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Background

The coexistence in an individual of psychiatric and psy-

choactive substance use disorders is an important clinical

challenge for psychiatry (Krausz 1996). The term dual

diagnosis is often used to describe these individuals whorepresent a heterogeneous group comprising people who

have different types of mental disorder with differing

degrees of severity. They may be using one or more of a

range of psychoactive substances with varying frequency

and in varying amounts (Franey 1996). The nature of the

relationship between drug use and mental illness is

complex. Substance use and/or withdrawal can precede

and contribute to the development of psychiatric syn-

dromes or symptoms. Substance use may also exacerbate

a pre-existing psychiatric condition whilst a primary

mental disorder can itself precipitate substance use

(Crome 1996).

Prevalence data from the USA indicate that in inner city

areas up to 60% of schizophrenic patients also use alcohol

and other psychoactive substances (Test et al. 1989, Regier

et al. 1990). A dual diagnosis has been associated withpoor medication compliance, higher levels of positive

symptoms, including delusions and paranoia, significant

depressive symptoms, increased rates of suicidal behaviour

and higher rates of violence, and is a predictor of poor

treatment outcome (Drake & Wallach 1989).

In the UK a survey of patients with psychosis who attend

an inner city community mental health service identified

rates of 31% and 16% for alcohol and drug use, respec-

tively (Menezes et al. 1996). The Royal College of

Nursing, in a survey of mental health nurses, found that

Journal of Psychiatric and Mental Health Nursing, 1998, 5, 137142

1998 Blackwell Science Ltd 137

Staff perceptions of substance use among acute psychiatry in-patients

I . R Y R I E1 B S C D i p N R M N & J . M cGOW AN 2 D i p H E ( M en ta l N urs ing )

1Lecturer in Mental Health Nursing, Kings College, University of London, Cornwall House, London and 2StaffNurse, The Bethlam and Maudsley NHS Trust, Denmark Hill, London

RYRIE I. & McGOWAN J. (1998)Journal of Psychiatric and Mental Health Nursing5,

137142

Staff perceptions of substance use among acute psychiatry in-patients

This paper reports on a small-scale study undertaken in two inner city acute psychiatric

wards to identify the proportion of patients known to use drugs or alcohol and the

perceptions of staff regarding these patients. Data collection involved a retrospective auditof patient notes and the administration of a questionnaire to nursing staff. The findings

were broadly consistent with other research studies. Over half of the patient sample was

reported to use illicit drugs or alcohol and in one third of cases this use was thought to have

contributed to their current admission. Questionnaire results indicated that staff felt ill-

equipped to offer an adequate response although all respondents welcomed opportunities

to develop their knowledge and skills. The findings are discussed in light of the existing

literature, and some tentative conclusions are drawn concerning the development and

provision of effective integrated services for individuals with psychiatric and psychoactive

substance use disorders.

Keywords: acute psychiatry, dual diagnosis, substance use

Accepted for publication: 29 September 1997

Correspondence:

Iain Ryrie

Lecturer in Mental Health

Nursing

Kings College

University of London

Cornwall HouseLondon SE1

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68% of respondents reported illicit drug use by patients in

the psychiatric unit in which they worked (Sandford

1995). Similar perceptions have been reported by special

hospital staff and drug use has also been implicated in

more than 50% of admissions to a regional secure unit

(McKeown & Liebling 1995, Smith et al. 1994).

Effective management of this condition requires the inte-

gration of specialist mental health and substance use inter-ventions that allow multiple problems to be monitored

and prioritized simultaneously (Osher & Kofoed 1989).

Although some dual diagnosis posts have been established

in the UK, mental health nurses tend to report deficits in

the knowledge and skills necessary to offer an integrated

service (Sandford 1995, McKeown & Liebling 1995).

This paper reports on the preliminary stages of a project

that was initiated to address these challenges within a psy-

chiatric in-patient setting. The scope of the project includes

identification of staff training needs, development of hospi-

tal policy to address substance use and the provision of a

group programme for individuals with a dual diagnosis.

The work has been informed by a research project to iden-

tify the proportion of in-patients known to use drugs or

alcohol and the perceptions of staff regarding dually diag-

nosed patients. The research findings are presented in this

paper.

Method

The study was undertaken in an inner city NHS trust pro-

viding community- and bed-based services to a population

of

47 000. The local community is ethnically very mixedwith high levels of homelessness and social deprivation.

The trust has two acute admission wards with a combined

bed capacity of 38 and a nursing compliment of 32 full-

time equivalents. On average there are 190 acute admis-

sions a year with a mean bed occupancy level of 104%

(excluding extra contractual referrals).

Two instruments were developed for use in the study by

a team of nursing and audit staff. The first, a retrospective

audit tool containing 22 items, gathered the following

patient information from medical and nursing notes:

demographic and diagnostic details; evidence of past drug

or alcohol use from current admission data; contribution

of drug/alcohol use to current admission; and the compli-

cations and management of drug/alcohol use during hospi-

talization. A sample of 20 sets of patient notes were

randomly selected for inclusion in the study.

The second instrument, a semi-structured staff question-

naire containing 16 items, was designed to elicit the fol-

lowing information: demographic and professional details;previous drug work experience and training; perceptions

of dual diagnosis and its management; and the training and

support requirements of staff. The questionnaire was sent

with a covering letter to all multidisciplinary team

members across the two wards including nurses, doctors,

occupational therapists, social workers and psychologists.

An attempt was also made to contact one individual in each

discipline to act as a liaison person who would encourage

completion of the questionnaire. Overall however, the

response rate was poor except from nursing staff (62.5%

response, n 20). This may reflect a more acute awareness

and interest among nurses concerning the problems experi-

enced by dually diagnosed patients. Alternatively, since the

research was a nursing initiative it may simply reflect a

greater willingness to participate.

Findings

Audit data are initially presented followed by results from

staff questionnaires. Because of the low response rate from

most disciplines only nursing data are reported.

Audit results

Thirteen of the patients were men and seven were women,

with a combined mean age of 40 years. Sixteen of the notes

(80%) reported substance use prior to the current admis-

sion. Table 1 presents diagnoses for the 16 patients

together with the categories of drugs used, whether or not

these drugs were considered to have contributed to the

current admission, Mental Health Act status and any

history of violence towards others.

Seven of the patients were known to use illicit sub-

stances, six were using alcohol and three were using both

I. Ryrie & J. McGowan

138 1998 Blackwell Science Ltd,Journal of Psychiatric and Mental Health Nursing5, 137142

Table 1 Patients known to use drugs or alcohol

Drugs used prior Substance use Detained under mental History of

to admission a factor in admission health act violence

diagnosis (n) illegal (n) alcohol (n) (n) (n) (n)

Paranoid psychosis 3 3 2 1 2

Bipolar disorder 4 3 2 2 3 2

Alcohol dependence 2 2 2

Schizophrenia 4 4 2 2 2 2

Aids related psychosis 1 1 1

Psychotic depression 2 2 1

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illicit drugs and alcohol. Although the amount and fre-

quency of use was not documented two patients were

admitted specifically for alcohol dependence and in a

further seven cases drug/alcohol use was considered to

have contributed to admission. Just under half of the

sample (n 7) were detained under the Mental Health Act

and six patients, all of whom were known to use illicit

drugs, had a history of violence towards others.During admission substance use was reported to lead to

management problems in eight patients and was

specifically addressed in the treatment and care plans of 10

patients. The most frequent interventions offered in

descending order were: liaison with specialist services;

detoxification with medication; urinalysis; counselling;

omission of medications; cautioning of patients; and the

instigation of structured patient observation schedules. On

one occasion a patients behaviour required physical

restraint, which was attributed to their drug use. On

another a patient was searched. Prior to admission three

patients received specialist support from drug/alcohol

agencies. In preparation for discharge, specialist aftercare

and support had been secured for five patients.

Four patients were reported to have brought substances

into the ward and on two occasions these had been passed

on to other patients. These activities resulted in staff either

cautioning, counselling or closely observing the patient

and, when appropriate, their visitors. On one occasion

substances were confiscated from the patient.

Questionnaire results

Table 2 presents data on the professional qualifications of

nursing staff, number of years in mental health work, pre-

vious experience in substance use work and whether they

had received training in substance use.

Of the 11 staff who had previous experience in sub-

stance use work seven had acquired this in specialist facili-

ties and four through work on acute psychiatric wards.

Two members of staff had received training in substance

use on specialist courses whilst the remainder had acquired

their knowledge through basic nurse training or as part of

other generic courses. The majority of staff (n 14) had

received no substance use training.

Although three staff felt themselves to be adequately

informed to work in this area all respondents (n 20) rec-

ognized a need for further training. A clear priority was

given to broad-based training programs that would equip

staff with a repertoire of skills and interventions for man-

aging substance use problems. More specifically it was felt

that these should include assessment skills, appropriate

health education information, counselling skills, andknowledge of the interactions between illicit drugs, alcohol

and prescribed medications. Respondents also emphasized

the need for training on the management of intoxicated

individuals that should be underpinned with robust multi-

disciplinary protocols to guide practice.

Substance use among patients was perceived as a

problem by all respondents. The most frequently used sub-

stance was cannabis, followed by alcohol and ampheta-

mines. Ecstasy, LSD, cocaine, heroin, benzodiazepines,

khat (natural/legal stimulant most often sold as twigs

which are chewed) and solvents were also reported but to a

lesser extent. The main consequences of substance use

were reported to be an exacerbation of psychiatric symp-

toms and a protracted recovery rate. The specific symp-

toms that appeared to be most affected included agitation

and aggression, anxiety, social withdrawal, depression and

sleep disturbances. Respondents also reported social prob-

lems including financial, familial and legal, and physical

problems such as neglect, withdrawal symptoms and risk

of HIV or hepatitis infection.

When asked to document the professional issues that

substance use raised in the work setting, of primary

concern was the increased need for risk assessment to gaugethe danger an individual posed to themselves or others.

This was followed by care management difficulties arising

from drugs and alcohol being on the ward and from the

presence of intoxicated individuals. Other important issues

included problems of assessing mental state due to the

effects of drugs, non-compliance with prescribed treatment,

the need to police some patients and their visitors and the

resultant loss of rapport and therapeutic alliance with the

patient. Four respondents felt the problem of substance use

emphasized the inadequacy of their current skills.

Finally, respondents were asked to comment on ways in

which they felt services for this patient group could be

Staff perceptions of substance use

1998 Blackwell Science Ltd,Journal of Psychiatric and Mental Health Nursing5, 137142139

Table 2 Nursing staff

Years in Experience in Training in

mental substance use work substance use work

health work Yes No Yes No

Professional qualification (n) (mean) (n) (n) (n) (n)

Registered Mental Nurse 9 7.5 6 3 4 5

Dip HE (Mental Nursing) 5 1 2 3 1 4

Enrolled Nurse 2 15.5 1 1 2

Health Care Assistant 4 2.25 2 2 1 3

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improved. Many of the issues already presented, such as

staff training and the development of protocols, were

repeated in this section. Additionally, staff emphasized the

need for multidisciplinary commitment through which the

difficulties experienced by nursing staff could be acknowl-

edged and a consistent approach to patient management

exercised across medical teams. It was also suggested that a

specialist team of nurses should be developed to managethis patient group, with designated beds on one of the

wards and with close and consistent relations with the spe-

cialist drug services. This point was underpinned by ques-

tioning the current suitability of generic acute psychiatric

wards for the care of these patients.

The development of education packs for psychiatric

patients that specifically address substance use were con-

sidered desirable, and one respondent felt compulsory

aftercare may prove beneficial.

Discussion

Substance use

The data support clinical impressions and other studies in

finding a high rate of substance use among psychiatric in-

patients (Smith et al. 1994, McKeown & Liebling 1995,

Sandford 1995). Although the sample size was small the

finding that 80% of subjects had used substances prior to

their admission is considerably higher than rates found in

other UK studies (Smith et al. 1994, Menezes et al. 1996).

This difference may be due to a number of possible factors.

No standardized screening criteria were used in this studywhilst other researchers have employed instruments and

methodologies with specific cut-off points for the detection

of problematic drug or alcohol use.

In this study although evidence of substance use was

sought from current admission data it may have occurred

at a much earlier time in the patients life. Similarly, any

evidence of use was documented whilst other researchers

have sought levels of use that equate with diagnostic crite-

ria for abuse or dependence. With these limitations in mind

a more meaningful indicator in this study is the finding that

substance use was considered to have contributed to

admission in nine of the 20 patients. If this figure isadjusted for the two patients admitted with a diagnosis of

alcohol dependence syndrome then the proportion of

patients thought to have used substances immediately prior

to admission is 35% (n 7).

Whilst there is clearly a need for standardized screening

tools among this population, the use of instruments

designed to detect abuse or dependence that have origi-

nally been validated among persons with single disorders is

questionable. Although the relationship between substance

use and psychiatric symptomatology is poorly understood,

evidence suggests illness decompensation may occur fol-

lowing consumption of small amounts of drugs and

alcohol without the development of a full dependence

syndrome (Drake et al. 1990, Lieberman et al. 1990).

Therefore any substance use among psychiatric patients

should be considered potentially harmful and may indicate

disorder in a high proportion of these individuals (Dixonet al. 1993).

The higher rate of use found in this study may also be

attributable to the location within which the sample was

generated. The catchment area of the hospital includes a

part of London known for the sale of illicit substances.

Following evidence in the literature that persons with

severe mental illness may be attracted to substance use in

order to self-medicate or to aid social interactions then the

community within which these patients live offered oppor-

tunities in this respect (Lamb 1982, Dixon et al. 1990).

In addition to alcohol the most commonly reported

illicit substances were cannabis and amphetamines, which

confirms the findings of other studies (McKeown &

Liebling 1995, Sandford 1995, Menezes et al. 1996). Staff

perceptions were also consistent with other studies con-

cerning the consequences of substance use by psychiatric

patients. Exacerbated symptomatology and protracted

recovery rates were predominantly reported. A relation-

ship with specific symptoms such as anxiety, social with-

drawal and depression was emphasized together with the

perception that substance use led to agitation and aggres-

sion. Staff highlighted a number of social sequelae, includ-

ing financial and legal difficulties, that are known tonegatively affect psychiatric symptoms (Johnson et al.

1997). It is also of interest that risk of HIV infection was

raised as an issue by staff since elevated rates of infection

among psychiatric patients have been noted in the litera-

ture (Kelly et al. 1995).

Management

Particular management concerns for staff were the most

appropriate responses to intoxicated individuals and the

presence of substances on the ward which they believed, at

times, were passed on to other patients. These issues presentstaff with a number of difficulties. Whilst an approach in

which patients are regularly searched and their visitors

policed might go some way towards reducing the availabil-

ity of drugs, this is not conducive to the maintenance of a

therapeutic alliance with patients. This clearly presents a

dilemma for staff and one that is not easily reconciled. It is

further exacerbated by a lack of clarity on such issues

within the unit as well as inconsistencies between medical

teams regarding their response. Consequently, nursing



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staff, who are faced with these challenges 24 hours a day,

felt unsupported and unsure of their actions.

Among the interventions offered by staff to manage sub-

stance use was the omission of medications. This would

seem an appropriate response since the mixing of psy-

chotropic medication with an unknown combination of

psychoactive substances is potentially hazardous. However,

since substance use often compromises the protectiveeffects of psychotropic medications (Mueser et al. 1995)

this intervention may go some way to explaining the pro-

tracted recovery rates found among these patients. This

point also makes a strong case for the use of psychosocial

interventions, including the psychological management of

positive symptoms such as delusions and paranoia, to com-

pensate for the vulnerabilities of psychiatric patients.

Staff training and experience in substance use work

Although more than 50% of staff (n 11) had previous

experience in substance use work only two had receivedany specialist training, and all respondents reported an

existing need for training. Given the proportion of patients

who were thought to have used substances, and whose

conditions were complicated by their use, these findings

suggest staff are ill-prepared to offer an adequate response

to patients. This is borne out by the finding that whilst 16

patients were reported to be known users of illicit drugs or

alcohol, specific reference to these problems was evident in

the care plans of only 10 patients.

However, the response by nursing cannot stand alone

from the contribution of other disciplines. This fact washighlighted by respondents who emphasized the need for a

multidisciplinary approach through which treatment pro-

tocols and strategies could be developed to ensure consis-

tency throughout the hospital and between disciplines.

This point echoes recommendations made by McKeown &

Liebling (1995).

The training needs identified by respondents indicate a

desire to develop knowledge and competence in assessment

skills, clinical interventions and management responses.

There was no sense of unwillingness by staff to care for this

client group and several suggestions were made for

improving care, including the development of specialistskills within the team.

Conclusions

The findings from this study broadly reflect existing

research on the use of drugs and alcohol by psychiatric

patients. The phenomenon is not uncommon and may

compromise an individuals health and prolong their expe-

rience of illness. However, deficits in the knowledge and

skills of nursing staff suggest they are currently ill-

equipped to meet the needs of these patients. A lack of con-

sensus between disciplines regarding the management and

treatment of this patient group compounds this problem.

The development of management protocol and ward

policy between disciplines was seen as desirable to limit

the availability and use of substances, and to ensure a con-

sistent response should a patient be found intoxicated orin possession of substances. A consistent management

response is certainly important but will not by itself ensure

effective treatment. Whilst substance use may result in any

number of deleterious consequences for the patient it

should also be recognized that for some their use may give

meaning to their lives, may ameliorate psychiatric symp-

toms and may alleviate the side-effects of psychotropic

medications. Against this backdrop measures to limit the

use of substances within the ward must be combined with

interventions that offer patients alternative strategies to

manage their life problems. The challenge is therefore

significant, requiring the integration of substance use and

acute psychiatry interventions.

In light of this challenge it is encouraging that staff rec-

ognize their current limitations and also express a desire to

develop specialist skills within their teams. Given this will-

ingness a high priority for hospital management should

now be the provision of specialist training and the estab-

lishment of a multidisciplinary working group to develop a

co-ordinated service response.

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