Key priorities for implementation

Key priorities for implementation

Working with adults and young people with psychosis and coexisting substance misuse

  • When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:

    • stigma and discrimination are associated with both psychosis and substance misuse

    • some people will try to conceal either one or both of their conditions

    • many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

Recognition of psychosis with coexisting substance misuse in adults and young people

  • Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. If the person has used substances ask them about all of the following:

    • particular substance(s) used

    • quantity, frequency and pattern of use

    • route of administration

    • duration of current level of use.

In addition, conduct an assessment of dependency (see Drug misuse: opioid detoxification [NICE clinical guideline 52] and Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence [NICE clinical guideline 115]) and also seek corroborative evidence from families, carers or significant others[2], where this is possible and permission is given.

Secondary care mental health services

Competence

  • Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

Pathways into care

  • Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse.

  • Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate substance misuse services because of a diagnosis of psychosis.

Coordinating care

  • Consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams, and known to be:

    • severely dependent on alcohol or

    • dependent on both alcohol and benzodiazepines or

    • dependent on opioids and/or cocaine or crack cocaine.

      Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

Substance misuse services

Competence

  • Healthcare professionals in substance misuse services should be competent to:

    • recognise the signs and symptoms of psychosis

    • undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services.

Inpatient mental health services

Substance misuse

  • All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others[2]. These should include: search procedures, visiting arrangements, planning and reviewing leave, drug and alcohol testing, disposal of legal and illicit substances, and other security measures. Soon after admission, provide all service users, and their families, carers or significant others[2], with information about the policies and procedures.

Specific issues for young people with psychosis and coexisting substance misuse

Assessment and treatment

  • Those providing and commissioning services should ensure that:

    • age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse and

    • transition arrangements to adult mental health services are in place where appropriate.



[2] 'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

  • National Institute for Health and Care Excellence (NICE)