Psychosis with coexisting
substance misuse
Implementing NICE guidance
March 2011
NICE clinical guideline 120
What this presentation covers
Background
Epidemiology
Scope
Key priorities for implementation
Costs and savings
Discussion
Find out more
Background
• Psychosis: a group of severe mental health disorders.
The main forms are schizophrenia, bipolar disorder or
other affective psychosis.
• Substance misuse: the harmful use of any psychotropic
substance.
• People with both psychosis and substance misuse are
associated with significantly poorer health outcomes
than those with a single disorder.
• People with psychosis may use substances to
cope with symptoms.
Epidemiology
• The annual prevalence for psychotic disorder in the
UK:
- 5 per 1000 in adults within private households
- 9 per 1000 for those aged 30–44 years
- 18 per 1000 in adults with African-Caribbean family
background.
• Approximately 40% of people with psychosis are
diagnosed with substance misuse at some point.
Scope
The NICE guideline covers the assessment and
management of adults and young people with a clinical
diagnosis of psychosis with coexisting substance misuse.
It provides recommendations for the healthcare setting
and for clinical management.
It does not look at:
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people with late onset (after age 60)
primary prevention
diagnosis
management of violence.
Key priorities for
implementation
• Working with adults and young people (engagement)
• Recognition
• Secondary care mental health services (competence,
preventing exclusion)
• Substance misuse services (competence, preventing
exclusion)
• Inpatient mental health services
• Specific issues for young people
Engagement
• When working with people with suspected psychosis
and substance misuse, take time to engage the person,
build a respectful, trusting, non-judgemental
relationship, in an atmosphere of hope and optimism.
• Be direct and use a flexible and motivational
approach.
Recognition of psychosis
with coexisting
substance misuse
• Healthcare professionals should routinely ask people
with known or suspected psychosis about their use of
substances.
• If the person has used substances ask them about the:
• substances used
• quantity, frequency and pattern of use
• route of administration
• duration of current level of use.
Competence
Healthcare professionals in secondary mental health care should:
• ensure they are competent in the recognition, treatment and
care of people with psychosis and substance misuse
• consider having supervision, advice, consultation and
training from substance misuse specialists
• seek support e.g. professional supervision, staff support
groups.
Healthcare professionals in substance misuse services should be
competent to:
• recognise signs and symptoms of psychosis
• undertake a mental health needs and risk assessment to
know when and how to refer to mental health services.
Preventing exclusion
Do not exclude adults and young people with
psychosis and coexisting substance misuse from
• age-appropriate mental healthcare and
accommodation because of their substance misuse.
or
• from age-appropriate substance misuse services and
accommodation because of a diagnosis of psychosis.
Secondary care mental
health services
• Consider seeking specialist advice and initiating joint
working arrangements when the person is known to be:
• severely dependent on alcohol or
• dependent on alcohol and benzodiazepines or
• dependent on opioids and/or cocaine or crack
cocaine.
• Mental health services should continue to provide
care coordination.
Inpatient mental health services
• Inpatient mental health services should ensure they
have policies and procedures to promote a drug and
alcohol-free therapeutic environment.
• Policies and procedures should:
• be developed with service users and their families
• include search procedures, visiting arrangements,
planning and reviewing leave, substance testing,
substance disposal.
• Provide all service users, their families and carers
with information about the policies.
Specific issues for young
people with psychosis
and substance misuse
Those providing and commissioning services should
ensure that:
• age-appropriate mental health services are
available for young people with psychosis and
coexisting substance misuse and
• transition arrangements to adult mental health
services are in place where appropriate.
Families, carers and
significant others
• Encourage families and carers to be involved
• Negotiate confidentiality and information sharing
• Offer a carers’ assessment
• Ensure needs of young carers are assessed
• Offer information about the nature of treatment
• Offer information about local support groups.
Costs and savings
The guideline on psychosis and coexisting substance
misuse is unlikely to result in a significant change in
resource use in the NHS. However, the recommendations
may result in additional costs/savings in the following areas
depending on local circumstances:
• training for healthcare professionals
• secondary care mental health services
• policies and procedures for providers of inpatient
services.
Discussion
• How can we ensure that this guideline reaches all
healthcare professionals working in primary and
secondary services?
• How do we need to change our practice to implement
these recommendations?
• What further training do we need on interventions for
psychosis and/or substance misuse?
• How can we work better with mental health and/or
substance misuse services?
Find out more
Visit www.nice.org.uk/guidance/CG120 for:
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the guideline
the quick reference guide
‘understanding NICE guidance’
costing statement
audit support
baseline assessment tool
clinical case scenarios
slide set
Podcast
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References
Conrod, P. J. & Stewart, S. H. (2005) A critical look at dual-focused
cognitive-39 behavioral treatments for comorbid substance use and
psychiatric disorders: 40 strengths, limitations, and future directions.
Journal of Cognitive Psychotherapy: 41 An International Quarterly, 19, 265289.
Gregg, L., Barrowclough, C. & Haddock, G. (2009) Development and 22
validation of a scale for assessment of reasons for substance use in 23
schizophrenia: the ReSUS scale. Addictive Behaviours, 34, 830-837
Schneier, F. R., & Siris, S. G. (1987) A review of psychoactive substance
use 20 and abuse in schizophrenia: patterns of drug choice. Journal of
Nervous and 21 Mental Disease, 175, 641-652.