Substance misuse in psychiatric inpatients: comparison of a screening questionnaire survey with case notes

BMJ 2003; 327 doi: (Published 02 October 2003) Cite this as: BMJ 2003;327:783
  1. Ben Barnaby, assistant psychologist1,
  2. Colin Drummond (colin.drummond{at}, professor of addiction psychiatry1,
  3. Annie McCloud, clinical lecturer in addictive behaviour1,
  4. Tom Burns, professor of community psychiatry2,
  5. Nicola Omu, specialist registrar in psychiatry3
  1. 1 Department of Addictive Behaviour and Psychological Medicine, St George's Hospital Medical School, University of London, London SW17 0RE
  2. 2 Department of Psychiatry, St George's Hospital Medical School
  3. 3 South West London and St George's Mental Health NHS Trust, London SW17 7DJ
  1. Correspondence to: C Drummond
  • Accepted 21 July 2003


Doctors are poor at taking alcohol histories in many clinical settings.1 2 Given the increasing prevalence of drug misuse in the general population and in psychiatric patients, the extent of detection of drug misuse is also important. For patients with comorbid substance misuse and psychiatric problems, the UK Department of Health states, “Individuals with dual problems deserve high quality, patient focused, and integrated care. This should be delivered within mental health services.”3 If substance misuse is not detected, however, such care is unlikely to be delivered. We examined data to investigate the prevalence of alcohol and drug misuse in inpatients admitted to psychiatric wards and the extent and accuracy of detection by the psychiatrists doing assessments on admission.

Substance misuse and related history in the case notes of 200 patients admitted to psychiatric wards in London*

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Participants, methods, and results

We aimed to approach all new admissions to six acute psychiatric wards in two London hospitals over three months. Patients who consented completed the alcohol use disorders identification test (AUDIT) and a short version of the substance abuse assessment questionnaire.4 An AUDIT score ≥ 8 indicates hazardous alcohol use and ≥ 15 indicates alcohol dependence. We excluded patients who did not speak English, who were admitted to the psychiatric intensive care unit, or who were younger than 18 or older than 75. We also excluded patients admitted to specialist wards for addiction or eating disorders and those admitted to forensic wards.

We studied case notes to determine whether a history of substance misuse had been recorded on current admission, its comprehensiveness, whether relevant investigations had been performed, and whether any screening tools had been completed. We considered alcohol and illicit drugs separately. A full history was one including the age of first misuse of each substance, and questions about problems related to using substances and symptoms of dependence, periods of abstinence, and use of specialist services. A partial history contained any one or more of these but less than a full history.

Of a total of 364 new admissions, 326 (89%) were eligible; we approached 263 patients, and 200 (76% of those eligible) gave consent. Not seeing patients was usually because they were admitted and discharged over a weekend or because they absconded.

Of the 200 patients who took part, 106 (53%) were men and 94 (47%) were women. Mean age was 41 years; 158 (79%) were white and 22 (11%) were black. A total of 97 (49%) scored ≥ 8 on AUDIT, indicating hazardous alcohol use—53% of men and 44% of women. Forty four (22%) scored ≥ 15 or above on AUDIT, indicating alcohol dependence. More than half of the patients (110; 58%) reported lifetime substance misuse, and 52 (27%) reported taking illicit drugs in the 30 days before admission. One patient had had a full alcohol history taken; 54 (27%) had partial alcohol histories in their notes. Three quarters of patients (146; 73%) had no record of using alcohol in their notes. Most patients (148; 74%) had no record of drug misuse in their notes. The ratio of women to men who use alcohol hazardously (1:1.2) was considerably higher than in the general population (1:2.5).5


Substance misuse is common in psychiatric inpatients, but most patients have not been asked about these disorders by admitting psychiatrists. The high prevalence of substance misuse and low screening rates could have an important impact on the quality of the treatment provided, including missed opportunities for substance misuse intervention.

Staff in mainstream mental health services, particularly admitting psychiatrists, urgently need training in detecting and managing comorbid substance misuse. “To overlook or neglect substance misuse in the course of mental health treatment will result in poor treatment outcome.”3


  • Contributors All authors designed the project and drafted the paper. BB, AMcC, and NO collected the data. BB, CD, and AMcC analysed the data. CD is guarantor.

  • Funding No additional funding.

  • Competing interests None declared.

  • Ethical approval Not needed.


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