Mental Health and
Substance Use
Nature & Extent
Derek Tobin
Team Manager COMPASS Programme
COMPASS Programme
Definitions
• Dual Diagnosis
• Combined mental health and substance use
problems
• More than “dual problems”- likely to have
complex health and social needs
• Wide range of people with varying degrees of
need- need individualised treatment
Serious mental illness
E.g. someone with
bipolar affective disorder
who smokes cannabis
twice per week
E.g. Someone with
schizophrenia
and alcohol dependence
Table 1
Minor substance use Severe substance use
E.G. Someone with anxiety E.g. someone with heroin
who snorts cocaine dependency and
occasionally depression
Minor mental illness
Policy Drivers and related Documents
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Dual Diagnosis Good Practice Guide (2002)
Inpatient Dual Diagnosis Guidance (2006)
Standards for Better Health
NIMHE Suicide Toolkit
NSF 5 Years On
Health Care Commission
Themed review in dual diagnosis
The management of Dual Diagnosis in prisons (2009)
Prevalence
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Cantwell (1999) Nottingham first episode psychosis 37% (1 year)
Weaver (2001) Inner London Community mental health and substance use
services 24% (recent-last 30 days)
Phillips (2003) Inner London (in-patient setting) 49% (last 6 months)
Graham (2001) Birmingham (MH and SU services) identified 24% SMI
problems with drugs/alcohol
– More likely to be using at impairment/dependence level
– More likely to be in AOT (26-45% of case-loads depending on location)
– Over representation of African-Caribbean in AOT (46%)
Priebe et al (2003) London AOT 29% misused at least 1 type of
substance(last 6 months)
– 20% misused/dependent on drugs
– 16% misused/ dependent on alcohol
– Most common street drug was cannabis (23%), followed by cocaine
(7.4%)
On track: Helping People Get Better
Forensic Units
• Studies have shown prevalence of use toward upper end of range in
both medium and high security patients (Steele et al, 2003; Da Silva
et al, 2003, Madden et al, 1999; Beck et al 2002)
• Isherwood et al (2001) found 57% of consecutive referrals to a
forensic psychiatric service in London had an ICD 10 diagnosis of
substance misuse
• In a national review of MSU’s, Melzer et al (2000) found that 58% of
patients had social or health problems related to substance misuse
Consequences of Dual Diagnosis
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Increased likelihood of self-harm and violence
Poor physical health (including HIV, hep B and C)
Frequent relapse and re-hospitalisation
Higher rates compulsory detention
Forensic mental health care and criminal justice
system
Higher overall risk of untoward incidents
Difficulty getting access to appropriate aftercare
Poor medication adherence
Family problems
Homelessness
Higher overall service costs
Higher levels of social exclusion
CLINICAL CORRELATES
Specific consequences depend on individual and type
of substance used but broadly alcohol/drug use can
affect on 3 levels:
• Symptoms
• Social
• Treatment Outcome
See Drake, R.E., McLaughlin, P., Pepper, B . And Minkoff, K. )1994) Dual Diagnosis of Major Mental Illness and Substance Disorder;
An Overview. In K. Minkoff and R.E. F Drake. Dual Diagnosis of Major Mental Illness and Substance Disorder. NY; Jossey-Bass Inc.
On track: Helping People Get Better
CLINICAL CORRELATES continued
Specific consequences depend on individual and type of substance used but broadly
alcohol/drug use can impact upon 3 areas
There is a higher likelihood of the following in those individuals with co-existing SU and
SMI problems than those with SMI alone…
• Symptoms
–Earlier onset and more severe
symptoms
–Violence and aggressive behaviour
–Exacerbation of symptoms
–Depression and suicidal behaviour
–Other health consequences
• Treatment Outcome
–Non-engagement in treatment
–Increased hospitalisations
–Poor prognosis
–Medication non-adherence
–Higher service costs
–Fall between services
• Social
–Poor social functioning
–Family discord
–Housing instability
–Financial problems
–Risky sexual behaviour
–Imprisonment
In summary…
Clients with psychosis and
substance
misuse
problems have poorer
outcomes than those with
either
disorder
alone
(Drake et al.,1989).
Reasons for use
• Why do people with mental health
problems use drugs/alcohol?
REASONS FOR SUBSTANCE USE
• Socialisation
Substance use in social situations
Substance use with peers
Desire to be with other people
Limited other social opportunities
To feel “normal” and “accepted” by others
Cultural norms
REASONS FOR SUBSTANCE USE
• Coping
With persistent, distressing symptoms (e.g.
hallucinations, negative symptoms).
Severe depression or anxiety
Medication side effects
Loneliness
REASONS FOR SUBSTANCE USE
• Pleasure Enhancement
Substance use for enjoyment
Limited other leisure activities
Lack of close relationships
Boredom
Not working
NB. Reasons for starting substance use may be different from reasons that maintain it.
From Mueser, K.T. and Gingerich, S. (1994). Coping with Schizophrenia; A Guide for Families. Oakland, CA; New Harbinger Pubs Inc. Chapter
12, pp 245-272
ALCOHOL: Effect on mental health and some interactions
with commonly used psychotropic medications:
Alcohol is a central nervous system (CNS) depressant.
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Exacerbates depression
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Disinhibiting effect, suicide attempts more likely (15% people with serious
drinking problems kill themselves and most who do so are depressed)
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Sedative effects of antidepressants exacerbated and action impaired
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Exacerbates mania – increases likelihood and level of disinhibited behaviour
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Increases sedative effects of anti-psychotic medication
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Psychotic symptoms common as part of alcohol withdrawal syndrome
Long term delusional disorders and dementias noted
with prolonged and heavy use
Georgiou (1999) ISDN (1999)
CANNABIS: Effect on mental health and some interactions with
commonly used psychotropic medications:
Cannabis is an hallucinogenic and all rounder.
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THC (Tetrahydrocannabinols) effects some dopamine receptors; therefore heavy
use has been shown to increase frequency and severity of relapse for those with
psychosis.
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Disorientates to time and space
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Exacerbates paranoid delusions
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Depression/A motivational syndrome noted
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Cannabis use is an independent risk factor for more psychotic relapses and
aggravation of psychotic and disorganization symptoms (D Linszel et al 2004)
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Can increase anxiety levels and be a trigger for panic attacks leading to an
increase/complications for people with depression
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In mania, paranoia can manifest as grandiosity
Georgiou (1999) ISDN (1999)
COCAINE/CRACK COCAINE & AMPHETAMINES:
Effect on mental health and some interactions with
commonly used psychotropic medications:
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These drugs are CNS stimulants.
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Exacerbates psychotic symptoms for those with diagnosed psychosis
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Drug precipitated/induced psychosis
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Opposes action of anti-psychotic medication
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Will initially induce euphoria/lift mood but mood will lower following
use of drug: use will exacerbate depression
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Will exaggerate delusional elements of mania and
hypomania
Georgiou (1999) ISDN (1999)
RISKS OF NON-DETECTION
• Misdiagnosis
• Inadequate treatment planning
- Suboptimal pharmacological treatment for both
- Neglect of interventions for substance misuse
- Inappropriate referrals
• Poor treatment outcomes
e.g. - relapse
- rehospitalisations
• Economic/service costs
• Poor experience of services
Training and Development
• Dual Diagnosis training is advocated by
most policy documents
• Staff should be appropriately recruited and
trained for the work they do
• Gap around sustaining capabilities after
training
• Need to consider the retention of learning
by the use of specialist supervision and
support, forums/interest groups
Dual Diagnosis Good practice Guide 2002
• Mainstreaming
• Doesn’t advocate a separate DD services, but advocates
services that can support mainstreaming
• Mental health services should take primary responsibility
for those with serious mental health problems (like
schizophrenia) and substance use
• AOT likely to provide care for those with dual diagnosis
as typically hard to engage and chaotic users of services
• Substance use services should take primary
responsibility for those with primary substance problems
and common mental health problems (anxiety,
depression)
• However mental health and substance use services
should work together and support each other
The COMPASS Programme Model
Cognitive behavioural Integrated Treatment
(C-BIT)
• Based on a shared care integrated approach with a
target service user group based on local
need.Prevalence (Graham et al 2001) & Training &
support needs surveys (Graham & Maslin 2002).
• Evidence based interventions Cognitive Behavioural
Integrated Treatment (published Wiley & Sons 2004)
• Training and clinical input to teams
• Harm reduction/abstinence Philosophy.
COMPASS Interventions
• Intensive Input to Assertive Outreach Teams / Homeless
Team / EIS
– Train teams + Support to deliver integrated treatment approach (CBIT)
– COMPASS clinician based one day per week in the above teams
• Consultation-Liaison Service
– Offered to clients outside of AOR etc, for e.g., PCL, R&R, inpatients,
CDTs etc
– Screening/assessment + brief intervention over 12-weeks Evaluation:
before & follow-up measures
• Training
- Staff within inpatient units trained in ‘how to run groups’ for their
clients.
– Drug and alcohol awareness Training
– C-BIT Training
Principles of C-BIT Approach &
Integrated Treatment
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Harm reduction/abstinence approach
Flexible, but structured approach
Stage-wise treatment
Collaborative relationship
Guided discovery
Integration of substance use and mental
health treatment
• Flexibility and specialisation of clinicians
Achievement of Integrated treatment in
mainstream mental health teams.
• Service users
• No Fall Between
services
• Not duplicating
Assessment
• Complex needs
addressed concurrently.
• Enhanced engagement
and retention in
treatment
• Access to interventions
for cannabis use
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Teams
Enhanced skills
Consistency
Ownership of client
group
Clearly identified
roles/responsibilities
Support to deliver
structured interventions
Comprehensive
services.
Consistent approach.
C-BIT Outcomes
• Significant Improvement in Confidence and
Skills
• Improvement in staff ability to implement
components of C-BIT
• Integrated treatment could be achieved
• Managers reported significant changes Teams
• Evidence of reduction in units of alcohol and
substance related beliefs.
• Service user Study (Research)
COMPASS Programme
Contact Details
• Derek Tobin
• derek.tobin@bsmhft.nhs.uk
• Tel 0121 301 1750