Impact of Substance Use Disorder on Quality of Inpatient Mental Health Services for People With Anxiety and Depression

Abstract

Objective: Substance use disorders are commonly comorbid with anxiety and depressive disorders and are associated with poor treatment outcomes. The mechanisms underlying this association remain unclear—one possibility is that patients with anxiety/depressive disorders and substance use disorders receive poorer treatment. Concerns have been raised about the quality of inpatient care received by patients with substance use disorders. The purspose of this research was to examine the quality of care received by inpatients with an anxiety or depressive disorder, comparing subgroups with or without a comorbid substance use disorder. Methods: This was a retrospective case-note review of 3,795 patients admitted to inpatient psychiatric wards in England. Data were gathered on all acute admissions with anxiety/depressive illness over a 6-month period, for a number of measures of quality of care derived from national standards. Association of coexisting substance use disorders with a variety of quality of care outcomes (relating to assessment, care planning, medication management, psychological therapies, discharge, crisis planning, and follow-up) was investigated using multivariable regression analyses. Results: In all, 543 (14.3%) patients in the study had a secondary diagnosis of a substance use disorder. Patients with substance use disorders were less likely to have had care plans that were developed jointly (i.e., with input from both patient and clinician; odds ratio [OR] = 0.76, 95% confidence interval [CI] [0.55, 0.93], p = .034) and less likely to have had their medication reviewed either during the admission (OR = 0.83, 95% CI [0.69, 0.94], p = .030) or at follow-up after discharge (OR = 0.58, 95% CI [0.39, 0.86], p = .007). Carers of patients with substance use disorders were less likely to have been provided with information about available support services (OR = 0.79, 95% CI [0.57, 0.98], p = .047). Patients with substance use disorders were less likely to have received adequate (at least 24 hours) notice in advance of their discharge (OR = 0.72, 95% CI [0.54, 0.96], p = .033), as were their carers (OR = 0.63, 95% CI [0.41, 0.85], p = .007). They were less likely to have a crisis plan in place at the point of discharge (OR = 0.85, 95% CI [0.74, 0.98], p = .044). There was also strong evidence that patients with substance use disorders were less likely to have been referred for psychological therapy (OR = 0.69, 95% CI [0.55, 0.87], p = .002). Conclusions: We found evidence of poorer quality of care for inpatients with anxiety and depressive disorders with comorbid substance use disorders, highlighting the need for more to be done to support these patients. Discrepancies in care quality may be contributed to the poor treatment outcomes experienced by patients with substance use disorders, and strategies to reduce this inequality are necessary to improve the well-being of this substantial patient group.

Keywords:

• anxiety disorders
• depressive disorders
• comorbidity
• inpatient services
• quality of care

Acknowledgements

The authors would like to thank all members of the NCAAD team at the Royal College of Psychiatrists for their support with this study.

Disclosure statement

LF and DB each received a consultancy fee (payable to the Universities of East London and Southampton, respectively) from the RCPsych for their input to the NCAAD.

Data availability statement

All authors had access to the full study data set. The data set is held by the NCAAD team at the RCPsych Center for Quality Improvement and could be made available on request.

Additional information

Funding

RW is supported by a UK National Institute for Health Research (NIHR) Academic Clinical Fellowship. The Imperial Biomedical Research Center Facility which is also funded by the NIHR provided support for this project. The NCAAD was funded by the Royal College of Psychiatrists in conjunction with the McPin Foundation—an independent mental health research charity. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, RCPsych, or the Department of Health.