Prevalence & Management of Co-morbidity: Findings from the COSMIC study Tim Weaver Centre for Research on Drugs & Health Behaviour Department of Primary Care and Social Medicine / Department of Psychological Medicine Imperial College London

The COSMIC Study: Co-morbidity of Substance Misuse & Mental Illness Collaborative Study THE STUDY TEAM Imperial College: Tim Weaver, Vikki Charles, Zenobia Carnwath, Peter Madden, Dr Adrian Renton, Prof Gerry Stimson, Prof Peter Tyrer, Prof. Thomas Barnes, Dr Chris Bench, Dr Susan Paterson C&NWL Mental Health NHS Trust : Dr William Shanahan Dr Jonathon Greenside, Dr Owen Jones, Turning Point, Brent: Dr Chris Ford Community Health Sheffield NHS Trust: Dr Nicholas Seivewright Helen Bourne, Dr Muhammad Z Iqbal, Nottingham Healthcare NHS Trust: Dr Hugh Middleton Sylvia Cooper, Dr Neil Wright, Dr Katina Anagostakis,

Aims of the Presentation Review epidemiological data on co-morbidity & summarise evidence about the prevalence and nature of co-morbidity in SM and MH treatment populations generated by the COSMIC study. Discuss implications for service development in the context of; –current policy, and, –recent evidence for the effectiveness specialist treatment or service delivery interventions.

METHOD

Study Aims To estimate the prevalence of co-morbid substance misuse and mental health problems (co-morbidity) amongst current patients of substance misuse and mental health services. To describe the range of co-morbid presentations among these populations To assess the treatment needs (met and unmet) Assess whether there are differences in the prevalence of co-morbidity between populations drawn from London and provincial urban areas.

Study Design DESIGN: Cross sectional survey in four centres. Census of CMHT & substance misuse caseloads & assessment interviews with random samples from each population ASSESSMEMTS: Alcohol: AUDIT Non-prescribed drugs: Questions about use in past year / month by drug type, Severity of Dependence Scale & Hair & Urine analysis (MH sample ONLY) Psychosis: OPCRIT. Personality Disorder: PAS–Q CPRS (measures global symptomatology) sub-scales for assessment of Depression (MADRS) Anxiety (BAS)

FINDINGS

FINDINGS: Drug Services Subjects: Assessed & allocated on census date Random interview sample of 353 cases selected Full patient interview & casenote audit data obtained in 278 cases (79%) Study Populations: –Drug Services (n=216): 93% in treatment for problems related to opiate use. 78% report lifetime injecting drug use –Alcohol Services (n=62): AUDIT confirmed 57 (92%) used alcohol at ‘harmful levels’, 2 (3%) abstinent, 3 (5%) reported non-harmful use

Service Reported Co-morbidity (year) Service recorded psychiatric diagnosis obtained from keyworkers who also identified cases needing MH assessment We compared this with ‘gold standard’ measures obtained at interview  KEY FINDING: Reported diagnosis lacks validity, under-estimates prevalence of psychiatric disorder Specificity good (>90%), sensitivity poor (20% - 35%)

Drug Treatment Population: Prevalence of Drug Use (Past Month) N(%) Heroin107(51.7) * Stimulants85(41.1) * Crack Cocaine67(32.4) Cocaine Powder26(12.6) Amphetamine18(8.7) Non-prescribed sedatives, benzo’s61(29.5) Cannabis129(62.3) ALCOHOL Harmful or hazardous use in past year (and reported use in past month) 60(29.0) * 38% used opiates and stimulants in past month

Drug Treatment Population Prevalence of Psychiatric Disorder (year) (n=216) n(%)95% CI Psychotic disorder17(7.9) Personality disorder80(37.0)30.6 – 43.9 Severe Depression58(26.9)21.1 – 33.3 Minor Depression87(40.3)33.7 – 47.1 Severe Anxiety41(19.0)14.0 – 24.9 One or more disorder161(74.5)68.2 – 80.2

Drug Treatment Population Prevalence estimates compared Prevalence high but consistent with previous estimates Psychosis: 7.9% (year). 9 times general pop rate (Jenkins et al, 1998) –Compares with 6.2% (lifetime) (Regier et al, 1990) Severe Depression: 26.9% (year). –Estimates in US and Europe 23% - 37% (Regier et al, 1990; Limbeek et al, 1992; Hendriks, 1990). Personality Disorder: 37%. –Range of estimates (35% - 73%) (Verheul, 2001).

Drug Treatment Population Prevalence of Psychiatric Disorder (year)

Drug Treatment Population Services providing mental health interventions (past month) for co-morbid patients (n=161)

Alcohol Treatment Population Prevalence of Psychiatric Disorder (year) (n=62) N(%)95% CI Psychotic disorder12(19.4) Personality disorder33(53.2)40.1 – 66.0 Severe Depression21(33.9)21.1 – 33.3 Minor Depression87(40.3)22.3 – 47.0 Severe Anxiety20(32.3)20.9 – 45.3 One or more disorder53(85.5)74.6 – 92.7

FINDINGS: Community Mental Health Team Population SUBJECTS CPA patients, aged 16-64, assessed and allocated to CMHT on census date Random interview sample of 400 cases selected Interviews completed in 282 (70.5%) cases Study Population - Psychosis: 77%, PD & Depression: 16%, severe depression: 7%  KEY FINDING: Service reports of substance misuse lacked validity, and under-estimated prevalence. Prevalence estimation based on Interview sample.

Mental Health Population Self-reported co-morbidity (year) (n=282) N%95% CI Problem Drug Use84(29.8)24.5 – 35.5 Drug Dependence47(16.7)12.5 – 21.5 Alcohol Misuse72(25.5)20.5 – 31.0 Drug use &/or Alcohol124(44.0)38.1 – 49.9

Mental Health Population Self-reported Drug Use (year) N=282 n%95% CI Cannabis71(25.2)20.2 – 30.7 Sedatives21(7.4)4.6 – 11.2 Crack / Cocaine20(7.1)4.4 – 10.7 Opiates14(5.0)2.7 – 8.2 Ecstasy11(3.9)2.0 – 6.9 Amphetamines11(3.9)2.0 – 6.9

Mental Health Population Prevalence estimates compared PROBLEM DRUG USE: Prevalence higher than previously reported –30.9% vs 15.8% (Menezes et al, 1996) Significant differences between London & non-London –Problem drug use: 42.1% v 21.4%; x 2 1df=13.9, p<0.001 –Drug dependency: 24.6% v 11.3%; x 2 1df=8.6, p=0.005 ALCOHOL MISUSE: Prevalence (25.2%) comparable with other UK studies –20% - 32% (Wright et al, 2000; Duke et al, 1994; Menezes et al, 1996). No significant difference between London & non-London

Mental Health Population Services providing Alcohol related interventions to patients with harmful alcohol use (n=72)

Mental Health Population Services providing drug related interventions to patients with problem drug use (n=84)

DISCUSSION & CONCLUSIONS

IMPLICATIONS FOR SERVICE DEVELOPMENT Prevalence Prevalence is high in both treatment populations –Most drug patients have some psychiatric disorder –Poly-drug use is highly prevalent in drug treatment populations (and associated with co-morbid mental health problems) –In some centres co-morbid patients represent majority of CMHT patients Clinical presentations heterogeneous

Management Assessment: MH & SM services fail to identify co-morbidity in a high proportion of patients Few patients meet criteria for joint management. Possibly ‘low potential’ for cross-referral? Drug & Alcohol services provide some MH interventions, >50% get no specialist care CMHTs provide interventions for very few patients with drug / alcohol problems (<20%)

Policy Implications Co-morbidity too prevalent to be managed by sub- teams or ‘dual-diagnosis’ specialists Heterogeneity (and low cross-referral potential) means full extent of co-morbidity cannot be managed by parallel or serial treatment models Co-morbidity needs to be managed systemically within mainstream mental health services SM services need additional resources to better manage non-referable co-morbidity –Develop capacity to manage co-morbidity within MH & SM services –Training a priority if effective management is to be achieved –Research needed to support development of evidence-based service models & treatment interventions

COSMIC Study Publications: Weaver, T., et al (2003) Co-morbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 183, Weaver, T., et al. (2004) What are the implications for clinical management and service development of prevalent co-morbidity in UK mental health and substance misuse treatment populations? Drugs: Education, Policy & Prevention, 11(4), Jones, OB et al (2004) Prevalence of personality disorder in a substance misuse treatment population and associated co-morbidity. Addiction, 99, Executive Summary of Dept of Health report: NTA. Research in to Practice Series (forthcoming)