. They may then decide to cut down, attempt change, relapse, try again and gradually develop more stable changes.
Progress is rarely linear.
The case worker's task is not to force someone through this process.
Instead, try to understand where they currently are.
If someone has no intention of stopping cannabis, a productive conversation might still be possible about whether they would consider using less often.
If someone is not willing to stop drinking, they may still agree not to drink when feeling suicidal.
If someone uses opioids and is not ready for treatment, they may still engage with overdose-prevention advice.
This brings us to an important concept.
3.18 Harm Reduction
Sometimes the safest and most realistic goal is not immediate abstinence.
Harm reduction means reducing the risks associated with substance use even when the person is not currently willing or able to stop completely.
Depending on the substance and circumstances, this might involve specialist advice about:
avoiding dangerous combinations of substances
overdose prevention
naloxone
blood-borne virus testing
safer injecting advice
avoiding using alone
recognising signs of overdose
reducing quantity or frequency
engaging with treatment services.
Harm reduction should be provided by appropriately trained professionals and services.
The principle for case workers is important:
A person does not have to achieve abstinence before we can help make them safer.
3.19 "No Wrong Door"
Historically, people experiencing both mental illness and substance misuse have sometimes fallen between services.
A mental health service might say:
"We can't treat the mental health problem until they stop using drugs."
A substance misuse service might say:
"Their mental health is too complicated for us."
The person then receives inadequate treatment for both problems.
Modern guidance is clear that this should not happen.
NICE states that people with psychosis and coexisting substance misuse should not be excluded from mental health care because of substance use, and should not be excluded from substance misuse treatment because they have psychosis.
NHS England similarly describes "no wrong door" and "everybody's job" as key principles when supporting people experiencing co-occurring mental health and alcohol or drug problems.
For the case worker, this means helping services communicate with one another rather than simply redirecting the person from one organisation to another.
3.20 The Case Worker's Role in Coordinated Care
People with co-occurring difficulties frequently have several professionals involved.
They may have:
a GP
psychiatrist
community mental health team
substance misuse worker
housing worker
social worker
probation officer
family members or carers.
Without coordination, everyone may know one part of the story while nobody sees the whole picture.
This is where case work can be especially valuable.
You may notice that the substance misuse worker does not know that someone's paranoia has recently worsened.
The psychiatrist may not know that the person has resumed heavy drinking.
The GP may not know that they are taking non-prescribed tablets bought online.
The case worker can help ensure that relevant information reaches the appropriate people, subject to confidentiality, consent and safeguarding requirements.
NICE recommends coordinated, multidisciplinary working and assessment for people experiencing psychosis alongside substance misuse.
3.21 Relapse Does Not Mean Failure
Substance misuse often follows a relapsing course.
Someone may stop drinking for six months and then begin again.
It can be tempting for professionals to think:
"We are back at the beginning."
That is rarely true.
The person may have learned which situations trigger their drinking. They may have demonstrated that they can maintain abstinence for six months. They may engage with support more quickly this time.
A relapse should therefore prompt curiosity:
What changed?
Was there a relationship breakdown?
Did their depression worsen?
Did they stop attending appointments?
Did they return to a social environment where substances were readily available?
Did medication side effects become difficult to tolerate?
The purpose is not to identify someone to blame.
It is to understand what can be learned.
3.22 When Someone Does Not Want Help
People have the right to make choices that professionals may consider unwise, provided that relevant legal and capacity considerations do not indicate otherwise.
A person may continue drinking despite knowing the health risks.
They may decline referral to a substance misuse service.
They may choose to continue using cannabis.
Your role is not to punish them or withdraw support because they have made a choice you disagree with.
You can continue to:
provide information
discuss risks
encourage engagement
offer opportunities for change
monitor wellbeing
respond if risk increases.
At the same time, declining treatment does not mean that serious risk should be ignored.
Where concerns arise regarding safeguarding, capacity, serious self-neglect, risk of harm or medical emergency, normal escalation procedures still apply.
3.23 Recognising an Emergency
Most substance use that case workers encounter will not require an ambulance.
Some situations, however, can become medical emergencies very quickly.
Seek urgent medical or emergency assistance according to local procedures if a person:
is unconscious or cannot be woken
has very slow, abnormal or absent breathing
has a suspected opioid overdose
has a seizure
is severely confused or disorientated
is experiencing severe alcohol withdrawal
has taken a significant or unknown overdose
is experiencing severe agitation or behaviour that creates immediate danger
has significant chest pain after stimulant use
has severe difficulty breathing
has a markedly altered level of consciousness
appears otherwise seriously physically unwell.
Do not wait until you know exactly what substance was taken.
Do not assume that someone is "just drunk".
Do not leave an unconscious person to "sleep it off".
The principle is the same as in the physical health lesson:
You do not need to diagnose the problem before recognising that someone needs urgent help.
4. Clinical Perspective
Always Ask About Substances
One of the easiest mistakes to make is simply not asking.
People do not always volunteer substance use.
Someone may tell you about anxiety, depression and poor sleep for several appointments before mentioning that they drink a bottle of spirits each evening.
Substance use should therefore form part of routine mental health enquiry where relevant.
Normalising the question can help:
"I ask everyone this because alcohol and drugs can have quite a big effect on mental health."
Ask What the Substance Does for the Person
If you understand the function of the substance, you understand much more about why change is difficult.
Someone who uses cannabis recreationally at weekends presents a different situation from someone who says:
"It's the only thing that stops the voices."
The second person may be frightened of losing what they perceive as an essential coping strategy.
That fear needs to be understood if engagement is going to succeed.
Look for Change From Baseline
If someone normally drinks two beers at weekends and suddenly begins drinking every day, something has changed.
If someone who has been abstinent from cocaine for a year begins using again, something may have happened.
Changes in substance use can be an early indication of worsening mental health or increasing social stress.
Ask:
"What's been happening recently?"
Do Not Assume Intoxication Explains Everything
Someone who has been drinking can still have:
a head injury
low blood sugar
an overdose
infection
suicidal intent
acute psychosis
another medical emergency.
Do not allow intoxication to become a reason for overlooking other serious conditions.
Do Not Recommend Sudden Alcohol Cessation Without Considering Dependence
This is a particularly important clinical safety point.
If someone appears dependent on alcohol, abrupt cessation may be dangerous.
Seek clinical advice and help them access appropriate treatment.
Never Punish Honesty
If someone tells you they have relapsed, disclose dangerous substance use or admit that they have been mixing drugs with medication, your immediate response matters.
If honesty produces anger or punishment, the next disclosure may not happen.
Try:
"I'm glad you've told me. Let's work out what this means and what we need to do next."
Remember That Risk Can Change Quickly
Someone's risk when sober may be very different from their risk when intoxicated.
Someone who confidently says they would never act on suicidal thoughts may become impulsive after consuming large quantities of alcohol.
Substance use should therefore be considered whenever there is a significant change in self-harm, suicide, aggression, vulnerability or safeguarding risk.
Stay Within Your Role
Do not prescribe detoxification plans.
Do not tell someone how to alter prescribed medication.
Do not provide technical injecting advice unless this specifically falls within your trained role.
Do not attempt to diagnose complex substance-related syndromes yourself.
Your job is to:
ASK → UNDERSTAND → SUPPORT → COORDINATE → ESCALATE
5. Summary
Mental health difficulties and substance misuse frequently occur together, and the relationship between them can be complex.
Some people use substances to manage psychological distress. Substance use can then create further mental, physical and social problems, producing a cycle that may become increasingly difficult to break.
Case workers should therefore ask routinely and non-judgementally about alcohol and drug use, focusing not only on whether someone uses substances but also on the amount, frequency, pattern, purpose and consequences of their use.
Alcohol, cannabis, stimulants, opioids and other substances can all affect mental state and risk in different ways. Particular attention should be given to overdose, severe intoxication, alcohol withdrawal, medication interactions and sudden changes in mental state.
Substance misuse can also significantly alter suicide, self-harm, vulnerability and behavioural risk. NICE and NHS England guidance emphasises coordinated care rather than excluding people from services because their presentation is complicated by substance use.
For case workers, the central principles are:
ASK → UNDERSTAND → SUPPORT → COORDINATE → ESCALATE
Ask about substance use openly and without judgement.
Understand what the person is using, why they are using it and how it affects them.
Support realistic change and harm reduction rather than relying solely on instructions to stop.
Coordinate with mental health, primary care and substance misuse services where appropriate.
Escalate when there are concerns about overdose, withdrawal, serious physical illness, severe deterioration or significant risk.
Above all, remember that substance misuse is not a reason to withdraw compassion, support or mental healthcare.
6. Further Reading
NICE CG120 – Coexisting Severe Mental Illness (Psychosis) and Substance Misuse
This is particularly useful for understanding the principles of coordinated care, recognition of substance misuse in mental health settings, risk assessment, non-exclusion from services and multidisciplinary working.
NICE CG115 – Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence
Provides guidance on assessing and treating harmful drinking and alcohol dependence, including the importance of empathetic, non-judgemental care and medically assisted withdrawal where appropriate.
NICE CG51 – Drug Misuse in Over 16s: Psychosocial Interventions
Provides guidance on effective psychosocial approaches to drug misuse and emphasises dignity, respect, appropriate professional competence and support for families and carers.
NHS England – Acute Inpatient Mental Health Care for Adults and Older Adults
Includes useful principles for working with people who have co-occurring alcohol or drug problems, including the concepts of "no wrong door", partnership working and harm reduction.
NHS England – Mental Health Personalised Care Framework
Provides contemporary guidance on coordinated, person-centred mental healthcare and specifically recognises the importance of identifying and managing co-occurring drug and alcohol problems when considering safety and risk.
7. Knowledge Check
Question 1
A person experiencing severe anxiety tells you that they drink alcohol every evening because it is the only thing that helps them relax. What is the best initial response?
A. Tell them they must stop immediately
B. Tell them that alcohol never helps anxiety
C. Explore what the alcohol does for them, how much they are drinking and what consequences it is having
D. Ignore the drinking and focus only on the anxiety
Correct answer: C
Understanding the function and pattern of someone's substance use is an important first step.
The alcohol may provide temporary relief while also contributing to worsening anxiety, poor sleep or dependence.
A is incorrect because immediate cessation may be inappropriate, particularly if dependence has developed.
B is too simplistic. Alcohol may provide short-term subjective relief even when it worsens anxiety overall.
D is incorrect because the anxiety and alcohol use may be closely interconnected.
Question 2
Which statement best describes the relationship between substance misuse and mental health?
A. Substance misuse always causes mental illness
B. Mental illness always leads to substance misuse
C. The relationship can work in both directions and varies significantly between individuals
D. The two should be treated entirely separately
Correct answer: C
Mental health problems may contribute to substance use, substances may worsen or contribute to psychiatric symptoms, and both may interact over time.
A and B are too absolute.
D is incorrect because good care should consider both conditions together.
Question 3
A person who drinks heavily every day tells you they intend to stop drinking completely tonight. What is the most important consideration?
A. Everyone should stop alcohol immediately
B. They may require assessment because sudden withdrawal can be dangerous if they are dependent
C. They should replace alcohol with cannabis
D. They should reduce their psychiatric medication at the same time
Correct answer: B
Abrupt withdrawal from alcohol in a dependent person can lead to serious complications, including seizures and delirium tremens.
A is incorrect because immediate unsupervised cessation may be unsafe in someone who is dependent.
C and D are inappropriate and potentially dangerous advice.
Question 4
Which is the best way to ask about drug use?
A. "You don't use illegal drugs, do you?"
B. "Why are you taking drugs?"
C. "Lots of people use alcohol or drugs when they're struggling. Are you using anything at the moment?"
D. Avoid asking unless the person raises it first
Correct answer: C
A neutral, normalising question is more likely to encourage honest disclosure.
A suggests that there is a preferred answer.
B may sound accusatory.
D risks missing clinically important information.
Question 5
A person with psychosis tells you that cannabis helps them relax, but their paranoia has recently increased. What is the best response?
A. Tell them cannabis definitely caused their psychosis
B. Ignore the cannabis because it relaxes them
C. Explore whether changes in cannabis use may be associated with changes in their paranoia and discuss this with the clinical team
D. Immediately discharge them from the mental health service
Correct answer: C
Cannabis can affect psychotic symptoms, particularly in vulnerable individuals, but the relationship should be explored carefully rather than oversimplified.
NICE states that even relatively low levels of substance use can have significant effects in people experiencing psychosis.
A makes an unsupported causal assumption.
B ignores potential risk.
D directly conflicts with NICE guidance that people should not be excluded from mental healthcare because of substance misuse.
Question 6
Which of the following may indicate opioid overdose?
A. Extreme drowsiness or unconsciousness with very slow breathing
B. Mild hunger
C. Increased interest in exercise
D. Mild insomnia alone
Correct answer: A
Opioids can suppress respiration. A person who is unconscious or has dangerously slow or absent breathing requires emergency medical attention.
Naloxone can temporarily reverse opioid overdose and is an important harm-reduction intervention.
Question 7
A person tells you they resumed cocaine use after six months without using it. What is the most helpful approach?
A. Tell them that all their previous progress has been lost
B. Discharge them because treatment has failed
C. Explore what happened before the relapse and what can be learned from it
D. Avoid discussing it to prevent embarrassment
Correct answer: C
Relapse does not mean that previous progress has disappeared.
Understanding the factors that preceded relapse may help prevent future recurrence.
A may reinforce hopelessness.
B is punitive and therapeutically unhelpful.
D misses an important opportunity to understand the person's current difficulties.
Question 8
Which statement best represents the principle of harm reduction?
A. Nothing useful can be done unless a person stops using substances completely
B. Risk can sometimes be reduced even when the person is not ready for complete abstinence
C. Substance misuse should simply be accepted without discussion
D. Case workers should provide their own detoxification programmes
Correct answer: B
Harm reduction aims to reduce serious consequences even when abstinence is not immediately achievable.
This might include referral for naloxone, safer-use advice or support to reduce consumption through appropriately trained services.
A is incorrect because meaningful risk reduction may still be possible.
C does not address potentially preventable harm.
D would usually fall outside a case worker's professional role.
Question 9
A person with depression tells you that they sometimes think about suicide but would never act on the thoughts. They then explain that when heavily intoxicated they become very impulsive. What should you do?
A. Ignore the alcohol because they denied suicidal intent when sober
B. Recognise that intoxication may alter the risk and escalate or assess according to local procedures
C. Tell them simply to stop drinking
D. Wait until the next routine appointment
Correct answer: B
Alcohol and other substances can reduce inhibition and increase impulsivity.
The person's risk when intoxicated may therefore differ considerably from their risk when sober.
A and D could overlook significant risk.
C alone does not adequately address the immediate safety concern.
Question 10
A person with psychosis is told that the substance misuse service will not support them because of their mental illness, while their mental health service says they must stop using drugs before they can receive treatment. Which principle is most relevant?
A. People should choose only one service
B. Mental illness should always be treated before substance misuse
C. The person should receive coordinated care and should not be excluded from either service solely because both problems coexist
D. Substance misuse automatically makes mental health treatment ineffective
Correct answer: C
NICE recommends that people experiencing psychosis alongside substance misuse should not be excluded from mental health services because they use substances, or from substance misuse services because they experience psychosis.
NHS England similarly promotes the principle of "no wrong door" for people with co-occurring mental health and substance use problems.
This is particularly important for case workers, who may need to help coordinate care across several different services.
