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: [email protected] To order this publication, call TSO on See also back cover. For general enquiries, contact the National Statistics Customer Enquiry Centre on (minicom: ) [email protected] 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

10 x

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

21 1.6 The questionnaire In addition to substance use the questionnaire looked at various aspects of psychiatric morbidity. Those which have been used in this report are: neurotic symptoms and disorders (using the CIS-R Revised Clinical Interview Schedule); CIS-R score type of neurotic disorder number of neurotic disorders probable personality disorder from self-report; and probable psychosis. The way in which these disorders were assessed in the survey is discussed in Appendix B. Questions to gather information on a range of factors that might be related to mental disorder were also included in the survey questionnaire. The topics covered were: General health and service use self-perceived health status: the SF-12 and long-standing illness medication and service use GP, inpatient, outpatient, day activity services and community care lifetime experience of treatment in mental hospitals/wards Socio-demographic data personal characteristics: eg age, marital status, ethnicity Education and employment Finances income and debt Accommodation - tenure, stability, quality Stressful life events experienced Social networks and social support Activities of daily living difficulties and help received Intellectual functioning New Adult Reading Test (NART) TICS-m and animal naming test (adults aged 60 and over) For more details on the questionnaire see the main report (Singleton et al, 2001) or the Technical Report of the survey (Singleton et al, 2002). 1.7 Access to data Background, aims and methods Anonymised data from the survey is held at the Data Archive, University of Essex. Independent researchers who wish to carry out their own analyses should apply to the Archive for access. For further information about archived data, please contact: ESRC Data Archive University of Essex Wivenhoe Park Colchester Essex CO4 3SQ Tel: (UK) FAX: (UK) [email protected]. References Anthony J C and Helzer J (1991) Syndromes of drug abuse and dependence, in Robins L N and Regier D A (eds), Psychiatric Disorders in America, The Free Press: New York, Anthony J C, Warner L and Kessler R (1994) Comparative Epidemiology of dependence on tobacco, alcohol, controlled substances and inhalants. Basic findings from the National Comorbidity Survey. Experimental Clinical Psychopharmacology 2 (3), Babor T F, de la Fuente J R, Saunders J and Grant M (1992) AUDIT The Alcohol Use Disorders Identification Test: Guidelines for use in Primary Health Care, World Health Organisation: Geneva. Crum R M, Helzer J E and Anthony J C (1993) Level of education and alcohol abuse and dependence in adulthood; a further inquiry. The American Journal of Public Health 83(6), Farrell M, Howes S, Bebbington P, Brugha T, Jenkins R, Marsden J, Taylor C and Meltzer H (2001) Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a National Household Survey. British Journal of Psychiatry 179, Gill B, Meltzer H, Hinds K and Petticrew M (1996) Psychiatric Morbidity among the Homeless, TSO: London. Hall W and Farrell M (1997) Comorbidity of mental disorders with substance misuse. British Journal of Psychiatry 171, 4 5. Helzer J E and Pryzbeck T R (1988) The co occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment. Journal of Studies on Alcohol 49, Jarvis M and Wardle J (1999) Social Patterning of health behaviours: the case of cigarette smoking in Marmot M and Wilkinson R (eds), Social Determinants of Health. OUP: Oxford, pp

22 1 Background, aims and methods Kendall P C and Clarkin J F (1992) Introduction to special section: Comorbidity and treatment implications. Journal of Consulting and Clinical Psychology 60, Kershaw A, Singleton N and Meltzer H (2000) Survey of the health and well being of homeless people in Glasgow, ONS: London. Kessler R (1994) The National Comorbidity Survey of the United States. International Review of Psychiatry 6, Kessler R, Crum R M and Warner L A (1997) Lifetime co occurrence of DSM III R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Study. Archives of General Psychiatry 54, Kish L (1965) Survey Sampling, Wiley & Sons: London. Meltzer H, Gatward R, Goodman R and Ford T (2000) The mental health of children and adolescents in Great Britain, HMSO: London. Meltzer H, Lader D, Corbin T, Singleton N, Jenkins R and Brugha T (2002a) Non fatal suicidal behaviour among adults aged 16 to 74 in Great Britain, TSO: London. Meltzer H, Singleton N, Lee A, Bebbington P, Brugha T and Jenkins R (2002b) The social and economic circumstances of adults with mental disorders, TSO: London. O Brien M, Singleton N, Sparks J, Meltzer H and Brugha T (2002) Adults with a psychotic disorder living in private households, 2000, TSO: London. Pirzada S R, Ries R and LoGerfo J P (1997) Cost of comorbid alcohol and drug problems. American Journal of Addiction 6(3), Robins L N and Regier D A (1991) Psychiatric Disorders in America. The Epidemiological Catchment Area Study, The Free Press (Macmillan): New York. Wu L T, Kouzis A C and Leaf P J (1999) Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey. American Journal of Psychiatry 156(8), Saunders J B, Aasland O G, Babor T F, de la Fuente J R and Grant M (1993) Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption II. Addiction 88, Singleton N, Farrell M and Meltzer H (1999) Substance misuse among prisoners in England and Wales, TSO: London. Singleton N, Bumpstead R, O Brien M, Lee A and Meltzer H (2001) Psychiatric morbidity among adults living in private households, 2000, TSO: London. Singleton N, Lee A and Meltzer H (2002) Psychiatric morbidity among adults living in private households, 2000: Technical Report, ONS: London. Stockwell T, Murphy D and Hogson R (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. British Journal of Addiction 78, Walker A, Maher J, Coulthard M, Goddard E and Thomas M (2001) Living in Britain: Results from the 2000 General Household Survey, TSO: London. 6

23 2 Prevalence of smoking, drinking and drug taking Prevalence of smoking, drinking and drug taking Introduction This chapter provides an overview of the prevalence of smoking, drinking and drug taking behaviour in the whole population. The data are analysed by sex and ethnic group. Other surveys are available that, because of their larger sample sizes and regular occurrence, provide better sources of data on the prevalence of tobacco, alcohol and drug use and on time trends. Information on smoking and drinking is collected by the General Household Survey and the Health Survey for England (Walker et al, 2001; Prior and Primatesta, 2002). The British Crime Survey provides data on drug use (Ramsay et al, 2001). However the survey reported here differs from these other sources in that information was collected on substance dependence, the cooccurrence of psychiatric morbidity and the overlap between use of the different substances. In this chapter the data on substance use are presented here for our sample, which covers a different age range to other surveys. In addition data on dependence is described and the overlap between the three behaviours is explored. 2.2 Smoking Smoking status Overall 30% of adults aged 16 to 74 reported current smoking, 23% were ex-regular smokers and 47% had never smoked regularly. The percentages are very similar to those reported by adults of the same age in the 2000/2001 General Household Survey (GHS), with the only statistically significant difference being that a slightly higher percentage of people reported never being a regular smoker in the GHS (50% compared with 47%). There was no statistically significant gender difference in the proportions who reported currently being a smoker or a non-smoker. However men were more likely than women to report heavy smoking (11% compared with 7%), and conversely were less likely to report light smoking (8% compared with 10%). Men were also more likely to be ex-smokers (27% compared with 19%). (Table 2.1) 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. Predictably the proportion of ex-regular smokers increased with age from 6% in the youngest category (16 to 19) to 45% in the oldest category (70 to 74). Similarly, prevalence of never smoking regularly declined with age from 64% in the youngest to 41% in the oldest age group. (Table 2.2 and Figure 2.1) The variation in the proportion who had never smoked regularly demonstrates a well reported sex difference (see, for example, Jarvis and Wardle, 1999). The data in Table 2.2 reflects changes in smoking prevalence over time. There are lower proportions of men starting smoking now than was the case in the past. For men, the percentage who have never smoked regularly is greater in the younger age groups. However, for women there is a fairly constant proportion who have never smoked regularly across the age groups; from the age of 20 to 74 the percentage ranged from 47% to 56%. Thus, among the younger age groups, a smaller proportion of women than men have never smoked. For example 61% of women aged 16 to 19 had never smoked regularly, compared with 66% of men. In contrast, in the older groups, the proportion of women who had never smoked regularly was dramatically higher than among men, for example in the 65 to 69 age group it was 51% among women compared with 30% of men. Men had a higher prevalence of heavy smoking compared with women across all ages, and the difference was most pronounced in the 20 to 24 age band where 10% of men were heavy smokers, compared to 4% of women. (Table 2.2) Ethnic minority groups reported lower rates of heavy cigarette smoking and were more likely to have never smoked cigarettes compared to the 7

24 2 Prevalence of smoking, drinking and drug taking Figure 2.1 Smoking status by age Percentage Age Never regular Ex-regular Light Moderate Heavy White population. South Asian women were far less likely to have ever smoked than any other group; 91% had never smoked regularly compared with 50% of White women. The Health Survey for England 1999 included a larger sample of ethnic minorities and therefore provides more detailed analysis of smoking by ethnic group (Erens et al, 2001). (Table 2.3) Time between waking and first cigarette The time from waking to smoking the first cigarette of the day is considered to be a good proxy measure for heavy and dependent smoking. In general, lighting up less than 15 minutes after waking indicates significant nicotine dependence. We would expect these figures to correlate reasonably well with self-reported heavy smoking. Unsurprisingly, rates are lower among smokers in the youngest age group at 18% and climbs incrementally to 35% by the age band 35 to 39 and then remain fairly level, before dropping slightly in the oldest groups. (Table 2.4) Age started smoking Approximately one quarter (24%) of smokers said they started smoking under the age of 15 and 58% started in the 15 to 19 age range. In the youngest age group women have significantly higher rates of early smoking initiation than men, however this pattern is reversed in the older groups. For example, among those aged 16 to 19, 59% of women started smoking under the age of 15 compared with 39% of men, whereas among those aged 70 to 74, 16% of women started smoking at this age, compared with 35% of men. (Table 2.5) 2.3 Alcohol This section examines alcohol consumption among adults aged 16 to 74. The pattern of quantity and frequency of drinking is considered as well as the prevalence of problem drinking. Chapter 1 and Appendix B describes in more detail the questions on drinking used in this section Frequency of drinking and amount drunk Around one in eight people (12%) reported not having any alcoholic drinks in the past year. Women were more likely than men to be nondrinkers (14% compared with 9%). However just under half of the population drank more than twice a week (48%), and 21% of men and 12% of women drank four or more times per week. (Table 2.6) Table 2.7 and 2.8 examine two questions taken from the Alcohol Use Disorder Identification Test (AUDIT). 8

25 Prevalence of smoking, drinking and drug taking 2 Figure 2.2 Prevalence of hazardous drinking in the past year by ethnicity and sex Percentage White Black South Asian Other groups Ethnicity Those who had an alcoholic drink over the past year were asked how many standard drinks containing alcohol they had on a typical day when they were drinking. Respondents were told that a standard drink is the equivalent of a half pint of beer, a single measure of spirits or a glass of wine, which corresponds to one unit of alcohol. Just under half (47%) reported that on a usual drinking day one to two 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. Men tended to consume more alcoholic drinks than women; 11% of men reported usually having ten or more drinks, whereas only 2% of women drank this amount. (Table 2.7) Respondents were asked how often they drank 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. Men were more likely than women to drink six or more drinks at a time. (Table 2.8) Hazardous drinking Women The AUDIT is a structured instrument, developed by the World Health Organisation, that assesses drinking on an ascending scale indicating increasing levels of alcohol problems as revealed by reported physical, psychological and social consequences. Men Previous studies have shown that a score of 8 or above indicates a hazardous level of drinking. There are a number of items in the scale that address issues of alcohol dependence as part of overall hazardous use but the AUDIT does not have a recognised cut-off point to indicate dependency. Therefore the Severity of Alcohol Dependence Questionnaire (SAD-Q) (Stockwell et al, 1983) was completed by those scoring above 10 on the AUDIT scale in order to provide a standardised measure of dependence. Overall 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 16 or more, which is a sign of a more severe drinking problem. AUDIT scores were highest in the younger groups of both men and women and peaked in the early twenties then steadily declined with increased age. Men were more likely to be classified as hazardous drinkers than women (38% compared with 15%) and to score 16 or more on the AUDIT score (6% compared with 2%). (Table 2.9) AUDIT scores were significantly higher in the White group than the Black or South Asian groups. South Asian women scored lowest on the AUDIT questionnaire, with a mean score of 1, compared with 5 for the whole sample. (Table 2.10 and Figure 2.2) 9

26 2 Prevalence of smoking, drinking and drug taking Figure 2.3 Prevalence of alcohol dependence in the past year by age and sex (a) Women Rates per thousand Age Mild dependence Moderate dependence Severe dependence (b) Men Rates per thousand Age Mild dependence Moderate dependence Severe dependence Alcohol dependence Seven per cent of the sample were assessed as being dependent on alcohol. For the majority of these cases the dependence was classified as mild. The prevalence in the population were 69 per 1,000 for mild dependence, 4 per 1,000 for moderate dependence and 1 per 1,000 for severe dependence. Men were more likely to show signs of dependence than women, and younger people were more likely to have signs of any dependence than the older groups. However, all cases of severe dependence were found among people aged between 30 and 65. (Table 2.11 and Figure 2.3) Due to relatively low prevalence of alcohol dependence, detailed variation between ethnic groups is difficult to interpret. However, White adults had a higher prevalence of dependence than South Asian adults (75 per 1,000 compared with 25 per 1,000). (Table 2.12) 2.4 Drug use and dependence Drug use Drug use varies markedly with age so when considering the results presented here it is 10

27 Prevalence of smoking, drinking and drug taking 2 Figure Proportion in each age group reporting ever using each of the five most commonly used drugs by age 500 Rates per thousand Age Cannabis Ecstasy Amyl nitrite (poppers) Amphetamines Magic mushrooms Any drug important to bear in mind that the data covers people across the age range 16 to 74 years. Tables 2.13 to 2.15 show the rate of using different types of drugs, ever, in the past year and in the past month. As prevalence of use of most drugs was low the tables present rates per thousand. However, in the text the rates are presented as percentages for easier reading. Rates per thousand are converted into percentages by dividing by ten, and conversely percentages can be changed into rates per thousand by multiplying by ten. Respondents were given a list of illicit drugs and asked if they had ever taken any, excluding use prescribed by a doctor; 27% report doing so, with 11% reporting illicit drug use in the past year, and 6% in the past month. The equivalent figures presented in rates per thousand are 266, 106 and 64. Cannabis accounts for the majority of self-reported illicit drug use in the population. Nearly one in four (24%) report ever using cannabis. The next most common drug reported is amphetamine, with 7% saying they had used it at some time. One in twenty people have tried magic mushrooms at some point. Lifetime prevalence rates for use of ecstasy, cocaine or LSD were all 4%, for tranquillisers 3% and for volatile substances 1%. Crack, heroin, non-prescribed methadone and anabolic steroids had been used by less than 1% of the sample. (Table 2.13) Looking at drug use in the last year, one in ten (10%) reported using cannabis, one in fifty (2%) reported using amphetamines, cocaine or ecstasy, and less than one in a hundred (1%) reported using any of the other drugs. Questions on drug use in the last month found that 6% used cannabis, 1% used ecstasy and the other drugs were reported at lower rates. (Table ) In 1993, the first survey of psychiatric morbidity among adults in private households (Meltzer et al, 1995) 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%. People in their twenties were most likely to have ever used at least one of the drugs covered in the survey. Rates of any drug use are highest for those in their early twenties, where more than half have used drugs at some time in their lives (52%), and then rates decline with age, indicating a general change in drug use over the past two decades. Figure 2.4 illustrates the effect of age on lifetime experience of the five most commonly used drugs. (Table 2.13 and Figure 2.4) 11

28 2 Prevalence of smoking, drinking and drug taking Men were more likely than women to have used drugs over their lifetime (32% compared with 21%), in the past year (13% compared with 8%) and in the past month (9% compared with 4%). (Table 2.13 to 2.15) Analysis by ethnic group showed that South Asian men were least likely to have used drugs in the last year (5% compared with 14% for White males). However, since drug use is so strongly age-related these rates will be influenced by differences in the age structures of different population groups. (Table 2.16) Drug dependence The prevalence of dependence on any drug was 4%. It should be noted that the threshold for dependence used here is quite low. People who are frequent users (i.e. daily users for a fortnight or more) or who have developed some tolerance for the drug so require more to get the same affect will be assessed as dependent. A large proportion of those assessed as dependent on cannabis and ecstasy had only scored one on the dependence questions. This threshold was used to provide comparability with the 1993 survey but may overestimate dependence on some drugs. Drug dependence showed similar patterns of variation by age, sex and ethnicity to those in drug use. With the exception of tranquillisers, men were more likely than women to be dependent on all types of drugs. Dependence was highest in the early twenties then tended to decline in the older age groups. Dependence on cannabis was reported most often (3%). (Table 2.17) Among women, those who identified their ethnic group as Black or Other groups were most likely to be dependent on drugs (4% and 6% respectively) and those describing themselves as White were the least likely (2%). On the other hand, among men, those from White or Other ethnic groups were most likely to be dependent on drugs (6% in each case) and South Asian men were least likely to be dependent (less than 1%). (Table 2.18) Degree of drug dependence was assessed by the number of positive answers given to a set of five questions; if someone answered yes to at least one question they were defined as dependent (see Appendix B for more information on the questions asked). More than half of those who were assessed as being dependent on cannabis had only answered yes to one question, whereas those dependent on heroin or non-prescribed methadone generally answered positively to all the questions. This suggests, as would be expected, a higher level of dependence among heroin users. The statement which cannabis users mostly endorsed was that they used every day for two weeks or more. Ecstasy users were most likely to say they need larger amounts of the drug to get an effect. Care should be taken when interpreting the results of Table 2.19 due to the low numbers of respondents on which the figures are based. (Table 2.19) Injecting drug use It is generally recognised that injecting drugs is a relatively infrequent behaviour in the population and may be heavily concentrated in populations such as the homeless and the offending population (Kershaw et al, 2000; Singleton et al, 1999). However it is useful to have estimates derived from household samples for comparison. In this survey respondents who had reported using illicit drugs were asked if they had ever injected drugs. Looking at the whole population, 4 per 1,000 (that is less than half of one per cent) had ever injected, 2 per 1,000 had injected regularly and 1 per 1,000 had injected in the past month. 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. (Table 2.20) Of those who had ever injected, 39% did so regularly, 22% injecting more than a hundred times and 17% injected in the last month. The mean age for starting injecting was between 20 and 21, however the age of starting ranged from 11 to 44, with 9% saying they started under the age of 16. These figures need to be interpreted with caution as they are made up of only 37 respondents and there is a risk that this does not reflect the pattern of behaviour in the larger population of injectors. (Table 2.21) Overdose experience This section looks at accidental overdoses. Information regarding deliberate overdoses are 12

29 covered in Meltzer et al, Of those who have ever used illegal drugs, 4% reported ever experiencing an accidental overdose. Men were twice as likely as women to have had an overdose (6% compared to 3%). Of the 47 people who reported ever using heroin, 23% reported experiencing an accidental overdose. Similarly, of the 39 people who have ever injected 22% have experienced an overdose. As the numbers using illicit drugs are small care needs to be taken when interpreting these results. (Table 2.22) Sixty per cent of those who had experienced an overdose had only one and 40% had multiple overdoses, with the majority of these having two or three overdoses in their life. (Table 2.23) 2.5 Interaction between smoking, drinking and drug taking It is well recognised that smoking, drinking and drug taking are behaviours that cluster together (see for example Meltzer et al, 1995 and Farrell, 2001). This analysis explores the strength of association. Table 2.24 to 2.30 show the interaction between the different substances. The first set of interaction tables look at the percentage who have ever used drugs or have used drugs in the last year, by cigarette smoking status (Table ) and AUDIT score (Table ). There was an increased prevalence in drug use for each additional substance used. It is noteworthy that at all ages and for both sexes smokers are twice as likely to have ever used drugs as non-smokers. Nearly one in four (24%) smokers had used drugs in the last year compared to around one in twenty non-smokers (5%). Similarly, those with a higher AUDIT score were more likely to have ever used drugs, or to have used drugs in the past year. Comparing those with an AUDIT score of less than 8, with those with a score of 8 or more, the percentage who had ever taken drugs rose from 19% to 47%. Among people aged 16 to 44, those who score zero on the AUDIT score (mainly nondrinkers) are less likely to report using drugs than those who score 1 to 7 on the AUDIT score. This difference does not remain for those aged 45 to 74. The pattern of increased drug use among those who smoke or have signs of alcohol misuse was observed for both drug use in the past year or over Prevalence of smoking, drinking and drug taking a person s lifetime, and for men and women of all age groups. (Table ) Tables 2.28 and 2.29 investigate the three-way interaction between AUDIT scores, smoking status and drug taking (either lifetime experience or in the past year). People who only drink or only smoke are less likely to take drugs than those who do both. Figure 2.5 shows that as AUDIT score increased the percentage who reported ever using drugs increased. Also, within each AUDIT score grouping, current smokers are more likely to have ever used drugs than non smokers. Non-smokers with an AUDIT score of zero were the least likely to report taking drugs ever (6%), whereas smokers with an AUDIT score of 16 or more were the most likely to report this (77%). The pattern was similar for drug use in the past year; the equivalent figures were 2% and 57%. (Table and Figure 2.5) Logistic regressions were run to look at the interactions between the three substances, controlling for age and sex. The odds of being a smoker increased for both hazardous drinkers and for people dependent on drugs. Of course these interactions occur in both directions so it is no surprise that when hazardous drinking was the dependent variable, heavy smoking and dependent drug use were strongly associated, with a more than doubling of risk. As expected, being dependent on any drug was related to smoking and drinking, with heavy smokers having a twelve fold increase in odds Percentage reporting ever using drugs Figure Percentage reporting ever using drugs by AUDIT score and smoking status AUDIT score Non-smoker Current smoker 2 13

30 2 Prevalence of smoking, drinking and drug taking of dependence and those scoring above 16 on the AUDIT score having a six fold increase, once the other factors have been taken into account. However age was also a major risk factor for dependent drug use with the youngest group having thirty fold greater odds than the oldest group. (Table 2.30) The associations between lifetime use of different types of drugs were also investigated. Those who use cannabis were least likely to use the other drugs, whereas those who have ever used heroin were most likely to have also used the other drugs listed. (Table 2.31) References Erens B, Priatesta P and Prior G (2001) The health of Minority Ethnic groups 99, TSO: London. Farrell M, Howes S, Bebbington P, Brugha T, Jenkins R, Marsden J, Taylor C and Meltzer H (2001) Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a National Household Survey. British Journal of Psychiatry 179, Jarvis M and Wardle J (1999) Social Patterning of health behaviours: the case of cigarette smoking, in Marmot M and Wilkinson R (eds), Social Determinants of Health. OUP: Oxford, pp Kershaw A, Singleton N and Meltzer H (2000) Survey of the health and well-being of homeless people in Glasgow, ONS: London. Meltzer H, Gill B, Petticrew M and Hinds K (1995) OPCS Surveys of Psychiatric Morbidity in Great Britain, Report 3: Economic activity and social functioning of adults with psychiatric disorders, HMSO: London. Meltzer H, Lader D, Corbin T, Singleton N, Jenkins R and Brugha T (2002) Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain, TSO: London. Prior G and Primatesta P (eds) (2002) Health Survey for England, TSO: London. Ramsay M, Baker P, Golden C, Sharp C and Sondhi A (2001) Drug misuse declared in 2000: results from the British Crime Survey, TSO: London. Singleton N, Meltzer H, Gatward R, Coid J and Deasy D (1998) Psychiatric Morbidity among Prisoners in England and Wales, TSO: London. Stockwell T, Murphy D and Hogson R (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. British Journal of Addiction 78, Walker A, Maher J, Coulthard M, Goddard E and Thomas M (2001) Living in Britain: Results from the 2000 General Household Survey, TSO: London. 14

31 Prevalence of smoking, drinking and drug taking 2 Table 2.1 Cigarette smoking status (compared with the 2000 General Household Survey) by sex Psychiatric Morbidity General Household of adults, 2000 Survey, 2000/2001* Cigarette smoking status % % Women Smoker Heavy 7 7 Moderate Light 10 9 Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light 8 7 Non-smoker Ex-regular Never regular Base All adults Smoker Heavy 9 9 Moderate Light 9 8 Non-smoker Ex-regular Never regular Base *Adults aged only. 15

32 2 Prevalence of smoking, drinking and drug taking Table 2.2 Prevalence of cigarette smoking by age and sex Age All Cigarette smoking status % % % % % % % % % % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base

33 Prevalence of smoking, drinking and drug taking 2 Table 2.3 Prevalence of cigarette smoking by ethnicity and sex Ethnicity White Black South Asian* Other Groups All Cigarette smoking status % % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base * Indian, Pakistani or Bangladeshi. Includes those who did not answer the question on ethnicity. 17

34 2 Prevalence of smoking, drinking and drug taking Table 2.4 Time between waking and first cigarette by age and sex Age All Time between waking and % % % % % % % % % % % % % first cigarette Women Less than 5 minutes to 14 minutes to 29 minutes minutes but less than 1 hour hour but less than 2 hours hours or more Base: current smokers Men Less than 5 minutes to 14 minutes to 29 minutes minutes but less than 1 hour hour but less than 2 hours hours or more Base: current smokers All adults Less than 5 minutes to 14 minutes to 29 minutes minutes but less than 1 hour hour but less than 2 hours hours or more Base: current smokers

35 Prevalence of smoking, drinking and drug taking 2 Table 2.5 Age started smoking cigarettes regularly by age and sex Age All Age started smoking % % % % % % % % % % % % % cigarettes regularly Women Under and over Base: current smokers and ex-regular smokers Men Under and over Base: current smokers and ex-regular smokers All adults Under and over Base: current smokers and ex-regular smokers

36 2 Prevalence of smoking, drinking and drug taking Table 2.6 Frequency of drinking alcohol in past year by sex Men Women All Frequency of drinking alcohol in past year % % % Never Monthly Two to four times a month Two to three times a week Four or more times a week Base Table 2.7 Amount usually drunk by (those who reported drinking alcohol in past year) by sex Men Women All Number of standard drinks* on a typical drinking day % % % One or two Three or four Five or six Seven, eight or nine Ten and over Base: those who reported drinking alcohol in past year * One standard drink = 1 unit of alcohol. Table 2.8 Frequency of drinking six or more drinks on one occasion during the past year by sex Men Women All Frequency of drinking 6 or more drinks % % % Never Less than monthly Monthly Weekly Daily or almost daily Base

37 Prevalence of smoking, drinking and drug taking 2 Table 2.9 Prevalence of hazardous drinking by age and sex Age All AUDIT score % % % % % % % % % % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base

38 2 Prevalence of smoking, drinking and drug taking Table 2.10 Prevalence of hazardous drinking by ethnicity and sex Ethnicity White Black South Asian* Other Groups All AUDIT score % % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base * Indian, Pakistani or Bangladeshi. Includes those who did not answer the question on ethnicity. 22

39 Prevalence of smoking, drinking and drug taking 2 Table 2.11 Prevalence of alcohol dependence by age and sex (rate per thousand population) Age SAD-Q Score All Rates per thousand in past six months Women Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base Men Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base All adults Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base

40 2 Prevalence of smoking, drinking and drug taking Table 2.12 Prevalence of alcohol dependence by ethnicity and sex (rate per thousand population) Ethnicity SAD-Q Score White Black South Asian* Other Groups All Rates per thousand in past six months Women Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base Men Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base All adults Score 0 3: No dependence Score 4 19: Mild dependence Score 20 34: Moderate dependence Score 35 60: Severe dependence Base * Indian, Pakistani or Bangladeshi. Includes those who did not answer the question on ethnicity. 24

41 Prevalence of smoking, drinking and drug taking 2 Table 2.13 Lifetime experience of illicit drug use by age and sex (rate per thousand population) Age Women All Rates per thousand Drugs ever used Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base Men Drugs ever used Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base All adults Drugs ever used Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base

42 2 Prevalence of smoking, drinking and drug taking Table 2.14 Illicit drug use in the past year by age and sex (rate per thousand population) Age All Women Rates per thousand Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base Men Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base All adults Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base

43 Prevalence of smoking, drinking and drug taking 2 Table 2.15 Illicit drug use in the past month by age and sex (rate per thousand population) Age All Women Rates per thousand Drugs used in past month Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances Any drug Base Men Drugs used in past month Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances Any drug Base All adults Drugs used in past month Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances Any drug Base

44 2 Prevalence of smoking, drinking and drug taking Table 2.16 Illicit drug use in the past year by ethnicity and sex (rate per thousand population) Ethnicity Women White Black South Asian* Other Groups All Rates per thousand Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base Men Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base All adults Drugs used in past year Cannabis Amphetamines Cocaine Crack Ecstasy Heroin LSD Magic mushrooms Methadone Tranquillisers Amyl nitrite (poppers) Anabolic steroids Volatile substances Any drug Base * Indian, Pakistani or Bangladeshi. Includes those who did not answer the question on ethnicity. 28

45 Prevalence of smoking, drinking and drug taking 2 Table 2.17 Prevalence of drug dependence by age and sex (rate per thousand population) Age Women All Rates per thousand in past year Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base Men Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base All Adults Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base

46 2 Prevalence of smoking, drinking and drug taking Table 2.18 Prevalence of drug dependence by ethnicity and sex (rate per thousand population) Ethnicity Women White Black South Asian* Other Groups All Rates per thousand in past year Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base Men Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base All adults Dependence on... Cannabis Amphetamines Cocaine Crack Ecstasy Heroin / Methadone Tranquillisers Volatile substances No dependence Cannabis only Other drug(s) with or without cannabis dependence Any drug dependence Base * Indian, Pakistani or Bangladeshi. Includes those who did not answer the question on ethnicity. 30

47 Prevalence of smoking, drinking and drug taking 2 Table 2.19 Degree of drug dependence by drug type (rate per thousand population) Degree of drug dependence* Cannabis Amphetamines Cocaine Crack Ecstasy Heroin/ Tranquillisers Methadone Rates per thousand in past year All adults Any dependence Base = 8580 * Number of positive responses to the five questions assessing dependence on each of the drugs listed. Table 2.20 Prevalence of injecting drugs (rate per thousand population) Table 2.21 Prevalence, frequency and age started injecting drugs among those who have ever injected All adults Whole sample Those who have ever used drugs Rates per thousand reporting each level of use Ever injected drugs 4 17 Ever injected regularly 2 7 Injected in the last month 1 3 Base Percentage reporting Ever injected regularly 39 Number of times injected Less than 10 times to 100 times 31 More than 100 times 22 Injected in the last month 17 Age started injecting and over 1 Base: those who have ever injected 37 31

48 2 Prevalence of smoking, drinking and drug taking Table 2.22 Ever experienced an accidental drug overdose Table 2.23 Number of accidental overdoses over lifetime by sex, age and whether ever used heroin or injected Percentage who have experienced an accidental drug overdose Base: those who have ever taken drugs Row percentage All adults Sex Men Women % How many times overdosed Once and over 6 Base: those who have ever overdosed 87 All Age and over 5 62 Has ever used heroin Has ever injected

49 Prevalence of smoking, drinking and drug taking 2 Table 2.24 Prevalence of self-reported drug use (ever) by cigarette smoking status, age and sex Age All Cigarette smoking status Percentage reporting ever using drugs Women Smoker Non-smoker Ex-regular Never regular Men Smoker Non-smoker Ex-regular Never regular All adults Smoker Non-smoker Ex-regular Never regular Bases Women Smoker Non-smoker Ex-regular Never regular Men Smoker Non-smoker Ex-regular Never regular All adults Smoker Non-smoker Ex-regular Never regular

50 2 Prevalence of smoking, drinking and drug taking Table 2.25 Prevalence of self-reported drug use in the past year by cigarette smoking status, age and sex Cigarette smoking status Age All Percentage reporting using drugs in the past year Women Smoker Non-smoker Ex-regular Never regular Men Smoker Non-smoker Ex-regular Never regular All adults Smoker Non-smoker Ex-regular Never regular Bases Women Smoker Non-smoker Ex-regular Never regular Men Smoker Non-smoker Ex-regular Never regular All adults Smoker Non-smoker Ex-regular Never regular

51 Prevalence of smoking, drinking and drug taking 2 Table 2.26 Prevalence of self-reported drug use (ever) by AUDIT score, age and sex Age All AUDIT score Percentage reporting ever using drugs Women Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Men Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) All adults Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Bases Women Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Men Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) All adults Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker)

52 2 Prevalence of smoking, drinking and drug taking Table 2.27 Prevalence of self-reported drug use in the past year by AUDIT score, age and sex All Age AUDIT score Percentage reporting using drugs in the past year Women Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Men Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) All adults Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Bases Women Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) Men Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker) All adults Score Score Score of less than 8 (non-hazardous drinker) Score 8 and over (hazardous drinker)

53 Prevalence of smoking, drinking and drug taking 2 Table 2.28 Prevalence of self-reported drug use (ever) by cigarette smoking status, AUDIT score and sex AUDIT score Cigarette smoking status Score of less Score 8 and All than 8 over (non-hazardous (hazardous drinker) drinker) Percentage reporting ever using drugs Women Non-smoker Current smoker Men Non-smoker Current smoker All adults Non-smoker Current smoker Bases Women Non-smoker Current smoker Men Non-smoker Current smoker All adults Non-smoker Current smoker

54 2 Prevalence of smoking, drinking and drug taking Table 2.29 Prevalence of self-reported drug use in the past year by cigarette smoking status, AUDIT score and sex Cigarette smoking status AUDIT score Score of less Score 8 and All than 8 over (non-hazardous (hazardous drinker) drinker) Percentage reporting using drugs in the past year Women Non-smoker Current smoker Men Non-smoker Current smoker All adults Non-smoker Current smoker Bases Women Non-smoker Current smoker Men Non-smoker Current smoker All adults Non-smoker Current smoker

55 Prevalence of smoking, drinking and drug taking 2 Table 2.30 Odds ratios for the co-occurrence of substance misuse Current smoker Hazardous drinker Dependent on any drug (AUDIT = 8 and over) Adjusted 95% confidence Adjusted 95% confidence Adjusted 95% confidence odds ratio interval odds ratio interval odds ratio interval Lower Upper Lower Upper Lower Upper Smoking status Never regular Ex-regular 1.65 *** *** Light 2.00 *** *** Moderate 2.14 *** *** Heavy 2.46 *** *** AUDIT score (Hazardous drinking) Score: Score: *** *** Score: *** *** Drug dependence No drug dependence Any drug dependence 7.01 *** *** Sex Female Male 0.85 *** *** *** Age group *** ** *** *** *** *** * *** *** *** *** *** *** *=p<0.05; **=p <0.01; ***=p<

56 2 Prevalence of smoking, drinking and drug taking Table 2.31 Interaction between use of different types of drugs by sex Women Drug ever used Cannabis Amphetamines Cocaine/ Ecstasy Heroin Tranquillisers Acid/ Volatile crack mushrooms substances Percentage of those using each drug Drugs ever used Cannabis [16] Amphetamines [13] Cocaine/crack [11] Ecstasy [11] Heroin [18] Tranquillisers [9] Acid/mushrooms [11] Volatile substances [7] Base Men Drugs ever used Cannabis Amphetamines Cocaine/crack Ecstasy Heroin Tranquillisers Acid/mushrooms Volatile substances Base All adults Drugs ever used Cannabis Amphetamines Cocaine/crack Ecstasy Heroin Tranquillisers Acid/mushrooms Volatile substances Base

57 3 Socio-economic factors associated with substance use Socio-economic factors associated with substance use Introduction This chapter looks at the key socio-demographic and economic characteristics associated with smoking, hazardous drinking and dependence on any drug. Tables 3.1 to 3.3 show the prevalence of substance use among different groups. Table 3.4 presents the results of a logistic regression analysis, which looks at which socio-economic factors are independently associated with substance use. The characteristics covered in this chapter include age, sex, ethnicity, marital status, education, employment, housing, area of residence and financial factors. The glossary gives details of the derivation of the variables used in the analysis. 3.2 Socio-economic factors associated with smoking Personal characteristics In the previous chapter the association between age and smoking was described; on the whole younger people were more likely to smoke than older people. The logistic regression confirmed that smoking was independently associated with age. Those aged 16 to 24 were nearly six times more likely to be smokers than the oldest age group (those aged 65 to 74), once other factors had been taken into account. The risk of being a smoker gradually fell with age. The odds of being a smoker in the 35 to 54 age group were around four times those of the oldest age group, but fell to just over two in the 55 to 64 age group. The fall is accounted for presumably by smoking cessation but also by the premature death of smokers. (Table 3.4) Analysis by marital status found that being married was associated with non-smoking (77% of married people were non-smokers) and conversely the highest smoking rates were reported by those who were cohabiting or were divorced or separated (42% and 41%, respectively, were current smokers). Logistic regression analysis indicated that people who were cohabiting, single, widowed and divorced or separated all had increased likelihood of current smoking even when age, gender and other factors were controlled for, with odds ratios (OR) of between 1.40 and (Tables 3.1 and 3.4) Employment, financial and educational characteristics People who were unemployed or working in a manual occupation were more likely to smoke than the employed, the economically inactive or nonmanual workers. Forty-eight per cent of unemployed people reported smoking compared with 29% of people who were employed or economically inactive. People who worked in nonmanual occupations reported low rates of current smoking at 24% compared with 38% of people whose work involved manual labour. These associations remained significant when other factors were controlled for in the logistic regression analysis, but were generally quite weak. (Table 3.1 and 3.4) Smoking was associated with having a lower household income and being in financial difficulty. Thirty-nine per cent of people with a gross weekly income of under 200 reported being current smokers compared to 24% of those whose gross income was 600 or over. However this was not statistically significant in the logistic regression modelling when other factors were controlled for. Forty-eight per cent of those in financial difficulty were current smokers compared to 24% of those with no money problems and being in financial difficulty nearly doubled the odds of being a current smoker on logistic regression modelling (OR=1.89). (Table 3.1 and 3.4) Twenty-two per cent of people with qualifications 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. In the logistic regression analysis those with the lowest level of final education had twice the odds of those with A levels or above of being current smokers. Obviously the level of final education and the age that people leave school are strongly associated, except for those who later return to 41

58 3 Socio-economic factors associated with substance use adult education. Therefore it is not surprising to find that those who stayed at school longer had lower rates of current smoking. Thirty-four per cent of those leaving school at 16 or younger reported current smoking compared with 20% of those leaving at 19 or older. The logistic regression analysis showed a reduction in the risk of smoking in those reporting spending a longer period of time in education even after the level of educational qualifications obtained and other socio-economic characteristics are taken into account. (Table 3.1 and 3.4 and Figure 3.1) Figure Percentage who smoke by highest educational qualification In summary, the logistic regression showed that smoking was strongly associated with age and people were also more likely to smoke if they were White, unemployed or economically inactive, in a manual occupation, had qualifications below A level or equivalent, left school at a younger age, lived in rental accommodation or were in financial difficulty. This concurs with data from the Health Survey for England and the General Household Survey which demonstrated that socio-economic deprivation is associated with smoking (Prior and Primatesta, 2002; Walker et al, 2002). Jarvis (1999) reports that poorer groups have the same desire to quit smoking as other socio-economic groups, but are significantly less likely to succeed in doing so Socio-economic factors associated with hazardous drinking Percentage A level or above GCSE level qualification No qualifications As described in Chapter 1, the AUDIT questionnaire was the main instrument used to assess alcohol problems. Those who scored 8 or above on the AUDIT are classed as hazardous drinkers. Hazardous drinking is defined as an established pattern of drinking which brings with it the risk of physical or psychological harm, now or in the future. This section considers which of a range of socio-economic factors are associated with hazardous drinking Accommodation characteristics People who owned or were buying their home reported current smoking rates of 24% compared with 48% of people who were categorised as social renters and 42% of those categorised as private renters. The logistic regression analysis confirmed this association, showing that social and private renters were at 1.77 and 1.65 times greater odds of smoking, respectively, compared with owneroccupiers, once other factors had been taken into account. People living in urban areas were more likely to report current smoking: 32% did so compared with 25% of rural or semi-rural dwellers. This trend remained even after other factors were taken into account in the logistic regression analysis. (Table 3.1 and 3.4) Personal characteristics Hazardous drinking was very strongly age-related, falling significantly with increasing age. In the logistic regression model, the 16 to 24 age group had the highest odds ratios for hazardous drinking compared with the oldest age group at The odds for the 25 to 34 age group were slightly lower at 2.04, in the 35 to 44 age group they fell again to 1.75 and in the 45 to 54 they were down again to The odds for people aged 55 to 64 were similar to those for people aged over 64. The odds of having a hazardous drinking pattern were three times greater for men than women. Being of White ethnic origin was also significantly associated with hazardous drinking. (Tables 3.2 and 3.4) Marital status showed a marked association with hazardous drinking behaviour. Of those who were married, 20% reported patterns of hazardous drinking compared with 38% who reported 42

59 Socio-economic factors associated with substance use 3 Figure Hazardous drinking by marital status Percentage Married Cohabiting Single Widowed Divorced or separated Marital Status cohabiting and 41% of those who were single, while 13% of those who were widowed and 24% of those who were divorced or separated also did so. Logistic regression indicated that cohabiting or being single, divorced or separated were all associated with increased risk of hazardous drinking when other factors were controlled for. (Tables 3.2 and 3.4 and Figure 3.2) Employment, financial and educational characteristics There was no statistically significant difference between people who were employed or unemployed in terms of the levels of hazardous drinking (31% and 36% respectively). Being economically inactive appeared to reduce the risk of hazardous drinking (only 16% reported this) however in the logistic regression analysis this effect did not hold once age and other factors were controlled for. Thirty per cent of those in manual occupations reported patterns of hazardous drinking compared to 24% in non-manual occupations. Logistic regression analysis indicated that the difference was still significant after other factors had been taken into account, with manual occupations having increased risk of hazardous drinking behaviour (OR=1.34) compared with those in non-manual occupations. (Tables 3.2 and 3.4) People were also grouped according to weekly household income. The rate of hazardous drinking initially rose as income increased then levelled off. Among those with a gross weekly household income under 200 only 19% reported hazardous drinking, compared with 24% of those with income between 200 and 400 and 30% of those with income of 400 or more. Regression analysis indicates that this relationship remains, even after other factors have been accounted for. Benefit recipients were half as likely to report hazardous drinking compared to non-recipients (17% compared with 35%). Thus, restricted income was generally associated with lower rates of reported hazardous drinking. However, it is also worth noting that of those in financial difficulty, 34% reported hazardous drinking behaviours compared with 24% of those who had no financial difficulty, and being in financial difficulty remained significantly associated with hazardous drinking (OR=1.37) after income and other socio-economic factors were taken into account. (Tables 3.2 and 3.4) Those with higher education levels had a slightly greater likelihood of having a hazardous drinking problem than those with fewer qualifications. However this difference was not significant once other factors, such as income, had been taken into account. The rate of hazardous drinking did not differ much in relation to the age of leaving school, within all groups rates were similar to the total population except for those who currently remained in school. This group were more likely to have hazardous drinking behaviours (36% compared with 26% in the whole sample) but, once other factors are taken into account in the logistic regression, they had lower odds compared with the other groups (OR=0.57) suggesting that the comparatively high rate of hazardous drinking is 43

60 3 Socio-economic factors associated with substance use largely a reflection of the very high proportion of young people in this group. (Tables 3.2 and 3.4) Accommodation characteristics About a quarter of those who owned or were buying their home (25%) or who were social renters (24%) reported hazardous drinking compared with 39% of private renters. Private renters had marginally, but significantly, increased odds (OR=1.29) of being a hazardous drinker compared to non-renters when other factors were controlled for. (Tables 3.2 and 3.4) 3.4 Socio-economic factors associated with drug dependence Being married was strongly associated with a reduced risk of reporting drug dependence compared to being single, divorced or cohabiting. Four per cent of single people reported being dependent on other drugs with or without cannabis compared with 2% of those cohabiting, 1% of those who were divorced or separated, and less than half a percent of those who were married or widowed. The logistic regression analysis confirmed that these differences still held after all other factors had been taken into account; there was no statistical difference between those who were married or widowed, but, compared to the base category of married people the odds ratio of being dependent on drugs were, 2.29 for people who are divorced or separated, 3.00 for people who were cohabiting and 3.18 for single people. (Tables 3.3 and 3.4) The numbers reporting any drug dependence were much smaller than those reporting smoking and drinking behaviour; 4% of the total sample were assessed as dependent on drugs with 3% dependent on cannabis alone and 1% on other drugs. Tables showing the prevalence of drug dependence were included in Chapter 2 and these showed that dependence was more common among men and younger people in general, therefore it is important to consider the sex and age composition of different subgroups. It should be noted that the majority of people assessed as drug dependent in this survey are regular cannabis users only Personal characteristics Younger age was significantly associated with any drug dependence in the logistic regression analysis. Adults under the age of 35 were far more likely to be dependent on drugs than those in the older age groups. Those aged between 25 and 34 had odds of any drug dependence around ten times greater (OR=9.50) and those aged 16 to 24 had odds of around 16 times greater (OR=16.39) than those in the oldest age group (people aged 65 to 74) once other factors had been taken into account. There was little difference between those aged 45 to 74 in terms of whether they were dependent on drugs. As was the case for hazardous drinking, the odds of being dependent on drugs were around three times greater for men than women (OR=2.78). (Tables 3.3 and 3.4) Employment, financial and educational characteristics Unemployed people reported higher rates of drug dependence of any type. For example, 4% were dependent on drugs other than cannabis, compared with 1% of people who were employed or economically inactive. In the logistic regression analysis both the economically inactive and people who were unemployed were more likely to report dependence on any drug compared with those who were employed once other factors were taken into account (odds ratios of 1.54 and 2.33 respectively). (Tables 3.3 and 3.4) Manual workers were more likely to report drug dependence than non-manual workers (5% compared with 3%), however there was not a significant difference once all other factors in the logistic regression model had been taken into account. (Tables 3.3 and 3.4) People with higher levels of education had higher rates of drug dependence. Four per cent of those with qualifications of GCSE level or above were defined as dependent, compared with 2% of those with lower qualifications. However, once other factors were taken into account in the logistic regression model there was no significant difference. (Tables 3.3 and 3.4) 44

61 The amount of income available to the household was not associated with rates of drug dependence. Those who were not receiving benefits were slightly more likely to be dependent on drugs (5% compared with 2% of non-recipients), although this was not significant in the logistic regression analysis. People who were in financial difficulty were five times more likely to be dependent on drugs than those with no monetary problems (10% compared with 2%). The logistic regression analysis confirmed that this difference still held after all other factors had been taken into account. (Tables 3.3 and 3.4) Accommodation characteristics People who owned or were buying their home were least likely to be dependent on drugs and renters were most likely. For example, 2% of owneroccupiers, 5% of social renters and 11% of private renters were dependent on drugs. The logistic regression analysis showed that private renters were more likely to be dependent on drugs than owneroccupiers (OR=2.11), but there was little difference between owners and social renters in terms of drug dependence, all other factors being equal. People who said they might have to leave their accommodation before they want to were more likely to be dependent on drugs than those who felt they could stay as long at they wanted (9% compared with 3%). This association was still significant once other factors had been accounted for in the logistic regression analysis. (Tables 3.3 and 3.4) Socio-economic factors associated with substance use hazardously or being dependent on drugs. Being of White ethnic origin, working in a manual occupation and living in an urban area were associated with being a smoker or hazardous drinking, but not with drug dependency. Having a higher weekly household income and not being a benefit recipient were associated with hazardous drinking, but not with being a current smoker or being dependent on drugs. Having no qualifications was only associated with being a current smoker. Overall these tables indicate that a wide range of socio-economic factors have an effect on smoking, drinking and drug taking behaviour. However many of these effects are not particularly strong and each, individually, should be seen as just one component of the complex multi-factorial influences on these complicated social behaviours. References Jarvis M and Wardle J (1999) Social Patterning and Individual Health behaviours: the case of cigarette smoking, in Marmot M and Wilkinson R (eds), Social Determinants of Health, Oxford University Press: Oxford. Prior G and Primatesta P (eds) (2002) Health Survey for England 2000, TSO: London. Walker A, Maher J, Coulthard M Goddard E and Thomas M. (2001) Living in Britain: Results from the 2000 General Household Survey, TSO: London. 3 In summary, the factors that were most associated with being dependent on drugs were being male, young, non-married, unemployed, having left school at a young age, poor security of tenure and being in financial difficulties. However the results should be interpreted with care as the number of drug dependent individuals was small. 3.5 Overview There were significant social factors associated with smoking, drinking and dependent drug use. The logistic regression analysis showed that being male, young, non-married and living in privately rented accommodation and being in financial difficulty were associated with smoking, drinking 45

62 3 Socio-economic factors associated with substance use Table 3.1 Cigarette smoking status by socio-economic factors Cigarette smoking status Current Non- Base smoker smoker Row percentages Marital status Married Cohabiting Single Widowed Divorced or separated Employment status Employed Unemployed Economically inactive Socio-economic group Non manual Manual Armed Forces or no answer Highest educational qualification A level or above GCSE level No qualifications Age left school 16 or younger or older Not yet finished Housing tenure Owns Social renter Private renter Locality Urban Rural or semi-rural Security of accommodation Can stay as long they like Might have to leave before they want to Gross weekly household income Under but under but under and over In financial difficulty* No Yes Benefit recipient Not benefit recipient Benefit recipient All * Those who are defined as in financial difficulty are those who were behind in paying bills or had borrowed money in the last year or who had to use less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 46

63 Socio-economic factors associated with substance use 3 Table 3.2 Hazardous drinking by socio-economic factors AUDIT score (whether hazardous drinker) Hazardous Non- Base drinker (AUDIT drinker (AUDIT score 8 score <8) and over) Row percentages Marital status Married Cohabiting Single Widowed Divorced or separated Employment status Employed Unemployed Economically inactive Socio-economic group Non manual Manual Armed Forces or no answer Highest educational qualification A level or above GCSE level No qualifications Age left school 16 or younger or older Not yet finished Housing tenure Owns Social renter Private renter Locality Urban Rural or semi-rural Security of accommodation Can stay as long they like Might have to leave before they want to Gross weekly household income Under but under but under and over In financial difficulty* No Yes Benefit recipient Not benefit recipient Benefit recipient All * Those who are defined as in financial difficulty are those who were behind in paying bills or had borrowed money in the last year or who had to use less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 47

64 3 Socio-economic factors associated with substance use Table 3.3 Drug dependency by socio-economic factors Type of drug dependence Dependent on Dependent on Dependence on No dependence Base other drug(s) cannabis only any drug with or without cannabis Row percentages Marital status Married Cohabiting Single Widowed Divorced or separated Employment status Employed Unemployed Economically inactive Socio-economic group Non manual Manual Armed Forces or no answer Highest educational qualification A level or above GCSE level No qualifications Age left school 16 or younger or older Not yet finished Housing tenure Owns Social renter Private renter Locality Urban Rural or semi-rural Security of accommodation Can stay as long they like Might have to leave before they want to Gross weekly household income Under but under but under and over In financial difficulty* No Yes Benefit recipient Not benefit recipient Benefit recipient All * Those who are defined as in financial difficulty are those who are behind in paying bills or had borrowed money in the last year or who had to use less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 48

65 Socio-economic factors associated with substance use 3 Table 3.4 Odds ratios of socio-economic factors associated with substance use by socio-economic factors Current smoker Hazardous drinker (AUDIT = 8 and over) Dependent on any drug Adjusted 95% confidence Adjusted 95% confidence Adjusted 95% confidence odds ratio interval odds ratio interval odds ratio interval Lower Upper Lower Upper Lower Upper Sex Female Male 1.13 * *** *** Age group *** *** * *** *** * *** *** *** *** *** *** Ethnic origin White Black 0.63 * *** South Asian 0.51 ** *** Other ** Marital status Married Cohabiting 1.66 *** *** *** Single 1.40 *** *** *** Widowed 1.67 ** Divorced or Separated 1.52 *** *** ** Employment status Employed Unemployed 1.42 * *** Economically inactive 1.17 * * Socio-economic group Non manual Manual 1.30 *** *** Armed Forces or no answer 0.66 * ** Highest educational qualification A-level or above 1.00 GCSE level 1.40 *** No qualifications 2.00 *** Age left school 16 or younger ** ** or older 0.66 *** * Not yet finished 0.29 *** *** * *=p<0.05; **=p <0.01; ***=p< Table continued on page 50. Indian, Pakistani or Bangladeshi. Those who are defined as in financial difficulty are those who are behind in paying bills or had borrowed money in the last year, or who had to used less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 49

66 3 Socio-economic factors associated with substance use Table 3.4 continued Odds ratios of socio-economic factors associated with substance use by socio-economic factors Current smoker Hazardous drinker (AUDIT = 8 and over) Dependent on any drug Adjusted 95% confidence Adjusted 95% confidence Adjusted 95% confidence odds ratio interval odds ratio interval odds ratio interval Lower Upper Lower Upper Lower Upper Housing tenure Owns Social renter 1.77 *** Private renter 1.65 *** * *** Locality Urban Rural or semi rural 0.83 ** ** Gross weekly household income Under but under but under *** and over 1.53 *** In financial difficulty No Yes 1.89 *** *** *** Benefit recipient Not benefit recipient 1.00 Benefit recipient 0.72 *** Security of accomodation Can stay as long as wants 1.00 Might have to leave before wants to 1.54 * *=p<0.05; **=p <0.01; ***=p< Indian, Pakistani or Bangladeshi. Those who are defined as in financial difficulty are those who are behind in paying bills or had borrowed money in the last year, or who had to used less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 50

67 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Relationships between psychiatric morbidity and smoking, drinking and drug use Introduction This chapter looks at the relationship between substance use (smoking, drinking and drugs) and mental disorders among adults living in private households in Great Britain. The prevalence of substance use and dependence in groups with psychiatric disorders were compared with rates in the general population. The chapter examines levels of smoking, alcohol misuse and dependence, drug use and drug dependence by: neurotic symptoms and disorders; CIS-R score type of neurotic disorder number of neurotic disorders probable personality disorder from self-report; and probable psychosis. The CIS-R score gives an indication of the overall severity of neurotic symptoms. A score of 12 or more indicates significant levels of neurotic symptoms and a score of 18 signifies a level which is likely to require treatment. Six neurotic disorders are examined: generalised anxiety disorder, mixed anxiety and depressive disorder, depressive episode, phobias, obsessive compulsive disorder and panic disorder. The measures of personality disorder used in this report are from the Structured Clinical Interview for DSM-IV (SCID-II) self-completion questionnaire rather than the clinical interview, and may therefore include people who would not reach the threshold for a clinical assessment of personality disorder. The assessment of psychosis used in this chapter derives mainly from clinical interviews using SCAN (Schedules for Clinical Assessment in Neuropsychiatry). The probable psychosis group also includes some people who were selected for the clinical interview but who refused a second interview or could not be contacted at that stage. In these cases the assessment of psychotic disorder is based on answers given in the initial lay interview. For more detailed information on these definitions and measures see Appendix B. The final section of this chapter presents the results of logistic regression analyses looking at the association between measures of mental health and substance use, while taking into account other socio-economic factors. Some disorders only occur in a fraction of the population limiting the amount of analysis that can be conducted. 4.2 Smoking and mental disorders Current smoking, and in particular heavy smoking, was associated with all the measures of mental disorders examined. Individuals who were classified as having a disorder were more likely to be heavy smokers, and were less likely to be light smokers, ex-smokers or to have never smoked. This trend was true for both men and women. People with a CIS-R score of 12 or above were more likely to smoke than those with a score below 12 (44% compared with 27%) and were less likely to be an ex-smoker (18% compared with 24%) or to have never smoked regularly (38% compared with 49%). (Table 4.1 and Figure 4.1) A similar pattern occurred when the individual categories of disorders were examined. People with depressive episodes, phobias or obsessive compulsive disorders were twice as likely to smoke than people with no neurotic disorder. (Table 4.2) Comorbid neurotic disorders were associated with higher rates of substance use. There was a progressive increase in the rates of heavy smoking, from 7% for no disorder to 15% for one disorder to 23% for two or more disorders. Further, there was a decrease in the percentage who have never smoked regularly from 49% for no disorder to 39% for one disorder to 30% for two or more disorders. (Table 4.3) People assessed as having anti-social personality disorder (ASPD) based on the SCID self-report form, with or without another disorder, had higher 51

68 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Figure 4.1 Smoking status by CIS-R score Percentage and over CIS-R score Never regular Ex-regular Light Moderate Heavy rates of heavy smoking and lower rates of nonsmoking than those with either no evidence of personality disorder or other types of personality disorder only. A fifth (20%) of those with ASPD only reported heavy smoking compared with only 7% of people without a personality disorder. The group with a personality disorder other than antisocial had a similar pattern of smoking to the general population than to those with ASPD. (Table 4.4) For those classified with probable psychosis, rates of heavy smoking were significantly elevated with 35% reporting heavy smoking whereas the corresponding figure among those without psychosis was only 9%. Conversely, rates of nonsmoking were substantially lower in the probable psychosis sample; 9% reported being ex-smokers compared with 23% among those with no evidence of psychosis, and 28% reported they had never been a regular smoker compared with 47% of those without psychosis. (Table 4.5) 4.3 Hazardous and dependent drinking and mental disorders The degree of hazardous and dependent drinking within groups with mental disorders was measured. The analysis in this chapter considers both people who scored 8 or above on the AUDIT score (who are described as hazardous drinkers) and those who had a more extreme score of 16 or above (harmful drinkers). The alcohol dependence measure was also valuable to use as its groupings are more discriminatory, with only a tiny proportion of respondents being classified as having moderate or severe dependence. Women with significant levels of neurotic symptoms, as shown by a CIS-R score of 12 or above, were more likely than those without to have an AUDIT score of 8 or more (hazardous drinkers) or of 16 or more (harmful drinking). 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. For men there were no differences between those with a CIS-R score above or below 12 in whether they were a hazardous drinker, however there was a difference in the proportion showing more extreme drinking patterns. Seven per cent of men with a significant level of neurotic symptom scored above 16 on the AUDIT, compared with 3% of men without significant levels of neurotic symptom. (Table 4.6 and Figure 4.2) Similarly, there were few differences between the various types of neurotic disorders and the general population in the percentage who scored above 8 on the AUDIT score, however people with neurotic disorders were more likely have an AUDIT score of 16 or more. Of the neurotic disorders examined people with obsessive compulsive disorder were most likely to have a drink problem. (Table 4.7) The likelihood of having an AUDIT score of 16 or more (harmful drinkers) was greater for people 52

69 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Figure 4.2 Women 100 AUDIT score by CIS-R score by sex Men Percentage Percentage and over CIS-R score and over CIS-R score Audit Score 0 7 Audit Score 8 15 Audit Score Audit Score 0 7 Audit Score 8 15 Audit Score presenting with multiple disorders rather than a single disorder. This was true for both sexes. The likelihood of being a hazardous drinker was increased for women with multiple disorders, but there was no difference for men. (Table 4.8) Showing evidence of anti-social personality disorder (ASPD) on the SCID-II self-completion questionnaire was significantly associated with higher rates of hazardous drinking compared with both the general population and to those with a personality disorder other than an anti-social one. Fifty-nine per cent of those with a ASPD alone and 55% of those with an ASPD with another personality disorder were classified as hazardous drinkers, compared with 25% of both those a personality disorder which was not ASPD and those without a personality disorder. The ASPD group had a mean AUDIT score of ten, which was much greater than the score of five for the remainder of the population. (Table 4.9) There was no significant relationship between probable psychosis and AUDIT score. (Table 4.5) Analysis by alcohol dependence revealed similar patterns to the AUDIT score analysis. People with neurotic disorder (particularly phobias, obsessive compulsive disorders or multiple disorders) and those with evidence of anti-social personality disorder were more likely to be dependent on alcohol than individuals without these conditions. Less than 1% of the general population were classified as being moderately or severely dependent on alcohol, but this figure rose to 2% for people with any neurotic disorder, 5% amongst those with a phobia and to 6% among individuals with two or more neurotic disorders. (Tables 4.10 to 4.13) 4.4 Drug use and dependence and mental disorders Both men and women with significant levels of neurotic symptoms (CIS-R score of 12 or above) were more likely to have used drugs or to be dependent on them. For example people who had a CIS-R score of at least 12 were more than twice as likely to have used any drug in the last month than those who scored less (12% compared with 5%). Interestingly, although there is initially an increase in drug use as CIS-R score increased, there was no significant difference between those with a score of 12 to 17, and a score above 18. (Table 4.14) People with each of the different types of neurotic disorder showed greater rates of drug use and dependency than those without a neurotic disorder. People with obsessive compulsive disorder were the most likely to use drugs or have signs of dependence; in comparison to the general population they were three times more likely to have used drugs in the last month (15% compared 53

70 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Figure 4.3 Drug dependence by type of personality disorder Percentage No disorder Other disorder only Anti-social only Anti-social with other disorder Type of disorder Dependent on cannabis only Dependent on other drug(s) with or without cannabis with 5%) and were more likely to be dependent on drugs other than cannabis (7% compared with 1%). Having multiple disorders rather than only one disorder did not increase the prevalence of drug use and dependency. (Table 4.15 and 4.16) There is some difficulty in considering anti-social personality disorder (ASPD) in the context of illegal drug involvement. Some of the behaviours associated with illegal drug use can score as criteria for ASPD and this must be taken into account when exploring the strength of association of these conditions. The association of use, regular use and dependence on cannabis and other drugs was strong for people with ASPD with or without another type of personality disorder compared to those with no personality disorder or with other types of personality disorder only. Around one in three people with ASPD had used drugs in the last month (32%) compared with one in twenty of those without a personality disorder (5%). (Table 4.17 and Figure 4.3) Rates of drug use among people with probable psychosis were not significantly higher than those without. This finding contrasts with those reported from clinical studies but this may relate to the small size of the sample or to the fact that this was a household rather than an institutional survey. However it also worth noting that in a programme of surveys in 1993/94 which covered both households and residential institutions for people with mental disorder, the levels of reported drug use among people living in institutions were similar to those in the household population (Farrell et al, 1998). It is possible that those who make demands on services are more likely to have both severe mental health and drug related problems and that this accounts for some of the differences. This is an area that merits further exploration and research. (Table 4.5) 4.5 Logistic regression analysis and overview A logistic regression analysis was carried out looking at whether having a psychiatric disorder affected the likelihood of current smoking, hazardous drinking or being dependent on any drug once other factors were taken into account. The logistic regression was identical to the model used in Chapter 3 (Table 3.4), with the addition of grouped CIS-R score and measures of probable personality and psychotic disorder. The analysis confirmed that the associations shown in the previous tables in this chapter remained, even after the interactions with the factors in the model (such as age and educational level) were taken into account. Showing evidence of anti-social personality disorder doubled the odds of being a smoker or hazardous drinker and more than quadrupled the odds of drug dependence. Having a high CIS-R score increased the odds of being a smoker or being dependent on drugs, but was not associated with hazardous drinking. Having a CIS- R score between 12 and 17 increased the likelihood of being a smoker (odds ratio=1.64) with the odds ratio remaining similar even for those who had a 54

71 Relationships between psychiatric morbidity and smoking, drinking and drug use CIS-R score of 18 or more (odds ratio=1.66). The odds of being dependent on drugs increased as the CIS-R score increased; for those with a CIS-R score between 12 and 17 the odds of being dependent on drugs were 2.69, and for those with a CIS-R score of 18 or more the odds ratio was Probable psychosis was not associated with increased substance use or dependence, although this may be due to the small number of people who are classified as having this condition. (Table 4.18) 4 In summary, the prevalence of smoking, drinking and drug use and dependence was greater for people with mental disorders compared to those without. The exception was for probable psychosis which was not significantly related to increased drinking and drug use. High CIS-R score had a stronger relationship with smoking than it did for measures of drinking or drug use. Anti-social personality disorder and obsessive compulsive neurotic disorder showed very high levels of use and dependence on tobacco, alcohol and drugs. Reference Farrell M, Howes S, Taylor C, Lewis G, Jenkins R, Bebbington P, Jarvis M, Brugha T, Gill B and Meltzer H (1998) Substance misuse and psychiatric comorbidity: an overview of the OPCS National Psychiatric Morbidity Survey. Addictive Behaviour 23(6),

72 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.1 Cigarette smoking status by CIS-R score (grouped) and sex CIS-R score (grouped) and over and over All Cigarette smoking status % % % % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base

73 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.2 Cigarette smoking status by type of neurotic disorder and sex Type of neurotic disorder Mixed anxiety/ Generalised Obsessive Any No All depressive anxiety Depressive Any compulsive Panic neurotic neurotic disorder disorder episode phobia disorder disorder disorder disorder Cigarette smoking status % % % % % % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker [12] Heavy [5] Moderate [4] Light [3] Non-smoker [17] Ex-regular [8] Never regular [9] Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base

74 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.3 Cigarette smoking status by number of neurotic disorders and sex Number of neurotic disorders None One Two or more All Cigarette smoking status % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base

75 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.4 Cigarette smoking status by probable personality disorder and sex Type of personality disorder No Anti-social Anti-social with Other disoder All* disorder only other disorder only Cigarette smoking status % % % % % Women Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base Men Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base All adults Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Base * Includes the one case with a missing value for type of personality disorder. 59

76 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.5 Substance use and dependence by psychotic disorder No Proabable All psychosis psychosis % % % Smoking status Smoker Heavy Moderate Light Non-smoker Ex-regular Never regular Audit score Has problem (score 8 and over) Mean Alcohol dependence No dependence Mild dependence Moderate or severe dependence Last time used drugs Never A year or more ago More than a month but less than a year In past month Drug dependence Dependent on cannabis only Dependent on other drug(s) with or without cannabis No dependence Base

77 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.6 Prevalence of hazardous drinking by CIS-R score (grouped) and sex CIS R score (grouped) and over and over All AUDIT score % % % % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base

78 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.7 Prevalence of hazardous drinking by type of neurotic disorder and sex Type of neurotic disorder Mixed anxiety/ Generalised Obsessive depressive anxiety Depressive Any compulsive Panic Any No disorder disorder episode phobia disorder disorder disorder disorder AUDIT score % % % % % % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: [15] Score: [8] Score: [6] Hazardous drinking (Score 8 and over) [14] Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All 62

79 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.8 Prevalence of hazardous drinking by number of neurotic disorders and sex Number of neurotic disorders None One Two and over All AUDIT score % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base

80 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.9 Prevalence of hazardous drinking by probable personality disorder and sex Type of personality disorder No Anti-social Anti-social with Other disorder All* disorder only other disorder only AUDIT score % % % % % Women Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base Men Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base All adults Score: Score: Score: Hazardous drinking (Score 8 and over) Mean AUDIT Score Base * Includes the one case with a missing value for type of personality disorder. 64

81 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.10 Prevalence of alcohol dependence by CIS R score (grouped) and sex CIS R score (grouped) and over and over All Alcohol dependence % % % % % % % (based on SAD Q score) Women No dependence Mild dependence Moderate or severe dependence Base Men No dependence Mild dependence Moderate or severe dependence Base All adults No dependence Mild dependence Moderate or severe dependence Base

82 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.11 Prevalence of alcohol dependence by type of neurotic disorder and sex Type of neurotic disorder Mixed anxiety/ Generalised Obsessive depressive anxiety Depressive Any compulsive Panic Any No disorder disorder disorder phobia disorder disorder disorder disorder Alcohol dependence % % % % % % % % % (based on SAD-Q score) Women No dependence Mild dependence Moderate or severe dependence Base All Men No dependence [21] Mild dependence [6] Moderate or severe dependence [2] Base All adults No dependence Mild dependence Moderate or severe dependence Base

83 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.12 Prevalence of alcohol dependence by number of neurotic disorders and sex Number of neurotic disorders None One Two and over All Alcohol dependence (based on SAD-Q score) % % % % Women No dependence Mild dependence Moderate or severe dependence Base Men No dependence Mild dependence Moderate or severe dependence Base All adults No dependence Mild dependence Moderate or severe dependence Base

84 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.13 Prevalence of alcohol dependence by probable personality disorder and sex Type of personality disorder No Anti-social Anti-social with Other disorder All* disorder only other disorder only Alcohol dependence % % % % % (based on SAD-Q score) Women No dependence Mild dependence Moderate or severe dependence Base Men No dependence Mild dependence Moderate or severe dependence Base All adults No dependence Mild dependence Moderate or severe dependence Base * Includes the one case with a missing value for type of personality disorder. 68

85 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.14 Drug use and dependence by CIS-R score (grouped) and sex CIS R score (grouped) Drug use and dependence and over and over All Percentage reporting Women Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base Men Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base All adults Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base

86 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.15 Drug use and dependence by type of neurotic disorder and sex Type of neurotic disorder Drug use and dependence Mixed anxiety/ Generalised Obsessive depressive anxiety Depressive Any compulsive Panic Any No disorder disorder disorder phobia disorder disorder disorder disorder Percentage reporting All Women Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base Men Ever used any drug [11] Used any drug in last year [5] Used any drug in last month [5] Dependent on cannabis only [3] Dependent on other drug(s) with or without cannabis [1] Any drug dependence [4] Base All adults Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base

87 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.16 Drug use and dependence by number of neurotic disorders and sex Number of neurotic disorders Drug use and dependence None One Two and over All Percentage reporting Women Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base Men Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base All adults Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base

88 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.17 Drug use and dependence by probable personality disorder and sex Type of personality disorder No Anti-social Anti-social with Other disorder All* disorder only other disorder only Drug use and dependence Percentage reporting Women Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base Men Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base All adults Ever used any drug Used any drug in last year Used any drug in last month Dependent on cannabis only Dependent on other drug(s) with or without cannabis Any drug dependence Base * Includes the one case with a missing value for type of personality disorder. 72

89 Relationships between psychiatric morbidity and smoking, drinking and drug use 4 Table 4.18 Odds ratios of psychiatric morbidity and socio-economic factors associated with substance use Current smoker Hazardous drinker (AUDIT = 8 and over) Dependent on any drug Adjusted 95% confidence Adjusted 95% confidence Adjusted 95% confidence odds ratio interval odds ratio interval odds ratio interval Lower Upper Lower Upper Lower Upper CIS-R score * *** *** and over 1.66 *** *** Personality disorder No disorder Anti social disorder only 2.28 *** *** *** Anti social plus another disorder 2.07 *** *** *** Other disorder only Sex Women Men 2.91 *** *** Age group *** *** *** *** *** *** * *** *** ** Ethnic origin White Black 0.65 * *** South Asian 0.51 ** *** Other ** Marital status Married Cohabiting 1.58 *** *** *** Single 1.44 *** *** *** Widowed 1.62 ** Divorced or seperated 1.50 *** *** ** Employment status Employed Unemployed 1.93 * Economically inactive Socio-economic group Non manual Manual 1.35 *** *** Armed Forces or no answer * = p<0.05; ** = p <0.01; *** = p< Table continued on page 74. Indian, Pakistani or Bangladeshi. Those who are defined as in financial difficulty are those who are behind in paying bills or had borrowed money in the last year, or who had to used less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 73

90 4 Relationships between psychiatric morbidity and smoking, drinking and drug use Table 4.18 continued Odds ratios of psychiatric morbidity and socio-economic factors associated with substance use Highest educational qualification A-level or above GCSE level 1.44 *** No qualifications 2.03 *** Age left school 16 or younger ** * or older 0.68 *** Not yet finished 0.31 *** ** * Housing tenure Owns Social renter 1.76 *** Private renter 1.59 *** *** Locality Urban Rural or semi rural 0.83 ** ** Gross weekly income Under but under but under *** and over 1.55 *** In financial difficulty No Yes 1.72 *** *** *** Benefit Non benefit recipient Benefit recipient 0.71 *** Other factors not significantly associated with any of the substances Psychotic disorder * = p<0.05; ** = p <0.01; *** = p< Current smoker Hazardous drinker (AUDIT = 8 and over) Dependent on any drug Adjusted 95% confidence Adjusted 95% confidence Adjusted 95% confidence odds ratio interval odds ratio interval odds ratio interval Lower Upper Lower Upper Lower Upper Indian, Pakistani or Bangladeshi. Those who are defined as in financial difficulty are those who are behind in paying bills or had borrowed money in the last year, or who had to used less, or were disconnected from, basic utilities (water, gas, electricity and telephone). 74

91 5 Help seeking, treatment and service use Help seeking, treatment and service use Introduction This chapter reports on patterns of current treatment and health service contact for smokers, drinkers and drug users. For each substance the chapter investigates, firstly, present treatment for emotional or mental problems, and secondly, use of health and care services. Finally specific questions relevant to help or treatment for particular substance use problems are investigated. Current treatments received for mental or emotional problems include use of medication and access to therapy or counselling. The medications considered are those used in the treatment of mental disorders (psychoactive medications). The drugs are from the British National Formulary classes of hypnotics and anxiolytics, antidepressants, and medication used in the treatment of psychotic illness. Counselling or therapy includes counselling, psychotherapy, behaviour or cognitive therapy, art, music or drama therapy, social skills training, marital or family therapy and sex therapy. Service use includes consultations with a general practitioner (GP) or family doctor, in-patient stays and treatment or check-ups as an out-patient or a day-patient. A distinction was made between whether individuals used the service for a mental or emotional problem or because of a physical complaint. In addition, respondents were asked whether they used any community or day activity services. Respondents were also asked about any help for mental and emotional problems that they had been offered in the past year but which they had turned down. As well as these general questions on service utilisation, the questionnaire included some additional questions specific to each type of substance, including: questions on smoking cessation; reasons for giving up drinking; and whether any treatment, help or advice had been received specifically because of drug use. There is considerable interest in the impact of tobacco smoking, heavy drinking and illicit drug use on service utilisation. In the first place, the adverse health effects are likely to result in increased use of health services and secondly the associated personal and social problems are likely to result in greater use of community services. The main report of the 2000 survey showed that people with a mental disorder made greater use of health services and medication (Singleton et al, 2001). While increased levels of service utilisation associated with heavy smoking, drinking and drug use are a reasonable assumption, many epidemiological studies report that alcohol and drug dependence is associated with low levels of recent service contact when compared to other disorders. The disorders related to substance misuse are least likely to be currently treated compared to other mental disorders (Hall and Farrell, 1997). Patterns of heavy drinking and illicit drug use and dependence are much more common in young men than other groups. However, young men s contact with health and community services tends to be through emergency services for trauma and other acute problems and they otherwise have low levels of contact with services. Therefore, the estimates of service utilisation for heavy alcohol and drug users might be lower than expected, as they will reflect the age and sex composition of this group. In the same way that multiple disorders are associated with increased service utilisation so also is comorbidity with substance use, thus having multiple and complex problems is associated with increased levels of service utilisation. 5.2 Tobacco smokers A higher proportion of current smokers reported receiving treatment for a mental or an emotional problem compared with non-smokers (10% compared with 6%). Heavy smokers were most likely to receive treatment, both medication and 75

92 5 Help seeking, treatment and service use counselling or therapy, and people who had never smoked regularly were the least likely; 13% of heavy smokers had received any treatment compared with 5% of those who had never smoked regularly. (Table 5.1) Heavy smokers were most likely to have used health, community or day activity services for a mental or emotional problem, and people who had never smoked were the least likely. People who had never smoked or who used to smoke were least likely to have spoken to their GP in the past year or in the past two weeks because of a mental or emotional problem, whereas heavy smokers were the most likely. The proportion of respondents who spoke to their GP because of a mental or emotional problem increased as degree of smoking increased; 10% of non-smokers had spoken to their GP for this reason in the last year, compared with 13% of light smokers, 17% of moderate smokers and 20% of heavy smokers. A similar pattern was shown for GP visits for a mental or emotional problem in the past two weeks. Heavy and moderate smokers were also most likely to have made an in-patient or outpatient visit in the last quarter because of a mental or emotional problem (2% compared to 1% of non-smokers), or to have used community care or day activity services, and people who have never smoked regularly were the least likely. Speaking to the GP or having an in-patient or outpatient visit for a physical rather than an emotional problem revealed a different pattern. People who used to smoke regularly but had now given up (exregular smokers) were most likely to have used all of these services. Presumably some people had stopped smoking due to health reasons. There was little difference in the proportion of light, moderate, heavy smokers and non-smokers using such services. (Table 5.2) Five per cent of current smokers had turned down help that was offered for mental and emotional problems in the past year. The equivalent percentage for non-smokers was 2%. (Table 5.3) Current smokers were asked whether they would like to give up smoking and 71% of women and 72% of male smokers reported they would like to stop. 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. About a fifth (21%) of men and women reported they thought it would be very easy to not smoke for a day, 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, maybe because they were less addicted or because fewer had tried giving up; 19% of people aged 16 to 24 thought it would be very difficult, compared with 30% of people aged 25 to 34, and 40% to 41% of those in the age groups above 35. (Table 5.4) Tables look at desire to give up smoking and perceived difficulty of giving up for a day by various mental health measures. Figure 5.1 GP visits by smoking status Percentage Never regular Ex-regular Light Moderate Heavy Smoking status Mental or emotional complaint in past year Physical complaint in past year 76

93 Smokers were grouped by CIS-R score (which indicates the severity of neurotic symptoms). Smokers with a score of 12 or more were more likely to wish to stop smoking, with 79% stating they wished to stop compared with 70% of those with a lower score. However people with higher CIS-R scores were also far more likely to anticipate great difficulty in not smoking for a day, with 51% saying it would be very difficult compared to 29% of people with lower levels of neurotic symptoms. As CIS-R scores increased through the groups 0 to 5, 6 to 11 and 12 to 17, the likelihood of wanting to give up smoking also increased and the feeling that stopping smoking for a day would be difficult became more prevalent. However, there was no real difference between people with a CIS-R score of 12 to 17 and those with a higher score. (Table 5.5) As shown above, high levels of neurotic symptoms (as shown by a CIS-R score of 12 or more) were associated with higher smoking rates, increased rates of wishing to stop and increased rates of reported difficulty stopping for a day: all of which suggest higher rates of nicotine dependence. People with generalised anxiety disorder were most likely to want to give up smoking (79% compared with 69% of people with no neurotic disorders). People with depressive episodes were most likely to think that stopping smoking for a day would be very difficult; 59% felt this way compared with 30% of those with no neurotic disorders. (Table 5.6) Figure Percentage who felt it would be very difficult to not smoke for a day by type of personality disorder Help seeking, treatment and service use People with a personality disorder (PD) other than anti-social, and those with anti-social PD combined with another type of PD, were most likely to think that it would be very difficult to stop smoking for a day (40% and 50% respectively), compared with 34% of people with an anti-social PD only and 30% of those with no personality disorder. (Table 5.7) People diagnosed as having probable psychosis were also more likely to think that stopping smoking for a day would be hard; 59% thought it would be very difficult, compared to 35% of people with no psychotic disorder. (Table 5.8) 5.3 Hazardous drinkers and dependent drinkers Tables look at treatment and health service use by level of alcohol problem. The SAD-Q and AUDIT scores were combined to create three categories: People with an AUDIT of less than 8 (no hazardous drinking). People with an AUDIT of 8 or more and a SAD-Q score of less than 4 (hazardous drinking but not alcohol dependent). People with an AUDIT of 8 or more and a SAD-Q score 4 or more (alcohol dependent). Hazardous drinkers who were not dependent on alcohol were less likely to be receiving medication (with or without counselling) than non-hazardous drinkers or people with no alcohol dependence (4%, 6% and 8% respectively). Individuals with alcohol dependence were more likely to be receiving counselling or therapy for a mental or emotional problem; 4%, compared with 2% of people who were not dependent. (Table 5.9) 5 Percentage No disorder Other disorder only Anti-social only Type of disorder Anti-social with other disorder There was no difference between non-hazardous drinkers and people with alcohol dependence in terms of use of health-, community- or dayservices. Hazardous drinkers without signs of dependence were in fact less likely to use many of these services. For example, among this group 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. Similarly only 4% of people with hazardous but non-dependent drinking had 77

94 5 Help seeking, treatment and service use used a community care service in the last year compared to 7% of non-hazardous drinkers and 8% of people dependent on alcohol. (Table 5.10) It is interesting that, compared with non-hazardous drinkers, dependent drinkers have similar levels of health service use and hazardous but non-dependent drinkers actually tend to use fewer health services. This may reflect the fact that young men, who are known to use fewer health care services, are overrepresented among hazardous drinkers. Eight per cent of people with alcohol dependence had turned down help offered for mental and emotional problems in the past year. Three per cent of people without signs of dependence had done the same. (Table 5.11) Four per cent of people used to drink but have given up drinking at some point in their lives. They were asked what the main reason was that made them stop drinking. Nearly half (49%) gave health concerns as the reason. Men aged 55 to 74 were most likely to give this response (64%) compared with, for example, 44% of women of the same age. Not liking it was the second most frequent answer for both men and women, although a higher proportion of women gave this as their main reason (25%) compared with 15% of men. The next most common answers were religious reasons (6%) and not being able to afford it (4%). Very few people had given up because of their parent s advice or influence. Religion was a more common reason among those aged 16 to 34 (11%), compared with people aged 55 to 74 (2%). Not liking alcohol was more frequent in the 35 to 74 year old group (24% of people aged 35 to 54 and 22% of people aged 55 to 74 compared with 12% of people aged 16 to 34). (Table 5.12) 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: 82% had spoken to their GP because of a physical complaint compared with 61%; 28% had spoken to their GP due to mental, nervous or emotional problem compared with 12%; and 14% had not spoken to their GP compared with 37% of the general population. (Table 5.13) 5.4 Drug dependence People with drug dependence were categorised as: dependent on cannabis alone; dependent on drugs other than cannabis (which included opioids, cocaine and amphetamines); or not dependent on drugs. Figure 5.3 Main reason for stopping drinking Can't afford it (4%) Religious reasons (6%) Other (20%) Health reasons (49%) Don't like it (21%) 78

95 Overall it might be expected that people with dependence on drugs other than cannabis would be most likely to have received treatment or used health care services, while those dependent on cannabis only would be more similar to the nondependent population in terms of health service use. On the whole this was found to be true, although the differences were not dramatic. People with no drug dependence were similar to those who were dependent on cannabis only with respect to health service use, with the exception that people dependent on cannabis 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 other 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% compared with 11% of people with no drug dependence); 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. However, this probably reflects the younger age profile of the drug dependent population. (Table ) As was the case with hazardous drinkers, younger men make up a large proportion of the drug dependent population and young men are also less likely to make use of health services compared to the total adult population. As a result, the increase in service utilisation by people with dependence on drugs other than cannabis (mainly young men) is likely to be even greater than it appears from the comparisons with the adult population aged 16 to 74. Help seeking, treatment and service use Similar to the analysis on alcohol dependence, those who were dependent on drugs were more likely to have declined services offered to them for mental or emotional problems in the past year than people without signs of dependence; 15% of people dependent on drugs other than cannabis had declined such services compared to 8% of those who were dependent on cannabis only and 3% of those who were not dependent on drugs. (Table 5.16) As well as the general questions on service use, the section on drug use included some questions about receipt of help, support and advice for drug problems. Of men and women who had used drugs at some point in their lifetime 2% reported ever receiving advice or help with regard to their drug use and 1% reported treatment in the last year. The small group of drug dependent women aged 55 to 74 were most likely to have received treatment ever or in the last year compared to all other groups, however this finding should be viewed cautiously because of the small number of people on which it is based. (Table 5.17) Many people who have experimented briefly with drugs will not have required any help, so it is important to look at patterns of help-seeking in relation to recent drug use and drug dependence. Recent users were more likely to have reported ever receiving treatment, help or advice because they were using drugs; 6% of people who had used drugs in the last month compared with 1% of those who had taken drugs a year or more ago. The percentage reporting receiving treatment, help or advice was higher among those who were dependent. Ten per cent of people who were dependent on any drugs reported receiving such help, and 23% people dependent on drugs other than cannabis reported this. (Table 5.18) References Hall W and Farrell M (1997) Comorbidity of mental disorders with substance misuse. British Journal of Psychiatry 171, 4 5. Singleton N, Bumpstead R, O Brien M, Lee A and Meltzer H (2001) Psychiatric morbidity among adults living in private households, 2000, TSO: London. 5 79

96 5 Help seeking, treatment and service use Table 5.1 Treatment received for mental or emotional problems by cigarette smoking status Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Type of treatment for mental % % % % % % % % or emotional problem No treatment Medication only Counselling or therapy only Both medication and counselling Base * Includes missing cases. Table 5.2 Health care services used by cigarette smoking status Cigarette smoking status Heavy Moderate Light Ex- Never All All non- All* regular regular current smokers smokers Percentage reporting using each service Used the following service because of a mental or emotional problem Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Used the following service because of a physical complaint Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Community care services used In past year In past quarter Day care services used In past year In past quarter Base * Includes missing cases. 80

97 Help seeking, treatment and service use 5 Table 5.3 Services turned down by cigarette smoking status Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Percentage turning down help Has turned down a service Base Turned down help from Community Psychiatric Nurse Social Worker Occupational/Industrial Therapist Psychiatrist Other nursing services Home help/home care worker Counselling service Other Base: those turning down a service * Includes missing cases. 81

98 5 Help seeking, treatment and service use Table 5.4 Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by age and sex Age Women All Percentage reporting Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers Men Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers All adults Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers

99 Help seeking, treatment and service use 5 Table 5.5 Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by CIS-R score (grouped) and sex CIS-R score (grouped) and over and over All Women Percentage reporting Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers Men Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers All adults Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers

100 5 Help seeking, treatment and service use Table 5.6 Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by type of neurotic disorder Type of neurotic disorder Mixed anxiety/ Generalised Obsessive Any No depressive anxiety Depressive Any compulsive Panic neurotic neurotic disorder disorder episode phobia disorder disorder disorder disorder All Percentage reporting Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers Table 5.7 Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by personality disorder Type of personality disorder Anti-social with No disorder Anti-social only other disorder Other disorder only All Percentage reporting Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers Table 5.8 Whether would like to give up smoking altogether and difficulty of not smoking for a whole day by psychotic disorder No psychotic Probable All disorder psychosis Percentage reporting Would like to give up smoking Difficulty of not smoking for a day Very easy Fairly easy Fairly difficult Very difficult Base: current smokers

101 Help seeking, treatment and service use 5 Table 5.9 Treatment received for mental or emotional problems by level of alcohol problem Level of alcohol problem No hazardous Harzardous drinking Alcohol All* drinking 1 not dependent 2 dependent 3 Type of treatment for mental % % % % or emotional problem No treatment Medication only Counselling or therapy only Both medication and counselling Base * Includes missing cases. 1 AUDIT score <8. 2 AUDIT score 8 but SAD-Q score AUDIT score 8 and SAD-Q score 4 and over. Table 5.10 Health care services used by level of alcohol problem Level of alcohol problem No hazardous Hazardous drinking Alcohol All* drinking 1 not dependent 2 dependent 3 Percentage reporting using each service Used the following service because of a mental or emotional problem Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Used the following service because of a physical complaint Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Community care service used In past year In past quarter Day care service used In past year In past quarter Base * Includes missing cases. 1 AUDIT score <8. 2 AUDIT score 8 but SAD-Q score AUDIT score 8 and SAD-Q score 4 and over. 85

102 5 Help seeking, treatment and service use Table 5.11 Services turned down by level of alcohol problem Level of alcohol problem No hazardous Hazardous drinking Alcohol All* drinking 1 not dependent 2 dependent 3 Percentage turning down help Has turned down a service Base: all adults Turned down help from Community Psychiatric Nurse Social Worker Occupational/Industrial Therapist Psychiatrist Other nursing services Home help/home care worker Counselling service Other Base: those who have turned down a service * Includes missing cases. 1 AUDIT score <8. 2 AUDIT score 8 but SAD-Q score AUDIT score 8 and SAD-Q score 4 and over. 86

103 Help seeking, treatment and service use 5 Table 5.12 Main reason for stopping drinking by age and sex Women Age All % % % % Main reason stopped drinking Health reasons Don t like it Religious reasons Can t afford it Parent s advice/influence Other Base: those who used to drink but stopped Men Main reason stopped drinking Health reasons [8] Don t like it [3] Religious reasons [4] Can t afford it [2] Parent s advice/influence [-] Other [8] Base: those who used to drink but stopped All adults Main reason stopped drinking Health reasons Don t like it Religious reasons Can t afford it Parent s advice/influence Other Base: those who used to drink but stopped Table 5.13 Contact with GP by whether stopped drinking because of health reasons Stopped drinking because of health reasons % % Spoke to a GP in the last year about a... physical complaint only mental, nervous or emotional problem only 3 3 physical or a mental, nervous or emotional problem 25 9 Did not spead to GP in last year Base All 87

104 5 Help seeking, treatment and service use Table 5.14 Treatment received for mental or emotional problems by drug dependence Level of drug dependence Dependent on other No dependence Dependent on drug(s) with or cannabis only without cannabis All* Type of treatment received for % % % % mental or emotional problem No treatment Medication only Counselling or therapy only Both medication and counselling Base * Includes missing cases. Table 5.15 Health care services used by drug dependence Type of dependence Dependent on No Dependent on drug(s) with or dependency cannabis only without cannaabis All* Percentage reporting using each service Used the following service because of a mental or emotional problem Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Used the following service because of a physical complaint Inpatient stay or outpatient visit in the last quarter Spoke to GP in past year Spoke to GP in past two weeks Community care service used In past year In past quarter Day care service used In past year In past quarter Base * Includes missing cases. 88

105 Help seeking, treatment and service use 5 Table 5.16 Services turned down by drug dependence Level of drug dependence Dependent on No Dependent on other drug(s) with dependence cannabis only or without cannabis All* Percentage turning down help Has turned down a service Base: all adults Turned down help from Community Psychiatric Nurse 6 - [1] 0 Social Worker 10 - [4] 0 Occupational/Industrial Therapist 5 - [1] 0 Psychiatrist 9 [2] [3] 0 Other nursing services 6 [1] [1] 0 Home help/home care worker Counselling service 50 [9] [8] 2 Other 15 [3] [2] 0 Base: those turning down a service * Includes missing cases. Table 5.17 Whether received any treatment, help or advice because they were using drugs (ever and in the past year) by age and sex Age All Women Percentage reporting treatment, help or advice Ever In the last year Base: those who have ever taken drugs Men Ever In the last year Base: those who have ever taken drugs All adults Ever In the last year Base: those who have ever taken drugs

106 5 Help seeking, treatment and service use Table 5.18 Receipt of treatment, help or advice because of drug use by time last used drugs and drug dependence Percentage receiving treatment Base Row percentages Last time used drugs A year or more ago More than a month but less than a year In past month Drug dependence No dependence Dependence on cannabis only Dependence on any drugs Dependence on other drug(s) with or without cannabis

107 6 Stressful life events, social networks and social support Stressful life events, social networks and social support Introduction It is important to put smoking, drinking and drug taking behaviour into a broader context. In Chapter 3 some basic socio-economic factors were explored as risk factors to involvement with tobacco, alcohol and other drugs. This chapter looks at whether a range of other social factors vary between people with different experiences of substance use. The chapter examines: Stressful life events experienced at any time and in the past six months: the number of stressful events experienced, and the specific type of experience. Time spent in Local Authority (LA) care or in an institution as a child. Social functioning characteristics: perceived social support, the size of the primary support group, and number of friends seen in the previous week. It should be noted that the direction of influence of these factors cannot be determined in a cross sectional survey such as this. For example, from these data we cannot ascertain whether homelessness causes a higher rate of drinking or vice versa. However, the extent of the association between factors such as homelessness, domestic violence, victimisation and other related phenomenon and some categories of substance misuse compared to the general population provides a useful insight into the broader social morbidity associated with these conditions. The first section of this chapter describes the social context measures. The remaining sections examine, in turn, associations between these measures and smoking, drinking and drug use. 6.2 Social context measures Stressful life events All respondents were shown three sets of cards which listed a range of stressful life events (18 in total) and were asked to say which, if any, they had suffered at any time of their life. If an event was reported in the lifetime of the individual, a further question established whether this was within the past six months. Events included relationship problems, illness and bereavement; employment and financial crises; and victimisation experiences, all of which might have an adverse effect on a person s mental health. The cards were used in the ONS survey of psychiatric morbidity among prisoners (Singleton et al, 1998). However, not all common stressful events were listed. Moving house and having a baby were excluded as previous research has shown that events such as these are unlikely to significantly increase risk for psychiatric disorders (Brugha et al, 1985). When looking at the number of events experienced, it should be remembered that the events may not carry equal weight in terms of their psychological impact. Additionally, the influence of recent compared with lifetime experiences may be different. The impact of some events on an individual will be strong even if it happened a long time ago, such as being sexual abused as a child. For other cases, for example being sacked, the event may only have a strong effect if it has happened recently, but may have less impact if it happened years ago. Also some events are likely to be found in combination with others; for example running away from home and homelessness. Relationship problems, illness or bereavement To what extent did survey respondents experience relationship problems, illness or bereavement in their lifetime and in the past six months? The specific events enquired about were: separation or divorce; serious illness, injury or assault; serious problem with a close friend or relative; serious illness; injury or assault to a close friend or relative; and death of a close relative. Employment and financial crises Five events were included under the heading employment and financial crises: problems with the police involving a court appearance, major financial crisis, having looked for work for one month and over; something valued being lost or stolen and being made redundant or sacked. 91

108 6 Stressful life events, social networks and social support Victimisation experiences Stressful events that respondents were shown on the third card included running away from home, sexual abuse, violence in the home, ever having been homeless, violence at work and being bullied. Institutional care In addition to asking about the eighteen life events, two additional questions were asked relating to receipt of care outside of the family in childhood: whether they had spent time in local authority care (including foster care), or in an institution (such as a children s home, borstal or young offenders unit but not ordinary boarding schools) Social support and social network Perceived social support was assessed from respondents answers to seven questions. These were originally used in the 1987 Health and Lifestyle survey, and were also included in the 1992 Health Survey for England (Breeze et al, 1994) and the ONS (OPCS) surveys of psychiatric morbidity among adults in private households and in institutions catering for people with mental disorder (Meltzer et al, 1995; Meltzer et al, 1996). The seven questions take the form of statements that individuals could say were not true, partly true or certainly true for them: There are people I know among my family and friends Another group of questions assessed the extent of respondents social networks. These were also adapted from questions used in the other ONS (OPCS) surveys of psychiatric morbidity and focused on the numbers of people (aged 16 and over) that respondents felt close to. Here again the frame of reference was broadened to include everyone the individual was acquainted with, rather than just friends and relatives. Information was collected about three groups of people: adults living inside the household that respondents felt close to; relatives, aged 16 or over, living outside the household that respondents felt close to; and friends or acquaintances living outside the household that would be described as close or good friends. Close friends and relatives form an individual s primary support group. Previous research has suggested that adults with a primary support group of three people or fewer are at greatest risk of psychiatric morbidity (Brugha et al, 1987; Brugha et al, 1993). Respondents were asked how many friends they had seen during the past week and from their responses three size bands were constructed: none, one or two and three or more friends. who do things to make me happy; who make me feel loved; who can be relied on no matter what happens; who would see that I am taken care of if I needed to be; who accept me just as I am; who make me feel an important part of their lives; and who give me support and encouragement. Scores of 1 to 3 were obtained for each question and overall scores ranged from 7 to 21. The maximum score of 21 indicated no lack of perceived social support; scores of 18 to 20 indicated a moderate lack, and scores of 17 and below showed that individuals perceived a severe lack of social support. 6.3 Tobacco use The current body of knowledge on the subject suggests there would be few differences between smokers and non-smokers across most of the social context variables. To explore the extent to which this holds true across the range of levels of tobacco use, smokers were categorised as light, moderate or heavy; and non-smokers as ex-regular and never regular, and these groups were compared to the population as a whole. In general, there was a weak association between smoking behaviour and the social functioning and social support measures explored, with heavy smokers being more likely to both have experienced stressful events and have lower levels of social support. 92

109 There were differences in the pattern of the association between number of stressful life events experienced (over the lifetime and in the past six months) and smoking status. Among non-smokers, ex-smokers had a higher lifetime prevalence of stressful life events than people who had never smoked regularly (97% had experienced at least one stressful life event compared with 94% of those who never smoked). However, this is probably a reflection of the high proportion of older people among ex-smokers (described in Chapter 2), since older people will have had longer exposure to the risk of stressful life events. Heavy and moderate smokers were more likely to have had stressful experiences in their lifetime than light smokers (97% compared with 92%). A much greater difference between smokers and non-smokers is found when recent experiences, rather than lifetime experiences, are considered. Almost a third (32%) of smokers had experienced one of the stressful life events covered in the survey in the past six months, and there was little difference between light, moderate and heavy smokers. In comparison, less than a quarter (23%) of non-smokers, both ex-smokers and those who had never smoked, reported a stressful event in the past six months. (Table 6.1) It might be expected that heavy smoking would be associated with some forms of increased social morbidity such as divorce, separation, unemployment and more general social stresses. Stressful life events, social networks and social support Tables consider the associations between smoking status and the individual events covered by the survey. Separation and divorce was associated with level of smoking in both men and women. Among heavy smokers 43% had experienced separation or divorce, compared to 30% of light smokers and 23% of non-smokers. Personal injury, illness and assault were also more frequent among women who smoke heavily; among this group almost a third (32%) had experienced injury, illness or assaults compared to a fifth (20%) of women who had never smoked, or were light or moderate smokers. (Table 6.2 and Figure 6.1) Lifetime experiences of unemployment and major financial problems were strongly associated with heavy smoking for men, but the association was less marked for women who smoke heavily. Around one in four (24%) men who smoked heavily had suffered a financial crisis during their lifetime, compared with about one in ten (11%) men who had never smoked. Almost a half (49%) of male heavy smokers had been made redundant or sacked compared with around a third (32%) of men who had never smoked. Ex-regular smokers were just as likely as heavy smokers to have been made redundant or sacked at sometime in their lives; their smoking status at the time of loss of work could have been either current smoker or exsmoker but this finding may simply reflect an association of both variables with age. (Table 6.3) 6 Figure 6.1 Percentage who have ever experienced separation or divorce by smoking status Percentage Never regular Ex-regular Light Moderate Heavy Smoking status 93

110 6 Stressful life events, social networks and social support Smoking, particularly heavy smoking, was associated with increased rates of lifetime experience of violence in the home, sexual abuse, running away from home, being homeless and being expelled from school for both men and women. Among current smokers 12% had experienced violence in the home, 11% had run away from home and 8% had been homeless; the corresponding figures among non-smokers were 5%, 3% and 2%. It is hard to assess patterns over the past six months as the frequencies are low. (Table 6.4) Experience of being cared for outside of the family as a child was associated with smoking, particularly heavy smoking, as an adult. 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). (Table 6.5) 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 nonsmokers), and were least likely to have seen more than two friends in the last week (70% compared with 76% of non-smokers). (Table 6.6) Overall these findings indicate that bad experiences in both childhood and adulthood are associated with smoking, particularly heavier smoking. The direction of effect however is more difficult to determine. Is it that people with major current life stresses are more likely to smoke heavily or is it that past experience of serious life stress predisposes the individual to heavier smoking? Jarvis et al (1999) have reported that socio-economic deprivation is associated with heavy smoking. Other psychiatric morbidity surveys of people who are homeless, in prison or in psychiatric institutions (Farrell et al, 1998) indicate very high rates of heavy smokers in these populations. These vulnerable groups are also more likely to have highly stressful lives, and lower levels of social support. 6.4 Alcohol use and dependence The spectrum of drinking behaviour ranges from light to moderate to heavy. The expectation is that problems of social functioning will be more strongly associated with the heavier rather than the lighter end of the spectrum. Two drinking measures have been used in this chapter; one measures alcohol misuse (based on the AUDIT score) and one measures dependence (based on the SAD-Q score). (For more information on these measures see Appendix B.) For the purposes of this section the AUDIT score was grouped into zero to 7, 8 to 15, and 16 to 40. People who scored 8 or more on the AUDIT were defined as hazardous drinkers. Based on the SAD-Q score respondents were grouped as have no dependence, mild dependence, or moderate or severe dependence. When considering the association between the pattern of drinking behaviour and lifetime experiences of stressful life events it is important to bear in mind the strong association of hazardous drinking with younger age which was described in Chapter 2. Some events, such as the death of a friend or relative, would be expected to be reported with far more frequency by older people. However, despite this, a marked association between problematic drinking patterns and stressful life events was found. The number of stressful events that people had experienced in their lifetime was associated with increasingly problematic or dependent drinking. The difference was most pronounced among the most extreme drinkers. For example, 1% of nonhazardous drinkers had experienced over 10 stressful events over their lifetime, compared with 7% of people who scored 16 or more on the AUDIT score, and 21% of those who were moderately or severely dependent on alcohol. The differences were more pronounced when looking at events over the last six months rather than lifetime experiences. Harmful drinkers (people with an AUDIT score of 16 or more) and the moderate and severely dependent group reported a greater number of stressful life events in the past six months, at 44 and 51 events compared with an average of 26 events for the overall population. (Table 6.7) 94

111 Stressful life events, social networks and social support 6 Alcohol misuse and dependence was associated with having had an injury, illness or assault. Around a quarter of non-hazardous drinkers (26%) or people with no dependence (25%) had experienced an injury, illness or assault during their lifetime, compared with about a third of those with either an AUDIT score above 16 (33%) or those with mild dependence (34%). Among the most extreme category (people with moderate or severe alcohol dependence) over half reported such an experience (54%). It is probable that personal injury may have been a direct result of alcohol use. Serious injury, illness or assault to a close relative over one s lifetime was also highest for people who were moderately or severely alcohol dependent (48% compared with 24% for the whole sample). In addition, lifetime experience of separation and divorce was strongly associated with moderate and severe dependence; two-thirds (67%) of people in this category had experienced separation or divorce, compared to around a quarter (26%) of people who were not alcohol dependent. (Table 6.8 and Figure 6.2) Figure 6.2 Percentage Percentage reporting ever experiencing personal injury, illness or assault by alcohol dependence No dependence Mild dependence Moderate or severe dependence Having a recent serious problem with a close friend or relative was also associated with problematic drinking. Seven per cent of people with an AUDIT score of 16 or more reported a problem with a friend or relative in the last six months compared to 3% of those with an AUDIT score of less than 16. However this difference was not significant when looking at lifetime experiences. (Table 6.8) All the employment and financial crises measures were associated with having a high AUDIT score, both over lifetime and over the previous six month period. For example, comparing people with an AUDIT score of 16 or more with those with a score of less than 8, 43% had been made redundant or sacked at some time in their lives compared with 28% of those with low scores. Similarly, 23% had had a financial crisis compared with 11% of nonhazardous drinkers. 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. For men, but not women, having something lost or stolen was significantly associated with increased AUDIT score. (Table 6.9) All the victimisation experiences listed in Table 6.10 were more likely to have happened during the lifetime of those people who had a drinking problem. Among people with no dependence on alcohol, 18% had been bullied, 7% had suffered violence in the home, 1% had been expelled from school and 3% had been homeless. However, people who had moderate to severe dependence on alcohol were much more likely to have suffered these negative experiences; 51% had been bullied, 43% had suffered violence in the home, 21% had been expelled from school and 26% had been homeless. (Table 6.10) More people with problematic or dependent drinking reported being in institutional care in childhood, but the only difference that was statistically significant was that individuals with an AUDIT score of 16 or above were more likely to have spent time in a children s home, borstal or young offenders unit than those with an ADUIT score below 8 (6% compared with 2%). (Table 6.11) When looking at stressful events there is a gradual increase in the likelihood that an event had occurred as the AUDIT score or SAD-Q score increases, whereas for measures of social support the differences are usually only apparent for the most extreme measure. There were no statistically significant differences between those scoring zero to 7, and those scoring 8 to 15 on the AUDIT on all three measures of social support. There was also no 95

112 6 Stressful life events, social networks and social support statistical difference between people with an AUDIT score of 16 or above and those with a lower score in terms of size of primary support group or the number of friends seen in the previous week. However people with moderate or severe dependence were more likely to perceive a lack of social support, have a smaller primary support group and to have seen fewer friends in the last week (although this last difference did not reach statistical significance). Of those with moderate or severe dependence 36% reported a severe lack of social support compared to 8% of the total population. (Table 6.12) Overall these findings indicate that increasingly problematic and dependent drinking is associated with earlier disruptive childhood experiences and other stressful experiences such as victimisation, domestic violence or financial difficulties. drugs one to twelve months ago and 28% of those who had used drugs a year or more ago. Half (50%) of people dependent on drugs with or without cannabis reported a stressful event in the last six months, compared to around a quarter (26%) of people in the sample as a whole. The main gender difference was that, among people who had used drugs in the past month, women were more likely to have experienced a recent stressful event than men were (46% compared with 38%). (Table 6.13 and 6.14 and Figure 6.3) Figure Stressful life event occuring in past six months by when last used drugs 6.5 Drug use and dependence These same indicators of social functioning and experience were explored for drug use and dependence. The proportion of the population reporting involvement with drugs, either over their lifetime or in the recent past, is significantly smaller than those reporting tobacco and alcohol involvement so the bases for comparison are rather small in many instances. The age effect may have an even greater impact on the drug data than it does for the smoking or drinking analysis. There is a birth cohort effect with younger groups significantly more likely to report a lifetime experience of ever using drugs compared to the above 40 age group and this is likely to effect reports of lifetime experience of certain events compared to the population as a whole. People who have used or are dependent on drugs had more stressful experiences both over their lifetime and in the past six months. Those who were, or had been, involved with drugs were more likely to have had over ten stressful experiences in their lifetime, or to have had a stressful experience in the last six months. People with more recent drug use reported more stressful experiences than those with less recent use. For example 41% of those who had used drugs in the past month had experienced a stressful event in the past six months compared to 35% of those who had used Percentage Never used drugs Year or more ago 1 up to 12 months ago Last time used drugs In past month People who had used drugs were more likely to have experienced separation or divorce over their lifetime than people who had never used drugs, for example 42% of those with any drug dependence had experienced this compared to 27% of the general population. Having had a serious problem with a close friend or relative was also associated with drug use. For example people who were dependent on any drugs were twice as likely as the general population to have had such a problem (31% compared with 15%). Those using drugs were more likely to report a recent death of a close friend or relative. Thirteen per cent of those who had used drugs in the last month had a close friend or relative die during the six months before the interview compared to 8% across the whole sample. (Table 6.15 and 6.16) 96

113 The likelihood of reporting having had an employment or financial crisis was greater for people who had used drugs, particularly for those who showed signs of dependence. Comparing lifetime experience among people with drug dependence to levels in the general population: 40% had been made redundant or sacked compared with 30%; 48% spent more than a month looking for work compared with 23%; and 22% experienced a major financial crisis compared with 11%. There were also clear differences when examining differences in the last six months. For example, those who had used drugs in the last year were three times as likely as those who had never used drugs to have been made redundant or sacked (6% compared with 2%). 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%. (Table 6.17 and 6.18) Stressful life events, social networks and social support Authority care before the age of sixteen. For example, people who had used drugs in the year before the interview were twice as likely as those who have never taken drugs to have spent time in an institution (4% compared with 2%). However, not all of these differences reached statistical significance. (Table 6.21 and 6.22) People with current or past experience of drug use had similar sized primary support groups and had seen similar numbers of friends in the last week compared with the population as a whole. However, people who reported using drugs in the past month or who were dependent on drugs other than cannabis were more likely to feel they lacked social support (37% and 44% compared with 30% for the whole sample). (Table 6.23 and 6.24) In summary, the tables suggest there is an association between stressful life events and drug use and dependence. Those most likely to experience these kind of events are dependent on drugs, with or without concurrent cannabis dependence. This group were the most severe drug users, the majority of whom were heroin users. However one should note that these constitute just under 1% of the total sample so the analysis is based on very small numbers and needs to be interpreted with due caution. 6 All the measures of drug use and dependency in Table 6.19 and 6.20 show increased likelihood of the individual having been victimised. People who were dependent on drugs other than cannabis, the majority of whom were dependent on heroin, tended to be the most likely to have suffered such experiences. Comparing this group with the general population: 32% had been bullied compared with 18%; 17% reported having been homeless compared with 4%; and 28% had run away from home compared with 5%. (Table 6.19 and 6.20) A higher percentage of people with experience of drug use and dependency had spent time in an institution as a child or had been taken in to Local 6.6 Conclusion These results provide some indicators of economic and social functioning and lifetime experience of chronic adversity associated with substance use. The data suggests that stressful life events (such as separation and divorce, personal injury, unemployment, financial crisis, violence in the home and homelessness), childhood institutionalisation and lack of social support are associated with general substance involvement with greater levels of heavy smoking, hazardous and dependent drinking, and drug use and dependence. However, it is not possible from a cross-sectional survey to assess whether these behaviours are causative of these events or vice versa or whether the observed association indicates a general association with broader levels of social and economic disadvantage. 97

114 6 Stressful life events, social networks and social support References Breeze E, Maidment A, Bennett N, Flatley J and Carey S (1994) Health Survey for England, 1992, HMSO: London. Brugha T, Bebbington P, Tennant C, and Hurry J (1985) The List of Threatening Experiences: a subset of 12 life event categories with considerable long-term contextual threat. Psychological Medicine 15, Brugha T S, Sturt E, MacCarthy B, Potter J, Wykes T and Bebbington P E (1987) The Interview Measure of Social Relationships: the description and evaluation of a survey instrument for assessing personal social resources. Social Psychiatry 22, Brugha T S, Wing J K, Brewin C R, MacCarthy B and Leasge A (1993) The relationships of social network deficits in social functioning in long term psychiatric disorders. Social Psychiatry and Social Epidemiology 28, Farrell M, Howes S, Taylor C, Lewis G, Jenkins R, Bebbington P, Jarvis M, Brugha T, Gill B and Meltzer H (1998) Substance misuse and psychiatric comorbidity: an overview of the OPCS National Psychiatric Morbidity Survey. Addictive Behaviour 23(6), Jarvis M and Wardle J (1999) Social Patterning of health behaviours: the case of cigarette smoking, in Marmott M and Wilkinson R (eds), Social Determinants of Health, OUP: Oxford, pp Meltzer H, Gill B, Petticrew M and Hinds, K (1995) OPCS Surveys of Psychiatric Morbidity in Great Britain, Report 3: Economic activity and social functioning of adults with psychiatric disorders, HMSO: London. Meltzer H, Gill B, Petticrew M and Hinds, K (1996) OPCS Surveys of Psychiatric Morbidity in Great Britain, Report 6: Economic activity and social functioning of residents with psychiatric disorders, HMSO: London. Singleton N, Meltzer H, Gatward R, Coid J and Deasy D (1998) Psychiatric Morbidity among Prisoners in England and Wales, TSO: London. 98

115 Stressful life events, social networks and social support 6 Table 6.1 Number of stressful events in lifetime and past six months by cigarette smoking status and sex Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Women % % % % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base Men Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes missing cases. Table continued on page

116 6 Stressful life events, social networks and social support Table 6.1 continued Number of stressful events in lifetime and past six months by cigarette smoking status and sex Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Women % % % % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months or more Any stressful event in past 6 months Base * Includes missing cases. 100

117 Stressful life events, social networks and social support 6 Table 6.2 Illness, bereavement and relationship problems in lifetime and past six months by cigarette smoking status and sex Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Women Percentage reporting Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base Men Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base All adults Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base * Includes all cases. 101

118 6 Stressful life events, social networks and social support Table 6.3 Employment and financial crises in lifetime and past six months by cigarette smoking status and sex Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Women Percentage reporting Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base Men Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base All adults Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base * Includes all cases. 102

119 Stressful life events, social networks and social support 6 Table 6.4 Victimisation experiences in lifetime and past six months by cigarette smoking status and sex Cigarette smoking status Women Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Percentage reporting Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base Men Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base All adults Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base * Includes all cases. 103

120 6 Stressful life events, social networks and social support Table 6.5 Institutional care in childhood by cigarette smoking status and sex Women Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Percentage reporting Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base Men Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base All adults Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base * Includes all cases. 104

121 Stressful life events, social networks and social support 6 Table 6.6 Social functioning characteristics by cigarette smoking status and sex Cigarette smoking status Heavy Moderate Light Ex-regular Never All current All non- All* regular smokers smokers Women % % % % % % % % Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base Men Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base All adults Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base * Includes all cases. 105

122 6 Stressful life events, social networks and social support Table 6.7 Number of stressful events in lifetime and past six months by AUDIT score, alcohol dependence and sex AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 20) dependence Women % % % % % % % % Number stressful life events in lifetime [1] [2] [1] [1] [2] to [1] 1 Any lifetime stressful event [8] 95 Number stressful life events in past 6 months [4] [4] and over Any stressful event in past 6 months [4] 25 Base Men Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base

123 Stressful life events, social networks and social support 6 Table 6.7 continued Number of stressful events in lifetime and past six months by AUDIT score, alcohol dependence and sex AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 20) dependence All adults % % % % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes missing cases. 107

124 6 Stressful life events, social networks and social support Table 6.8 Illness, bereavement and relationship problems in lifetime and past six months by AUDIT score, alcohol dependence and sex Women AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 40) dependence Percentage reporting Lifetime Death of close friend/other relative [5] 73 Death of close relative [5] 55 Separation or divorce [6] 29 Serious injury/illness/assault to you [6] 22 Serious injury/illness/assault to close relative [4] 26 Serious problem with close friend/relative [1] 16 Past six months Death of close friend/other relative [1] 9 Death of close relative [1] 3 Separation or divorce [1] 2 Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base Men Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base All adults Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base * Includes all cases. 108

125 Stressful life events, social networks and social support 6 Table 6.9 Employment and financial crises in lifetime and past six months by AUDIT score, alcohol dependence and sex AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 40) dependence Women Percentage reporting Lifetime Made redundant or sacked [2] 19 Looking for work for more than one month [4] 14 Something valued lost or stolen [4] 20 Major financial crisis [2] 8 Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month [1] 2 Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base Men Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base All adults Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base * Includes all cases. 109

126 6 Stressful life events, social networks and social support Table 6.10 Victimisation experiences in lifetime and past six months by AUDIT score, alcohol dependence and sex Women AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 40) dependence Percentage reporting Lifetime Bullying [1] 17 Violence in the home [3] 10 Running away from your home [3] 5 Being homeless [3] 3 Violence at work Sexual abuse [1] 5 Being expelled from school [1] 1 Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base Men Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base All adults Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base * Includes all cases. 110

127 Stressful life events, social networks and social support 6 Table 6.11 Institutional care in childhood by AUDIT score, alcohol dependence and sex Women AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 40) dependence Percentage reporting Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit [1] 2 Taken into Local Authority care [1] 2 Base Men Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base All adults Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base * Includes all cases. 111

128 6 Stressful life events, social networks and social support Table 6.12 Social functioning characteristics by AUDIT score, alcohol dependence and sex AUDIT score Alcohol dependence (based on SAD-Q) Hazardous No Mild Moderate or All* drinker dependence dependence severe (scores 8 40) dependence Women % % % % % % % % Perceived social support score grouped Severe lack [6] 6 Moderate lack [2] 18 No lack [8] 76 Size of primary support group grouped [6] [5] 31 9 and over [5] 65 Number of friends seen in last week None [4] 3 One or two [7] 19 Three and over [4] 78 Base Men Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base All adults Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base * Includes all cases. 112

129 Stressful life events, social networks and social support 6 Table 6.13 Number of stressful events in lifetime and past six months by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month Women % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base Men Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes all cases. Table continued on page

130 6 Stressful life events, social networks and social support Table 6.13 continued Number of stressful events in lifetime and past six months by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month All adults % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes all cases. 114

131 Stressful life events, social networks and social support 6 Table 6.14 Number of stressful events in lifetime and past six months by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base Men Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes all cases. Table continued on page

132 6 Stressful life events, social networks and social support Table 6.14 continued Number of stressful events in lifetime and past six months by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any drug only with or without cannabis All adults % % % % % Number stressful life events in lifetime to Any lifetime stressful event Number stressful life events in past 6 months and over Any stressful event in past 6 months Base * Includes all cases. 116

133 Stressful life events, social networks and social support 6 Table 6.15 Illness, bereavement and relationship problems in lifetime and past six months by illicit drug use and sex Last time used drugs Women Never used Year or 1 up to In past All* drugs more ago 12 months ago month Percentage reporting Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base Men Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base All adults Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base * Includes all cases. 117

134 6 Stressful life events, social networks and social support Table 6.16 Illness, bereavement and relationship problems in lifetime and past six months by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women Percentage reporting Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base Men Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base All adults Lifetime Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Past six months Death of close friend/other relative Death of close relative Separation or divorce Serious injury/illness/assault to you Serious injury/illness/assault to close relative Serious problem with close friend/relative Base * Includes all cases. 118

135 Stressful life events, social networks and social support 6 Table 6.17 Employment and financial crises in lifetime and past six months by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month Women Percentage reporting Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base Men Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base All adults Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base * Includes all cases. 119

136 6 Stressful life events, social networks and social support Table 6.18 Employment and financial crisis in lifetime and past six months by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women Percentage reporting Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base Men Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base All adults Lifetime Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Past six months Made redundant or sacked Looking for work for more than one month Something valued lost or stolen Major financial crisis Problem with police involving court appearance Base * Includes all cases. 120

137 Stressful life events, social networks and social support 6 Table 6.19 Victimisation experiences in lifetime and past six months by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month Women Percentage reporting Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base Men Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base All adults Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base * Includes all cases. 121

138 6 Stressful life events, social networks and social support Table 6.20 Victimisation experiences in lifetime and past six months by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women Percentage only Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual Abuse Being expelled from school Base Men Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexualabuse Being expelled from school Base All adults Lifetime Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Past six months Bullying Violence in the home Running away from your home Being homeless Violence at work Sexual abuse Being expelled from school Base * Includes all cases.

139 Stressful life events, social networks and social support 6 Table 6.21 Institutional care in childhood by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month Women Percentage reporting Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base Men Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base All adults Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base * Includes all cases. 123

140 6 Stressful life events, social networks and social support Table 6.22 Institutional care in childhood by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women Percentage reporting Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base Men Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base All adults Up to the age of 16: Spent time in a children institution such as children s home, borstal or young offenders unit Taken into Local Authority care Base * Includes all cases. 124

141 Stressful life events, social networks and social support 6 Table 6.23 Social functioning characteristics by illicit drug use and sex Last time used drugs Never used Year or 1 up to In past All* drugs more ago 12 months ago month Women % % % % % Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three or more Base Men Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base All adults Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base * Includes all cases. 125

142 6 Stressful life events, social networks and social support Table 6.24 Social functioning characteristics by drug dependence and sex Drug dependence No Dependent Dependent on Dependent All* dependence on cannabis other drug(s) on any only with or without drug cannabis Women % % % % % Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base Men Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base All adults Perceived social support score grouped Severe lack Moderate lack No lack Size of primary support group grouped and over Number of friends seen in last week None One or two Three and over Base * Includes all cases. 126

143 Appendix A Statistical terms and their interpretation Appendix A Statistical terms and their interpretation A1 Confidence intervals The percentages and means quoted in the text of this report represent summary information about a variable (eg CIS-R score) based on the sample of people interviewed in this study. However, extrapolation from these sample statistics is required in order to make inferences about distribution of that particular variable in the population. This is done by calculating confidence intervals around the statistic in question. These confidence intervals indicate the range within which the true (or population) percentage is likely to lie. Where 95% confidence intervals are calculated, this simply indicates that one is 95% confident that the population percentage lies within this range. (More accurately, it indicates that, if repeated samples were drawn from the population, the percentage would lie within this range in 95% of the samples.) Confidence intervals are calculated on the basis of the sampling error (see below). The upper 95% confidence intervals are calculated by adding the sampling error (SE) multiplied by 1.96 to the sample percentage or mean. The lower confidence interval is derived by subtracting the same value. 99% confidence intervals can also be calculated, by replacing the value 1.96 by the value A2 Sampling errors The sampling error is a measure of the degree to which a percentage (or other summary statistic) would vary if repeatedly calculated in a series of samples. It is used in the calculation of confidence intervals and statistical significance tests. In this survey simple random sampling did not take place, a multi-stage stratified sampling design was used. In addition, the data was weighted firstly to take account of differing selection probabilities and, secondly, to compensate for non-response using post-stratification. To take account of the complex sample design and weighting procedures used in this survey, sampling errors were calculated using STATA and the sampling errors associated with key estimates are shown in tables available on the National Statistics website ( However, this does not affect the interpretation of the sampling errors or their use in the calculation of confidence intervals. The effect of a complex sampling design on the precision of survey estimates is usually quantified by means of the design factor (deft). For any survey estimate, the deft is calculated as the ratio of the standard error allowing for the full complexity of the survey design to the standard error assuming a simple random sample. The standard error based on a simple random sample multiplied by the deft gives the standard error of a complex design. se(p) = deft x se(p) sys where: se(p) sys = p(1 - p) N The formula to measure whether the differences between the percentages is likely to be due entirely to sampling error for a complex design is: se(p 1 -p 2 ) = deft 12 * p 1 (100 - p 1 ) deft + 22 * p 2 (100 - p 2 ) n 1 n 2 where p 1 and p 2 are observed percentages for the two sub-samples and n 1 and n 2 are the sub-sample sizes. The 95% confidence interval for the difference between two percentages is then given by; (p 1 -p 2 ) +/ x se(p 1 -p 2 ) If this confidence interval includes zero then the observed difference is considered to be a result of chance variation in the sample. If the interval does not include zero then it is unlikely (less than 5% probability) that the observed differences could have occurred by chance. The standard errors of survey measures which are not presented in the following tables for sample subgroups may be estimated by applying an appropriate value of deft to the sampling error. The choice of an appropriate value of deft will vary according to whether the 127

144 Appendix A Statistical terms and their interpretation basic survey measure is included in the tables. Since most deft values are relatively small (1.1 or less) the absolute effect of adjusting sampling errors to take account of the survey s complex design will be small. In most cases it will result in an increase of less than 10% over the standard error assuming simple random sampling. However, for some regional estimates the deft is greater and caution should be exercised when considering the significance of apparent differences between regions. Whether it is considered necessary to use deft or to use the basic estimates of standard errors assuming a simple random sample is a matter of judgement and depends chiefly on how the survey results will be used. A3 Significance It is stated in the text of the report that some differences are significant. This indicates that it is unlikely that a difference of this magnitude would be found due to chance alone. Specifically, the likelihood that the difference would occur simply by chance is less than 5%. This is conventionally assumed to be in frequent enough to discount chance as an explanation for the finding. 128

145 Appendix B Appendix B Psychiatric disorders and their assessment Psychiatric disorders and their assessment B B1 Calculation of CIS-R symptom scores and algorithms to produce ICD-10 classification of neurotic disorders 1. Calculation of CIS-R symptom scores Calculation of symptom score for Somatic Symptoms Score one for each of: Noticed ache or pain/discomfort for four days or more in past seven days Ache or pain/discomfort lasted more than three hours on any day in past week/on that day Ache or pain/discomfort has been very unpleasant in past week Ache or pain/discomfort has bothered you when you were doing something interesting in past week Calculation of symptom score for Fatigue Score one for each of: Felt tired/lacking in energy for four days or more in past seven days Felt tired for more than three hours in total on any day in past week Felt so tired/lacking in energy that you ve had to push yourself to get things done on at least one occasion during past week Felt tired/lacking in energy when doing things you enjoy or used to enjoy at least once during past week Calculation of symptom score for Concentration and forgetfulness Score one for each of: Noticed problems with concentration/memory for four days or more in past week Could not always concentrate on a TV programme, read a newspaper article or talk to someone without mind wandering in past week Problems with concentration actually stopped you from getting on with things you used to do or would like to do Forgot something important in past seven days Calculation of symptom score for Sleep Problems Score one for each of: Had problems with sleep for four nights or more out of past seven nights Spent at least 1 /4 hour trying to get to sleep on the night with least sleep in the past week Spent three or more hours trying to get to sleep on four nights or more in past week Slept for at least 1 /4 hour longer than usual sleeping on the night you slept the longest in the past week Slept for more than three hours longer than usual on four nights or more in past week. Calculation of symptom score for Irritability Score one for each of: Felt irritable or short tempered/angry on four days or more Felt irritable or short tempered/angry for more than one hour on any day in past week Felt so irritable or short tempered/angry that you wanted to shout at someone in past week (even if you hadn t actually shouted) Had arguments, rows or quarrels or lost your temper with someone in past seven days and felt it was unjustified on at least one occasion Calculation of symptom score for Worry about Physical Health Score one for each of: Worried about physical health/serious physical illness on four days or more in past seven days Felt that you had been worrying too much, in view of actual health 129

146 B Appendix B Psychiatric disorders and their assessment Worrying had been very unpleasant in past week Not able to take mind off health worries at least once by doing something else in past week Calculation of symptom score for Depression Score one for each of: Unable to enjoy or take an interest in things as much as usual in past week Felt sad, miserable or depressed/unable to enjoy or take an interest in things on four days or more in past week Felt sad, miserable or depressed/unable to enjoy or take an interest in things for more than three hours in total on any day in past week When sad, miserable or depressed did not become happier when something nice happened, or when in company Calculation of symptom score for Depressive ideas Score one for each of: Felt guilty or blamed yourself when things went wrong when it hasn t been your fault at least once in past seven days Felt that you are not as good as other people during past week Felt hopeless, for instance about your future, during past seven days Felt that life isn t worth living in past week Thought of killing yourself in past week Calculation of symptom score for Worry Score one for each of: Been worrying about things other than physical health on four or more days out of past seven days Have been worrying too much in view of your circumstances Worrying has been very unpleasant in past week Have worried for more than three hours in total on any of past seven days Calculation of symptom score for Anxiety Score one for each of: Felt generally anxious/nervous/tense on four or more of past seven days Anxiety/nervousness/tension has been very unpleasant in past week When anxious/nervous/tense, have had one or more of following symptoms: - heart racing or pounding - hands sweating or shaking - feeling dizzy - difficulty getting your breath - butterflies in your stomach - dry mouth - nausea or feeling as though you wanted to vomit Felt anxious/nervous/tense for more than three hours in total in any one of past seven days Calculation of symptom score for Phobias Score one for each of: Felt nervous/anxious about (situation/thing) four or more times in past seven days On occasions when felt anxious/nervous/tense, had one or more of following symptoms: - heart racing or pounding - hands sweating or shaking - feeling dizzy - difficulty getting your breath - butterflies in your stomach - dry mouth - nausea or feeling as though you wanted to vomit Avoided situation or thing because it would have made you anxious/nervous/tense once or more in past seven days Calculation of symptom score for Panic Score one for each of: Anxiety or tension got so bad you got in a panic (eg felt that you might collapse or lose control unless you did something about it) once or more in past week. Feelings of panic have been very unpleasant or unbearable in past week. This panic/worst of these panics lasted longer than 10 minutes. 130

147 Calculation of symptom score for Compulsions Score one for each of: Found yourself doing things over again (that you had already done) on four days or more in last week Have tried to stop repeating behaviour/doing these things over again during past week Repeating behaviour/doing these things over again made you upset or annoyed with yourself in past week Repeated behaviour three or more times during past week. Appendix B Psychiatric disorders and their assessment pessimism about future suicidal ideas or acts disturbed sleep diminished appetite 4. Social impairment 5. Fewer than four from: lack of normal pleasure /interest loss of normal emotional reactivity a.m. waking 2 hours early loss of libido diurnal variation in mood diminished appetite loss of 5% body weight psychomotor agitation psychomotor retardation B Calculation of symptom score for Obsessions Score one for each of: Unpleasant thoughts or ideas kept coming into your mind on four days or more in last week Tried to stop thinking any of these thoughts in past week Became upset or annoyed with yourself when you have had these thoughts in past week Longest episode of having such thoughts was 1/4 hour or longer 2. Algorithms for production of ICD-10 diagnoses of neurosis from the CIS-R ( scores refer to CIS-R scores) The neurotic disorders reported were produced from the CIS-R schedule which is reproduced as part of the questionnaire in Appendix B of the Technical Report of the survey (Singleton et al, 2002). The production of the six categories of disorder occurred in two stages: first, the informants responses to the CIS-R were used to produce specific ICD-10 diagnoses of neurosis. This was done by applying the algorithms described below. Second, the range of ICD-10 diagnoses were grouped together to produce categories used in the calculation of prevalence. F32.00 Mild depressive episode without somatic symptoms 1. Symptom duration 2 weeks 2. Two or more from: depressed mood loss of interest fatigue 3. Two or three from: reduced concentration reduced self-esteem ideas of guilt F32.01 Mild depressive episode with somatic symptoms 1. Symptom duration 2 weeks 2. Two or more from: depressed mood loss of interest fatigue 3. Two or three from: reduced concentration reduced self-esteem ideas of guilt pessimism about future suicidal ideas or acts disturbed sleep diminished appetite 4. Social impairment 5. Four or more from: lack of normal pleasure /interest loss of normal emotional reactivity a.m. waking 2 hours early loss of libido diurnal variation in mood diminished appetite loss of 5% body weight psychomotor agitation psychomotor retardation F32.10 Moderate depressive episode without somatic symptoms 1. Symptom duration 2 weeks 2. Two or more from: depressed mood loss of interest fatigue 3. Four or more from: reduced concentration reduced self-esteem ideas of guilt pessimism about future suicidal ideas or acts disturbed sleep diminished appetite 4. Social impairment 131

148 B Appendix B Psychiatric disorders and their assessment 5. Fewer than four from: lack of normal pleasure /interest loss of normal emotional reactivity a.m. waking 2 hours early loss of libido diurnal variation in mood diminished appetite loss of 5% body weight psychomotor agitation psychomotor retardation F32.11 Moderate depressive episode with somatic symptoms 1. Symptom duration 2 weeks 2. Two or more from: depressed mood loss of interest fatigue 3. Four or more from: reduced concentration reduced self-esteem ideas of guilt pessimism about future suicidal ideas or acts disturbed sleep diminished appetite 4. Social impairment 5. Four or more from: lack of normal pleasure /interest loss of normal emotional reactivity a.m. waking 2 hours early loss of libido diurnal variation in mood diminished appetite loss of 5% body weight psychomotor agitation psychomotor retardation F32.2 Severe depressive episode 1. All three from: depressed mood loss of interest fatigue 2. Four or more from: reduced concentration reduced self-esteem ideas of guilt pessimism about future suicidal ideas or acts disturbed sleep diminished appetite 3. Social impairment 4. Four or more from: lack of normal pleasure /interest loss of normal emotional reactivity a.m. waking 2 hours early loss of libido diurnal variation in mood diminished appetite loss of 5% body weight psychomotor agitation psychomotor retardation F40.00 Agoraphobia without panic disorder 1. Fear of open spaces and related aspects: crowds, distance from home, travelling alone 2. Social impairment 3. Avoidant behaviour must be prominent feature 4. Overall phobia score 2 5. No panic attacks F40.01 Agoraphobia with panic disorder 1. Fear of open spaces and related aspects: crowds, distance from home, travelling alone 2. Social impairment 3. Avoidant behaviour must be prominent feature 4. Overall phobia score 2 5. Panic disorder (overall panic score 2) F40.1 Social phobias 1. Fear of scrutiny by other people: eating or speaking in public etc. 2. Social impairment 3. Avoidant behaviour must be prominent feature 4. Overall phobia score 2 F40.2 Specific (isolated) phobias 1. Fear of specific situations or things, e.g. animals, insects, heights, blood, flying etc. 2. Social impairment 3. Avoidant behaviour must be prominent feature 4. Overall phobia score 2 F41.0 Panic disorder 1. Criteria for phobic disorders not met 2. Recent panic attacks 3. Anxiety-free between attacks 4. Overall panic score 2 F41.1 Generalised anxiety disorder 1. Duration 6 months 2. Free-floating anxiety 3. Autonomic overactivity 4. Overall anxiety score 2 F41.2 Mixed anxiety and depressive disorder 1. (Sum of scores for each CIS-R section) Criteria for other categories not met 132

149 F42 Obsessive-compulsive disorder 1. Duration 2 weeks 2. At least one act /thought resisted 3. Social impairment 4. Overall scores: obsession score=4, or compulsion score=4, or obsession+compulsion scores 6 3. Grouping neurotic disorders (and depressive episode) into broad categories Depression Appendix B Psychiatric disorders and their assessment a positive answer to question 5a in the Psychosis Screening Questionnaire which refers to auditory hallucinations. The presence of any one of these criteria was sufficient for a person to screen positive for psychosis. Then a sub-sample of people were selected to take part in a second stage interview carried out by specially trained psychologists employed and supervised by the University of Leicester. The people included in the subsample can be divided into 3 groups which were selected using different sampling fractions as follows: B F32.00 and F32.01 were grouped to produce mild depressive episode (i.e. with or without somatic symptoms). F32.10 and F32.11 were similarly grouped to produce moderate depressive episode. Mild depressive episode, moderate depressive episode and severe depressive episode (F32.2) were then combined to produce the final category of Depressive disorder. Phobias The ICD-10 phobic diagnoses F40.00, F40.01, F40.1 and F40.2, were combined into one category of phobia. Categories for analysis This produced six categories of neurosis for analysis: Mixed anxiety and depressive disorder Generalised anxiety disorder Depressive disorder All phobias Obsessive compulsive disorder Panic disorder B2 Assessment of Probable Psychosis A two-stage approach was adopted to provide an assessment of psychotic disorder in the survey. In the first stage interviews, carried out by ONS interviewers, screening questions were included to identify people who might have a psychotic disorder. The factors used to identify people who might have a psychotic disorder had been found in the 1993 survey of psychiatric morbidity among private households and the 1997 survey of psychiatric morbidity among prisoners to be the best predictors of the likelihood of receiving an assessment of psychotic disorder at a second stage semi-structured clinical interview. These were: a self-reported diagnosis or symptoms (such as mood swings or hearing voices) indicative of psychotic disorder; receiving anti-psychotic medication; a history of admission to a mental hospital; and all those who screened positive for psychotic disorder; half of those who screened positive for antisocial or borderline personality disorder but not psychosis; and 1 in 14 of those who screened screened positive for other types of personality disorder or screened negative for both disorders. The second stage interviews used the SCAN v2.1 (Schedules for Clinical Assessment in Neuropsychiatry), a semi-structured interview which provides ICD-10 diagnoses of psychotic disorder. An assessment of the prevalence of psychotic disorder could be obtained by simply weighting up the results from the sub-sample who had a second stage SCAN interviews to take account of varying sampling fractions and non-response. However, there are problems with this approach: 1. The second stage sample design included a SCAN assessment of people who screened negative for psychosis in the first stage interview which allows some assessment of the prevalence of psychotic disorder among this group, who are likely to be cases that are unknown to services. However, the bulk of the positive cases are likely to be in the screen positive group. Logistic regression analysis showed that the most important predictor of a positive SCAN assessment among the stage 2 sample was the presence of one or more of the screening criteria and that the odds of a positive assessment increased dramatically the more criteria were present. However, there were some positive cases among those who screened negative and because of the different sampling fractions used, these cases get a much higher weight than the majority of cases which occurred among the screen positives. 133

150 B Appendix B Psychiatric disorders and their assessment The effect of the wide range of weights is to produce an estimate with a high coefficient of variation (the sampling error as a proportion of the estimate itself) and with a very wide confidence interval around it, which is shown (estimate 1) in Table B.1. Thus for all adults the prevalence estimate is 1.1% with a 95% confidence interval ranging from 0.5% to 1.7% while for women the prevalence estimate is 1.6% with a 95% confidence interval ranging from 0.4% to 2.7%. Estimates which cover such a wide possible range are very difficult to use for policy purposes, eg for predicting the numbers of people who might require services, or for monitoring trends over time. 2. The comparatively small size of the sub-sample which completed a 2nd stage interview limits the amount of additional analysis, such as cooccurrence of disorders and social and economic factors associated with disorders, which can be done using this second-stage sample only. Therefore there is a requirement for some measure of probable/possible disorder for the sample as a whole to be used for these types of analysis and for the consideration of variations in prevalence of disorder among different sub-groups. The results obtained from the second stage interviews can be viewed as belonging to two groups for whom the prevalence of psychotic disorder can be obtained with different degrees of precision. The first group is people who screen positive for psychotic disorder from which we have SCAN assessments for all who agreed to a second interview. The prevalence of disorder is comparatively high among this group and a high proportion were interviewed, so the precision of the estimate for this group is quite good and the confidence interval quite narrow as is shown in Table B.1. The prevalence estimate for this group is 13.3% (95% CI ) and the coefficient of variation (CV) is 20%. The second group are those who screened negative for psychotic disorder. Among this group psychotic disorder is likely to be extremely rare and, since only a small proportion could be included in the second stage of the survey, any estimate of the prevalence among this group will be extremely imprecise. The sample of screen negatives taken was small and alternative samples of screen negatives would quite possibly have given very different estimates. The prevalence estimate obtained for this group is 0.6% (95% CI ), which is very much lower than in the screen positive group and is much less precise having a CV of 47%, double that of the screen positive estimate. In this sample all the false negatives on the psychosis screen were found among women a fact which is reflected in the wide confidence intervals around the estimate for women shown in estimate 1 in Table B.1. This might be due to true differences in prevalence between men and women, differences in responses to the screening questions, differences in the way the SCAN interviewers interpreted symptoms between men and women or a chance finding resulting from the sampling for the second stage. There was no difference between men and women in the proportion screening positive for psychosis. However, women were more likely than men to receive a positive SCAN assessment when other factors, such as the presence of different screening criteria, were controlled for and it appeared that the psychosis screen worked better for men than for women. Comparison between the detailed responses in the SCAN interviews for the false negative cases and other positive cases showed no apparent differences, except that the screen negatives were not receiving services and did not show evidence of significant disability or distress. It may be that men with psychotic disorder are more likely than women to be known to services and receiving treatment but the difference between the men and women shown in estimate 1 is not statistically significant indicating that it could just be an artefact of the particular sample selected in the survey. The finding of some SCAN positive cases among the screen negatives does suggest that a prevalence rate based solely on screen positives (estimate 2) is likely to be an underestimate. However, in view of the wide confidence interval, it is also quite possible that estimate 1, which includes the screen negatives, may be itself a substantial overestimate. Therefore, it was decided that it would not be useful to use the prevalence estimate which includes the SCAN data from screen negatives in the report because of the imprecision and uncertainty associated with it. It is recognised that any estimate that does not take account of false negatives on the screen will be an underestimate, but the extent of that underestimate and the importance of it is uncertain. The problem of obtaining an assessment of psychotic disorder for those people who sifted positive for psychosis but did not have a SCAN interview because they refused a second interview or could not be contacted at that time was dealt with slightly differently in the 1993 survey of adults in private households and the 1997 survey of prisoners. In both cases the relationship between the initial interview data and the SCAN assessment data for those who completed both 134

151 Appendix B Psychiatric disorders and their assessment B Table B.1 Alternative estimates of psychosis prevalence Assessment based on... Sample size Prevalence 95% CI Sampling CV* Estimate LL UL Error 1. SCAN interviews only including Men % screen negatives Women % All adults % People who screened positive % People who screened negative % 2. SCAN or prisons algorithm for Men % screen positives (screen negatives Women % assumed negative) All adults % * Coefficient of Variation = Sampling Error/Estimate stages was considered to identify factors indicative of likely psychotic disorder. In 1993, those taking antipsychotic medication and who reported that they had a psychotic illness or that their doctor told them they had such an illness were considered as having a functional psychosis. In the survey of prisoners there was some additional information available and it was found that the presence of any 2 of the sift criteria described above was a better indicator of probable psychosis. In this survey data, there continued to be a good relationship between the screening criteria and the likelihood of a positive SCAN assessment and it was decided to use the same approach as adopted in the 1997 prison survey for providing an assessment of probable psychosis for those people who sifted positive for psychosis but did not complete a SCAN interview. In summary, the assessment of probable psychosis used in this survey was obtained for individual respondents as follows: For those who sifted positive for psychosis and undertook a SCAN interview, the SCAN assessment was used. For those who sifted positive for psychosis but did not complete a SCAN interview, an assessment based on whether or not they reported two or more of the screening criteria at the initial interview was applied. All those who screened negative for psychosis at the initial interview were designated psychosis negative regardless of whether or not they had undertaken a SCAN interview. The prevalence estimates obtained in this way are shown as estimate 2 in Table B.1 and were used throughout the survey report. B3: The Assessment of Personality Disorder 1. The SCID-II screening questionnaire The screening questionnaire from the Structured Clinical Interview for DSM-IV was included in the initial interview. It consisted of 116 questions which were arranged in groups covering the following types of personality disorder: Avoidant Dependent Obsessive-compulsive Schizoid Schizotypal Paranoid Histrionic Narcissistic Borderline Conduct disorder and adult antisocial behaviour. The questionnaire was completed using Computer- Assisted Self-Interviewing procedures. Each question asked the respondent to indicate whether or not they had a particular personality characteristic, for example Are you the kind of person who.... All questions had three answer categories: Yes No Don t know/does not apply. A score of 1 was given for each question to which a respondent answered Yes. Algorithms developed for use in the 1997 survey of psychiatric morbidity among prisoners were then used to provide total scores for number of diagnostic criteria met for each type of personality disorder. 135

152 B Appendix B Psychiatric disorders and their assessment Table B.2 Making assessments of probable personality disorder from the SCID-II self-completion questionnaire for screening for second stage interview Type of PD & Initial screening cut-off interview scores Criterion Description questions Avoidant PD 1 Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, Score 6+ criteria disapproval or rejection pd1 2 Is unwilling to get involved with people unless certain of being liked pd2 3 Shows restraint within intimate relationships because of fear of being ridiculed pd3 4 Is preoccupied with being criticised or rejected in social situations pd4 5 Is inhibited in new inter-personal situations because of feelings of inadequacy pd5 6 Views self as socially inept, personally unappealing, or inferior to others pd6 7 Is unusually reluctant to take personal risks or to engage in new activities because they may prove embarassing pd7 Dependent PD 1 Has difficulty making everyday decisions without an excessive amount of advice and reassurancee from others pd8 Score 6+ criteria 2 Needs others to assume responsibility for most major areas of his or her life pd9 3 Has difficulty expressing disagreement with others because of fear of loss of support or approval pd10 4 Has difficulty initiating projects or doing things on his or her own (due to lack of self-confidence in judgement or abilities rather than due to a lack of motivation or energy pd11 5 Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant pd12 6 Feels uncomfortable or helpless when alone, because of exaggerated fears of being unable to care for him or herself pd13 7 Urgently seeks another relationship as a source of care and support when a close relationship ends pd14 8 Is unrealistically preoccupied with fears of being left to take care of him or herself pd15 Obsessive- 1 Is preoccupied with details, rules, lists, order, organisation or schedules to the extent that the major compulsive PD point of the activity is lost pd16 Score 6+ criteria 2 Shows perfectionism that interferes with task completion (eg is unable to complete a project because his or her own overly strict standards are not met pd17 3 Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships pd18 4 Is overconscientious, scrupulous and inflexible about matters of morality, ethics or values pd19 5 Is unable to discard worn out or worthless objects even when they have no sentimental value pd20 6 Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things pd21 7 Adopts a miserly spending style towards both self and others; money is viewed as something to be hoarded for future catastrophes pd22 8 Shows rigidity and stubbornness pd23 Paranoid PD 1 Suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her pd25 Score 5+ criteria 2 Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates pd26 3 Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her pd27 4 Reads hidden demeaning or threatening meanings into benign remarks or events pd28 5 Persistently bears grudges, i.e. is unforgiving of insults, injuries or slights pd29 6 Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack pd31 7 Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner pd32 Schizotypal PD 1 Ideas of reference (excluding delusions of reference) 2+ of pd33, pd34, pd35 Score 4+ criteria 2 Odd beliefs or magical thinking that influences behaviour and is inconsistent with sub-cultural norms (eg superstitiousness, belief in clairvoyance, telepathy or 6th sense in children and adolescents, bizarre fantasies or preoccupations) All of pd36, pd37, pd38 3 Unusual perceptual experiences, including bodily illusions 2+ of pd39, pd40, pd41 4 Odd thinking and speech (eg vague, circumstantial, metaphorical, overelaborate or stereotyped) n.a. 5 Suspiciousness or paranoid ideation 4+ of pd25, pd26, pd27, pd28, pd32 6 Inappropriate or restricted affect n.a. 7 Behaviour or appearance that is odd, eccentric or peculiar n.a. 8 Lack of close friends or confidantes other than first degree relatives pd42 9 Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self Schizoid PD 1 Neither desires nor enjoys close relationships, including being part of a family pd44 Score 4+ criteria 2 Almost always chooses solitary activities pd45 3 Has little, if any, interest in having sexual experiences with another person pd46 4 Takes pleasure in few, if any, activities pd47 5 Lack of close friends or confidantes other than first degree relatives pd42 6 Appears indifferent to the praise or criticism of others pd48 7 Shows emotional coldness, detachment or flattened affectivity pd49 Histrionic PD 1 Is uncomfortable in situations in which he or she is not the centre of attention pd50 Score 6+ criteria 2 Interaction with others is often characterised by inappropriate sexually seductive or provocative behaviour pd51 3 Displays rapidly shifting and shallow expression of emotions n.a. pd43 136

153 Appendix B Psychiatric disorders and their assessment B Table B.2 Making assessments of probable personality disorder from the SCID-II self-completion questionnaire for screening for second stage interview Type of PD & Initial screening cut-off interview scores Criterion Description questions Histrionic PD 4 Consistently uses physical appearance to draw attention to self pd52 continued 5 Has style of speech that is excessively impressionistic and lacking in detail n.a. 6 Shows self-dramatisation, theatricality and exaggerated expression of emotion pd53 7 Is suggestible, i.e. easily influenced by others and circumstances pd54 8 Considers relationships to be more intimate than they actually are pd55 Narcissistic PD 1 Has grandiose sense of self-importance (eg exaggerates achievements and talents, expects to be Score 7+ criteria recognised as superior without commensurate achievements) Both of pd56 and pd 57 2 Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love pd58 3 Believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) Both of pd60 & pd61 4 Requires excessive admiration pd62 5 Has a sense of entitlement, i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations pd64 6 Is interpersonally exploitative, i.e. takes advantage of others to achieve his or her own ends 2+ of pd65, pd66, pd67 7 Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others pd68 8 Is often envious of others or believes that others are envious of him or her pd70 &/or pd71 9 Shows arrogant, haughty behaviours or attitudes pd72 Borderline PD 1 Frantic efforts to avoid real or imagined abandonment pd73 Score 7+ criteria 2 A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation pd74 3 Identity disturbance: markedly and persistently unstable self-image or sense of self All out of pd75, pd76, pd77, pd78 4 Impulsivity in at least 2 areas that are potentially self-damaging (eg spending, sex, substance abuse, reckless driving, binge eating) PD79 5 Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour pd80 & pd81 6 Affective instability due to a marked reactivity of mood (eg intense episodic dysphoria, irritability or anxiety, usually lasting a few hours and only rarely more than a few days pd82 7 Chronic feelings of emptiness pd83 8 Inappropriate, intense anger or difficulty controlling anger (eg frequent displays of temper, constant anger, recurrent physical fights 2+ of pd84, pd85, pd86 9 Transient, stress-related paranoid ideation or severe dissociative symptoms pd87 Conduct Disorder 1 Before age 15 often bullied, threatened or intimidated others pd88 Score 2+ criteria 2 Before age 15 often initiated physical fights pd89 3 Before age 15 has used a weapon that can cause serious harm to others (eg a bat, brick, broken bottle, knife or gun) pd90 4 Before age 15 has been physically cruel to people pd91 5 Before age 15 has been physically cruel to animals pd92 6 Before age 15 has stolen while confronting a victim (eg mugging, purse snatching, extortion, armed robbery) pd93 7 Before age 15 has forced someone into sexual activity pd94 8 Before age 15 has deliberately engaged in fire setting with the intention of causing serious damage pd95 9 Before age 15 has deliberately destroyed other s property (other than by fire setting) pd96 10 Before age 15 has broken into someone else s house, building or car pd97 11 Before age 15 often lies to obtain goods or favours or to avoid obligations (i.e. cons others) pd98 12 Before age 15 has stolen items of non trivial value without confronting a victim (eg shoplifting, stealing but without breaking and entering, forgery) pd Before age 15 has run away from home overnight at least twice while living in parental home or parental surrogate home (or once without returning for a lengthy period) pd Before age 13 often stayed out at night despite parental prohibitions pd Before age 13 often truant from school pd102 Adult antisocial 1 Since age 15 failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly 2+ of pd110, pd111, behaviour performing acts that are grounds for arrest pd112, pd113 Score 3+ criteria 2 Deceitfulness, as indicated by repeated lying use of aliases or conning others for profit or pleasure pd114 & pd115 3 Impulsivity or failure to plan ahead pd103 &/or pd104 4 Irritability and aggressiveness, as indicated by repeated physical fights or assaults 2+ of pd105, pd106, pd107, pd108 5 Reckless disregard for safety of self or others pd116 6 Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations yinact = 6 7 Lacks remorse as indicated by being indifferent to, or rationalising having hurt, mistreated or stolen from another pd109 Antisocial PD 1 Age 18 and over (all 3 criteria) 2 Conduct disorder score 2+ 3 Adult antisocial behaviour score

154 B Appendix B Psychiatric disorders and their assessment Table B.2 shows the questions used to assess each criteria for the different types of personality disorder and the cut-off used to provide a positive screening assessment for that type of personality disorder. The question numbers shown are those used in the questionnaire which is shown in Appendix B of the technical report (Singleton et al, 2002). In the second-stage interview the full SCID-II interview was carried out and the recommended cut-off points use for assigning personality disorder assessments. Each criterion was explored in turn with standard probes and thresholds for marking a criterion as present. The cutpoints used in the second-stage were: B4 Avoidant PD Dependent PD Obsessive-compulsive PD Paranoid PD Schizotypal PD Schizoid PD Histrionic PD Narcissistic PD Borderline PD Antisocial PD 4 or more criteria 5 or more criteria 4 or more criteria 4 or more criteria 5 or more criteria 4 or more criteria 5 or more criteria 5 or more criteria 5 or more criteria 2 or more conduct disorder criteria and 3 or more adult antisocial criteria and aged 18 and over. The Assessment of Alcohol Misuse and Dependence 1. The AUDIT Questionnaire and how it is scored The Alcohol Use Disorders Identification Test (AUDIT) was used for the assessment of alcohol misuse. This provides a score based on a series of questions covering different aspects of drinking behaviour as shown below. How often do you have a drink containing alcohol? Never (0) Monthly or less (1) Two or four times a month (2) Two to three times a week (3) Four or more times a week (4) How many drinks containing alcohol do you have in a typical day when you are drinking? 1 or 2 (0) 3 or 4 (1) 5 or 6 (2) 7 to 9 (3) 10 or more (4) How often do you have six or more drinks on any one occasion? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you found that you were not able to stop drinking once you had started? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you failed to do what was normally expected of you because of drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never (0) Less than monthly (1) 138

155 Monthly (2) Weekly (3) Daily or almost daily (4) Appendix B Psychiatric disorders and their assessment Responses to each question are given a score from 0 to 3. A total score is then computed by adding the scores for all items. An assessment of level of alcohol dependence is then made based on the total score as follows: B Have you or someone else been injured because of your drinking? No (0) Yes, but not in the last year (2) Yes, during the last year (4) Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested that you should cut down? Scoring No (0) Yes, but not in the last year (2) Yes, during the last year (4) The total score is computed across all 10 items and the threshold score to indicate hazardous drinking behaviour was deemed to be Assessing alcohol dependence using the SAD-Q People who scored 10 or more on the AUDIT questionnaire then completed the Severity of Alcohol Dependence Questionnaire (SAD-Q). This was completed using Computerassisted Self Interviewing. The SAD-Q is composed of a series of 20 questions, the exact wording of which can be found in the questionnaire in Appendix C. For the first 12 questions respondents are asked to recall a period of heavy drinking in the last six months and then to say to what extent they experienced a range of symptoms of dependence. The response categories given are: never, or almost never sometimes often or always, or nearly always Using the same reference period and response categories, respondents are then asked to say often they drank different amounts each day at that time, ranging from 1/4 a bottle of spirits, or the equivalent, up to 2 bottles of spirits a day. The last 4 questions ask the respondent to imagine they have had a period of abstinence from drinking and then drunk heavily for two days and say to what extent they would exhibit four signs of dependence in those circumstances. The response categories used for these questions are: not at all slightly moderately or quite a lot. Score 0 to 3 = no dependence Score 4 to 19 = mild dependence Score 20 to 34 = moderate dependence Score 35 to 60 = severe dependence People who did not complete the SAD-Q because they had an AUDIT score of less than 10 were assessed as having no dependence. B5 Calculating a score for drug dependence 1. Source of questions Questions on drug use and dependence were taken from the U.S. ECA study. They were used in the ONS (OPCS) surveys of psychiatric morbidity among the private household population, residents of institutions catering for people with mental health problems, and homeless people in paper questionnaire format. They were also used in the ONS survey of psychiatric morbidity among prisoners which used computer-assisted interviewing. In the current study informants were asked about their dependence on eight main categories of drug (cannabis, amphetamines, cocaine, crack, opiates, ecstasy, tranquillisers and solvents). Five questions focused on drug dependence. 2. Questionnaire 1. Have you ever used any one of these drugs every day for two weeks or more in the past twelve months? 2. In the past twelve months have you used any one of these drugs to the extent that you felt like you needed it or were dependent on it? 3. In the past twelve months, have you tried to cut down on any drugs but found you could not do it? 4. In the past twelve months did you find that you needed larger amounts of these drugs to get an effect, or that you could no longer get high on the amount you used to use? 5. In the past twelve months have you had withdrawal symptoms such as feeling sick because you stopped or cut down on any of these drugs? 3. Scoring Each positive response scored 1 and a positive response to any of the above five questions was regarded as having at least some level of drug dependence. References Singleton N, Lee A and Meltzer H (2002) Psychiatric Morbidity among adults living in private households 2000: Technical Report, TSO: London. 139

156 C Appendix C Sections on substance use from the questionnaire Appendix C Sections on substance use from the questionnaire None of the questions on substance use are asked of proxies Smoking Smokintr Cigever The following questions are about smoking. Have you ever smoked a cigarette? (1) Yes (2) No Ask respondents who have ever smoked a cigarette (Cigever = 1) Cignow Do you smoke cigarettes at all nowadays? (1) Yes (2) No Ask respondents who smoke cigarettes nowadays (Cignow = 1) QtyWknd About how many cigarettes a day do you usually smoke at weekends? Ask respondents who smoke cigarettes nowadays (Cignow = 1) QtyWeek About how many cigarettes a day do you usually smoke on weekdays? Ask respondents who smoke cigarettes nowadays (Cignow = 1) CigType Do you mainly smoke... (1) Filter tipped cigarettes (2) Or plain or untipped cigarettes (3) Or hand rolled cigarettes? Ask respondents who smoke cigarettes nowadays (Cignow = 1) EasNoSmk How easy or difficult would you find it to go without smoking for a whole day... (1) Very easy (2) Fairly easy (3) Fairly difficult (4) Very difficult Ask respondents who smoke cigarettes nowadays (Cignow = 1) GiveUp Would you like to give up smoking altogether? (1) Yes (2) No Ask respondents who smoke cigarettes nowadays (Cignow = 1) FirstCig How soon after waking do you usually smoke your first cigarette? (1) Less than 5 minutes (2) 5 to 14 minutes (3) 15 to 29 minutes (4) 30 mins but less than 1 hour (5) 1 hr but less than 2 hours (6) 2 hours or more Ask respondents who don t smoke cigarettes nowadays (Cignow = 2) CigReg Did you smoke cigarettes... (1) Regularly, that is at least one cigarette a day (2) Or did you smoke them only occasionally? Ask respondents who used to smoke cigarettes regularly (CigReg = 1) CigUsed About how many cigarettes did you smoke in a day when you smoked them regularly? Ask respondents who used to smoke cigarettes regularly (CigReg = 1) CigStop How long ago did you stop smoking cigarettes regularly? (1) Less than 6 months ago (2) 6 months but less than a year ago (3) 1 year but less than 2 years ago 140

157 (4) 2 years but less than 5 years ago (5) 5 years but less than 10 years ago (6) 10 years or more ago Ask respondents who smoke cigarettes nowdays or used to smoke regularly (CigNow = 1 or CigReg = 1) Appendix C Sections on substance use from the questionnaire (5) Can t afford it (6) Other Ask respondents who used to drink but stopped (TeeTotal = 2) StopDrin C CigAge Drinking DrinkNow How old were you when you started to smoke cigarettes regularly? (1) Never smoked cigarettes regularly (2) Under 10 (3) (4) (5) (6) 25 or over Do you ever drink alcohol nowadays, including drinks you brew or make at home? (1) Yes (2) No Ask respondent who say they do not drink alcohol nowdays (DrinkNow = 2) DrinkAny Do you only drink on special occasions? (1) Very occasionally (2) Never Ask respondents who never drink alcohol nowdays (DrinkAny = 2) TeeTotal Have you always been a non drinker, or did you stop drinking for some reason? (1) Always a non drinker (2) Used to drink but stopped Ask respondents who have always been a non drinker (TeeTotal = 1) NonDrink What would you say is the main reason you have always been a non drinker? (1) Religious reasons (2) Don t like it (3) Parent s advice/influence (4) Health reasons What would you say was the MAIN reason you stopped drinking? (1) Religious reasons (2) Don t like it (3) Parent s advice/influence (4) Health reasons (5) Can t afford it (6) Other Drinking self completion Ask respondents who drink alcohol nowadays, even if only occasionally (DrinkNow = 1 or DrinkAny = 1) DrkIntro The next set of questions, which is about drinking and drug use, is for you to fill in yourself on the computer. Ask respondents who drink alcohol nowadays, even if only occasionally (DrinkNow = 1 or DrinkAny = 1) DrTest Is this the first time you have used computers? (1) Yes (2) No (9) Don t Understand/Does Not Apply Ask respondents who drink alcohol nowadays, even if only occasionally (DrinkNow = 1 or DrinkAny = 1) DrTest2 Which of the following hot drinks do you like? (1) Tea (2) Coffee (3) Hot Chocolate (4) Bovril (5) Ovaltine (6) None of these The Alcohol Use Disorders Identification Test (AUDIT) Ask respondents who drink alcohol nowadays, even if only occasionally (DrinkNow = 1 or DrinkAny = 1) DrkOft In the last 12 months, how often have you had a drink containing alcohol? 141

158 C Appendix C Sections on substance use from the questionnaire (1) Never (2) Monthly (3) Two to four times a month (4) Two to three times a week (5) Four or more times a week The following set of questions (DrAmt to Advised) are asked of respondents who have drank alcohol in the last 12 months (DrkOft = 2 to 5) DrAmt LotOften NotStop FailDrk MornDrk How many standard drinks containing alcohol do you have on a typical day when you are drinking? (A standard drink is half a pint of beer, a single measure of spirits or a glass of wine.) (1) One or two (2) Three or four (3) Five or six (4) Seven, eight, or nine (5) Ten or more How often do you have 6 or more drinks on one occasion? (1) Never (2) Less than monthly (3) Monthly (4) Weekly (5) Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started? (1) Never (2) Less than monthly (3) Monthly (4) Weekly (5) Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of drinking? (1) Never (2) Less than monthly (3) Monthly (4) Weekly (5) Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (1) Never (2) Less than monthly (3) Monthly Guilty NoMem Injured Advised (4) Weekly (5) Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? (1) Never (2) Less than monthly (3) Monthly (4) Weekly (5) Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? (1) Never (2) Less than monthly (3) Monthly (4) Weekly (5) Daily or almost daily Have you or someone else been injured as a result of your drinking? (1) Yes, but not in the last year (2) Yes, during the last year (3) No Has a relative, a friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? (1) Yes, but not in the last year (2) Yes, during the last year (3) No The Severity of Alcohol Dependence questionnaire (SAD Q) The following set of questions (Intro to Craved) are asked of respondents who have an AUDIT score of 10 or more (see Appendix B for definition of the AUDIT score) Intro Please recall a typical period of heavy drinking in the last 6 MONTHS. (Or an occasion when you have drunk a lot.) Which month was this? (1) January (2) February (3) March (4) April 142

159 Woke (5) May (6) June (7) July (8) August (9) September (10) October (11) November (12) December During that period of heavy drinking in intro, how did you feel? Would you say that... I woke up feeling sweaty Appendix C Sections on substance use from the questionnaire Fright Despair (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I was frightened of meeting people first thing in the morning (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? C Shook Violent Drench Dread (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... My hands shook first thing in the morning (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... My whole body shook violently first thing in the morning if I didn t have a drink (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I woke up absolutely drenched in sweat (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I dreaded waking up in the morning Awoke Morn Quick During that period of heavy drinking in intro, how did you feel? Would you say that... I felt at the edge of despair when I awoke (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I felt very frightened when I awoke (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I liked to have a morning drink (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I always gulped my first few drinks down as quickly as possible (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? (1) Never, or almost never (2) Sometimes 143

160 C Appendix C Sections on substance use from the questionnaire Shakes During that period of heavy drinking in intro, how did you feel? Would you say that... I drank in the morning to get rid of the shakes (3) Often (4) Or always, or nearly always? Ask respondents who drank a bottle of spitits (or equivalent) during the period of heavy drinking (Whole = 2, 3 or 4) Crave (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? Two During that period of heavy drinking in intro, how did you feel? Would you say that... I drank more than 2 bottles spirits a day (or 30 pints of beer/ 15 cans strong lager/8 bottles table wine) Quarter During that period of heavy drinking in intro, how did you feel? Would you say that... I had a very strong craving for drink when I awoke (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? During that period of heavy drinking in intro, how did you feel? Would you say that... I drank more than 1/4 bottle of spirits a day (or 4 pints of beer/2 cans strong lager/1 bottle table wine) (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? Ask respondents who drank a quarter bottle of spitits (or equivalent) during the period of heavy drinking (Quarter = 2, 3 or 4) Half During that period of heavy drinking in intro, how did you feel? Would you say that... I drank more than 1/2 bottle spirits a day (or 8 pints of beer/4 cans strong lager/2 bottles table wine) (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? Ask respondents who drank a half bottle of spitits (or equivalent) during the period of heavy drinking (Half = 2, 3 or 4) Whole During that period of heavy drinking in intro, how did you feel? Would you say that... I drank more than 1 bottle spirits a day (or 15 pints of beer/8 cans strong lager/4 bottles table wine) (1) Never, or almost never (2) Sometimes (1) Never, or almost never (2) Sometimes (3) Often (4) Or always, or nearly always? Ask all respondents completing the SAD-Q Sweat Hshake Bshake Imagine the following situation (1) You have been COMPLETELY off drinks for a FEW WEEKS (2) You then drink VERY HEAVILY for TWO DAYS How would you feel the morning after those two days of heavy drinking? Would you say that... I would start to sweat (1) Not at all (2) Slightly (3) Moderately (4) Or, quite a lot? Imagine the following situation (1) You have been COMPLETELY off drinks for a FEW WEEKS (2) You then drink VERY HEAVILY for TWO DAYS How would you feel the morning after those two days of heavy drinking? Would you say that... My hands would shake (1) Not at all (2) Slightly (3) Moderately (4) Or, quite a lot? Imagine the following situation (1) You have been COMPLETELY off drinks for a FEW WEEKS (2) You then drink VERY HEAVILY for TWO DAYS How would you feel the morning after those two days of heavy drinking? Would you say that... My body would shake (1) Not at all (2) Slightly (3) Moderately (4) Or, quite a lot? 144

161 Craved Appendix C Sections on substance use from the questionnaire ADrug C Drug use Imagine the following situation (1) You have been COMPLETELY off drinks for a FEW WEEKS (2) You then drink VERY HEAVILY for TWO DAYS How would you feel the morning after those two days of heavy drinking? Would you say that... I would be craving for a drink (1) Not at all (2) Slightly (3) Moderately (4) Or, quite a lot? Self completion DrgIntro2 The next set of questions, which is about drug use, is for you to fill in yourself on the computer. DrgTest DrgTest2 DrgIntro The first two questions are to check that you know how to answer the questions in this section. Is this the first time you have used computers? PRESS 1 FOR YES, PRESS 2 FOR NO THEN PRESS ENTER If you think the question DOES NOT APPLY to you or you DO NOT UNDERSTAND the question press 9 (1) Yes (2) No Which of the following hot drinks do like? PLEASE ENTER THE NUMBERS OF ALL THE DRINKS THAT YOU LIKE (1) Tea (2) Coffee (3) Hot Chocolate (4) Bovril (5) Ovaltine (6) None of these This section is about drug use. By drugs we mean things like cannabis, speed and heroin. We do not mean drugs that you have taken or are taking on a doctor s prescription. PRESS ENTER TO CONTINUE. ADrug2 Have you EVER taken any of the drugs listed below even if it was a long time ago? Please type the numbers of ALL those drugs you have used. (1) Cannabis (marijuana, grass, hash, ganja, blow, draw, skunk, weed, spliff) (2) Amphetamines (speed, whizz, uppers, billy) (3) Cocaine or coke (4) Crack (rock, stones) (5) Ecstasy (E) (6) Heroin (smack, skag, H, brown) (7) Acid or LSD (8) None of these And, have you EVER taken any of the drugs listed below (not prescribed by a doctor) even if it was a long time ago? (1) Magic mushrooms (2) Methadone or physeptone (3) Semeron (4) Tranquilisers (temazepam, valium) (5) Amyl nitrate (poppers) (6) Anabolic steroids (steroids) (7) Glues, solvents, gas or aerosols (to sniff) (8) None of these Ask respondents who have taken at least one of the drugs listed in ADrug (ADrug 8) YDrug In the LAST 12 MONTHS have you taken any of these drugs? Please type the numbers of ALL those drugs you have used in the LAST 12 MONTHS. (1) Cannabis (marijuana, grass, hash, ganja, blow, draw, skunk, weed, spliff) (2) Amphetamines (speed, whizz, uppers, billy) (3) Cocaine or coke (4) Crack (rock, stones) (5) Ecstasy (E) (6) Heroin (smack, skag, H, brown) (7) Acid or LSD (8) None of these Ask respondents who have taken at least one of the drugs listed in ADrug2 (ADrug2 8) YDrug2 And, in the LAST 12 MONTHS have you taken any of these drugs? Please type the numbers of ALL those drugs you have used in the LAST 12 MONTHS. (1) Magic mushrooms (2) Methadone or physeptone (3) Semeron 145

162 C Appendix C Sections on substance use from the questionnaire (4) Tranquilisers (temazepam, valium) (5) Amyl nitrate (poppers) (6) Anabolic steroids (steroids) (7) Glues, solvents, gas or aerosols (to sniff) (8) None of these The following set of questions (AgeStrt to UseMB4) are asked for each drug taken in the last 12 months (excluding magic mushrooms, semeron, amyl nitrate, anabolic steroids and glues, solvents, gas or aerosols) AgeStrt NumUse More2wk Needed CutDrg IncDrg Withdr How old were you when you first used (NAME OF DRUG)? How many times have you ever used (NAME OF DRUG)? (1) Less than 10 times (2) 10 to 100 times (3) More than 100 times? During the past 12 months, have you used (NAME OF DRUG) every day for two weeks or more? (1) Yes (2) No In the past 12 months have you used (NAME OF DRUG) to the extent that you felt like you needed it or were dependent on it? (1) Yes (2) No In the past 12 months have you tried to cut down on (NAME OF DRUG) but found you could not do it? (1) Yes (2) No In the past 12 months did you find that you needed larger amounts of (NAME OF DRUG) to get an effect, or that you could no longer get high on the amount you used to use? (1) Yes (2) No UseMB4 (1) Yes (2) No Now thinking about the past month, have you used (NAME OF DRUG) in the past month? (1) Yes (2) No Ask respondents who have used a drug in the past month (UseMB4 = 1) OftenB4 About how often were you using (NAME OF DRUG) in the past month? (1) About daily (2) 2 to 3 times per week (3) About once a week (4) Less than once a week Ask respondents who have taken at least one of the drugs listed in either ADrug or ADrug2 (ADrug and ADrug2 8) ODEver Have you ever experienced a drugs overdose where you accidentally took too much or the drug was stronger than you were used to? (1) Yes (2) No Ask respondents who have experienced an overdose (ODEver = 1) OdTimes How many times in your life? (1) Once (2) 2 or 3 times (3) 4 or 5 times (4) 6 9 times (5) 10 or more times Ask respondents who have ever taken one of the following: amphetamines, cocaine or coke, crack, ecstasy, heroin, methadone or physeptone, or tranquilisers (ADrug = 2 to 6 or ADrug2 = 2 or 4) InjIntr The next questions are about your own experience of drug injecting. In the past 12 months have you had withdrawal symptoms such as feeling sick because you stopped or cut down on (NAME OF DRUG)? 146

163 Ask respondents who have ever taken one of the following: amphetamines, cocaine or coke, crack, ecstasy, heroin, methadone or physeptone, or tranquilisers (ADrug = 2 to 6 or ADrug2 = 2 or 4) Appendix C Sections on substance use from the questionnaire Ask respondents who have taken at least one of the drugs listed in either ADrug or ADrug2 (ADrug and ADrug2 8) TreatInt C InjEver Have you ever injected drugs? Do not include drugs that you were prescribed by a doctor. (1) Yes (2) No Ask respondents who have ever injected drugs (InjEver = 1) InjAge About how old were you when you first injected? Ask respondents who have ever injected drugs (InjEver = 1) InjReg Have you ever injected regularly? (1) Yes (2) No Ask respondents who have ever injected drugs (InjEver = 1) InjOften About how many times have you EVER injected? (1) Less than 10 times (2) 10 to 100 times (3) More than 100 times? Ask respondents who have ever injected drugs (InjEver = 1) InjMB4 Did you inject in the last month? (1) Yes (2) No Ask respondents who injected drugs in the last month (InjMB4 = 1) InjOftB4 About how often did you inject in the last month? (1) About daily (2) 2 to 3 times per week (3) About once a week (4) Less than once a week We would now like to ask you about any treatment, help or advice that you may have had in relation to drug use. Ask respondents who have taken at least one of the drugs listed in either ADRUG or ADRUG2 (ADrug and ADrug2 8) TreatOut Have you EVER received any treatment, help or advice because you were using drugs? (1) Yes (2) No Ask respondents who have ever received treatment because they were using drugs (TreatOut = 1) TreatB4 Thinking about the past 12 months, did you receive any treatment, help or advice because you were using drugs? (1) Yes (2) No Ask respondents who received treatment in the past 12 months because they were using drugs (TreatB4 = 1) TreatFrm Who was that from? (1) GP or family doctor or other practice staff (2) Community Drug Team, (CDT) (3) Hospital (outpatient and/or inpatient) (4) Residential rehab unit (5) Other (specify) Ask respondents who received treatment from other (TreatFrm = 5) XTreatFr Please specify the other source of treatment/advice. Ask respondents who have ever used heroine, methadone or physeptone (Adrug = 6 or ADrug2 = 2) PresMeth Have you ever been prescribed methadone? (1) Yes (2) No 147

164 C Appendix C Sections on substance use from the questionnaire Ask respondents who have ever been prescribed methadone (PresMeth = 1) Meth12mo Have you been prescribed methadone in the past 12 months? (1) Yes (2) No Ask respondents who have ever been prescribed methadone in the past 12 month (Meth12mo = 1) Meth1mo Have you been prescribed Methadone in the past month? (1) Yes (2) No END OF QUESTIONNAIRE 148

165 Appendix D Appendix D Glossary of survey definitions and terms Glossary of survey definitions and terms D Adults In this survey adults were defined as persons aged 16 or over and less than 75. Alcohol dependence Alcohol misuse was measured using two different instruments. First the Alcohol Use Disorders Identification Test (AUDIT) was used to assess hazardous drinking (see below). Those who scored 10 or above on the AUDIT were also asked the Severity of Alcohol Dependence Questionnaire (SAD-Q). People who scored 4 or more on the SAD-Q were considered to be dependent on alcohol. CIS-R (Clinical Interview Schedule revised version) The CIS-R is an instrument designed to measure neurotic symptoms and disorders, such as anxiety and depression. It comprises 14 sections each covering a particular type of neurotic symptom. Scores are obtained for each symptom based on frequency, duration and severity in the past week. Individual symptom scores can be summed to provide an overall score for the level of neurotic symptoms. A score of 12 or more indicates the presence of significant levels of neurotic symptoms while a score of 18 or more indicates symptoms of a level likely to require treatment. If required, diagnoses of 6 specific neurotic disorders can be obtained by looking at answers to the various sections of the CIS-R and applying algorithms based on the ICD-10 diagnostic criteria for research. Drug dependence In the year prior to interview drug dependence was measured by asking all those who had used drugs in the past year a series of five questions. These covered: daily use of the drug for two weeks or more; feelings of dependence; inability to cut down; need for increasing quantities; withdrawal symptoms. For a person to be considered dependent, a positive response to any one of these questions was required. Economic activity/employment status Economically active persons are those over the minimum school-leaving age who were working or unemployed in the week before the week of interview. These persons constitute the labour force. Working persons This category includes persons aged 16 and over who, in the week before the week of interview, worked for wages, salary or other form of cash payment such as commission or tips, for any number of hours. It covers persons absent from work in the reference week because of holiday, sickness, strike or temporary lay-off, provided they had a job to return to with the same employer. It also includes persons attending an educational establishment during the specified week if they were paid by their employer while attending it, people who worked in Government training schemes and unpaid family workers. Persons are excluded if they have worked in a voluntary capacity for expenses only, or only for payment in kind, unless they worked for a business, firm or professional practice owned by a relative. Full-time students are classified as working, unemployed or inactive according to their own reports of what they were doing during the reference week. Unemployed persons This survey used the International Labour Organisation (ILO) definition of unemployment. This classifies anyone as unemployed if he or she was out of work in the four weeks before interview, 149

166 D Appendix D Glossary of survey definitions and terms or would have been but for temporary sickness or injury, and was available to start work in the two weeks after the interview. Otherwise, anyone out of work is classified as economically inactive. The treatment of all categories on this survey is in line with that used in the Labour Force Survey (LFS). 6. No formal qualifications For the analyses in this report these groupings were collapsed into three categories: A levels or above which covers the first three groups, GCSE level which includes all other groups except the last one, and no qualifications which equates to the no formal qualifications group above. 150 Educational level Educational level was based on the highest educational qualification obtained and was initially grouped as follows: 1. Degree or higher degree NVQ Level 5 2. Teaching qualification HNC/HND BRC/TEC Higher BTEC/SCOTVEC Higher City and Guilds Full Technological Certificate Nursing Qualifications (SRN, SCM, RGN, RM, RHV, Midwife) NVQ Level 4 3. GCE A levels and AS levels SCE Higher ONC/OND/BTEC/TEC/BTEC not higher City and Guilds Advanced/Final Level GNVQ (Advanced Level) NVQ Level 3 4. GCE O level passes (Grade A C if after 1975) GCSE (Grades A C) CSE Grade 1 SCE Ordinary (Bands A C) Standard Grade (Level 1 3) School Certificate or Matric City and Guilds Craft/Ordinary Level GNVQ (Intermediate level) NVQ Level 2 5. CSE Grades 2 5 GCE O level Grades D and E after 1975 GCSE (Grades D,E,F,G) SCE Ordinary (Bands D and E) Standard Grade (Level 4,5) Clerical or Commercial qualifications Apprenticeships NVQ Level 1 and GNVQ (Foundation Level) CSE ungraded Ethnicity Household members were classified into nine groups by the person selected for interview. For analysis purpose these nine groups were subsumed under 4 headings: White, Black, South Asian and Other. White Black Caribbean Black African Black Other Indian Pakistani Bangladeshi Chinese Other Hazardous alcohol use White Black South Asian Other Hazardous alcohol use is a pattern of drinking carrying with it a high risk of damage to health in the future. The prevalence of alcohol misuse in the previous year was assessed using the Alcohol Use Disorders Identification Test (AUDIT) at the initial interview. An AUDIT score of eight or above indicates hazardous alcohol use. Household The standard definition used in most surveys carried out by ONS Social Survey Division, and comparable with the 1991 Census definition of a household, was used in this survey. A household is defined as single person or group of people who have the accommodation as their only or main residence and who either share one meal a day or share the living accommodation. (See E McCrossan A Handbook for interviewers. HMSO: London 1991.)

167 Marital Status Informants were categorised according to their own perception of marital status. Married and cohabiting took priority over other categories. Cohabiting included anyone living together with their partner as a couple. Neurotic disorders, depression or anxiety disorders These are characterised by a variety of symptoms such as fatigue and sleep problems, forgetfulness and concentration difficulties, irritability, worry, panic, hopelessness, and obsessions and compulsions, which are present to such a degree that they cause problems with daily activities and distress. The prevalence of neurotic symptoms in the week prior to interview was assessed using the revised version of the Clinical Interview Schedule (CIS-R) (see above). A score of 12 and over indicates the presence of significant neurotic symptoms while a score of 18 and over indicates symptoms of a level likely to require treatment. Psychiatric Morbidity The expression psychiatric morbidity refers to the degree or extent of the prevalence of mental health problems within a defined area. Psychoses These are disorders that produce disturbances in thinking and perception that are severe enough to distort the person s perception of the world and the relationship of events within it. Psychoses are normally divided into two groups: organic psychoses, such as dementia and Alzheimer s disease, and functional psychoses, which mainly cover schizophrenia and manic depression. Social Class Based on the Registrar General s 1991 Standard Occupational Classification, Volume 3 OPCS, HMSO: London, social class was ascribed on the basis of the informants own occupation. If the Appendix D Glossary of survey definitions and terms informant was unemployed or economically inactive at the time of interview but had previously worked, social class was based on the most recent previous occupation. The classification used in the tables are as follows: Descriptive Definition Social Class Professional I Intermediate occupations II Non- Skilled occupations manual non-manual III NM Skilled occupation manual III M Partly-skilled IV Manual Unskilled occupations V Armed Forces Social class was not determined where the subject had never worked, or if the subject was a full-time student or where occupation was inadequately described. Social class was grouped into non-manual, manual and armed forces or no answer. Tenure Three tenure categories were created: Owns includes people who owned outright (that is they bought without a mortgage or loan or that their mortgage or loan has been paid off) and those who owned with mortgage (includes co-ownership and shared ownership schemes). Social renter means rented from local authorities, New Town corporations or commissions or Scottish Homes, and housing associations which include co-operatives and property owned by charitable trusts. Private renter includes rent from organisations (property company, employer or other organisation) and from individuals (relative, friend, employer or other individual). D 151

168 D Appendix D Glossary of survey definitions and terms 152