Transcript SUBSTANCE MISUSE IN PSYCHIATRY

SUBSTANCE MISUSE IN PSYCHIATRY
March 2016
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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
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Co-existing mental health and substance problems may affect 3070% 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 2033% patients in mental health settings
Alcohol and drug misuse in psychotic patients is reported in 515% patients in addiction services
Anxiety and depression are the most common associated
conditions
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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
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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
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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
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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
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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
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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 nonconfrontational 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
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Most commonly associated mental illnesses are:
Anxiety
Depression
Personality problems
Psychosis
Memory disorders
Others: Attention deficit hyperactivity disorder, post traumatic
stress disorder, eating disorders
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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
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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
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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
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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
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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
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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
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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
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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 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
Marta Di Forti M, et al (2015) Proportion of patients in south London with first-episode psychosis attributable to use of high potency
cannabis: a case-control study. The Lancet Psychiatry, Vol. 2, No. 3, p233–238
NICE (2011) Psychosis with coexisting substance misuse, Assessment and management in adults and
young people. NICE clinical guideline 120 https://www.nice.org.uk/guidance/cg120
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.pdf
Schifano F, Orsolini L, Papanti G, & Corkery J. (2015) Novel psychoactive substances of interest for psychiatry. World Psychiatry
2015;14:p15-26