Motivational interviewing among psychiatricin-patients with substance use disorders

Introduction

Alcohol and other drug (AOD) use among peoplewith mental illnesses is a major public healthproblem. Comorbidity of substance misuse andmental disorders is common and often associatedwith severe illness, failure to access treatment orinadequate treatment delivery (1). Grace et al. (2)have recently reported that in-patients in psychi-atric hospital who screen positive for cannabis useare significantly more likely to relapse and requirehospitalization than those negative for use. Yetresearch investigating specific interventions for thisform of comorbidity has been sparse and of poorquality (3).

There is good evidence that brief interventionscan be effective in the treatment of alcohol prob-lems in people without mental illness (e.g. Refs4, 5). There is also evidence that brief interventionsin the form of a motivational interview can beeffective preparations for further AOD treatment,enhancing in-patient treatment involvement (6)and reducing substance misuse among out-patients(7). It appears that longer interventions also benefit

alcohol dependent patients and that structured andscheduled follow-up should be available (5). Fur-ther, Heather (8) has argued that evidence for theeffectiveness of brief interventions is much strongerin the area of opportunistic interventions in thenon-treatment seeking population than for briefinterventions in specialist settings for those seekinghelp with AOD use.

Motivational interviewing has been describedas a component of several interventions forsubstance misuse among people with comorbidmental and substance misuse disorders (e.g.,Refs 1, 9–11). Teesson et al. (1) suggested thatengagement in a Specialist Substance MisuseService (SSMS) for AOD problems for peoplewith mental illnesses may be more successful ifmotivational interviewing techniques are usedbefore referral to the SSMS. Recently, Swansonet al. (12) reported that a 1-h motivationalinterview just prior to discharge from psychiatrichospital significantly improved the proportionof psychiatric and dually diagnosed patientswho attended their first psychiatric out-patientappointment.

Baker A, Lewin T, Reichler H, Clancy R, Carr V, Garrett R, Sly K,Devir H, Terry M. Motivational interviewing among psychiatric in-patients with substance use disorders.Acta Psychiatr Scand 2002: 106: 233–240.ªBlackwell Munksgaard 2002.

Objective: There were three aims of the present study: 1) to documentpatterns of substance misuse among psychiatric in-patients withcomorbid alcohol and other drug (AOD) use; 2) to examineassociations among psychiatric and substance use diagnoses andreadiness to change; and 3) to evaluate the effectiveness of anopportunistic motivational interview on engagement in a SpecialistSubstance Misuse Service (SSMS).Method: One hundred and sixty subjects were randomly assigned toreceive either a motivational interview or no intervention.Results: Overall, 66.3% of subjects met intervention threshold forcannabis, 60.6% for alcohol and 22.5% for amphetamines. There wasa bimodal distribution of stage of change for cannabis use which wasassociated with age, with precontemplation being associated with olderage and less frequent use. Attendance at the SSMS was low andunrelated to intervention status.Conclusion: A different approach to treatment is recommended,including early intervention among cannabis users.

Amanda Baker1, Terry Lewin1,2,Heidi Reichler1, Richard Clancy2,Vaughan Carr1,2, Rachel Garrett1,Ketrina Sly1, Holly Devir1,Margarett Terry21Centre for Mental Health Studies, University ofNewcastle, Callaghan, Australia and 2Hunter MentalHealth, Newcastle, Australia

Key words: behaviour therapy; cognitive therapy;comorbidity; dual diagnosis; in-patients, schizophrenia;substance abuse

Dr Amanda Baker, Centre for Mental Health Studies,University of Newcastle, University Drive, Callaghan,New South Wales 2308, AustraliaE-mail: amanda.baker@newcastle.edu.au

Accepted for publication February 11, 2002

Acta Psychiatr Scand 2002: 106: 233–240Printed in UK. All rights reserved

Copyright ª Blackwell Munksgaard 2002

ACTA PSYCHIATRICASCANDINAVICAISSN 0001-690X

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Aims of the study

There were three aims of the present study: 1) todocument patterns of substance misuse amongpsychiatric hospital in-patients with comorbidAOD use; 2) to examine associations among thepsychiatric and substance use diagnoses and readi-ness to change; and 3) to evaluate the effectivenessof an opportunistic motivational interview onengagement in an SSMS. AOD use during the12-month follow-up will be reported in a futurepaper.

Material and methods

Existing specialist substance misuse service

This project was conducted within acute units of apublic psychiatric hospital which services a catch-ment population of 330 000 adults in the Hunterregion, 150 km north of Sydney, New South Wales(NSW). An SSMS for in-patients and out-patientswith comorbid mental illness and AOD problemsoperated within the grounds of the hospital. Inter-ventions offered through this service were mainlygroup based with a psychosocial and psychoedu-cational focus. Whilst reduced AOD use wasaccepted as a treatment goal, the ultimate goal forpatients with a dual diagnosis was abstinence.Harm minimization strategies were utilizedthroughout treatment. Pharmacological interven-tions were limited to disulfiram for patients withalcohol dependence who met program criteria.

Subjects

Subjects were in-patients of an acute psychiatrichospital who were invited a few days after admis-sion to participate in a longitudinal study ofsubstance misuse among people with mental ill-ness. Inclusion criteria were: in-patient status in thepsychiatric hospital, capable of interview, likely toreside in the local geographical region during thenext 12 months, and consumption of alcohol and/or other drugs during the months prior to admis-sion at a sufficient level for intervention. Inter-vention threshold for AOD consumption atpretreatment was defined as meeting diagnosticcriteria for current (past 6 months) abuse ordependence on the Structured Clinical Interviewfor DSMIII-R (SCID, 13), the use of any illicitdrug on a weekly basis (or the equivalent scoreof 0.14 or higher on the Drug Use Scale of theOpiate Treatment Index, 14), in the month priorto interview, or alcohol consumption exceedingrecommended National Health and Medical

Research Committee levels, four standard drinksper day for men and two for women (15). Onehundred and sixty-nine patients were identified aspotentially suitable for the study either throughtheir medical records and/or by direct referral fromhospital staff. The purpose, design and componentsof the study were described to these patients andthey were told that, on giving written informedconsent to enter the study, they would be randomlyassigned to either one session of counselling or toreceive information about AOD use. Subjectswere assured that any information they gave toresearchers was confidential and that refusal toparticipate would not affect their relationship withthe mental health service in any way. One hundredand sixty patients met inclusion criteria (i.e. inter-vention threshold for AOD misuse) and wereassessed between September 1996 and July 1998.Follow-up data at 3-months were available for112 subjects (70.0% of the sample). Based onannual hospital admissions data for the participa-ting units, it was estimated that we recruitedapproximately 50% of the patients who had aprimary discharge diagnosis of substance abuse ordependence.

Motivational interview

The main aims of the motivational interview wereto reduce AOD use and to increase participation inthe SSMS. The intervention occurred immediatelyfollowing the preintervention assessment and com-prised of a motivational interview (16), which wasconducted individually and lasted 30–60 min. Thesessions were guided by a therapist manual and aleaflet summarizing the session was given to thepatient upon its conclusion. Subjects were providedwith feedback regarding their current levels ofAOD consumption. The positive and negativeaspects associated with AOD use were discussedincluding possible interactions between currentlevels of consumption and psychiatric symptoma-tology, medication and adherence to medication.Possible factors contributing to AOD use were alsodiscussed. Where concerns were identified withAOD use, the therapist sought elaboration with theaim of enhancing recognition of a discrepancybetween the subject’s goals (e.g. staying out ofhospital) and current behaviour (e.g. smokingcannabis several times daily). Education was pro-vided interactively about safer consumption levels.The therapist aimed to follow this process witheach substance used by the subject. Nicotinereduction was not targeted in this study as aspecific and different intervention would have beenneeded. A harm reduction approach was taken

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whereby individuals chose their own goals, if any,for changing one or more drug classes. When asubject showed evidence of having arrived at thedetermination or action stages of change (17),potentially beneficial cognitive-behavioural copingstrategies were discussed. Subjects were encour-aged to identify previously successful and unsuc-cessful coping attempts. Successful strategies wereencouraged (e.g. avoiding other users and certainplaces) and new strategies identified (e.g. atten-ding the SSMS). Relapse prevention strategiesdeveloped by Marlatt and Gordon (18) werediscussed.

Control group subjects were informed that theywere using substances at a hazardous level and thatthey should reduce their consumption to saferlevels. All subjects (i.e. intervention and controlconditions) were then accompanied to the SSMS,given a description of the service, introduced to thereceptionist, encouraged to attend, and providedwith a pamphlet about the service. An entry wasmade in the subject’s case notes that they had beenencouraged to attend the service.

The therapists were four well-trained psycholo-gists. The first author provided both initial trainingand weekly supervision in motivational interview-ing and cognitive-behavioural coping strategies.

Measures

Data were collected on demographic characteris-tics, discharge diagnosis, history of any treatmentfor drug dependence, current drug use and reasonsfor drug use. The Alcohol Use Disorders and Non-alcohol Psychoactive Substance Use Disorderssections of the SCID (13) were used to determinelifetime and current (past 6 months) substanceabuse or dependence. The Opiate Treatment Index(OTI) (14) was used to assess consumption of 11classes of drug during the month preceding inter-view (including the admission period). The OTIwas also used to measure injecting risk-takingbehaviour via the drug use section of the HIVRisk-taking Behaviour Scale (HRBS) (19), socialfunctioning and crime. All measurements on theOTI pertained to the 1-month period prior tointerview except for the Social Scale which assessedthe 6 months prior to interview. Psychiatric diag-noses were determined by the responsible cliniciansand obtained from the patients’ medical records.The DSM-IV (20) Axis 1 discharge diagnoses weresubsequently collapsed to create the following(non-substance use) categories: schizophrenia,mood disorder, other, and none. The Brief Symp-tom Inventory (BSI, 21), was employed to measureself-reported symptomatology.

Following Fowler et al. (22), subjects were askedto nominate their main reasons for using eachsubstance reported on the OTI. Reasons for usewere grouped under four main categories: drugintoxication effects, dysphoria relief, social effects,and illness and medication-related side-effects (22).In most cases, these reasons were self-generated. Asmall number of subjects chose to select a reasonfrom a prepared list of common reasons for use.Subjects were able to state more than one reason.For the purposes of analysis, the first stated reasonfor use was taken as the main reason for use.

A 10-rung contemplation ladder was used as ameasure of readiness to change each category ofAOD used in the month prior to interview (23).Because subjects’ responses were clustered aroundthe five rungs with verbal anchors, the categorieswere subsequently collapsed as follows: 0 – ‘Nothought of quitting or cutting down’; 1 – ‘Think Ineed to consider quitting or cutting down some-day’; 2 – ‘Think I should quit or cut down but notquite ready’; 3 – ‘Starting to think about how tochange my drinking/using patterns’; and 4 –‘Taking action to quit or cut down’.

Participation in the SSMS was measured by‘engagement’, namely, any attendance during the3 months following initial interview and meannumber of attendances by attendees. Staff of theSSMS maintained attendance records from whichrelevant information was extracted for participantsin this study.

Statistical analysis

Data were analysed using SPSS for Windows(version 10). Analyses examining group differenceson continuous outcome variables were either t-tests(e.g. intervention vs. control conditions) or simpleanalyses of variance (ANOVA) (e.g. stage ofchange comparisons). Categorical variables wereanalysed using chi-square tests. As a partial controlfor the number of statistical tests, a threshold forsignificance of P < 0.01 was adopted.

Results

Characteristics of patients at preintervention assessmentand patterns of alcohol and other drug use

The preintervention sample comprised 160 psychi-atric in-patients with coexisting AOD problems.Ninety percent of these subjects (n ¼ 144) reportedcurrent (past 6 months) substance abuse or depen-dence on the SCID, 89.4% (n ¼ 143) reported atleast weekly consumption of AOD on the OTI,while 79.4% (n ¼ 127) met both inclusion criteria.

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The demographic and clinical characteristics of thesample are displayed in Table 1. The majority ofthe sample were: male, single, receiving pensions,and had not completed senior high school or post-school qualifications. Over half of the sample hadpreviously been treated for AOD problems and aquarter of the sample had previously attended theSSMS. Admission to psychiatric hospital in theyear prior to the index admission was common,with over one-third of the sample having beenadmitted. Schizophrenia and mood disorder werethe most common non-substance abuse dischargediagnoses. Almost 20% of the sample did not havea non-substance Axis 1 discharge diagnosis recor-ded in their medical records. An examination ofscores on the BSI for this group revealed a similarlevel of symptomatology to the other groups andconsequently they were retained in the study. Two-thirds of the sample had a discharge diagnosis ofsubstance abuse or dependence recorded in theirmedical records, with alcohol and cannabis abuseor dependence being the most frequent diagnoses.

Table 2 reports the patterns of substance use for11 substances, including lifetime use, SCID abuseor dependence, OTI scores for the last month, andthe percentage of subjects meeting SCID, OTI andour composite intervention threshold for eachsubstance. Almost half of the sample (47.5%,n ¼ 76) met our composite intervention thresholdfor one substance only; a third met interventioncriteria for two substances (33.8%; n ¼ 54); and

the remainder met criteria for between three andsix substances (9.4, 6.9, 1.3 and 1.3%, respectively).As shown in Table 2, lifetime use of tobacco,alcohol and cannabis was almost universal.Tobacco smoking among the sample is describedin detail elsewhere (24). The right-hand column ofTable 2 also demonstrates that the percentage ofthe sample meeting intervention threshold washighest for cannabis, alcohol and amphetamines.

A comparison of Tables 1 and 2 reveals thatsubjects received a substance abuse diagnosis lessfrequently by treating clinicians than by theresearchers (65.0 vs. 90.0%). In fact, only two-thirds (67.6%) of those with a current SCIDdiagnosis of substance abuse or dependencereceived a discharge diagnosis of substance abuseor dependence. Table 2 also shows the mean levelof use for each category of drug assessed on theOTI. The mean number of drug classes used bysubjects in the month prior to interview was 3.34(SD ¼ 1.28). All subsequent analyses focus onsubstances for which the composite interventionthreshold was met by at least 20% of the sample(i.e. alcohol, cannabis and amphetamines).

Associations between readiness to change and other keyvariables

Table 3 presents a breakdown of subjects meetingintervention criteria for alcohol, cannabis andamphetamine use according to their reasons for

Table 1. Characteristics of the sample at preintervention assessment (n = 160)

Male 75.0% (n = 120)Mean age (SD, range) 30.87 years (10.23, 16–70)Married or co-habiting 15.6% (n = 25)Completed upper high school 8.8% (n = 14)Receiving pension or benefits 76.3% (n = 122)Mean number of prior psychiatric hospital admissions (SD, range) 4.33 (7.86, 0–55)Previous treatment for substance abuse 55.6% (n = 89)Attended specialist treatment service (SSMS) in past 24.4% (n = 39)

Psychiatric hospital admissions during the previous 12 months:At least one admission 38.1% (n = 61)Mean number of admissions (SD, range) 2.57 (3.25, 1–20; n = 61)Average length of admission (days) (SD, range) 15.58 (14.63, 1–63)

Index admission:Primary DSM-IV non-substance Axis I discharge diagnosis (n = 157) Schizophrenia 37.6% (n = 59)

Mood disorder 29.3% (n = 46)Other 13.4% (n = 21)None 19.7% (n = 31)

DSM-IV Axis II discharge diagnosis (n = 157) 16.6% (n = 26)Average length of admission (days) (SD, range) 13.98 (13.41, 1–68)Discharge diagnosis of substance abuse or dependence (n = 157) Alcohol 31.2% (n = 49)

Cannabis 15.3% (n = 24)Tranquilizers 8.9% (n = 14)Amphetamines 7.0% (n = 9)Heroin 5.1% (n = 8)Other 9.6% (n = 15)Any diagnosis 65.0% (n = 102)

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substance use. Alcohol and amphetamine wereused mainly for ‘dysphoria relief’ and ‘drugintoxication effects’, while cannabis was usedprimarily for its ‘intoxication effects’.

Table 4 presents comparisons between subjectsmeeting and not meeting intervention thresholdfor the three focal substances, including

demographic, psychiatric, and treatment historycomparisons. Subjects above threshold for can-nabis or amphetamine use were significantlyyounger than those who did not warrant anintervention [t(158) ¼ 5.58, P < 0.001; t(158) ¼2.65, P < 0.01, respectively]. Axis 1 non-substanceabuse diagnosis was not significantly related tointervention threshold for alcohol, cannabis oram-phetamines. However, there was a non-significanttrend for a higher percentage of cannabis usersabove threshold to be diagnosed with schizophreniathan those below threshold (v2 ¼ 8.49, df ¼ 3,P < 0.05).

The stages of change nominated by subjectsreaching intervention threshold criteria for alco-hol, cannabis or amphetamine use during themonth prior to interview are shown in Table 5.Inspection of these data revealed that stage of

Table 2. Patterns of substance use

Last 6 monthsLifetime abuse Abuse or dependence Usage last Above OTI Above composite

Lifetime use or dependence (SCID intervention month (OTI) OTI mean by Threshold (%) Intervention threshold*Substance (%) (n = 160) (%) (n = 160) threshold) (%) (n = 160) n % users (SD) (n = 160) (%) (n = 160)

Tobacco 95.6 - 148 (92.5) 23.88 (13.66) -Alcohol 100.0 79.4 54.4 130 (81.3) 8.52 (11.80) 40.6 60.6Cannabis 91.3 60.6 50.6 109 (68.1) 7.72 (12.06) 62.5 66.3Amphetamines 66.9 29.4 21.9 35 (21.9) 0.98 (1.24) 12.5 22.5Tranquilizers 66.3 15.0 11.3 55 (34.4) 1.81 (2.39) 25.6 11.3�

Hallucinogens 58.8 6.2 0.0 7 (4.4) 0.07 (0.08) 0.6 0.6Other opiates 42.5 9.4 6.9 21 (13.1) 3.26 (10.77) 8.8 10.0Heroin 38.8 16.2 12.5 23 (14.4) 0.84 (0.73) 12.5 13.8Inhalants 30.6 3.1 0.6 2 (1.3) 75.7 (105.06) 1.3 1.3Cocaine 28.8 5.0 1.9 5 (3.1) 0.13 (0.17) 0.6 2.5Barbiturates 7.5 1.9 0.6 0 (0.0) 0.00 (0.00) 0.0 0.6

*Meeting either SCID or OTI intervention thresholds. � Based on SCID criteria which separates prescribed from non-prescribed tranquilizers.

Table 3. Percentage of subjects endorsing reasons for substance use in the monthprior to interview among subjects meeting threshold for intervention for alcohol,cannabis and amphetamine use

Reasons for useAlcohol(n = 91)

Cannabis(n = 102)

Amphetamines(n = 25)

Drug intoxication effects 35.2 56.9 44.0Dysphoria relief 47.3 19.6 36.0Social 14.3 8.8 8.0Illness/medication 2.2 1.1 0.0Other 1.1 13.7 12.0

Table 4. Comparisons between subjects above and below the intervention thresholds for alcohol, cannabis and amphetamines

Alcohol Cannabis Amphetamines

Below threshold Above threshold Below threshold Above threshold Below threshold Above threshold

Sample (n) 63 97 54 106 124 36Gender (male) (%) 81.0 71.1 74.1 75.5 78.2 63.9Age (mean, SD) 29.02 (10.24) 32.07 (10.09) 36.67 (11.31) 27.92 (8.22)** 32.00 (10.84) 26.97 (6.45)*

Prior psychiatric 5.24 (9.31) 3.74 (6.76) 5.51 (9.29) 3.73 (7.01) 4.24 (7.42) 4.63 (9.37)Admissions (mean, SD)

Prior AOD Treatment (%) 58.7 53.6 57.4 54.7 54.8 58.3

Axis I diagnosis (%)Schizophrenia 41.9 34.7 22.6 45.2 ns 34.1 50.0Mood disorder 37.1 24.2 34.0 26.9 33.1 14.7Other 8.1 16.8 15.1 12.5 13.0 14.7None 12.9 24.2 28.3 15.4 19.5 20.6

SSMS attendance previous12 months (%) 11.1 7.2 7.4 9.4 6.5 16.7

SSMS attendance during3-months following admission (%) 19.0 15.5 20.4 15.1 13.7 27.8

**P < 0.001; *P < 0.01; ns: P < 0.05 non-significant trend.

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change for drinking was more evenly distributedthan that for cannabis use which was distributedbimodally. Half of the amphetamine users were atthe action stage of change. In view of the bimodaldistribution for cannabis use, stage of change wasregrouped into precontemplation, early contem-plation and late contemplation/action stages ofchange. Analyses of variance were performed toinvestigate whether age and gender were associ-ated with stage of change for cannabis use. Agewas significantly associated with stage of change(F(2,103) ¼ 6.1, P < 0.01). Scheffe follow-up testsrevealed that those at the late contemplation/action stage were significantly younger (25.51 vs.31.67 years) than precontemplators (P < 0.01).There was no association between stage of changefor cannabis use and gender (v2 ¼ 1.41, df ¼ 2ns). For comparison, the first three and last twostages of change (precontemplation/early contem-plation vs. late contemplation/action stage) werecompared among the alcohol and amphetamineusers who met intervention threshold criteria.There were no significant relationships betweenage, gender and stages of change for alcohol andamphetamine use.

Effect of intervention on engagement in an SSMSat 3-month follow-up

Attendance at the SSMS during the 3-monthperiod following admission was analysed amongsubjects above intervention threshold for alcohol,cannabis and amphetamine use according to stageof change (late contemplation/action stage vs.precontemplation/early contemplation). Therewere no significant differences between the respect-ive percentage of subjects who attended the SSMSamong threshold drinkers (19.6 vs. 9.8%), canna-bis users (16.4 vs. 13.7%) or amphetamine users(36.0 vs. 9.1%).

There were no differences between interven-tion conditions in terms of attendance at theSSMS (motivational interview: 13/79, 16.5% vs.control condition: 14/81, 17.3%; v2 ¼ 0.02, df ¼ 1ns). The SSMS attendees in the motivational

interview condition averaged 4.46 sessions (SD ¼3.23) and the SSMS attendees in the controlcondition averaged 5.79 sessions (SD ¼ 2.81)(t(25) ¼ –1.11 ns).

Discussion

This study examined levels of AOD use, stage ofchange and reasons for use among in-patients in apsychiatric hospital. It also assessed the effective-ness of a motivational interview compared withusual treatment on engagement of subjects in anSSMS. The major conclusion of this evaluation isthat a motivational interview did not enhanceengagement in an SSMS. This is a troubling findingin that what works to engage people in services inother (i.e. non-psychiatric) settings does not workin the context of severe mental illness, yet prob-lematic substance use is so prevalent and associ-ated with major adverse outcomes in this group.

One possible reason for the failure of the moti-vational interview to engage people in the SSMS isthe severity and chronicity of substance use prob-lems and mental illness among the sample. Mostsubjects had several previous admissions to apsychiatric hospital and a high proportion ofsubjects were diagnosed as abusing or dependentupon substances. The severity of substance useproblems among this sample is also evident fromthe high levels of injecting risk-taking behaviour,criminality and social dysfunction, which are sim-ilar to levels displayed by samples of opiate users(25). Despite chronic and severe problems, fewsubjects reported being at the action stage forreducing substance use. As brief interventions areless effective with people with greater levels ofdependence (5), a longer intervention may havebeen more effective in engaging the present samplein specialist treatment. It is also possible that themotivational interview may have been more effect-ive if it had been conducted closer to discharge fromhospital or as part of the discharge procedure.

The present study also demonstrates the diffi-culty in attracting people with mental illness intoseparate specific treatment services for their AODuse problems, even when motivational interviewingis conducted beforehand, as suggested by Teessonet al. (1). With so few patients attending the SSMS,and with such a high prevalence of problematicsubstance use in the sample, integrating assess-ment, recognition and intervention skills for sub-stance abuse problems with standard psychiatriccare is indicated to enhance enrolment and beginthe engagement process. Commencing the processof engagement on the in-patient ward with integ-rated in-patient/community specialist dual diagno-

Table 5. Percentage of users above intervention threshold who nominated stage ofchange for substance use in the month prior to interview

Stage of changeAlcohol(n = 97)

Cannabis(n = 106)

Amphetamines(n = 36)

No thought of quitting 12.4 28.3 2.9Someday quit 10.3 4.7 8.6Not quite ready 19.6 15.1 20.0Starting to think about quitting 27.8 14.2 17.1Taking action to quit 29.9 37.7 51.4

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sis staff (trained in both mental health andsubstance misuse treatment) rather than relyingon referral and attendance to a separate servicemay be useful. Hospital staff would need to betrained in the detection and assessment of AODproblems as the current study showed a discrep-ancy between clinician and researcher rates ofidentification. Similar discrepancies have beenreported in a recent Danish study (26).

The finding that subjects tend to report usingsubstances because of positive expectancies of drugeffect rather than in response to symptoms ofmental illness is similar to the findings of others(e.g. Refs 1, 22), as is the finding of few differencesin consumption patterns between patients withschizophrenia and those with other diagnoses (27).Successful engagement and retention in any inter-vention may require recognition of positive aspectsof use but also cognitive interventions whichaddress expectancies regarding drug effect (9).Over a third of amphetamine users at the latecontemplation/action stage of change at pretreat-ment attended the SSMS during the 3 monthsfollowing the interview. This implies that a sizeableproportion of amphetamine users admitted topsychiatric hospital regard their amphetamine useas a problem worth doing something about. It ispossible that amphetamines produce a greaterseverity or immediacy of adverse effects relativeto cannabis.

On the other hand, almost one-third of thepeople who met intervention threshold criteria forcannabis use were at the precontemplation stage.The link between the bimodal distribution of stageof change for cannabis and age (precontemplationand older age; contemplation/action and youngerage) may reflect an experience, for some, of noimmediately obvious association between cannabisuse and adverse psychiatric effects. It is alsopossible that the older contemplators had learnedbetter how to manage cannabis consumptionwithout experiencing much by way of adverseeffects. The conjunction of younger age and moreadvanced stage of change among subjects meetingthreshold for intervention suggests that educationand intervention efforts should be made earlyamong young cannabis users before mental healthproblems develop and during first episodes ofmental illness. Management of cannabis use withinrelatively safe limits may be a realistic goal ofintervention for some, and may be particularlyimportant for those with a diagnosis of schizo-phrenia, given the trend for a higher percentage ofcannabis users above intervention threshold to bediagnosed with schizophrenia than those belowthreshold in the present study.

In the current study, a motivational interviewwas not effective in enhancing engagement inspecialist out-patient services for AOD treatment.The absence of benefits of the intervention, the lowparticipation rates in the SSMS and the relativelyhigh proportion of cannabis users who remain atprecontemplation all suggest it may be worthwhiletrying a different treatment approach. Detectionand intervention for AOD problems amongin-patients in psychiatric hospital may be improvedby fully integrating treatment of AOD problemswithin psychiatric care. Subsequent to the currentstudy and to enhance engagement in treatment, theSSMS has been restructured to include an integ-rated 16-bed in-patient unit, community team andliaison worker. Mental health staff may need initialtraining and ongoing consultation/liaison withclinicians experienced in mental health and AODtreatment. Early intervention for cannabis users isindicated both prior to the development of mentalhealth problems and during first episodes ofmental illness. There is also a clear need for moreintensive investigation of these and other possibleinterventions for this very serious and widespreadproblem.

Acknowledgements

This work was funded by a Research Into Drug Abuse Grant(RIDAG) from the Commonwealth Department of Health andAged Care. Natalia Carter assisted in piloting the study. Wewish to thank the study participants and the ward and medicalrecord department staff of the hospital from which participantswere recruited.

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