The drugs don’t work

Why do around half of young people with a severe mental health
problem use street drugs? Think for a moment of a typical scenario
for the early onset of psychotic symptoms. A young man is away from
home at college and studying hard for his exams. He’s feeling under
a lot of pressure and he starts hearing voices. His first reaction
is fear – could he be going mad, is he going be locked up? Does he
go to his GP for help? Does he talk to his friends or his parents?
Possibly, but more likely he turns to alcohol or drugs to block out
his fears and have some relief from his symptoms.

Angela Jones’ (not her real name) son started using drugs at the
age of 15. Over the next 18 months he became extremely ill,
culminating in him being sectioned. She says: “He was using drugs –
mainly cannabis. We knew that something was going wrong. But we
didn’t know whether this was normal adolescent behaviour or not. We
know now that he was using the drugs to quell what was happening in
his head. There were a lot of voices. He said, ‘The drugs on the
street are far better than the ones they’re giving me.'”

Whatever relief users find they provide, it is widely acknowledged
that street drugs, including cannabis, crack and cocaine, can
exacerbate psychotic symptoms.

There is also a growing body of evidence that for some young people
cannabis may actually cause psychosis. Studies from Sweden and the
Netherlands indicate that regular cannabis users are several times
more likely to be subsequently diagnosed with schizophrenia than
those who don’t use the drug.

Robin Murray is a consultant psychiatrist working at the Maudsley
Hospital in south London. He points out that, while people with
schizophrenia do not take more alcohol, heroin or ecstasy than the
rest of the population, they are more than twice as likely to smoke
cannabis regularly. He believes the increasing availability of the
drug is one of the reasons why the incidence of schizophrenia has
doubled in south London since the 1960s.

So while for many young people a spliff on a Friday night is as
normal as a can of lager, for an unfortunate minority, it may spell
the beginning of severe mental illness. Exactly what makes some
cannabis users develop psychosis is unclear, but it seems to be a
mixture of genetic predisposition and social and environmental
factors.

Rethink (previously the National Schizophrenia Fellowship) is
trying to tackle the ignorance surrounding severe mental illness by
getting service users and staff to talk to young people at college
and university. Mike Hartley, operations manager for the charity in
Yorkshire and the north east, says: “The idea is to inform young
people so they don’t hide symptoms that are causing them concern.

“Service users talk about their experience and encourage people to
go to their GP or ring a helpline. It’s about encouraging people to
be open and honest.”

Early intervention can dramatically improve the life chances of a
young person who is developing psychotic symptoms, as well as
reducing the risk of them of developing a serious drug dependency.
Andrew Higgins, Rethink operations manager for the south west,
says: “There’s a strong relationship between a short duration of
untreated psychosis and a higher level of recovery. If symptoms are
treated early, someone has a good chance of getting back to where
they were before they developed symptoms, in terms of their social
functioning, concentration, and ability to hold down a place at
college or a job. Hopefully, we reach people a long time before
they get to an acute ward.” The reality, however, is that even once
they are referred for treatment, teenagers may have to wait for up
to 18 months.

Teenagers often fall between child and adolescent mental health
services (CAMHS) and adult services. Higgins says: “A colleague
with a daughter who was using drugs and developing psychosis took
her to children’s services and was told, ‘We don’t do psychosis’,
and that he needed to take her to adult services. When he contacted
them they told him to go back to CAMHS.”

As well as the relatively small number of young people who develop
psychosis while still in their teens, there is a much larger number
of children with a range of mental health problems who use drugs as
a way of trying to cope with difficulties in their lives.

Dr Mirza, consultant psychiatrist with the South London and
Maudsley NHS Trust and senior lecturer at the Institute of
Psychiatry, says that in the country as a whole, services for
teenagers that combine treatment of both drug dependency and mental
illness are almost non-existent.

He agrees that specialist inpatient care for teenagers is needed in
the most extreme cases. At the moment most severely mentally ill
teenagers who are using drugs have to be admitted to an adult ward
or private clinic, if they are treated at all. But he believes the
first priority should be to develop multi-disciplinary,
community-based support.

He explains: “There’s a strong association between trauma and
substance abuse – numbing your brain with anything you can get.
Many of the young people I work with who have disciplinary problems
and are using drugs – the so-called ‘bad kids’ – also have a lot of
sadness in their lives. Some have suffered neglect or abuse, or
post-traumatic stress disorder from war or conflict. They use drugs
as a way of dealing with their problems. Mental health
professionals have a role here, although by and large people in
CAMHS don’t feel they have the ability to deal with substance abuse
problems.”

Mirza says many of these young people have multiple needs and
chaotic lifestyles. “If you want to help them you have to go out to
them. We are trying to develop an extensive outreach service. We
have created a network of professionals – the service is based in
CAMHS but we have people from social services, the voluntary
sector, education and youth offending. If you look at service
developments in other countries what seem to be successful are
services which meet their needs together,” he says.

Of the 400-500 young people aged between 14 and 18 referred to the
Lambeth CAMHS team in south London, around a quarter have
significant substance abuse problems – at least 100 a year. Yet in
many parts of the country there is no provision at all. Hartley
says that in the 15 local authority areas he covers, only three or
four have any service for teenagers with a dual diagnosis. He says,
“There’s definitely a move towards early intervention and involving
families, but it’s still embryonic.”

Like other agencies working with homeless people, the London-based
charity Centrepoint picks up some of the thousands of young people
whose mental health needs have not been addressed. Maura O’Brien,
co-ordinator of the multiple needs team, echoes the message that
young people use drugs as a form of self-medication. “Often they
find the drug or alcohol gives them some relief from their
symptoms. We help them to look at reasons why they are using a
drug, and see what makes them feel better and worse,” she
explains.

In line with new guidelines from the Department of Health on dual
diagnosis promoting integrated treatment, O’Brien believes an
integrated approach to supporting people with mental health
problems is the most effective. “We often find people have to go
around a number of different services. People with crack psychosis
are often told by mental health services they have to give up the
crack. They don’t find that very helpful. Clinical outcomes tend to
be better with one practitioner.”

But while the inadequacy of provision for adults with a dual
diagnosis is slowly being addressed, children’s services still have
a long, long way to go. Yet there’s no doubt that early
intervention is the answer. Jones says: “With Tom, the signs were
there when he started secondary school. At 15 he was using cannabis
as a form of self-medicationÉ it’s so important that we reach
people early.”