5.1. INTRODUCTION
Due to a paucity of evidence, the GDG addressed the review questions concerning assessment (review question 1.1.1) and care pathways and referral guidance (review question 1.4.1) using expert consensus. For further information about the methods used in this chapter, see Chapter 3, Section 3.5.6; for a list of all review questions see Appendix 6.
The challenge in providing treatment and care for people with psychosis and coexisting substance misuse has been the disparity between clinical models used in different parts of the care system, particularly between addiction/substance misuse specialities and the mainstream mental health services. This has been compounded by the two services being funded and commissioned separately, and variation and confusion over which service holds clinical responsibility for people with differing relative severities of each condition. This has, at worst, led to the exclusion of individuals with a coexisting disorder from both services, and, more often, to variable access to services and then attempts at parallel or sequential treatment, which may become disjointed and where accountability and governance is dispersed.
In Models of Care for Treatment of Adult Drug Misusers: Update 2006 (National Treatment Agency for Substance Misuse, 2006) there is a workable definition of a care pathway and the required components:
An integrated care pathway (ICP) describes the nature and anticipated course of treatment for a particular service user and a predetermined plan of treatment. A system of care should be dynamic and able to respond to changing individual needs over time. It should also be able to provide access to a range of services and interventions that meet an individual's needs in a comprehensive way.
The pathway therefore seeks to standardise the steps taken through access, assessment, treatment and discharge as well as provide guidance points for the thresholds and relationships between different treatment teams and services. Care pathways have been developed for drug misuse and for schizophrenia and bipolar disorder within NICE guidelines (NCCMH, 2006, 2008a, 2008b, 2010).
A care pathway for people with psychosis and coexisting substance misuse designed specifically for this guideline is summarised in (Chapter 9 includes a companion care pathway for young people). Both and the following text are designed to be illustrative and offer some broad principles and direction, rather than to be prescriptive. They are sufficiently broad to take into account local context regarding the availability of services, individual need, and clinical discretion while providing a framework based on expert consensus.
Care pathway for people with psychosis and coexisting substance misuse – right care at the right intensity.
5.2. PRINCIPLES UNDERPINNING CARE PATHWAYS
5.2.1. Access to mainstream services
The key message in the Dual Diagnosis Good Practice Guide (Department of Health, 2002) is that people with psychosis and coexisting substance misuse deserve access to good-quality, person-centred and coordinated care and that mainstream mental health services should take responsibility for addressing their needs, drawing on support from substance misuse services. The rationale for this, which the GDG endorsed, is that ‘substance misuse is usual rather than exceptional among people with severe mental health problems’. Locally agreed care pathways need to be explicit so that responsibilities are clear. In addition, mechanisms for resolving disagreements about team responsibility and specialist input need to be in place, such as regular care pathway meetings with executive powers.
The quadrant model (Department of Health, 2002) offers a tool for titrating the likely intensity of care and service involvement required based on the assessed relative severity of mental illness and substance misuse. People who score high on both counts of need (for example, unstable schizophrenia with substance dependency) would therefore be candidates for coordinated specialist care where available, or care from the mental health team with input from substance misuse services where required. Similarly a person with alcohol dependence with moderate depressive symptoms would more likely be managed by substance misuse services and primary care services. The GDG decided however that it was not possible to simply plot service provision against the need identified by each quadrant because the provision of services varies locally and the evidence for integrated services compared with standard care is not robust (see Chapter 6).
5.2.2. Skills and competencies
Skills and competencies for working with people with psychosis and coexisting substance misuse need to be developed through training and supervision to match demand. Suitable frameworks exist for developing skills at core, generalist and specialist levels depending on the type of staff and their exposure to people with psychosis and coexisting substance misuse (Hughes, 2006). For example, staff working in psychiatric inpatient settings, early intervention in psychosis services and assertive outreach teams are likely to have high exposure. The competencies encompass values and attitudes, knowledge and skills, and practice development. In the review of service models reported in Chapter 6, one RCT (Craig and colleagues – see below) was identified during the search, but excluded from the review that examined the effectiveness of staff training; this is reviewed in more detail below.
Clinical evidence for substance misuse training
Craig and colleagues (Craig et al., 2008; Hughes et al., 2008; Johnson et al., 2007) undertook a cluster-randomised trial involving brief (5-day) substance misuse training of case managers working within CMHTs in south London (called the ‘COMO’ study). In addition to the training, the case managers received supervision from the trainer during the follow-up period. Forty case managers received training and 127 of their service users with coexisting psychosis and substance misuse were followed up over 18 months. Thirty-nine case managers did not receive the training and 135 of their service users were also followed-up.
There was no significant difference at follow-up in terms of inpatient bed days, admissions and substance use (Johnson et al., 2007). Craig and colleagues (2008) reported that there were no significant differences in service costs, but symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) and needs for care were significantly lower at follow-up in the group whose case managers were trained. Hughes and colleagues (2008) reported that the training course in psychosis and coexisting substance misuse interventions had a significant effect on secondary measures of staff knowledge and self-efficacy that was detectable at 18 months' post-training. However improvements in attitudes towards working with people who used substances in mental health settings failed to reach statistical significance.
This study did not meet the eligibility criteria for the review of service delivery models in Chapter 6 but does provide some evidence for this review that a training programme for staff in substance misuse combined with supervision may have an impact on symptoms. The brief training course had only a modest impact on staff knowledge and skills in working with people who misuse substances.
Health economic evidence of substance misuse training
The study by Craig and colleagues (2008) included an economic evaluation, comparing the costs and outcomes of a programme for case managers receiving substance misuse training with a waitlist control condition. A societal perspective was used for the cost analysis. The CSRI was used to collect resource use data over the 18-month follow-up period, including inpatient days, healthcare professional visits (psychiatrist, social worker, GP, or drug or alcohol worker), medication and criminal justice (court, police, prison). An array of effectiveness measures were used in the study including psychiatric symptoms (BPRS), drug and alcohol consumption, quality of life (Manchester Short Assessment) and social functioning. Mean total 18-month costs were £18,672 in the intervention group and £17,639 in the control group, resulting in a difference of £1,033 (95% CI, –£5,568 to £6,734). The authors did not attempt to synthesise incremental costs and outcomes, therefore the economic evaluation took the form of a simple cost analysis. Although the results of the analysis are applicable to the UK context, it is difficult to interpret whether the training programme was cost effective, given the variety of outcome measures used and the variability across the effectiveness measures of the training programme compared with the control group.
5.2.3. Choice
While at times people may struggle to make informed choices about their care and treatment options, it is good practice to promote shared decision-making using the assumption of competency unless assessed otherwise. Even where capacity may be limited, the active involvement of families, carers or significant others can reinforce messages from services about personal responsibility and consideration of the impact the individual's choices have upon themselves and others. Motivation and stage of readiness for change concerning substance misuse behaviour are key points determining routes on the care pathway. Sustained change comes about from engaging in a constructive alliance with the individual where they are supported in working through the stages of change without losing their sense of capability and self-direction towards shared goals.
5.3. PRIMARY CARE
5.3.1. Identification and assessment
For this care pathway, ‘primary care’ refers to general practice, accident and emergency departments and psychological therapy services in primary care. Services are generalist, office or department based, and offer limited intensity and frequency of contact. GPs are commonly the first healthcare professionals that worried individuals or families, carers or significant others will choose to consult, and they often have a long-term relationship with and perspective on people and families on their list. Frequent consultations with people presenting with apparently minor ailments may signal underlying issues they are reluctant to disclose and the GP's task is to elicit these hidden concerns. General practice and other primary care services play a key role in early identification and appropriate referral, with full assessment of psychosis and harmful substance misuse taking place in secondary care mental health or addictions services.
Initial assessment in primary care
Ziedonis and Brady (1997) suggested that primary care professionals should always maintain a high index of suspicion for either substance misuse in people with psychosis, or mental illness in people who misuse substances. These authors go on to suggest that when psychosis or substance misuse is detected, initial assessment for the other disorder should always take place and the findings included in referrals for secondary assessment. Alertness to and assessment for signs of current intoxication is particularly pertinent in presentations to accident and emergency departments.
It is important for primary care practitioners to suspect and exclude physical causes for presenting symptoms, including acute intoxication, withdrawal, and side effects from medications.
Primary care also plays a role in screening for physical comorbidities, which have a high rate of incidence in individuals with substance misuse and psychosis, including liver damage, blood borne viruses, cognitive changes, and nutritional deficiencies, particularly where dependent drinking and injecting drug use is suspected.
Further assessment in primary care
Primary care practitioners may see individuals over a period of time and may hear the concerns of families, carers or significant others. They are therefore in an ideal position to detect the insidious decline in functioning that may be the premonitory signs of a psychotic illness. Substance misuse may present with very similar symptoms, and it is the GP's task to establish the duration and extent of substance misuse in relation to the onset of symptoms. For example, a service user may describe increasing consumption of alcohol to the point where it takes priority over other activities and results in a shortage of money, self-neglect and social withdrawal. They may clearly be distinguished from an individual who describes hearing voices and withdraws from social contact due to paranoid beliefs about others, but has a few drinks in order to sleep.
It will usually be helpful to make an assessment of the person's social support networks of family, friends, and co-workers and the degree to which these networks are predicated around substance use activities. Families, carers or significant others may also need an assessment of their needs.
Where significant substance use is detected in primary care, the practitioner will usually need to assess the extent to which this substance use is problematic to the individual and those with whom they come into contact, including children, and whether there is physical or psychological dependency on the substance.
5.3.2. Management
GPs or other primary care practitioners will normally refer a person with a first presentation of suspected psychosis for secondary assessment and not attempt to treat symptoms except to manage crises until a secondary care appointment can be obtained.
While people with a diagnosis of psychosis and substance misuse will normally be managed in secondary care, they remain service users of primary care and GPs may play a key role as a source of background information and may be the first to be aware of changes in people's physical and mental health as well as their social situation. Therefore, close liaison with the secondary care team will be necessary, and efforts should normally be made to include primary care practitioners in CPA reviews.
People with psychosis are known to have poorer physical health than the average service user and thus will benefit from annual health checks, including monitoring of weight, blood pressure, cardiovascular risk (if indicated) and respiratory symptoms, and, if they smoke, a smoking cessation intervention. Regular blood test monitoring is indicated for some medications, such as lithium. Individuals taking psychotropic medication will need to be counselled regarding contraception, and may need information on the safety of psychotropic drugs during pregnancy.
The Quality and Outcomes Framework (QOF) (British Medical Association & NHS Employers, 2009)7 for schizophrenia, bipolar disorder and other psychosis asks practices to keep a register of these service users and to record how many of them have had a review within the previous 15 months. This should indicate that the service user has been offered routine health promotion and prevention advice appropriate to their age, gender and health status. In addition, there are further indicators for the percentage of service users on lithium who have had their renal and thyroid function measured in the past 15 months and a therapeutic lithium level recorded in the past 6 months.
Primary care practitioners may also need to provide information and support to families, carers or significant others, and monitor and assess the welfare of any children involved.
5.3.3. Discharge back to primary care
People with psychosis and coexisting substance misuse may be discharged back to primary care when their secondary care team is satisfied that their psychotic illness is stable and their substance use has stopped or is stable at a level that is unlikely to affect their mental health. Indicators of relapse, and contingency plans in the event of a crisis, need to be agreed before discharge.
The GP may need to see people with psychosis and coexisting substance misuse at least for annual review and more often if indicated. They may need to ask questions to elicit symptoms of relapse of psychosis as well as gain an accurate picture of the type and quantity of substances the individual is using and the stability of their lifestyle. Prescribing records may give an indication of people's adherence to their prescribed medication, but in addition they should normally be asked directly about adherence and any side effects or other problems they may be experiencing. Changes to medication would not normally be made by primary care practitioners, but GPs may liaise with secondary care staff for advice about any changes deemed necessary and if indicated the service user may be seen for a secondary care review.
5.4. SECONDARY CARE (GENERAL MENTAL HEALTH SERVICES)
5.4.1. Assessment
The NICE Schizophrenia (NCCMH, 2010, Section 2.4), Bipolar Disorder (NCCMH, 2006, Section 4.4.4) and Drug Misuse (NCCMH, 2008a, Section 3.7; 2008b, Section 6.2) guidelines outline the key points of good practice for comprehensive assessment and the use of assessment questionnaires and tools. Such tools have not been validated in populations with psychosis and coexisting substance misuse, but by consensus, the GDG considered them suitable. (Preliminary discussion of assessment and diagnostic criteria can be found in Chapter 2.)
Assessment of substance use will normally be an integral component of mental health assessments. Some substances can trigger psychotic episodes (in use and/or withdrawal) and some can trigger relapse in pre-existing psychotic disorders. Evidence suggests that substance use is often inadequately assessed and therefore under-detected (Barnaby et al., 2003; Noordsy et al., 2003), resulting in potential misdiagnosis and inappropriate treatment (Carey & Correia, 1998). Even low levels of substance use by people with psychosis can worsen symptoms.
Expert advice and assessment from substance misuse services will normally need to be sought where there is complexity and high risk, for example injecting opiate use and dependency, or substances less commonly encountered in general mental health services. Referral thresholds for advice and subsequent interventions from substance misuse services are described in Section 5.5.1.
5.4.2. Engagement and sources of information
Regardless of the circumstances at first presentation, engaging the person and working towards establishing a collaborative, respectful, trusting relationship is essential. This may require considerable sensitivity, flexibility and persistence. While the healthcare professional and the service user may have differing views on whether the psychosis or the substance misuse is the ‘main problem’, working with the person on what they see as the priority can provide a basis for working more collaboratively in the short term, and building on the relationship over the longer term.
A similar collaborative relationship is also required with the service user's family, carers or significant others, if they are involved in their care. They can provide helpful information to contribute to the assessment process and may subsequently provide support with treatment.
Given the multiple needs of people with psychosis and substance misuse, other service providers may be involved or have knowledge of the person (for example, their GP, accident and emergency staff, housing providers, probation staff, or drug and alcohol services). As well as contributing to the assessment, maintaining constructive relationships and sharing information with these staff will be essential in developing effective care plans.
Confidentiality may be a particular concern for this population and their families, carers or significant others, for example knowing whether information about use of substances will negatively impact on treatment received, knowledge about illegal activity will be passed on to the police, information about their diagnosis will be passed on to employers, or concerns about parenting abilities will be communicated to families' and children's services. Wherever possible the organisation's confidentiality policy should be explained at the outset. It is important to highlight that the care plan is likely to involve working with other agencies and as such information sharing is an integral part of providing appropriate care. Consent to obtain and share such information should be sought at an early stage. Under some circumstances (for example, where there is a risk to children or vulnerable adults) it may be necessary to break confidentiality and pass on information to relevant agencies. Where possible, service users should be made aware of the action being taken.
Reliable systems and protocols for ensuring the safety of staff in both outpatient and community settings will normally include avoiding assessing or treating people who are severely intoxicated. A non-confrontational approach will need to be taken to rearrange the assessment on a future occasion.
During assessment, most information is likely to be obtained by asking the person themselves unless they are floridly psychotic. Supplementing self-report with observation is important in the assessment, especially when people are reluctant to reveal their experience or details of their substance use or financial status.
The GDG was concerned about the routine use of biological testing because of its potential to work against a collaborative approach. In typical healthcare settings a case-by-case approach set against a clearly explained rationale for care and treatment is preferred. The NICE Drug Misuse: Psychosocial Interventions guideline provides a thorough review of biological testing, and also clinician-rated and self-report identification questionnaires and their potential for identifying drug misuse in high-risk populations (NCCMH, 2008b, Section 6.2.1). The guideline states that while ‘urine testing for the absence or presence of drugs is an important part of assessment and monitoring’, ‘routine screening for drug misuse is largely restricted in the UK to criminal justice settings, including police custody and prisons …. it is sparsely applied in health and social care settings’ (NCCMH, 2008b).
5.4.3. Components of assessment
provides an overview of the assessment components for people with suspected psychosis and substance misuse (left-hand column) and key factors to consider when obtaining such information (right-hand column). This table is consistent with related NICE guidance detailed in Section 5.4.1.
Assessment – Components and considerations.
Having drawn together information from the assessment, some consideration of the relationship between mental health and substance misuse will be possible. Knowing when the person last used particular substances may be important in determining whether their current presentation could be related to substance use alone, or whether it is a contributory factor to an underlying psychotic presentation. However, it can be difficult to distinguish symptoms and effects of mental illness from the effects of misused substances.
There has been a tendency to try to identify the primary and secondary diagnosis, however, even with careful history taking it can sometimes not be possible to disentangle symptoms, and it is recommended that both are considered primary and treated at the same time.
It is important to obtain a picture of the person's reasons for using substances and their understanding of the relationship between their substance use and mental health. For example, some people will believe that drinking alcohol lifts their low mood, while others will have insight into the fact that crack cocaine makes them more paranoid.
When a diagnosis has been reached it will normally be fully explained and discussed with the person and their family, carers or significant others subject to consent. Information about substance use, prescribed medications, and the interaction between medication and illicit or non-prescribed substances should also be discussed and written information offered.
5.4.4. Care planning
Care planning is normally a collaborative process between the healthcare professional and the service user, together with, where appropriate, their family, carers or significant others, and any other agencies.
Understanding the person's perceptions of their substance use and motivation for change is essential for planning appropriate care and treatment. The transtheoretical model of change provides a helpful framework for informing decisions (Prochaska & Di Clemente, 1986; Prochaska et al., 1992). It is important to note that the person's motivation to make changes may be different for different substances. It should be borne in mind, however, that although substance use is likely to have detrimental effects on health, and professionals will usually think the person should work towards abstinence, many people will be unwilling or unable to do so.
Working collaboratively and accepting the person's relative autonomy is essential in maintaining a therapeutic relationship. Being non-judgemental, avoiding confrontation and maintaining optimism are likely to be associated with better long-term outcomes (Miller & Rollnick, 2002; Raistrick et al., 2006).
5.4.5. Safeguarding
Although it is essential to work collaboratively with people with psychosis and substance misuse, it is also important to recognise that those dependent upon them may also need help, and sometimes protection. When someone with psychosis and coexisting substance misuse looks after or has significant involvement with dependent children, the needs and safeguarding of the child must be secured according to the Common Assessment Framework (see Chapter 9). The care co-ordinator or key worker may need to ensure that children's services are alerted to the need for assessment and possible help for the child. Similarly, when dependent or vulnerable adults are involved, the vulnerable adult may need to be assessed (including risks) at home and any necessary safeguarding procedures initiated.
5.5. SECONDARY MENTAL HEALTHCARE REFERRAL TO SPECIALIST SUBSTANCE MISUSE SERVICES
5.5.1. Referral threshold
Specialist substance misuse services, whether hospital (inpatient units) or community based (community drug and alcohol teams), are dedicated to providing assessment and treatment for problematic alcohol and drug use, for example, heroin and cocaine. There is no reason why people with psychosis and coexisting substance misuse should be excluded from access to substance misuse services because of a diagnosis of psychosis.
Referral from mainstream mental health services for specialist advice and joint working with specialist substance misuse services will occur where people with psychosis are known to be severely dependent on alcohol, dependent on both alcohol and benzodiazepines or dependent on opioids, although there will be variation between services.
As can be seen in (see page 103), tertiary referral allows access to more specialist skills, knowledge and resources, including opiate prescribing and inpatient detoxification, residential rehabilitation, and support or treatment groups.
Because motivation is an important element of entry criteria to specialist substance misuse services, secondary care professionals may need to help individuals toward readiness for change.
5.5.2. Assessment and recognition
The possible coexistence of psychosis among people who come to specialist substance misuse services is often underestimated at least in part because of the complex clinical picture when substance misuse is severe, involves the use of multiple substances and in people with personality disorder or other mental health problems. This is further complicated by that fact that substances may well be used to combat particular psychiatric symptoms or experiences, such as anxiety, depression, intrusive thoughts, difficulties sleeping or more severe and troublesome experiences such as hallucinations. Moreover, significant life events, such as bereavement, divorce and trauma, are frequently associated with the emergence of mental health problems, including relapse for people with psychosis, and are commonly also triggers for the beginning of, or a significant increase in, substance misuse. Furthermore, substance misuse may alter the presentation of symptoms – improving some and worsening others; this is especially so when a person is either intoxicated or experiencing withdrawal. For these, and many other reasons, assessment of mental state for people with substance misuse problems can prove to be difficult and recognition of a coexisting psychosis delayed.
It is important that the assessment of people with a substance misuse problem is comprehensive – it may need to take place over several meetings and over an extended period. It is also important to obtain additional information and history from family, carers or significant others, where this is permitted and feasible. Ideally assessment will cover not only all the information needed for a substance misuse assessment and a mental health assessment, but also aim to examine how the person's behaviour, mental state and experiences co-vary (or not) with changing patterns of substance misuse, how patterns of substance misuse may co-vary (or not) with changes in mental state, and how both substance misuse and mental state change in light of different life events. Understanding changes in mental state when someone misusing substances becomes either relatively or completely abstinent can be crucial in making the right diagnostic formulation, not least because communicative and cognitive functions can be greatly improved at these times. In any event, for some people where the index of suspicion for the coexistence of a psychosis with known substance misuse is high, use of the Mental Health Act (1983; amended 1995 and 2007, HMSO, 2007) (for assessment) can be necessary and decisive.
5.5.3. Interfaces and coordination
Substance misuse services will normally need to work closely with secondary mental health services to ensure that there are agreed local protocols derived from these guidelines that set out responsibilities and processes for assessment, referral, treatment and shared care across the whole care pathway for people with psychosis and coexisting substance misuse. This includes substance misuse professionals being available for care programme meetings for individuals receiving shared care with a secondary care mental health team. Secondary care community mental health services will usually need to continue to monitor and treat psychosis, and provide care coordination.
Referral and signposting options will always need to be discussed with and agreed by the service user. There may be a choice of agencies and it is important that the service user is informed and involved in a shared decision. A range of tier 2 and 3 drug and alcohol services will need to be considered in this respect (see Section 5.5.5), in line with the principle of the right care at the right intensity outlined in Section 5.2.1. Specialist liver clinics, probation services and homeless or housing agencies are also interfaces to be managed and fostered. There needs to be clarity around the role of each service, clearly reflected in the care plan, with regular communication and appropriate sharing of information between agencies.
Advocates working in voluntary organisations and other third sector groups will need to be involved in care planning and care programming where this is agreed with the service user.
5.5.4. Responsibility for prescribing
Where a treatment plan is agreed involving secondary care and specialist substance misuse services the responsibility for any opiate substitute prescribing will need to be clearly agreed between the consultants for the two teams, incorporated into the service user's written care plan, and implemented according to the prescribing guidelines. The service user will need to be seen regularly.
Advice and guidelines on prescribing for service users with substance misuse problems, for example, home assisted alcohol withdrawal programmes, should be available from substance misuse services. Mental healthcare professionals working with people with psychosis and coexisting substance misuse will need to consider having supervision, advice, consultation and/or training from professionals with expertise in substance misuse to aid in developing and implementing treatment plans for people with substance misuse within secondary care mental health services.
5.5.5. Differences in care frameworks
People with psychosis and severe coexisting substance misuse will need to remain under the care of secondary care, managed within the Care Programme Approach (CPA), a term that describes the approach used in secondary adult mental healthcare to assess, plan, review and co-ordinate the range of treatment, care and support needs for people in contact with secondary mental health services who have complex characteristics.
Specialist drug services operate under Models of Care for Treatment of Adult Drug Misusers: Update 2006 (National Treatment Agency for Substance Misuse, 2006), whereas specialist alcohol services function according to Models of Care for Alcohol Misusers (MoCAM) (Department of Health & National Treatment Agency for Substance Misuse, 2006). Both models of care utilise a four-tier framework and these refer to the level of the interventions provided and not the provider organisations:
Tier 1 interventions include provision of drug- or alcohol-related information and advice, screening and referral. For alcohol misuse, tier 1 can also involve simple brief interventions.
Tier 2 interventions for drug misuse include provision of drug-related information and advice, triage assessment, referral to structured drug treatment, brief psychosocial interventions, signposting to support groups such as Narcotics Anonymous (NA), harm reduction interventions (including needle exchange) and aftercare. For alcohol misuse, interventions include provision of open access facilities and outreach that provide: alcohol-specific advice, information and support; signposting to mutual aid groups such as AA; extended brief interventions to help reduce alcohol-related harm; and assessment and referral of people with more serious alcohol-related problems for care-planned treatment.
Tier 3 interventions include provision of community-based specialised drug and/or alcohol misuse assessment and coordinated care-planned treatment and drug specialist liaison.
Tier 4 interventions include provision of residential specialised drug and/or alcohol treatment, which is care planned and coordinated to ensure continuity of care and aftercare.
5.6. INPATIENT AND RESIDENTIAL SERVICES
5.6.1. Adult mental health services
Substance misuse is a common and major problem within adult inpatient mental health settings (Barnaby et al., 2003; Bonsack et al., 2006; Phillips & Johnson, 2003; Sinclair et al., 2008), with alcohol, cannabis and cocaine being the most commonly misused substances in inner urban settings. Service users with psychosis who misuse substances spend more time as inpatients and are admitted more frequently (Isaac et al., 2005; Menezes et al., 1996). Very high rates of cannabis use were found in a study of service users admitted to an inner urban psychiatric intensive care unit and those who continued to misuse cannabis (despite the best attempts of staff to restrict access to the drug) spent longer in hospital (Isaac et al., 2005).
Violence is also a major cause of concern on acute inpatient wards, and substance misuse has been identified by staff as an important contributor to such violence (Healthcare Commission, 2007). This is consistent with the epidemiological finding that most of the serious offending behaviour in people with schizophrenia that is over and above what is seen in the general population occurs in the context of a comorbid substance-use disorder (Fazel et al., 2009b). In the substance misusing population as a whole, cocaine and alcohol are particularly associated with violence (Macdonald et al., 2008).
People with psychosis are usually admitted to a general adult mental health inpatient ward because of deterioration in their mental state and/or evidence of increased risk either to themselves or others. Substance misuse may be a coincidental factor or play a causal role in the circumstances surrounding admission. In either case, assessment and management of the substance misuse should follow the general principles outlined above in other settings.
The Department of Health has issued specific guidance about the management of people with mental illness and coexisting substance misuse being cared for in day hospital and inpatient settings (Department of Health, 2006). Particular difficulties that potentially face healthcare professionals in inpatient settings include: the place and role of routine and occasional testing of biological samples (urine, blood, hair and, for alcohol, breath) as part of an agreed treatment plan; the requirement for policies on searching; and the practical management of episodes of substance misuse occurring in inpatients. This requires the development of local policies on the management of substances found on the premises, consideration of exclusion of visitors believed to be bringing in illicit substances and good liaison with the police. For detained service users, management of ongoing substance misuse may involve a review of their leave status and the appropriate level of security for safe and effective care.
Admission of service users with psychosis and coexisting opiate misuse to an adult psychiatric inpatient unit is uncommon; but when it happens it poses particular challenges. In this context it is imperative that an appropriate assessment by an expert in substance misuse and/or advice to the adult psychiatric team is available before developing a treatment plan for the opiate misuse. The treatment plan will often include prescription of substitute opiates (methadone or buprenorphine). Healthcare professionals working within adult mental health services generally, and in inpatient settings in particular, need to be familiar with current guidelines on the management of substance misuse provided by the National Treatment Agency (Department of Health, 2007).
5.6.2. Secure mental health services
Although substance misuse is a considerable problem within general adult mental health services, both in the community and especially in inpatient units, a significant past history of substance misuse is even more common among service users in secure care (Department of Health, 2006; D'silva & Ferriter, 2003; Isherwood & Brooke, 2001). Inpatients in medium secure units report high levels of previous substance misuse, which has commonly continued after admission (Wyte et al., 2004). Historically, dedicated substance misuse programmes were lacking within secure services despite the robust epidemiological evidence that links substance misuse with offending behaviour in people with a psychotic illness (Scott et al., 2004). Secure services now commonly provide structured substance misuse interventions, but these are only in the early stages of evaluation (Miles et al., 2007).
5.6.3. Substance misuse inpatient services
There is evidence that a diagnosis of psychosis is much more prevalent in people in contact with community substance misuse services than in the general population (Weaver et al., 2003). There appears to be no data on the prevalence of psychosis that is not a consequence of substance misuse among inpatients in substance misuse services who are admitted for detoxification. People who become or are acutely psychotic while being treated in a substance misuse inpatient setting are often appropriately referred for treatment in general adult psychiatric inpatient services (an exception here is delirium tremens in the context of alcohol withdrawal, which is a medical emergency and would not occur in a competent inpatient setting providing assisted alcohol withdrawal). There is no evidence that a diagnosis of a psychotic illness is a contraindication for admission for treatment of coexisting substance misuse where the psychotic illness has been effectively treated.
5.6.4. Residential and supported housing services
Residential and supported housing services for people with a diagnosis of a psychotic illness inevitably work with people who misuse substances. The general principles of assessment, treatment and care set out above are relevant to staff working in these settings, which will commonly be delivered through agencies other than the housing provider. There is a lack of evidence about how residential and supported housing services should work most effectively with people with psychosis and coexisting substance misuse although some practice guidance has been developed (Turning Point, 2007).
Residential and supported housing services for people with substance misuse have in the past commonly been reluctant to take in people with a psychotic illness, despite the fact that psychosis is common among people who misuse substances (Weaver et al., 2003). The National Treatment Agency for Substance Misuse has identified a need for residential programmes that take account of the specific needs of ‘drug misusers with severe and enduring mental health problems’ (National Treatment Agency for Substance Misuse, 2006). There is no evidence that a diagnosis of a psychotic illness is a contraindication for residential rehabilitative services for people with coexisting substance misuse where the psychotic illness has been effectively treated.
5.6.5. Prison mental health services and the criminal justice system
The Bradley Report (Department of Health, 2009a), and the subsequent government response and delivery plan (Department of Health, 2009b), focus on people with mental health problems and learning disabilities who become involved with the criminal justice system and makes wide-ranging recommendations. The report recognises the prevalence of psychosis with coexisting substance misuse in this population and makes a specific recommendation to develop improved services in prisons for these people. Current problems within the prison system echo those outside:
Mental health services and substance misuse services in prisons do not currently work well together; national policy is developed separately for mental health and for substance misuse, and this is reflected on the ground, where dual diagnosis is used as a reason for exclusion from services rather than supporting access.
8
In terms of the care pathway the report calls for liaison and court diversion services to reduce the need for custodial interventions and allow access to appropriate treatment at an earlier stage in people's offending behaviour. The Bradley Report also calls for better links with community mental health services when people with psychosis and coexisting substance misuse are leaving prison.
5.7. FROM EVIDENCE TO RECOMMENDATIONS
There is only a limited amount of empirical evidence about the prevalence, pattern and epidemiology of different combinations of psychosis and coexisting substance misuse. Such information is necessary to target resources at groups most at risk of very poor outcomes, to determine whether early intervention might be more effective than interventions for long-standing comorbidity and to investigate whether different interventions are required for separate diagnostic groups and types of substance. In addition, little research is available to determine how healthcare professionals should work together to provide the most appropriate care and treatment for people with psychosis and coexisting substance misuse. Where evidence is exists, it is often collected in different countries, such as the US, where the interventions, training and competence of professionals, the configuration of the healthcare system, and in particular, what counts as ‘standard care’, may be very different. The GDG, nevertheless, extrapolated where possible and practical. The following recommendations are, therefore, developed through an iterative process, synthesising the collective experience of the GDG to develop a framework of good practice recommendations that it is hoped will support healthcare professionals develop services in mental health and, in particular substance misuse, services so that people with psychosis and coexisting substance misuse can receive the care and treatment most likely to bring benefit and improve their lives and those of their families, carers or significant others.
The recommendations for good practice cover five main areas: (1) working with adults and young people with psychosis and coexisting substance misuse, (2) recognition, (3) primary care, (4) secondary care mental health services, and (5) substance misuse services.
When working with people with psychosis and coexisting substance misuse, the GDG thought that a number of safeguarding issues were important and needed recommendations. (There is further discussion of safeguarding in Chapter 9.) In addition, the GDG felt that voluntary sector organisations had an important role to play in lives of people with psychosis and coexisting substance misuse, therefore, recommendations were made about collaborative working.
With regard to recognition, given that substance misuse is usual rather than exceptional among people with psychosis, the GDG felt it was vital that healthcare professionals in all settings ask service users about substance use, and where appropriate, an assessment of dependency should be conducted using the existing NICE Drug Misuse (NICE, 2007a, 2007b) and Alcohol-use Disorders (NICE, 2011) guidelines. Likewise, in people with known or suspected substance misuse, there should be an assessment for possible psychosis.
In primary care, the GDG felt that there was a clear rationale (supported by Department of Health guidance) to recommend that people with psychosis or suspected psychosis, including those who are suspected of having coexisting substance misuse, should be referred to either secondary care mental health services or child and adolescent mental health services (CAMHS) for assessment and further management. Likewise, people with substance misuse or suspected substance misuse who are suspected of having coexisting psychosis, should be referred to either secondary care mental health services or CAMHS.
In secondary care mental health services, the GDG felt there was a need to recommend that healthcare professionals should ensure they are competent in the recognition, treatment and care of people with psychosis and coexisting substance misuse. In addition, mental health professionals should consider having supervision, advice, consultation and/or training from specialists in substance misuse services. The GDG considered that this would aid in the development and implementation of treatment plans for substance misuse within adult community mental health services and CAMHS. Also, because adults and young people with psychosis and coexisting substance misuse are often excluded from age-appropriate services for no justifiable reason, the GDG felt there was a strong rationale for recommending against exclusion. Finally, the GDG made a number of recommendations covering the process of assessment and the use of biological or physical testing. Regarding the latter, the GDG felt there was a place for testing when used as part of a care plan if the service user agrees. After much discussion, the GDG decided that biological or physical testing should not be used in routine screening for substance misuse, and should only be considered in inpatient settings as part of assessment and treatment planning; consent needs to be sought, and where mental capacity is lacking, healthcare professionals should refer to the Mental Capacity Act (2005).
In substance misuse services, the GDG saw a clear need to recommend that healthcare professionals should be competent to recognise the signs and symptoms of psychosis, and undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services. The GDG also felt that recommendations for joint working needed to be made as this was not, in their experience, done well.
Although there is a paucity of evidence regarding all aspects of assessment and care pathways, the GDG felt that two research recommendations should be given priority. First, as described above, the prevalence, risk and protective factors, and course of illness for different combinations of psychosis and coexisting substance misuse needs to be examined. Second, there are cogent reasons given the high prevalence of substance misuse among service users with a psychosis that staff working within mental health services develop, as part of their basic training and continuing professional development, skills and knowledge in substance misuse assessment and treatment interventions. More research is required on how this training is provided and the impact of ongoing supervision when working with people with psychosis and coexisting substance misuse. The GDG considered that the responsibility for monitoring the physical health of people with psychosis and coexisting substance misuse should remain in primary care as recommended in the NICE Schizophrenia guideline (NICE, 2009a).
