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 who
represent 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 with
poor medication compliance, higher levels of positive
symptoms, including delusions and paranoia, signicant
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 identied
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 . RYRI E
1
B S C Di p N RMN & J . Mc GOWAN
2
Di p HE ( Me nt al Nur s i ng)
1
Lecturer in Mental Health Nursing, Kings College, University of London, Cornwall House, London and
2
Staff
Nurse, The Bethlam and Maudsley NHS Trust, Denmark Hill, London
RYRIE I. & McGOWAN J. (1998) Journal of Psychiatric and Mental Health Nursing 5,
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 audit
of patient notes and the administration of a questionnaire to nursing staff. The ndings
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 ndings 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 House
London SE1
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 decits 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
identication 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 ndings 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 mixed
with 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 rst, 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 reect 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 reect 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 Nursing 5, 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
illicit drugs and alcohol. Although the amount and fre-
quency of use was not documented two patients were
admitted specically 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
specically addressed in the treatment and care plans of 10
patients. The most frequent interventions offered in
descending order were: liaison with specialist services;
detoxication 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 ve 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 conscated from the patient.
Questionnaire results
Table 2 presents data on the professional qualications 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 specically it was felt
that these should include assessment skills, appropriate
health education information, counselling skills, and
knowledge 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 specic 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 nancial, 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 gauge
the danger an individual posed to themselves or others.
This was followed by care management difculties 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 Nursing 5, 137142 139
Table 2 Nursing staff
Years in Experience in Training in
mental substance use work substance use work
health work Yes No Yes No
Professional qualication (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
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
difculties 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 manage
this 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 specically address substance use were con-
sidered desirable, and one respondent felt compulsory
aftercare may prove benecial.
Discussion
Substance use
The data support clinical impressions and other studies in
nding 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
nding 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 study
whilst other researchers have employed instruments and
methodologies with specic 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 nding that
substance use was considered to have contributed to
admission in nine of the 20 patients. If this gure is
adjusted 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 (Dixon
et 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
conrms the ndings 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 specic 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 nancial and legal difculties, that are known to
negatively 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 present
staff with a number of difculties. 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
I. Ryrie & J. McGowan
140 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 137142
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 protective
effects 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 received
any 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 ndings
suggest staff are ill-prepared to offer an adequate response
to patients. This is borne out by the nding that whilst 16
patients were reported to be known users of illicit drugs or
alcohol, specic 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 was
highlighted 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 identied 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 specialist
skills within the team.
Conclusions
The ndings from this study broadly reect 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, decits 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 or
in 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
signicant, 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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