Mental disorders and substance use disorders (SUD) commonly occur together, impacting healthcare outcomes. The diagnosis of substance use is often inadequate when comorbidity is present. It is vital to understand the prevalence of substance use amongst psychiatric patients to inform both clinical practice and service development in South Africa.
To ascertain the prevalence and clinical correlates of SUD amongst acute psychiatric inpatients.
The setting for this study was Helen Joseph Hospital acute psychiatric ward.
A cross-sectional study was conducted whereby consecutively admitted patients were invited to participate in a structured clinical interview utilising the alcohol use disorders identification test (AUDIT) and drug use disorders identification test (DUDIT) questionnaires. Statistical comparisons were made between those with and without SUD.
Of 150 participants, 100 (67%) were identified with a SUD. Those with SUD were younger (
Substance use disorders are highly prevalent amongst psychiatric inpatients. The AUDIT and DUDIT are potentially useful screening tools in routine clinical practice. Greater collaboration between psychiatric and substance rehabilitation services is recommended.
Mental illness and substance use disorders (SUD) are estimated to affect 16% of the world’s population
There is a well-established relationship between mental disorders and SUD, including high levels of comorbidity recorded between the two conditions,
Population surveys
There is a need to establish prevalence rates of substance use amongst psychiatric patients in South Africa to inform both clinical practice and service development. However, Morojele, Saban and Seedat
Using their own data collection tool in a prospective survey amongst acute admissions at a psychiatric hospital, Weich and Pienaar
The primary aim of this study was to determine the prevalence of SUD using standardised screening instruments, and to describe their clinical correlates, amongst patients admitted to an acute psychiatric ward in a general hospital. A secondary objective was to compare the prevalence rates of SUD according to the clinical records with prevalence rates when using screening questionnaires. In terms of clinical presentation, we hypothesised that those with SUD would show higher rates of psychosis and aggressive symptoms.
A cross-sectional study was conducted amongst patients admitted to the acute psychiatric unit at Helen Joseph Hospital, a tertiary academic general hospital in Johannesburg, Gauteng province, South Africa. The unit is a 30-bed, mixed male and female, acute adult assessment ward accepting referrals from surrounding clinics as well as the casualty. The city areas served by the hospital are well known for a high level of crime and drug-related problems.
The inclusion criteria required the participants to be 18 years or older, conversant in English or Afrikaans, and have capacity to consent. All patients admitted to the unit between 01 February and 31 May 2016 were approached by the principal investigator (A.A.) as soon as they were clinically stable enough to provide informed consent.
Following written informed consent, the patients were interviewed and the socio-demographic and clinical information, in accordance with a questionnaire developed by the researcher (A.A.), was obtained. The socio-demographic details obtained included gender, race, relationship status, highest level of education, employment status, whether receiving a disability grant, religion and handedness.
This was then followed by the administration of both the alcohol use disorders identification test (AUDIT) and drug use disorders identification test (DUDIT) by the principal investigator. The hospital’s clinical records were used to establish the date of admission and discharge, admission status in accordance with the
The AUDIT and DUDIT questionnaires have both been confirmed as valid and reliable tools amongst acute psychiatric inpatients internationally
In this article, participants were considered to have a SUD if they screened positive for hazardous, harmful or dependent alcohol on the AUDIT, or screened positive for hazardous, harmful or dependent drug use on the DUDIT, or clinically met the DSM-5 criteria for SUD by their treating doctor.
Categorical variables were summarised by frequency and percentage tabulation, and continuous variables were described by the mean, standard deviation, median and interquartile range. These study variables were compared between the groups of patients with and without a SUD. The
Ethical clearance was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (HREC M151013).
A total of 177 patients were admitted over the 4-month period, from 01 February to 31 May 2016. Of these admissions, 10 had severe behavioural disturbance warranting immediate transfer to a specialist hospital for further involuntary care, four did not speak either English or Afrikaans, three lacked capacity to consent because of neurocognitive disorders and two were under the age of 18 years and thus were excluded and eight declined to participate. Following informed consent, the study population consisted of 150 participants.
Of the 150 participants, 62.7% (
Socio-demographic characteristics of the sample.
Variable | Category | Number | % |
---|---|---|---|
Age | 18–39 years | 115 | 76.7 |
40 years or more | 35 | 23.3 | |
Gender | Female | 56 | 37.3 |
Male | 94 | 62.7 | |
Population group | Black | 101 | 67.3 |
Mixed race | 26 | 17.3 | |
White | 20 | 13.3 | |
Indian | 2 | 1.3 | |
Other | 1 | 0.7 | |
Relationship status | Single | 87 | 58.0 |
In a relationship | 63 | 42.0 | |
Highest level of education | None | 1 | 0.7 |
Primary | 10 | 6.7 | |
High School | 64 | 42.7 | |
Matric | 51 | 34.0 | |
Tertiary | 24 | 16.0 | |
Employment status | Unemployed | 81 | 54.0 |
Employed | 55 | 36.7 | |
Student or pensioner | 14 | 9.3 | |
Disability grant | No | 127 | 84.7 |
Yes | 23 | 15.3 | |
Presentation | Index to psychiatry | 60 | 40.0 |
Repeat | 90 | 60.0 | |
Number of admissions in the last 2 years | 1 | 84 | 56.0 |
2 or more | 66 | 44.0 |
Almost 80% (
Psychiatric symptoms on admission.
From the clinical notes by the treating doctor, it was observed that SUD was diagnosed in 60.0% (
Clinical psychiatric diagnosis on discharge.
Administration of the AUDIT showed that 44.6% (
Percentage of sample in each alcohol use disorders identification test and drug use disorders identification test category.
Substance use comorbidity according to alcohol use disorders identification test and drug use disorders identification test categories.
AUDIT results | DUDIT results |
|||||||
---|---|---|---|---|---|---|---|---|
No or low drug use |
Hazardous or harmful use |
Drug dependence |
Total |
|||||
% | % | % | % | |||||
No or low alcohol use | 50 | 33.3 | 26 | 17.3 | 7 | 4.7 | 83 | 55.3 |
Hazardous or harmful use | 21 | 14.0 | 17 | 11.3 | 11 | 7.3 | 49 | 32.7 |
Alcohol dependence | 8 | 5.3 | 5 | 3.3 | 5 | 3.3 | 18 | 12 |
AUDIT, Alcohol use disorders identification test; DUDIT, drug use disorders identification test.
The findings of the two methods did not correspond in 23% (
Comparison of the alcohol use disorders identification test and drug use disorders identification test findings of substance use disorders with a clinical diagnosis of substance use disorders.
Substance use disorder (clinical diagnosis) | Substance use (AUDIT or DUDIT) |
|||||
---|---|---|---|---|---|---|
No SUD |
SUD |
Total |
||||
% | % | % | ||||
No SUD | 37 | 24.7 | 23 | 15.3 | 60 | 40 |
SUD | 13 | 8.7 | 77 | 51.3 | 90 | 60 |
AUDIT, alcohol use disorders identification test; DUDIT, drug use disorders identification test; SUD, substance use disorders.
The demographic and clinical characteristics of those who screened positive for SUD by the AUDIT and DUDIT tools were compared with the group who did not (see
Comparison of characteristics between those without and with substance use disorders on alcohol use disorders identification test and drug use disorders identification test.
Variable | Category | No SUD |
SUD |
|||
---|---|---|---|---|---|---|
Age | 18–39 years | 30 | 60.0 | 85 | 85.0 | 0.0010 |
40 years and above | 20 | 40.0 | 15 | 15.0 | - | |
Gender | Female | 26 | 52.0 | 30 | 30.0 | 0.0120 |
Male | 24 | 48.0 | 70 | 70.0 | - | |
Disability grant | No | 37 | 74.0 | 90 | 90.0 | 0.0150 |
Yes | 13 | 26.0 | 10 | 10.0 | - | |
Involuntary | 25 | 50.0 | 63 | 63.0 | 0.0730 | |
Assisted | 24 | 48.0 | 30 | 30.0 | - | |
Voluntary | 1 | 2.0 | 7 | 7.0 | - | |
Brought by | Family member | 39 | 83.0 | 60 | 61.2 | 0.0250 |
Police | 6 | 12.8 | 18 | 18.4 | - | |
Ambulance | 1 | 2.1 | 10 | 10.2 | - | |
Self | 1 | 2.1 | 10 | 10.2 | - | |
Other | 2 | 4.0 | 3 | 3.0 | - | |
Psychiatric diagnosis (working diagnosis in clinical records) | Substance use disorder | 13 | 26.0 | 77 | 77.0 | < 0.0001 |
Substance-induced psychotic disorder | 5 | 10.0 | 41 | 41.0 | < 0.0001 |
|
Substance-induced mood disorder | 0 | 0.0 | 12 | 12.0 | 0.0088 |
|
Substance intoxication | 1 | 2.0 | 14 | 14.0 | 0.0210 |
|
Substance withdrawal | 0 | 0.0 | 3 | 3.0 | 0.5500 | |
Psychotic owing to medical condition | 5 | 10.0 | 7 | 7.0 | 0.5400 | |
Schizophrenia | 17 | 34.0 | 12 | 12.0 | 0.0020 |
|
Schizoaffective disorder | 1 | 2.0 | 2 | 2.0 | > 0.9900 | |
Bipolar 1 disorder | 18 | 36.0 | 15 | 15.0 | 0.0059 |
|
Bipolar 2 disorder | 0 | 0.0 | 1 | 1.0 | > 0.9900 | |
Major depressive disorder | 0 | 0.0 | 3 | 3.0 | 0.5500 | |
Anxiety | 0 | 0.0 | 3 | 3.0 | 0.5500 | |
Post-traumatic stress | 1 | 2.0 | 0 | 0.0 | 0.3300 | |
Personality disorder | 4 | 8.0 | 12 | 12.0 | 0.5800 | |
Other | 2 | 4.0 | 12 | 12.0 | - | |
Medical comorbidity | HIV | 8 | 16.0 | 12 | 12.0 | 0.4500 |
Epilepsy | 2 | 4.0 | 3 | 3.0 | > 0.9900 | |
Head injury | 1 | 2.0 | 3 | 3.0 | > 0.9900 | |
Hypertension | 3 | 6.0 | 3 | 3.0 | 0.4000 | |
Diabetes | 1 | 2.0 | 2 | 2.0 | > 0.9900 | |
None | 36 | 72.0 | 80 | 80.0 | 0.3000 | |
Presentation | Index | 15 | 30.0 | 45 | 45.0 | 0.0810 |
Repeat presentation | 35 | 70.0 | 55 | 55.0 | - | |
Number of admissions in the last 2 years | 1 | 25 | 50.0 | 59 | 59.0 | 0.4800 |
2 or more | 25 | 50.0 | 41 | 41.0 | - |
SUD, substance use disorders.
, Significant differences (
There was a statistically significant association between SUD and younger age (
Those with a SUD on AUDIT or DUDIT were more likely to have a clinical diagnosis of SUD or a substance-related condition (
A total of 72.7% participants (
In this cross-sectional study of 150 acute psychiatric inpatients, we aimed to describe the prevalence of SUD and their clinical correlates using standardised screening instruments. A total of 67% of participants were identified as having SUD upon administration of the AUDIT and DUDIT questionnaires. Alcohol use was identified in 45% patients, other drug use in 47%, with evidence of comorbid use of alcohol and other drugs in 25% patients.
In South Africa, variable prevalence rates of SUD amongst psychiatric inpatients have been found.
This study revealed a higher prevalence of SUD than that found in a previous study conducted in the same unit.
However, the prevalence in our sample was less than the 81.2% found amongst patients admitted with first episode psychosis in the Eastern Cape.
When comparing to international prevalence rates of SUD, the prevalence of SUD in this study is higher than that reported in Iceland, which reported SUD in 58% of male and 32% of female psychiatric inpatients.
In the overall sample, schizophrenia was diagnosed in 19.3% (
In contrast, amongst general medical or surgical admissions, prevalence rates for alcohol (10%), cannabis (7%) and other substances (4.5%) have been reported
We found that those with SUD were more likely to be male and single person, which is consistent with the findings of local and international studies.
Whilst the SUD group was more likely to be brought to hospital by police or ambulance, there was no increased rate of aggression, psychosis or mania, which are conditions that could result in a need for police or ambulance escort. Estrangement from family members as a result of the negative effects of SUD may be a possibility. Even though we did not confirm higher rates of psychosis and aggressive symptoms amongst those with SUD, 14 of the 16 participants referred for further involuntary care (usually related to aggressive, disruptive behaviour) screened positive for SUD. It is also not known if any of the 10 participants who were ineligible for study inclusion because of immediate transfer to Sterkfontein Hospital had used substances.
Despite high rates of substance use, only two participants were referred to inpatient rehabilitation centres upon discharge, which was arranged privately by their families This finding is consistent with the low referral rate described by the South African Community Epidemiology Network on Drug Use (SACENDU).
Psychiatric services generally do not offer substance rehabilitation. In South Africa, substance use management falls under the National Department of Social Development, which is obliged to implement inter-sectoral strategies for early detection and treatment under the
Clients with both psychiatric and SUD have reported greater satisfaction with an integrated dual diagnosis treatment approach.
In 76% (
Generalisability may be limited as this study was conducted at only one acute centre with a small sample size. A larger sample size could also have revealed more significant differences in clinical correlates. The screening tools used did not assess for which drugs were used. This is an important information as the wide range of available substances cause varying risks of addiction, severity of tolerance and different symptoms. The tools have been validated in English; however, the investigator’s translating the tool into Afrikaans is not a standardised practice. Language considerations should be made according to the centre’s needs.
Notwithstanding the limitations, our study adds to the growing body of evidence of a high prevalence of SUD amongst patients admitted to psychiatric units in South Africa, particularly young men. Two-thirds of the participants were identified with SUD. The AUDIT and DUDIT questionnaires are cost-effective and quick to administer. Consideration should be given to their routine use to enhance the clinical identification in populations with high numbers of substance users.
Despite the high prevalence of SUD, only two participants went to an inpatient rehabilitation facility following discharge. The severity of the SUD was not consistently noted by clinicians, which could inform whether inpatient or outpatient SUD rehabilitation services are required. Thus, we encourage the specification of disorders to improve clinical services. Further research should explore the referrals and follow-up to outpatient services. Although not all substance users require inpatient rehabilitation, the low referral rate may be partly because of psychiatric services and substance rehabilitation facilities being managed by different governmental departments. Thus, improved collaboration of services is recommended.
The authors thank Diagnostic Management and Statistical Analysis (DMSA) for the data analysis.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
A.A. designed the study and was the principal investigator. L.J.R. assisted with protocol and write-up of the article.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.