Schizophrenia and Substance Abuse; Which Came First, the Chicken or the Egg?

Schizophrenia and Substance Abuse; Which Came First, the Chicken or the Egg? Terry V. Hites Prof. Bramlage Dual Diagnosis / Co-Occurring Disorders December 6, 2008 Schizophrenia and substance abuse; which came first, the chicken or the egg? This is a greatly debated topic within families of schizophrenics that abuse alcohol.

In this paper I hope to explore the prevalence of substance use with those that suffer from schizophrenia, the age of onset and the age of first use, treatment issues, recovery issues, and finally, the issues regarding the high rate of suicidal thoughts, attempts, and completions within this specific population of individuals. “The 2002 National Survey on Drug Use and Health in the United States found that over 23% of adults suffering from serious mental illness abused alcohol or other drugs.

In the population without a serious mental illness only 8. 2% abused alcohol or other drugs. Among adults who abused alcohol or other drugs, 20. 4% had a serious mental illness” (Cherry, 2007, p. 37). “Over 75% of people with a co-occurring disorder who were surveyed during treatment reported a history of childhood physical abuse” (p. 38). Interestingly enough, surveys have shown that individuals are readily willing to address their substance abuse but are not so willing to acknowledge their co-occurring mental illness (p. 9-50). “The lifetime prevalence of substance use disorders (SUD) in schizophrenia is close to 50%. Substance abuse in schizophrenia is associated with numerous negative consequences, including psychotic relapses criminality, homelessness, unemployment, treatment non-compliance, and health problems” (Potvin, 2007, p. 792). In this population, “substance abuse is highly prevalent” (p. 792) not just used by a few individuals; but people will abuse substances to cope with the negative or positive symptoms of their illness.

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When looking at the symptoms that they experience, Potvin goes on to say, “addicted schizophrenia patients suffer from more severe depressive symptoms, relative to non-abusing patients” (p. 793). Furthermore, the research also shows that males experience the depression more severe than females (p. 797); the depression scale includes anhedonia, psycho motor retardation, etc. (p. 796). Keith goes on to say, “Substance abuse affects approximately half of patients with schizophrenia and can act as a barrier to compliance” (2007, p. 59). “The lifetime prevalence of substance abuse (excluding smoking) in patients with schizophrenia has been estimated to be approximately 35 to 55%” (p. 260). “In addition to experiencing these more severe symptoms, or potentially also as a result, psychosocial problems such as occupational, housing or financial difficulties and crime are endemic in the dual-diagnosis population” Keith asserts (p. 261). When examining the prevalence of the co-occurring disorders, one would be remiss to not identify the etiology of each. It could be tempting to conclude that PAS [psychoactive substances] use exacerbates depressive symptoms in a subgroup of schizophrenia patients, because long-term use of alcohol, cannabis and cocaine is associated with depressive symptoms” (Potvin, 2007, p. 797). Although these assertions may be concluded, it is also important to not “draw inferences about causality, and the reverse explanation cannot be ruled out. That is, severe depressive symptoms may lead patients to use PAS, as proposed by the self-medication hypothesis” (p. 97). “Psychoactive substance use in juveniles and adults is highly correlated with a number of psychiatric diagnoses, including schizophrenia. Young adults with schizophrenia have a 3 times higher prevalence of substance use disorders (SUD’s) than the corresponding age group in the US general population. " (Hsiao, 2007, p. 88). While the amount of research data on this age group is limited due to studies not addressing them, it is difficult to generalize the data collected (p. 88). Alcohol and marijuana were the two most commonly abused agents in our sample. This is consistent with population-based studies of adolescents. The onset of substance use preceded the onset of psychosis in all of our subjects with co-occurring SUD and schizophrenia. Therefore, it is possible that substance abuse precipitated or exacerbated psychosis in these subjects. Epidemiological and neuroscientific evidence suggests that substance abuse, especially cannabis abuse, can precipitate psychosis in vulnerable subjects.

Their sample of 50,413 male adolescents who were suspected of having behavioral problems, Weiser et al. found that adolescents who self-reported abuse of drugs at age 16-17 years were twice as likely to be hospitalized later for schizophrenia” (p. 95). Hsiao goes on to state that, “the onset of substance use preceded their reports of psychotic symptoms in 90% of the cases” (p. 95). In accordance of the research Keith emphasizes that, “the onset of substance abuse often occurs before or around the time of onset of schizophrenia.

In a study in which 232 patients with first episodes of schizophrenia were interviewed, 62% reported that drug abuse began before the onset of schizophrenia symptoms, and 51% said the same of alcohol abuse. Within this population, 34. 6% of drug abuse and 18. 2% of alcohol abuse began within the same month as the onset of schizophrenia symptoms. In addition, patients with schizophrenia are twice as likely to have had a history of substance abuse at the time of the first episode of schizophrenia than are healthy subjects” (p. 260).

Keeping all of these early onset of use issues and early occurrences of the illness in mind there is a tremendous amount of barriers between the individual and their recovery. Next we will explore what issues are barriers to their treatment. “[T]he realization that co-occurring problems are best treated with an integrated approach has only recently been recognized by the treatment community” states Cherry, (p. 38-39). Universal screening is needed but many barriers stand in the way of its implementation, from training time to building an infrastructure of clinicians who support everyone being screened, (p. 9). Ultimately, universal screening is as much about the attitudes of administrators and clinicians as it is about having a reliable and valid screen to identify co-occurring disorders. Nonetheless, a screen that is quickly administered, easy to interpret and takes little or no training to administer can break down many of those barriers. Even though there are barriers to instituting a screening procedure during intake, the importance of screening for concurrent substance abuse and mental health problems is crucial in the effort to provide effective treatment for people with a co-occurring disorder” (p. 0). Potvin reminds us in his research that, “ideally, depressive symptoms would be measured both during the active phase of substance abuse and after a period of drug withdrawal, to determine whether the observed differences reflect the acute effects of PAS or more stable traits” (p. 797). Likewise, “[p]ersons with mental heath or substance abuse disorders may not seek help, at least not in the form of professional treatment (i. e. , psychotherapy, medication), because these treatment options are perceived by the person, family, or social network as inappropriate or undesirable” (Kuppin, 2008, p. 20). Kuppin goes on to say, “[t]hese findings offer important insights for furthering our understanding of how we think about the discrepancy between mental illness and substance abuse prevalence and treatment seeking and adherence” (p. 124). Research echoes with relapse among individuals in this particular population; nonetheless, there are those who investigate options available to improve compliance. “Many patients with schizophrenia may abuse substances for “hedonistic” reasons, while others may use them in an attempt to reduce symptoms or distress.

Alcohol, in particular, can tend to be used more often than illicit drugs, such as opioids or cannabis, though it has also been reported that patients may turn either to alcohol or illicit drugs to alleviate the negative symptoms inadequately treated, or potentially made worse by conventional antipsychotic and the side effect of dysphoria associated with these agents. However, although patients may believe that substance abuse ameliorates symptoms of schizophrenia, data suggest that many of these underlying symptoms may, in fact, be worsened” (Keith, 2007, p. 260).

Therein lies the problem, trying to convince a person that the drug he is using is hurting him, when all he sees is this drug is the only thing that keeps me from hurting myself or others; and in itself that is the lie they tell themselves, they do end up trying to hurt themselves, statistics show it. Additionally, statistics show that non-compliant dual-diagnosed patients account for 57% of hospital readmissions, which is an average of 1. 5 admissions per patient each year (p. 261). “As schizophrenia is a lifelong illness, it requires long term, uninterrupted treatment to optimize outcomes.

The low rate of therapy compliance already associated with schizophrenia can be further compromised when patients are also active substance abusers. Intoxication may impair judgment; reduce motivation to pursue long-term goals and lead to a devaluation of the protection offered by antipsychotic medications, resulting in increased hospital readmissions and significantly more severe symptoms” (p. 262). Treatment is further compromised when a patient does not fully “buy into” his treatment regime and comply with his doctors, counselors, or therapists.

Research shows that several different ways have been developed to try to improve compliance such as pharmacologic methods, case management, and assertive community treatment programs; these do help but improved insight and attitudes about schizophrenia has shown to be most helpful for an individual to take ownership for their recovery. “Moreover, without treatment, many individuals continue to experience several relapses because the untreated disorder is not addressed” (Cherry, 2007, 39). Atypical antipsychotics are recommended for reducing substance abuse in schizophrenia patients and have been shown to be effective in this manner” (Keith, 2007, 259). Studies however do show that those that have developed a strong alliance with their therapist are more likely to comply with a prescribed medication regime (p. 262). Keith additionally adds that, “treatment for persons who have both schizophrenia and substance abuse was evaluated by incorporating cognitive-behavioral drug relapse prevention strategies into a skills training method originally developed to teach social and independent living skills to patients with schizophrenia.

Results demonstrated that participants learned substance-abuse management skills, and that their drug use decreased. Improvements were also noted in medication adherence, psychiatric symptoms and quality of life” (p. 263). All in all, recovery is possible for the dual-diagnosed patient, but long term treatment and persistence is required; studies have shown that most individuals experience a long line of relapses and several suicidal attempts before fully embracing recovery. Although it is an ugly part of recovery for many of those with schizophrenia, suicidal thoughts and attempts are common. [S]uicide accounts for approximately10-20% of patient deaths in schizophrenia. In this context, the identification of factors contributing to depression in schizophrenia may have implications for the prevention and treatment of these symptoms” (Potvin, 2007, 793). Research has shown that this particular population is at an increased risk after being prescribed clozapine or olanzapine and they are currently abusing substances; likewise an increased awareness needs to be made by those working with these individuals to identify and screen for the suicidal ideation (Keith, 2007, p. 61). In conclusion, the prevalence of schizophrenia and substance abuse is great in this country; as well as the age of onset of symptoms and age of first use. Individual treatment issues as well as recovery issues can act as a barrier to one achieving recovery. Although recovery has been shown to be attainable, suicidal thoughts and attempts can be a major deterrent to many individuals experiencing it; through increased compliance via pharmacological services, case management or other methods, individuals can see it.

So, schizophrenia or substance abuse; which came first, the chicken or the egg? I’ll let you decide; personally I will work in the framework of integrated treatment and work with the co-occurring disorder. References Cherry, A. L. , Dillon, M. E. , Hellman, C. M. ,  & Barney, L. D. (2007). The AC-COD Screen: Rapid Detection of People with the Co-Occurring Disorders of Substance Abuse, Mental Illness, Domestic Violence, and Trauma. Journal of Dual Diagnosis*, [No Volume/Issue], 35-53. Academic Search Complete. Ebsco Host.

OSU/Lima Campus Lib. , Lima, OH. 10 October 2008 . Hsiao, R. , &  McClellan, J. (2007). Substance Abuse in Early Onset Psychotic Disorders. Journal of Dual Diagnosis*, [No Volume/Issue], 87-99. Academic Search Complete. Ebsco Host. OSU/Lima Campus Lib. , Lima, OH. 10 October 2008 . Keith, S. (2007). Dual Diagnosis of Substance Abuse and Schizophrenia: Improving Compliance with Pharmacotherapy. Clinical Schizophrenia & Related Psychoses, 1(3), 259-269. Academic Search Complete. Ebsco Host. OSU/Lima Campus Lib. , Lima, OH. 10 October 2008 .

Kuppin. (2008). Public Conceptions of Serious Mental Illness and Substance Abuse, Their Causes and Treatments: Findings from the 1996 General Social Survey. American Journal of Public Health, 96(10), S120. Academic Search Complete. Ebsco Host. OSU/Lima Campus Lib. , Lima, OH. 10 October 2008 . Potvin. (2007). Meta-analysis of depressive symptoms in dual-diagnosis schizophrenia. Australian and New Zealand Journal of Psychiatry, 41(10), 792-799. Academic Search Complete. Ebsco Host. OSU/Lima Campus Lib. , Lima, OH. 10 October 2008 .

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