Substance use and misuse remain a feature of everyday life in the UK today. It is a cause of death and disability and a marker of deprivation and inequality. The health, social and criminal justice systems currently in place are not able to provide the flexible response in which the public can have confidence and to which they can adhere. While much of the debate has centred on younger people, including children and adolescents, attention has recently turned to older people who are misusing cannabis and heroin as well as over-the-counter and medically prescribed medications. The remarkable contributions of neuroscience over the half-century of 1960–2010 have demonstrated the biological basis of substance misuse, which can become a chronic medical condition, much like diabetes and hypertension. There is exciting potential for the development of new pharmaceutical agents for the treatment of substance misuse. An aspiration we have is towards a new public understanding of addiction through education so that people can make informed choices based on realistic policies.

The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical, and psychosocial factors. The assessment, treatment, and aftercare of alcohol-related and other comorbid mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas such as alcohol-related brain damage and drug interactions with alcohol that deserve special attention.

In 1980, Robin Murray raised the question ‘Why are the drug companies so disinterested in alcoholism?’ (Murray, 1980). Since then, we have witnessed the evolution of a ‘specialist addiction field’ (Edwards, 2002), including rapid developments in pharmacological treatments for problem use of alcohol, opiates and nicotine. In this review we discuss some of these pharmacological agents and then summarise the evidence on the treatment of combined or coexisting disorders, also described as ‘dual diagnosis’ (e.g. Banerjee et al, 2002; Crawford et al, 2003).

Dual diagnosis: a definition (see also chapter 13)

‘Dual diagnosis’ is one of a number of terms and phrases (Box 12.1) used to refer to people who have coexisting problems of mental disorder and substance misuse (including alcohol, nicotine and illicit drugs). It is also applied to people with two coexisting conditions, for example learning disability and mental disorder (Banerjee et al, 2002), although it does not take that meaning in this chapter.

The group of people with dual diagnosis is heterogeneous, with complex, changing needs. They may have had previous traumatic experiences such as childhood sexual abuse, bullying at school or a broken and dysfunctional family life. Furthermore, mental disorder and substance misuse sit on separate dimensions, each with its own continuum of severity. ‘Dual diagnosis’ covers someone with bipolar disorder who is also alcohol dependent, and someone who has schizophrenia and smokes cannabis a few times a week. As a result of this complexity, numerous operational definitions may be applied in different clinical and social settings, thus complicating and confusing communication.

Epidemiology

Specialists in obstetrics and gynaecology should be aware of the nature and extent of substance misuse in the UK. It is important to realise the scale of the problem, especially in young people, including young women of reproductive age. The trend is towards increased use over the last decade. Polydrug misuse (the ‘pick and mix’ phenomenon) is common.

The age at which young people start substance misuse is decreasing. Young people misuse for many reasons: because their friends do, out of curiosity, to feel good, because of low self-esteem, poor achievement at school, family history of drugs or drink, violence in the family and emotional distress.

The Confidential Enquiries into Maternal Deaths (2000–2002) found that, when all deaths up to 1 year from delivery were taken into account, psychiatric illness was not only the leading cause of indirect death, but also the leading cause of maternal deaths overall. Of the 391 women whose deaths were reported to the Enquiries, 8% were substance misusers.

An overwhelming 20% of 13 year olds and 25% of 15 year olds smoke daily. For the first time girls have overtaken boys in prevalence of cigarette use. Nearly 50% of young men aged 16–24 years drink over the ‘safe’ recommended limit of 3 units of alcohol per day for adult men. Some 40% of young women drink more than 2 units per day (or the safe limit for adult women). Twenty-four percent (2.3 million) of 16–24 year olds have used an illicit drug in the previous year.

Introduction

Gender differences in the prevalence of mood disorders have been well documented. Prior to adolescence, the rate of depression is more or less similar in girls and boys; yet, with the onset of puberty, there is an associated increase in prevalance of depression as well as other psychiatric disorders in girls (Figure 3.1). Puberty is also a period of social and sexual tension; these can be the precipitating factors for the development of psychological disorders such as eating disorders, anxiety, panic attacks, substance and alcohol misuse.

It is not known what proportion of the psychological change around puberty and the subsequent teens is the direct consequence of adolescence itself as opposed to the direct psychoneuroendocrine effects of previously unfamiliar cyclical hormone changes. There are many changes occurring at this period of life. It would be naïve to attribute all of the psychological changes at puberty to a single hormonal, genetic, environmental, familial or psychosocial factor and all of these must be considered.

Puberty

Puberty is the period of time during which secondary sexual characteristics are being developed. Menstruation begins and the psychosexual outlook of girls changes. The most important fact about pubertal changes is that it varies in the age of onset, time of development and order of appearance. The average age of menarche in the UK is 13 years and 95% of the population will reach it between the ages of 11 years and 15 years.

Introduction

The menstrual cycle commences with the maturation of the hypothalamo-pituitary-ovarian axis. At menarche each ovary contains about 300 000 primordial follicles. Once maturation has commenced, follicles proceed to either maturation or atresia; the latter is the fate of the majority. The high luteal phase levels of progesterone produced by the corpus luteum resulting from ovulation are blamed for most of the physical and behavioural premenstrual symptoms. At least one premenstrual symptom occurs in 95% of women during the reproductive age. The physical symptoms (mastalgia, bloatedness) have also been attributed to progesterone through induced fluid retention. However, there is now much evidence to suggest that this is not true.

Premenstrual syndrome

Premenstrual syndrome (PMS) is a psychological and somatic disorder of unknown aetiology. Hormonal and other, possibly neuroendocrine, factors probably contribute. There has been a reluctance, until relatively recently, to accept PMS as a serious condition. This has arisen because of a general failure to distinguish true PMS from the milder physiological premenstrual symptoms occurring in the normal menstrual cycle of the majority of women.

DEFINITION

A woman can be diagnosed as having PMS if she complains of recurrent psychological or somatic symptoms (often both), occurring specifically during the luteal phase of the menstrual cycle and resolving by the end of menstruation. These symptoms must be so severe that they disrupt the woman's normal functioning, quality of life and interpersonal relationships. Symptoms must have occurred in at least four of the previous six cycles.