1. September 2015 SUBSTANCE MISUSE IN PSYCHIATRY

2.  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

3.  Co-existing mental health and substance problems may affect 30- 70% 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 20- 33% 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

4.  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

5.  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

6.  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

7.  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

8.  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

9.  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

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

11.  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

12.  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

13.  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

14.  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

15.  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

16.  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

17.  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

18.  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

19. 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 http://www.scie.org.uk/publications/briefings/briefing30/http://www.scie.org.uk/publications/briefings/briefing30/ Findings (2014) Authoritative review reveals limitations of medicating dependence http://findings.org.uk/count/downloads/download.php?file=Lingford_Hughes_AR_2.txt 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 1-54 http://www.bap.org.uk/pdfs/BAPaddictionEBG_2012.pdf http://www.bap.org.uk/pdfs/BAPaddictionEBG_2012.pdf NICE (2011) Psychosis with coexisting substance misuse, Assessment and management in adults and young people. NICE clinical guideline 120 http://www.nice.org.uk/nicemedia/live/13414/53729/53729.pdfhttp://www.nice.org.uk/nicemedia/live/13414/53729/53729.pdf Royal College of Psychiatrists (2002) Co-existing problems of mental disorder and substance misuse (dual diagnosis) Royal College of Psychiatrists, London www.rcpsych.ac.uk/pdf/ddipPracManual.pdfwww.rcpsych.ac.uk/pdf/ddipPracManual.pdf