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Prevalence & Management of Co-morbidity: Findings from the COSMIC study. Tim Weaver Centre for Research on Drugs & Health Behaviour Department of Primary Care and Social Medicine / Department of Psychological Medicine Imperial College London.

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Prevalence & Management of Co-morbidity: Findings from the COSMIC study

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Prevalence & Management of Co-morbidity: Findings from the COSMIC study

Tim Weaver

Centre for Research on Drugs & Health Behaviour

Department of Primary Care and Social Medicine /

Department of Psychological Medicine

Imperial College London

The COSMIC Study:Co-morbidity of Substance Misuse & Mental Illness Collaborative Study


Imperial College:Tim Weaver, Vikki Charles, Zenobia Carnwath,Peter Madden, Dr Adrian Renton, ProfGerry Stimson, Prof Peter Tyrer, Prof. Thomas Barnes, Dr Chris Bench, Dr Susan Paterson

C&NWL Mental Health NHS Trust : Dr William Shanahan

Dr Jonathon Greenside, Dr Owen Jones,

Turning Point, Brent: Dr Chris Ford

Community Health Sheffield NHS Trust: Dr Nicholas Seivewright

Helen Bourne, Dr Muhammad Z Iqbal,

Nottingham Healthcare NHS Trust: Dr Hugh Middleton

Sylvia Cooper, Dr Neil Wright, Dr Katina Anagostakis,

Aims of the Presentation

  • Review epidemiological data on co-morbidity & summarise evidence about theprevalence and nature of co-morbidity in SM and MH treatment populations generated by the COSMIC study.

  • Discuss implications for service development in the context of;

    • current policy, and,

    • recent evidence for the effectiveness specialist treatment or service delivery interventions.


Study Aims

  • To estimate the prevalence of co-morbid substance misuse and mental health problems (co-morbidity) amongst current patients of substance misuse and mental health services.

  • To describe the range of co-morbid presentations among these populations

  • To assess the treatment needs (met and unmet)

  • Assess whether there are differences in the prevalence of co-morbidity between populations drawn from London and provincial urban areas.

Study Design


  • Cross sectional survey in four centres.

  • Census of CMHT & substance misuse caseloads & assessment interviewswith random samples from each population


  • Alcohol: AUDIT

  • Non-prescribed drugs:Questions about use in past year / month by drug type, Severity of Dependence Scale & Hair & Urine analysis (MH sample ONLY)

  • Psychosis: OPCRIT.

  • Personality Disorder:PAS–Q

  • CPRS (measures global symptomatology) sub-scales for assessment of Depression (MADRS) Anxiety (BAS)


FINDINGS: Drug Services


  • Assessed & allocated on census date

  • Random interview sample of 353 cases selected

  • Full patient interview & casenote audit data obtained in 278cases (79%)

  • Study Populations:

    • Drug Services (n=216): 93% in treatment for problems related to opiate use. 78% report lifetime injecting drug use

    • Alcohol Services (n=62): AUDIT confirmed 57 (92%) used alcohol at ‘harmful levels’, 2 (3%) abstinent, 3 (5%) reported non-harmful use

Service Reported Co-morbidity (year)

  • Service recorded psychiatric diagnosis obtained from keyworkers who also identified cases needing MH assessment

  • We compared this with ‘gold standard’ measures obtained at interview

  • KEY FINDING:Reported diagnosis lacks validity, under-estimates prevalence of psychiatricdisorder

    • Specificity good (>90%), sensitivity poor (20% - 35%)

Drug Treatment Population: Prevalence of Drug Use (Past Month)

*38% used opiates and stimulants in past month

Drug Treatment PopulationPrevalence of Psychiatric Disorder (year)

Drug Treatment PopulationPrevalence estimates compared

Prevalence high but consistent with previous estimates

  • Psychosis: 7.9% (year). 9 times general pop rate (Jenkins et al, 1998)

    • Compares with 6.2% (lifetime) (Regier et al, 1990)

  • Severe Depression: 26.9% (year).

    • Estimates in US and Europe 23% - 37% (Regier et al, 1990; Limbeek et al, 1992; Hendriks, 1990).

  • Personality Disorder: 37%.

    • Range of estimates (35% - 73%) (Verheul, 2001).

Drug Treatment PopulationPrevalence of Psychiatric Disorder (year)

Drug Treatment Population Services providing mental health interventions (past month) for co-morbid patients (n=161)

Alcohol Treatment PopulationPrevalence of Psychiatric Disorder (year)

FINDINGS: Community Mental Health TeamPopulation


  • CPA patients, aged 16-64, assessed and allocated to CMHT on census date

  • Random interview sample of 400 cases selected

  • Interviews completed in 282 (70.5%) cases

  • Study Population - Psychosis: 77%, PD & Depression: 16%, severe depression: 7%

  • KEY FINDING: Service reports of substance misuse lacked validity, and under-estimated prevalence. Prevalence estimation based on Interview sample.

Mental Health PopulationSelf-reported co-morbidity (year)

Mental Health PopulationSelf-reported Drug Use (year)

Mental Health PopulationPrevalence estimates compared


  • Prevalence higher than previously reported

    • 30.9% vs 15.8% (Menezes et al, 1996)

  • Significant differences between London & non-London

    • Problem drug use: 42.1% v 21.4%; x21df=13.9, p<0.001

    • Drug dependency: 24.6% v 11.3%; x21df=8.6, p=0.005


  • Prevalence (25.2%) comparable with other UK studies

    • 20% - 32% (Wright et al, 2000; Duke et al, 1994; Menezes et al, 1996).

  • No significant difference between London & non-London

Mental Health PopulationServices providing Alcohol related interventions to patients with harmful alcohol use (n=72)

Mental Health PopulationServices providing drug related interventions to patients with problem drug use (n=84)



Prevalence is high in both treatment populations

  • Most drug patients have some psychiatric disorder

  • Poly-drug use is highly prevalent in drug treatment populations (and associated with co-morbid mental health problems)

  • In some centres co-morbid patients represent majority of CMHT patients

    Clinical presentations heterogeneous


  • Assessment:MH & SM services fail to identify co-morbidity in a high proportion of patients

  • Few patients meet criteria for joint management. Possibly ‘low potential’ for cross-referral?

  • Drug & Alcohol services provide some MH interventions, >50% get no specialist care

  • CMHTs provide interventions for very few patients with drug / alcohol problems (<20%)

Policy Implications

  • Co-morbidity too prevalent to be managed by sub-teams or ‘dual-diagnosis’ specialists

  • Heterogeneity (and low cross-referral potential) means full extent of co-morbidity cannot be managed by parallel or serial treatment models

  • Co-morbidity needs to be managed systemically within mainstream mental health services

  • SM services need additional resources to better manage non-referable co-morbidity

    • Develop capacity to manage co-morbidity within MH & SM services

    • Training a priority if effective management is to be achieved

    • Research needed to support development of evidence-based service models & treatment interventions

COSMIC Study Publications:

  • Weaver, T., et al (2003) Co-morbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 183, 304-313.

  • Weaver, T., et al. (2004) What are the implications for clinical management and service development of prevalent co-morbidity in UK mental health and substance misuse treatment populations? Drugs: Education, Policy & Prevention, 11(4), 329-348.

  • Jones, OB et al (2004) Prevalence of personality disorder in a substance misuse treatment population and associated co-morbidity. Addiction, 99, 1306-1314.

  • Executive Summary of Dept of Health report:

  • NTA. Research in to Practice Series (forthcoming)

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