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The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical, and psychosocial factors. The assessment, treatment, and aftercare of alcohol-related and other comorbid mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas such as alcohol-related brain damage and drug interactions with alcohol that deserve special attention.
The psychosocial characteristics of older heroin-dependent patients (defined as 45 years and over) attending a specialist addiction clinic in Stoke on Trent, UK were studied using retrospective record analysis of the case notes of the 20 oldest heroin-dependent patients. This study draws attention to the multiple psychosocial problems facing ageing heroin addicts. On average, patients were 48 years old, had first been exposed to heroin at age 29, 85% were injectors and the majority were polydrug users. In 20% a major life event had preceded first use of heroin. Nineteen were male, 17 were single, only 10% were employed, while just 10% did not have a criminal history. Depression, self-harm and memory disturbance were frequently reported. Retention in treatment was a feature, with consequent improvements including reduction in criminality and injecting behaviour. However, there is little specific guidance on treatment, training or policy for this group in the UK.
This chapter outlines the historical background of alcohol problems, current classificatory systems for diagnosis, psychological and physical related disorders, and the epidemiology of alcohol disorders. A variety of research methodologies have been adopted to examine the relative contribution of genetic and environmental factors to alcohol dependence. Explanatory models for age and sex differences in adolescent drug use can be derived from a variety of theories, including social learning theory and social control theory. The general protocol is adapted from that developed for nicotine dependence and is a useful way to formulate the assessment process, because it translates into specific management plans. Psychological treatments are pivotal to treatment effectiveness, even when pharmacological treatments are administered. The relationships between alcoholism and other psychiatric disorders are some times complex, and it is not always easy to achieve abstinence from alcohol to make an adequate assessment of the nature of the relationship.
Summary The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.
In 1980, Robin Murray raised the question ‘Why are the drug companies so disinterested in alcoholism?’ (Murray, 1980). Since then, we have witnessed the evolution of a ‘specialist addiction field’ (Edwards, 2002), including rapid developments in pharmacological treatments for problem use of alcohol, opiates and nicotine. In this review we discuss some of these pharmacological agents and then summarise the evidence on the treatment of combined or coexisting disorders, also described as ‘dual diagnosis’ (e.g. Banerjee et al, 2002; Crawford et al, 2003).
Dual diagnosis: a definition (see also chapter 13)
‘Dual diagnosis’ is one of a number of terms and phrases (Box 12.1) used to refer to people who have coexisting problems of mental disorder and substance misuse (including alcohol, nicotine and illicit drugs). It is also applied to people with two coexisting conditions, for example learning disability and mental disorder (Banerjee et al, 2002), although it does not take that meaning in this chapter.
The group of people with dual diagnosis is heterogeneous, with complex, changing needs. They may have had previous traumatic experiences such as childhood sexual abuse, bullying at school or a broken and dysfunctional family life. Furthermore, mental disorder and substance misuse sit on separate dimensions, each with its own continuum of severity. ‘Dual diagnosis’ covers someone with bipolar disorder who is also alcohol dependent, and someone who has schizophrenia and smokes cannabis a few times a week. As a result of this complexity, numerous operational definitions may be applied in different clinical and social settings, thus complicating and confusing communication.
This review focuses on screening and assessment in general psychiatric settings, where drug use is unlikely to be known to service providers. It builds on the recurrent finding that psychiatric patients are at high risk of substance misuse. The application of self-report questionnaires and rating scales and more in-depth assessment instruments is outlined, as are biological screening techniques. The use of brief self-completion questionnaires probably offers the most practical approach to routine screening by non-specialist staff in general hospital settings. The importance of implementing such tools lies in reaching an accurate diagnosis, choosing treatments more appropriately and monitoring the management of patients' psychiatric disorders.
The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.
It is not easy to establish with any confidence the prevalence of drug misuse in older people. The issue is confounded by variations in definition of what constitutes ‘elderly’ and ‘drug misuse’, and by the types of sample used (Tables 1 and 2). There are few large-scale studies in the UK, and much of the information has been extrapolated from the American findings. The available information can be organized into four main areas: