Mental Health Coordinating Council

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Mental illness and smoking
Mental illness and substance use (MISU)

Mental illness and smoking

Most of the information provided in the section on smoking, below, paraphrases the data provided in: Smoking reduction and cessation for people with schizophrenia, Guidelines for general practitioners, available online at: www.health.vic.gov.au/mentalhealth/publications/smoke

How many people living with a mental illness are regular smokers?

On average, smoking is over three times more prevalent among people with a mental illness compared with the general population. Approximately 75% of Australians experiencing schizophrenia smoke, in comparison with around 20% of the population as a whole.
People with schizophrenia also tend to smoke more cigarettes per day, and smoke brands of cigarettes which have high levels of nicotine and tar.

What is the effect of smoking on a person's mental health?

Smoking can have effects on mental health, both in the short and long-term.

1. Medication: The tar in cigarettes has been shown to induce liver enzymes, which increase the metabolism of some antipsychotic medications. This can result in the need for increased doses of medication to obtain the same level of effectiveness.
2. Finances: People with schizophrenia and other mental illnesses often have limited incomes. The high financial cost of a regular smoking habit can leave little money for basic necessities, thus causing emotional and physical stress.
3. Restricted Activities: Participation in recreational activities may be restricted by the public smoking ban in many venues (e.g. cinemas), as may participation in education (e.g. vocational courses) and work.
4. Personal Appearance: The effects of heavy smoking on an individual's personal appearance may further complicate attempts to obtain work or to socialise.
5. Cessation Issues: Many individuals living with a mental illness (and those who are not) are highly susceptible to depression following the cessation of smoking.

All these factors combine to reduce the effectiveness of efforts and the treatment and/or rehabilitation of an individual's mental health condition. 

Why might people experiencing schizophrenia be more likely to smoke?

1. Effects on Dopamine: Dopamine is a chemical substance which transmits impulses in the brain.The negative symptoms of schizophrenia, such as a lack of energy, motivation and 'affective blunting' (restricted emotional experience and expression) are thought to be due to decreased dopamine activity in the brain.  Studies have shown that nicotine increases the activity of dopamine, and may thus reduce these negative symptoms.
2. Effects on Cognitive Dysfunction: Nicotine has been shown to increase alertness, and enhance concentration and information processing. This may be of benefit to individuals, such as those with schizophrenia, for whom cognitive dysfunction may be part of their illness or a side effect of antipsychotic medication.
3. Relaxation: Whilst it can cause stimulation, Nicotine has also, paradoxically, been shown to aid in relaxation - reducing tension, anxiety and anger. It may therefore provide a coping mechanism for individuals who suffer mental illnesses that effect their ability to deal with negative feelings and stressful situations.
4. Depression: Observations that Nicotine withdrawal can provoke the onset of depression have led to speculation that Nicotine may have an antidepressant effect due to its effect on various neurotransmitter systems.
5. Ritual: The ritual of smoking provides relief from boredom. It also provides a means of social interaction: evidence suggests that within institutions there is considerable social pressure in favour of smoking, both from other mental health clients, and from staff, who may use smoking as a means of engaging clients and as a bonding tool - 'Let's go for a smoke and talk about it' (SANE Australia Smoke Free Kit).

Conventional smoking programs do not always consider the unique benefits, listed above, that people living with a mental illness may derive from smoking. One resource that does is the SANE Australia Smoke Free Kit. To purchase the kit please visit SANE Australia at: http://www.sane.org/

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Mental illness and substance use (MISU)

What is substance abuse?

Substance abuse is a pattern of drug use (including alcohol, prescription and illegal drugs) that is problematic and/or destructive, but does not fulfill the criteria for substance dependence.

What does the term MISU mean?

The term MISA (Mental Illness and Substance Abuse) is increasingly used to refer to people who have coexisting substance abuse and mental illness or psychiatric disability.

Why is MISU such an important issue in mental health? 

People living with a mental illness are at an increased risk of developing problematic alcohol or drug use, especially those aged 18-25 years. Dual diagnosis (MISU) is associated with a host of social, behavioural, psychological and physical problems, including: increased psychiatric symptom severity; suicidal behaviour; greater non-compliance with treatment; more hostile and agressive behaviours; increased risk of violence to others; higher rates of offending, imprisonment and homelessness, and longer duration of admission to psychiatric inpatient units. (www.mhcc.org.au/factsheets/factsheet7.htm).

Why do people with a mental illness use substances?
People with a mental illness use substances for a variety of reasons: to relax, to cope or to self-medicate (i.e. relieve the symptoms of mental illness or prescription medication.

How does substance abuse affect individuals with mental illness?
The use of certain substances may worsen symptoms of mental illness. For example, it may increase delusions, increase agitation and affect general mood stability (i.e. it may make an individual feel more depressed or anxious).

People with dual diagnosis may also relapse more and require hospitalisation more frequently.

Finally, the symptoms of substance use and withdrawal can be quite similar to the symptoms of mental illness. Thus withdrawal may exacerbate or bring on the symptoms of mental illness in individuals where both problems are present.

What problems have been identified with MISU service delivery?
Since the emergence of the issue of dual diagnosis in the 1980s, a number of key problems in service delivery have been identified. Due to the plurality of their problems, MISA clients are frequently bounced from one relevant service to another ("ping pong therapy"). At a service level, treatment for individuals with  MISU has traditionally been provided in separate mental health and alcohol and other drug programs in serial or "parallel" fashion. MISU service users must negotiate between the two systems - systems which often have differing philosophical approaches. An integrated approach to service delivery (i.e. cross training of staff in both mental health and subth stance abuse) is needed to cater to the unique needs of MISU clients.

What is happening regarding MISU? What Services are Available?

A number of services designed to address the problems of dual diagnoses clients in tandem have emerged in recent years. The NSW State Dual Diagnosis Project, managed by the Centre for Mental Health aims to develop a strategy to meet the needs of people with MISU, via cooperation between alcohol, drug and mental health services.

In relation to services for person suffering a dual diagnosis of drug addiction and mental illness, current initiatives include:

1. A new committee titled the NSW Health Comorbidity Subcommittee (Drug and Alcohol and Mental Health) is currently being established, made up of both clinicians and senior staff from the Centre for Drug and Alcohol (CDA) and the Centre for Mental Health (CMH).
   
   The Dual Diagnosis Systems Analysis Project will enable a measure of the severity of affliction and characteristic diagnostic combinations of co-morbidity in the clinical population served by drug and alcohol and mental health services, and will identify best practice responses to varying presentations of dual diagnosis.
   
   As part of the project interviews, site visits and focus groups were conducted with key informants, including mental health services, drug and alcohol services, consumers and carers regarding the management of clients with co-morbidity.
   
   A final discussion paper will summarise the findings of the systems analysis including:
   
   • Summary of the literature analysis
   • An overview of the system and the gaps in service provision, based on case studies and interviews with service providers
   • Analysis of the mental health data and the drug and alcohol survey data
   
   The discussion paper will also provide an overview of the key areas where change is required, and will inform the development of a strategic framework for managing co-morbidity.
   
   
2. Cannabis Clinics:
   A key goal of the cannabis clinics is to deal with complex cannabis related presentations, in particular, the clinics will provide services to people with problematic cannabis use and mental health problems.
   
   Three clinics, established by CDA, have commenced operation:
   
   • Western Sydney clinic at Parramatta and Westmead Hospital, commenced December 2003
   • Central Coast clinic at Gosford with outreach services to health centres in Wyong, Woy Woy, Erina, Long Jetty and Kanwal, commenced October 2004
   • Central West clinic at Orange commenced November 2005 with outreach services to Bathurst, Parkes, Cowra, Forbes and Condobolin (not yet formally launched)
   
   The Southern clinic operating from Sylvania will be opened later in 2006. This new clinic will initially operate from the Sylvania Community Health Centre and transfer to the new community health facility at Sutherland Hospital when construction is completed. Outreach services will also be available to clients at Engadine and Menai.
   
   
3. Consultation Liaison:
   Joint 24 Hour Emergency Department mental health and drug and alcohol acute services response models are being developed.  Drug and alcohol consultation liaison services currently operate at Nepean Hospital, to support their Psychiatric Emergency Care Services (PECS). A second site is being considered.
   
   
4. Local Initiatives:
   Area Health Services undertake and fund local programs that specifically target people with a dual diagnosis, such as “Manage Your Addiction and Mental Illness” (MYAMI) program established in Sydney West Area Drug and Alcohol services.
   
   
5. Education/Training:
   A certificate IV Dual Diagnosis Traineeship (ITAB) is being planned which will develop complementary mental health competency modules as part of the drug and alcohol apprenticeship, along with supporting log books, manuals and promotional material.
   
   CDA, in collaboration with TAFE NSW, is developing a Diploma of Community Services Case Management (Dual Diagnosis) with a focus on Aboriginal health.
   
   
6. A Dual Diagnosis Planning Forum was held in May 2006. The planning forum  will inform the development of a strategic framework for the management of clients with co-morbid mental health and substance use disorders.
   
   
7. A resource manual on drug and alcohol issues has been developed for use by mental health workers. This is soon to be released. A resource kit on mental health issues for drug and alcohol issues is also being developed.
   

Strategy Dual Diagnosis Project: The Dual Diagnosis Support Kit

Strategy Dual Diagnosis Project is a partnership between MHCC and NSW Department of Community Services. Funded by the Australian Government Department of Family and Community Services, the Dual Diagnosis Project was developed in recognition of the growing numbers of children affected by parental dual diagnosis in child protection and health services in NSW.

In accordance with the objectives of this project, MHCC in partnership with DOCS has developed a kit which provides resources for foster carers and caseworkers dealing with children whose parents are affected by mental illness and substance misuse. The Kit is the result of over two years work by the National Illicit Drug Strategy Dual Diagnosis Project – a Funded by the Australian Government Department of Family and Community Services. The Support Kit forms part of a comprehensive approach to educating workers and carers about parental dual diagnosis, and compliments a series of training packages available to NGOs and carer groups. It can be ordered from : http://www.community.nsw.gov.au/html/news_publications/dual_diagnosis.htm

For links to other dual diagnosis related services, please visit the NSW Office of Drug & Alcohol Policy's Dual Diagnosis Page at: http://www.alcoholinfo.nsw.gov.au/dependence,_disease_and_treatment/dual_diagnosis