|Year : 2016 | Volume
| Issue : 2 | Page : 117-121
A study of tobacco and substance abuse among mentally ill outpatients in a tertiary care general hospital
Anju Gupta1, Deepak Gauba2, Triptish Bhatia3, Smita N Deshpande3
1 Department of Psychiatry, Dr. BSA Hospital, New Delhi, India
2 Department of Medical, BSES Yamuna Power Limited, New Delhi, India
3 Department of Psychiatry, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
|Date of Web Publication||4-Nov-2016|
Smita N Deshpande
Department of Psychiatry, PGIMER and Dr. Ram Manohar Lohia Hospital, Park Street, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Background: The comorbidity of substance abuse and mental disorder is known to exist and may cause many diagnostic, prognostic, and management difficulties. Indian data are sparse in this area. Objectives: The aim of the study was to identify the prevalence and pattern of substance abuse in psychiatric outpatients and to examine the relation between demographic variables and drug abuse pattern. Materials and Methods: Medical records of the patients attending psychiatry outpatient clinic at a tertiary care general hospital over a 3-month period were reviewed. Information was obtained from medical chart and Drug Abuse Monitoring Scale pro forma about substance abuse. Psychiatric diagnosis made by a qualified psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition diagnostic criteria, as recorded in the case record form, was used. Observation: The results revealed that 50.8% (half) of all psychiatry outpatients were using one or more substances including tobacco in the last month prior to registration (1 month prevalence) and 28.35% were using substances at any time in their life prior to the last month (lifetime prevalence). Male patients had 6 to 8 times higher substance abuse than female patients. Tobacco and alcohol were found to be the most common substances of abuse, followed by cannabis. Part-time and full-time employed male patients consumed more alcohol and tobacco than unemployed patients. Conclusions: Substance abuse was common among mentally ill outpatients and could be the cause of various health hazards and hence requires due attention.
Keywords: Psychiatry hospital, substance abuse, tobacco
|How to cite this article:|
Gupta A, Gauba D, Bhatia T, Deshpande SN. A study of tobacco and substance abuse among mentally ill outpatients in a tertiary care general hospital. J Mental Health Hum Behav 2016;21:117-21
|How to cite this URL:|
Gupta A, Gauba D, Bhatia T, Deshpande SN. A study of tobacco and substance abuse among mentally ill outpatients in a tertiary care general hospital. J Mental Health Hum Behav [serial online] 2016 [cited 2019 Jun 25];21:117-21. Available from: http://www.jmhhb.org/text.asp?2016/21/2/117/193431
| Introduction|| |
Mental disorders and substance abuse disorders often co-exist and demand an attention of researchers and health policy makers. Substance abuse among psychiatric patients often goes undetected ,, and can cause many problems such as diagnostic difficulties, , poor prognosis,  increased psychiatric admission, ,, violence,  suicidal behavior,  and excess service costs. 
The Western research data indicate substance abuse in up to half of the psychiatric patients. ,, There are fewer Indian published studies. One study from Southern India, reported current use of 36% nicotine in hospitalized psychiatric patients associated with male gender, a diagnosis of bipolar disorder, and risk of other substance use problems. 
The present study was carried out to identify the prevalence and pattern of substance abuse in psychiatric outpatients and to examine correlation if any, between demographic variables and drug abuse patterns.
| Materials and Methods|| |
The study was conducted at the Psychiatry department of a multi-specialty hospital (central government funded) in Central Delhi in India, catering to patients from all over New Delhi and nearby states. Case records of patients attending psychiatry outpatient department (OPD), between 18 and 65 years of age, over a 3-month period, were included. Case records of patients with primary substance abuse disorder were excluded. All patients who attended psychiatry OPD were worked up by junior residents for obtaining detailed history, and then case was transferred to a qualified psychiatrist (senior resident or specialist) who assessed the case in detail and supplemented the history and did Mental Status Examination. All patients attending this OPD are routinely screened by the Drug Abuse Monitoring Scale (DAMS) pro forma  for substance abuse, and assessed using Commercial and Government Entity (CAGE)  and alcohol use disorders identification test (AUDIT)  at their first contact. Pro forma such as CAGE, AUDIT, and DAMS were filed in by the treating psychiatrist, post graduate students, or junior residents (trained) at their first contact.
Data were obtained from a review of the medical chart and DAMS pro forma. Chart review provided information about sociodemographic, substance abuse data, and mental illness diagnosis made by a qualified psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition diagnostic criteria. A total of 1395 patients attended the general psychiatry OPD during the study period. Their records were reviewed. Seventy-nine were excluded as their records lacked complete information.
Instrument used - drug abuse monitoring system (2002)
This is a simple precoded monitoring tool developed by the World Health Organization for assessing drug use patterns. Its usefulness in Indian setting has been confirmed by various studies. , There are 19 items in the DAMS instrument which include demographic parameters (8 items), drug use history (1 item), intravenous drug use (2 items), physical complications (3 items), concurrent illness (2 items), and previous treatment (2 items). This pro forma is filled out on the 1 st day of contact with the client and his/her informant and can be subsequently revised if the patient remained in contact for a longer duration. On the basis of drug use pattern, substance use is categorized as current use and ever use. "Current use:" If one or more substances were consumed during 30 days of registration and "Ever use:" If substances were consumed during their lifetime prior to 1 month of contact. Ever use cases do not include cases who are defined as current users.
SPSS Inc. version 16  was used for statistical analysis. Frequencies and percentages were used to describe the data. Categorical data were analyzed using Chi-square analysis. A significance level of 5% was used (P = 0.05). For continuous variables, t-tests were used to compare the findings.
| Results|| |
A total of 1395 patients attended the general psychiatry OPD during the study period, out of which, 1316 patients were recruited in the study and 79 were excluded as their records lacked complete information.
Sociodemographic profile - out of 1316 patients, 733 were males and 583 were females. Mean age of the sample was 36.42 ± 14.97 years.
Males were more educated than females as 52.96% males and 32.45% females had passed middle school. Among the sample, 28.21% males and 19.64% females were graduates and further qualified, while 5.25% males as compared to 11.75% females were primary school educated. Illiteracy was higher in females: 13.54% males and 36.4% females could not read or write.
Two-third of the patients (60.50% males and 67.70% females) were married, 34.80% males and 22.39% females were unmarried and 4.68% males and 9.87% females were divorced, separated, or widowed.
Three-fourth (75.35%) of the male patients were either part-time or full-time employed. Only one-fourth were either unemployed (9.43%) or were students (8.73%), and rest (6.47%) were irregularly employed. A total of 73.85% of females were homemakers. Only 19.54% females were employed while 16.54% unemployed and 7.39% were students.
Half of the patients (53.29% males and 54.35% females) were staying in a joint family and 37.42% males versus 42.61% female in nuclear family. Rest of the 8.9% males and 3.83% females lived alone or with friends away from their family. Among these, only two male patients were staying alone due to substance abuse.
Mental Illness - The most common disorder recorded in the case records was major depressive disorder (25.4% males, 22.29% females) followed by psychotic disorders: Schizophrenia and related disorders (21% males, 22.46% females) and bipolar disorder - 5% males and 4.45% females. Anxiety disorder was recorded in 15.5% males and 18.85% females; 5.4% males and 10.97% suffered from stress-related disorders and 2.9% males and 3.25% females were diagnosed with mental retardation. Other psychiatric disorders including deferred diagnosis were reported in 24.9% males and 18.35% females.
Medical Illnesses - Medical illnesses were found to be common. Jaundice was reported in 9.2%, hypertension and COPD in 9.3%, diabetes mellitus in 0.4%, sexually transmitted disorders in 0.7%, seizure disorder in 0.4% of the patients, and other medical disorders were recorded in 0.1% of the patients.
Prevalence of substance use
Male patients - 44.33% of the male psychiatry patients were current users and 25.65% were ever users. Tobacco was found to be the most common substance of abuse with the rate of 24.8% followed by alcohol (15.4%) and cannabis (2.5%) for current use. The current use for opioid and benzodiazepines was 1.09% and 0.54%, respectively. The past use in males was 16% for alcohol, 6.8% for tobacco, 0.68% opioid, 1.9% cannabis, and 0.25% for benzodiazepines. In our sample, alcohol "Ever use" was found to be more than tobacco "Ever use." One of the reasons could be that in our society, alcohol is consumed occasionally on different social occasions, but not tobacco.
Female patients - Current and past substance abuse among female patients was found to be 6.5% and 2.7%, respectively. The most common substance abuse among female patients was tobacco. Two-third of the substance abuse (4.42% current use and 0.9% past use) by female patients was tobacco. One-third was other substances including mainly alcohol and benzodiazepines.
"Current use" of substance was higher than "Ever Use" in both genders and substance wise. "Ever Use" is equivalent to the past use (as described in DAMS above) and not equal to the lifetime prevalence. These higher findings for "Current use" can be explained by the fact that a person starts using substance at around 18-20 years of age, and number of persons using substance increases as age progresses up to around 40 years, and the mean age of our sample was 36.42 ± 14.97 years.
All patients reported at the psychiatry OPD were screened on AUDIT and CAGE questionnaire, but no one was found to be dependent on alcohol. All were alcohol abusers as they scored <8 on AUDIT and nobody scored one on CAGE.
Out of total patients, 1.4% had sought treatment for substance abuse in the past and another 1.4% were hospitalized previously for substance abuse treatment.
Prevalence of substance use in specific psychiatric disorder was calculated only for male patients as there were very few females (current use in 12 females and past use in five only) who were consuming substances other than tobacco. The current substance abuse among male patients with psychotic disorders including schizophrenia was 46.6%, bipolar disorder was 46.8%, depression was 35.5%, anxiety disorders was 30.5%, and stress-related disorders was 21.65%. Patients with anxiety disorders and stress-related disorders were reportedly not consuming opioids and cannabis. No patient with psychosis was reportedly abusing opioids. Patients with mental retardation were not abusing any substance except one patient smoking currently.
Relation of substance abuse with sociodemographic variables in male psychiatry patients
Part-time and full-time employed male patients were found to be consuming more alcohol (P < 0.001) and tobacco (P < 0.001) than unemployed patients. Unmarried patients consumed more tobacco (P = 0.029) and cannabis (P = 0.008) than married. Education and living arrangement was not found to be related to substance abuse.
| Discussion|| |
This cross-sectional cohort study of outpatients at a general psychiatric hospital in India provided important data regarding substance abuse among psychiatry patients. This study revealed that 50.8% (more than half) of all psychiatry outpatients - particularly males - were abusing one or more substances such as tobacco, alcohol, cannabis, opioid, and benzodiazepines in the last 1 month (current use) and 28.35% were abusing at any time in their life prior to the last month (ever use). As this was a treatment-seeking population, "Current use" of substance was higher than "Ever Use" in both genders and substance wise. "Ever Use" is equivalent to the past use (as described in DAMS above) and not equal to the lifetime prevalence. The two types of use were mutually exclusive.
Tobacco constituted the major proportion of the substance abuse in our sample. One-third of the substance abuse among females and half of the substance abuse among males was tobacco alone. Tobacco was observed in 29.22% of the sample (males - 24.8% and female - 4.42%), which is little less than the prevalence of 36% reported by Chandra et al.  in hospitalized psychiatry patients from Southern India. The Global Adult Tobacco Survey India 2010 has reported 24% current tobacco prevalence in general population in New Delhi, which is lesser than ours in psychiatry outpatients. 
When we calculated prevalence after excluding tobacco, the prevalence rate of remaining substances came down to 21.68% for current use and 20.58% for ever use, which is similar to that reported by the UK surveys of community samples, for example, Menezes et al.  21%; Cantwell et al. 20%;  Weaver et al.,  and Graham et al.  24%. Two studies were conducted in the US and Ireland on current misuse/dependence among inpatients, both reported rates of 19%. ,
One outpatient study by Duke et al.  also reported nearly similar rates, i.e., 16%. All the above studies were of patients with psychotic disorders, whereas the prevalence rates from our study cover a wider range of diagnoses. Though the study was unicentric, the sample size was quite large compared to previous studies.
In contrast, there are also studies reporting substance abuse in almost half of the psychiatric patients. ,, Kamali et al.  found lifetime prevalence rate of 40% in inpatients sample and Weaver et al.  in a multi-centric community study showed nearly similar result, i.e., 44% for the past 1 year. However, few studies reported use in only one-third of the psychiatric patients. ,,
All these studies did not include tobacco in prevalence rate. The higher prevalence rates in these studies might be due to many factors such as methodological differences, instruments used for substance abuse, the population and location of the study, and cultural factors. The cultural differences across different countries play an important role and can influence the pattern and prevalence of substance abuse.
We found rates of substance abuse in mentally ill patients similar to that of general population. The prevalence rate of substance abuse among New Delhi's general population was estimated to be 52% by Mohan et al.,  which is similar to our result, i.e. 50.8% in mentally ill patients. This is in contrast with the Western data indicating higher rates in mentally ill than in general population. , Loss of employment due to illness and unavailability of money to buy drugs might be the reasons for not finding higher rates in our study.
Our result suggests six to 8 times higher substance abuse in male patients (44.33%) than in female patients (6.5%). This is in line with the trend seen in Indian general population. A survey by Reddy and Chandrashekar  showed similar difference for substances abuse between men (11.9 /1000) and women (1.7/1000). In India, most of the females remain at home and are less exposed to substance abuse. In our sample, three-fourth of the females were homemakers and perhaps, not financially independent to access more expensive substances of abuse.
Among male current users, apart from tobacco (24.8%), alcohol (15.4%) was the most common substance of abuse followed by cannabis (2.5%) and opioid (1.09%). This is similar to the pattern seen in India, reported by National Household Survey indicating the current (1-month period) use of alcohol, cannabis, and opiates as 21.4%, 3%, and 0.7%, respectively, in general population. 
This pattern of alcohol and cannabis, being the most common substances of abuse for people with psychotic disorders, is also observed in many Western studies. ,,,, This contrasts with the contribution made by high rates of abuse of cocaine found in the US. 
In our sample, no patient with psychosis and anxiety disorder was found to be abusing opioids which are costlier, illegal, and not available as easily as alcohol and tobacco. Patients with anxiety disorders and stress-related disorders were not consuming cannabis. Cannabis is known to enhance anxiety symptoms and hence not preferred among these disorders. Patients with mental retardation were not abusing any substance except one patient found to be smoking.
Information on substance use was collected by interviewing the patients and their relatives on their first contact. Confirmatory tests such as urine toxicology were not done. Thus, substance use could have been underestimated or unrecognized in some patients.
As in any retrospective study, the prevalence of lifetime substance abuse may have been under-estimated.
Because comorbidity was assessed within treatment populations, findings may not be generalizable to the same diagnostically defined groups within general population.
| Conclusions|| |
Substance abuse was common among outpatients with mental illness in India and could be the cause of various health hazards and hence requires due attention. It might be easily neglected by medical staff and need to be routinely screened.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ananth J, Vandewater S, Kamal M, Brodsky A, Gamal R, Miller M. Missed diagnosis of substance abuse in psychiatric patients. Hosp Community Psychiatry 1989;40:297-9.
Shaner A, Khalsa ME, Roberts L, Wilkins J, Anglin D, Hsieh SC. Unrecognized cocaine use among schizophrenic patients. Am J Psychiatry 1993;150:758-62.
Condren RM, O'Connor J, Browne R. Prevalence and patterns of substance misuse in schizophrenia. A catchment area case - Control study. Psychiatr Bull 2001;25:17-20.
Lehman AF, Myers CP, Corty E. Assessment and classification of patients with psychiatric and substance abuse syndromes. Hosp Community Psychiatry 1989;40:1019-25.
Hall W, Farrell M. Comorbidity of mental disorders with substance misuse. Br J Psychiatry 1997;171:4-5.
Hunt GE, Bergen J, Bashir M. Medication compliance and comorbid substance abuse in schizophrenia: Impact on community survival 4 years after a relapse. Schizophr Res 2002;54:253-64.
Grant BF. DSM-IV, DSM-III-R, and ICD-10 alcohol and drug abuse/harmful use and dependence, United States, 1992: A nosological comparison. Alcohol Clin Exp Res 1996;20:1481-8.
Hasin DS, Tsai WY, Endicott J, Mueller TI, Coryell W, Keller M. Five-year course of major depression: Effects of comorbid alcoholism. J Affect Disord 1996;41:63-70.
Scott H, Johnson S, Menezes P, Thornicroft G, Marshall J, Bindman J, et al.
Substance misuse and risk of aggression and offending among the severely mentally ill. Br J Psychiatry 1998;172:345-50.
Appleby L, Shaw J, Amos T, McDonnell R, Harris C, McCann K, et al.
Suicide within 12 months of contact with mental health services: National clinical survey. BMJ 1999;318:1235-9.
Hoff RA, Rosenheck RA. The cost of treating substance abuse patients with and without comorbid psychiatric disorders. Psychiatr Serv 1999;50:1309-15.
Miller NS, Fine J. Current epidemiology of comorbidity of psychiatric and addictive disorders. Psychiatr Clin North Am 1993;16:1-10.
Goldsmith RJ. Overview of psychiatric comorbidity. Practical and theoretic considerations. Psychiatr Clin North Am 1999;22:331-49, ix.
Mueser KT, Yarnold PR, Rosenberg SD, Swett C Jr., Miles KM, Hill D. Substance use disorder in hospitalized severely mentally ill psychiatric patients: Prevalence, correlates, and subgroups. Schizophr Bull 2000;26:179-92.
Chandra PS, Carey MP, Carey KB, Jairam KR, Girish NS, Rudresh HP. Prevalence and correlates of tobacco use and nicotine dependence among psychiatric patients in India. Addict Behav 2005;30:1290-9.
Ministry of Social Justice and Empowerment (MSJE), Government of India and United Nations Office on Drugs and Crime (UNODC), Regional Office for South Asia (ROSA). Drug abuse monitoring survey (DAMS): A profile of treatment seekers. New Delhi: MSJE, Government of India and UNODC, ROSA; 2002.
Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-7.
Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption - II. Addiction 1993;88:791-804.
Mohan D, Ray R, Sharma HK, Desai NG, Tripathy BM, Purohit DR, et al
. Collaborative Study on Narcotic Drugs and Psychotropic Substances, Report, Indian Council of Medical Research New Delhi; 1992.
Mohan D, Ray R, Pal H, Sharma HK. Community-Based Pilot Project at Barabanki, Mandsuar and Imphal. Report, Ministry of Health & Family Welfare, New Delhi; 2000.
SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.
Global Adult Tobacco Survey. Report, Ministry of Health & Family Welfare, New Delhi; 2010.
Menezes PR, Johnson S, Thornicroft G, Marshall J, Prosser D, Bebbington P, et al.
Drug and alcohol problems among individuals with severe mental illness in South London. Br J Psychiatry 1996;168:612-9.
Cantwell R, Brewin J, Glazebrook C, Dalkin T, Fox R, Medley I, et al
. Prevalence of substance abuse in first episode psychosis. Br J Psychiatry 1999;174:150-3.
Weaver T, Rutter D, Madden P, Ward J, Stimson G, Renton A. Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: Prevalence and service needs in an inner London borough. Soc Psychiatry Psychiatr Epidemiol 2001;36:399-406.
Graham HL, Maslin J, Copello A, Birchwood M, Mueser K, McGovern D, et al.
Drug and alcohol problems amongst individuals with severe mental health problems in an inner city area of the UK. Soc Psychiatry Psychiatr Epidemiol 2001;36:448-55.
Fisher MS Sr., Bentley KJ. Two group therapy models for clients with a dual diagnosis of substance abuse and personality disorder. Psychiatr Serv 1996;47:1244-50.
Kamali M, Kelly L, Gervin M, Browne S, Larkin C, O'Callaghan E. The prevalence of comorbid substance misuse and its influence on suicidal ideation among in-patients with schizophrenia. Acta Psychiatr Scand 2000;101:452-6.
Duke PJ, Pantelis C, McPhillips MA, Barnes TR. Comorbid non-alcohol substance misuse among people with schizophrenia: Epidemiological study in central London. Br J Psychiatry 2001;179:509-13.
Weaver T, Madden P, Charles V, Stimson G, Renton A, Tyrer P, et al.
Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. Br J Psychiatry 2003;183:304-13.
Drake RE, Mercer-McFadden C. Assessment of substance use among persons with chronic mental illness. In: Lehman AF, Dixon LB, editors. Double Jeopardy: Chronic Mental Illness and Substance Use Disorders. Australia: Harwood Academic Publishers; 1995. p. 47-62.
Wright S, Gournay K, Glorney E, Thornicroft G. Dual diagnosis in the suburbs: Prevalence, need, and in-patient service use. Soc Psychiatry Psychiatr Epidemiol 2000;35:297-304.
Mohan D, Chopra A, Sethi H. Incidence estimates of substance use disorders in a cohort from Delhi, India. Indian J Med Res 2002;115:128-35.
Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry 1997;54:313-21.
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, et al.
Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA 1990;264:2511-8.
Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian J Psychiatry 1998;40:149-57.
United Nations and Government of India. The Extent, Pattern and Trends of Drug Abuse in India - National Survey - 2004. New Delhi: Office of Drugs and Crime, United Nations and Ministry of Social Justice and Empowerment, Government of India; 2004.
Cuffel BJ, Heithoff KA, Lawson W. Correlates of patterns of substance abuse among patients with schizophrenia. Hosp Community Psychiatry 1993;44:247-51.
Drake RE, Osher FC, Noordsy DL, Hurlbut SC, Teague GB, Beaudett MS. Diagnosis of alcohol use disorders in schizophrenia. Schizophr Bull 1990;16:57-67.
Lehman AF, Myers CP, Dixon LB, Johnson JL. Defining subgroups of dual diagnosis patients for service planning. Hosp Community Psychiatry 1994;45:556-61.
Fowler IL, Carr VJ, Carter NT, Lewin TJ. Patterns of current and lifetime substance use in schizophrenia. Schizophr Bull 1998;24:443-55.
Shaner A, Eckman TA, Roberts LJ, Wilkins JN, Tucker DE, Tsuang JW, et al.
Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers - A government-sponsored revolving door? N Engl J Med 1995;333:777-83.