Phillips & Johnson reported on the very high prevalence of drug use among those with psychosis on psychiatric wards in two Boroughs in inner London (Psychiatric Bulletin, June 2003, 27, 217–220). During 2002, on one of the wards included in their study, we routinely collected urine specimens for drug screening from all new admissions. Data from 69 admissions suggested that drug use was even higher in those with non-psychotic illnesses.

There is a positive way of looking at this problem. One obvious but frequently overlooked reason for the high prevalence of substance misuse among in-patients is simply that many clinicians look to admit heavy users because they believe that doing so provides them with an opportunity to detoxify, or at least cut down substantially, on their drug use. More research is needed to establish to what extent this is successful but, on the whole, clinical impressions would suggest that it is. Users of crack cocaine with psychosis in particular seem to benefit from a period of abstinence enforced, or partially enforced, by their admission.

For this reason, continuing drug use by an in-patient should not be seen as an unreserved failure, especially if it is continuing at levels lower than it was prior to admission. Even when the drug use is relatively unchanged, the admission can be viewed optimistically, as an opportunity for clinicians to provide counselling to the in-patient in a way that is rarely possible in the community.