9.1. INTRODUCTION
There is a paucity of evidence relating to young people with psychosis and coexisting substance misuse with regard to all the review questions (for a list of all questions see Appendix 6). Therefore, the GDG developed by expert consensus specific recommendations for young people (for further information about the methods used in this chapter, see Chapter 3, Section 3.5.6). A care pathway for young people is summarised in . As with Chapter 5, the pathway and the text that follows are designed to be illustrative and offer some broad principles and direction, rather than to be prescriptive.
Care pathway for young people with psychosis and coexisting substance misuse.
Adolescence is a period of major developmental transitions – physically, psychologically and socially. During this period young people experience emotional distress, frequent interpersonal disruptions and challenges in establishing a sense of identity. These factors can act as both stressors for those vulnerable to a psychotic illness and as difficulties that can lead to substance misuse as a form of escape or self-treatment.
Little research has been carried out on the specific factors that lead young people to be vulnerable to both psychosis and substance misuse. Furthermore, little is known about the effectiveness of interventions specific to this age group. This chapter, therefore, covers what is known about prevalence, outcomes and service configuration for young people. In the absence of more specific evidence, the principles of intervention will be drawn from and adapted from the adult literature.
This guideline uses the term ‘young people’ to refer to people aged between their 14th and 18th birthdays, as people of this age generally prefer this descriptor to the term ‘adolescent’.
9.2. PREVALENCE
It is not simple to identify the prevalence of substance misuse and psychosis in young people. Studies exploring the age range might include a discussion about each of the disorders, but rarely combine them. Studies that do investigate combined disorders usually do not focus on people aged under 18 years. A systematic review of coexisting substance use in people with psychosis carried out by Carra and Johnson (2009) pointed to wide variations in prevalence rates. Most recent UK studies reported rates of between 20 and 37% in mental health settings, and 6 and 15% in addiction settings (Carra & Johnson, 2009). Inpatient, crisis and forensic settings are, not surprisingly, higher, that is, 38 to 50% (Carra & Johnson, 2009). People from inner cities and some ethnic groups are over represented (Carra & Johnson, 2009). It should be emphasised that there are varying age ranges in these studies and few specifically focused on young people.
9.2.1. General practice
A study undertaken from 1993 to 1998 of comorbid psychiatric illness and substance misuse estimated that there were at least 195,000 comorbid service users and 3.5 million GP consultations involving comorbid service users of all ages in England and Wales (Frisher et al., 2004). An unanticipated finding was that each year 80 to 90% of comorbid service users were newly diagnosed, although existing service users may have continued to receive treatment. Thus, there is a significant problem in terms of primary care workload. The number of people newly developing comorbidity in primary care increased year on year. The impact on health services is far in excess of that for mono-morbid service users; those with a comorbidity have an extra consultation frequency for all problems, estimated as an excess of 1,115,751 consultations in England and Wales in 1998.
During the 6-year study period, the annual comorbidity rate increased by 62%, but rates of comorbid schizophrenia, paranoia and psychoses increased by 128%, 144% and 147%, respectively (Frisher et al., 2004). In this study, the level of comorbidity increased at a higher rate among younger service users, which indicates that comorbidity may increase, perhaps at a faster rate than observed in the study period, in future years. All comorbid diagnoses – including schizophrenia and psychosis – peaked at ages 16 to 24 or 25 to 34. In 1998, it was estimated that there were about 20,000 people with a comorbidity aged between 16 to 34 (7,773 in the 16 to 24 age range and 12,949 in the 25 to 34 age range) in primary care.
The data reported by Frisher and colleagues (2004) indicate that substance misuse may be precipitating more serious forms of comorbidity, although it is by no means clear that this is the case. For example, nearly all diagnoses of comorbid schizophrenia precede substance misuse. In this study (Frisher et al., 2004), the majority (54%) of service users had a psychiatric diagnosis first, and half become comorbid within 6 months of the first diagnosis.
The findings on transition from mono-morbidity to comorbidity have major implications for understanding and preventing comorbidity. It is possible that people with comorbidity may be qualitatively different in the form of their mono-morbidity than those who remain mono-morbid. Early development of comorbidity suggests that there may be characteristics already present at the mono-morbid stage that may predict the likelihood of developing comorbidity. Identifying such characteristics in future research might contribute to the early management or prevention of comorbidity in primary care.
9.2.2. Community substance misuse and mental health services
Weaver and colleagues (2003) conducted a multicentre study that derived estimates of psychosis and coexisting substance misuse (76% of whom were diagnosed with schizophrenia) in the 16 to 30 age range. They found that one third of their sample was misusing substances. Although the age range looked at in this study exceeds the range considered for young people in this guideline, it is helpful in providing a figure on substance misuse in the community.
9.2.3. First-episode psychosis
Donoghue and colleagues (2009) utilised data from two epidemiological studies of first-episode psychosis (the Schizophrenia in Nottingham study and the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study), demonstrating that for those aged 16 to 29 years, there was a significant increase from 14.9 to 30.1% in all substance-use disorders between 1992 to 1994 and 1997 to 1999 (Donoghue et al., 2009). Similarly, for cannabis-specific substance-use disorder, there was a significant increase from 3.2 to 10.6%. These increases were seen in both males and females.
9.3. IMPACT OF SUBSTANCE MISUSE ON OUTCOME IN PSYCHOSIS
In a group of service users treated with psychological therapy for first-episode psychosis, 33% of those under 21 years had self-reported substance misuse (Haddock et al., 2006). Of relevance is the finding that young people may have differing needs with regard to engagement. Counselling appeared to be more beneficial for the younger age group.
An Australian study (Wade et al., 2006) in people aged 15 to 30 years (mean age 21.6 years) reported that substance misuse (53% at follow-up) was an independent risk factor for problematic recovery in first-episode psychosis (for example, increased risk of admission, relapse of positive symptoms and shorter time to relapse). However, substance misuse was not associated with longer time to remission.
Hides and colleagues (2006) has pointed to a bi-directional relationship between substance misuse and cannabis relapse in that a higher frequency of cannabis use was predictive of psychotic relapse (if medication adherence, other substance use and duration of untreated psychosis were controlled for), while an increase in psychotic symptoms was predictive of relapse to cannabis use. In this study, only 15% of service users had not used any illicit substance in the previous 12 months.
9.4. ASSESSMENT AND DIAGNOSIS
Many aspects of the assessment and diagnosis of young people with psychosis and coexisting substance misuse will be the same or similar as for adults. This is covered in detail in Chapter 5.
As is the case for adults, healthcare professionals in all settings should routinely ask young people with known or suspected psychosis about their use of substances. This may include questions about type and method of administration, quantities and frequency. It is important for healthcare professionals in all settings to routinely assess young people with known or suspected substance misuse for possible psychosis.
For young people with psychosis and coexisting substance misuse presenting to mental health services, a comprehensive assessment of both conditions is crucial. This includes an assessment of psychiatric, psychological and physical health, home and family environment, educational or employment status, medication, risk to self and others, relationships and social networks, forensic and criminal justice history, strengths and aspirations. Assessing the relationship between substance use, emotional state and reasons for substance use is also important. In addition, gaining corroborative evidence where possible is helpful in order to assess the impact of substance misuse on mental state and behaviour.
The assessment of young people may take time and involve multiple sessions due to difficulty with concentration, ambivalence, lack of clarity about the purpose of the assessment(s), and the need to gradually gain trust and confidence in the practitioners and service. There are three crucial goals of an assessment: (1) to conduct the assessment in such a manner that fosters and promotes continuing engagement; (2) to ensure the safety of the young person; and (3) to determine which substance(s) the young person is dependent on in order to determine whether administration of a pharmacological agent – possibly for detoxification – is appropriate. It is important to note that even if the young person is not dependent on a substance, serious harm may result from drug misuse.
The comprehensive assessment of a young person presenting with psychosis and coexisting substance misuse is similar to what is described for adults in Chapter 5. The issues brought up for adults, however, apply even more strongly for young people, as they are more complex to engage, are more vulnerable, and can experience serious problems as a result of substance misuse, without having substance dependence. Additional differences between adults and young people relate to service delivery, as services for young people are usually provided separately from those for adults.
9.5. SERVICE CONFIGURATION AND CARE PATHWAYS
9.5.1. Introduction
Interventions for young people with psychosis and coexisting substance misuse may be provided by a range of agencies and services within each agency. Agencies will include Children's Services, which may be involved around social care, housing, education or safeguarding. Youth offending services may be involved. However, once a diagnosis of psychosis with coexisting substance misuse has been made, mental health services will usually be provided by specialist child and adolescent mental health services (CAMHS) or early intervention in psychosis services (EIS). Specialist substance misuse interventions for young people may be available from within core mental health services or from specialist substance misuse services.
9.5.2. Tier structure of child and adolescent mental health services
In order to recognise the different levels of interventions for many mental health problems in children and young people, CAMHS has been organised into four main levels, or tiers, of delivery (Department of Health, 2004; Health Advisory Service, 1995) (see Text Box 1).
Tier 1. CAMHS
Professionals at Tier 1 are most likely to encounter young people with psychosis and coexisting substance misuse when a change in their behaviour is noticed. This could be unusual or otherwise out-of-character behaviour, a decline in academic performance or increasing social isolation. Tier 1 professionals are unlikely to be involved in diagnosing psychosis, but may become aware of substance misuse difficulties. They could also become involved in providing for the young person's physical healthcare, social and educational needs when the young person's mental health needs are being met. Awareness of psychosis and substance misuse in young people may prevent inappropriate dismissal of their presenting difficulties and encourage Tier 1 professionals to refer on to appropriate services.
For Tier 1 professionals to be able to fulfil these roles they will need appropriate training. Training programmes for Tier 1 staff may require modification to cover psychosis with substance misuse or behaviours suggestive of the diagnosis. This training may be most effectively targeted at services that have young people with higher rates of mental health concerns, for example Key Stage 4 Pupil Referral Units. Following appropriate training Tier 1 professionals may be involved in the sensitive detection of psychosis and substance misuse. When identified, such concerns should lead to referral to, or consultation with, Tier 2 professionals.
Tier 2. CAMHS
Tier 2 professionals provide consultation and training to Tier 1 professionals in regard to all mental health problems. Tier 2 professionals therefore require an awareness of the problems of young people with psychosis and coexisting substance misuse and competence to detect psychotic symptoms or the early features of psychosis in young people. If a diagnosis of psychosis or early features of psychosis is suspected, a referral to Tier 3 CAMHS or EIS teams can be made according to local protocols.
Tier 3. CAMHS
Tier 3 services can provide a comprehensive assessment of the young person with psychosis and coexisting substance misuse. When a diagnosis of psychosis is made, it is important for Tier 3 professionals to consider the possibility of substance misuse.
When a diagnosis of psychosis and coexisting substance misuse has been made, priority should be given to both treatment of the psychosis and of the substance misuse. Constant review of risk is of key importance, and if the young person presents with a high risk to themselves or others due to their psychosis, then it is important to consider inpatient admission.
All the mainstays of treatment, including prescribing medication, monitoring mental state and providing psychological and psychosocial interventions can be offered in Tier 3 CAMHS or by EIS teams or by collaboration between the two.
Given that most young people with psychosis and coexisting substance misuse live with their families, with foster parents, or in social services residential placements, involving families and carers in treatment is helpful. Families and carers can be involved in relapse prevention work as well as working with professionals in supporting the young person. Interventions to support parents, including family therapy, should be offered to all families and include a focus on high levels of criticism and intrusiveness (expressed emotion) when identified.
Because many young people with psychosis and coexisting substance misuse require a multi-agency response, clarity about the responsibilities of each agency facilitates the delivery of care. As well as their mental health and substance misuse needs, young people with psychosis and coexisting substance misuse will often have housing, employment or educational needs. Agencies must strive to collaborate to provide coordinated care. Different thresholds for entry into services can compromise this objective. For example, Tier 3 professionals may have concerns about a young person's social care that may not meet social service thresholds for intervention. This can reduce the effectiveness of therapeutic interventions as Tier 3 staff become involved in trying to coordinate or meet social care needs. Likewise social services may find accessing specialist therapy services for some of the young people they care for difficult because, for example, despite ongoing substance misuse, Tier 3 staff may consider that the young person's mental health difficulties are in remission and therefore subthreshold for active intervention. Failure to engage at all with the young person in these circumstances may prevent the success of social services interventions to improve the young person's social care and increase likelihood of relapse. Professionals need to work flexibly and creatively around these tensions over service thresholds. Respecting the validity of the principles leading to the development of thresholds while trying to meet the needs of the young person is required in these circumstances.
It is important for Tier 3 teams to develop sub-teams of professionals with expertise in the management of young people with psychosis and coexisting substance misuse either separately or in collaboration with EIS teams. One model of collaboration widely adopted is for CAMHS to provide psychiatric input whilst EIS provide care co-ordination and psychosocial interventions. In some areas, stand-alone CAMHS psychosis services have been set up. Tier 3 CAMHS professionals must also have the capacity to provide consultation and training to Tier 2 staff.
Healthcare professionals working in Tier 3 can also follow the recommendations for adults in other chapters.
Tier 4. CAMHS
For young people with psychosis and coexisting substance misuse, Tier 4 CAMHS principally comprise inpatient services. There is usually a limited role for other Tier 4 services such as specialist outpatient services and home-based treatment teams, as most non-bed based treatments can be picked up by other services such as Tier 3 CAMHS or EIS teams.
Inpatient services
Admission to an inpatient unit will usually be indicated due to the level of risk identified in managing the young person in the community. This can often present in an acute crisis. Admissions for the management of acute risk should be clearly linked to an acute exacerbation of risk, time-limited, and with clear goals in mind. Such admissions may also be required when risk is high and the motivation of the service user to collaborate in community treatment is very low or non-existent. The aim of such admissions is usually to ensure that the service user is just ‘community ready’. Transfer back to the community is clearly facilitated when the young person is effectively engaged in a structured outpatient programme.
Other factors warranting consideration for admission by a Tier 4 team for treatment of psychosis and coexisting substance misuse include other Axis I difficulties combined with a significant deterioration in functioning and reduced capacity of either the family or community team to manage the young person.
If a young person's needs are thought to be best met by an adult ward and they choose this (for example if they are almost 18 years and adult services are much closer to home), then it is acceptable for them to be admitted to an adult mental health ward. It is also acceptable for a young person aged 16 or 17 years to spend a short time on an adult ward if an age-appropriate bed is not available. In both circumstances, safeguarding measures need to be in place while the young person is on the adult ward. It is never acceptable for a young person aged under 16 years to be admitted to an adult ward. (See the Mental Health Act 1983; amended 1995 and 2007; Section 31 [HMSO, 2007] and MHA Code of Practice [Department of Health, 2008].)
Specialist home-based treatment teams
These teams for young people are in the early stages of development in the UK and consequently their place in the treatment of psychosis and coexisting substance misuse has yet to be established. Like inpatient services, existing teams frequently manage acute risk and attempt to address chronic risk and/or low functioning service users.
Services are likely to take different forms depending on their focus on acute or chronic issues. When focused on acute risk, services usually combine characteristics of assertive outreach and crisis intervention with intensive case management. These services have proved effective both when Tier 3 treatment has been disrupted and as a mechanism for organising an effective outpatient intervention plan. Typically services have a capacity for rapid and intensive engagement lasting no more than a few weeks, followed by service user/family-centred intensive case management.
Services focused on chronic risk and/or low functioning are characterised by a stronger psychotherapy focus, a longer duration of treatment and an active engagement phase pre-treatment. These services have also been used as a ‘step down’ from inpatient services when inpatient stays have become ineffective, or for community rehabilitation. This type of intervention might be considered when parenting has become distorted by the service user's presentation and family relationships are undermining individually-focused treatment plans.
In most cases, psychoeducational work with parents is required prior to implementing more intensive interventions that may often be experienced as intrusive. These forms of home-based treatment are best avoided where there are longstanding concerns about parental capacity.
Home-based treatment services, regardless of whether they focus on the treatment of acute or chronic issues, share a number of characteristics: they require experienced staff with expertise in psychosis and coexisting substance misuse and a team structure that allows a high level of supervision and the effective management of risk in the community; each is likely to offer time-limited treatment but of different durations; and each is likely to balance limit setting with developing autonomy. Services need to effectively differentiate young person, parents, family, and wider system interventions and to focus primarily on the management of risk and the promotion of functioning.
9.6. EARLY INTERVENTION IN PSYCHOSIS SERVICES
Early intervention services (EIS) are assertive community-based multidisciplinary teams that provide care for people aged between 14 and 35 years with a first presentation of psychotic symptoms during the first 3 years of psychotic illness (Department of Health, 2001) and are primarily concerned with the identification and treatment of the early phase of psychotic illness. For young people (aged 14 to 18 years), EIS often work according to locally agreed protocols with Tier 3 and 4 CAMHS.
Often, the initial focus of the EIS is on engagement in order to develop a shared, individualised recovery-focused treatment plan that incorporates a range of interventions including antipsychotic drugs, CBT, family intervention, vocational activity and reduction of substance misuse. As substance use and misuse is so common in people presenting with a first episode of psychotic illness, there are sound clinical reasons why EIS staff would consider the possibility of substance misuse in a young person presenting with psychotic symptoms, and if a diagnosis of psychosis and coexisting substance misuse is made, it should be ensured that treatment for both conditions is offered.
Interventions for substance misuse may be complicated if the young person's peer group is also using substances and so there is a strong rationale for why staff in EIS need to develop strategies to help enable the young person to recognise the impact of their substance use on their psychotic symptoms. In order to do this, EIS staff will need to fully assess substance use including type, amount and frequency of use of each substance as well as understanding the context in which the substance is used and its function.
9.7. SPECIALIST SUBSTANCE MISUSE SERVICES FOR YOUNG PEOPLE
The Health Advisory Service reports (1996 (2001) identified a four-tier framework for specialist substance misuse services for young people, similar to that described above for CAMHS. However, the functions of each tier, rather than the professional discipline involved, are the focus. Different models and configurations have developed in different regions due to a variety of factors including the prevalence of substance misuse, the general level of affluence or deprivation, existing services, and leadership in service development and innovation. A key issue is that interventions for young people whose substance misuse is serious enough to require specialist help are not isolated, but integrated with other medical and social services so that continuity is established and maintained.
Tier 1. universal, generic and primary services
This tier is aimed at all young people. It provides information and advice, health promotion and support to all young people and their families and carers. At this level, vulnerable individuals with risk factors including child protection issues may be identified. It is important for staff in such generic and mainstream services to be aware of the need for a destigmatising non-confrontational empathic approach to substance use and be equipped to identify where more complex interventions may be required.
Tier 2. specialist services
This tier is directed at vulnerable children who are in contact with children's services such as CAMHS, youth offending teams, paediatrics, child psychology and voluntary services and who are potentially vulnerable to substance use. Staff should be skilled in the comprehensive assessment of children and young people and appreciate the context of developmental issues. Implementation of advice and counselling, crisis management, outreach, interventions with the family, as well as competence in ‘brief interventions’ or motivational techniques for substance misuse is part of the role. Collaboration with agencies in the formulation of care planning so that interventions are integrated – and substance misuse interventions are not delivered in isolation – is a key component.
Tier 3. specialist addiction services
This tier comprises a multidisciplinary team to deliver a complex range of interventions for young people who have harmful and potentially serious substance misuse problems and dependence. Close collaboration with CAMHS, youth justice, voluntary agencies and medical services is needed in the delivery of these complex care plans. These services should be integrated with children's services and should cater for the needs of young people and not be based on adult models. Staff should be competent in the delivery of the range of pharmacological and individual, group and family psychological interventions that are available for dependent substance use. Training can be provided to staff to understand the intricacies of the relationship between mental, physical and social problems and substance misuse in this age group so that appropriate links can be forged between the diverse agencies in the locality or region.
Tier 4. very specialised services
This tier provides intensely focused pharmacological and psychological interventions that require implementation in a residential or inpatient setting or in a structured day programme, due to the severity of the problems. Since there are no residential units for young people who misuse substances at present, units such as inpatient CAMHS, forensic or paediatric units might be appropriate for different stages of the care plan. Inpatient detoxification for alcohol dependence or titration of opiate substitution treatment are examples of medical interventions requiring inpatient treatment. Intense daily psychological support may only be achieved in an inpatient CAMHS unit or a structured day programme. Coordination of support for accommodation, education and other social needs may also require crisis and fostering placements in order to achieve stability and safety in critical situations, rather than the professional groups involved in provision of care.
Children and young people may need a range of services from a number of tiers at different times. Tiers 3 and 4 should not be involved without support from Tiers 1 and 2. Tiers 1 and 2 are key to the development of a broader base, a more comprehensive approach and the establishment of credibility and trust. Continuity of care from Tier 1, particularly in health and education, is crucial. Where possible, coordination and management of the intervention can be done within Tier 1. This would reduce the stigmatisation and attempt to ‘normalise’ the child and his/her family. For those young people not connected with Tier 1, any other services involved may want to ensure re-integration and provision of services at Tier 1. Tiers 3 and 4 act as a base for specialist opinion and focused interventions.
9.7.1. Transition to adult services
The transition to adult services for young people is often marked by a series of discontinuities in terms of personnel, frequency of treatment (often less intense in adult services) and treatment approach, and often a failure to recognise and adapt treatment to developmental stage. Parents who are used to being intensively involved with CAMHS may feel disengaged with adult services. In such circumstances the CPA and joint working between adult mental health services and CAMHS may facilitate the transition. A period of engagement with adult services before handover is preferable. Flexible working around age limit cut-offs is also likely to be helpful in promoting smooth transitions.
If the young person is primarily being managed in CAMHS, protocols with adult mental health services need to be in place to ensure the straightforward transition of young people to adult services when they turn 18 years old (or in some localities 16 years). It is preferable that such protocols ensure that access criteria to adult services are consistent with young people who have been previously treated by CAMHS, and that EIS are involved in this process.
In exceptional circumstances where no age-appropriate services are available for young people, establishing protocols for admitting young people to adult wards is important. These protocols should include liaison with and involvement of CAMHS.
9.8. INTERVENTIONS
9.8.1. Clinical evidence review
A number of existing NICE guidelines have reviewed the evidence for interventions used to treat young people with psychosis without substance misuse (that is, Bipolar Disorder [NCCMH, 2006]), and young people with substance misuse without psychosis (that is, Alcohol-use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence [NCCMH, 2011]; Drug Misuse: Opioid Detoxification [NCCMH, 2008a]; and Drug Misuse: Psychosocial Interventions [NCCMH, 2008b]).
For the purposes of the guideline, the review questions relating to young people with psychosis and coexisting substance misuse were sub-questions of those for adults and, therefore, the review protocols are not repeated here (see Chapters 6, 7 and 8).
Where no evidence existed for a particular intervention in young people with psychosis and coexisting substance misuse, the GDG used informal consensus to reach a conclusion about whether it was appropriate to cross-reference to existing NICE guidelines.
9.8.2. Studies considered for review
Based on the searches conducted for Chapters 6, 7 and 8, only one RCT (Geller et al., 1998) focusing specifically on young people with psychosis and coexisting substance misuse met eligibility criteria. Several further RCTs (Edwards et al., 2006; Green et al., 2004; Kemp et al., 2007) included young people, but interpretation of the evidence is difficult as the majority of participants were over 17 years old. One review (Crome & Bloor, 2005), which examined interventions for ‘substance misuse and psychiatric comorbidity in adolescents’, included the study by Green and colleagues (2004), but no other research specifically about psychosis. In addition, one review (Bender, et al., 2006) systematically searched for studies of interventions for ‘dually diagnosed adolescents’. However, all of the evidence reviewed was for young people with common mental health disorders, not psychosis.
9.8.3. Evidence for the use of pharmacological interventions
One RCT (Geller et al., 1998) randomised 25 young people aged 12 to 18 years who had bipolar disorder and coexisting substance dependency disorder to treatment with lithium or placebo. The results suggested that lithium may be effective in terms of numbers of participants screening positive for drug use after 6 weeks of treatment. This study was also reviewed for the NICE guideline Bipolar Disorder (NCCMH, 2006), in which the evidence for psychiatric outcomes was judged to be inconclusive and of overall low quality. Substance misuse outcomes were not examined. The participants had less than 2 months' history of substance misuse, and the lithium serum levels achieved were high (0.9 to 1.3 meq/l; the guideline recommended 0.6 to 0.8 meq/l).
9.8.4. Guiding principles for treatment
Given the paucity of evidence relating to interventions for young people with psychosis and coexisting substance misuse, the GDG developed a set of guiding principles for treatment.
First, mental health services are the preferred service to lead the treatment of a young person with psychosis and coexisting substance misuse. At the same time, it is necessary for specialist substance misuse services to be involved in the management of young people with opiate misuse and they may advise or offer a service to those with cannabis misuse, stimulant misuse, or severe alcohol misuse or dependence. A collaborative coordinated approach is likely to be the most helpful.
Engagement
Engagement is an essential precursor to treatment. Without it, treatments, especially psychological, psychosocial and environmental, are less likely to be effective. It is important to take time to engage the young person by adopting a straightforward, non-confrontational, non-judgemental and optimistic approach. Assessing readiness to change can help inform care planning and treatment options.
Risk management
Young people with psychosis and substance misuse can at times present with high risk to either themselves or others due to their psychosis, their substance misuse or a combination of the two. Careful and thorough risk assessments are needed at initial presentation and whilst ill, with risk management plans put in place to address any risks identified.
Medication for psychosis
Medication for the treatment of bipolar disorder should follow the NICE guideline (NICE, 2006). A guideline for the treatment of young people with psychosis and schizophrenia was in development at the time of writing; in the meantime guiding principles can be adopted from the adult schizophrenia guideline (NICE, 2009a).
In the UK, licensing of antipsychotic drugs for the treatment of schizophrenia and bipolar disorder in people under 18 years is variable, with some manufacturers not recommending these drugs in those under the age of 18 and the drugs themselves not licensed for this use in this age group. However despite this, considerable clinical experience of their use in young people has been developed from open trials and from some controlled evaluations of drug treatments.
In 2000, the Royal College of Paediatrics and Child Health issued a policy statement on the use of unlicensed medicines or the use of licensed medicines for unlicensed applications, in children and young people. This states clearly that such use is necessary in paediatric practice and that doctors are legally allowed to prescribe unlicensed medicines where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion (Joint Royal College of Paediatrics and Child Health/Neonatal and Paediatric Pharmacists Group Standing Committee on Medicines, 2000).
Caution should be taken with possible drug interactions with substances of misuse. Dosage should be adjusted according to age and weight/body mass index.
Psychological and psychosocial interventions
The following psychological and psychosocial interventions, used in adults, are also used in young people either on their own or in combination:
The choice of intervention depends on the nature of the problem and which approach may appear more appropriate and suitable, particularly for substance misuse. Motivational enhancement therapy is increasingly used and evidence is accumulating about its benefits and cost effectiveness. Some young people may feel more comfortable concentrating on behavioural methods rather than treatments that use abstract forms of reasoning. Intervention needs to focus not only on the substance misuse but also the psychiatric disorders (Chan et al., 2008; Rowe et al., 2004).
In the UK, there is also emphasis on harm reduction, including needle exchange, prevention of drug-related deaths, and treatment for physical illness and injury. Active support for families, and developing social skills and competence in parents and children, is a recent focus. The Iowa Strengthening Families Program (Molgaard et al., 1994), Preparing for the Drug Free Years (Spoth et al., 2004) and community reinforcement and family training (Waldron et al., 2007) are examples.
Treatment of substance misuse
Where available, relevant NICE guidelines can be used to inform treatment of substance misuse. In addition, it should be noted that young people who misuse substances who are referred to Tier 3/4 services are likely to have some psychological and physical coexisting conditions as well as polysubstance misuse. Thus, treatment of substance misuse should take account of these possibilities. Constant and consistent review of a young person's clinical state is crucial, as unpredictability is a feature of young people who misuse substances.
For relevant pharmacological treatments, section 9.8.3 can be consulted in addition to relevant NICE guidelines. It is crucial that dependence is diagnosed if medications for withdrawal or substitution are going to be prescribed. Medications should be prescribed by experienced practitioners who are aware of the risks in young people. Medications, apart from buprenorphine, are not licensed for use in people aged under 18 years. For detoxification of alcohol dependence and management of opiate dependence by detoxification or substitution, specialist substance misuse services should be involved.
Input from other agencies
Young people with psychosis and substance misuse often have a range of social needs. These should be fully assessed and housing, education, employment and youth offending services may need to be involved.
There are several key elements that contribute to the quality and effectiveness of young people's substance misuse services. These include having a comprehensive assessment, an integrated approach, family involvement, developmental appropriateness, engagement and retention, qualified staff, gender and cultural competence and evaluation of outcomes (Knudsen, 2009). Of note was the finding that treatment quality was significantly greater in programmes offering intensive levels of care.
9.8.5. Issues of consent to treatment for young people
It is desirable to gain informed consent from both the young person and their parents, not least because the success of any treatment approach significantly depends upon the development of a positive therapeutic alliance between the young person, the family and the professionals. In most outpatient settings, consent is usually straight forward, as the young person will generally have a choice to, at least, accept or decline treatment. Nevertheless, it is important to provide information about the potential risks and benefits of the intervention being offered, and where appropriate, a choice given between different treatment options.
There may be times when professionals consider inpatient admission to be necessary, but either the young person or the family does not consent. Under the Mental Health Act (1983; amended 1995 and 2007, HMSO, 2007), there have been some changes to the law regarding young people under the age of 18 years.
If a young person aged 16 or 17 years old has capacity to give or refuse consent for treatment, it is no longer possible for the person with parental authority to over-rule the young person's wishes. However, for those under the age of 16 years a ‘Gillick competent’ young person can still be admitted against his or her wishes with the consent of someone with parental authority. While the use of parental consent is legal, the Code of Practice for the Mental Health Act (Department of Health, 2008) advises against this, suggesting it is good practice to consider the use of other appropriate legislation, usually the Mental Health Act. This includes safeguards such as the involvement of other professionals, a time limit and a straightforward procedure for appeals and regular reviews. It also avoids a possible conflict with the Human Rights Act (1998; HMSO, 1998a).
On the other hand, a ‘Gillick competent’ young person below the age of 16 years has the right to consent to treatment. If the person with parental authority objects, these objections must be considered but will not necessarily prevail.
Alternative legislation includes using a care order (Section 31) under the Children Act 1989 (HMSO, 1989; HMSO, 2004) or a specific issue order (Section 8). Both of these options normally involve social services and can be time consuming. Another, more rapid alternative to the Children Act, is to apply for a wardship order, which in an emergency can be organised by telephone.
9.8.6. Clinical evidence summary
In one small trial (N = 25) assessing pharmacological interventions for young people, lithium was compared with placebo. Based on this evidence (GRADED low quality), it was not possible to reach a decision about the effectiveness of pharmacological interventions for young people with psychosis and coexisting substance misuse.
There was no evidence for psychological or psychosocial interventions for young people with psychosis and coexisting substance misuse.
9.8.7. Health economic evidence (interventions for young people)
No studies assessing the cost effectiveness of interventions for young people with psychosis and coexisting substance misuse were identified by the systematic search of the economic literature undertaken for this guideline. Details on the methods used for the systematic search of the economic literature are described in Appendix 9.
9.9. FROM EVIDENCE TO RECOMMENDATIONS
Based on the limited evidence base, the GDG were required to extrapolate from data that may not accurately address treatment effectiveness for young people with psychosis and coexisting substance misuse. The GDG therefore developed guiding principles of treatment and recommendations based on consensus. The GDG recognises that as new evidence emerges on treatment for young people with psychosis and coexisting substance misuse, the recommendations in this guideline will be revised and updated accordingly. The recommendations cover competency, identification and referral, and assessment and treatment.
The GDG felt that professionals in Tier 1 CAMHS should be competent to recognise early signs of psychosis and substance misuse, while Tier 3 and 4 CAMHS, and EIS healthcare professionals, should be competent with regard to managing psychosis and coexisting substance misuse. Regarding identification and referral, the GDG felt that professionals in Tier 1 should seek advice from Tier 2 staff when signs of psychosis are detected in young people. In Tier 2 services, referral should be made according to local protocols. The GDG also thought that it was important that all young people with psychosis or suspected psychosis seen by professionals in Tier 3 or 4 services, or EIS, should be asked about substance misuse. Referral to Tier 4 CAMHS should be done directly when a comprehensive assessment reveals a high risk of harm to self or others. In terms of assessment, the GDG thought that there needed to be a recommendation to ensure that healthcare professionals are familiar with the legal framework that applies to young people. In terms of treatment, the GDG felt that recommendations for the treatment of adults should be followed, but adapted for young people if necessary. It was also recognised that other agencies, including children's services, should be involved to ensure that the young person's educational, employment, family and housing needs are met. Finally, the GDG thought that a recommendation directed at commissioners was needed to ensure that age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse, and that transition arrangements to adult mental health services are in place where appropriate.
In addition, the GDG discussed that because onset of psychosis at a younger age is also an indicator of poor prognosis, people with a combination of younger age of onset and coexisting substance misuse may have a particularly poor prognosis. A clearer understanding of the risk and protective factors for substance misuse in young people with psychosis, and the interrelationship of the two conditions over time, may facilitate the development of treatment approaches for the coexisting conditions in this group. This may then improve the longer-term outcome for a group of people who tend to have a poor prognosis.
9.10. RECOMMENDATIONS
9.10.1. Clinical practice recommendations
Competence
- 9.10.1.1.
Professionals in Tier 1 (primary care and educational settings) should be competent to recognise early signs of psychosis and substance misuse in young people.
- 9.10.1.2.
Healthcare professionals in Tier 3 (community mental health teams) and Tier 4 (specialist inpatient and regional services) CAMHS, and in early intervention in psychosis services, should be competent in the management of psychosis and substance misuse in young people.
Identification and referral
- 9.10.1.3.
Professionals in Tier 1 (primary care and educational settings) should seek advice or consultation from Tier 2 CAMHS (primary care) when signs of psychosis are detected in young people. If healthcare professionals in Tier 2 CAMHS detect signs of psychosis in young people, a referral to Tier 3 CAMHS or early intervention in psychosis services for young people should be made according to local protocols.
- 9.10.1.4.
Ask all young people seen in Tier 3 and Tier 4 CAMHS and in early intervention in psychosis services who have psychosis or suspected psychosis about substance misuse (see 5.8.1.8).
- 9.10.1.5.
Children and young people who, after comprehensive assessment, are considered to be at high risk of harm to themselves or others, should be referred directly to Tier 4 CAMHS including inpatient services where necessary.
Assessment and treatment
- 9.10.1.6.
Healthcare professionals working with young people with psychosis and coexisting substance misuse should ensure they are familiar with the legal framework that applies to young people including the Mental Health Act (1983; amended 1995 and 2007), the Mental Capacity Act (2005), and the Children Act (2004).
- 9.10.1.7.
For psychological, psychosocial, family and medical interventions for young people, follow the recommendations for adults in this guideline; they may need to be adapted according to the young person's circumstances and age. In addition, other agencies, including children's services, should be involved to ensure that the young person's educational, employment, family and housing needs are met.
- 9.10.1.8.
When prescribing medication, take into account the young person's age and weight when determining the dose. If it is appropriate to prescribe unlicensed medication, explain to the young person and/or their parents or carers the reasons for doing this.
- 9.10.1.9.
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.
9.10.2. Research recommendations
- 9.10.2.1.
What risk factors predict the onset of substance misuse in young people with psychosis? (For further details see Appendix 12.)
