1. 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

2. 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,

3. 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.

4. METHOD

5. 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.

6. 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)

7. FINDINGS

8. 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

9. 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%)

10. 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

11. Drug Treatment Population Prevalence of Psychiatric Disorder (year) (n=216) n(%)95% CI Psychotic disorder17(7.9)4.7- 12.3 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

12. 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).

13. Drug Treatment Population Prevalence of Psychiatric Disorder (year)

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

15. Alcohol Treatment Population Prevalence of Psychiatric Disorder (year) (n=62) N(%)95% CI Psychotic disorder12(19.4)10.4 - 31.4 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

16. 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.

17. 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

18. 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

19. 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

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

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

22. DISCUSSION & CONCLUSIONS

23. 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

24. 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%)

25. 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

26. 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, 304-313. 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), 329-348. Jones, OB et al (2004) Prevalence of personality disorder in a substance misuse treatment population and associated co-morbidity. Addiction, 99, 1306-1314. Executive Summary of Dept of Health report: http://www.mdx.ac.uk/www/drugsmisuse/execsummary.html NTA. Research in to Practice Series (forthcoming)