Abstract
There is increasing recognition that problematic drug and alcohol use is highly prevalent among people with major mental illnesses [1, [2]]. North American studies report comorbidity rates of about 50% in psychiatric populations [3, [4]], and recent Australian research has demonstrated a lifetime prevalence of 59.8% for substance use among outpatients with schizophrenia [5]. Comorbidity is associated with poorer patient outcomes including increased frequency of hospitalisation [6, [7], [8], [9]], homelessness [7, [10]] and imprisonment [9].
Comorbidity presents a challenge to mental health professionals in terms of detection, assessment and management. Despite recent research defining the extent of the problem, detection rates remain low [7, [11], [12], [13]]. Over the past decade, there has been e m e rging consensus among clinicians and researchers that the most effective means of addressing comorbidity is through an integrated treatment model. Integration refers to the simultaneous provision of both mental health and drug and alcohol treatment by the same individual, team or organisation [14]. The responsibility of combining mental health and substance use interventions rests with the service provider [15]. The burden of coordinating two disparate treatment systems is thus removed from the patients themselves.
Integration depends on mental health staff possessing both mental health and drug and alcohol knowledge and skills. A number of studies have evaluated the drug and alcohol education and training of health professionals at an undergraduate, postgraduate and continuing education level. Many have medical education as the sole focus and few are specific to mental health staff [16, [17], [18], [19]].
In 1993 the National Centre for Education and Training on Addiction (NCETA) evaluated the drug and alcohol content of Australian tertiary curricula [20]. A remarkable lack of drug and alcohol education was noted in schools of nursing. De Crespigny [16] states that few nurses know how to prevent, recognise, assess and manage alcohol intoxication, withdrawal or regular harmful use. Most are unable to describe basic drug and alcohol information and many are ill-informed about referral services. De Crespigny argues strongly for drug and alcohol issues to be a core area of undergraduate education in nursing and an important part of postgraduate and continuing education for nurses.
According to Glass-Crome [21], medical students receive inadequate training regarding alcohol treatment. Reasons include the low priority given to addictions in time-constrained undergraduate curricula and negative attitudes to outcome. In 1989, Weller et al. [17] surveyed 730 general practitioners in Australia to determine their knowledge, attitudes and beliefs regarding drug and alcohol related health problems. They found knowledge deficits and pessimism among respondents regarding drug and alcohol issues. The authors supported improved drug and alcohol training at the undergraduate level. In a similar survey of 793 primary care physicians in Maryland, USA, Duszynski et al. [18] reported that only 10% of respondents felt strongly confident in screening, counselling and referring patients with drug and alcohol problems. They recommended the development of specific substance abuse education programs as part of primary care physician continuing education.
In one of the few studies with an exclusive mental health focus, Roche et al. [19] conducted a survey of 254 Australian psychiatric trainees to determine their drug and alcohol related knowledge, diagnostic skills and attitudes. Overall, trainees were found to have adequate levels of knowledge and problem-solving abilities, yet few were aware of evidence supporting early intervention and brief advice as an effective form of intervention. The authors urge medical educators to adopt up-to-date, skills-based training strategies. This view is supported by Katz [22] in a recent editorial regarding the ongoing neglect of training in substance disorders for psychiatrists-in-training in the USA.
As part of an ongoing initiative to improve service delivery to patients with comorbid psychotic illness and problematic substance use, Central Sydney Area Health Service (CSAHS) is developing an education program for all mental health staff regarding drug and alcohol problems and comorbidity. Before implementation, it was important to ascertain the existing knowledge, experience and attitudes of mental health staff regarding the assessment and management of patients with problematic substance use. The present survey was conducted in order to provide: (i) directions for education and training; and (ii) a baseline for future evaluations.
Method
Questionnaire
A 47-item questionnaire was developed by the authors and individually posted to 536 community and hospital-based clinical mental health staff employed by CSAHS in November 1997. Each questionnaire was identified with a number so that a second copy of the questionnaire could be sent to staff who had not returned their questionnaires within 4 weeks.
Staff were asked their age, gender, professional designation and most frequent place of work. They were also asked to specify the number of years they had worked in mental health and to describe previous drug and alcohol training and work experience.
Knowledge was assessed by 21 multiple-choice and true/false questions. Eight questions were about alcohol and the remainder covered a range of commonly used drugs, including tobacco. The content was guided by the aims outlined in the Strategic Plan for Nurse Education and Nursing Management of Alcohol and Other Drugs of the New South Wales Drug and Alcohol Directorate 1991 [23]. Questions were concerned primarily with the recognition and management of intoxication, withdrawal and overdose states. Provision was made at all questions for respondents to state that they did not know the answer. Although psychometric testing of the survey instrument was not undertaken, equivocal questions were removed after feedback from two specialists in the drug and alcohol field and a pilot group not sub-sequently surveyed.
Among other questions, respondents were asked to rate their own levels of knowledge and competence when dealing with patients with problematic drug and alcohol use. Five questions explored the respondents' assessment of current service provision and possible additional resources. Attitudes were surveyed in two areas: (i) the role of the mental health professional in the provision of drug and alcohol treatment; and (ii) the willingness of respondents to gain further training in drug and alcohol skills (copy of the questionnaire available on request).
Scoring procedure for actual knowledge
There was no weighting of questions. Correct answers received a single point. Incorrect answers, missing values and answers of ‘don’ t know' were scored as zero. An overall score was then calculated from the sum of all the correct answers.
Scoring procedure for perceived knowledge and competence
Staff were asked to rate how knowledgeable they considered themselves to be in the following areas: the identification of drug and alcohol abuse and dependence; the identification of drug and alcohol withdrawal and drug overdose; the management of detoxification from drugs and alcohol; the ongoing management of drug and alcohol problems; and the management of patients with both a psychotic illness and drug and alcohol problems. A four-point scale of options (very, moderately, only a little, not at all) was provided for staff to tick the statement which, in their opinion, best described their knowledge.
Staff were also asked to indicate how competent they regarded themselves in undertaking the following drug and alcohol interventions: the identification and assessment of drug and alcohol problems; awareness of, and referral to, drug and alcohol services; the management of detoxification and overdose; the provision of brief intervention, motivational interviewing, relapse prevention and ongoing management of drug and alcohol problems. This was scored in the same manner as above.
Internal consistency was high (α == 0.94 for both scales).
Statistical analysis
Most of the data are presented as observed rates. Associations between actual knowledge, self-perceived knowledge and competence were determined by Pearson Correlation coefficients. Analysis of variance tests were used to determine the association between actual knowledge and previous drug and alcohol training and between actual knowledge and drug and alcohol work experience. Categorical variables were examined using chi-squared tests. Strength of association is reported as an odds ratio. Dimensional variables were analysed using t-test (two-sample) or analysis of variance (ANOVA) tests when appropriate. Logistic regression was used in some multivariate analyses. Alpha was set at 0.05.
Methods
Characteristics of respondents
Profile of survey respondents: Central Sydney Area Health Service clinical mentalhealth staff
Patient contact and management
Eighty-five percent of staff reported having contact with patients with both a psychotic illness and problematic drug and/or alcohol use once a month or more; 41% of all respondents reporting daily contact.
Sixty percent of staff felt that the management of this patient group was inadequate. Of those who believed management to be inadequate, the perception across professions was that this happened mainly because patients with comorbid drug and alcohol problems were very difficult to treat (73%). Lack of knowledge was the reason given by only 7% and lack of services by 20%.
Actual knowledge
There was no significant difference in overall knowledge between work sites. In general, questions about alcohol had a higher cumulative rate of correct answers than questions about other drugs. Over 80% of staff were able to correctly describe three symptoms and signs of alcohol intoxication and withdrawal.
Increased knowledge was associated with previous drug and alcohol work experience and even more strongly with previous drug and alcohol training. (F3,327 == 18.7, p < 0.001) Surprisingly, it was not associated with frequent exposure to patients with psychotic illnesses and problematic drug and/or alcohol use.
History-taking
Most staff described taking a comprehensive history always or usually in each of seven different drug and alcohol domains. These were use of tobacco, alcohol, cannabis, amphetamines and benzodiazepines, the use of other drugs (e.g. cocaine, hallucinogens), and abuse of prescription medications. Forty-eight percent of staff stated that they always or usually take a comprehensive history in all seven areas. Greater knowledge increased the likelihood of reporting comprehensive history-taking over and above profession, previous drug and alcohol experience and regular contact with patients with psychotic illness and drug and alcohol problems.
Referral
Close to 40% of respondents stated that they referred patients to drug and alcohol services for advice and/or management once a month or more. Medical staff made referrals more frequently than nursing or allied health staff.
Fifteen percent of staff stated that they referred less than once a month because they managed patients' drug and alcohol problems themselves. Sixteen percent referred less than once a month because they believed their patients were too ill to benefit from drug and alcohol services.
Perceived knowledge and competence
There was a moderate correlation between actual knowledge and self-perceived knowledge (r == 0.50) and between actual knowledge and self-perceived competence (r == 0.47). There was a high correlation between perceived knowledge and perceived competence (r == 0.87). Therefore, those staff who performed better in the actual knowledge section were more likely to believe themselves to be knowledgeable and competent in dealing with drug and alcohol problems.
There was no difference in actual knowledge, perceived competence or perceived knowledge between those staff who found the management of patients with comorbid conditions more difficult than other patients and those staff who found the management no more difficult.
Attitudes
Almost all staff (82%) found dealing with patients with both a psychotic illness and problematic drug and alcohol use moderately or very difficult. Eighty percent felt dealing with this patient group was ‘more difficult’ than dealing with other patients.
Over 80% of staff believed that as mental health professionals they had a role in the assessment and referral of patients with drug and alcohol problems and in educating and providing information to these patients. Seventy-three percent felt that they had a role to play in the management of this patient group. Only 15% stated that they did not see a role for them-selves and 12% were unsure.
Further education
Overall, 95% of staff were willing to spend one hour a month or more on further training regarding patients with both psychotic illness and problematic drug and alcohol use. Only 5% of respondents stated that they were not interested in further training.
Discussion
This survey is one of only a few to have studied the drug and alcohol-related knowledge, experience and attitudes of mental health staff. As far as we are aware, it is unique in surveying a multidisciplinary population.
Analysis of non-respondents was not performed as it was not possible to access employee records. However, as the results were evenly distributed across all sectors and professions, the data can be viewed as reasonably representative of the population surveyed. The multidisciplinary population of this study and the fact that a large proportion of respondents were hospital-based limits the generalis-ability of the results. The response rate of 63% compares favourably with that of other surveys with a drug and alcohol focus [17, [18], [19]].
The majority of staff surveyed indicated they had regular contact with patients with comorbid psychotic illness and drug and alcohol problems. Forty percent reported daily contact. These results were not surprising as a study of 99 patients with schizophrenia conducted in Central Sydney in 1995 found that 58% of subjects aged 18–29 years had had drug or alcohol abuse problems within the 3 months prior to the index admission [24]. As mentioned earlier, a recent study in the Hunter Area Health Service found a 59.8% lifetime prevalence rate for substance abuse or dependence in a sample of 194 outpatients with schizophrenia [5]. These findings are consistent with prevalence rates for psychosis and substance use reported in North American studies [2].
Overall, staff had better knowledge scores when answering questions about alcohol, compared with other drugs. In their survey of psychiatric trainees, Roche et al. [19] found that trainees had better theoretical knowledge of sedative-hypnotics and benzodiazepines compared with alcohol. Theoretical knowledge of opiates was worse than knowledge of alcohol. Specific knowledge deficits should be identified and addressed in future education programs.
Most staff viewed the management of this patient group as inadequate and more difficult than that of other patients. Irrespective of profession, staff who described management as inadequate perceived this to be mainly because the patients with comorbid drug and alcohol problems are difficult to treat. Although arguably true, this finding may reflect a sense of frustration often pervasive among staff who regularly work with this patient group [25]. Recognition and acceptance by staff of the chronic and relapsing nature of both psychotic illnesses and substance use disorders is pivotal to the success of an integrated treatment model [26]. According to Ridgely [27], instead of viewing each relapse as a treatment failure, staff need to learn to look upon each entry into treatment as a ‘window of opportunity’(p.34). This focus reframes apparent treatment failures and can encourage optimism within the staff body.
It is noteworthy that despite these difficulties described above, more than two-thirds of the staff thought that the management of drug and alcohol problems was part of the role of a mental health professional. Even greater numbers of staff believed they had a role to play in assessing and referring, and providing education and information to patients with drug and alcohol problems. These findings are consistent with those of Roche et al. [19], who found that approximately 90% of psychiatric trainees agreed that drug and alcohol problems are an area of responsibility for medical practitioners.
Several commentators have voiced opinions as to whose role it is to provide drug and alcohol management in psychiatric settings. Gafoor and Rassool [28] believe that mental health nurses are best placed to develop effective interventions for patients with both psychotic illnesses and drug and alcohol problems. They point out that nurses may be reluctant to intervene with substance use problems either because they lack knowledge and expertise or because they may have negative attitudes towards substance misusers. They believe there is a pressing need for mental health nurses to develop their knowledge and clinical expertise in substance misuse in order to be able to respond effectively to patients with drug and alcohol problems.
Pols et al. [29] state that psychiatrists have also been reluctant to extend their skills to patients with drug and alcohol problems. They argue that substance use disorders have, are, and always will be, a major area of responsibility for psychiatrists. Although our investigation did not address the question of knowledge-versus experience-based education, we found that, unlike previous drug and alcohol training, increased frequency of exposure to this patient group did not increase actual knowledge. This supports the combined approach of Chappel [30], who advocates that psychiatrists-in-training receive not only adequate education in substance use disorders, but also supervised clinical training in drug and alcohol units. Roche et al. [19] warn that psychiatrists will have little confidence in appropriate therapeutic approaches when treating patients with alcohol and other drug problems unless sufficient training is provided.
The relationship between education, training and confidence is supported by the finding from our survey that increased perceived competence was associated with increased knowledge. In other words, if staff had more knowledge they felt more confident and better equipped to deliver a required intervention. This was also described in a recent study by Graham et al. [30] in which a group of 88 nurses showed a significantly greater increase in knowledge and feelings of competence after participating in an intense drug and alcohol educational workshop, when compared with a control group.
Lastly, we are encouraged that the overwhelming majority of respondents perceive a need for further drug and alcohol education and training. Future evaluation of the education and training program in development will identify and review the outcomes of this program for both staff and patients. Further research needs to better describe the relationship between staff education and training and staff attitudes to substance misuse, and between staff education and training and patient outcomes.
Footnotes
Acknowledgements
This paper was produced as part of the Central Sydney Area Health Service Psychosis and Substance Use (formerly Dual Diagnosis) Project. The authors wish to thank the participating staff of Central Sydney Area Mental Health Services, and Dr Stephen Jurd and Dr Deborah Zador for their comments. Consultation with Mr Martin Evans of the Central Coast Area Health Service and the clerical support of the Central Sydney Area Drug and Alcohol Services is gratefully acknowledged.