Medically assisted alcohol withdrawal (MAAW) is increasingly undertaken on acute adult psychiatric wards.

Comparison of the quality of MAAW between acute adult wards and specialist addictions units in mental health services.

Clinical audit conducted by the Prescribing Observatory for Mental Health (POMH). Information on MAAW was collected from clinical records using a bespoke data collection tool.

Forty-five National Health Service (NHS) mental health trusts/healthcare organisations submitted data relating to the treatment of 908 patients undergoing MAAW on an acute adult ward or psychiatric intensive care unit (PICU) and 347 admitted to a specialist NHS addictions unit. MAAW had been overseen by an addiction specialist in 33 (4%) of the patients on an acute adult ward/PICU. A comprehensive alcohol history, measurement of breath alcohol, full screening for Wernicke's encephalopathy, use of parenteral thiamine, prescription of medications for relapse prevention (such as acamprosate) and referral for specialist continuing care of alcohol-related problems following discharge were all more commonly documented when care was provided on a specialist unit or when there was specialist addictions management on an acute ward.

The findings suggest that the quality of care provided for medically assisted withdrawal from alcohol, including the use of evidence-based interventions, is better when clinicians with specialist addictions training are involved. This has implications for future quality improvement in the provision of MAAW in acute adult mental health settings.

Input from Assertive Alcohol Outreach Teams (AAOTs) reduces the ‘burden’ on already overstretched community mental health teams (CMHTs).

AAOTs are specialist addictions services. This project focuses on an AAOT based in the London, which engages with people with severe alcohol and illicit substance misuse problems.

Previous research has shown that input from AAOTs reduces hospital admissions. This project examined the impact of AAOT input on reducing the ‘burden’ on CMHTs.

The full caseload of the Southwark-based AAOT was reviewed, including mental health records, general practitioner notes, hospital notes and discharge summaries. We collected data on diagnoses and previous hospital admissions. Patients were assessed to determine whether they met criteria to be open to a CMHT (the presence of complex or serious mental health problems, in addition to addictions).

The caseload was made up of 39 patients, 85% of patients were deemed to meet criteria for being under the care of a CMHT. Only 15% of patients are currently under the care of a CMHT. 87% of patients had at least one comorbid psychiatric diagnosis. 72% of patients had had at least one emergency department or medical hospital admission due to mental health-related problems. 39% had previous admissions to mental health wards. 21% of patients has been admitted under Section of Mental Health Act.

The majority of AAOT patients have severe mental health problems in addition to addictions. The patients are complex and often have a history of disengagement from standard mental health services. Formal diagnosis and treatment of comorbid mental health problems is challenging in the presence of protracted drug and alcohol misuse. AAOT input appears to address a serious ‘gap’ in supporting patients with complex mental health needs who are often ineligible for CMHT input or disengage from CMHT support.

Since 2012 England has seen year-on-year reductions in people accessing specialist community alcohol treatment, and year-on-year increases in alcohol-related hospital admissions.

We examined perceived barriers to accessing specialist treatment, and perceived reasons behind hospital admission increases.

We conducted focus groups (n = 4) with service users and semi-structured interviews (n = 16) with service providers and service commissioners at four specialist community alcohol services in England, which experience either high or low rates of alcohol dependence prevalence and treatment access. Themes and subthemes were generated deductively drawing upon Rhodes’ risk environment thesis. Data were organised using the framework approach.

Data reveal a treatment sector profoundly affected at all levels by changes implemented in the Health and Social Care Act (HSCA) 2012. Substantial barriers to access exist, even in services with high access rates. Concerns regarding funding cuts and recommissioning processes are at the forefront of providers’ and commissioners’ minds. The lack of cohesion between community and hospital alcohol services, where hospital services exist, has potentially created an environment enabling the reduced numbers of people accessing specialist treatment.

Our study reveals a treatment sector struggling with a multitude of problems; these pervade despite enaction of the HSCA, and are present at the national, service provider and individual service level. Although we acknowledge the problems are varied and multifaceted, their existence is echoed by the united voices of service users, service providers and service commissioners.

Screening for alcohol use disorders identifies a wide range of needs, varying from hazardous and harmful drinking to alcohol dependence. Stepped care offers a potentially resource-efficient way of meeting these needs, but requires evaluation in a randomised controlled trial.

To evaluate the feasibility, effectiveness and cost-effectiveness of opportunistic screening and a stepped care intervention in primary care.

A total of 1794 male primary care attendees at six practices in South Wales were screened using the Alcohol Use Disorders Identification Test (AUDIT). Of these, 112 participants who scored 8 or more on the AUDIT and who consented to enter the study were randomised to receive either 5 minutes of minimal intervention delivered by a practice nurse (control group) or stepped care intervention consisting of three successive steps (intervention group): a single session of behaviour change counselling delivered by a practice nurse; four 50-minute sessions of motivational enhancement therapy delivered by a trained alcohol counsellor; and referral to a community alcohol treatment agency.

Both groups reduced alcohol consumption 6 months after randomisation with a greater, although not significant, improvement for the stepped care intervention. Motivation to change was greater following the stepped care intervention. The stepped care intervention resulted in greater cost savings compared with the minimal intervention.

Stepped care was feasible to implement in the primary care setting and resulted in greater cost savings compared with minimal intervention.

Alcohol misuse is a risk factor in suicide and parasuicide.

To measure the prevalence of alcohol use disorders in a cohort of psychiatric admissions using the Alcohol Use Disorders Identification Test (AUDIT), and the relationship between the AUDIT score and suicidality.

Consecutive psychiatric admissions were interviewed with a lifestyle survey that included the AUDIT, and admission case notes were reviewed.

Out of 200 subjects, 48.5% scored 8 or more (indicating hazardous or harmful alcohol use) and 22.5% scored 16 or more (indicating significant alcohol dependence) on the AUDIT. There were no significant gender differences. Alcohol misuse was strongly associated with suicidality.

The AUDIT questionnaire should be incorporated into psychiatric assessments when risk of self-harm is being evaluated. Further research is warranted to examine the impact of interventions for alcohol use disorders in psychiatric settings on self-harm and suicidal ideation.

There is evidence that people with a history of sexual abuse may have an increased risk of developing alcohol and drug problems.

A self-completion sexual abuse questionnaire was designed and administered to a sample of attenders at three London alcohol services. Drinking behaviour was assessed using the Severity of Alcohol Dependence Questionnaire and the Alcohol Problems Questionnaire, and additional data were derived from case notes.

Fifty-four per cent of women and 24% of men identified themselves as victims of sexual abuse or assault. For the majority this had started before the age of 16 and involved non-relatives. Subjects with a history of sexual abuse were younger, reached drinking milestones earlier, were more likely to have a family history of alcohol misuse and had more alcohol-related problems than non-abused subjects. Sexual abuse, age and alcohol dependence predicted level of problems in a regression analysis.

The high rates of sexual abuse and its association with indications of increased morbidity suggest it is an important issue for the management of alcohol problems. More use could be made of self-completion questionnaires for the investigation of sexual abuse.