Int J Ment Health Addiction DOI 10.1007/s11469-015-9548-z
Using the WHO ASSIST to Assess Drug and Alcohol Misuse in the Acute Mental Health Setting to Guide Treatment Interventions Karen R. Heslop & Calum Ross & John Berkin & Dianne Wynaden
# Springer Science+Business Media New York 2015
Abstract This article reports the prevalence of alcohol and substance use in 695 patients with mental illnesses admitted to an inner city acute mental health unit over a 14 month period. Data were collected from routine screening for alcohol and substance use on admission to the acute mental health unit using the World Health Organisation (WHO) Alcohol Smoking and Substance Involvement Screening Test (ASSIST). The substances most frequently used were tobacco, alcohol and cannabis. Interventions aimed at decreasing the frequency of use and harms associated with use of tobacco, alcohol and cannabis therefore have the greatest potential to improve health outcomes in this population. As drug and alcohol impact significantly on mental health outcomes, assessment of substance use, recognition of addictive behaviours, withdrawal management that includes appropriate pharmacological intervention and supportive counselling that is initiated in the acute mental health setting and continued post discharge are important to the person’s recovery and ongoing quality of life. Keywords Alcohol and substance assessment . Co-occurring mental illness . Prevalence . WHO ASSIST The National Drug Strategy Household Survey indicated that in 2010, 15 % of Australians aged 14 or more had recently used illicit drugs, 15 % were daily smokers and 7.2 % used alcohol on a daily basis (Australian Institute of Health and Welfare 2011). While this survey provides the best available data, accurate assessment of the number of people who use substances such as opioids, amphetamines, cocaine, and cannabis in the general population is likely to be underestimated as these substances are commonly used illegally (Degenhardt and Hall 2012). Estimating the prevalence of use of these substances within acute mental K. R. Heslop (*) : C. Ross : J. Berkin Department of Psychiatry, Royal Perth Hospital, GPO Box X2213, Perth, WA 6001, Australia e-mail:
[email protected] K. R. Heslop : D. Wynaden School of Nursing and Midwifery, Curtin University, Perth, Australia
Int J Ment Health Addiction
health inpatient facilities is problematic as obtaining data regarding alcohol and substance use generally occurs as part of a comprehensive mental state examination. This information often remains within the individual’s health record and is not always used to determine the impact on mental health or to guide policy on service delivery needs. Many health professionals hold a negative perception regarding the effectiveness of mental health services to provide care to people with mental illness and co-occurring alcohol and substance use (Adams 2008). Although health professionals perceive the assessment and treatment of alcohol and substance use as being important they tend to view it as a secondary health issue to the person’s mental illness and therefore beyond the scope of their core business (Wykes et al. 2011). This is problematic when population data suggests that substance misuse in populations with co-occurring mental illness is increasing (Moore et al. 2012). It is known that co-occurring mental illness and substance misuse is associated with significantly poorer clinical and social outcomes (Carra and Johnson 2009) (Moore et al. 2012). Individuals often experience worsening of psychiatric symptoms, increased reliance on institutional services, poor medication adherence, homelessness, increased risk of blood borne infection, poor social outcomes and increased contact with the criminal justice system (Adams 2008). Illicit drug use can also result in impairment in cognitive function in healthy individuals and may increase deficits in cognitive function in individuals suffering psychosis (Donoghue et al. 2012) and lead to poorer physical health outcomes (Adams 2008; Bradley 2013). There is a need for acute mental health services to adopt alcohol and substance treatment interventions that reduce the frequency of use and minimise harms associated with use and improve health outcomes for the majority of patients in their care. This article reports on the prevalence of substance use of patients with mental illness admitted to an inner city acute mental health unit over a 14 month period. Data collected was obtained from routine screening for drug and alcohol on admission to the acute mental health unit using the World Health Organisation (WHO) Alcohol Smoking and Substance Involvement Screening Test (ASSIST) (Newcombe et al. 2005). The WHO ASSIST is a valid, reliable and brief screening instrument that can be used to detect harmful substance use. This screening tool takes approximately 10 min to complete and is easily administered by health care professionals to assess the use of psycho-active substances in general health care settings (Hides et al. 2009) and mental health settings (Bradley 2013). It allows clinicians the ability to identify psychoactive substance use in individuals who use a number of substances (Humeniuk et al. 2008) and discriminates between substance use, abuse and dependence (Newcombe et al. 2005). The tool assesses the use of tobacco, alcohol, cannabis, cocaine, amphetamine, sedative, hallucinogen, opioid and ‘other’ drugs use. Although this tool relies on self-report, with inherent risks of over or under reporting, the tool has been demonstrated to correlate with ICD 10 classification mental and behavioural disorders alcohol and substance use (Bradley 2013) and other standard assessments for alcohol and substance use (Humeniuk et al. 2008) (Hides et al. 2009).
Method Ethical Clearance Clearance to conduct the study was obtained from the Royal Perth Hospital Human Research Ethics Committee and permission was sought from appropriate department heads.
Int J Ment Health Addiction
Setting This study was undertaken in an inner city acute mental health inpatient unit in Perth, Western Australia. The diagnostic profile of inpatient population during the time of data collection was classified according to the 10th revision of the International Classification of Disease (ICD 10). The most common primary ICD 10 diagnoses were; personality disorders and acute reactions, major affective disorders, schizophrenia disorders, paranoid and acute psychotic disorders, and other affective and somatoform disorders. A small proportion of individuals were admitted with a primary diagnosis of drug and alcohol related disorders. Data Collection Data relating to drug and alcohol use was collected between 1st April 2011 and 1st December 2012 from all patients admitted to an acute mental health unit for treatment of their mental illness using the ASSIST as part of as part a routine clinical admission interview. The ASSIST was administered by mental health nurses who had received training in the use of the instrument and associated interventions provided in the ASSIST-Linked intervention manual. Each patient was asked if they currently or had in their lifetime used tobacco, alcohol, cannabis, cocaine, amphetamines, benzodiazepines, hallucinogens, opioids and ‘other drugs’. They were then asked a further six questions about their use of the identified substances (outlined in Table 1). Each response was scored according to the ASSIST scoring legend and recorded on a single page version of the tool. Scores for each of the identified substance were totalled. A total score of 3 or less for tobacco, cannabis, cocaine, amphetamines, benzodiazepines, hallucinogens and opioids and 10 or less for alcohol indicated that the individual was at a low risk of harm from their current pattern of use and were the provided with general health information about drugs and alcohol. Those scoring 4–26 for substances, and 11–26, for alcohol indicated the person’s use posed a moderate risk to their health and were offered a range of brief interventions such as motivational counselling and education regarding risks and harms of using substances. Individuals scoring 27 or greater were deemed to be at a high risk to their health and were offered more intensive interventions and referral to a specialist treatment service following discharge. Patients who reported daily/almost daily use of tobacco were assessed for nicotine replacement treatment using the Fagerstrom Assessment (Department of Health and Western Australia 2012) and due to the non-smoking policy in Western Australian hospitals were offered nicotine replacement therapy (NRT) in the form of nicotine patches (21, 14 or 7 mg/ 24 h patches depending of level of use), nicotine inhalers (10 mg) and other supportive measures. All patients were asked if they had ever used any drug by injection. If they had within the last 3 months they were provided with a BRisk of Injecting^ card (as per the ASSIST-Linked intervention manual) and they were assessed for the need for testing for blood borne viruses and if required referred to a specialist service for treatment on discharge. Two additional questions were added to the ASSIST questionnaire to alert the clinician to the potential for withdrawal and appropriate withdrawal management for patients who indicated daily or almost daily use of alcohol or benzodiazepines. Alcohol withdrawal was assessed and managed according to an alcohol withdrawal scale as per local policy and prescribed an appropriate pharmacological regimen. Those who had
Int J Ment Health Addiction Table 1 ASISST screening questions Question 1
In your life time have you ever used the following substances? (Tobacco, Alcohol, Cannabis, Cocaine, Amphetamines, Inhalants, Benzodiazepines, Hallucinogens, Opioids)
Yes No
Question 2
In the past 3 months, how often have you used …….? (the substance answered YES in Q1).
Question 3
During the past 3 months, how often have you had an urge to use ……? (the substance answered YES in Q1).
0 - Never 2 - Once/Twice 3 - Monthly 4 - Weekly 6 - Daily/almost daily 0 - Never 3 - Once/Twice 4 - Monthly 5 - Weekly 6 - Daily/almost daily
Question 4
During the past 3 months how often has your use of …… led to health, social, legal or financial problems? (the substance answered YES in Q1).
0 - Never 4 - Once/Twice 5 - Monthly 6 - Weekly 7 - Daily/almost daily
Question 5
During the past 3 months how often have you failed to do what was normally expected of you because of …….? (the substance answered YES in Q1).
0 - Never 5 - Once/Twice 6 - Monthly 7 - Weekly 8 - Daily/almost daily
Question 6
Has a friend or relative or anyone else ever expressed concern about your use of ……? (the substance answered YES in Q1).
0 - Never 3 - Yes not in the past 3 months 6 - Yes in the past 3 months
Question 7
Have you ever tried and failed to control, cut down or stop using ….? (the substance answered YES in Q1).
0 - Never 3 - Yes not in the past 3 months 6 - Yes in the past 3 months
Is withdrawal from substance during admission likely?
Yes No
Have you ever used any drug by injection (non-medical use)?
0 - Never 1 - Yes not in the past 3 months 2 - Yes in the past 3 months
been taking regular benzodiazepines were assessed by the treating medical team and prescribed an appropriate reducing regimen as per the local guidelines. Data Analysis Raw data and total scores were entered into an Excel spreadsheet and exported to a SPSS database for statistical analysis. Demographic and prevalence data were analysed using descriptive statistics. Chi-square analysis was used to analyse difference according to gender and age.
Int J Ment Health Addiction
Results Demographics Data were collected from 695 patients; 341 (49.1 %) were male and 326 (46.9 %) female, mean age was 38 years (range 16 to 84 years). Twenty nine (4 %) participants did not indicate their gender or age. See Table 2 for breakdown of demographic characteristics. Life Time Use Four hundred and sixty nine patients (67.5 %) had used tobacco and 503 (72.4 %) had use alcohol at some time during their life. Three hundred and thirty one (46.6 %) reported cannabis use. Lifetime use of benzodiazepines and amphetamines was reported by approximately one third of patients, while less than a fifth reported a lifetime use of cocaine, hallucinogens or inhalants. See Table 3 for a breakdown of lifetime use. Current/Recent Use One hundred and sixty patients (23 %) reported using no substances at the time of admission. One hundred and fifty two (21.9 %) reported using a single substance and the remaining 382 (54.9 %) reported using 2 or more substances. See Table 4. Of those who used cannabis in combination, all but three reported co-occurring tobacco use. Of those who used only a single substance 67 (44.1 %) reported using tobacco and 73 (48 %) alcohol. Three hundred and seventy patients (53.7 %) reported daily, or almost daily, tobacco use, 257 (37 %) reported alcohol use at least weekly and 107 (15.4 %) used cannabis at least weekly. Cocaine, inhalants, and hallucinogens were used weekly or more than weekly by less than 1 % suggesting minimal current use of these substances on admission. See Table 5 current substance use. Level of Addiction The extent to which patients are addicted to each substance was assessed in question 3 Bhow often in the past 3 months have you had the urge to use (the substance)^ and question 7 BHave you ever tried and failed to control, cut down or stop using (the substance)^. A significant number of patients reported the urge to use three substances on a daily basis; 336 (48.3 %) tobacco, 129 (18.6 %) alcohol and 77 (11.1 %) cannabis. Fewer patients reported
Table 2 Demographic characteristics
Age in years
Male
Female
16–25
44
70
26–35
80
86
36–45
90
63
46–55
81
58
56–65
32
38
>66 Total
14 341
10 325
Missing (29)
Int J Ment Health Addiction Table 3 Lifetime substance use (n=695) No
%
Yes
%
Tobacco
226
32.5
469
67.5
Alcohol
185
26.6
503
72.4
Cannabis
361
51.9
331
47.6
Cocaine Amphetamine
582 440
83.7 63.3
113 255
16.3 36.7
Inhalants
640
92.1
55
7.9
Benzodiazepines
464
66.8
231
33.2
Hallucinogens
580
83.5
115
16.5
Opioids
560
80.6
135
19.4
the urge to use amphetamines (31, 4.5 %) and benzodiazepines (39, 7.5 %). More than 90 % of respondents reported never having the urge to use cocaine, inhalants, hallucinogens and opioids – see Table 6. Two hundred and thirty one (33.2 %) patients reported having tried and failed to cut down or reduce smoking (17.8 % in the past 3 months), and 161 (23.2 %) had tried to cut down or reduce alcohol consumption (14.7 % in the past 3 months). Controlling the use of cocaine, inhalants, benzodiazepines, hallucinogens and opioids was less problematic with less than 5 % indicating difficulty controlling or cutting down use of these substances. See Table 7 for breakdown. Harms Associated with Substance Use/Abuse More than a quarter of patients reported that friends or relatives had expressed concern about their use of tobacco (175, 25.2 %) or alcohol (184, 26.5 %) with 17.7 % reporting this concern expressed within in the previous 3 month for alcohol and 17.1 % tobacco. Friends and relatives were reported to express concern about cannabis and amphetamine use by 91 (13.1) and 65 (9.3 %) of respondents respectively (see Table 8). A number of patients reported health, social, legal and financial problems associated with substance use within previous 3 months; 102 (15.1 %) reporting issues with tobacco, 107
Table 4 Number of substance use at admission (n=695)
Number of Substances
n
%
0
160
23.0
1
152
21.9
2
145
20.9
3
126
18.1
4
58
8.3
5
26
3.7
6
15
2.2
7 8
7 2
1.0 0.3
9
3
0.4
Int J Ment Health Addiction Table 5 Substance use within previous 3 months (n=695) Never n
Once/twice
Monthly
Weekly
Daily/almost daily
%
n
%
n
%
n
Tobacco
296
42.6
7
1
7
1
15
2.2
370
53.7
Alcohol
291
41.9
86
12.4
61
8.8
113
16.3
144
20.7
Cannabis Cocaine
511 671
73.5 96.5
54 17
7.8 2.4
23 2
3.3 0.3
32 3
4.6 0.4
75 2
10.8 0.3
Amphetamine
584
84
33
4.7
16
2.3
38
5.5
24
3.5
Inhalants
687
99.8
4
0.6
1
0.1
2
0.3
1
0.1
Benzodiazepines
585
84.2
28
4.0
9
1.3
20
2.9
53
7.6
Hallucinogens
677
97.4
12
1.7
3
0.4
0
Opioids
635
91.4
22
3.2
2
0.3
11
%
n
0 1.6
%
3
0.4
25
3.6
(15.4 %) alcohol, 46 (6.6 %) cannabis and 40 (5.8 %) amphetamines. See Table 9 for breakdown. One hundred and thirty five (19.4 %) of patients reported failing to do what was expected of them at least once due to alcohol consumption. A small number of respondents reported cannabis (59; 8.5 %) and amphetamine (43; 6.2 %) use contributed to them failing to do what was expected of them (see Table 10). Inhalants, benzodiazepines, hallucinogens and opioids caused less harm, with less than 5 % reporting health, social, legal and financial problems or failing to do what was expected of them due to substance use (data not shown). Gender and Age Significant gender differences were observed with tobacco, alcohol, cocaine and benzodiazepine use. Males used tobacco and alcohol significantly more frequently than females. Females tended to use significantly more cocaine and benzodiazepines than males (see Table 11). Significant age differences were observed with tobacco, alcohol, cannabis, and amphetamine use. The majority of patients aged 16–55 years (461, 69.2 %) reported using tobacco with 293 (63.5 %) scoring 4–26 putting them at moderate risk. Respondents aged 16–55 years tended to use more alcohol than older respondents with 90 (13.5 %) respondents aged 16– Table 6 Urge to use (substance) in the past 3 months (n=695) Never n
%
Once/twice
Monthly
Weekly
Daily/almost daily
n
n
n
n
%
%
%
%
Tobacco
329
47.3
19
2.7
1
0.1
10
1.4
336
48.3
Alcohol
415
59.7
56
8.1
25
3.6
70
10.1
129
18.6
Cannabis Cocaine
547 678
78.7 97.6
38 7
5.5 1.0
13 2
1.9 0.3
20 4
2.9 0.6
77 4
11.1 0.6
Amphetamine
606
87.2
21
3.0
9
1.3
28
4.0
31
4.5
Inhalants
690
99.3
2
0.3
0
0
1
0.1
2
0.3
Benzodiazepines
662
89.5
11
1.6
8
1.2
15
2.2
39
5.6
Hallucinogens
683
98.3
5
0.7
3
0.4
1
0.1
3
0.4
Opioids
651
93.7
10
1.4
3
0.4
8
1.2
23
3.3
Int J Ment Health Addiction Table 7 Tried and failed to control, cut down or stop using substances (n=695) Yes - not in the past 3 months
Yes - in the past 3 months
%
n
n
Never n
%
%
Tobacco
464
66.8
107
15.4
124
17.8
Alcohol
534
76.8
59
8.5
102
14.7
Cannabis
602
86.6
43
6.2
50
7.2
Cocaine
689
99.1
3
0.4
3
0.4
Amphetamine
638
91.8
26
3.7
31
4.5
Inhalants
689
99.1
4
0.6
2
0.3
Benzodiazepines Hallucinogens
669 690
96.3 99.3
11 3
1.6 0.4
15 2
2.2 0.3
Opioids
675
97.1
9
1.3
11
1.6
55 years scoring greater than 27 requiring intensive intervention compared with only 5 (0.75 %) aged 56 years and older. The majority of cannabis users were aged 16–45 years (140; 88.1 % compared to 19; 11.9 %, over 46 years), their scores indicated they were at moderate risk and that brief interventions were provided for majority 119 (75 %) of cannabis users. Brief interventions were most frequently provided for younger amphetamine users who tended to be less than 45 years old (94; 87 %) with the majority (74; 68.5 %) reporting scores of 4–26 putting them at moderate risks and that. See Table 12.
Discussion In this sample population the prevalence of alcohol and substance use of patients admitted to acute mental health setting was higher than the national average (Australian Institute of Health and Welfare 2011). The most problematic substances used were tobacco, alcohol and cannabis (See Table 5). Interventions aimed at decreasing the frequency of use and harms associated with use of tobacco, alcohol and cannabis therefore have the greatest potential to improve health outcomes in this population. Tobacco Use In the sample of patients with acute mental illness reported here, tobacco use was three times higher than the national average (of 15.1 % in 2010) (Australian Institute of Health and Table 8 Friends or relatives expressed concern about use (n=695) Never n
%
Yes - not in the past 3 months
Yes - in the past 3 months
n
n
%
%
Tobacco
520
74.8
56
8.1
119
17.1
Alcohol Cannabis
511 604
73.5 86.9
61 39
8.8 5.6
123 52
17.7 7.5
Amphetamine
630
90.6
21
3.0
44
6.3
Int J Ment Health Addiction Table 9 Health, social, legal and financial problems in previous 3 months (n=695) Never n
%
Once/twice
Monthly
Weekly
n
n
n
%
%
Daily/almost daily %
n
%
Tobacco
553
81
27
3.9
2
0.7
54
7.8
46
6.6
Alcohol
535
77
53
7.6
11
1.6
59
8.5
37
5.3
Cannabis
632
90.9
17
2.4
9
1.3
20
2.9
17
2.4
Amphetamine
641
92.2
14
2.0
4
0.6
18
2.6
18
2.6
Welfare 2011) with 53.7 % of respondents reporting daily, or almost daily, tobacco use. Of these respondents many (15 %) reported more social, legal and financial problems associated with tobacco use (see Table 9). These issues compound poorer physical health and more reported lifetime medical conditions experienced by this group (Cooper et al. 2012). It is recognised that public health strategies to reduce tobacco smoking such as increased pricing (Roussos 2013) and applying age constraints, effective in the general population are of little benefit for those with psychotic and mood disorders (Thornton et al. 2012a) with 40 % of tobacco being consumed by people with mental illness (Shekelle et al. 1999). There is therefore a need to develop strategies specifically targeted to people with serious mental illness (Moore et al. 2012). There are many strategies that have been reported beneficial in reducing smoking in hospital settings (Barak et al. 2011). Provision of motivational counselling (Ha and Choi 2012), the inclusion of cognitive behavioural therapy that focuses on mood management as part of the cessation intervention and pharmacological measures such as Bupropion and Varenicline have been demonstrated to be useful interventions in this group (Mogami 2007). Specific ward based brief interventions strategies have proven to be effective (Mantler et al. 2012) when targeted at smoking minimisation and cessation (Ha and Choi 2012). Adding nicotine replacement therapy to intensive counselling interventions further increases the effect of hospital-initiated interventions and should be routinely offered (Frame and Kercher 1991) (Marsh et al. 2013) Health professional attitude and understanding of the interaction between smoking and mental illness and treatment is an important contributing factor to the success of smoking cessation interventions (Adams 2008) (Wykes et al. 2011) (Sheehan et al. 1998) (Pinikahana et al. 2002). It is generally accepted that there is a general deficit in clinician’s knowledge about tobacco dependence, treatment and its relation with mental illness (Cape et al. 2006) (Sheehan et al. 1998) (Happell et al. 2002) (Ratschen et al. 2009); with many unaware, for example that smoking can decrease blood levels of antipsychotic medications, and that stopping smoking could reduce the dose of needed (Ratschen et al. 2009). It has been noted
Table 10 Failed to do what was expected within past 3 months (n=695) Never
Once/twice
Monthly
Weekly
Daily/almost daily
n
%
n
%
n
%
n
%
n
%
Alcohol Cannabis
560 636
80.6 91.5
48 18
6.9 2.6
29 10
4.2 1.4
28 14
4.0 2.0
30 17
4.3 2.5
Amphetamine
652
93.8
12
1.7
9
1.3
10
1.4
12
1.7
Int J Ment Health Addiction Table 11 Intervention and total substance score by gender (n=667) Substance Tobacco
Score
Amphetamine
2
0.002*
14.839
2
0.001*
1.675
2
0.433
6.214
2
0.045*
0.019
2
0.991
0.419a
1
0.725
6.304
2
0.043*
3.327
2
0.190
1.726
2
0.422
160 142
0–10 11–26
Intensive None Brief Intensive
35
24
210 72
246 44
59
36
0–3
None
254
254
4–26
Brief
63
56
24
16
0–3
None
336
313
4–26
Brief
3
12
27 > 0–3
Intensive None
2 286
1 273
4–26
Brief
38
36
Intensive
17
17
0–3
None
336
323
4–26
Brief
5
3
0–3
Intensive None Brief Intensive
0
0
300
269
32 9
51 6
0–3
None
337
318
4–26
Brief
2
7
27 > Opioids
12.787
121
4–26 27 > Hallucinogen
Sig
185
27 > Benzodiazepine
df
Brief
Intensive Inhalant
X2
None
27 > Cocaine
Female n=326
0–3
27 > Cannabis
Male n=341
4–26 27 > Alcohol
Intervention
2
1
0–3
None
Intensive
319
298
4–26
Brief
16
23
27 >
Intensive
6
5
*p<0.005 a Fishers exact test
that in areas where the prevalence of smoking within mental healthcare providers is higher than that of the general population, fewer interventions are provided clients to assist them reduce or cease and it is generally non-smoking healthcare professionals that are more likely to engage their clients in tobacco-related interventions (Margolis et al. 2009). There has been a policy shift toward smoke-free mental health facilities in Australia and throughout the world (Shekelle et al. 1999). Although the majority of mental health professionals agree that health-care facilities should promote a healthy environment, most (particularly those who smoke) support the individual’s right to smoke (Wykes et al. 2011). It could be argued that smoke-free policies place mental health professionals and mental health service users in adversarial relationships with health professionals being required to ‘police’ the nonsmoking policy. These attitudes along with complex issues related to choice, rights and duty of care make smoke-free policies in mental health units’ contentious (see (Shekelle et al. 1999) for a review of the issues). The recent decision by the Western Australian Department of Health to relax its smoke-free policy in 2013 to exempt patients admitted to locked mental
Int J Ment Health Addiction Table 12 Intervention and total substance score by age (n=666) Substance
Tobacco
Score
16–2 n = 114
26–3 n = 166
36– 45 n = 153
46– 55 n = 139
56– 65 n = 70
>66 n= 24
0–3 None
45
58
54
66
43
14
4–26 Brief
65
81
85
62
24
10
27 > Intensive Alcohol
0–10 None 11–26 Brief 27 > Intensive
Cannabis
Amphetamine
Benzodiazepine
Hallucinogen
14
11
3
0
106 21
99 21
60 6
23 0
11
34
26
19
4
1
113
108
120
70
24
4–26 Brief
30
36
35
18
0
0
12
17
10
1
0
0
0–3 None
108
158
152
137
69
24
4–26 Brief
5
7
0
2
1
0
27 > Intensive 0–3 None
1 80
1 129
1 130
0 127
0 68
0 24
4–26 Brief
23
25
15
10
1
0
11
12
8
2
1
0
0–3 None
113
160
152
139
70
24
4–26 Brief
1
6
1
0
0
0
0–3 None
100
130
126
125
64
23
4–26 Brief
13
32
21
10
6
1
1 109
4 159
6 153
4 139
0 70
0 24
3
6
0
0
0
0
27 > Intensive 0–3 None 4–26 Brief 27 > Intensive
Opioids
27 100 32
72
27 > Intensive Inhalant
4 67 36
0–3 None 27 > Intensive
Cocaine
X2
Intervention Age in years
2
1
0
0
0
0
0–3 None
106
142
144
131
69
24
4–26 Brief
5
21
5
7
1
0
27 > Intensive
3
3
4
1
0
0
df Sig
37.202 10 <0.001*
43.800 10 <0.001*
61.243 10 <0.001*
11.762 10
0.301
40.782 10 <0.001*
11.466
5
0.043*
19.136 10
0.039*
19.321 10
0.036*
24.381 10
0.007*
*p<0.05
health facilities in some circumstances (Wynn 2002) is an example of how such contentions influence policy decisions. The danger with this perception is that smoking becomes perceived as an aberrant behaviour rather than a substance addiction for which health focused interventions should legitimately be provided. The alternative is to consider a smoke-free policy as potentially providing an opportunity to encourage a person with a mental illness to reduce or cease smoking. Admission to the smoke-free of the mental health unit may be the first time a person with a mental illness is exposed to trained mental health staff who can support them to cease smoking and to the effective use of Nicotine Replacement Therapy (NRT) (Shekelle et al. 1999). It has been noted that for many, unplanned attempts at quitting are more likely to succeed for at least 6 months (with the odds ratios of success 2.6 times higher, 95 % confidence interval 1.9 to 3.6) compared to planned attempts (Shirey et al. 2011).
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While WA Health actively encourages the prescription and use of NRT to manage symptoms of withdrawal, like in many areas there is little follow-up when the client is transitioned from inpatient to community care (Elwyn et al. 2003) and few tobacco cessation interventions for these individuals within the community (Reinhardt and Ray 2003). Yet it is at this point that intervention strategies would be most beneficial as patients’ intention to cease smoking at the point of discharge has been demonstrated to be directly related to their subsequent smoking behaviour post discharge (Newhouse et al. 2006). While it is true that many patients who abstain from smoking while in hospital will revert to their former smoking behaviours post discharge (Shekelle et al. 1999) some will successfully abstain from smoking following discharge (Shirey et al. 2011). For the 32.2 % of patients previously tried and failed to control, cut down or stop smoking (Table 7) in our sample, an unplanned period of abstinence from smoking imposed by an admission to hospital for their mental health issue may be the extra motivation they require to successfully reduce or cease smoking (Newhouse et al. 2006). Good clinical practice requires appropriate management of smoking in the mental health setting. It is important that all mental health professional are skilled at recognising addictive behaviours and nicotine dependence. They also must have a good understanding of first line pharmacological intervention to address nicotine withdrawal (NRT) and be able to explain its use both in smoking cessation and for temporary abstinence while in hospital (Shekelle et al. 1999). This along with a good understanding brief interventions and supportive therapy that can be initiated as an in-patient during the acute phase of their illness (Frame and Kercher 1991) (Marsh et al. 2013) and adoption of strategies that can be continued in the community (Elwyn et al. 2003) improves the chances of sustained smoking behavioural change to improve the longer term health outcomes of this population (Margolis et al. 2009) (Shirey et al. 2011). Alcohol Use The frequency of daily/almost daily alcohol use in this sample was 20.7 % (see Table 3) which is more than twice the reported population average for Australia of 8.1 % reported in the National Drug Strategy Household Survey 2010 (Australian Institute of Health and Welfare 2011). In this sample younger males used alcohol more frequently (see Tables 11 and 12) which reflects data previously reported (Moore et al. 2012) national trends (Australian Institute of Health and Welfare 2011). Previous reports suggest that individuals with mental disorders tend to have a more chronic and disabling type of alcohol disorder (Hughes 2008) which is reflected in the data presented here. Approximately 20 % of all patients who reported using alcohol in our sample met the DSM-IV-TR Diagnostic Criteria for Alcohol Abuse and Dependence. Alcohol use, like tobacco use, is legal in Australia but is generally more widely accepted to be part of ‘Australian culture’. This is evident in the widespread commercial television and radio advertising of alcohol that promotes different brands, competitive pricing and locality of alcohol outlets and inclusion of alcohol in many social occasions and sporting events (Happell et al. 2014; Henderson et al. 2007). However unlike smoking, the prohibition of alcohol use in hospital settings is almost universally accepted with mental health units required to comply with organisational alcohol-free policies. Comorbid use of alcohol is also more likely to be perceived negatively by mental health professionals. This may be due the challenging and antisocial behaviours often associated with alcohol abuse/intoxication frequently experienced in acute mental health and emergency department settings (Happell et al. 2008) (Forlenza et al. 2009).
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The potential of life threatening withdrawal seizures (Petersen et al. 1999) and the risk of suicide while intoxicated (Happell 2008) improve the likelihood that interventions and appropriate management (alcohol withdrawal management with appropriate pharmacological management) will be offered while an inpatient in an acute mental health facility. It is also likely that patients will have a period of unplanned abstinence from alcohol while they are in an acute mental health facility which provides the opportunity to for health professional to initiate supportive therapies and in some cases pharmacological interventions that can be continued post discharge. A wide range of well-established hospital and community services that provide assessment, treatment and support for alcohol dependence and withdrawal and support abstinence (Kelly et al. 2012) provided by government and non-government funded agencies (Australian Institute of Health and Welfare 2012) enable patients to be transitioned from hospital services to community support agencies relatively efficiently. Good clinical practice for people with a mental illness and co-occurring alcohol use/abuse in acute mental health setting share the same hallmarks as described above for those who smoke; appropriate assessment of use, recognition of addictive behaviours, acute withdrawal management that includes appropriate pharmacological intervention and supportive counselling that is initiated while in hospital and continued post discharge (Mills et al. 2009) (Goghari et al. 2010). The challenge for acute mental health services is to provide a range of interventions that are acceptable and targeted at younger alcohol users and address the strong social pressures that influence alcohol use (Thornton et al. 2012b). Cannabis Use The relationship between the use of cannabis and mental illness is well established (Moore et al. 2012) with Australian population data indicating that people aged 18 years who had reported using cannabis in the previous 12 months were more likely to have been diagnosed or treated for a mental illness (Australian Institute of Health and Welfare 2011). In this sample 26.5 % of patients reported using cannabis within the previous 3 months with 10.6 % reporting daily/almost daily cannabis use, double the number people in the general population reporting cannabis (10.3 % in 2010) use within the previous 12 months (Australian Institute of Health and Welfare 2011). Heavy cannabis users at greater risk of harms in this sample tended to be young males, consistent with other reports (Kavanagh et al. 2004) (Moore et al. 2012). All but three of those who used cannabis with another substance reported co-occurring tobacco use, consistent with an increasing body of literature that reports co-occurring nicotine and cannabis dependence (Draper et al. 2003) (Winblad et al. 2004) (Portet et al. 2006; Seitz et al. 2012). As many as two-thirds of cannabis users have been reported to combine cannabis with tobacco (Gerace et al. 2013). This and the fact that current cigarette smoking is a clinical indicator of increased risk of cannabis relapse (Seitz et al. 2012) further supports the need for proactive strategies to assess and treat nicotine addiction and manage nicotine dependent behaviours within the acute mental health setting as discussed above. Recent evidence suggests that those with co-occurring cannabis and nicotine addiction are more likely to meet criteria for bipolar disorder, anxiety disorders, and paranoid, schizotypal, narcissistic, and borderline personality disorders (Portet et al. 2006). The higher than reported rates of tobacco and cannabis co-use reported in this group may reflect a large proportion of patients being admitted with these diagnoses. Motivational or brief counselling alone has been demonstrated to have limited effect in cannabis users (Baker et al. 2002). Additionally limitations with pharmacological treatments for severe co-morbid conditions such as schizophrenia/cannabis dependence
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necessitate the use of more intensive treatments and the use of creative combinations of psychotherapies, behavioural and pharmacological interventions (Kelly et al. 2012). It is suggested that the efficacy of interventions would be improved if they include prevention and intervention strategies that address the perceived beneficial effects of use (pleasure enhancement, conformity, acceptance and relief of positive symptoms and side effects (Spencer et al. 2002) and encourage cannabis users to seek alternative pleasurable activities may reduce the relapse rate (Thornton et al. 2012b). Providing a period of abstinence from cannabis during an inpatient admission, generally achievable as cannabis is illegal in Australia also increases the opportunity for mental health professionals to provide intense interventions within the acute setting that can be continued post discharge.
Conclusion The WHO ASSIST was used to assess the prevalence of co-occurring alcohol and substance use in a sample of 695 patients with diagnosed mental illness admitted to an acute mental health unit in Western Australia. A review of the data identified that most substances most frequently used were tobacco, alcohol and cannabis. The greatest potential for improving health outcomes for this population is effective strategies to reduce the frequency of use and the harms associated with tobacco, alcohol and cannabis. This can be achieved by appropriate assessment of use, recognition of addictive behaviours, withdrawal management that includes appropriate pharmacological intervention and supportive counselling that is initiated while in hospital and continued post discharge.
Conflict of interest There no conflict of interest for any author.
Funding This study was supported by a grant awarded to the first author from the Royal Perth Hospital Nursing Research Foundation
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