Research Article: Identification and management of alcohol use and illicit substance use in outpatient psychiatric clinics in Sweden: a national survey of clinic directors and staff

Date Published: March 6, 2019

Publisher: BioMed Central

Author(s): Christopher Sundström, Elisabeth Petersén, Kristina Sinadinovic, Peter Gustafsson, Anne H. Berman.


Swedish national guidelines recommend that all health care settings systematically screen patients for alcohol use and illicit substance use. When hazardous use is identified, it should immediately be addressed, preferably through brief interventions (BI). It is well known that the prevalence of alcohol use and illicit substance use among psychiatric patients is high, but it is not known to what extent screening and BI are routinely carried out in such clinics.

Two online surveys investigating the use of screening and BI for alcohol and illicit substances were constructed; one for psychiatric outpatient clinic directors and one for staff at these clinics. The main analyses were calculated as simple frequencies. In secondary analyses, we investigated the associations between substance abuse training, type of clinic and screening/BI delivery. For these analyses, the Chi square test was used.

Most clinic directors reported that they have guidelines to screen for alcohol (93.1%) and illicit substance use (78.9%) at initial assessment. Fifty percent reported having guidelines for delivering BI when identifying hazardous alcohol use (35.9% for hazardous illicit substance use). Among staff, 66.6% reported always screening for alcohol use and 57.8% reported always screening for illicit substance use at initial assessment. Further, 36.7% reported that they usually deliver BI when identifying hazardous alcohol use (35.7% for hazardous illicit substance use). Secondary analyses indicated that staff with substance abuse training were significantly more likely to screen for alcohol use than staff without such training. Further, staff at psychosis clinics were significantly less likely to screen for both alcohol and substance use than staff at both general and specialist psychiatric clinics.

Most clinic directors reported having clear guidelines for staff to screen for alcohol use and illicit substance use, but fewer staff members than expected indicated that these guidelines were adhered to. Providing training about substance use disorders for staff may increase use of screening for alcohol use, and psychosis clinics may need to improve their screening routines.

The online version of this article (10.1186/s13722-019-0140-x) contains supplementary material, which is available to authorized users.

Partial Text

It is well known from epidemiological studies that people with a psychiatric disorder frequently have a concurrent substance abuse or dependence concerning either alcohol or illicit substances [1–3]. Prevalence of substance abuse or dependence among persons in the general population with anxiety or depression is estimated to be 25–30%, with markedly higher levels among those with more severe psychiatric disorders such as schizophrenia [1]. The prevalence is believed to be just as high among patients in psychiatric clinics [4–7]. Individuals with concurrent psychiatric disorder and substance use problems have a worse treatment prognosis [8] and an increased risk of later relapse in their psychiatric disorder [9]. Hazardous alcohol use, a drinking pattern not deemed to be a fully developed alcohol abuse or dependence but with potential to lead to adverse consequences, is also problematic in a psychiatric setting. Excessive drinking commonly interferes with psychosocial functioning and raises the risk of subsequent escalation of alcohol problems. In fact, even moderate alcohol intake has a negative impact on clinical course and response to treatment [10, 11], and may interact negatively with common psychiatric medications such as fluoxetine [11] and benzodiazepines [12]. Reduced hazardous drinking among psychiatric patients has been associated with more rapid symptom improvement in anxiety and depression [13]. Hazardous illicit substance use is not an equally established concept, but it is not controversial to suggest that sporadic use of illicit substances also has negative implications for treatment and recovery from psychiatric disorders.

The main purpose of this study was to assess the existence of guidelines for screening and BI for substance use (alcohol and illicit substances) at psychiatric outpatient clinics in Sweden, as well as actual use of screening and BI among staff at these clinics. Almost all clinic directors who responded to the survey indicated that they had clear guidelines for staff to screen for alcohol use and illicit substance use during initial assessment, suggesting high level of awareness in psychiatric clinics about the importance of identifying substance abuse and dependence. However, only about two-thirds of staff members stated that they routinely screened for alcohol during initial assessment, and even fewer stated that they routinely screened for illicit substances. Furthermore, about half of responding clinic directors indicated that they had guidelines for offering BI, while about one-third of staff members indicated that they actually used BI regularly, suggesting that BI is not an integrated part of psychiatric treatment in Sweden.

Almost all clinic directors stated that they had clear guidelines for staff to screen for alcohol use and illicit substance use, but use of screening among staff was markedly lower than would be expected. Our results thus suggest a gap between the guidelines that the clinic directors report and actual adherence to guidelines by staff. Substance abuse training among staff is rare and may be a contributing factor to low adherence since those indicating that they had substance abuse training reported performing screening and brief intervention to a greater degree. Provision of substance abuse training to staff in psychiatry might thus be a key factor needed to improve frequency of screening and brief intervention. Clinics specializing in psychosis might need to consider making extra efforts to improve screening practices.




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