Quality statement 1: Initial identification of coexisting substance misuse

Quality statement

People aged 14 and over with suspected or confirmed severe mental illness are asked about their use of alcohol and drugs.

Rationale

People who have severe mental illness and substance misuse have significantly poorer outcomes than people who have either severe mental illness or substance misuse alone. Identifying substance misuse as soon as possible, by asking people about it when they attend services, such as child and adolescent mental health services (CAMHS), mental health services, emergency departments, general practice and services within the criminal justice system, gives a better chance of tailored care and treatment plans being effective. Initial identification and subsequent comprehensive assessment also help to reduce the risk of worsening psychiatric symptoms and homelessness, to reduce contact with the criminal justice system and to improve physical health.

Quality measures

Structure

Evidence of local arrangements to ensure that people aged 14 and over with suspected or confirmed severe mental illness are routinely asked about substance misuse.

Data source: Local data collection, for example, written clinical protocols to ensure people aged 14 and over with suspected or confirmed severe mental illness are asked routinely, and at least every 12 months, about substance misuse.

Process

a) Proportion of people aged 14 and over with suspected severe mental illness who are asked about their use of alcohol and drugs.

Numerator – the number in the denominator who are asked about their use of alcohol and drugs.

Denominator – the number of people aged 14 and over with suspected severe mental illness.

Data source: Local data collection, for example, audits of patient records

b) Proportion of people aged 14 and over with confirmed severe mental illness who are asked about their use of alcohol and drugs.

Numerator – the number in the denominator who are asked about their use of alcohol and drugs.

Denominator – the number of people aged 14 and over with confirmed severe mental illness.

Data source: Local data collection, for example, audits of patient records. The number of people with psychosis in the community and in secondary care who had their alcohol and substance misuse recorded in the preceding 12 months for 2017/18 was collected by the National Clinical Audit of Psychosis. The Indicators no longer in Quality Outcomes Framework (INLIQ) extraction for 2019/20 will include the number of people with schizophrenia, bipolar affective disorder and other psychoses who had a record of alcohol consumption in the preceding 12 months (Former Quality Outcomes Framework indicator MH007. Data available for previous years from NHS Digital.) 

Outcome

Incidence of people aged 14 and over with severe mental illness newly identified as having coexisting substance misuse.

Data source: Local data collection, for example, audit of patient records and referrals.

What the quality statement means for different audiences

Service providers (such as general practices, emergency departments and mental health services, including CAMHS and services provided within the criminal justice system) ensure that people aged 14 and over with suspected or confirmed severe mental illness are asked about coexisting substance misuse. Services ensure that all staff are trained to discuss this sensitively so that people do not feel judged or stigmatised and can be honest in their responses.

Healthcare practitioners (such as GPs and practice nurses, accident and emergency practitioners and mental health professionals, including those working in CAMHS and services within the criminal justice system) ask people aged 14 and over with suspected or confirmed severe mental illness about substance misuse. The level of the discussion should be appropriate to the setting (for example, a more detailed discussion is likely in a mental health service). Practitioners should be sensitive and bear in mind that people may not wish to divulge all the details of substance use, perhaps because of stigma or the requirements of probation terms.

Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services in which people aged 14 and over with suspected or confirmed severe mental illness are asked about coexisting substance misuse. They monitor whether the services they commission have effective joint working arrangements to provide care and support for people with coexisting severe mental illness and substance misuse.

People aged 14 and over with suspected or confirmed severe mental illness are asked whether they drink alcohol or use drugs (prescription and non-prescription). If alcohol or drugs are affecting their physical and mental health or relationships, or might do in the future, they are offered help and support.

Definitions of terms used in this quality statement

Severe mental illness

Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Asking about use of alcohol and drugs

Healthcare professionals routinely ask people about their use of alcohol and prescribed and non-prescribed (including illicit) drugs (examples of drugs used include illegal drugs such as cannabis, cocaine, crack cocaine and heroin, prescribed drugs that have not been prescribed to the person using them or are not taken in the way that was intended such as diazepam and 'over-the-counter' medicines that can be bought from the chemist such as codeine linctus). People are also asked about their use of new psychoactive substances. The level of detail obtained depends on the setting and how much information the person wishes to provide at that time.

Where possible, the person should be asked about all of the following:

  • particular substance(s) used

  • quantity, frequency and pattern of use

  • route of administration

  • duration of current level of use.

Healthcare professionals should also seek corroborative evidence from families, carers or significant others (a partner, friends or anyone important to the person), where this is possible and permission is given.

[Adapted from NICE's guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings, information for the public, recommendation 1.2.1 and expert opinion]

Substance misuse

Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Equality and diversity considerations

The symptoms of severe mental illness can be different in young people than in adults. Mental health and substance misuse professionals need to take this into account when working with young people and should be aware that young people may present with quite subtle manifestations of mental illness. Professionals working with young people, for example, in the criminal justice system or substance misuse services, should have access to advice from a CAMHS team.

Coexisting severe mental illness and substance misuse can occur in older people but there are often misconceptions that this is an issue for younger people. Older people should be asked about substance misuse when they present to services.