Substance misuse in psychiatric inpatients: comparison of a screening questionnaire survey with case notes
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7418.783 (Published 02 October 2003) Cite this as: BMJ 2003;327:783
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Sir, In the course of Dr Vrabtchev’s erudite comments on the
evaluation of psychiatric patients, I was gratified by references to our
evaluation protocol as ‘a very good one used in the Liaison Department of
St. George’s Hospital in London’. We have always liked to lead where
others follow, and it is a delight to see such wise judgement on display.
Competing interests:
Head of the St George's Liaison Service
Competing interests: No competing interests
Barnaby et al. have presented to us a study with an elegant,
uncomplicated design and accessible results. Yet, some of the findings
seem hard to swallow or are simply unbelievable. The most astonishing fact
we face is the lack of any record of alcohol history and illicit substance
misuse in 73% and 74% respectively of the cases. Not surprisingly the
authors are advocating for urgent need of training. The practice of the
admitting psychiatrists seems so poor that one cannot avoid to think that
there is a case for negligence here. It is legitimate, however, to ask is
the reality on these acute psychiatric wards(not specified by the authors)
reflected accurately by this study.
The authors seem to have concentrated on studying only the clerking
done by the admitting psychiatrist. In practice, however, vast majority of
the patients admitted to acute psychiatric wards had already been assessed
and clerked elsewhere(Emergency Rooms, Outpatients, Police Stations, their
own homes etc.). It is unclear whether all of the participants were
originally assessed on the ward by the admitting psychiatrist. Some
hospitals have assessment protocols(I must say that I have seen a very
good one to be used in the Liaison Department of St. George’s Hospital in
London). The study does not indicate whether such protocols were in use or
whether looking into such protocols was considered at all. In their
comments Barnaby et al. imply that “staff in mainstream services” are in
urgent need of training. However, there is no evidence that clerking from
any other staff have been studied(nursing admission, Care Plans, etc). As
for the lack of routine blood tests and urine toxicology, my experience is
that it is rarely necessary and often impractical for these to be
performed at the time of admission(which seems to be recorded by this
study. These should, however, be done within the first day of the
inpatient stay.
Overall, it seems to me that by focusing only on the clerking of
psychiatric admissions the authors might have omitted crucial information
that may be to the contrary of their findings. If, however, I am wrong we
must accept that we read an example of poor practice and I hope the
authors would bring this to the attention of the teams working in these
hospitals.
References:
1.Barnaby et al. Substance misuse in psychiatric inpatients:
comparison of a screening questionnaire survey with case notes. BMJ
2003;327:783-4
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir/Mamdam,
As an "admitting psychiatrist" working on an acute, general adult
psychiatric ward in a busy London teaching hospital, I found Barnaby et
al's article on substance misuse amongst psychiatric in patients very
interesting and initially slightly shocking. That only 1 patient out of
their sample of 200 had a full alcohol history taken appears as though a
lot of us are not taking adequately detailed histories. From our first
days of clinical medicine as students we are taught the importance of
taking a good history. This is then re-emphasised during our
undergraduate psychiatry placements, psychiatry being a speciality where
taking a thorough history and performing a detailed mental state
assessment (the latter being akin to taking a history) are even more
pertinent in making an accurate diagnosis. However in defence of
"admitting psychiatrists" I would like to add that when clerking in
admissions on call it is often very difficult to take a fully
comprehensive psychiatric history due to amongst other factors, time
constraints and the inability of acutely unwell and disturbed patients to
submit to this. Even once admitted the pressure to discharge patients and
the generally busy nature of many general wards mean that taking adequate
drug and alcohol histories are luxuries that time will not permit. One
also has to consider that many patients will be well known to the team
either from previous admission to the ward or from regular community
contact with their key worker- the latter will often have a reasonable
idea of many aspects of the patient's lifestyle prior to admission
including drug and alcohol usage. In closing I wish to applaud Barnaby et
al. on their paper and their conclusions and agree wholeheartedly with
their sentiments. However I feel that it is also important to put this in
context.
Competing interests:
None declared
Competing interests: No competing interests
artificial separation between self-medication and substance abuse
The problem is that there is an artificial separation in the culture
of psychiatry, between patients who are suffering identifiable psychiatric
illness, and patients who have been using illicit drugs or alcohol.
Doctors who work in the field of substance abuse find that the majority of
patients initiate and continue to use illicit drugs, as well as alcohol,
in order to self-medicate during symptomatic episodes of stress,
depression, and psychosis. The problem, for the psychiatrist, is to
decide whether or not the presenting symptoms could be drug induced :
however, although drug abuse may complicate the presentation, it does not
pose an insurmountable challenge to patient care.
Illicit drug use is very common, in cities. Suicide rates are
increasing : however, as this study illustrates, the necessary link
between depression, suicidality and self-medication (or what is usually
termed drug addition or substance misuse), is not necessarily being made
in the dicipline of mainstream psychiatry. The reality is, that people
who feel psychologically unwell, stressed, or emotionally upset, take
drugs because they are trying to feel better. Insomnia is one of the
commonest reasons given for alcohol abuse, and for continuing cannabis
use.
This study is very important in illustrating the need for
psychiatrists to understand the social, psychological and medical roots of
alcohol and drug use, rather than continuing to separate these habits and
addictions, from what is thought to be mainstream psychological
symptomatology.
Competing interests:
None declared
Competing interests: No competing interests