PERSISTENCE OF SUBSTANCE USE-RELATED HOSPITAL UTILIZATION AMONG PSYCHIATRIC CONSULTATION PATIENTS
Riitta Alaja*,
Kaija Seppä1 and
Pekka Sillanaukee2
Consultation-Liaison Unit, Tampere University Hospital, P.O. Box 2000, FIN-33521, Tampere, Finland,
1 Tampere University, Finland and
2 Pharmacia & Upjohn, Alcohol Related Diseases, Diagnostics, Uppsala, Sweden
Received 3 September 1998;
in revised form 3 November 1998;
accepted 1 December 1998
 |
ABSTRACT
|
---|
Among 86 consecutive consultation-liaison (C-L) patients with current substance use-related hospital attendance, the case records revealed an average history of 5.9 years in male patients and 5.3 years in female patients of repeated substance use-related hospital visits. A history of at least 1 year was found in 60% (52/86) of patients. The history had started at the age of early 30s with attempted suicide as the most common principal diagnosis. By the age of 40, there had been several hospital visits for various health problems. However, 48% (41/86) of the patients had never received substance use treatment. It appeared that opportunities to intervene with substance use were frequently missed on hospital encounters, a finding also observed in earlier studies.
 |
INTRODUCTION
|
---|
General hospital patients commonly have severe substance use problems for which no substance use treatment has been provided. In two earlier studies, 34 out of 53 general hospital inpatients with alcohol problems (Lloyd et al., 1982
) and 38% of alcohol-dependent inpatients (Rumpf et al., 1998
) had not received any substance use treatment in their lifetime. Hospital utilization increases during the early years of alcohol problems, as was shown by Kolb and Gunderson (1983) in a controlled study of young men in naval service. Psychiatric consultations are requested for general hospital patients, i.e. for the evaluation of substance use disorders (Burton et al., 1991
). Of inpatient consultations in Finland, 28% deal with substance use disorders (Alaja et al., 1997
), and often at that point the clinical problems are complex (Alaja et al., 1998). How far substance use-related hospital visits can be traced back has not been estimated. Among general hospital consultation-liaison (C-L) patients, we measured the total persistence of substance use-related hospital utilization, especially prior to any substance use treatment. We also looked for the first indication of substance use in their case records and inquired about substance use treatment ever received.
 |
PATIENTS AND METHODS
|
---|
During 8 weeks, 433 consecutive patients were assessed by the C-L unit of Tampere University Hospital, Finland, and 86 (20%) of them were identified as having substance use-related hospital utilization currently. The identification criteria were: (1) presence of any hazardous use (i.e. with potential psychosocial and health risks) of any type of psychoactive substance, and concurrently (2) a clinical condition induced or exacerbated by substance use, or (3) neglect of medical treatment because of substance use, or (4) an injury or attempted suicide with substance use involvement. The identification was carried out by experienced C-L professionals, who also inquired of the patients whether they had received any substance use treatment in their lifetime, be it hospital or community. No enquiry was made about offers of treatment.
Subsequently, a senior psychiatrist (R.A.) reviewed all case record material of the patients with identification. Past years since the first substance use-related hospital visit until the current visit were coded as the period of substance use-related hospital utilization. Whenever present, a substance use-related diagnosis in the hospital record was coded as the first indication of substance use. The most significant other indication was secondarily coded: breath alcohol test, laboratory finding, clinical symptoms and signs, referral data, self-report, or report by significant others. The principal diagnosis on the first visit and all hospital care provided during the previous 10 years were also coded. Analysis of variance with 95% confidence intervals (CI), and Student's t-test were applied in the statistical analysis of the data. A probability level of <0.05 was considered significant.
A DSM-III-R diagnosis (American Psychiatric Association, 1987
) of alcohol or drug dependence was given to 50% (43/86) of the patients identified. The other half of the patients (43/86) fulfilled the criteria of substance abuse. Only in eight patients had primary hospital physicians defined substance use disorder as a referral diagnosis for psychiatric consultation. A reason for referral was attempted suicide in 37% (32/86) of patients. The mean age of male patients was 38 years (range 1565) and of female patients 40 years (range 1882). The age group 1850 years comprised 81% (70/86) of patients.
 |
RESULTS
|
---|
Since the first substance use-related hospital visit, the average period of substance use-related hospital utilization was 5.9 years (range 0.024.0; 95% CI 3.997.80) for male patients and 5.3 years (range 0.020.5; 95% CI 2.857.76) for female patients (Fig. 1
). At the first substance use-related visit, the mean age of male patients was 32 years (95% CI 29.3234.89) and of female patients 35 years (95% CI 28.8440.23). The first indication of substance use in the case record was most frequently a diagnosis or self-report among male patients and self-report among female patients (Table 1
). In the discharge summary, attempted suicide was the most common principal diagnosis (29%) at the first visit, and various physical or mental disorders were more common than any substance use disorder (Table 1
). Most patients had had several hospital visits and 76% (65/86) of them had had admissions. Of male patients 61% (34/56) and of female patients 37% (11/30) reported having received substance use treatment. In the consultation, seven patients reported previous substance use treatment, but such information or any other indication of substance use was not found in their case records.

View larger version (21K):
[in this window]
[in a new window]
|
Fig. 1. Distribution of the past years of substance use-related hospital utilization in relation to the frequency (bars) and cumulative percentage (line) of the consultation-liaison patients identified as having substance use-related hospital utilization currently.
|
|
View this table:
[in this window]
[in a new window]
|
Table 1. Main indication of substance use in the case record and principal diagnosis in the discharge summary at the first substance use-related hospital visit
|
|
A history of at least 1 year of substance use-related visits was found in 60% (52/86) of patients. Of these, 17/52 (33%) reported having never in their lifetime received substance use treatment. The average period since their first substance use-related visit was 6.9 years (range 1.021.1; 95% CI 3.510.2). During those years, all of them had had several hospital encounters.
 |
DISCUSSION
|
---|
In the general hospital C-L setting, a patient with current substance use-related hospital utilization was likely to have had several substance use-related hospital visits between the ages of 32 and 40 years. A substantial proportion of the patients had not received any substance use treatment in their lifetime, despite substance use-related hospital utilization. Confirming earlier reports, the case notes examined showed that opportunities to initiate substance use treatment appear to have been missed on hospital encounters. It is possible that treatment was offered, but not taken up by the patient, but we have no data on this point. Substance use was deficiently diagnosed and reported in case records, and even previous substance use treatment was under-reported. When diagnosing substance use problems, physicians rely very much on case records (Buchsbaum et al., 1992
) and on evidence of previous substance use treatment (Rundell and Hall, 1997
). To prevent the devastating clinical course of substance use (Schuckit et al., 1995
), more skills and effort are needed for the administration of substance use interventions in general hospitals.
 |
ACKNOWLEDGEMENTS
|
---|
This study was supported by a grant from the Medical Research Fund of Tampere University Hospital.
 |
FOOTNOTES
|
---|
* Author to whom correspondence should be addressed. 
 |
REFERENCES
|
---|
Alaja, R., Seppä, K., Sillanaukee, P., Tienari, P., Huyse, F. J., Herzog, T., Malt, U. F., Lobo, A. and the European Consultation-Liaison Workgroup (1997) Psychiatric referrals associated with substance use disorders: prevalence and gender differences. Alcoholism: Clinical and Experimental Research 21, 620626.[ISI][Medline]
Alaja, R., Tienari, P., Seppä, K., Tuomisto, M., Leppävuori, A., Huyse, F. J., Herzog, T., Malt, U. F., Lobo, A. and the European Consultation-Liaison Workgroup (1999) Patterns of comorbidity in relation to functioning (GAF) among general hospital psychiatric referrals. Acta Psychiatrica Scandinavica 99, 135140.[ISI][Medline]
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, revised. American Psychiatric Association, Washington, DC.
Buchsbaum, D. G., Buchanan, R. G., Poses, R. M., Schnoll, S. H. and Lawton, M. J. (1992) Physician detection of drinking problems in patients attending a general medicine practice. Journal of General Internal Medicine 7, 517521.[ISI][Medline]
Burton, R. W., Lyons, J. S., Devens, M. and Larson, D. B. (1991) Psychiatric consultations for psychoactive substance disorders in the general hospital. General Hospital Psychiatry 13, 8387.[ISI][Medline]
Kolb, D. and Gunderson, E. K. E. (1983) Medical histories of problem drinkers during their first twelve years of naval service. Journal of Studies on Alcohol 44, 8494.[ISI][Medline]
Lloyd, G., Chick, J. and Crombie, E. (1982) Screening for problem drinkers among medical inpatients. Drug and Alcohol Dependence 10, 355359.[ISI][Medline]
Rumpf, H.-J., Hapke, U. and John, U. (1998) Previous help seeking and motivation to change drinking behavior in alcohol-dependent general hospital patients. General Hospital Psychiatry 20, 115119.[ISI][Medline]
Rundell, J. R. and Hall, R. C. W. (1997) Past mental health or substance use treatment history and psychiatric differential diagnosis in consultation-liaison patients. Psychosomatics 38, 262268.[Abstract]
Schuckit, M. A., Anthenelli, R. M., Bucholz, K. K., Hesselbrock, V. M. and Tipp, J. (1995) The time course of development of alcohol-related problems in men and women. Journal of Studies on Alcohol 56, 218225.[ISI][Medline]