March 2021

Suffering in silence: people who use drugs overlooked in mental health

In Australia, mental health is no longer a taboo topic. Today, it receives more media attention and research funding than ever before. But there is one cohort – people who use drugs (PWUD) – that’s being left out of this important conversation.

As ‘Alex’ (not her real name), who works in the drug and alcohol field, puts it, “there’s a black hole and people who fall in are people who have mental health issues and addiction issues – and no one talks about it, because they’re voiceless”.

Examining the numbers

Every serious bit of published research about the topic has shown that the rate of mental health problems in people with drug dependencies (especially more serious behaviours like injecting drug use) is higher than for people in the general community. And mental health issues among Australians who report using illicit drugs are increasing, as seen in the graph.

Australian Institute of Health and Welfare (2020). National Drug Strategy Household Survey 2019. Chapter 8 – Priority population groups supplementary tables, Table 8.8.

Alex started experiencing anxiety early in life and ended up reaching out for help when it became too hard to function. She was prescribed highly addictive anti-anxiety medication. “It was a dream,” she says. “I’d never not felt anxious before.” But with no sustainable therapy or treatment for anxiety and depression, her mental health deteriorated.

Alex became dependent on her anti-anxiety medication, then started using ice. While in recovery she struggled to find affordable ongoing therapy and, ultimately, ended up on anti-depressants. When those didn’t work, Alex turned back to ice as a way to cope with the underlying anxiety and depression. “I knew it helped,” she says.

“There’s a black hole and people who fall in are people who have mental health issues and addiction issues – and no one talks about it, because they’re voiceless.”


This is a harrowing story, but it’s not an unusual one.

Up to 80 per cent of people in treatment for heroin dependence have at least one other mental health diagnosis. They are also more likely to attempt suicide. A study from 2005 found that 37 per cent of people in treatment for heroin dependence had attempted suicide – more than 10 times the rate of the general adult population.

A 2017 study by the Victorian Coroners Court and Turning Point found that many people who died from drug overdose were already known to the mental health system. In half of the 838 overdose deaths they examined, the subjects had a diagnosed mental illness, and around one-third of these had a history of mental illness and drug dependence lasting more than 10 years.

The same is seen among NSP clients: a Melbourne study found that 90 per cent of clients had at least one personality disorder, with two-thirds having three or more.

People who both inject drugs and have a mental health issue can suffer a wide range of additional harms, such as increased risk of contracting HIV and other blood-borne viruses.

An invisible cohort

If the evidence is clear – and it is – why don’t we hear more about it?

There have been two major government reviews on mental health in the past couple of years. Despite both reports stretching to hundreds of pages, neither devotes much space to PWUD.

In its interim report, the Royal Commission into Victoria’s Mental Health System acknowledges that mental health problems are common among PWUD. Emergency departments and mental health services are seeing more people with both poor mental health and illicit drug use, particularly methamphetamine use. But it has little to say beyond this. The final report had a small number of recommendations in relation to drug matters, but nothing about the legal reforms required to end stigma of people who use illicit drugs, including decriminalisation of use and possession or anything specific to services regularly dealing with the largest number of people with mental health and drug use issues: needle and syringe programs.

The Productivity Commission (the federal economic policymaking body) undertook an Inquiry into Mental Health which was handed to the Australian Government in November 2020. It recognises that improving outcomes for people with complex needs means making sure they have access to coordinated healthcare. It also means we need to address the stigma and discrimination that can lead to people not getting help even when they need it. But there is no real mention in the report of the critical role that NSPs play in this area, supporting people’s access to services, working to reduce stigma and linking people across the mental health and broader alcohol and drug service systems.

Professor Maree Teesson, Director of the Matilda Centre for Research in Mental Health and Substance Use at The University of Sydney, says PWUD are left out of public discussions around mental health because “we’re dealing with a double whammy”: mental health issues are hidden and drug use is stigmatised. In her view, health systems generally have become ever more specialised, creating silos: “The system is set up so that they have to go in one way or the other”. Instead, Maree says, “we need to specialise in person-based care, not disorder-based care”.

Professor Maree Teeson

“We need to specialise in person-based care, not disorder-based care.”

Professor Maree Teesson

Dr Jackie Hallam, Policy and Research Manager at the Alcohol, Tobacco and other Drugs Council of Tasmania, says it’s been harder to gain traction in “breaking down the myths and misinformation” around drugs than around mental health issues. While the mental health sector has made substantial progress in addressing stigma, the same isn’t true for drugs.

What does this silence mean?

“The opposite of addiction is connection,” Alex says. By shutting PWUD out of the public conversation around mental health issues, people’s feelings of isolation are exacerbated. In Alex’s words, “the silence fuels the health crisis”.

Maree points out the problems with the “siloed” approach in which mental health issues and drug use issues are addressed separately. Recent research has shown treatment outcomes for people are far better when both mental health and drug use issues are addressed together. If we continue to exclude PWUD from conversations about mental health – especially knowing their prevalence of mental health issues – then we’re failing them.

Sione Crawford, CEO of Harm Reduction Victoria, says: “We need to understand that PWUD, when they have mental health issues, very seldom get them dealt with effectively because the drug use overwhelms everything else.” PWUD, Sione continues, “have real trouble talking to mental health providers – the illicit drug use is the thing that’s blamed immediately for your problems”.

“People who use drugs have real trouble talking to mental health providers – the illicit drug use is the thing that’s blamed immediately for your problems.”

Sione Crawford

Alex says she needed help with mental health issues and wanted to stop using ice. But because she was classified as “an addict”, she couldn’t get this essential support. She was told by mental health professionals “We can’t really help you” – there was no suggestion of rehabilitation or therapy. “So where do you get help from when there is such a huge lack of ongoing mental health support after rehabilitation?” Alex asks.

The virtual absence of PWUD in discussions of mental health issues means we’re missing an opportunity to improve the community’s understanding of drug use issues.

Better public understanding of the prevalence of mental health issues among PWUD won’t single-handedly prevent stigma and discrimination, but it’s a start. And it will improve health outcomes: the stigmatising of PWUD reduces the likelihood that those who need care will actually get it – or even seek it in the first place.

Jackie suggests stigma is a problem not only for PWUD but also for people who work in the sector, who may experience “vicarious stigma”. Frontline staff such as NSP workers may feel devalued due to broader community attitudes, so it’s crucial that their mental health is also supported.

Where to from here?

Alex wants to see more support for PWUD with mental health issues, with practical solutions to treat people’s underlying past traumas. She wants to see more training for health professionals beyond the NSP sector so that it’s understood that drug use and mental illness often go hand-in-hand, thereby enabling these professionals to see the whole person, not just the addiction.

For now, Alex is hopeful that COVID-19 might be a catalyst for change in public understanding of dependence: “People who didn’t know about mental health issues now know about it and people who never used to drink have been drinking. Perhaps now they understand isolation.”

In Jackie’s view, the mental health sector has “come a long way in promoting good, healthy conversations” about mental illness. We now need to support frontline workers to have these conversations around mental health with PWUD. She points to the value of training around mental health issues and trauma-informed care. With the complex challenges faced by some clients of NSPs, no matter how much training has been offered, “there’s always need for more”, Jackie says.

Royal Commission into Victoria’s Mental Health System

In February 2019, the Victorian Government established the Royal Commission into Victoria’s Mental Health System. The Commission was asked to make recommendations on a range of issues, including prevention, early intervention, access to treatment and support to deliver better mental health outcomes for people living with mental illness and their families.

The Commission delivered its interim report in November 2019. The final report was released on 2 March 2021, containing 65 final recommendations.

The Victorian Government has committed itself to implementing all 65.

Productivity Commission Inquiry into Mental Health

The Productivity Commission Inquiry into Mental Health examined the key influences on people’s mental health, including the effect of mental health on people’s ability to participate in and prosper in the community and workplace, and the effects it has more generally on Australia’s economy and productivity.

The Commission recommended reforms across workplaces, schools and universities, the justice system, community groups and services for healthcare, psychosocial support, and housing to improve the mental health of people of all ages and cultural backgrounds.

The final report was released in November 2020.

– Karen Gelb