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Prevalence and severity of
substance misuse among
referrals to a local forensic
service
Sarah Isherwood & Deborah Brooke
Published online: 09 Dec 2010.
To cite this article: Sarah Isherwood & Deborah Brooke (2001) Prevalence and
severity of substance misuse among referrals to a local forensic service, The
Journal of Forensic Psychiatry, 12:2, 446-454, DOI: 10.1080/09585180110057154
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The Journal of Forensic Psychiatry Vol 12 No 2 September 2001 446–454
Prevalence and severity of
substance misuse among
referrals to a local forensic
service
SARAH ISHERWOOD and DEBORAH BROOKE
ABSTRACT Substance misuse is frequently present alongside mental illness
and personality disorder, complicating all aspects of management. We describe
self-reported levels of substance misuse in referrals to a forensic psychiatry
service, to establish degrees of dependency and co-morbidity with other diag-
nostic categories and to report the implications for treatment. There were 146
(
70%) of 209 consecutive referrals who completed a semi-structured question-
naire, including the Alcohol Use Disorders Identification Test (AUDIT),
Severity of Alcohol Dependency Questionnaire (SADQ), Alcohol Problem
Questionnaire (APQ) and, for frequent users of opiates or stimulants, the
Severity of Dependence Scales (SDS). Psychiatric diagnoses were made from
clinical assessment using the International ClassiŽcation of Diseases (World
Health Organization, 1992). ICD-10 diagnoses of substance misuse were found
in 83 (57%) subjects. A combination of mental illness and a substance misuse
diagnosis was found in 54 (37%). The subgroup accepted into forensic psychi-
atric services was found to have higher levels of co-morbidity, although levels
of dependency were low. Forensic services need expertise in assessing drug-
related morbidity; in motivational interviewing and other techniques for
encouraging change; and in consolidating recovery.
Keywords: substance misuse, co-morbidity, severity of dependency,
inpatient management
The Journal of Forensic Psychiatry
ISSN 0958-5184print/ISSN 1469-9478 online © 2001Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/0958518011005715 4

SUBSTANCE ABUSE 447
Rates of substance misuse are known to be increasing generally (Home
OfŽce, 1997). Although comparison between studies is difŽcult as different
criteria for substance misuse have been used, in adults with a psychotic illness
in the community the prevalence has been estimated at 11% for drinking over
the recommended limits and 11% for using any illicit drug (Foster et al.,
1996). In adults presenting with the Žrst episode of psychosis the prevalence
of substance misuse is 37% (Cantwell et al., 1999). In prison populations,
Gunn et al. (1991) gave an estimate of 23% for substance misuse (ICD-9)
among sentenced prisoners, and studies among remanded prisoners suggest
that about one-third have harmful use or dependence (Brooke et al., 1996:
Mason et al., 1997).
This survey examined the extent and severity of drug and alcohol misuse
among patients referred to a forensic psychiatry service in south-east
London. We describe the implications for forensic psychiatry services.
METHOD
Data were collected at a semi-structured interview on all consenting consec-
utive referrals over a 5-month period. The Žrst section of the questionnaire
collected demographic details, source and reason for referral, the charge or
conviction, and details of contact in the last year with substance misuse
services and any previous psychiatric contact. The diagnosis and clinical
recommendation from the accompanying clinical assessment was recorded.
In the second part of the questionnaire, all subjects completed an alcohol-
screening questionnaire, the Alcohol Use Disorders IdentiŽcation Test
(AUDIT; Saunders et al., 1993). The interviewer immediately scored this and
subjects who scored 8 or more, i.e. whose drinking could be described as
hazardous or harmful (Conigrave et al., 1995), completed two further ques-
tionnaires, the Severity of Alcohol Dependence Questionnaire (SADQ;
Stockwell et al., 1979 and Stockwell et al., 1983) and the Alcohol Problem
Questionnaire (APQ; Drummond, 1990). Only the general section of the
APQ was used, as the questions about employment, cohabiting partners and
children were not often relevant for these subjects.
All individuals were asked about their use of a range of drugs in the previous
6
months, or the last 6 months prior to admission to hospital or prison. Sub-
jects who reported daily or almost daily use of opiates or stimulants then com-
pleted the Severity of Dependence Scales (SDS; Sutherland et al., 1986) for each
class of drug. Individuals were interviewed at the Žrst point of contact, or as
soon as possible thereafter. This included outpatient departments, inpatient
wards (general adult, intensive care, medium-security and Special Hospital),
and the psychiatric court liaison service provided at three local magistrates’
courts. Assessments in the local prison (Belmarsh) were also included.

448 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 12 No. 2
Where consent was not obtained, demographic details and the reason for
non-completion were recorded. Subjects viewed as ‘too unwell’ at the time
of initial contact were reassessed at a later date within the study period by the
Ž
rst author. If they remained too unwell no further enquiry occurred. Infor-
mation was available from clinical assessments on a further 70 patients seen
within this time period.
Ethical approval was obtained both at a local level and from the Home
OfŽce, as a proportion of subjects would be interviewed in a custodial
setting.
Data were analysed in SPSS for Windows.
RESULTS
General information on the subjects
The service saw 209 people in the time period. In 146 cases consent was
obtained.
Reasons for non-completion of the questionnaire were: refused (7), too
unwell (12) and other (44), including 9 subjects who were at other prisons.
The most frequent reason for ‘other’ was lack of time; this was a particular
problem when the only contact with a subject was at a magistrates’ court.
Of the 146 cases, 140 (95%) were men. The mean age was 34.8 years (range
18.2 to 64.3 years). In terms of ethnicity 84 (58%) were white, 34 (23%) Black
Caribbean, and 28 (19%) ‘Other’.
There were 84 subjects (58%) who were referred by the court, the pro-
bation service or solicitors, 41 (28%) from HMP Belmarsh, and 21 (14%)
who were referred by psychiatrists. Over two-thirds of the sample were seen
at the magistrates’ court or in a prison setting. Subjects were seen at all stages
of their progress through the criminal justice system, both pre and post con-
viction, so some of the charges had not yet come to court. Index offences
(relevant for 137 subjects) were of a violent nature in about one third (57,
39%). About another third were accused of theft and property offences
including arson (47, 32%). The remainder were charged with sexual and other
offences (33, 23%). Seven (5%) were referred for risk assessments. The
alleged offence was missing in 2 (1%) cases.
The extent of substance misuse
Almost one-half of subjects (n = 61; 42%) scored 8 or more on the AUDIT
questionnaire indicating harmful use of alcohol. The mean score in the
general section of the Alcohol Problem Questionnaire for these 61 subjects
was 11; that is, they had an average of 11 social problems attributable to their

SUBSTANCE ABUSE 449
drinking. For comparison purposes, patients in specialized alcohol treat-
ment settings score an average of 11 in this section of the APQ (Drummond,
1990). Present or past drug use, including cannabis, was reported by 110
(75%) of the subjects, including 29 (20%) using intravenously. There were
4
2
4 subjects (30%) who reported daily or almost daily use of stimulants and
7 subjects (18%) who reported daily or almost daily use of opiates in the
last 6 months.
ICD-10 diagnoses
The ICD-10 diagnoses for the samples are shown in Table 1.
An ICD-10 substance misuse diagnosis was made in 83 (57%) cases. Mul-
tiple misuse diagnoses occurred in 57 subjects (39%). In 29 subjects (20%)
substance misuse was the sole diagnosis. ‘Dual diagnosis’, that is, a combi-
nation of mental illness and substance misuse, was found in 54 (37%).
Severity of dependency
In the group identiŽed by the AUDIT as hazardous drinkers (that is, scoring
8
0
and over; n = 61), the mean score on the SADQ was 18 (SD = 13.3, range
–56). The SADQ has a maximum possible score of 60. For the APQ general
section the mean score was 10.6 (SD = 5.5, range 0–21). The APQ maximum
score in the general section is 23. Daily or almost daily opiate use was
reported by n = 27 (18%). The mean score on the severity of dependency
Table 1 ICD-10 diagnoses among referrals to a local forensic service
ICD-10 diagnosis
Number of subjects (%)
n = 146
1
1
1
1
1
1
2
2
3
4
6
7
0.1: harmful use of alcohol
0.2: alcohol dependency
1.1: harmful use of opiates
25 (17)
26 (18)
7 (5)
15 (10)
20 (14)
18 (12)
40 (27)
14 (10)
24 (16)
4 (3)
1.2: opiate dependency
4.1 and 15.1: harmful use of stimulants
4.2 and 15.2: stimulant dependency
0.0: schizophrenia
5.0 and 29.0: schizoaffective disorders
1 and 32: affective disorders
1 and 43: neurotic disorders
0–60.9: personality disorders
0: mental retardation
18 (12)
1 (1)
No psychiatric diagnosis made
12 (8)
Note Subjects could have more than one diagnosis.

450 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 12 No. 2
scale for this group was 7.7 (SD = 4.5, range 0–15). There were 44 subjects
30%) who reported daily or almost daily use of stimulants. On the severity
(
of dependency scale the mean was 5.4 (SD = 4.7, range 0–15).
Previous treatment or contact with substance misuse services
Of the group with an ICD-10 diagnosis of harmful use or dependence (n =
83), 40 had sought help for this in the last year. Help was most frequently
sought from general psychiatric services (n = 18), and drug and alcohol agen-
cies (n = 17). Only a small number reported visiting either their GP or an
A&E department (n = 10), and 5 subjects reported obtaining other treatment
for their problem. Eleven subjects had attended more than one service.
Implications for forensic psychiatric services
After the initial assessment, 38 subjects stayed in treatment with forensic ser-
vices, 30 of whom had a major mental illness. Over half of this group had a
co-morbid substance misuse diagnosis. A further 4 subjects had a co-morbid
diagnosis of substance misuse and personality disorder. The most frequent
problems in this group were with stimulants and alcohol. Levels of depen-
dency, though measurable, were low (mean dependency score for stimulants
was 5, range 0–12, n = 15; the mean dependency score for alcohol was 12,
range 2–26, n = 12). Four subjects used opiates on a daily or almost daily
basis; the mean score on the severity of dependence scale was 8.5, range 5–12.
Non-completing group
Background characteristics of this group were compared, in terms of racial
origin, sex, source of referral and the nature of the offence, with the study
group. No signiŽcant difference was found between the groups apart from
the referral source. This had been expected due to the difŽculties with assess-
ments in the magistrates’ court.
DISCUSSION
Among referrals to a local forensic service, 57% had an ICD-10 diagnosis of
substance misuse and 37% had a co-morbid mental illness. In the referrals
subsequently accepted into forensic psychiatry services, about half had clini-
cally signiŽcant levels of substance misuse, albeit with low to moderate levels
of dependency. Of subjects with substance misuse, half had sought help in
the previous year. Thus referral to forensic services may be the Žrst oppor-
tunity to address substance-related problems. The severity of dependence of

SUBSTANCE ABUSE 451
substance misusers appears to be lower than in individuals presenting to sub-
stance misuse services who do not have a co-morbid mental illness.
Substance misuse, mental illness and outcome
The prevalence reported here is similar to previous work among detained
patients (Wheatley, 1998), and larger than that found in general adult psy-
chiatric services (Menezes et al., 1996).
A variety of factors may contribute to substance misuse by people with a
mental illness. Drugs and alcohol may facilitate social interactions (Bergman
and Harris, 1985; Test et al., 1989). They may be a means of self-medicating
for anxiety, boredom and psychotic symptoms, or improving negative symp-
toms (Dixon et al., 1990), and reducing neuroleptic side-effects (Miller and
Tannenbaum, 1989). It has been proposed that the rates of use have increased
since deinstitutionalization to assist integration into society (Bachrach, 1986).
Patients with mental illness and co-morbid substance misuse have a
worse prognosis. They are less compliant with outpatient treatment (Miller
and Tannenbaum, 1989); their clinical and social outcome may be worse
than those with severe mental illness alone (Lehman et al., 1993); they have
heavy use of emergency and inpatient services (Bartels et al., 1993; Menezes
et al., 1996); and inpatient episodes of suicidal or violent behaviour are more
frequent (Yesavage and Zarcone, 1983). The rates of offending and
imprisonment are higher and an association has been found between co-
morbidity and homelessness (Tessler and Dennis, 1989). There is a relation-
ship (possibly mutually reinforcing) between non-compliance and
continuing substance misuse. Johns completed a comprehensive review of
the international literature on the relationship between substance misuse,
mental illness and violence (Johns, 1997) and discussed the implications of
the findings for risk management and service provision. A review of homi-
cide enquiries found that, in the majority of cases discussed, the patient had
a history of substance misuse, and it was a major contributing factor to the
homicide in over half (Ward and Applin, 1998). The National Confidential
Enquiries have emphasized the need for co-ordinated care for people within
local services. None the less, the difficulties of managing co-morbid sub-
stance misuse in non-specialized services are significant: Drake (Drake,
Bartels et al., 1993; Drake et al., 1996) identified a lack of staff training,
experience and confidence in managing patients with substance misuse
problems.
Limitations of the study
The levels of substance misuse reported by subjects in this study were not
subject to external validation. They may have been inuenced by a desire for

452 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 12 No. 2
social acceptance and recall bias. Levels of drug use are under-reported in
criminal justice settings (Wish, 1988). The refusal rate was low but there were
subjects who were not able to complete the questionnaire due to difŽculties
with interviewing in magistrates’ courts and further interviews with this
group proved difŽcult to arrange. ICD-10 diagnoses were made from the
clinicalassessment without standardized interviews except with respect to the
questionnaires described for substance misuse.
Implications for practice
The Žnding of moderate levels of severity of dependence among these
subjects does not imply that it is easy for them to cut down or stop. On the
contrary, these scores are evidence of established dependency syndromes.
Treatment needs to be diverse, developing a wide range of skills including
social and practical skills, coping and problem-solving techniques, education
about substance misuse, motivational interviewing and goal-setting for
decreased substance misuse and training in behavioral skills for relapse pre-
vention. The impact of motivational and cognitive deŽcits associated with
severe mental illness needs to be minimized. Treatment should be available to
inpatients and outpatients. This has substantial implications for staff training
in forensic psychiatric services. Lastly, the effectiveness of techniques for this
patient group should be evaluated.
Few well-controlled trials of speciŽc interventions have been done. The
central feature of current models is the delivery of integrated care both for
severe mental illness and substance misuse by the same team (Drake, Bartels
et al., 1993; Drake, McHugo et al., 1993; Drake et al., 1996). A Dutch team
has reported encouraging results in an experimental treatment package used
in a small group of admissions to a forensic psychiatric unit where 50% of
patients have a substance misuse disorder (Van der Laan and Janssen, 1996).
Some recent pilot studies and projects in the USA have provided equivocal
results and there is difŽculty in assessing longer-term beneŽts with relatively
short follow-up periods. There is, however, a broad consensus about the
general requirements for effective treatment. Specialized care and treatment
can be conceptualized as an ongoing process. Marshall (1998) suggested the
development of closer links between addiction and general adult services,
particularly the provision of extra training and supervision in addiction treat-
ment techniques for mental health workers and the attachment of a special-
ist dual diagnosis keyworker. The skills of both substance misuse and forensic
services should complement each other in risk assessment and continuing
management.
Dr Sarah Isherwood, MBBS, MRCPsych, Three Bridges MSU, Uxbridge Road, Southall,
UB1 3EU, UK

SUBSTANCE ABUSE 453
Dr Deborah Brooke, MRCPsych, MPhil, consultant forensic psychiatrist, Bracton Centre,
Bexley Hospital, Old Bexley Lane, Bexley, Kent DA5 2BW, UK
Correspondence to Dr Isherwood
REFERENCES
Bachrach, L. L. (1986) ‘The Context of Care for the Chronic Mental Patient with
Substance Abuse Problems’. Psychiatric Quarterly 58: 3–14.
Bartels, S. J., Teague, G. B., Drake, R. E., Clark, R. E., Bush, P. W. and Noordsy, D.
L. (1993) ‘Service Utilization and Costs Associated with Substance Use Disorder
among Severely Mentally Ill Patients’. Journal of Nervous and Mental Disease
181: 227–32.
Bergman, H. C. and Harris, M. (1985) ‘Substance Abuse among Young Adult Chronic
Patients’. Psychosocial Rehabilitation Journal 9: 49–54.
Brooke, D., Taylor, C., Gunn, J. and Maden, A. (1996) ‘Point Prevalence of Mental
Disorder in Unconvicted Male Prisoners in England and Wales’. British Medical
Journal 313: 1521–4.
Cantwell, R., Brewin, J., Glazebrook, C., Dalkin, T., Fox, R., Medley, I. and Harrison,
G. (1999) ‘Prevalence of Substance Misuse in First-Episode Psychosis’. British
Journal of Psychiatry 174: 150–3.
Conigrave, K. M., Hall, W. D. and Saunders, J. B. (1995) ‘The AUDIT Questionnaire:
Choosing a Cut-off Score’. Addiction 90: 1349–56.
Dixon, L., Haas, G., Weiden, P. and Frances, A. (1990) ‘Acute Effects of Drug Abuse
on Schizophrenic Patients: Clinical Observations and Patients’ Self-reports’.
Schizophrenia Bulletin 16: 69–79.
Drake, R. E., Bartels, S. J., Teague, G. B., Noordsy, D. L. and Clark, R. E. (1993)
‘Treatment of Substance Misuse in Severely Mentally Ill Patients’. Journal of
Nervous and Mental Disease 181: 606–11.
Drake, R. E., McHugo, G. J. and Noordsy, D. L. (1993) ‘Treatment of Alcoholism
among Schizophrenic Outpatients: 4-year Outcomes’. American Journal of
Psychiatry 150: 328–9.
Drake, R. E., Mueser, K. T., Clark, R. E. and Wallach, M. A. (1996) ‘The Course,
Treatment and Outcome of Substance Disorder in Persons with Severe Mental
Illness’. American Journal of Orthnopsychiatry 66: 42–51.
Drummond, D. C. (1990) ‘The Relationship between Alcohol Dependence and
Alcohol-Related Problems in a Clinical Population’. British Journal of Addiction
85: 357–66.
Foster, K., Meltzer, H., Gill, B. and Hinds, K. (1996) Adults with a Psychotic Disorder
Living in the Community: OPSC Surveys of Psychiatric Morbidity. London:
HMSO.
Gunn, J., Maden, A. and Swinton, M. (1991) ‘Treatment Needs of Prisoners with
Psychiatric Disorders’. British Medical Journal 303: 338–40.
Home OfŽce (1997) ‘Statistics of Drug Addicts NotiŽed to the Home OfŽce, United
Kingdom’. Statistical Bulletin, issue 22/97.

454 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 12 No. 2
Johns, A. (1997) ‘Substance Misuse: a Primary Risk and a Major Problem of Comor-
bidity’. International Review of Psychiatry 9: 233–41.
Lehman, A. F., Herron, J. D., Schwartz, R. P. and Myers, C. P. (1993) ‘Rehabilitation
for Adults with Severe Mental Illness and Substance Abuse Disorders: a Clinical
Trial’. Journal of Nervous and Mental Disease 181: 86–90.
Marshall, J. (1998) ‘Dual Diagnosis: Co-morbidity of Severe Mental Illness and
Substance Misuse’. Journal of Forensic Psychiatry 9: 9–15.
Mason, D., Birmingham, L. and Grubin, D. (1997) ‘Substance Misuse in Remand
Prisoners: a Consecutive Case Study’. British Medical Journal 315: 18–21.
Menezes, P. R., Johnson, S., Thornicroft, G., Marshall, J., Prosser, D., Bebbington, P.
and Kuipers, E. (1996) ‘Drug and Alcohol Problems among Individuals with
Severe Mental Illness in South London’. British Journal of Psychiatry 168: 612–19.
Miller, F. T. and Tannenbaum, J. H. (1989) ‘Drug Abuse in Schizophrenia’. Hospital
Community Psychiatry 40: 847–9.
Saunders, J. B., Aasland, O. G., Babor, T. F., De La Fuente, J. R. and Grant, M. (1993)
‘
Development of the Alcohol Use Identification Test (AUDIT): WHO
Collaborative Project on Early Detection of Persons with Harmful Alcohol
Consumption – II’. Addiction 88(6): 791–804.
Stockwell, T., Hodgson, R., Edwards, G., Taylor, C. and Rankin, H. (1979) ‘The
Development of a Questionnaire to Measure Severity of Alcohol Dependence’.
British Journal of Addiction 74: 79–87.
Stockwell, T., Murphy, D. and Hodgson, R. (1983) ‘The Severity of Alcohol Depen-
dence Questionnaire: Its Use, Reliability and Validity’. British Journal of
Addiction 78: 145–55.
Sutherland, G., Edwards, G., Taylor, C., Phillips, G., Gossop, M. and Brady, R. (1986)
‘The Measurement of Opiate Dependence’. British Journal of Addiction 81:
458–94.
Tessler, R. C. and Dennis, D. L. (1989) A Synthesis of NIMH-Funded Research
Concerning Persons Who Are Homeless and Mentally Ill. Washington, DC:
NIHM Division of Education and Service System Liaison.
Test, M. A., Wallisch, L. S., Allness, D. J. and Ripp, K. (1989) ‘Substance Misuse in
Young Adults with Schizophrenic Disorders’. Schizophrenia Bulletin 15: 465–76.
Van der Laan, M. and Janssen, M. (1996) ‘Addressing Drug Abuse in a Dutch Forensic
Hospital’. Criminal Behaviour and Mental Health 6: 157–66.
Ward, M. and Applin, C. (1998) The Unlearned Lesson: The Role of Alcohol and Drug
Misuse in Homicides Perpetrated by People with Mental Health Problems.
London: Wynne Howard Books.
Wheatley, M. (1998) ‘The Prevalence and Relevance of Substance Use in Detained
Schizophrenic Patients’. Journal of Forensic Psychiatry 9: 114–29.
Wish, E. (1988) ‘Identifying Drug-abusing Criminals’. In Leukefeld, C. and Tims, F.
(eds) Compulsory Treatment of Drug Abuse: Research and Clinical Practice.
NIDA Research Monograph 86.
World Health Organization (1992) The ICD-10 ClassiŽcation of Mental and Behav-
ioural Disorders. Geneva: WHO.
Yesavage, J. A. and Zarcone, V. (1983) ‘History of Drug Abuse and Dangerous
Behaviour in Inpatient Schizophrenics’. Journal of Clinical Psychiatry 44: 259–61.