Ian Hamilton discusses the impact that substance use and addiction can have on a young person’s mental health.
Ian and freelance journalist Jo Carlowe discuss mental health problems and substance use co-occurring, the lack of data on young people’s substance use, risk factors and pathways to support.
Ian is also the author of our topic guide on addiction and substance use, it includes useful links and what’s in the pipeline.
Intro: This podcast is brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website www.ACAMH.org and follow us on social media by searching ACAMH.
Interviewer: Hello, welcome to the In Conversation podcast series for The Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Ian Hamilton, associate professor of addiction at the University of York. Ian is interested in the relationship between substance use and mental health and has written the ACAMH topic guide on addiction and substance use. Ian, welcome. Can you start by introducing yourself with a few details about your role?
Ian Hamilton: Yes, it’s a pleasure to do this. So I’m based, as you said, at the University of York. Prior to joining the university as a researcher and lecturer, I was working with mainly people who had drug and alcohol problems, but also co-occurring mental health problems. In fact, it’s really difficult to find people who have problems with addiction who don’t also have mental health problems. I worked as a psychiatric nurse with those people for 10, 15 years and then, using that experience, really, started the University, doing research into the same broad area really. So that’s what I’ve carried on doing since.
Interviewer: You may have partially answered this already because as you say, you trained and worked as a psychiatric nurse. How did you come to be interested in this dual relationship of substance use and mental health? Was it purely because you kept witnessing this dual relationship?
Ian Hamilton: Yes, in part but I think I was just also lucky in that the area I trained in had an NHS residential drug detox unit, which was one of, I don’t think any of them exists now, but going back 20-odd years, it was one of very few NHS funded residential detox inpatient units. So that’s where my interest was sparked. You know, people are very articulate. They clearly all had one thing in common and that was that they had experienced some kind of adversity as they were growing up or later on in adulthood. So it was through them, really. Just talking about their experiences and sharing those with me, that I became interested.
Interviewer: I’m curious about what the mental health issues were that you can differentiate from substance use issues.
Ian Hamilton: Yeah. Well, I mean there’s a whole spectrum, aren’t there? We know that some drugs are associated with very specific mental health reactions. So, you know, very obvious one that most people know about is cannabis. We still don’t know whether cannabis actually triggers psychosis, but it’s certainly strongly associated with it and you’d be hard pushed as a psychologist, as a medic, as a nurse, not to come across people who have developed mental health problems alongside their cannabis use. It also seems that when they reduce their cannabis use, for some of them, anyway, their, particularly, psychotic symptoms kind of tail away, but then when they restart cannabis use, unfortunately they experience, usually quite acute reactions. So there’s those kind of very distinct relationships. But I think generally, because there’s a commonality between poor mental health and problematic substance use, in particularly childhood or formative years, where people, I guess use substances to cope with whatever kind of trauma they’ve experienced. And alongside that, you have things like depression and anxiety or even post traumatic stress disorder. So you end up with this kind of tangle, really of you know, life events, substance abuse and reactive mental health problems.
Interviewer: Right. It’s probably quite hard to unpick.
Ian Hamilton: Yeah, I think it is and I think that’s the challenge for practitioners is, you know, I think practitioners and researchers are particularly curious about which came first. Was it the drug problem that then created the mental health problem or vice versa? And in truth, I’ve not met many clients who are equally as fascinated. They just want help. They don’t really care which came first but of course, understanding which came first may help with treatment. But it’s just that really sharing just an observation of the difference between what clients think is important and what practitioners see as important.
Interviewer: We’ll look at that in more detail. I just want to look at numbers. So, in your topic guide you cite home office figures on drug use and I’m wondering what is known about the prevalence and trends of drug use amongst young people in the UK?
Ian Hamilton: Well, it’s a pretty short reply. Not a lot really. I think some of the problems with counting the number of young people with a drug problem are similar to those with an adult. So I don’t want to go through it all but, for example, because most of these drugs are illegal, that in itself means it’s potentially a barrier to people admitting to you. And perhaps even more so as a child or a younger person. But also, I think part of the problem is just getting good accurate and reliable information about how many people are using drugs, whether you’re an adult or a young person. So, for example, in adults the particular problem is that people who are homeless and those in prisons and those with an address which is a university one are excluded from these surveys. Now, obviously the latter group doesn’t really apply to young people, but certainly, being in custodial care or not having a home, being roofless, means that we’ve underestimated the number of young people who use drugs. But the Home Office data is the best of what we have, really. What it does help with is spotting trends over time. So, you wouldn’t want to use a single year as being informative of what’s going on, but you can see trends over time.
Interviewer: And what about alcohol and tobacco? I think in the guide, you describe these as drugs, as much as any other substance, but played down in some way, I think. Would you agree?
Ian Hamilton: Yeah, I agree totally, Jo. So I mean, what the alcohol industry has very cleverly done is even informed the way that we use the expression, drugs and alcohol, separating the two and of course alcohol is a drug. It may be regulated in a different way, but it’s as much a drug as crack cocaine is, or amphetamines. So, you know, the industry has had a hand in this and many other things but yes. And alcohol and tobacco, of course, are two of the most commonly used drugs in society and, no great surprise, are also two of the drugs that we’re most likely to be initiated into as we develop through our life. Particularly in your teenage years, and we know that, unfortunately, they have quite severe health consequences for people when they’re used, you know, frequently and in a greater quantity.
Interviewer: So are they a kind of gateway for young people into other substance use?
Ian Hamilton: I think they definitely are and if we take the example of tobacco, rather uniquely in the UK, we have a tradition of rolling cannabis joints with tobacco, even though there may not be a need to do that. In the past, there was a need because it was the way you combusted cannabis resin but there isn’t always a need to do that now. So, we estimate that something like seven out of ten young people who smoke cannabis, do that with a joint as tobacco in it. So inadvertently, they may consider themselves as non-smokers, non tobacco smokers, but of course they’re, you know, opening themselves up to the risk of becoming dependent on tobacco, inadvertently through their exposure to cannabis joints.
Interviewer: I’m just wondering why alcohol and tobacco have been played down. Is that the pressure that comes from industry or is there something else at play?
Ian Hamilton: Yeah. No, I think that’s a good point. In part. I mean, we can’t just blame industry on its own and I think there’s just wider acceptance, isn’t there? That you can’t escape alcohol. You can escape tobacco. Tobacco, of course, because there’s been a concerted effort to reduce the population use of smoking and that’s largely been successful. But alcohol still remains embedded in everything that we do, culturally from birth to death and everything in between. So, as a drug in society, it’s a rather odd position to be in, where we celebrate. We kind of invite young people to use alcohol in a way that we wouldn’t do with many other drugs, really.
Interviewer: Yes, it’s often not thought about, isn’t it?
Ian Hamilton: Yeah, or even to the extent that we want to prepare young people for adult kind of career alcohol use by you know, this whole debate over whether it’s right or wrong to introduce alcohol to a child at an early age. And you know, we look to France for guidance on this and hold them in great esteem in terms of you know, having a little bit of alcohol with a meal, etcetera. I mean, I think it’s important to say, overall, whether it’s alcohol or any other drug, the vast majority of young people who use drugs won’t develop a problem. So, it might be better for their health if they reduce their intake but they’re not going to develop cancer or die early or have any other adverse outcome. In fact, most of what they will experience will be pleasure and that’s something that’s really been underplayed, I think, in drugs research. We need to say what’s normal and what’s normal is for young people not to use drugs rather than to use them. So, the vast majority of young people won’t use drugs. Of those that do, again, the vast majority will not come to any harm and likely just enjoy it but then grew out of their use.
Interviewer: Right. Of those young people that do experiment with drugs, and one thinks of adolescence as a time when you might be experimenting, what are the factors that make some young people at risk of developing problems with substance use while for others the impact is minimal?
Ian Hamilton: Yeah. So again, that’s a good point and we’re still trying to understand this. As best as we can tell, it would seem to be around a very strong correlation between adverse childhood events and drug use and of problem drug use, not just drug you. So, exactly. Why is one person, young person, able to pick up and drop cannabis as they choose, but for others, they end up using it every day and maybe go on to use other drugs. So, different theories explain this but one I’m particularly drawn to is this idea of self medication. So, actually what people find, young people find, is that drugs work in a way that nothing else they try does. So, cannabis, for instance may well just dampened down feelings or thoughts that they have that they find troublesome. It may even give them some pleasure and some feeling of warmth and contentment that they don’t get in life. So, in that way, they’re medicating against something that’s negative or adverse in their life or their current experience.
Interviewer: I suppose conversely, what factors are protective?
Ian Hamilton: Well, I don’t think this will be a surprise to anyone but having good family relations, having a family, first of all and having a supportive family as well is what’s broadly thought of or termed social capital. So, just again, family, having opportunities in terms of education and being encouraged, being supported, having networks of friends who, again, you have a healthy relationship with. And yes, I think just broadly being encouraged and when you do have problems, having some bank of experience of how to deal with those and some feeling of certainty that you can go and get help, should you need it. So, I think what we all strive for as parents and those that are interested in young people, just ensuring that they feel supported, feel encouraged and are nurtured. And obviously all of those aspects are compromised for young people who do end up having problems with drugs. It’s because again, they’re trying to soothe and trying to fill that void in their life.
Interviewer: I was going to ask about the signs that parents and professionals can look for, that indicate problem drug use in children young people. But from what you’re saying, you’re saying it’s really essential to have somebody, probably an adult rooting for you, batting for you. And actually, for some of the people most likely to be affected, they may not have that.
Ian Hamilton: They may not but I think, as I say, I’ve got to be careful here because our knowledge around who’s at risk is just developing and it’s shockingly poor, to be honest. So, our ability to predict who is at risk, particularly, which young person might be at risk. We can put together a constellation of factors, but it’s not foolproof. So, just falling out of education, perhaps having contact with the police and experience of abuse, would all be indicators but then, they don’t necessarily guarantee that someone will develop a drug problem. Equally, the absence of those factors doesn’t fully protect or mitigate young people from developing a problem with drugs. I think, as a parent or as a youth worker or even a professional who’s involved with young people, rather than going for the kind of let’s try and catch them out with their drug use approach, I think it may sound cliche. But just ensuring there’s open channels of communication and that all the interactions aren’t just about stuff that’s really serious around mental health and drug use. But rather, it’s just about building rapport and ensuring that trust is there, is far more important, I think.
Interviewer: Right, but are there any particular red flags that professionals, teachers and also parents and friends should look for as a sign that a young person is starting to have a problem with drugs?
Ian Hamilton: Yeah. I mean, in part, it might vary drug by drug. So, certain drugs produce certain behaviors and ways of acting and therefore, the signs and symptoms, as it were, will vary a little bit. But more broadly, I guess anything that you notice that’s a bit unusual. The person isolating themselves, perhaps asking for money more than they would do, being a bit secretive or a bit guarded. Or the other way, just behaving out of character. I think parents are quite well place to spot this. Someone who just appears a bit more talkative or a bit more outgoing than they usually are, might be a sign of a young person using a stimulant for example. But you’d want some other way of corroborating that and hopefully if you’re able to, the best way is just to find the right time to talk to the person about it. And when you raise your concerns, just be open and say, look. This is how it appears to me. What do you think? It’s done from a point of concern, rather than a point of, as I say, trying to catch someone out.
Interviewer: Let’s suppose that discussion takes place between a worried adult and a young person. If there does then appear to be a problem, where can they signpost that child for help?
Ian Hamilton: Well, I think it would depend on what’s going on. So again, I think for many people, that conversation might be sufficient and there’s no need to bring anyone else into it. I think obviously, if it’s something that the young person and the parent feels is a bit more serious and they feel out of depth with, then there’s some really good online resources. Probably my first port of call, other than online, would be to go and see your family doctor. I think that’s slightly easier to access than maybe, a specialist drug service because specialist drug services are really orientated around adults, in the main. I don’t think those are easy places to walk into for a parent or for a child. I think I would go down the route of trying to get some help from your local family doctor. If you don’t feel that has got you anywhere, or you’re not being taken seriously then yeah, I think you could try and get some help from your specialist drug team, of which there will be one in every area, up and down the country.
Interviewer: When you mentioned online resources, are there a couple that you can mention?
Ian Hamilton: Yeah, I think they’re on the topic guide but websites that are run by some of these larger drugs charities. So, for instance Addaction provide really good website and good basic information around drugs. DrugWise is another one. So, both of them and there are others. And also to say, Talk to Frank which is the government’s website. It’s really improved over the last year. It used to be a bit one-sided on the information it gave, as in it was all negative and scary around drugs. It seems somebody has worked on it and balanced it up a bit more. So, I think those three websites. So, Addaction, DrugWise or Talk to Frank, the government website, are three good ways to try and get information.
Interviewer: Okay, great. If something more specialist is required, what types of interventions are around that have been shown to be helpful?
Ian Hamilton: Well, that’s part of the problem. We have some interventions for adults, but there are very few, if any, of these interventions which are tested on particularly, young adolescents. So, although these young people may be offered things like motivational interviewing or cognitive behavioral therapy or even substitute prescribing where that’s appropriate, none of those have really been evaluated for young people. What we do know, however is whether you’re young middle-aged or old, the thing that seems to make the biggest difference in this area is nothing fancy and grander than the ability of the therapist to form a rapport. So to be honest, to be engaging, to give time, to be respectful and someone that builds trust. So, it seems that, irrespective of the intervention, it’s actually the therapist who makes the biggest difference. Again, it almost seems like common sense, but it’s worth saying, if you are able to find a therapist with all those qualities, it improves the outcomes, i.e. improves the benefits that you’ll experience when you do go for help.
Interviewer: To find that therapist, that would be through your GP or through your local drug service?
Ian Hamilton: Yeah, either. Probably, as I say, the GP in the first instance because they’ll have that relationship and know how to access their local drug team in the first instance, if that’s what they recommend. So, yeah, that would definitely be the first port of call.
Interviewer: Right. You’ve already mentioned this but you’ve described the research and evidence base for clinical interventions as adult-centric.
Ian Hamilton: Yeah.
Interviewer: What should be done to change that or what is being done?
Ian Hamilton: Well, I think, very little and part of the reason for that is understandably, researchers probably find young people quite difficult to, well, certainly as a topic and as an issue, find it quite difficult to engage with. You’ve got all the ethical issues to deal with, in addition to trying to recruit and keep in touch with young people once you’ve started a trial but I don’t think that should deter us from doing it. I’d like to see some funding calls from some of the big research funders to view this as a priority because we know that if we intervene early, not only is it economically sensible, but also just in terms of nipping in the bud any drug problem careers that might be developing at that age, we can really, as I say, stop and find alternative ways for people to get the help they need with whatever issues they’re trying to use drugs to mitigate. So, I think it makes sense to intervene as early as possible. Having the evidence base to support that is something we desperately need and I’d like to see research funders really get behind that and make it a priority.
Interviewer: And are there any research projects that you’re aware of, that are worth mentioning, around this area?
Ian Hamilton: No, not really. Not in terms of clinical interventions. I mean, there are some really good good pieces of work being done around drugs education, which is more around what should you offer in schools? So again, I refer to that in the topic guide. There’s a bit more information on that because that’s been a really troublesome area to try and work out what’s best. Actually, some of the older drugs education stuff given to young people actually made them more interested in drugs rather than less interested. So, it’s a really important area that we get right.
Interviewer: Right. What happened there? What type of thing that would have the opposite…?
Ian Hamilton: Well, we think what happened was, you can imagine what it’s like in a school assembly. You wheel in the person who is in recovery, which is fantastic. They are full of all sorts of stories of what their journey through addiction was like and you perhaps, have the police there, who talk about what will happen etcetera, etecetera. And we think what that might be doing, inadvertently and it’s obviously not the intention, but is actually sparking an interest in some young people in drugs, that they wouldn’t otherwise have had. So, it’s that classic thing, isn’t it? Of saying to people don’t do something and they do the opposite. So, that’s the last thing we want and also, I think some young people, when they heard all these scare stories, they couldn’t really relate to it. It wasn’t relevant to their experience with drugs. So again, this is why the Talk to Frank website is bit more balanced now and why any information given to young people or adults, for that sake, should be balanced. It should talk about pleasure as well as harm because that’s what people will recognise and be able to relate to. It’s just far more credible than trying to scare people.
Interviewer: Right. What policy changes or further clinical guidelines or training would you like to see to help prevent addiction in young people?
Ian Hamilton: I think one of the easy wins we could have, and I’m completely baffled as to why it hasn’t happened yet is the joining up of mental health and addiction services. So, I find it a curious separation given the crossover there is between the two. Most young people who will develop a drug and alcohol problem or have the early signs of it, will also be embarking on a career in mental health as well. So, if we could provide training and easy access to services which are fully integrated rather than separate and sat in silos, I think we could learn a lot from each other. Most importantly, we could ensure that young people get the kind of integrated and joined up help they need at the right time in the right place.
Interviewer: Is that starting to happen anywhere?
Ian Hamilton: It is. There’s one or two examples. I suspect, unless there’s any kind of central government push behind it or by the Department of Health, they’ll remain quirky and unusual rather than the norm. So, there’s areas such as those in Manchester which have a more integrated service for adults and young people and that should be celebrated. But, as I say, I suspect it’s an outlier and looks as it might remain that way unless there’s some kind of impetus from central government to really get behind that, nationally to integrate services. I guess it’s one of the things that must be really hard for people working with young people, whether they’re nurses or whatever other profession they come from, is they tend to be trained and have experience and confidence and skills in one of the areas but not both. So, those workers who are really experienced another stuff around mental health, but lack the confidence and the knowledge around what to do with people who have drug problems and vice versa. So, a lot of this is just about giving staff the confidence and the know-how, which isn’t particularly expensive.
Interviewer: Right. I’m assuming then, that some young people who have an addiction but do have mental health needs, get siloed off into one section. Somebody would say where they just have an addiction, it’s not a mental health issue and they actually don’t get those need supported, then.
Ian Hamilton: Yeah, absolutely, which I guess is frustrating for those young people or worse, just means that perhaps, they do get some help with their drug problem but their depression or anxiety continues. So, that obviously increases the risk of relapse. So, it’s not to say that over time, they won’t get through all that, but we could speed up the process of recovery. There are also some interesting gender differences that we see in adults, that I think needs to be explored in young people. So we knew that young women, I’m told, when I say young women, I’m talking about young adult women rather than adolescent women. We know that young adult women go from exposure to drugs to developing a problem much faster than men do. So, they developed their drug problem in a matter of a few years compared to men, who it takes a little bit longer for and I suspect that’s probably true for young women as well or girls, rather.
Interviewer: Is that is a physiological difference?
Ian Hamilton: It’s probably a combination of both. It’s probably, you know a mixture of environment and something biological as well. But again, we can’t even speculate what that’s about. It’s just an observation which I think needs probing and exploring a little bit more.
Interviewer: Right. Ian, what’s in the pipeline? Can you talk through any areas of research or innovative schemes that are yielding interesting results?
Ian Hamilton: Yeah. To go back to what we’ve mentioned, I am encouraged by what we’ve seen around young people in education because I think that’s got an obvious kind of advantage to it. In that it not only might help those who already have a problem in getting the help they need to buy being signposted or knowing where to get help but it also might prevent young people from developing a problem. So, I think ,God help us schools seem to be asked to do more and more, don’t they? But at school, at those really informative and important years, if we can offer some information for young people that prevents them developing a problem. Or if they are on the verge of developing a problem, get them the support and help they need, then that’s great. And it seems like that evidence is working. It’s being translated into practice, it’s being implemented. We need some follow-up from it and unfortunately, that’s again, the kind of research that doesn’t really get funded. We tend to fund research which maybe lasts a year or two, but doesn’t follow young people up for 5, 10 years and that’s what we need.
Interviewer: Right? So, has there been some research into what educational messages or schemes are effective?
Ian Hamilton: Yeah, there has. To their credit, the government, through the Department of Health, has funded that and really put its weight behind it, having seen the outcomes of that. So, it’s not often we can say this but we have to thank politicians for adopting the evidence and for putting their money where their mouth is and rolling it out across the country. So that’s fantastic.
Interviewer: Right. So, it sounds like the need now is some more research into child-centric research into what works, clinically.
Ian Hamilton: Absolutely because no matter how good those educational interventions are, we’ll never get to zero. There will always be kids, unfortunately, who’ll develop a problem. So, being able to have a menu of options for clinical interventions, which have good evidence behind them and have been tested on children, perhaps, as we do with adults. We need to engage those children in a conversation about what they think might work. Quite often young people’s voices are missing from that type of research and although adults are increasingly being invited to participate, I’d hope the same is also true of young people. They have the knowledge. They have the first-hand experience of what worked and what didn’t work for them.
Interviewer: Ian, you’ve written the ACAMH topic guide on addiction, as we’ve mentioned. Can you give a short summary some of the themes that you’ve included in this?
Ian Hamilton: Broadly introduce what the issues are with addiction. Are we talking about just a few young people? Are we talking about most young people, etcetera? Then, the guide takes you through what we already know. So, for instance, talking about the particular drugs that young people are exposed to and develop a problem with. It then moves onto areas of uncertainty and that’s probably where we focused a little more in this discussion. Uncertainty around the problems that some young people face and the solutions to those problems and then a bit of a glimpse into the future. So, what’s coming down the road and what we can look forward to in terms of young people and drug use and drug problems.
Interviewer: Brilliant. Ian, is there anything you’d like to say that I haven’t asked?
Ian Hamilton: You know, I think this is a really important area to be working in for anyone working with young people. Very obviously, it’s a critical period in life and if we can help people at this stage and set them off on the right track and set them up well with good relationship with services then, that’s a major achievement.
Interviewer: And do you have a takeaway message for those listening to this podcast?
Ian Hamilton: Yeah. I think I’m going right back to the beginning and that is looking at this at a macro-level, just looking at the population. I think what we really need to remember is most young people don’t use drugs and one of the problems we have in research and in practice is we only see young people that develop problems. We can perhaps, end up with a slightly squinted view or a biased view of young people and drugs. So, if we remember that most young people don’t use drugs and of those that do, the vast majority experience pleasure. It’s just unfortunately, there is a small but significant number who do develop a problem. And of course, those are the ones that we see, not all the ones who do fine.
Interviewer: Ian, thank you ever so much. You can find Ian Hamilton’s topic guide on addiction and substance use on the ACAMH website. That’s www.ACAMH.org and Twitter at ACAMH. ACAMH is spelt A-C-A-M-H.
Intro: This podcast was brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short.
Ian is an Associate Professor of Addiction at the University of York. He is a lecturer in mental health in the Department of Health Sciences, with an interest in the relationship between substance use and mental health (Dual Diagnosis).
Ian trained and worked as a mental health nurse in South London, working with people who had a severe mental health problem and used drugs or alcohol problematically. He joined the Department in 2004 as a lecturer. His interest in this client group has continued through his work with teams which come into contact with such clients, and also facilitating sessions in this area.