A national survey of substance misuse and treatment outcome in ...

The Journal of Forensic Psychiatry & Psychology Vol 15 No 4 December 2004 595–605

A national survey of substance misuse and treatment outcome in psychiatric patients in medium security FIONA SCOTT, SEAN WHYTE, RACHEL BURNETT, CAROL HAWLEY and TONY MADEN

ABSTRACT This is the first national study of outcome in medium security, based on all 959 discharges between 1/4/97 and 31/3/98. Case notes were used to collect data about demographic and clinical characteristics, including substance misuse. Criminal and hospital records, plus a questionnaire sent to the responsible consultant, were used to measure outcome in the 12 months following discharge. Drug use was common, with more than three quarters (76%) of the patients ever having used any drug, including 51% with a clinically significant drug problem and 40% with alcohol problems. There were strong associations between substance misuse and age, ethnicity, diagnosis and length of stay. Patients with substance misuse problems were significantly more likely to be re-convicted during the follow up period but were not significantly more likely to be re-hospitalized. Those with alcohol problems had significantly more re-admissions than those without. Formal substance misuse treatment programmes were rare in the units surveyed, and our findings suggest that there is a large unmet need for services among mentally disordered offenders in medium security.

The Journal of Forensic Psychiatry & Psychology ISSN 1478-9949 print/ISSN 1478-9957 online # 2004 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/14789940412331305556

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Keywords: substance misuse, alcohol, comorbidity, medium security, reconviction, rehospitalization

INTRODUCTION Research over the last decade has consistently shown high levels of substance misuse among the mentally ill. The Epidemiological Catchment Area study suggests that the chances of having an addictive disorder are increased almost three-fold by the presence of a mental disorder (Regier et al., 1990). The higher prevalence of substance misuse among the mentally ill may be explained by a patient’s desire to self medicate, to relieve the boredom of being an inpatient, to lessen anxiety, or to increase social contact (Test, Wallisch, Allnesss and Ripp, 1989). The situation is similar for mentally disordered offenders. Chiles, von Cleve, Jemelka and Trupin (1990) found that 84% of offenders in prison with a primary psychiatric diagnosis other than substance abuse disorder also had a diagnosis of drug or alcohol abuse or dependence. Of particular concern are the associations that have been shown between drug and alcohol misuse and higher rates of violence (Lindqvist and Allebeck, 1989; Swanson, Holzer, Ganju and Tsutomu Jono, 1990; Cuffel, Shumway, Choulijan and MacDonald, 1994; Soyka, 2000), other offending (Scott et al., 1998) and hospitalization (Menezes et al., 1996). An association between substance misuse and violent behaviour has been repeatedly demonstrated in patients discharged from hospital (e.g. Steadman et al., 1998; Swartz, Swanson, Hiday, Borum, Wagner and Burns, 1998). The few studies on mentally ill offenders in medium secure units have also found high rates of substance misuse (Wheatley, 1998; Baxter, RabeHesketh and Parrott, 1999; Maden, Rutter, McClintock, Friendship and Gunn, 1999), however the studies are limited to single units. We present the first national study of substance misuse, re-conviction and re-hospitalization of all patients discharged from medium security in England and Wales in a 1 year period. In addition to prevalence data, we examine associations with outcome, using measures of re-conviction and re-hospitalization.

METHOD Design The study employs a retrospective cohort design, looking at all patients leaving medium secure units in England and Wales during the year beginning on 1st April 1997.

SUBSTANCE MISUSE AND OUTCOME IN MEDIUM SECURITY

Procedure The researchers visited all participating units and information was extracted from the patients’ medical records. Proformas were used to collect information about patient characteristics including ethnicity, diagnosis, previous psychiatric and forensic histories, status under the Mental Health Act 1983, and drug use. Diagnoses were taken from the patient’s discharge summary; the clinical diagnosis applied by the treating clinician was accepted without revision. A diagnosis of psychotic disorder included schizophrenia and related psychoses and mood disorder, psychotic type. We collected follow-up data by contacting the consultant responsible for the patient after discharge/transfer from medium security. A separate proforma was developed for this purpose, including information on the patient’s location for all 12 months of the follow up period, contact with psychiatric services, and re-admissions to hospital. Consultants were asked to complete a questionnaire dealing with each of these topics. We extracted further information from medical records covering the follow-up period, whenever possible. The Offenders Index at the Home Office provided data on re-conviction. As the study was retrospective, and as convictions can take a long time to be processed and to appear in the records, we were able to collect conviction data for 2 years post-discharge, whilst the rest of the follow-up was limited to 1 year. Drug use was recorded if there was a record in the notes of the patient having expressed that they had used the drug. Patients were recorded as having alcohol or illicit drug problems (substance misuse) if there was a record of excessive (e.g. daily) use or if it was explicitly stated in the notes that the patient had a problem with substance misuse. This definition was adopted on both practical and pragmatic grounds, as in everyday clinical practice substance misusers will rarely be identified using a formal assessment instrument. Participants The sample included all patients discharged or transferred, following a first admission, from medium security in England and Wales between 1/4/97 and 31/3/98. Subsequent admissions were not included in the total number of admissions or discharges, although they were regarded as readmissions for the patients concerned when they were followed up. There were a total of 34 units involved in the study which excluded dedicated units for people with learning disability only. Six private and 28 NHS units were involved in the study. There were 971 first admissions, accounting for a total of 1023 discharges; patients who were transferred to another MSU within the study period were identified and not included as a new admission for that unit.

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Twelve patient records could not be located resulting in a final sample of 959 patients consisting of 843 men (88%) and 116 women (12%). It was sometimes impossible to locate all the necessary information within medical records, so some of the analyses are based on samples of less than 959.

RESULTS Data were analysed using the Statistical Package for Social Sciences (SPSS) version 10, and Microsoft Excel 97 Data Analysis ToolPak. The chi squared test was used for most parametric analyses, except for continuous data where the t-test and ANOVA were employed. Where non-parametric methods were appropriate, the Mann–Whitney/Wilcoxon test was used as described in the text. Prevalence and point prevalence of substance use More than three quarters of the sample (693 patients, 76%) reported ever having used drugs. The most common drug ever used was cannabis (635 patients, 72%) followed by amphetamines (315 patients, 36%). A breakdown of all drugs and numbers of patients ever having used them is shown in Figure 1, which compares the rates from this study with those found in the 2000 British Crime Survey (Ramsey, Baker, Goulden, Sharp and Sondhi, 2001).

Figure 1 Lifetime prevalence of drug use in patients in medium security, by type of drug


Current alcohol problems were reported for nearly half of the sample (381 patients, 40%), and just over half (468 patients, 51%) reported current drug problems, suggesting that substance misuse is a significant problem in this population. In the rest of these results, alcohol and drug use refer to current use. Demographic features of substance users There were no significant differences between men and women for alcohol misuse: 41% of male patients and 35% of female patients had alcohol problems (w2 = 1.71, p = 0.19). There was however, a significant difference for illicit drug misuse, with 52% of men and 35% of women having drug problems (w2 = 11.38, p 5 0.0001). There was a highly significant difference in age for alcohol misusers (mean age for those with alcohol problems 36, for those without problems 33; t = 7 4.73, two tailed, p 5 0.0001). The mean age of patients with drug problems was 31, compared to patients without drug problems who had a mean age of 38 (t = 8.56, two tailed, p 5 0.001). However, the clinical significance of this is small, as the effect size is low (0.27); the statistical significance of the difference reflects only the large sample. In analysing patients’ ethnic groups, we compared only white and AfroCaribbean patients, as the other groups were too small for statistical analysis. There were significant differences between Afro-Caribbean and white patients for alcohol misuse, with 312 (47%) of white patients having alcohol problems and 39 (19%) of Afro-Caribbean patients having alcohol problems (w2 = 47.99, p 5 0.0001). Overall there were no significant differences in rates of drug use (70% of white patients used, compared to 78% of Afro-Caribbean patients; w2 = 0.26, p = 0.61), although within each drug group there were significant differences between white and Afro-Caribbean patients, as shown in Table 1. Note that white patients had significantly greater rates of misuse for all drugs except cannabis and cocaine. Clinical features of substance users Seven hundred and thirty-two patients (76%) had a primary or secondary diagnosis of a psychotic disorder excluding drug induced psychosis; they were less likely than those with other disorders to have alcohol problems (38% of psychotic patients as against 50% of nonpsychotic patients; w2 = 10.04, p = 0.002). Fifty-one per cent of the 732 patients with psychotic disorders had drug problems compared to 50% of those with other diagnoses; this finding was not significant (w2 = 0.067, p = 0.796).

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Table 1 Comparison of rates of drug misuse in white and black patient groups Drug

Proportion of white patients using (%)

Proportion of black patients using (%)

p value for difference*

67 14 35 41 21 22 9

81 2 18 18 34 12 2

5 0.001 5 0.001 5 0.001 5 0.001 5 0.001 5 0.01 5 0.01

Cannabis Solvents Hallucinogens Amphetamines Cocaine Opiates Benzodiazepines *Based upon chi-squared test.

Personality disorder also showed significant associations with substance misuse. Of the 186 patients with either a primary or secondary diagnosis of personality disorder, 106 (58%) had alcohol misuse problems compared to 273 (37%) patients with no personality disorder and alcohol problems (w2 = 26.57, p 5 0.0001). Similarly patients with personality disorder were more likely to have problems with drug misuse than patients with no primary or secondary diagnosis of personality disorder (58% compared to 49% respectively, w2 = 4.74, p = 0.029). There was also a significant difference in the ages at which patients committed their first offences. Those with drug problems had a mean age of 17 at their first offence, compared to 21 for those without drug problems (t = 7.1, two tailed, p 5 0.0001). Patients without a recorded drug problem had a mean duration of admission of 462 days, almost 100 more days than the mean stay of those with drug problems (366 days; Mann–Whitney/ Wilcoxon W = 210913, p = 0.013). Relationship between substance use and re-offending There is a significant association between alcohol misuse and re-conviction: 70 (49%) of the 142 patients who were re-convicted in 2 years had an alcohol problem compared to 311 (39%) of the 787 patients not reconvicted (w2 = 4.76, p = 0.029). The association between re-conviction and drug misuse was even stronger than that with alcohol. More than three quarters (112, 79%) of those reconvicted in the 2 years post discharge had a drug problem, compared to 356 (46%) of those who were not re-convicted (w2 = 53.08, p 5 0.0001). Regression analysis of the number of convictions in the first 2 years after discharge supports the significance of the latter association, but not the former. Drug use and alcohol use together were significant predictors of the


number of convictions (F = 10.4, df = 2, p 5 0.0001; R2adj = 0.02), but this was entirely due to drug use (t = 4.40, p 5 0.00001); alcohol use alone was not associated with the number of convictions (t = 7 0.33, p = NS). Follow-up There were 159 patients who were untraced at follow-up. Of those, more than half (84, 53%) had drug problems. Twenty-six of these patients could simply not be found once they were discharged; for some, no formal arrangements were in place for follow-up and for others, they failed to engage with services. Three of the eight patients who died during the follow-up period had been identified as having drug problems; it is unknown whether drug use was related to any of the deaths. A further 33 were untraced as they were discharged back to prison; it was rare for there to be any planned follow-up for patients discharged back to prison. The tracking of prisoners was made more difficult because of their frequent moves between prisons. We were only likely to obtain data on prisoners if they were referred back to the medium secure unit in which they were originally treated. Four of the patients had left the country and 21 could not be traced because of a lack of response from the presumed Responsible Medical Officer. Relationship between substance use and re-hospitalization Of the 381 patients with a recorded alcohol problem, 62 (16%) were readmitted to a psychiatric unit compared to 91 (16%) of the 570 patients with no recorded alcohol problems. These proportions are not significantly different (w2 = 0.21, p = 0.9). Similarly, 84 (18%) patients with a drug problem were readmitted compared to 69 (14%) without a drug problem. This difference is also not significant (w2 = 3.55, p = 0.17). Regression analysis also demonstrated no significant association between substance misuse and the number of re-hospitalizations: neither alcohol misuse nor drug misuse was associated (t = 1.01 and 1.86 respectively, p = NS for both; R2adj = 0.006). DISCUSSION This was the first national study on outcome since medium secure units were introduced more than 20 years ago. This study confirms previous findings from individual units that the prevalence of substance misuse is high, with over three quarters of all patients ever having used drugs and over half of all patients having current problematic use, compared to just over 6%

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prevalence of drug misuse in the general population (Regier et al., 1990). Although the results from previous studies with medium secure patients and our levels of substance misuse are similar, other comparisons are difficult because of the differences in follow-up period and other criteria. Baxter et al. (1999) followed up only schizophrenic patients from discharge up until a certain point; up to 10 years later. Wheatley (1998) also only studied patients with schizophrenia but with no outcome measure. Men were more likely than women to be drug misusers, but not alcohol misusers. Afro-Caribbean patients were as likely as white patients to misuse drugs overall, but this was entirely due to their higher rates of use of cannabis and cocaine: white patients had greater rates of use of all other recorded drugs. White patients were also significantly more likely than black patients to be alcohol misusers. Being diagnosed with a psychotic disorder (other than drug-induced psychosis) was associated with a decrease in alcohol problems and no difference in drug misuse. Having a personality disorder was associated with both drug and alcohol misuse. These two categories account for the bulk of admissions to medium secure units. The low proportion of patients with diagnoses of personality disorder (20%) most likely represents under-reporting (i.e. not giving diagnostic labels which might be thought unhelpful in treatment or prognosis). Patients with alcohol or drug problems were respectively 3 or 7 years younger on average. Patients with substance misuse problems also started their criminal careers on average 4 years earlier, at age 17 instead of 21. While this is not proof of causation, it suggests that the factors which lead individuals to misuse substances also predispose the individual to early criminal behaviour and earlier admission to psychiatric units. Other studies have also suggested that non-forensic psychiatric patients with substance misuse problems spend more time in hospital (Menezes et al., 1996), but we found that their average stay was shorter than patients without substance misuse problems. This is probably because length of stay in medium security is determined by factors that are less important in other, non-forensic psychiatric settings. For example, there may be legal restrictions on discharge, and rehabilitation is slower in patients who have committed serious offences. As medium security is a tertiary, specialist service, it holds some of the most refractory cases of treatment resistant schizophrenia, where there may be a prolonged disturbance of the mental state, independent of any substance misuse. On the other hand, patients admitted to medium security because of the effects of drugs on their mental state, may improve rapidly once their access to substances is restricted. Despite previous findings of an association between substance misuse and re-admission to hospital (Gupta, Hendricks, Kenkel, Bhatia and Haffke, 1996; Drake and Wallach, 1989), we found no significant associations between re-admission during the follow-up period and drug or alcohol


problems. This might reflect the duration of the follow-up period and the relatively low rate of readmission overall in our study. Another contributing factor may be that more than half of patients untraced at follow up were recorded as having substance misuse problems and it may be that they were admitted elsewhere. Both alcohol and drug misuse showed an association with re-conviction after discharge, the association with drug misuse being stronger; moreover, patients with drug problems committed more offences after discharge on average. Psychiatric patients with drug problems are likely to cost the criminal justice system more money. The National Treatment Outcome Research Study found that in a drug misuser population, every £1 spent on drug treatment saves over £3 in crime related and other costs (Gossop, Marsden and Stewart, 1999). The costs in relation to mentally disordered offenders are likely to be even higher, given the high cost of medium secure beds. Despite its economic importance, there are few known formal therapeutic interventions for patients with comorbid substance misuse problems in medium secure units. There are similar problems in other health settings. Weaver, Hickman, Rutter, Ward, Stimson and Renton (2001) examined the prevalence of mental illness in substance misuse services and conversely the prevalence of substance misuse in community mental health teams, and found that only a minority of patients received treatment for both problems. An outpatient intervention study in Australia evaluated a programme based on harm minimization which involved assessment, goal planning and treatment which included education, advice, links to specialist services and motivational interviewing (Teeson and Gallagher, 1999) but found no reduction in substance misuse. Other studies have described treatment programmes for dually diagnosed patients (Kavanagh et al., 1998) and suggested components of an integrated treatment programme (Drake, Bartels, Teague, Noordsy and Clarke, 1993) however evaluated programmes were scarce. More work needs to be done on the efficacy and outcome of each type of intervention in mentally disordered offenders, as it may be that conventional substance misuse treatments will need considerable adaptation for a population that is predominantly mentally ill. The obvious advantage of this study is that all discharges were included, so as to eliminate sampling bias. The limitations are those of any case note study, reliant on clinical definitions of drug use and problematic use; the data were not collected with the study in mind, and are therefore both less rigorous and less complete than in a prospective cohort study. This problem is reduced in a medium secure forensic sample, as the case notes are detailed and include large amounts of third-party information, but it cannot be ignored. Drug use is likely to be under-reported, suggesting that our figures underestimate the size of the problem.

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Re-conviction data are accepted as an underestimate but generally representative of actual offending as many offences go undetected or are not prosecuted, but there is currently no better measure of criminal activity. The findings of this study suggest that substance misuse is a predictor of poor outcome, has important clinical implications for prognosis, and is linked with increased crime. Conversely, it has shown that substance misuse problems are associated with briefer courses of treatment, rather than the opposite. The dramatic increase in crime in recent years, and the associations between crime and drugs have been highly publicized in the UK and still few substance misuse treatment programmes have been introduced for patients with dual diagnoses in medium secure units. There is a great need for more formal treatment programmes for comorbid substance misuse, and better liaison with substance misuse services. REFERENCES Baxter, R., Rabe-Hesketh, S. and Parrott, J. (1999) ‘Characteristics, Needs and Reoffending in a Group of Patients with Schizophrenia Formerly Treated in Medium Security’. The Journal of Forensic Psychiatry 10(1): 69–83. Chiles, J. A., von Cleve, E., Jemelka, R. P. and Trupin, E. W. (1990) ‘Substance Abuse and Psychiatric Disorders in Prison Inmates’. Hospital & Community Psychiatry 41(10): 1132–4. Cuffell, B. J., Shumway, M., Chouljian, T. L. and Macdonald, T. (1994) ‘A Longitudinal Study of Substance Use and Community Violence in Schizophrenia’. The Journal of Nervous and Mental Disease 182(12): 704–8. Drake, R. E., Bartels, S. J., Teague, G. B., Noordsy, D. L. and Clark, R. E. (1993) ‘Treatment of Substance Abuse in Severely Mentally Ill Patients’. Journal of Nervous and Mental Disease 181(10): 606–11. Drake, R. E. and Wallach, M. A. (1989) ‘Substance Misuse Among the Chronic Mentally Ill’. Hospital and Community Psychiatry 40(10): 1041–6. Gossop, M., Marsden, J. and Stewart, D. (1998) NTORS at one year: The National Treatment Outcome Research Study: Changes in substance use, health and criminal behaviours at one year after intake. Department of Health. Gupta, S., Hendricks, S., Kenkel, A. M., Bhatia, S. C. and Haffke, E. (1996) ‘Relapse in Schizophrenia: Is There a Relationship to Substance Abuse?’ Schizophrenia Research 20: 153–6. Kavanagh, D. J., Young, R., Boyce, L., Clair, A., Sitharthan, T., Clark, D. and Thompson, K. (1998) ‘Substance Treatment Options in Psychosis (STOP): A New Intervention for Dual Diagnosis’. Journal of Mental Health (UK) 7(2): 135–43. Lindqvist, P. and Allebeck, P. (1989) ‘Schizophrenia and Assaultative Behaviour: The Role of Alcohol and Drug Abuse’. Acta Psychiatrica Scandinavia 82: 191–5. Maden, A., Rutter, S., McClintock, T., Friendship, C. and Gunn, J. (1999) ‘Outcome of Admission to a Medium Secure Psychiatric Unit: Short- and Long-term Outcome’. British Journal of Psychiatry 175: 313–6.

SUBSTANCE MISUSE AND OUTCOME IN MEDIUM SECURITY Menezes, P., Johnson, S., Thornicroft, G., Marshall, J., Prosser, D., Bebbington, P. and Kuipers, E. (1996) ‘Drug and Alcohol Problems Among Individuals with Severe Mental Illness in South London’. British Journal of Psychiatry 168: 612–9. Ramsey, M., Baker, P., Goulden, C., Sharp, C. and Sondhi, A. (2001) Home Office Research Study 224: Drug Misuse Declared in 2000 – Results from the British Crime Survey. London: Home Office. Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L. and Goodwin, F. K. (1990) ‘Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse’. Journal of the American Medical Association 264(19): 2511– 8. Scott, H., Johnson, S., Menezes, P., Thornicroft, G., Marshall, J., Bindman, J., Bebbington, P. and Kuipers, E. (1998) ‘Substance Misuse and Risk of Aggression and Offending Among the Severely Mentally Ill’. British Journal of Psychiatry 172: 345–50. Soyka, M. (2000) ‘Substance Misuse, Psychiatric Disorder and Violent and Disturbed Behaviour’. British Journal of Psychiatry 176: 345–50. Steadman, H. J., Mulvey, E. P., Monahan, J., Robbins, P. C., Appelbaum, P., Grisso, T., Roth, L. H. and Silver, E. (1998) ‘Violence by People Discharged from Acute Psychiatric Inpatient Facilities and By Others in the Same Neighbourhoods’. Archives of General Psychiatry 55: 393–401. Swanson, J. W., Holzer, C. E., Ganju, V. K. and Tsutomu Jono, R. (1990) ‘Violence and Psychiatric Disorder in the Community: Evidence from the Epidemiologic Catchment Area Surveys’. Hospital and Community Psychiatry 41(7): 761–70. Swartz, M. S., Swanson, J. W., Hiday, V. A., Borum, R., Wagner, H. R. and Burns, B. J. (1998) ‘Violence and Severe Mental Illness: The Effects of Substance Misuse and Non-adherence to Medication’. American Journal of Psychiatry 155(2): 226– 31. Teeson, M. and Gallagher, J. (1999) ‘Evaluation of a Treatment Programme for Serious Mental Illness and Substance Use in an Inner City Area’. Journal of Mental Health 8(1): 19–28. Test, M. A., Wallisch, L. S., Allness, D. J. and Ripp, K. (1989) ‘Substance Use in Young Adults with Schizophrenic Disorders’. Schizophrenia Bulletin 15(3): 465–76. Weaver, T., Hickman, M., Rutter, D., Ward, J., Stimson, G. and Renton, A. (2001) ‘The Prevalence and Management of Comorbid Substance Misuse and Mental Illness: Results of a Screening Survey in Substance Misuse and Mental Health Treatment Populations’. Drug and Alcohol Review 20(4): 407–16. Wheatley, M. (1998) ‘The Prevalence and Relevance of Substance Use in Detained Schizophrenic Patients’. Journal of Forensic Psychiatry 9(1): 114–29.

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