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.

Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: prevalence and service needs in an inner London borough

BACKGROUND

There is great concern in the UK, and other countries, about the clinical management of psychosis and substance misuse co-morbidity. However, relatively little is known about the UK prevalence and management of co-morbidity.

METHOD

We implemented a screening survey of patients who were in treatment with an inner London adult mental health service and measured the prevalence of substance misuse amongst 851 psychotic patients. Caseworkers reported substance misuse and assessed clinical management arrangements.

RESULTS

Current prevalence of substance misuse was 24.4% (95% CI: 21.3-27.1). Rates of co-morbidity were higher in males (31% vs 16%, chi2 1df=26.0, P < 0.001) and patients over 51 (chi2 3df=50.1, P < 0.001). Adjusted odds of co-morbidity in patients under 51 were 0.19 (95% CI: 0.10-0.34) and 0.47 for females (95% CI: 0.32-0.69). Substance misuse interventions were provided to 20% of co-morbid patients--Only 5% were compliant.

CONCLUSIONS

The findings suggest substance misuse may be highly prevalent amongst psychotic patients. Most co-morbid patients do not receive appropriate treatment. The development of evidence-based interventions should be a priority.

Pharmacy-based needle exchange (PBNX) schemes in south east England: a survey of service providers

AIMS

To describe the activities of service providers with regard to (i) the business operation and policies defining pharmacy-based needle exchange (PBNX) in South East England; (ii) the day-to-day work of PBNX outlets from the provider perspective; and (iii) problems encountered by PBNX providers.

DESIGN

(i) Postal self-completion questionnaire to all participating PBNX community pharmacies in South East England; and (ii) postal self-completion questionnaire to needle exchange coordinators.

SETTING

Community pharmacy needle exchanges.

PARTICIPANTS

Pharmacists in charge of needle exchange; and needle exchange coordinators.

FINDINGS

Data were collected (i) from 381/440 (86.7%) participating community pharmacists, and (ii) 32/36 (88.9%) of coordinators. The study found that PBNX was reaching injecting drug users (many of whom used PBNX regularly), and providing a wide range of injecting equipment. Although pharmacists reported that problems such as shoplifting occurred relatively frequently, more serious problems such as violence were relatively rare. However, PBNX pharmacists reported needing further training for themselves and their staff. Suggested improvements included better advertising of services and improving returns rates for used injecting equipment.

CONCLUSION

Needle exchange can reasonably be provided by non-specialist health care professionals such as community pharmacists. However, attention should to be paid to the educational needs of service providers who also require adequate support.

Estimating the prevalence of problem drug use in inner London: a discussion of three capture-recapture studies

AIMS

To provide an evidence base of estimates of the prevalence of problem drug use in inner London.

DESIGN

Re-analysis of three capture-recapture studies using subjects aged 15-49 years, that aim to estimate the hidden population from analysing the overlaps between three data sources.

SETTING

Newham (1995) Camden and Islington (C&I) (1993/4) and Lambeth, Southwark and Lewisham (LSL) (1992).

PARTICIPANTS

Each study collected data from three sources of problem drug users including: the Regional Drug Misuse Database, specialist drug agencies, HIV tests, social services, police arrests and court records. In LSL opiate users were analysed separately. The studies identified 1832 individuals in LSL, 543 in Newham, and 1321 in C&I.

MEASUREMENTS

Poisson models were fitted to the data testing different interactions between the data sources representing potential dependencies. The simplest model was selected on the basis of its AIC score and log-likelihood ratio tests.

FINDINGS

The number of hidden problem drug users were estimated to be 12,500 (95% CI 9600-16,100) in LSL with 4400 (3200-6100) opiate users; 7000 (5000-10,000) in C&I and 3800 (2000-7200) in Newham. The prevalence of problem drug use in those aged 15-49 was estimated to be 3.1% (2.5-3.9%) in LSL with 1.3% (1.0-1.6%) opiate users; and 3.6% (2.7-4.9%) and 3.3% (1.9-5.7%) in C&I and Newham, respectively.

CONCLUSIONS

Despite the inherent problems with capture-recapture methods, our three studies establish an evidence base for estimates of problem drug use in London. It is important that a larger study is carried out in London.

Drug injecting and HIV infection: new directions for social science research

An overview is presented of the relationship between drug injecting and HIV infection. The pattern of spread of HIV infection among drug injectors and risk factors associated with the spread of HIV among drug injectors are considered, together with evidence on the adoption of behavior changes intended to reduce such risks. Some promising reduction in risky behaviors has been evident among established drug injectors. Public health prevention strategies, such as syringe distribution and exchange and AIDS outreach work, appear to have fostered decreases in HIV-related risks among drug injectors. The role of methadone maintenance remains uncertain. Despite advances, many obstacles remain. The future research agenda requires work on prevention strategies and the role of drug user treatment. Social scientists need to address the fact that patterns of drug-using behavior reflect powerful "structural factors" such as poverty, unemployment, and housing conditions.