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

1. 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

2. The COSMIC Study:Co-morbidity of Substance Misuse & Mental Illness Collaborative Study THE STUDY TEAM 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,

3. 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.

4. METHOD

5. 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.

6. Study Design DESIGN: • Cross sectional survey in four centres. • Census of CMHT & substance misuse caseloads & assessment interviewswith random samples from each population ASSESSMEMTS: • 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)

7. FINDINGS

8. FINDINGS: Drug Services Subjects: • 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

9. 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%)

10. Drug Treatment Population: Prevalence of Drug Use (Past Month) *38% used opiates and stimulants in past month

11. Drug Treatment PopulationPrevalence of Psychiatric Disorder (year)

12. 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).

13. Drug Treatment PopulationPrevalence of Psychiatric Disorder (year)

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

15. Alcohol Treatment PopulationPrevalence of Psychiatric Disorder (year)

16. FINDINGS: Community Mental Health TeamPopulation SUBJECTS • 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.

17. Mental Health PopulationSelf-reported co-morbidity (year)

18. Mental Health PopulationSelf-reported Drug Use (year)

19. Mental Health PopulationPrevalence estimates compared PROBLEM DRUG USE: • 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 ALCOHOL MISUSE: • 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

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

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

22. DISCUSSION & CONCLUSIONS

23. IMPLICATIONS FOR SERVICE DEVELOPMENTPrevalence 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

24. Management • 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%)

25. 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

26. 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: http://www.mdx.ac.uk/www/drugsmisuse/execsummary.html • NTA. Research in to Practice Series (forthcoming)