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Clinical Aspects of Substance Abuse in Persons With Schizophrenia
Phenomenology
It seems well established now that, when they coexist, both addiction and schizophrenia present a more problematic clinical picture with a less favourable outcome, compared with their occurence in isolation. Substance-abusing schizophrenia sufferers fare more poorly than their nonabusing counterparts in just about every clinical parameter or measure. Similarly, when compared with addiction patients who do not suffer from psychosis, addiction patients with chronic psychosis are known to experience considerably more difficulties in terms of psychosocial consequences, access to treatment, and therapeutic response.
Some features that characterize the clinical picture of schizophrenia when it co-occurs with substance abuse are as follows:
1. Earlier outbreak of psychotic symptoms. This finding is consistent across many clinical surveys (1). On average, schizophrenia sufferers with a lifetime history of substance use disorders come to the attention of psychiatric services several years earlier than do those without such history. Of course, it is quite probable that toxic prompting accelerates the clinical manifestation of the psychotic illness. However, the significant association brought to light by these surveys could also be caused by a heightened proclivity to use drugs among individuals with more rapidly developing psychosis.
2. More severe productive symptoms. This is another undisputed finding recorded in a wide variety of studies. When compared with single-diagnosis schizophrenia patients, individuals with dual disorders are more likely to engage in violent behaviour (22). In fact, comorbid substance abuse explains most of the variance in violent occurrences between schizophrenia sufferers and control subjects without psychosis (23). Substance abuse is associated also with higher positive-symptom scores; particularly in regard to delusional and hallucinatory disturbances (24,25).
3. Poorer therapeutic response and less favourable course of illness. Several studies have shown that substance-abusing schizophrenia patients do not benefit from treatment as much as their nonabusing counterparts (1,26). Their remission rates are lower, their psychotic symptoms recur more readily, they require more inpatient treatment, their employment record is poorer, they tend to receive more welfare assistance, their housing and accommodations pattern is more unstable, and they make more visits to the emergency room. All this occurs in the context of a lesser observance of treatment programs, for they also tend to miss more clinic appointments and day- program sessions and to comply less with the prescribed pharmacotherapy (27).
4. Less severe negative symptoms? Some clinical research findings suggest this feature, but it is not as well established an observation as are the previous ones. Some authors have found a negative linear correlation between amount of cannabis use and negative-symptom scores (28). A similar finding emerged in a clinical survey conducted by the present author, but the significant difference was seen only in patients aged 35 years or under. The negative-symptom ratings did not seem to be influenced by drug use status in the older subjects with chronic psychosis (29). Perhaps the greater severity of negative symptoms characteristic of the more advanced illness stages causes a “ceiling effect,” whereby the assessment instruments are no longer able to detect differences between older-aged comparison groups.
Other authors have reported that persons with schizophrenia who use drugs present a more functional premorbid personality and appear to be have better interpersonal skills than do those in the nonusing comparison group (30). However, this observation was reported in a sample of patients who were mostly using cocaine—a group likely to have been preselected for better social efficacy, because cocaine is considerably more difficult to procure than alcohol, nicotine, or even cannabis.
The psychotic comorbidity confers some peculiar characteristics on the picture of addiction and has a significant negative impact on its clinical management:
1. Chaotic, polymorphous, and opportunistic substance abuse. In addition to the most frequently abused substances (nicotine, alcohol, and cannabis) (5), many persons with schizophrenia misuse drugs that are rather unknown outside the clientele of psychiatric services; for instance, the anticholinergic agents prescribed to treat EPSEs. They also resort to over-the-counter preparations such as cough and decongestant syrups, which contain codeine, other opioids, or sympathomimetic stimulants. Many of these patients can only afford to use drugs when they receive their monthly allowance or when they obtain them from someone else. This results in intermittent heavy binges, often with acute consequences that require immediate intervention (that is, emergency room visits). It is not uncommon for these patients to take whatever substance is available to them, without discrimination.
2. Limited motivation. Because of the rather deprived and simple existence they lead, many of these patients see little need to significantly change their habits. They do not readily see substance abuse as threatening their quality of life or as impeding their pursuit of personal goals (31).
3. Limited access to treatment. Patients with psychosis are often deemed ineligible for admission into addiction-treatment programs, most of which have no psychiatric resources or input. Even if accepted, however, these patients are not well served in time-limited programs that rely heavily on intensive and indiscriminate group interventions, because such traditional addiction services are clearly unable to attend to the dual pathology. Conversely, most continuing care psychiatric services, where most of these patients are usually seen, do not adequately treat the addiction problem. In fact, the substance use disorder often remains totally untreated (32).
Treatment Programs
It is now generally accepted that substance use disorders in those with chronic psychosis cannot be properly treated using a parallel approach, wherein each disorder is dealt with separately by 2 different care systems. There is a growing awareness of the need to integrate treatment within a single, comprehensive program that offers patients with dual disorders all the therapy they need from care providers who are properly qualified to attend to both the addiction and the psychiatric illness. Given the multiple and special needs of patients with chronic psychosis, it is rather obvious that such combined treatment programs can only be set up within psychiatric services, particularly services that offer long-term, continuing care (32,33).
This integrated approach has already been tested through randomized controlled studies (34,35) and found to be superior to standard treatments in most outcome measures: there is better participation and treatment retention, less drug and alcohol use, higher quality-of-life scores, more stable housing, and higher ratings in general levels of functioning.
The essential elements of a well-organized integrated therapy program include open-ended continuity of care; assertive case management; on-site addiction treatment, including specialized pharmacotherapy; psychiatric therapy that is mindful of the addiction comorbidity; supervised, safe housing; and occupational and work rehabilitation.
The better-designed programs provide the resources necessary to attend to dual-pathology patients through all the contingencies of their condition: acute detoxification and psychiatric stabilization inpatient services when necessary; longer-term residential rehabilitation for selected patients in a therapeutic community model, with adequate psychiatric monitoring and care; and continuing ambulatory treatment, the mainstay of the program. A dual-disorder program is best understood in terms of phases:
1. Engagement. the initial period, in which the main goal is to secure a stable and persisting affiliation with the program, regular attendance, compliance with the essential requirements, and a minimum degree of participation. This phase could last for months or years, and it is important to keep in sight the primary goals, even at the expense of tolerating the patient’s initial lack of readiness to address the substance abuse problem. The following is an example of the therapy curriculum at this early stage:
proactive case management in-depth assessment of psychiatric and addiction status fine-tuned psychiatric pharmacotherapy adapted health education positive reinforcement (rewards) for participation control over social support family intervention an accessible recreational or leisure management program contingencies
2. Persuasion. In this second phase, well-engaged patients are exposed to ongoing motivational therapies at different levels, both individually with the case manager and in “dual problem” group discussions. The goal at this point is to help patients better understand their particular substance abuse problems and set goals for therapy. Ideally, the work in this phase leads to the patient’s accepting addiction therapy. Some intervention modalities in this phase are as follows:
continuing monitoring of the patient’s psychiatric and addiction condition, including longitudinal charting of crises and treatment events (for example, adapted health records, monthly Addiction Severity Index [ASI] scoring [36], timeline follow-back record [37], and urine toxicology screening) drug and mental illness education for patients and significant others social-skills training (38) systematic motivational enhancement work (39) introduction of “maintenance and change” program tracks
3. Active addiction treatment. In this phase, the therapeutic activities involve patients who have opted for effecting the necessary changes in their alcohol and drug habits and see themselves as needing therapy for that specific purpose. To that end, the program could offer the following interventions:
stabilization and detoxification optimized psychiatric and addiction pharmacotherapy continuous clinical and laboratory monitoring psychiatric case management, individual addiction counselling, and housing and social support control family intervention goal setting and a scaled goal-attainment reward program dual-diagnosis cognitive-behavioural therapy (CBT) sessions (40) dual-diagnosis social-skills training (41) peer support and 12-step program integration prevocational counselling and work placement support
4. Maintenance and relapse prevention phase. Both schizophrenia and addiction are chronic disorders that require continuous, open-ended treatment. Of course, treatment intensity and the frequency of contacts can be considerably scaled back once the patient has shown steady remission. However, the program must always provide the conditions for easy reentry into active care if patients are either lapsing or fully relapsed. In fact, the most likely treatment course is one of repeated interventions over time, and the occasional readmission should be seen as the norm. The following are examples of curriculum components in the program designed to help maintain change and avoid full relapse:
continuing individual case management, with close monitoring of occupational and leisure activities and housing conditions appropriate long-term pharmacotherapy emergency plan to be observed by patients, next of kin, and program staff in case of relapse time-limited relapse prevention therapy sessions (that is, periodic reinforcement) open-ended, therapist-led support sessions continuing participation in a peer-support group
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