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West London Mental Health Care NHS Trust, Uxbridge Road, Southall, Middlesex UB1 3EU
Cranbourne Centre, Potters Bar
Borehamwood
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Abstract |
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To describe the work and patient characteristics of one of the first combined mental illness and drug and alcohol services (MIDAS) in the UK. We examined MIDAS as an assertive community service, for individuals receiving long-term community care. We selected the case files of the first 80 patients accepted over a 10-month period and examined variables including demographic details, diagnosis, associated substance use and length of engagement with the service.
RESULTS
Our findings show that there was no relationship between responders to the service and basic demographic data. Patients with bipolar affective disorder and personality disorders were more likely to use the service than patients with unipolar disorder or schizophrenia. Despite the use of an assertive service, there was difficulty engaging patients with schizophrenia and comorbid drug use. These same patients also had a high level of criminal convictions as well as a trend towards using alcohol and cannabis as their main substances of misuse. At 18 months 38% of patients had failed to remain engaged with the service.
CLINICAL IMPLICATIONS
This specialist type of service may be more useful than other services in engaging patients with comorbidity. Systematic research is required in the UK to explore the effectiveness of this type of new service. More innovative resources need to be identified to specifically deal with patients with severe mental illness and comorbid substance use.
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Introduction |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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The mental illness and drug and alcohol services (MIDAS) in East Hertsmere represents one such initiative involving the West Hertfordshire Health Authority. The remit of this service is to target patients with a severe mental illness who show evidence of drug and alcohol use that significantly interferes with the health of these individuals. An assertive outreach posture is frequently required for this group because of their lack of reliable contact with conventional mental health services. It may also be needed because of paucity of social networks, or poor compliance (Drake & Wallach, 1989).
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The current service |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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The service provided by MIDAS has four components:
The therapeutic options offered include individual supportive therapy, education and advice on financial and housing issues. There are also family meetings. The team engage patients in relaxation techniques including acupuncture and recreational support in the form of exercise at the gym, swimming, line-dancing, football, gardening, using a sauna and playing in a band. This is in addition to the team providing conventional medical and psychiatric support to all patients. Depot injections and out-patient appointments also occur on site.
Referrals
Referrals to MIDAS are accepted if the patient has evidence of an acute or
chronic mental disorder as well as a comorbid drug or alcohol problem.
Referrals are accepted from within the community mental health team. External
referrals, for example from general practitioners (GPs), are first assessed by
the general psychiatric team. Patients with primary drug and/or alcohol
misuse, but no other psychiatric, problems and organic brain syndromes (e.g.
dementia, delirium or amnesic syndrome) are excluded from the service.
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The study |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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Diagnoses were made using ICD-10 (World Health Organization, 1992). A retrospective case note analysis was undertaken by a consultant psychiatrist not directly linked to the MIDAS service (R.B.). Information collected included personal and associated demographic details and psychiatric, substance and social histories.
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Findings |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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Table 1 shows the characteristics of the patients with reference to their diagnosis. The patients had spent on average 5.6 years (Range 1 month-30 years) in contact with the psychiatric services before referral to MIDAS. Thirty-two (40%) were born locally. Fourteen (18%) had worked in the year prior to assessment. Twenty-two (27%) had no contact with their family in the preceding 3 months. None had been in care as a child. Eighty (100%) were White Caucasian, of whom 80 (100%) were British born.
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Thirty-one (39%) had a prior criminal conviction other than a driving offence and 10 (13%) had previously been imprisoned (Table 2). Fifty-two (66%) had a history of in-patient treatment. One (1.25%) had spent more than 1 continuous year as an in-patient. Table 3 gives a breakdown of reasons why patients failed to remain engaged and Table 4 shows the number of patients using some of the other services offered by MIDAS.
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Comment |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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Patterns of engagement
Patients with personality disorder were longer-term users compared to other
groups. It might be expected that patients with schizophrenia would be
short-term users of the service considering reported poor compliance with
treatment (Bebbington, 1995).
This is reflected in our study as these patients showed a 61% drop-out rate in
the first year. Although 55% of patients had disengaged from the service at 18
months, only 38% had left owing to non-engagement with treatment. This is
similar to previous assertive community treatment programmes
(Bond et al, 1991). In
that study, controls receiving normal treatments had a drop-out rate of
60%.
Substances used
Patients with schizophrenia in this population used alcohol and cannabis as
their main drugs of misuse. This reflects the general population, where
psychostimulants are used less frequently. Other studies have shown similar
results (Drake & Noordsy,
1994; Lehman et al,
1994). This is not in keeping with the reviews by Schneider and
Siris (1987) and Wright and
Klee (1999,
2001), where the population
with schizophrenia used psychostimulants more frequently. Of the 19 patients
with schizophrenia referred, only four (22.2%) reported psychostimulant use on
a regular basis as well as other substances. Our finding is in keeping with
Cuffel et al (1993),
that there are two groups of substance misusers. The first have high levels of
alcohol and cannabis use with very limited use of other substances and the
other use many substances including alcohol and cannabis.
Access to primary care
Forty-six per cent of patients were registered at only two of the nine
general practices in the area. This is much higher than the expected figure of
22 (27%) based on the practice size and assuming an even distribution of
patients across the practices. The authors have no knowledge of this
phenomenon occurring previously. It may be due to small high-density pockets
of dual diagnosis patients in their locality, possibly as a result of housing.
It may also be that patients with severe mental illness and substance misuse
have difficulty registering with local GPs, although this remains to be
tested. This would be a cause for concern if it was a nationwide
phenomenon.
Prior forensic history
The percentage of patients with previous convictions in this study is high
(46%). This figure is even higher for patients with schizophrenia and comorbid
drug use (61%).
The pattern is consistent with previous reports (Scott et al, 1998). Possible explanations include intoxication leading to offending activity, a higher incidence of dissocial personality traits or a higher rate of non-compliance in the dual diagnosis group. In another study, Soyka (1993) found that patients with schizophrenia and substance misuse had a conviction rate of 40.1% compared to 13.7% for schizophrenia alone. The higher rate of forensic activity in the MIDAS population is alarming, but may be explained by the relatively small numbers in the study.
Limitations of the service
Initial results may prove to be unrepresentative when compared to longer
periods of study and different phases of MIDAS, as this initial survey
included 25% of patients without dual diagnosis. Limitations of the service
are reflected in the high drop-out rates of those patients with schizophrenia
or unipolar disorder. Future randomisation to this or similar services would
be appropriate to determine the clinical effectiveness and cost-effectiveness
of this type of service delivery compared to generic drug and alcohol or
psychiatric services. Other problems are that the results of the study are not
easily generalisable to inner-city areas, especially as the population was not
multiracial. Ethnic minorities in East Hertsmere represent less than 0.1% of
the population and were not under-represented in the referral group.
Potential advantages of the service
The service described above can be seen as pioneering and providing a wide
range of treatment options simultaneously for both severe mental illness and
substance misuse. Some aspects are new and some are combinations of older
methods of service delivery. At present there is no clinical trial evidence
for the effectiveness of any intervention for patients with severe mental
illness and comorbid substance misuse
(Weaver et al,
1999).
We suggest the beneficial aspects of the service that have been established so far may be a result of the development of a broad-ranging mainstream service with a model of treatment informed from a multi-disciplinary perspective. This is in line with recent recommendations (Appleby et al, 1999: p. 12, Recommendation 14). The service is different in that there is less chance of becoming limited in perspective, which might occur in a team dealing solely with substance misuse or solely with psychiatric illness. Also, an established benefit is good communication within the team about both the mental health and substance misuse aspects of each patient. This is distinct from services that communicate specifically about only one aspect of the patients' comorbidity and are also unable to accommodate new needs rapidly. An example is the ability to access in-patient admissions for early detoxification before secondary deterioration of mental health or social circumstances. The other beneficial aspects of the service are as follows:
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Acknowledgments |
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References |
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TopAbstractIntroductionThe current serviceThe studyFindingsCommentReferences |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
