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What should we expect of Brief Interventions for Alcohol Misuse in Mental Health Settings? Peter Rice, Consultant Psychiatrist, NHS Tayside Alcohol Problems Service
Alcohol and Mental Health – Defining our contradictory and ambivalent attitudes and expectations.
ALCOHOL AND MENTAL HEALTH – A CORE ISSUE • Half of people referred from Primary Care to alcohol treatment services are already prescribed anti-depressants. • 27% of suicides studied in the UK had a “dual diagnosis” of mental illness and dependence. • Substance misuse is primary diagnosis in 14% of Scottish psychiatric readmissions.
THE NATURE OF THE GAP • “Individuals with substance misuse-related issues often did not have sufficiently severe mental health problems to be eligible for attention from community mental health teams which prioritised severe and enduring mental illness.” (CARES report) and • “Despite high prevalence rates of drug misuse, only a small number (less than 5%) of mental health patients exhibited patterns of drug use that would have been likely to satisfy eligibility criteria for statutory drug treatment programmes in their areas mainly because they were not opiate users.” (Department of Health 2004)
ALCOHOL PROBLEMS IN MENTAL HEALTH SETTINGS • Issues of diagnostic definition (especially personality disorder.) • Relationship between alcohol consumption and psychiatric symptoms • UK Psych morbidity survey found 12% males and 6% females with • co-exisiting psychiatric disorder and substance misuse. (Farrell 2001) • UK CMHT pts. 24-27% screen +ve for alcohol misuse • (Weaver et al 2003) • 40% of medium secure unit in-patients with alcohol problem • (Scott 2004)
The Severity of Alcohol Problems in Psychiatric Patients Study of 999 consecutive admissions to Australian in-patient unit. Approx 600 screened. Hulse and Saunders 2000 Drug Alc Rev, vol 19, p 291
What do we mean by “Brief Intervention” ? • Simple Structured Advice. 5-10 mins • Extended Brief Intervention 10-60 mins • Brief Treatment up to 5 sessions • Extended Treatment Structured therapy • Social Care • Pharmacology • Day Programmes • In patient care • Long term rehab • Housing support
What do outcome studies tell us? Western Australia studies. (Hulse and Tait) 999 psychiatric in-pts eligible. 144 into study. Received 45 min MI session or information pack. Self reported consumption at 6 months Re-admission rates over 5 years.
Western Australia Study – Consumption Outcomes at 6 Months Reduced consumption both groups. Greater reduction in MI group. 5 yr follow up showed both groups had fewer re-admissions than matched controls. Hulse and Tait 2002 Drug and Alc Review, 21, p105 Hulse and Tait 2003 Addiction, 98, p1061
What are the barriers to BI in Mental Health Settings? Knowledge ? Skills ? Attitudes ?
Alison Munro, H.E. Watson and Angus McFadyen Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: A randomised controlled trialInternational Journal of Nursing Studies, Volume 44, Issue 8, November 2007, Pages 1430-1438 • 49 mental health nurses • Measured attitudes and knowledge on comorbidity at baseline • Experimental group attended 4 day training course. • Repeat measure immediately post training and at 6 months.
Mental Health Nurses Knowledge about Comorbidity Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: International Journal of Nursing Studies, Volume 44, Issue 8, November 2007, Pages 1430-1438Alison Munro, H.E. Watson and Angus McFadyen
Mental Health Nurses Attitudes to Comorbidity Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: International Journal of Nursing Studies, Volume 44, Issue 8, November 2007, Pages 1430-1438Alison Munro, H.E. Watson and Angus McFadyen
Alison Munro, H.E. Watson and Angus McFadyen Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: A randomised controlled trialInternational Journal of Nursing Studies, Volume 44, Issue 8, November 2007, Pages 1430-1438 Knowledge scores showed improvement in both groups. No significant difference. Attitude scores showed significant positive change in attitudes in trained group. Positive attitude change in trained group increased over 6 months.
Mental Health services need to plan for the impact of alcohol misuse as an integral part of their work. • The response to alcohol problems will vary in content and intensity • in response to client need. • Staff training programmes should have a strong emphasis on • understanding and responding to staff attitudes to substance misuse. • The AUDIT is applicable in Mental Health settings. • The development of a stepped care approach to MH service design • offers opportunities to develop screening and brief intervention • approaches for hazardous and harmful drinking. • Assessment of the effectiveness of brief intervention and treatment • approaches in MH settings should be a UK research priority.