Severe mental illness and substance misuse

Safer services: conclusions from the report of the National Confidential Inquiry

In May 1999, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness published its first major report since it was reestablished at the University of Manchester (Appleby et al, 1999a). Entitled Safer Services, it presented findings from a two-year sample of suicides and an 18-month sample of homicides occurring in England and Wales, and on the basis of these put forward 31 recommendations for mental health services (Appleby, 1999b; Shaw et al, 1999). This article, modified from a chapter in Safer Services, discusses how services might deal with the risk of suicide and homicide or serious violence.

Cannabis use by people with severe mental illness – is it important?

Cannabis use is more common among people with severe mental illness than in the general population. It has detrimental effects on the course of the illness, physical health and social life of users, as well as being a financial burden on health services. It is important to understand why some people with severe mental illness continue to use cannabis, despite experiencing its effects on their condition. This article reviews research on the scale of cannabis use by such patients, the effects on the course of their illness, possible reasons to explain why they use it, and how they can be assessed in clinical settings, as well as providing some assessment tools to measure various characteristics related to cannabis use.

Treating depression complicated by substance misuse

Dependence on alcohol or other drugs is a depressing experience. The way of life of the individual who is dependent on alcohol is replete with incidents that are demoralising, waking daily with a hangover or with tremor and retching, coupled with amnesia for events of the night before, a sense of inability to face the day ahead and awareness of recriminations at work and at home. Little wonder that depressed mood is common in such circumstances. Similarly, the drug addict, when life is dominated by the daily problem of obtaining supplies of a substance that brings transient relief or pleasure but also experiences of an impoverished existence and low mood. Add to this the fact that the biological action of many commonly misused substances can induce depression then it is hardly surprising that depression is common in this population. There are also a smaller number who use alcohol or illicit drugs to cope with primary depression. Teasing out the interplay of affect and substance misuse is a challenge for the general psychiatrist and the addiction specialist.

Drug and alcohol misuse among in-patients with psychotic illnesses in three inner-London psychiatric units

Aims and Method

Ward staff were asked to rate whether in-patients with a diagnosis of functional psychotic illness also met criteria for a diagnosis of alcohol or drug misuse or dependence during the preceding 6 months. Those who demonstrated such evidence were then asked to report the nature and extent of their substance use and whether they continued to use as in-patients.

Results

264 in-patients with psychotic illness were screened for evidence of recent or current alcohol or drug misuse. According to staff reports, 127 (48.9%) met the criteria for substance misuse or dependence. The mean age of those with ‘dual diagnosis' was 34.7 years and 72% were male. Eighty-three (83%) of those with a history of current or recent alcohol or drug misuse reported that they had continued to use alcohol and/or illicit drugs in the in-patient wards during their current admission.

Clinical Implications

It appears difficult to prevent in-patients with drug or alcohol misuse problems from continuing to use substances in hospital. Further consideration and investigation of how best to manage this group is therefore required.

Substance use and misuse in psychiatric wards

Substance use has reached endemic proportions. Inevitably, the world of psychiatric wards must reflect issues arising in our society. Given that the populations of psychiatric wards are disproportionately younger, male and socially disadvantaged (quite apart from the impact of patients' problems that prompt admission), one might expect that drug misuse in them would match, if not outstrip, the general trend. Recognition of its impact is a key issue for patients and staff alike.

Drug and alcohol misuse among in-patients with psychotic illnesses in three inner-London psychiatric units

Aims and Method

Ward staff were asked to rate whether in-patients with a diagnosis of functional psychotic illness also met criteria for a diagnosis of alcohol or drug misuse or dependence during the preceding 6 months. Those who demonstrated such evidence were then asked to report the nature and extent of their substance use and whether they continued to use as in-patients.

Results

264 in-patients with psychotic illness were screened for evidence of recent or current alcohol or drug misuse. According to staff reports, 127 (48.9%) met the criteria for substance misuse or dependence. The mean age of those with ‘dual diagnosis' was 34.7 years and 72% were male. Eighty-three (83%) of those with a history of current or recent alcohol or drug misuse reported that they had continued to use alcohol and/or illicit drugs in the in-patient wards during their current admission.

Clinical Implications

It appears difficult to prevent in-patients with drug or alcohol misuse problems from continuing to use substances in hospital. Further consideration and investigation of how best to manage this group is therefore required.

MIDAS: a new service for the mentally ill with comorbid drug and alcohol misuse

Aims and Method

To describe the work and patient characteristics of one of the first combined mental illness and drug and alcohol services (MIDAS) in the UK. We examined MIDAS as an assertive community service, for individuals receiving long-term community care. We selected the case files of the first 80 patients accepted over a 10-month period and examined variables including demographic details, diagnosis, associated substance use and length of engagement with the service.

Results

Our findings show that there was no relationship between responders to the service and basic demographic data. Patients with bipolar affective disorder and personality disorders were more likely to use the service than patients with unipolar disorder or schizophrenia. Despite the use of an assertive service, there was difficulty engaging patients with schizophrenia and comorbid drug use. These same patients also had a high level of criminal convictions as well as a trend towards using alcohol and cannabis as their main substances of misuse. At 18 months 38% of patients had failed to remain engaged with the service.

Clinical Implications

This specialist type of service may be more useful than other services in engaging patients with comorbidity. Systematic research is required in the UK to explore the effectiveness of this type of new service. More innovative resources need to be identified to specifically deal with patients with severe mental illness and comorbid substance use.

Substance abuse and the trauma patient

Alcohol and other drugs of abuse are often associated with trauma. Alcohol and other drugs have an effect on patients’ behaviour, their vital signs, conscious level and pupils. IV drug abusers may have difficult venous access and may carry blood borne infections. Drug dependent patients are at risk of withdrawal symptoms which need to be recognized and treated. Acute intoxication may make the diagnosis of brain (and other) injuries difficult and chronic alcoholism may be associated with a variety of medical problems which may complicate the management of trauma and which lead to increased mortality. It is important not just to treat the injuries but to recognize the underlying substance abuse so that help can be offered and future injuries avoided.

Comorbid psychiatric diagnoses among individuals presenting to an addiction treatment program for alcohol dependence

A retrospective patient record review was conducted to examine comorbid psychiatric diagnoses, and comorbid substance use, among 465 patients below 45 years of age, presenting to a national alcohol addiction treatment unit in Dublin, between 1995 and 2006. Rates were high for depressive disorder (25.3%) particularly among females (35.4%). Lifetime reported use of substances other than alcohol was 39.2%, and further analysis showed significantly higher rates of deliberate self-harm among this group. Lifetime reported use of ecstasy was also significantly associated with depression in this alcohol-dependent population using logistic regression analysis. Implications and limitations of the findings are discussed.

Substance use disorder comorbidity with schizophrenia in families of Mexican and Central American ancestry

OBJECTIVES

The aims of this study were to estimate the frequency and course of substances use disorders in Latino patients with schizophrenia and to ascertain risk factors associated with substance use disorders in this population.

METHOD

We studied 518 subjects with schizophrenia recruited for a genetic study from the Southwest United States, Mexico, and Central America (Costa Rica and Guatemala). Subjects were assessed using structured interviews and a best estimate consensus process. Logistic regression, chi(2), t test, Fisher's exact test, and Yates' correction, as appropriate, were performed to assess the sociodemographic variables associated with dual diagnosis. We defined substance use disorder as either alcohol or substance abuse or dependence.

RESULTS

Out of 518 patients with schizophrenia, 121 (23.4%) had substance use disorders. Comorbid substance use disorders were associated with male gender, residence in the United States, immigration of Mexican men to the United States, history of depressive syndrome or episode, and being unemployed. The most frequent substance use disorder was alcohol abuse/dependence, followed by marijuana abuse/dependence, and solvent abuse/dependence.

CONCLUSION

This study provides data suggesting that depressive episode or syndrome, unemployment, male gender, and immigration of Mexican men to the United States were factors associated with substance use disorder comorbidity in schizophrenia. Binary logistic regression showed that country of residence was associated with substance use disorder in schizophrenic patients. The percentage of subjects with comorbid substance use disorders was higher in the Latinos living in the United States compared with subjects living in Central America and Mexico.

Effects of training community staff in interventions for substance misuse in dual diagnosis patients with psychosis (COMO study): cluster randomised trial

A cluster randomised controlled trial was used to investigate the effectiveness of training staff in 13 London community mental health teams (CMHTs) to deliver substance misuse interventions to patients with psychosis and comorbid substance misuse ('dual diagnosis'). The primary hypotheses, which were that experimental group patients would spend fewer daysin hospital over 18 months of follow-up and show reduced alcohol and drug consumption, were not confirmed, although confidence intervals were wide for some outcomes. Current UK policy guidance advocates training CMHT professionals to deliver dual diagnosis interventions, but the effectiveness of this strategy has not so far been demonstrated.

Co-morbidity and cannabis use in a mental health trust in South East England

AIM

The prevalence of co-morbidity (severe mental illness and substance) may be less in rural and semi-rural areas than inner cities. The aims were therefore to measure the prevalence of co-morbidity among patients of attending a mental health service in a semi-rural area South East England.

DESIGN AND PARTICIPANTS

Cross-sectional prevalence survey of 1,808 patients with detailed assessments from a representative sample of 373 patients identified as having a combination of severe mental illness and substance misuse. Interviews with key workers were performed using validated methods from the COSMIC study.

RESULTS

The response rates equalled or exceeded 90% for the various parts of the study. One-tenth of patients attending the Community Mental Health Teams (CMHTs) reported problematic use of illicit drugs and 17% reported alcohol problems in the past year. 22% of Community Drug and Alcohol Service (CDAS) clients reported a severe mental illness and 46% reported some other form of psychiatric disorder. Of patients with a combined diagnosis of mental illness and substance misuse, cannabis use was 4-fold more common amongst patients attending the CMHT than CDAS (33% vs. 8%) while use of amphetamine was five-fold higher in the CMHT group (10% vs. 2%). Patients with concurrent psychiatric and substance misuse problems represent a similar proportion of the aggregate caseload of both treatment services with observed prevalence amongst the CDAS and CMHT patients with a diagnosis for anxiety disorder (18% vs. 26%), minor depression (42% vs. 32%), personality disorders (32% vs. 36%), histories of self-harm (52% vs. 46%) and violence (33% vs. 30%) respectively.

CONCLUSIONS

Co-morbidity is common in clients amongst CMHT and CDAS clients although use of cannabis was significantly more common in CMHT clients than in CDAS clients.

The lived experience of community mental health nurses working with people who have dual diagnosis: a phenomenological study

Dual diagnosis (the combination of mental health and substance misuse problems) is a significant facing mental health nurses in the UK. The purpose of the study was to describe the lived experience of community mental health nurses working with people who have a dual diagnosis. A phenomenological approach was us and a purposive sample of seven community mental health nurses with experience of working with people with a dual diagnosis was selected. Data were collected through audiotaped, semi-structured interviews lasting approximately 1 h in duration and analysed using Colaizzi's (1978) method. Thirteen theme clusters relating to three major themes were identified: (1) difficulties in understanding the concept of dual diagnosis; (2) feeling deskilled when working with people who have a dual diagnosis; (3) struggling to work in a system which seeks to avoid people with dual diagnosis. Recommendations regarding the need for increased joint working between professionals, improved education and further research are made.

Is cannabis an anti-antipsychotic? The experience in psychiatric intensive care

BACKGROUND

Cannabis use is a major problem in inner cities and has been causally implicated in psychosis. Very few of the available hospital-based studies of the implications of cannabis usage have involved psychiatric intensive care units (PICU); but PICU receive many of the most challenging and resource-hungry-and incompletely understood-patients in the mental health system.

AIMS

To study the clinical impact of cannabis abuse in a PICU, and to compare the use of atypical and typical antipsychotics in this setting.

METHOD

115 patients admitted to a PICU consented to take part in an open label naturalistic study. BPRS, TCI-240, weight, length of admission and routine bloods were evaluated in all participants.

RESULTS

There was a high rate of cannabis abuse (71.3%) in the PICU population. Patients who abused cannabis spent longer in PICU because their psychoses were more severe. They were younger at first hospital admission. Cannabis also had metabolic implications, with higher blood glucose levels at admission and greater weight increase. Atypical antipsychotics were effective in treating psychosis inpatients positive to cannabis at admission.

CONCLUSION

Our findings suggest that cannabis abusers had a more severe psychotic illness, especially in schizophrenia. There are additional complications in terms of weight gain for cannabis users.

Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales

STUDY OBJECTIVE

To estimate the annual period prevalence of co-occurring psychiatric illness and substance misuse among patients in primary care.

DESIGN

Analysis of the general practice research database.

SETTING

England and Wales, 1993-1998.

PARTICIPANTS

Registered patients at 230 general practices representing 3.1% of the population. A comorbid case was defined as one with both a psychiatric diagnosis and substance misuse diagnosis (not including alcohol or tobacco) within a calendar year. A potentially chronic comorbid case was one that met this definition and, in addition, was treated in subsequent years for either a psychiatric condition or substance misuse.

MAIN RESULTS

The annual period prevalence of comorbidity increased from 50/100 000 patient years of exposure (PYE) to 80/100 000 PYE, an increase of 62% during the study period. Rates of comorbid psychoses, comorbid schizophrenia, and comorbid paranoia increased by 147%, 128%, and 144%. The average age of comorbid cases decreased from 38 years to 34 years. Over 80% of comorbid cases were newly diagnosed in each study year, although many are treated in subsequent years for either psychiatric illness or substance misuse.

CONCLUSIONS

This study provides data on the nature and extent of comorbidity in primary care in England and Wales. As the comorbidity rate is increasing by about 10% each year, and as comorbid cases are becoming younger, it is probable that the comorbidity rate will have increased beyond the study end point.

Comorbidity of substance misuse and mental illness in community mental health and substance misuse services

BACKGROUND

Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.

AIMS

To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.

METHOD

Cross-sectional prevalence survey in four urban UK centres.

RESULTS

Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.

CONCLUSIONS

Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

Substance use and schizophrenia: effects on symptoms, social functioning and service use

BACKGROUND

Studies examining the effects of substance use in patients with schizophrenia have produced conflicting results.

AIMS

To examine the effects of comorbid substance use on symptoms, social functioning and service use in patients with schizophrenia.

METHOD

Patients (n=316) with and without substance use problems from three centres participating in the Scottish Comorbidity Study were compared, using research interviews and case note review, on measures of symptoms, social functioning and service use.

RESULTS

Patients with substance use problems were younger, more likely to be male and had shorter duration of illness. They had more police contact and increased self-reported needs, but otherwise showed few differences when compared with those without such problems.

CONCLUSIONS

The presence of problem substance use had only modest impact on service use, symptoms or social functioning for this group of patients with schizophrenia. This has important implications for service development to meet the perceived needs of this group.

Mental health service provision in England

OBJECTIVE

To describe mental health service provision for adults of working age in England.

METHOD

Services in an inner London area are described so as to illustrate current patterns of service organization in England. National trends are then discussed.

RESULTS

Despite relatively low public expenditure, substantial progress has been made in deinstitutionalization and development of comprehensive community-based services. Persisting difficulties include high staff turnover, a minority of patients. who do not engage with community services, user and carer dissatisfaction with emergency services, and social exclusion because of stigma. Recent government policy advocates resolving some of these problems using new service models such as assertive outreach and crisis teams.

CONCLUSION

Closure of the large asylums has largely been accomplished. England is now entering a new phase in community service development, with a range of innovative developments aimed at resolving problems still encountered after the initial phases of integrated community service development.

Substitution therapy for heroin addiction

Substitution treatment for heroin addiction, defined here as maintenance prescribing of opioid agonist drugs to opioid dependent subjects, has increased in the last decade. The recent history of substitution treatment in five countries--Canada, the U.K., Australia, Israel, and France--is reviewed. In all five countries, the critical issues around substitution treatment are similar. The first key issue concerns the balance between making treatment accessible and attractive, and minimizing diversion to the black market. The second issue concerns the role of primary health care in delivering MMT. In general, there has been increasing involvement of primary health care, with training and support for practitioners. However, there remains uncertainty and official ambivalence over whether treatment should be restricted to specialist clinics and practitioners, or available through primary care. Most importantly, underlying these issues is the problem of stigma being associated with both addiction, and with substitution treatment. The underlying problem that treatment is often at odds with community values places enormous strains on substitution treatment, and makes the treatment system vulnerable to shifting community support and abrupt, politically-driven changes in policy.

Mental illness and substance misuse: a nursing challenge

The treatment of patients diagnosed with a coexisting psychiatric and psychoactive substance misuse disorder remains an important clinical challenge in mental health nursing. This is not only because of the complexity of the disorder, but also because an increasing number of patients are presenting both disorders (i.e. coexisting psychiatric and psychoactive substance disorder). This article will review the literature on the subject of severe mental illness and substance misuse by examining various issues, including the phenomenon of dual diagnosis and its prevalence, the nature of the relationship between substance misuse and severe mental illness, the extent of the problem of illicit substance use among the psychiatric population, treatment trends and management models.

Mental disorder and clinical care in people convicted of homicide: national clinical survey

OBJECTIVES

To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

Eighteen month sample of people convicted of homicide.

MAIN OUTCOME MEASURES

Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services.

RESULTS

718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide.

CONCLUSIONS

There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.