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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.
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.
Substance use and misuse are best viewed through the framework of a multifactorial biopsychosocial model, which acknowledges the interplay of genetic, familial, physiological, psychological and social factors. Age, role, gender, social group and peer pressure, the family, community and occupational environment, as well as overall cultural values and controls on substance use, will act upon substance-taking behaviour.
Substance misuse in the elderly population has been referred to as a silent epidemic. One of the factors that contributes to the appropriateness of this description is the difficulty of diagnosis in this age group. There is abundant evidence that substance misuse is under-diagnosed in elderly people and that this applies to both alcohol and drug misuse, although the general principles of a diagnostic approach are not age-related. The increased incidence of anxiety, depression, dementing illness, and physical illness in this population, independent of substance misuse, means that diagnoses can often be missed. The impact of co-morbidity (Figure 1) in older age groups is such that it remains the most important confounding factor in diagnosis. In this second section of the review we explore the range of psychiatric and physical illnesses that can coexist with, or be caused by, substance misuse in the elderly population. The issue of assessment as part of a treatment framework is considered in the third section of the review. The risk of missed diagnosis in this age group was illustrated in a study of diagnosis of substance misuse problems in patients aged 65 and over who had been admitted to hospital. Only three out of a total of 88 patients using benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were correctly identified. Of those who were identified only a small proportion were referred on for specialist treatment.
This review is the first in a three-part series on substance problems in older people. This section reviews terminology, epidemiology, outcome studies and policy directions. Subsequent articles will provide an overview of assessment, physical and psychological co-morbidity, as well as treatment options.
Historically, relationships with mental health professionals working in Russia have been difficult to sustain due to problems with access and perceived human rights infringements that existed earlier (Poloahij, 2001). This has resulted in many Russian psychiatric institutions having little opportunity to collaborate in international research or to take part in exchanges of information on service development. However, with the dissolution of the Soviet Union in 1991, Russia has been brought back into spheres of international cooperation in healthcare.
Managing drug misuse is a challenge to health care workers because of the social, psychological and physical factors that contribute to drug use. Multi-disciplinary working beyond routine discharge and referral letter has been recommended but no single model of shared-care will be appropriate for all situations. We developed an innovative approach to collaborative working between agencies, which led to early access to treatment of people who misuse drugs and their greater satisfaction with the care provided. This seamless approach to sharing assessment data is reported in this article. It offers a model of ‘shared-care’, which improves services for people who misuse drugs, within current resource levels.
Case registers have very little to do with computers or any other form of mechanical calculating machine. To write an article on case registers which concentrated on information technology would be as logical as an article on open heart surgery which confined itself to the finer points of scalpel technology. The creation of a case register is as simple or as complicated as the clinician wishes it to be; a case register at its purest is simply a list of contacts with patients, organised to a predetermined format, which allows the clinician to gain information from the list for education, research, planning or administration. The work needed to establish a case register, however, should not be underestimated, and the time spent in thinking through reasons for development of a register is a worthwhile investment. An understanding of the history of the development of psychiatric case registers may help those wishing to develop new registers to avoid treading well worn cul-de-sacs, while reviewing some of the work which has resulted from case registers may demonstrate the enormous potential of a well-designed register in facilitating the extension of knowledge about treatment and provision of services.