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Substance Misuse and
Mental Health
Manchester Mental Health &
Social Care Trust
1
Aims & Objectives
Aims: To raise awareness of issues of
drug use and SMI on 1st onset
psychosis
Objectives: To introduce –
 Different drugs and their effects
 How drugs interact with psychosis
 How this affects young people with a
vulnerability to psychosis
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Group Exercise
As a large group, list all the drugs, legal
or otherwise that you are aware of.
Discuss what kind of drugs they are and
how they affect people
Consider specifically how these effects
might be similar to, or might affect,
psychotic symptoms
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Depressants
Alcohol
Benzodiazepines
Solvents and gases
GHB (gammahydroxybutyrate)
4
Effects of Depressants
Relieves tension and anxiety
Impairs the efficiency of mental and physical
functioning
Decreases self control
Causes ‘drunkenness’ behaviour and
aggression
Causes drowsiness, sleep and in some cases
unconsciousness
Tolerance to these drugs is often developed
causing a physical dependence - alcohol
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Drugs that reduce pain
Opiates – heroin , morphine , opium
Opioids - codeine
Narcotic Analgesics - percadine
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Effects of Opiates
Reduces sensitivity to and the
emotional reaction of pain
Induces a feeling of warmth and
contentment
Higher doses can cause sedation,
stupor, sleep and unconsciousness
Tolerance and physical dependence can
be caused with repeated doses
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Stimulants
Amphetamines
Cocaine
Caffeine
Tobacco
Anabolic Steroids
Alkyl Nitrates
Hallucinogenic amphetamines (Ecstasy)
Khat
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Effects of Stimulants
Increased alertness
Diminished fatigue
Delays sleep
Increases the perceived ability to perform
physical tasks
Nervousness and anxiety (except tobacco)
Temporary psychotic states (except tobacco
and caffeine)
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Idiosyncratic effects
Anabolic steroids
Amyl Nitrates
 Increased aggression and
sex drive
 Diminished sexual
characteristics in both men
and women
 Rushing effect as blood
vessels dilate
 Headaches, vomiting
 Excessive use leads to
severe vomiting and
unconsciousness causing
fatalities
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Idiosyncratic Effects
Hallucinogenic
Amphetamines – ‘E’
 Feelings of empathy
with others
 Some forms – mild
hallucinations /
visual distortions
 Increased energy
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Drugs that alter
perception
LSD
Hallucinogenic mushrooms
Cannabis
DMT
Ketamine
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Effects of LSD,
Mushrooms, Cannabis
Heightened sensory experiences
Elevation of mood
Minimal risk of physical dependency
Pseudo hallucinations
Relaxation, drowsiness (cannabis)
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Cannabis & psychosis
People with a vulnerability to psychosis can
be extremely sensitive to the effects of
cannabis
Many young people smoke cannabis. Peer
pressure means that it is often difficult for
someone to refuse it when offered despite
knowing that it makes them feel paranoid etc
The links between cannabis and psychosis
are still being explored but some studies
seem to show a correlation, especially if
started at an early age
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Effects of DMT
Short lived 30-60 minutes
- intoxication
- hallucinations
- disorientated or anxious
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Effects of Ketamine
Exhilaration
Nausea
Numbness
Visual distortions
Strong doses >hallucinations / unconsciousness
Anxiety
Muscle spasms
Paranoia
Inability to feel / avoid pain
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Standardised Classification of
Schizophrenia
Hearing voices spoken aloud
Third person hallucinations
Hallucinations in the form of commentary
Somatic delusions
Thought Withdrawal of insertion
Thought Broadcasting
Delusional Perception
Feelings or actions experienced as made or
influenced by others
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Stress-vulnerability
Model
(Zubin and Spring, 1977)
Unwell
Stress
Well
Vulnerability
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The Stress-vulnerability Model
(Brabban & Turkington 2002)
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The ‘super-sensitivity’
model
Some people seem to be ‘super-sensitive’ to
the effects of different types of drugs (think of
examples among your own friends!)
For some, this sensitivity manifests itself in
the development of psychotic symptoms
(Holland 2002)
Even quite small amounts of substances can
have significant effects on some people
This ‘super-sensitivity’ can be very harmful for
them and upsetting for their families
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Stress Vulnerability
• Focuses on the existing levels of
vulnerability to psychosis
• Symptoms may be exacerbated by
either general stress and/or acute stress
• Increase in symptoms is likely to impact
on a number of areas: personal, social
and family
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Group Exercise
Within your groups using the case
study provided
Identify the stresses likely to be
exacerbating Sue's symptoms.
List these and then feed back as a large
group
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Problems in Defining
Dual Diagnosis
Medicalisation of human activity
Imprecise term
Encourages pessimistic prognoses
Used to describe other co-morbidity
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Prevalence
74.5% of users of drug services and 85.5% of users
of alcohol services experience mental health
problems
67.6% of drug treatment users and 80.6% of alcohol
treatment users had depression and/or anxiety
26.9% of drug treatment users and 46.8% of alcohol
treatment users suffered from severe depression
The figures are 19% and 32.3% for severe anxiety
7.9% of drug treatment users and 19.4% of alcohol
treatment users have a psychosis
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‘Dual diagnosis’
& Young People
Young people are more likely to be
exposed to drug use by their peers
Late adolescence is a time of changing
stress for everyone
We also know that late adolescence is a
high risk time for psychosis
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‘Dual Diagnosis’ &
Young People
Some studies have shown a link
between cannabis use and psychosis,
though this is a controversial area
(Arseneault et al 2004)
Helping young people with a
vulnerability to psychosis to make
informed decisions about their drug use
can be very helpful in controlling illness
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Detection of Substance
Misuse
The cost of non detection
Misdiagnosis
 Missed opportunity to engage
 Suboptimal pharmocotherapy
 Missed detoxification/rehabilitation
 Inappropriate referral

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Harmful Events and
Outcomes
SUBSTANCE MISUSE
HIV, Hepatitis B and C
Acquisitive crime
Non-acquisitive crime
Poorer general health
Lowering socioeconomic status
SERIOUS MENTAL ILLNESS
Significant levels of mental
impairment / distress
Poorer general health
Lower socio-economic status
Poor social function and
integration
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Harmful Events & Outcomes
in Dual Diagnosis
COMBINED CONDITIONS
HIV, Hepatitis B and C infection
Acquisitive / non acquisitive crime
Markedly poor general health
Markedly poor social and economic
standing
Markedly impaired mental health
Significant isolation from sources of
support
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Group Exercise
In small groups try to identify the
potential harm or risks that might be
associated with Sue’s substance use
Discuss these as large group
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Detection of Substance
Misuse
Aim is to identify



Substance Dependence
Substance Abuse
Harmful effects of Substance Use
Difficulties in detection/assessment




Concealment/poor eliciting
Intoxication mimics psychosis
Minimisation by staff and clients
Communication and perceptual disturbance
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Those who are most at risk !
Young males
Family history of substance use disorder
Homelessness
Disruptive behaviour
Isolation and poor familial relationships
Repeated hospitalisation
Legal problems
Physical presentation
At risk occupations
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Assessment
Screening - CAGE,MAST, DAST,
Self report
Reports from carers, family and friends
Observation -behaviour and physical,
mental state
Triggers, effects and consequences
Social function (Mueser et al 1995)
SATS – to measure willingness to change
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Focus on
Nature of problematic use
Factors associated with maintenance of
problematic substance using behaviours
Attitude towards substance use and
treatment
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Assessment Focus
Description

times, duration, frequency,quantity, severity of
effects, developmental use history
Psychological

relaxed, excited, psychosis
Physiological

tolerance, dependency, withdrawal,
Cognitive

positive and negative drug expectancies
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Assessment Focus
Behavioural

interpersonal coping strategies, communication
Environmental

social context of use, peer pressure
Clients’ level of motivation
Clients’ participation in treatment

past or present
Conditions associated with problematic use
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Group Exercise
Identify the questions you would ask
Sue and those who are close to her to
assess her substance use
Write these down and share with the
large group
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STAGE
DEFINITION
GOAL
Engagement
Client does not have regular
contact with clinician
To establish a working goal with
the client
Persuasion
Client has regular contact with
clinician, but does not want to
work on reducing substance
use
To develop the client's awareness
that substance use is a problem
and generate motivation to
change
Active
Treatment
Client is motivated to reduce
substance use as indicated by
reduction in substance use for
at least 1 month but less than
6
To help the client further reduce
substance use and, if possible,
attain abstinence
Relapse
Prevention
Client has not experienced
problems related to substance
use for at least 6 months (or is
abstinent)
To maintain awareness that
relapse could happen and to
extend recovery to other areas
e.g., social, relationships, work)
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Model of change
(Prochaska and DiClemente 1982)
Stability
Keeping it going
Making
changes
Planning change
Relapse
Thinking about change
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Not thinking about change
Motivational Interviewing
The Client Stage & Therapist Task
Not thinking about change (Precontemplation)
Be empathic
Raise the issue - record, monitor
Increase the clients perception of risks and
problems (pros and cons)
Provide information (leaflets etc)
Education about illness and management
Convince client that clinician has something to
offer - instil hope
Help resolve a pressing problem
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Motivational Interviewing
The Client Stage & Therapist Task
Thinking about Change (Contemplation)
Tip the balance - (Pros and cons)
Provide information
Monitoring (Keep diary)
Evoke reasons to change, risks of not changing;
strengthen the clients self efficacy for change of
current behaviour
Consider barriers to change
Educate about effects of substance misuse on mental
illness
Explore how substance abuse may interfere with
meeting other goals
41
Motivational Interviewing
The Client Stage & Therapist Task
Preparing to Change (Preparation)
Help client set goals
Action Planning
Explore barriers
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Motivational Interviewing
The Client Stage & Therapist Task
Making changes (Action)
Encourage and support is essential
Developing the use of problem solving such
as:
 Refusing offers to use substances
 Avoiding high risk situations
 Developing alternative leisure activities
 Structuring daily time
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Motivational Interviewing
The Client Stage & Therapist Task
Keeping it Going (Maintenance)
Encourage the evaluation of the decision to change
Review progress made by young person and risk
factors associated with relapse of substance misuse
Diary
Rewards
Identification of High risk situations and solutions
Help enhance other areas of clients functioning relationship skills, work or education, self care,
independent living skills, leisure activities
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Motivational Interviewing
The Client Stage & Therapist Task
Relapse
Re-engage
Review pro’s and con’s of change
Support
Explore options
Review goals
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Group Exercise
Identify which stage Sue is at using the
model depicting the cycle of change
Which behaviours have assisted you to
come to this conclusion?
Which interventions would you engage
Sue in at this stage?
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Conclusion
Drugs and alcohol are freely available and
often used by young people
Effects on people with vulnerability to
psychosis can be profound (super-sensitivity
model)
However, if the young person decides to
control their drug/alcohol use, their mental
health can improve.
There are ways of working with them that can
support them
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