Tobacco, alcohol and drug use and mental health

Transcription

1 Melissa Coulthard Michael Farrell Nicola Singleton Howard Meltzer Report based on the analysis of the ONS Survey of Psychiatric Morbidity among Adults in Great Britain carried out in 2000 for the Department of Health, the Scottish Executive Health Department and the National Assembly for Wales Tobacco, alcohol and drug use and mental health London: TSO

2 Crown copyright 2002 Published with the permission of the Controller of Her Majesty s Stationery Office (HMSO). This report has been produced by the Social Survey Division of the Office for National Statistics in accordance with the Official Statistics Code of Practice. ISBN X Applications for reproduction should be submitted to HMSO under HMSO s Class Licence: Alternatively applications can be made in writing to: HMSO Licensing Division St. Clement s House 2 16 Colegate Norwich NR3 1BQ Contact points For enquiries about this publication, contact Nicola Singleton Tel: nicola.singleton.@ons.gov.uk To order this publication, call TSO on See also back cover. For general enquiries, contact the National Statistics Customer Enquiry Centre on (minicom: ) info@statistics.gov.uk Fax: Letters: Room D115, Government Buildings, Cardiff Road, Newport NP10 8XG You can also find National Statistics on the Internet at About the Office for National Statistics The Office for National Statistics (ONS) is the government agency responsible for compiling, analysing and disseminating many of the United Kingdom s economic, social and demographic statistics, including the retail prices index, trade figures and labour market data, as well as the periodic census of the population and health statistics. The Director of ONS is also the National Statistician and the Registrar General for England and Wales, and the agency that administers the registration of births, marriages and deaths there.

3 Contents Page List of tables List of figures Notes to tables Authors acknowledgements Summary of key findings v vii viii ix xi 1 Background, aims and methods Background Review of previous research Coverage of this report Sampling and interviewing procedure Concepts and methods used in assessing substance use Tobacco use Alcohol use and dependence Drug use and dependence The questionnaire Access to data 5 2 Prevalence of smoking, drinking and drug taking Introduction Smoking Smoking status Time between waking and first cigarette Age started smoking Alcohol Frequency of drinking and amount drunk Hazardous drinking Alcohol dependence Drug use and dependence Drug use Drug dependence Injecting drug use Overdose experience Interaction between smoking, drinking and drug taking 13 3 Socio-economic factors associated with substance use Introduction Socio-economic factors associated with smoking Personal characteristics Employment, financial and educational characteristics Accommodation characteristics Socio-economic factors associated with hazardous drinking Personal characteristics Employment, financial and educational characteristics Accommodation characteristics Socio-economic factors associated with drug dependence Personal characteristics Employment, financial and educational characteristics Accommodation characteristics Overview 45 iii

4 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Introduction Smoking and mental disorders Hazardous and dependent drinking and mental disorders Drug use and dependence and mental disorders Logistic regression analysis and overview 54 5 Help seeking, treatment and service use Introduction Tobacco smokers Hazardous drinkers and dependent drinkers Drug dependence 78 6 Stressful life events, social networks and social support 91 Appendices 6.1 Introduction Social context measures Stressful life events Social support and social network Tobacco use Alcohol use and dependence Drug use and dependence Conclusion 97 A Statistical terms and their interpretation 127 B Psychiatric disorders and their assessment 129 C Sections on substance use from the questionnaire 140 D Glossary of survey definitions and terms 149 Page iv

5 List of tables Chapter 2 Prevalence of smoking, drinking and drug taking Page 2.1 Cigarette smoking status (compared with the 2000 General Household survey) by sex Prevalence of cigarette smoking by age and sex Prevalence of cigarette smoking by ethnicity and sex Time between waking and first cigarette by age and sex Age started smoking cigarettes regularly by age and sex Frequency of drinking alcohol in past year by sex Amount usually drunk (by those who reported drinking alcohol in past year) by sex Frequency of drinking six or more drinks on one occasion during the past year by sex Prevalence of hazardous drinking by age and sex Prevalence of hazardous drinking by ethnicity and sex Prevalence of alcohol dependence by age and sex (rate per thousand population) Prevalence of alcohol dependence by ethnicity and sex (rate per thousand population) Lifetime experience of illicit drug use by age and sex (rate per thousand population) Illicit drug use in the past year by age and sex (rate per thousand population) Illicit drug use in the past month by age and sex (rate per thousand population) Illicit drug use in the past year by ethnicity and sex (rate per thousand population) Prevalence of drug dependence by age and sex (rate per thousand population) Prevalence of drug dependence by ethnicity and sex (rate per thousand population) Degree of drug dependence by drug type (rate per thousand population) Prevalence of injecting drugs (rate per thousand population) Prevalence, frequency and age started injecting drugs among those who have ever injected Ever experienced an accidental drug overdose by sex, age and whether ever used heroin or injected Number of accidental overdoses over lifetime Prevalence of self-reported drug use (ever) by cigarette smoking status, age and sex Prevalence of self-reported drug use in the past year by cigarette smoking status, age and sex Prevalence of self-reported drug use (ever) by AUDIT score, age and sex 35 Page 2.27 Prevalence of self-reported drug use in the past year by AUDIT score, age and sex Prevalence of self-reported drug use (ever) by cigarette smoking status, AUDIT score and sex Prevalence of self-reported drug use in the past year by cigarette smoking status, AUDIT score and sex Odds ratios for the co-occurrence of substance misuse Interaction between use of different types of drugs by sex 40 Chapter 3 Socio-economic factors associated with substance use 3.1 Cigarette smoking status by socio-economic factors Hazardous drinking by socio-economic factors Drug dependency by socio-economic factors Odds ratios of socio-economic factors associated with substance use by socio-economic factors 49 Chapter 4 Relationship between psychiatric morbidity and smoking, drinking and drug use 4.1 Cigarette smoking status by CIS-R score (grouped) and sex Cigarette smoking status by type of neurotic disorder and sex Cigarette smoking status by number of neurotic disorders and sex Cigarette smoking status by probable personality disorder and sex Substance use and dependence by psychotic disorder Prevalence of hazardous drinking by CIS-R score (grouped) and sex Prevalence of hazardous drinking by type of neurotic disorder and sex Prevalence of hazardous drinking by number of neurotic disorders and sex Prevalence of hazardous drinking by probable personality disorder and sex Prevalence of alcohol dependence by CIS-R score (grouped) and sex Prevalence of alcohol dependence by type of neurotic disorder and sex Prevalence of alcohol dependence by number of neurotic disorders and sex Prevalence of alcohol dependence by probable personality disorder and sex Drug use and dependence by CIS-R score (grouped) and sex Drug use and dependence by type of neurotic disorder and sex 70 v

6 Page 4.16 Drug use and dependence by number of neurotic disorders and sex Drug use and dependence by probable personality disorder and sex Odds ratios of psychiatric morbidity and socio-economic factors associated with substance use 73 Chapter 5 Help seeking treatment and service use 5.1 Treatment received for mental or emotional problems by cigarette smoking status Health care services used by cigarette smoking status Services turned down by cigarette smoking status Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by age and sex Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by CIS-R score (grouped) and sex Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by type of neurotic disorder Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by personality disorder Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by psychotic disorder Treatment received for mental or emotional problems by level of alcohol problem Health care services used by level of alcohol problem Services turned down by level of alcohol problem Main reason for stopping drinking by age and sex Contact with GP by whether stopped drinking because of health reasons Treatment received for mental or emotional problems by drug dependence Health care services used by drug dependence Services turned down by drug dependence Whether received any treatment, help or advice because they were using drugs (ever and in the past year) by age and sex Receipt of treatment, help or advice because of drug use by time last used drugs and drug dependence 90 Chapter 6 Stressful life events, social networks and social support 6.1 Number of stressful events in lifetime and past six months by cigarette smoking status and sex Illness, bereavement and relationship problems in lifetime and past six months by cigarette smoking status and sex Employment and financial crises in lifetime and past six months by cigarette smoking status and sex Victimisation experiences in lifetime and past six months by cigarette smoking status and sex Institutional care in childhood by cigarette smoking status and sex Social functioning characteristics by cigarette smoking status and sex Number of stressful events in lifetime and past six months by AUDIT score, alcohol dependence and sex Illness, bereavement and relationship problems in lifetime and past six months by AUDIT score, alcohol dependence and sex Employment and financial crises in lifetime and past six months by AUDIT score, alcohol dependence and sex Victimisation experiences in lifetime and past six months by AUDIT score, alcohol dependence and sex Institutional care in childhood by AUDIT score, alcohol dependence and sex Social functioning characteristics by AUDIT score, alcohol dependence and sex Number of stressful events in lifetime and past six months by illicit drug use and sex Number of stressful events in lifetime and past six months by drug dependence and sex Illness, bereavement and relationship problems in lifetime and past six months by illicit drug use and sex Illness, bereavement and relationship problems in lifetime and past six months by drug dependence and sex Employment and financial crises in lifetime and past six months by illicit drug use and sex Employment and financial crises in lifetime and past six months by drug dependence and sex Victimisation experiences in lifetime and past six months by illicit drug use and sex Victimisation experiences in lifetime and past six months by drug dependence and sex Institutional care in childhood by illicit drug use and sex Institutional care in childhood by drug dependence and sex Social functioning characteristics by illicit drug use and sex Social functioning characteristics by drug dependence and sex 126 Appendix B Page B.1 Alternative estimates of psychosis prevalence 135 B.2 Making assessments of probable personality disorder from the SCID-II self-completion questionnaire for screening for second stage interview 136 vi

7 List of Figures Page Chapter 2 Prevalence of smoking, drinking and drug taking 2.1 Smoking status by age Prevalence of hazardous drinking in the past year by ethnicity and sex Prevalence of alcohol dependence in the past year by age and sex (women and men) Proportion in each age group reporting ever using each of the five most commonly used drugs by age Percentage reporting ever using drugs by AUDIT score and smoking status 13 Chapter 3 Socio-economic factors associated with substance use 3.1 Percentage who smoke by highest educational qualification Hazardous drinking by marital status 43 Chapter 4 Relationship between psychiatric morbidity and smoking, drinking and drug use 4.1 Smoking status by CIS-R score AUDIT score by CIS-R score by sex (women and men) Drug dependence by type of personality disorder 54 Chapter 5 Help seeking treatment and service use 5.1 GP visits by smoking status Percentage who felt it would be very difficult to not smoke for a day by type of personality disorder Main reason for stopping drinking 78 Chapter 6 Stressful life events, social networks and social support 6.1 Percentage who have ever experienced separation or divorce by smoking status Percentage reporting ever experiencing personal injury, illness or assault by alcohol dependence Stressful life event occurring in past six months by when last used drugs 96 vii

8 Notes to tables 1 Tables showing percentages The row or column percentages may add to 99% or 101% because of rounding. The varying positions of the percentage signs and bases in the tables denote the presentation of different types of information. Where there is a percentage sign at the head of a column and the base at the foot, the whole distribution is presented and the individual percentages add to between 99% and 101%. Where there is no percentage sign in the table and a note above the figures, the figures refer to the proportion of people who had the attribute being discussed, and the complementary proportion, to add to 100%, is not shown in the table. The following conventions have been used within tables: - no cases 0 values less than 0.5%.. data not available 2 Statistical significance Unless otherwise stated, differences mentioned in the text have been found to be statistically significant at the 95% confidence level. Standard errors that reflect the complex sampling design and weighting procedures used in the survey have been calculated and used in tests of statistical significance. Tables giving the standard errors for key estimates are shown in Appendix A. 3 Bases Bases represent the total numbers in the column groups, and are not affected by missing values in the row variables. Very small bases have been avoided wherever possible because of the relatively high sampling errors that attach to small numbers. In general, percentage distributions are shown if the base is 30 or more. Where the base is lower, actual numbers are shown in square brackets. viii

9 Authors acknowledgements We would like to thank everybody who contributed to the survey and the production of this report. We were supported by our specialist colleagues in ONS who carried out the sampling, field work and computing elements for the survey. Particular thanks are due to Professor Terry Brugha, Jane Smith and the rest of the team at the University of Leicester who were responsible for carrying out the second stage interviews for the survey and to Professor Jeremy Coid who provided training in administering the SCID-II interview. Great thanks are also due to all the ONS interviewers who worked on the survey. We were assisted at all stages of the survey by a group of expert advisors who we would like to thank for the valuable specialist advice they provided. The group comprised: Professor P Bebbington, University College, London Professor T Brugha, University of Leicester Dr D Bhugra, Institute of Psychiatry, London Professor J Coid, Forensic Psychiatry Research Unit, St. Bartholemew's Hospital Dr M Farrell, Institute of Psychiatry, London Professor G Lewis, University of Wales, Cardiff Dr M Prince, Institute of Psychiatry, London The project was steered by a group comprising the following, to whom thanks are also due for assistance and advice given at various stages of the survey. Ms J Davies (chair), Department of Health Mr J O Shea (secretariat), Department of Health Mr R Bond, Department of Health Mr A Boucher, Department of Health Ms S Carey, Office for National Statistics Mr D Daniel, Department of Health Dr T Fryers, University of Leicester Dr S Gupta, Department of Health Dr A Higgitt, Department of Health Professor R Jenkins, Institute of Psychiatry, London Dr D Jones, Department of Health Ms T Jones, National Assembly for Wales Dr J Loudon, Scottish Executive Mr G Russell, Scottish Executive Mr J Sweeney, National Assembly for Wales Most importantly, we would like to thank all the participants in the survey for their time and cooperation. ix

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11 Summary of key findings Summary of key findings Summary of key findings 1 Background, aims and methods This report is based on a survey, carried out between March and September 2000, of psychiatric morbidity among adults aged 16 to 74 living in private households in Great Britain. The analyses covered in this report are based on 8,580 full or partial interviews carried out by ONS interviewers. The report specifically looks at tobacco, alcohol and other drug use and dependence and their relationship to psychiatric morbidity. This survey differs from other sources in that it collected information on substance dependence and the co-occurrence of psychiatric morbidity and the overlap between use of the different substances. Topics covered include: prevalence of substance use and dependence, the frequency of injecting drugs and overdoses, and the interaction between smoking, drinking and drug taking; socio-economic factors associated with smoking, hazardous drinking and dependence on any drug; the relationship between substance use and mental disorders; patterns of help seeking behaviours and service utilisation; and experience of stressful life events, levels of social support and social deprivation among substance users. Alcohol problems were assessed through the Alcohol Use Disorders Identification Test, AUDIT, which was developed by the World Health Organisation. It assesses drinking on an ascending scale indicating increasing levels of alcohol problems as revealed by reported physical, psychological and social consequences. The Severity of Alcohol Dependence Questionnaire (SAD-Q) was completed by those scoring above 10 on the AUDIT scale to provide a standardised measure of dependence. Degree of drug dependence was assessed by a set of five questions which had been used in previous studies; if someone answered yes to at least one question they were defined as dependent. 2 Prevalence of smoking, drinking and drug taking Men were more likely than women to report heavy smoking (11% compared with 7%) or being an exsmoker (27% compared with 19%). Those aged 20 to 24 reported the highest prevalence of smoking (44%) and this figure decreased with age with only 14% of those in the 70 to 74 age range reporting smoking. The proportion of smokers who had their first cigarette less than 15 minutes after waking was lower in the youngest age group at 18% and climbs incrementally to 35% by the age band 35 to 39 and then remains fairly level, before dropping slightly in the oldest groups. Around one in eight people (12%) reported not having any alcoholic drinks in the past year. However just under half of the population drank more than twice a week (48%). xi

12 Summary of key findings Among those who had an alcoholic drink over the past year, just under half (47%) reported that on a usual drinking day one to two standard drinks would be consumed, just under a quarter (24%) reported drinking three or four drinks and nearly a third (30%) reported drinking five or more drinks. Respondents were asked how often they consumed six or more drinks on one occasion. Two per cent said they drank this amount daily or almost daily and 17% reported that it was a weekly occurrence. Around a quarter (26%) of respondents were assessed as being hazardous drinkers, as indicated by a score of 8 or above on the AUDIT questionnaire. Four per cent scored above 16, which is a sign of a more severe drinking problem. Seven percent of the sample were assessed as being dependent on alcohol. Men were more likely that women to: be classified as hazardous drinkers (38% compared with 15%); be dependent on alcohol (12% compared with 3%); and consume a large number of alcoholic drinks on a usual drinking day (11% reported usually having ten or more drinks, whereas only 2% of women drank this amount). Younger people generally had higher AUDIT scores and were more likely to show signs of dependence than older people. AUDIT scores were significantly higher in the White group than the Black or South Asian groups. Respondents were given a list of illicit drugs and asked if they had ever taken any, excluding use prescribed by a doctor; 27% reported doing so, 11% reported doing so in the past year and 6% reported doing so in the past month. The lifetime prevalence rate for use of cannabis was 24%, for amphetamines 7%, for magic mushrooms 5%, for ecstasy, cocaine or LSD 4%, for tranquillisers 3% and for glue 1%. Crack, heroin, nonprescribed methadone and anabolic steroids had been used by less than 1% of the sample. Six percent had used cannabis in the last month, 1% used ecstasy and the other drugs were reported at lower rates. The prevalence of dependence on any drug was 4% and dependence on cannabis was reported most often (3%). Men were more likely than women to have used drugs, ever (32% compared with 21%), in the past year (13% compared with 8%) and in the past month (9% compared with 4%), and to be dependent on drugs. The first survey of psychiatric morbidity among adults in private households in 1993 found that 5% of people aged 16 to 64 reported taking any drug in the past year, whereas among people of the same age in the current survey it was 12%. Among those who have ever used drugs, 17 per 1,000 had ever injected, 7 per 1,000 had injected regularly and 3 per 1,000 had injected in the past month. Of those who had ever injected, 39% did so regularly, 22% injecting more than a hundred times and 17% injected in the last month. Of those who had ever used illegal drugs, 4% reported having experienced an accidental overdose. Men were twice as likely as women to have had an overdose (6% compared to 3%). xii

13 Summary of key findings Smoking, drinking and drug taking are behaviours that cluster together. There was an increased prevalence in drug use for each additional substance used. Nearly one in four (24%) smokers had used drugs in the last year compared to around one in twenty (5%) non-smokers. Non-smokers with an AUDIT score of zero were the least likely to have reported taking drugs ever (6%), whereas smokers with an AUDIT score of 16 or more were the most likely to have reported this (77%). 3 Socio-economic factors associated with substance use Smokers were more likely than non-smokers to: be younger (those aged 16 to 24 were nearly six times more likely to be smokers than the oldest age group, once other factors had been taken into account); be cohabiting, or divorced or separated rather than married (42%, 41% and 23% respectively were current smokers); and have fewer qualifications (for example, 22% of people with qualification of A level standard or above reported current smoking compared with 32% of those with GCSE level only and 36% of those with no qualifications). Other factors associated with smoking were being unemployed, working in a manual occupation, having lower household income, being in financial difficulty and living in an urban area. The proportion who were classed as hazardous drinkers were greatest among people who were: younger (the 16 to 24 year old group had the highest odds ratios (2.67) for hazardous drinking compared with the oldest age group); male (the odds of reporting hazardous drinking were three times greater for men than women, once other factors were taken into account); single or cohabiting (41% of single people and 38% of those who were cohabiting were hazardous drinkers compared with 20% of married people); and living in households with higher gross weekly incomes (among those with a household weekly income under 200 only 19% reported hazardous drinking, compared with 30% of those with income of 400 or more). Hazardous drinkers were also more likely to be of White ethnic origin, in manual occupations and living in privately rented accommodation. They were also more likely be experiencing financial difficulties, such as being behind in paying bills. People with drug dependence were more likely to be: younger (those aged 16 to 24 had odds of any drug dependence around 16 times greater (OR=16.39) than people aged 65 to 74, once other factors had been taken into account); un-married (4% of single people reported being dependent on other drugs with or without cannabis compared with less than half a per cent of those who were married or widowed); unemployed (4% were dependent on drugs other than cannabis, compared with 1% of people who were employed or economically inactive); and in financial difficulty (they were five times more likely to be dependent on drugs than those with no monetary problems). Drug dependence was also associated with living in private rented accommodation, as well as with being male. xiii

14 Summary of key findings 4 Relationship between psychiatric morbidity and smoking, drinking and drug use Current smoking, and in particular heavy smoking, was associated with all the forms of mental disorders examined. For example people with significant levels of neurotic symptoms, as shown by a CIS-R score of 12 or above, were more likely to smoke than those with a score below 12 (44% compared with 27%). The likelihood of having an AUDIT score of 16 or more or being alcohol dependent increased for people with a CIS-R score of 12 or more, a neurotic disorder, multiple disorders or an anti-social personality disorder (ASPD) compared to those without these disorders. The likelihood of being classed as a hazardous drinker was greater for women, but not men, with a CIS-R score of above 12 or with a multiple disorder, and for men and women with a ASPD, compared to those without a disorder. For example, 21% of women with a CIS-R score of 12 or more were hazardous drinkers compared with 14% of those with lower scores. People with a CIS-R score of 12 or more, with a neurotic disorder or ASPD were more likely to use drugs or be dependent on drugs. Five percent of the general population reported using drugs in the last month, compared with 12% of people with a CIS-R score of 12 or more and 32% of people with an ASPD. 5 Help seeking, treatment and service use In general, heavy smokers were most likely, and non-smokers were least likely, to report use of the following treatments or services for a mental or emotional problem: currently receiving medication, counselling or therapy (13% and 5%); GP consultations in the past year and the past two week; community or day activity services in the past year and the past quarter; or in-patient or out-patient visit in the last quarter (2% and 1%). People who used to smoke regularly but had now given up were more likely than the other groups to report speaking to the GP or having an in-patient or out-patient visit for a physical problem. Current smokers were asked whether they would like to give up smoking and over 70% said they would. All age groups reported a similar rate of desire to stop (69% to 75%) except the oldest group, where only 56% reported wishing to stop. When asked about the difficulty of giving up smoking for a day 21% reported they thought it would be easy, while 31% of men and 37% of women thought it would be very difficult. The youngest age group were least likely to think it was difficult to give up smoking for a day; 19% of people aged 16 to 24 thought it would be very difficult, compared with 41% of those in the age groups above 34. Smokers with a CIS-R score of 12 or more were more likely to want to stop smoking, with 79% stating they wished to stop compared to 70% of those with a lower score. Similarly, smokers with generalised anxiety disorder or a personality disorder other than anti-social had a high proportion wanting to give up smoking. Smokers with a CIS-R score of 12 or more, a personality disorder other than anti-social, probable psychosis or smokers who have experienced depressive episodes were more likely to think it would be difficult to go without smoking for a day. For example 59% of smoker with probable psychosis thought it would be very difficult, compared to 35% of people with no psychotic disorder. xiv

15 Summary of key findings Compared with non-hazardous drinkers, dependent drinkers had similar levels of health service use and hazardous but non-dependent drinkers actually tended to use fewer health services. For example, among hazardous but non-dependent drinkers 9% had spoken to their GP in the past two weeks for a mental or emotional problem compared to 12% of non-hazardous drinkers and 15% of those with alcohol dependence. This may reflect the fact that young men, who are known to use fewer health care services, are over-represented among hazardous drinkers. Four per cent of people used to drink alcohol but have given up at some point in their lives. The main reasons given for why they stopped drinking were health (49%), not liking it (21%) and religion (6%). People who had stopped drinking for health reasons were more likely to have consulted their GP in the last year for either physical or emotional problems compared with the general population, for example 82% had spoken to their GP because of a physical complaint compared with 61% of the general population. People who were dependent on cannabis only were similar to people with no drug dependence with respect to health service use, with the exception that people dependent on cannabis only were more likely to have spoken to their GP about a mental or emotional problem; in the past year 18% had done so compared with 11% of people with no drug dependence. Individuals dependent on drugs (with or without cannabis) were more likely to use some services as a result of mental and emotional problems. This group were most likely: to be receiving current treatment (16% compared with 7% of people with no drug dependence); to have spoken to a GP about a mental or emotional problem in the past year (27% had done so); or to have used community care services (11% had used such services in the last quarter, compared to 3% of the remaining population). However people dependent on drugs other than cannabis were less likely to report an in-patient stay or out-patient visit because of a physical complaint in the previous three months; 9% reported doing so compared with 15% of people dependent on cannabis only and 19% of people with no dependence. Ten per cent of people who were dependent on any drugs and 23% of people dependent on drugs other than cannabis reported receiving advice or help with regards to drug problems in the past year. 6 Stressful life events, social networks and social support Almost a third (32%) of smokers had experienced one of the stressful life events covered in the survey in the past six months, compared with less than a quarter (23%) of non-smokers. Heavy smokers were most likely to have spent time in an institution as a child (6% had done so) or to have been taken into local authority care up to the age of sixteen (5% had been) while those who had never smoked regularly were least likely (1% in each case). Heavy smokers also had the lowest levels of social support. They were most likely to perceive a severe lack of social support (12% compared to 7% of non-smokers), have a primary support group of less than four people (10% compared to 4% of non-smokers) and were least likely to have seen more than two friends in the last week (70% compared with 76% of non-smokers). xv

16 Summary of key findings Hazardous and, in particular, dependent drinking was associated with: having had an injury, illness or assault; separation and divorce; having a recent serious problem with a close friend or relative; being made redundant or sacked; having a financial crisis; being bullied; suffering violence in the home; being expelled from school; and being homeless. One of the largest differences concerned problems with police involving a court appearance; 64% of people who where at least moderately alcohol dependent said this had happened to them at some time compared with 8% of people with no dependence. People with moderate or severe dependence were more likely to perceive a lack of social support or have a smaller primary support group; 36% reported a severe lack of social support compared to 8% of the total population. People who have used or are dependent on drugs reported more stressful experiences over their lifetime and in the past six months. They were more likely to report: experiencing separation or divorce; having had a serious problem with a close friend or relative; the recent death of a close friend or relative; an employment or financial crisis; being bullied; being homeless; and running away from home. One of the most extreme differences between people who had used drugs and those who had not was whether they had ever been in trouble with the police involving a court appearance. Looking at the whole sample, 9% of people reported this, however among those who had ever used drugs in the past month the figure was 28%, for people dependent on cannabis it was 32%, and for people dependent on other drugs it was 42%. xvi

17 1 Background, aims and methods Background, aims and methods Background This report is based on a survey of psychiatric morbidity among adults aged 16 to 74 living in private households in Great Britain. The report specifically looks at tobacco, alcohol and other drug use and dependence and their relationship to psychiatric morbidity. This survey was commissioned by the Department of Health, the Scottish Executive Health Department and the National Assembly for Wales. The survey was carried out in 2000 and is a repeat of a similar survey of adults living in private households conducted in A main report on the key findings of the survey (Singleton et al, 2001) looks at prevalence rates for mental disorders and compares people with different types of mental disorders with those without disorders on a range of sociodemographic, health, medication and service use measures. Comparisons are also made between results from the 1993 and 2000 surveys. The Technical Report gives details of the questionnaire and assessment, sampling and weighting procedures (Singleton et al, 2002) and is available on the National Statistics website ( This current report is one of a number of topic reports being produced. Those already available cover: suicidal thoughts and behaviours (Meltzer et al, 2002a); the social and economic circumstances of people with mental disorder (Meltzer et al, 2002b); and people with psychotic disorder (O Brien et al, 2002). Other reports will look at: personality disorder; and the mental health of older people (defined for the purpose of this survey as those aged 60 to 74 years). This report on tobacco, alcohol and other drug use and psychiatric comorbidity covers an area of major policy concern: that of mental health problems related to smoking, drinking and drug using behaviour (Hall and Farrell, 1997). There is a substantial burden to mental health services and other generic health and social services associated with people with major mental illness who are dependent on alcohol and other drugs, arising through increased levels of hospitalisation, increased duration of hospital stay and overall increased use of mental health services and poorer long term outcome (Wu et al, 1999; Pirzada et al, 1997). Much of this information is derived from the study of patterns of psychiatric service utilisation and descriptions of behaviour of those within clinical services. It is, therefore, important to look at the general population to find out if there is a similar pattern of association between substance misuse and mental health problems among those not in contact with clinical services. Smoking and drinking are relatively common, thus it is possible in a large household survey to look at the correlation between these behaviours and other psychiatric disorders. There is a lack of general awareness that smoking is significantly related to increased rates of all forms of psychiatric morbidity as well as being related to very significant levels of physical morbidity. This survey provides an opportunity to further explore the relationship between smoking and both major and minor psychiatric morbidity. Illicit drug use is less common but nevertheless important because of the substantial links between certain types of drug use and major psychiatric disorder. Secondary analysis of the 1993 survey reported on patterns of psychiatric comorbidity (Farrell et al, 2001) and further work was done looking at the co-occurrence of mental disorders and substance misuse among homeless people (Gill et al, 1996; Kershaw et al, 2000), prisoners (Singleton et al, 1999) and young people aged 11 to 15 years (Meltzer et al, 2000). This report focuses entirely on the topic of substance use and psychiatric comorbidity in the 1

18 1 Background, aims and methods general population and provides a stand-alone reference on the data from the national household survey which specifically relate to this topic. While some of the information included here was covered in the main report, this report provides a greater level of detail and discusses more fully the possible significance of many of the key findings. 1.2 Review of previous research The issue of comorbidity has been called the premier challenge of the 1990s (Kendall and Clarkin, 1992). The relationship between psychiatric disorders, substance consumption, misuse and dependence has been the subject of a number of large scale epidemiological surveys (Helzer and Pryzbeck, 1988; Robins and Regier, 1991; Kessler, 1994). The largest survey on comorbidity was the National Psychiatric Comorbidity Survey in the United States, otherwise known as the NCS (Kessler et al, 1994). The NCS found that approximately 14.1% of adults met criteria for alcohol dependence at some point in their lives (Anthony et al, 1994; Kessler et al, 1994). Within the 12 months prior to interview 2.5% met DSM III-R criteria for alcohol abuse and 4.4% for dependence (Kessler et al, 1997). Approximately one in four persons (24%) met criteria for nicotine dependence at some point in their lives while 7.5% met criteria for other drug dependence and 4.4% for other drug abuse (Anthony et al, 1994). Cannabis was the most common illicit drug of dependence (4.2% met lifetime criteria) followed by cocaine (2.7%), stimulant (1.7%), and sedative (1.2%) dependence (Anthony et al, 1994). Lifetime dependence on heroin was reported by 0.7% of the population. A number of factors are consistently reported to be associated with substance related disorders across a broad range of surveys in the United States, Europe and Australia. They are more common in males than in females, rates decline significantly with age and young people are more likely to meet criteria for all substance use disorders (Anthony et al, 1994). Persons meeting criteria for illicit substance use disorders are more likely to be unemployed, more likely to have completed fewer years of education and are less likely to be married (Anthony and Helzer, 1991). People with alcohol use disorders are more likely to be separated or divorced, more likely to be unemployed and more likely to have had fewer years of schooling (Crum, Helzer and Anthony, 1993). Also tobacco dependence is associated with lower socioeconomic status, more unemployment and fewer years in education (Anthony et al, 1994; Jarvis and Wardle, 1999). The relationship between nicotine, alcohol and drug dependence and psychiatric comorbidity in the 1993 Psychiatric Morbidity Survey in Great Britain has been investigated (Farrell et al, 2001). This found that 12% per cent of the non-dependent population were assessed as having any psychiatric disorder compared with 22% of the nicotine dependent, 30% of the alcohol dependent and 45% of the drug dependent population. 1.3 Coverage of this report The first report from the survey (Singleton et al, 2001) looked at prevalence and trends of a range of mental disorders and alcohol and drug use and dependence. It also examined the characteristics of those with alcohol or drug problems, and the medical treatment and services they use. However, it did not cover all the data collected on substance use. This report includes a more detailed analysis of alcohol and drug use, and features additional results on injecting and overdosing. It also looks at tobacco use, which was not described in the first report. The main aim of this report is to look in more detail at use of tobacco, alcohol and drugs and their association with psychiatric morbidity. Chapter 2 looks at the prevalence of smoking, drinking and drug use in the population, the degree of alcohol and drug dependence, and the frequency of injecting drugs and overdoses. The overlap between smoking, drinking and drug taking and the interaction between all three is considered also. Chapter 3 examines the socio-economic factors associated with smoking, hazardous drinking and dependence on any drug. The relationship between substance use and mental disorders is considered in Chapter 4, while Chapter 5 considers patterns of help seeking behaviours and service utilisation. Chapter 6 looks at the experience of stressful life events, levels of social support and social deprivation among substance users. 2

19 1.4 Sampling and interviewing procedure The survey was carried out between March and September A two-stage approach to the assessment of mental disorders was used. The first stage interviews were carried out by ONS interviewers and included structured assessment and screening instruments for measuring mental disorders, as well as covering a range of other topics, such as service use, risk factors for disorder and background socio-demographic factors. A subsample of people were then selected to take part in a second stage interview to assess psychosis and personality disorder, the assessment of which requires a more detailed interview than was possible at the first stage and some clinical judgement. These interviews were carried out by specially trained psychologists employed by the University of Leicester. The small users postcode address file (PAF) was used as the sampling frame for the survey because of its good coverage of private households in Great Britain. In the PAF, the postcode sectors were stratified on the basis of socio-economic group within NHS Regions and a sample of 438 postal sectors yielding 15,804 addresses was selected. Interviewers visited the 15,804 addresses to identify private households with at least one person aged 16 to 74 years. The Kish grid method was used to select systematically one person in each household (Kish, 1965). More details of sampling procedures can be found in the Technical Report. Overall, 10% of sampled addresses were ineligible because they contained no private households. Of the remaining addresses, 11% contained no-one within the eligible age range, which left an eligible sample of 12,792 addresses. Just under 70% of those approached agreed to take part in a first-stage interview and despite the length of the interview, 95% completed the full interview, i.e. 8,450 respondents. The analyses covered in this report are based on 8,580 full or partial interviews. 1.5 Concepts and methods used in assessing substance use While reading this section it may be useful to refer to Appendix C which contains the sections of the questionnaire relating to substance use, and to Background, aims and methods Appendix B which describes the assessment of alcohol misuse and alcohol and drug dependence Tobacco use Questions on smoking were adapted from the well established set used on the General Household Survey (GHS) (Walker et al, 2001). The section looks at whether people smoke, the amount they smoke, the age they started smoking, whether they would like to give up smoking, how easy they believe it would be to give up smoking and how soon after waking they smoke their first cigarette (a measure of nicotine dependence). In this report, smoking status is categorised into five groups: non-smokers, ex-regular smokers and light, medium or heavy smokers. It was important to distinguish between those non-smokers who used to smoke regularly (ex-regular smokers) and those who had never smoked regularly (never regular) as they were distinct groups with different behaviours. It was also important to group smokers depending on how heavily they smoked, as differences can be observed between these groups. Definitions were the same as those used in the GHS: those who smoke less than 10 cigarettes (light); those who smoke at least 10, but less than 20 (moderate); and those who smoke 20 or more per day (heavy) Alcohol use and dependence The first few questions are taken from the General Household Survey (GHS) questionnaire (Walker et al, 2001) and were asked by the interviewer. They assess whether people drink alcohol or not, and ask the reasons behind choosing not to drink, which the interviewer then codes into one of six categories. The remaining alcohol use questions were selfcompleted by the respondents on the laptop, rather than being asked by an interviewer. Alcohol problems were assessed through the Alcohol Use Disorders Identification Test, AUDIT (Babor et al, 1992). This measure was developed from a six-country World Health Organisation 1 3

20 1 Background, aims and methods collaborative project and has been shown to be a good indicator of hazardous drinking (Saunders et al, 1993). It defines hazardous alcohol use as an established pattern of drinking which brings the risk of physical and psychological harm. Taking the year before interview as a reference period, the AUDIT consists of 10 questions covering the following topics: Hazardous alcohol consumption; frequency of drinking typical quantity consumed frequency of heavy drinking Dependence symptoms; and impaired control over drinking increased salience of drinking morning drinking Harmful alcohol consumption feeling of guilt or remorse after drinking blackouts alcohol-related injury other people concerned about drinking Answers to all questions are scored from zero to 4 and then summed to provide a total score ranging from zero to 40. A total score of 8 or above is indicative of hazardous alcohol use. For the purpose of this report, people with a score of 16 or more are described as having a harmful pattern of drinking. Alcohol dependence was assessed using the Severity of Alcohol Dependence questionnaire, SAD-Q (Stockwell et al, 1983). The SAD-Q was asked of all respondents who had an AUDIT score of 10 or more. It consists of 20 questions, covering a range of symptoms of dependence, and possible scores range from zero to three on each question. Adding up the scores from all questions gives a total SAD- Q score of between zero and 60 indicating different levels of alcohol dependence. A total SAD-Q score of three or less indicates no dependence, while a score of four or above suggests some alcohol dependence. Mild dependence is indicated by a score of between 4 and 19, moderate dependence by a score of 20 to 34, and severe dependence by a SAD-Q score of 35 to 60. For some of the analysis in this report, moderate and severe dependence were combined into a single category due to the small numbers in these groups. The reference period for alcohol dependence was the six months prior to interview. In some tables both the AUDIT and the SAD-Q score were combined to form the following groupings: No hazardous drinking (AUDIT score of less than 8). Hazardous drinking not dependent (AUDIT score of 8 or more and a SAD-Q score of 0-3). Alcohol dependent (AUDIT score of 8 or more and a SAD-Q score of 4 or more) Drug use and dependence A number of questions designed to measure drug use were contained in the questionnaire. It was made clear to respondents that they should exclude any drugs that had been prescribed to them by a doctor. Information was first collected on all the types of drugs respondents had ever used, and then about drugs used in the previous year. Further information about drug use in the year, and month, preceding interview was collected about six drugs: cannabis, amphetamines, crack, cocaine, ecstasy, tranquillisers and opiates. Included in the questions about drug use in the past year and month were five questions to measure drug dependence. The topics covered by these questions were: Frequency of drug use: used drug every day for two weeks or more. Stated dependence: felt they needed it or were dependent on it. Inability to cut down: tried to cut down but could not. Need for larger amounts: needed more to get an effect. Withdrawal symptoms: feeling sick because stopped or cut down. A positive response to any of the five questions was used to indicate drug dependence. Because people could be dependent on more than one drug, they were further grouped into those who were: dependent on cannabis only; dependent on another drug (including those also dependent on cannabis); and not drug dependent. In addition information was collected from respondents on the age they started using drugs, experiences of overdoses and injecting, and on treatment, help or advice that they may have had in relation to drug use. 4