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New NICE Guidance To Help Manage Psychosis With Co-Existing Substance Misuse

NICE has today published a new clinical guideline that aims to help ensure people diagnosed with a form of psychosis, who also misuse substances, can be identified and treated effectively

Around 40% of people who have been diagnosed with psychosis have also misused a substance at some point in their lifetime. This is at least double the rate seen in the general population.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: ÒWhen these two conditions co-exist, patients can spend twice as long in hospital, compared with those who do not misuse substances. They experience poorer physical health, are less likely to take prescribed medication and more likely to Ôdrop outÕ of services. However, at present less than a fifth of people who have coexisting psychosis and substance misuse receive treatment for their substance misuse.

ÒThis guideline aims to help healthcare professionals guide people with psychosis and coexisting substance misuse to stabilise, reduce or stop their substance misuse, to improve treatment adherence and outcomes, and to enhance their lives.Ó

Recommendations include:

– Recognition of psychosis with coexisting substance misuse in adults and young people:ÊHealthcare professionals in all settings, including primary care, secondary careÊmental healthÊservices, 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.

– Secondary care mental health services:ÊConsider 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, and known to be: severely dependent on alcohol or dependent on both alcohol and benzodiazepines or dependent on opioids and/or cocaine or crack cocaine.

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

– Inpatient mental health services:ÊAll 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.

– Specific issues for young people with psychosis and coexisting substance misuse:ÊThose 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.

Dr Tim Kendall, Director of the National Collaborating Centre for Mental Health, Medical Director and Consultant Psychiatrist, Sheffield Health and Social Care NHS Foundation Trust said: ÒThis new guideline isnÕt about substance misuse causing psychosis, but about effectively managing the two conditions together. A person diagnosed with psychosis is twice as likely to also misuse substances Ð one of the reasons for this is that people with psychosis can often take various non-prescribed substances as a way of coping with their symptoms, and for a third of people with psychosis, this can lead to harmful or dependent use.Ó

Professor Peter Tyrer, Professor of Community Psychiatry, Imperial College, London and Chair of the Guideline Development Group said: ÒWe hope that these new recommendations will help doctors, nurses and other healthcare professionals to recognise coexisting psychosis and substance misuse; not just in mental health and substance misuse services, but across a wide range of settings. It is essential that these patients can access the right treatment for both conditions together, particularly when cannabis and alcohol are the substances involved, to ensure they have the best possible chance of achieving meaningful improvement in the long term.Ó



About the guidance

1. The guidance will be available on theÊNICE websiteÊfrom 23 March 2011.

2. Substance misuse is a broad term encompassing the harmful use of any psychotropic substance, including alcohol and either legal or illicit drugs. Such use is usually, but not always, regarded as a problem if there is evidence of dependence, characterised by psychological reinforcement of repeated substance-taking behaviour and, in some cases, a withdrawal syndrome. However, substance misuse can be harmful without dependence, especially among people with a coexisting psychosis. The two most commonly used drugs in this context are cannabis and alcohol.

3. Psychosis is used to describe a group of severe mental health disorders characterised by the presence of delusions and hallucinations that disrupt a personÕs perception, thoughts, emotions and behaviour. The main forms of psychosis areschizophreniabipolar disorderÊor other affective psychoses.

In the UK, the annual prevalence for probable psychotic disorder among adults living in private households is about 5 per 1000. Among those diagnosed with a psychotic disorder, studies show that prevalence for any substance misuse ranges from 24-36%.

NICE/Medical News Today

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