September 2015 SUBSTANCE MISUSE IN PSYCHIATRY

 Co-occurring mental health and substance problems are very common  Training, screening and assessment of complex co-occurring conditions  Recognition of the serious social, psychological and physical causes and complications resulting from combined mental health and substance problems  Treatment can be effective  Working with other professions and agencies in necessary to provide continuity of care for these often chronic disorders

 Co-existing mental health and substance problems may affect % of patients presenting to health and social care settings  75% patients attending drug services suffer from mental illness  85% patients attending alcohol services suffer from mental illness  40% patients attending mental health services have used substances  Alcohol and drug misuse in psychotic patients is reported in % patients in mental health settings  Alcohol and drug misuse in psychotic patients is reported in 5- 15% patients in addiction services  Anxiety and depression are the most common associated conditions

 Costs of caring for people with combined disorders is higher than for those with single disorders  Substances are misused for their psychoactive effect  Substance misuse if often missed and if substance misuse is not addressed, treatment is likely to be ineffective  Patients often do not receive comprehensive care due to:  Limited service provision  Poor coordination of care  Stigma  Exclusion from services

 Depression may lead to alcohol or cannabis use in order to alter mood  Chronic alcohol dependence may lead to depression  There may be no obvious link and people may take drugs because they like to  Complex presentations eg suicidal ideation, victimisation, poor physical self care, suspicion of services  Substance use eg intoxication, misuse, harmful use and dependent use eg withdrawal, may lead to or exacerbate a mental health problem, a physical health problem, and social problems

 Stigma and prejudice  Lack of services skilled and equipped to manage complex patients  Mental illness may lead to non-engagement, lack of motivation, lack of contact, poor attendance at appointments and difficulty in be receptive to treatment  Non-adherence to prescribed medication  Social isolation and exclusion  Patients may try to conceal mental illness and/or substance misuse

 Thorough assessment is necessary and the assessment protocol factsheet should be followed  Gathering of collateral information in a sensitive manner may produce information relevant to extent of use and complications  Mental state examination should take account of both substance problems and mental illness  Physical examination, urine and breathalyser, are important components  Polydrug use is the rule so all substances should be discussed

 Assume that patients have combined disorders  Serious life threatening conditions can be part of the presentation ie delirium tremens, Wernicke’s encephalopathy, overdose, benzodiazepine withdrawal, chaotic life style, polydrug use, require urgent medical admission  It is difficult to differentiate between delirium and psychiatric disorders with intoxication  Delirium must be excluded as it is a very dangerous condition which can lead to death if not treated  Assessments may take several appointments as additional information may need to be sought from other agencies

 The relationship of substance misuse to the presenting problems  Impact of disorders on on social, occupational and relationship functioning  Whether symptoms of intoxication, withdrawal and chronic use account for the presentation  It is not always easy to establish the direction of causality  Assessment is part of engagement with treatment which is essential to continue intervention. It should be non- confrontational and non-judgmental, aimed at building up trust and rapport  It is likely that re-assessment is necessary to monitor developments and link in with other agencies

 Most commonly associated mental illnesses are:  Anxiety  Depression  Personality problems  Psychosis  Memory disorders  Others: Attention deficit hyperactivity disorder, post traumatic stress disorder, eating disorders

 Try to engage patient in reduction or abstinence treatment plan  There may be more than one substance disorder and more than one mental illness  Provide practical support to respond to social and physical health care  Implement pharmacological interventions  Utilise psychological interventions with pharmacological treatments  Relapse: plan management in advance so as reduce a return to use

 Review diagnoses of psychosis especially if it was made during a crisis  Review effectiveness of previous and current treatment  Review acceptability of treatment to the patients  Discontinue ineffective treatments  Pharmacological and psychological treatments should follow each diagnosis ie for substance use disorders, psychiatric disorder, physical disorder  Consider the range of psychological treatments eg motivational interviewing, group or individual cognitive therapy, family therapy

 Stabilise and detoxify patients  Assess after 4-6 weeks for symptoms of mental illness  There is overlap between symptoms of mental illness and substance use disorder  if the patient is suicidal a clinical decision has to be made with regard to initiation of treatment for any mental illness in conjunction with treatment for substance misuse, and whether admission is necessary  In dependent users, alcohol and benzodiazepine withdrawal may require substitute prescribing and controlled withdrawal

 The treatment plan may need to be implemented over a prolonged period  Crisis should be managed or pre-empted if possible  Allowance should be made for the chaotic life styles  Particular groups have special needs eg young, older, pregnant, homeless, prisoners  Cessation of cigarette smoking should be encouraged

 Availability and accessibility of local services is necessary for coordination of care  Comprehensive facilities are likely to reduce relapse, rehospitalisation  Regular review, proactive engagement with carers, training and supervision of staff, can minimise risks  Referral for specialist support especially for vulnerable groups eg pregnancy, older people  Collaborative co-treatment of co-occurring disorders is more likely to yield positive outcomes than treating one in isolation

 Risks attributable to substance misuse need to be incorporated into the treatment plan  Appreciation of the physical problems patients face  Collaboration with other services  Corroboration with other sources with require negotiation and discussion about confidentiality

 Patients are likely to:  Be poorly compliant  Discharge themselves prematurely  Relapse  Be re-hospitalised  Die from accidents, injuries, accidental overdose and suicide  Experience pain, infection, injury and cancer  Experience homelessness, deprivation, unemployment, crime and violence

 Patients are likely to:  Be poorly compliant  Discharge themselves prematurely  Relapse  Be re-hospitalised  Die from accidents, injuries, accidental overdose and suicide  Experience pain, infection, injury and cancer  Experience homelessness, deprivation, unemployment, crime and violence

Crome I.et al (2009) SCIE Research briefing 30: The relationship between dual diagnosis: substance misuse and dealing with mental health issues. Social Care Institute for Excellence, London Findings (2014) Authoritative review reveals limitations of medicating dependence Latt, N. (2009) Addiction Medicine, Oxford: Oxford University Press Lingford-Hughes, A. R., Welch, S., Peters, L and Nutt, D. J., with expert reviewers Ball, D., Buntwal, N., Chick, J., Crome, I. B., et al. BAP updated guidelines: evidence based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP (2012) Journal of Psychopharmacology NICE (2011) Psychosis with coexisting substance misuse, Assessment and management in adults and young people. NICE clinical guideline Royal College of Psychiatrists (2002) Co-existing problems of mental disorder and substance misuse (dual diagnosis) Royal College of Psychiatrists, London