Psychosis with coexisting substance misuse: assessment and management in adults and young people
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Psychosis with coexisting substance misuse: assessment and management in adults and young people.

National Collaborating Centre for Mental Health and National Institute for Health and Clinical Excellence.
[UK] National Institute for Health and Clinical Excellence, 2011.

Psychosis plus harmful substance use is a toxic mixture which worsens the prospects of recovery from mental illness. How should it be dealt with, and what are the respective roles of mental health and substance use services? This UK guideline developed by an expert group has some of the answers.

Summary This account is largely an abridged version of the introduction and key priorities sections of the guidance. See the freely available original for the recommendations in full and their rationale and genesis.

This guideline covers the assessment and management of people aged 14 and older with a clinical diagnosis of psychosis plus coexisting substance misuse. It aims to help healthcare professionals guide these people to stabilise, reduce or stop their substance misuse, to improve treatment adherence and outcomes, and to enhance their lives. In this guideline, substance misuse is defined as the harmful use of any psychotropic substance including alcohol and legal or illicit drugs. Such use is usually seen as a problem if there is evidence of dependence. However, substance misuse can be harmful without dependence, especially among people with psychosis.

People with psychosis commonly take non-prescribed substances to cope with their symptoms; in a third this amounts to harmful or dependent use. At some time in their lives, about 40% misuse substances, at least double the rate in the general population. They also have a higher risk of relapse and hospitalisation, and higher levels of unmet needs, compared with other inpatients with psychosis who do not misuse substances. Substance misuse among individuals with psychiatric disorders is associated with significantly poorer outcomes than for individuals with a single disorder. Coexisting substance misuse worsens outcome for people with psychosis partly because the substances used may exacerbate the psychosis, and partly because they often interfere with pharmacological or psychological treatment.

Person-centred care

People with psychosis and coexisting substance misuse should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If they do not have the capacity to make decisions, professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Assembly Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.

If the person agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need. Care of young people in transition between child and adolescent mental health services (CAMHS) and adult services should be planned and managed according to the best practice guidance described in Transition: getting it right for young people. Adult and CAMHS healthcare teams should work jointly to provide assessment and services to young people with psychosis and coexisting substance misuse. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Key priorities for implementation

When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:
• stigma and discrimination are associated with both psychosis and substance misuse;
• some people will try to conceal either one or both of their conditions;
• many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. If the person has used substances, ask them about all of the following:
• particular substance(s) used;
• quantity, frequency and pattern of use;
• route of administration;
• duration of current level of use.

In addition, conduct an assessment of dependency (see these NICE guidelines on opioid detoxification and alcohol use disorders) and seek corroborative evidence from families, carers or significant others, where this is possible and permission has been given.

Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse, nor from age-appropriate substance misuse services because of a diagnosis of psychosis.

For most adults with psychosis and coexisting substance misuse, treatment for both conditions should be provided by healthcare professionals in secondary care mental health services such as community-based mental health teams. These services should consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams known to be:
• severely dependent on alcohol; or
• dependent on both alcohol and benzodiazepines; or
• dependent on opioids and/or cocaine or crack cocaine.
Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

Healthcare professionals in substance misuse services should be competent to:
• recognise the signs and symptoms of psychosis;
• undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services.

All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others. These should include: search procedures; visiting arrangements; planning and reviewing leave; drug and alcohol testing; disposal of legal and illicit substances; and other security measures. Soon after admission, provide all service users, and their families, carers or significant others, with information about the policies and procedures.

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.

Findings logo commentary For more on the care of psychiatrically ill problem substance users see this Findings hot topic.

Last revised 24 September 2013. First uploaded 24 September 2013

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