Subjective experiences related to alcohol use among schizophrenics

Antipsychotic medication-induced dysphoria: its meaning, association with typical vs. atypical medications and impact on adherence

Antipsychotic medication-induced dysphoria is a relatively under-recognized and understudied effect of antipsychotic medication. Although the term is encountered in clinical practice and in the literature, there is no consensus regarding its exact meaning. This article is a narrative review of the literature on antipsychotic medication and dysphoria based on a pubmed database search. We found that antipsychotic medication-induced dysphoria is a term used to describe a negative and unpleasant affective state which seems to be more often associated with high potency first-generation antipsychotics and could potentially lead to medication non-adherence. Though it is plausible to expect antipsychotic medication-induced dysphoria to be related to extrapyramidal symptoms, most especially akathisia, the nature of the association remains unspecified. Furthermore, there is some evidence that dopamine blockade maybe involved in the pathogenesis of antipsychotic medication-induced dysphoria. However, the limited methods of the currently available studies make it impossible to conclusively address the question of which class of antipsychotic (first- or second-generation) has a higher prevalence and severity of the syndrome.

An Intervention for Substance Abuse in Schizophrenia

Substance abuse in schizophrenia is a significant management problem for both clients and treatment agencies, impacting on psychotic symptoms, medication adherence, and participation in training and employment. However, there is little published work on the treatment of drug abuse in this population. This paper describes a cognitive-behavioural intervention for alcohol and cannabis abuse which integrates substance abuse treatment with other aspects of psychosis management.

Impact of substance use disorder on presentation and short-term course of schizophrenia

The aim of the present study was to compare a cohort of schizophrenia patients with substance use disorder (SUD) with a similar cohort of schizophrenia patients without SUD with regard to sociodemographic variables, clinical variables, psychopathology, anxiety symptoms, depressive symptoms, treatment outcome, and side effect profile of drugs. A total of 143 consecutive inpatients with ICD-10 DCR diagnosis of schizophrenia were included after obtaining informed consent. Patients were evaluated by a semistructured data sheet and Maudsley Addiction Profile. They were then rated by Positive and Negative Symptoms Scale, Calgary Depression Scale, Hamilton Anxiety Rating Scale, and Brief Psychiatric Rating Scale at presentation, three weeks, and six weeks. At three weeks and six weeks, they were also evaluated by UKU Side Effect Rating Scale. Substance abuse was detected in 63.6% schizophrenia patients. Nicotine was the commonest substance followed by cannabis and alcohol. Substance users had longer untreated illness and more depressive symptoms at presentation and six-week follow-up. Dual diagnosis patients had difficulty in abstraction at three and six weeks but not at presentation. Schizophrenia patients with SUD had more depressive symptoms. SUD appeared to mask abstraction difficulties at presentation. Schizophrenia patients with SUD should be carefully assessed for presence of depression.

Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA's Clinical Trials Network

OBJECTIVE

The purpose of the analysis was to examine the temporal course of improvement in symptoms of posttraumatic stress disorder (PTSD) and substance use disorder among women in outpatient substance abuse treatment.

METHOD

Participants were 353 women randomly assigned to 12 sessions of either trauma-focused or health education group treatment. PTSD and substance use assessments were conducted during treatment and posttreatment at 1 week and after 3, 6, and 12 months. A continuous Markov model was fit on four defined response categories (nonresponse, substance use response, PTSD response, or global response [improvement in both PTSD and substance use]) to investigate the temporal association between improvement in PTSD and substance use symptom severity during the study's treatment phase. A generalized linear model was applied to test this relationship over the follow-up period.

RESULTS

Subjects exhibiting nonresponse, substance use response, or global response tended to maintain original classification; subjects exhibiting PTSD response were significantly more likely to transition to global response over time, indicating maintained PTSD improvement was associated with subsequent substance use improvement. Trauma-focused treatment was significantly more effective than health education in achieving substance use improvement, but only among those who were heavy substance users at baseline and had achieved significant PTSD reductions.

CONCLUSIONS

PTSD severity reductions were more likely to be associated with substance use improvement, with minimal evidence of substance use symptom reduction improving PTSD symptoms. Results support the self-medication model of coping with PTSD symptoms and an empirical basis for integrated interventions for improved substance use outcomes in patients with severe symptoms.

Substance dependence and remission in schizophrenia: A comparison of schizophrenia and affective disorders

The present study examined psychiatric functioning, substance use and consequences, and motivation to change in people with schizophrenia and affective disorders and current or remitted cocaine dependence. Data were collected as part of a naturalistic, longitudinal study examining substance use, motivation to change, and the process of change in people with schizophrenia and affective disorders who were currently dependent or in remission from cocaine dependence. We examined the following questions: (1) Do those in remission show better psychiatric functioning than those who are currently dependent? (2) How do people with schizophrenia and current cocaine dependence differ in terms of substance use and consequences from people with schizophrenia in remission and people with affective disorders and current drug dependence? (3) What internal factors and external factors are associated with changes in substance use in schizophrenia and how do these compare to those in nonpsychotic affective disorders? Results indicated that people with schizophrenia and current dependence reported higher levels of positive and negative symptoms than those in remission. Remission status was related to less use of other drugs, fewer days of drug problems, less distress from drug problems, and more lifetime drug-related consequences. Those with current dependence reported more days of drinking and drinking to intoxication, as well as higher rates of current alcohol use disorders than the remitted group. When compared to those with affective disorders and cocaine dependence, those with schizophrenia and current dependence reported fewer days of problems associated with their drug use, less distress from drug problems, and fewer recent and lifetime consequences associated with their drug use. The schizophrenia dependent group generally showed the lowest readiness to change, fewest efforts being made to change, and lowest confidence in the ability to change. Implications of these findings are discussed.

Alcohol expectancies and drinking motives in college drinkers: Mediating effects on the relationship between generalized anxiety and heavy drinking in negative-affect situations

The current study tested the hypotheses that drinking to cope motives and alcohol expectancies of tension- and worry-reduction mediate the relationship between generalized anxiety (GA) and negative-affect heavy drinking in a cross-sectional sample of 782 college drinkers. As expected, structural equation modeling results indicated that alcohol expectancies mediated the relationship between GA and drinking to cope motives, and drinking to cope motives mediated the relationship between alcohol expectancies and heavy drinking in negative-affect situations. Unexpectedly, drinking to cope motives also mediated the relationship between GA and negative-affect heavy drinking. The model predicting negative-affect heavy drinking was tested in subsamples of 413 hazardous and 366 nonhazardous drinkers and did not differ structurally; however, omnibus measurement of model indirect effects was stronger for hazardous than nonhazardous drinkers. Finally, the results of a similar post-hoc model to predict general problem drinking support the specificity of the interrelationships among GA, cognitive mediators and to negative-affect drinking. These results inform cognitive-behavioral theories and interventions for comorbid GA and alcohol use problems.

Models of co-occurring substance misuse and psychosis: are personality traits the missing link?

Traditional models of co-occurring substance misuse in psychosis, including the vulnerability and coping (self-medication) hypotheses, have tended to focus on state-specific factors, such as the severity of substance misuse or psychotic symptoms. In contrast, more recent personality models posit that co-morbidity is related to individual differences in stable trait-specific personality variables that underlie affective outcomes, coping strategies and subsequent risk for substance use. This paper reviews the current evidence base for these three models, and suggests that future research examine the inter-relationships between trait and state-specific personality, affective and behavioural variables on co-morbidity.

Substance use in severe mental illness: self-medication and vulnerability factors

The aim of this article is to examine the onset and clinical correlates of substance use in patients with psychotic disorders. One hundred and eight inpatients and outpatients with DSM-IV psychotic disorders were evaluated with the SCI-SUBS, an instrument designed to explore the spectrum of substance use and its clinical correlates. Comparisons were made between subjects with (n=47) and without (n=61) a DSM-IV diagnosis of substance use disorder (SUD). In patients with an early onset of psychosis (<17 years), the onset of SUD was subsequent. Patients with SUD had higher substance sensitivity, higher sensation-seeking traits and were more likely to self-medicate than patients without SUD. The reasons for self-medication endorsed by patients with SUD included relieving depression, achieving or maintaining euphoria, improving self-confidence and social abilities. Our results, based on a cross-sectional study, suggest that early onset of psychosis, substance sensitivity and sensation-seeking traits represent vulnerability factors for SUD. The relationships between SUD and psychosis should be examined systematically and clarified in longitudinal studies.

Reasons for cannabis use: patients with schizophrenia versus matched healthy controls

OBJECTIVE

The aim of the present study was to compare self-reported reasons for cannabis use in patients with schizophrenia with those of matched healthy controls.

METHODS

Thirty-six stable outpatients with schizophrenia treated with atypical antipsychotics and 36 matched controls were included. They completed a questionnaire exploring 15 common reasons for use, established in other studies. results: Overall, patients more frequently agreed with the proposed reasons for use than controls. More specifically, patients with schizophrenia more often stated that they consumed cannabis to fight boredom and to ease social contacts.

CONCLUSIONS

Stable schizophrenia outpatients treated with atypicals do not use cannabis in order to reduce side-effects of medication or symptoms of their disorder. Rather, they used cannabis to overcome a feeling of social exclusion. Therefore, enhancing social participation of cannabis-using patients might be an effective strategy for reducing consumption.

Enhanced sensitivity to the euphoric effects of alcohol in schizophrenia

The purpose of this study was to determine whether schizophrenia was associated with alterations in alcohol response that might explain the elevated risk for AUDs in this population. In a randomized, double-blind, placebo-controlled, counter-balanced 3 test day laboratory study, the effects of alcohol were compared in 23 subjects with schizophrenia (without any previous alcohol use disorder (AUD) but with some alcohol exposure) and in 14 healthy subjects matched for age, gender, education, and lifetime exposure to alcohol. Standard alcohol drinks in a scheduled design were administered to produce blood alcohol levels of 0, 0.02-0.04 mg%, or 0.06-0.08 mg%. Schizophrenia symptoms, perceptual alterations, stimulant and depressant subjective effects of alcohol, and 'high' were measured before alcohol administration and at several post-drug time points. Verbal learning and recall, vigilance and distractibility, and motor function were assessed once per test day. Relative to healthy subjects, subjects with schizophrenia reported greater euphoria and stimulatory effects in response to alcohol. Alcohol produced small transient increases in positive psychotic symptoms and perceptual alterations without affecting negative symptoms. Alcohol also impaired several aspects of immediate and delayed recall, and vigilance, and distractibility. Schizophrenia patients showed increased euphoric and stimulatory responses to alcohol. These exaggerated positive responses to alcohol doses may contribute to the increased risk for AUDs associated with schizophrenia. The absence of 'beneficial' effects of alcohol does not support a self-medication hypothesis of alcohol use in schizophrenia.

Is cannabis use a contributory cause of psychosis?

OBJECTIVE

To assess whether cannabis use in adolescence and young adulthood is a contributory cause of schizophreniform psychosis in that it may precipitate psychosis in vulnerable individuals.

METHOD

We reviewed longitudinal studies of adolescents and young adults that examined the relations between self-reported cannabis use and the risk of diagnosis with a psychosis or of reporting psychotic symptoms. We also reviewed studies that controlled for potential confounders, such as other forms of drug use and personal characteristics that predict an increased risk of psychosis. We assessed evidence for the biological plausibility of a contributory causal relation.

RESULTS

Evidence from 6 longitudinal studies in 5 countries shows that regular cannabis use predicts an increased risk of a schizophrenia diagnosis or of reporting symptoms of psychosis. These relations persisted after controlling for confounding variables, such as personal characteristics and other drug use. The relation did not seem to be a result of cannabis use to self-medicate symptoms of psychosis. A contributory causal relation is biologically plausible because psychotic disorders involve disturbances in the dopamine neurotransmitter systems with which the cannabinoid system interacts, as demonstrated by animal studies and one human provocation study.

CONCLUSION

It is most plausible that cannabis use precipitates schizophrenia in individuals who are vulnerable because of a personal or family history of schizophrenia.

Cannabis use and psychosis

This paper reviews evidence on two hypotheses about the relationship between cannabis use and psychosis. The first hypothesis is that heavy cannabis use may cause a "cannabis psychosis"-a psychosis that would not occur in the absence of cannabis use, the symptoms of which are preceded by heavy cannabis use and remit after abstinence. The second hypothesis is that cannabis use may precipitate schizophrenia, or exacerbate its symptoms. Evaluation of these hypotheses requires evidence of an association between cannabis use and psychosis, that is unlikely to be due to chance, in which cannabis use precedes psychosis, and in which we can exclude the hypothesis that the relationship is due to other factors, such as other drug use, or a personal vulnerability to psychosis. There is some clinical support for the first hypothesis. If these disorders exist they seem to be rare, because they require very high doses of THC, the prolonged use of highly potent forms of cannabis, or a pre-existing (but as yet unspecified) vulnerability. There is more support for the second hypothesis, in that a large prospective study has shown a linear relationship between the frequency with which cannabis has been used by age 18 and the risks over the subsequent 15 years of a diagnosis of schizophrenia. It is still unclear whether this means that cannabis use precipitates schizophrenia, whether it is a form of "self-medication", or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is stronger evidence that cannabis use can exacerbate the symptoms of schizophrenia. Mental health services should identify patients with schizophrenia who use alcohol, cannabis and other drugs and advise them to abstain or to greatly reduce their drug use.

Treatment of substance use disorders in schizophrenia: a unifying neurobiological mechanism?

Substance use disorders (SUDs) are highly prevalent and are associated with poor outcomes among individuals with schizophrenia. Integrating treatments for both disorders improves outcomes. Numerous individual pharmacologic and psychosocial treatments have shown effectiveness at reducing substance use in individuals with a primary diagnosis of schizophrenia and co-occurring substance use disorders. Of these treatments, medications such as certain atypical antipsychotics and naltrexone, and psychosocial treatments such as contingency management, seem to be particularly promising. The development and evaluation of psychopharmacologic and psychosocial treatments for SUDs in schizophrenia would benefit from a better understanding of the neurobiological mechanisms underlying the effectiveness of such treatments. Several theories have been put forth to explain the heightened risk for SUDs in schizophrenia. Of these, brain reward circuitry dysfunction, hypothesized to be etiologically important in SUDs, may be an especially salient target for treatments aimed at the reduction of substance use in patients with schizophrenia. We review current pharmacologic and psychosocial treatments for SUDs in schizophrenia, and theoretical mechanisms underlying the increased risk for SUDs in this population. We propose that effective treatments may in part work through the modulation of brain reward circuitry dysfunction.

A Critical Look at Dual-Focused Cognitive-Behavioral Treatments for Comorbid Substance Use and Psychiatric Disorders: Strengths, Limitations, and Future Directions

Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere.

Subjective experiences on antipsychotic medications: synthesis and conclusions

OBJECTIVE

This report synthesizes the literature describing the phenomenology, clinical importance and biology of subjective responses to antipsychotic medications in schizophrenia. A patient's experience of an antipsychotic is important because unpleasant or dysphoric responses can impair therapeutic relationships, lead to medication non-adherence, and have direct negative effects on a patient's quality of life.

METHOD

The author selectively reviewed early studies of subjective responses to antipsychotics and integrated this literature with the work of the other investigators in this special section.

RESULTS

There is substantial evidence that second-generation antipsychotics have advantages in causing fewer dysphoric responses when compared with first-generation agents. Clinical and neuroimaging studies suggest that dopamine blockade is an important determinant of many of these dysphorias. At this point in time it is unclear whether dysphoria results from extrapyramidal symptoms--particularly akathisia and akinesia--or whether they are a direct result of decreased dopamine activity.

CONCLUSION

Clinicians and researchers should continue to monitor dysphorias in schizophrenia. Contributions by the authors in this supplement provide new and more refined methods for measuring subjective responses in future studies.

Cannabis use predicts future psychotic symptoms, and vice versa

AIMS

To assess if cannabis use is a risk factor for future psychotic symptoms, and vice versa, in adolescents and young adults from the general population.

DESIGN

Cohort study.

SETTING/PARTICIPANTS

'Zuid Holland' study, a 14-year follow-up study of 1580 initially 4-16-year-olds who were drawn randomly from the Dutch general population. Because cannabis use is generally condoned in the Netherlands, false-negative reports of cannabis use may occur less frequently than in countries with stricter drug policies, which supports the value of the present study.

MEASUREMENTS

Life-time cannabis use and psychotic symptoms, assessed with the Composite International Diagnostic Interview (CIDI).

FINDINGS

Cannabis use, in individuals who did not have psychotic symptoms before they began using cannabis, predicted future psychotic symptoms (hazard ratio = 2.81; 95% confidence interval = 1.79-4.43). However, psychotic symptoms in those who had never used cannabis before the onset of psychotic symptoms also predicted future cannabis use (hazard ratio = 1.70; 95% confidence interval = 1.13-2.57).

CONCLUSIONS

The results imply either a common vulnerability with varying order of onset or a bi-directional causal relationship between cannabis use and psychosis. More research on patterns and timings of these relationships is needed to narrow down the possibilities.

Cannabis use and psychotic disorders: an update

This paper evaluates three hypotheses about the relationship between cannabis use and psychosis in the light of recent evidence from prospective epidemiological studies. These are that: (1) cannabis use causes a psychotic disorder that would not have occurred in the absence of cannabis use; (2) that cannabis use may precipitate schizophrenia or exacerbate its symptoms; and (3) that cannabis use may exacerbate the symptoms of psychosis. There is limited support for the first hypothesis. As a consequence of recent prospective studies, there is now stronger support for the second hypothesis. Four recent prospective studies in three countries have found relationships between the frequency with which cannabis had been used and the risk of receiving a diagnosis of schizophrenia or of reporting psychotic symptoms. These relationships are stronger in people with a history of psychotic symptoms and they have persisted after adjustment for potentially confounding variables. The absence of any change in the incidence of schizophrenia during the three decades in which cannabis use in Australia has increased makes it unlikely that cannabis use can produce psychoses that would not have occurred in its absence. It seems more likely that cannabis use can precipitate schizophrenia in vulnerable individuals. There is also reasonable evidence for the third hypothesis that cannabis use exacerbates psychosis.

Severely mentally ill consumers' perspectives on drug use

Substance use disorders have serious negative consequences for severely mentally ill (SMI) adults, but many do not receive adequate substance abuse treatment. As part of a larger project on access barriers to substance abuse treatment for SMI clients, this qualitative study examined two potential client-level barriers to treatment: minimization of drug problems and perceived acceptability of drug use to reduce psychiatric symptoms. Open-ended interviews about drug use were conducted with 24 SMI adults with substance use problems. The majority of respondents identified drug use as a major problem in their lives. Respondents were aware of the impact of drugs on psychiatric symptoms, and most believed that the negative effects of drug use outweighed any short-term benefits. Nearly all respondents believed it was not acceptable for SMI adults to use drugs except marijuana. Contrary to findings in the literature that SMI adults deny or minimize drug problems, most respondents acknowledged the seriousness of their drug use, were aware of the negative effects of drug use on their psychiatric symptoms, and endorsed abstinence as the optimal treatment goal. These findings have implications for substance abuse treatment for SMI clients, particularly interventions that emphasize education about drug use as a way to increase motivation for treatment.

Measuring the emergence of tobacco dependence: the contribution of negative reinforcement models

This review of negative reinforcement models of drug dependence is part of a series that takes the position that a complete understanding of current concepts of dependence will facilitate the development of reliable and valid measures of the emergence of tobacco dependence. Other reviews within the series consider models that emphasize positive reinforcement and social learning/cognitive models. This review summarizes negative reinforcement in general and then presents four current negative reinforcement models that emphasize withdrawal, classical conditioning, self-medication and opponent-processes. For each model, the paper outlines central aspects of dependence, conceptualization of dependence development and influences that the model might have on current and future measures of dependence. Understanding how drug dependence develops will be an important part of future successful tobacco dependence measurement, prevention and treatment strategies.

Psychopharmacology of substance misuse and comorbid psychiatric disorders

The common occurrence of comorbid substance misuse and other psychiatric disorders has challenged the diagnostic and therapeutic skills of professionals concerned with the care of patients with these dual disorders. Combined pharmacological and psychological treatment approaches have evolved empirically drawing upon standard treatments with emphasis on psychosocial approaches to substance misuse for psychotic disorders and pharmacological approaches for mood disorders. Advances in the biology of both disorders have started to inform their psychopharmacology. The specific role of atypical antipscychotics is highlighted. Further studies of the biology of comorbidity will impact the use of effective pharmaceuticals such as clozapine with dual effects on schizophrenia and substance misuse.

Clinical interventions for severe mental illness and co-occurring substance use disorder

In order to more effectively treat substance use disorders in persons with severe mental illness, integrated treatment models have been developed for these 'co-occurring disorders.' The nature of clinical services provided in these programs is described in this article, with brief attention to research on these programs. Clinical services are generally guided by a stage model of change, in which the client's motivation to change (or stage of treatment: engagement, persuasion, active treatment, relapse prevention) informs the optimal selection of appropriate interventions. Psychotherapeutic services for co-occurring disorders include a range of individual (motivational interviewing, cognitive-behavioral counseling), group (stage-wise groups, social skills training, self-help), and family (single family, multifamily formats) interventions. Supplementary interventions are also commonly provided, including psychopharmacological, residential, coerced and involuntary, and vocational rehabilitation. Access to a range of different interventions for co-occurring disorders may improve the ability of clinicians to engage and tailor treatment to meet clients' unique needs. The research base supporting integrated treatment for co-occurring disorders is limited at this time owing to the small number of methodologically rigorous studies from which to draw conclusions. Nevertheless, the available evidence suggests that integrated treatment programs improve outcomes compared with nonintegrated approaches, and that more research is needed to evaluate the benefits of these programs.

How we do it: alcohol awareness group in the acute setting

This article highlights the need to provide interventions to those with mental health problems who also use alcohol or illicit substances. It identifies a group‐work package that aims to increase individuals' awareness of their use of substances, the impact this use may have upon their mental health and encourages a change in their behaviour to reduce the risk of alcohol or illicit drug related harm.

A family intervention program for dual disorders

OBJECTIVE

To provide a rationale for working with families of clients with psychiatric and substance use disorder, and to describe a new program, family intervention for dual disorders (FIDD).

METHOD

We developed and manualized the FIDD program, which includes both single-family and multiple-family group formats. We trained several clinicians at a local mental health center in the model and conducted a small pilot study.

RESULTS

Clinicians were able to implement the program, and to successfully engage families in treatment. Most clients demonstrated significant improvements in substance abuse over one to two years of treatment.

CONCLUSIONS

The FIDD program is feasible and appears to promote collaboration between families and professionals, thereby improving the course of dual disorders. Controlled research is underway to evaluate the effects of the FIDD program on client and family outcomes.

Psychosocial aspects of substance abuse by clients with severe mental illness

As the literature on co-occurring substance abuse in persons with severe mental illnesses has evolved, emphasis on biologic and pharmacologic factors has diverted attention from important psychosocial issues. The authors review recent research showing that a) psychosocial risk factors may explain consistently high rates of substance abuse by these persons, b) substance abuse is for most clients a socio-environmental phenomenon embedded in interpersonal activities, and c) both natural recovery processes and effective treatments rely on developing new relationships, activities, coping strategies, and identities. Thus, psychosocial issues are critical in our attempts to understand and address substance abuse in this population.

Insomnia, self-medication, and relapse to alcoholism

OBJECTIVE

This study was an investigation of the frequencies of insomnia and its self-medication with alcohol in a group of alcoholic patients, as well as the relationship of these variables to alcoholic relapse.

METHOD

The subjects were 172 men and women receiving treatment for alcohol dependence. They completed a sleep questionnaire, measures of alcohol problem severity and depression severity, and polysomnography after at least 2 weeks of abstinence.

RESULTS

On the basis of eight items from the Sleep Disorders Questionnaire, 61% of the subjects were classified as having symptomatic insomnia during the 6 months before treatment entry. Compared to patients without insomnia, patients with insomnia were more likely to report frequent alcohol use for sleep (55% versus 28%), had significantly worse polysomnographic measures of sleep continuity, and had more severe alcohol dependence and depression. Among 74 alcoholics who were followed a mean of 5 months after treatment, 60% with baseline insomnia versus 30% without baseline insomnia relapsed to any use of alcohol, a significant difference. Insomnia remained a robust predictor of relapse after application of logistic regression analysis to control for other variables. A history of self-medicating insomnia with alcohol did not significantly predict subsequent relapse.

CONCLUSIONS

The majority of alcoholic patients entering treatment reported insomnia symptoms. Given the potential link between insomnia and relapse, routine questions about sleep in clinical and research settings are warranted.

When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders

Substances such as alcohol, cocaine, amphetamine, and cannabis can produce psychotic reactions in individuals who are otherwise free of serious mental illness. However, persons with primary psychotic disorders, such as schizophrenia and bipolar disorder, who use these substances often present for treatment with signs and symptoms similar to those whose psychosis resulted from the use of drugs alone. While it is often difficult to distinguish substance-induced from primary psychoses, especially early in the course of treatment, this differential diagnosis has important implications for treatment planning. To help clinicians distinguish these two types of presentations, the authors first review the types of psychotic symptoms that can co-occur with substance use. They discuss the prevalence and patterns of substance use that have been found in patients with schizophrenia and other primary psychotic disorders and review the negative outcomes associated with substance use in this population. The prevalence of and types of symptoms and problems associated with psychotic symptoms that occur as a result of substance use alone are also reviewed. The authors describe assessment procedures for differentiating substance-induced and primary psychotic disorders. They stress the importance of accurately establishing the temporal relationship between the substance use and the onset and continuation of psychotic symptoms in making a differential diagnosis, as well as the importance of being familiar with the types of psychological symptoms that can occur with specific substances. The authors review the utility and limitations of a number of diagnostic instruments for assessing patients with co-occurring psychosis and substance use problems, including The Addiction Severity Index, The Michigan Alcohol Screening Test, and diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM. They then discuss the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), an instrument that has been developed to address the lack of a diagnostic interview that is suitable for assessing the comorbidity of substance use and psychiatric disorders. The article concludes with a discussion of the importance of an appropriate match between diagnosis and treatment and the current state of our knowledge concerning the most appropriate types of treatment interventions for patients with substance-induced psychosis and those with dual diagnoses.

Cannabis, vulnerability, and the onset of schizophrenia: an epidemiological perspective

OBJECTIVE

Second to alcohol, cannabis is the most frequently misused substance among patients with schizophrenia. The aim of this paper is to examine at early onset of psychosis whether the high comorbidity of schizophrenia and cannabis abuse is due to a causal relationship between the two disorders. Previous studies have mostly included chronic patients or samples with mixed stages of the psychotic illness.

METHOD

In a German catchment area with a population of 1,500,000, a representative first-episode sample of 232 patients with schizophrenia was included in the Age, Beginning and Course of Schizophrenia Study. By means of a structured interview, the Retrospective Assessment of the Onset of Schizophrenia, the onset and course of schizophrenic symptoms and of substance abuse was systematically assessed retrospectively. Information given by relatives validated the patients' reports.

RESULTS

Thirteen per cent of the sample had a history of cannabis abuse, which was twice the rate of matched normal controls. Male sex and early symptom onset were major risk factors. While cannabis abuse almost always preceded the first positive symptoms of schizophrenia, the comparison of the onset of cannabis abuse and of the first (prodromal) symptoms of schizophrenia differentiated three approximately equal groups of patients: group 1 had been abusing cannabis for several years before the first signs of schizophrenia emerged, group 2 experienced the onset of both disorders within the same month, and group 3 had started to abuse cannabis after the onset of symptoms of schizophrenia.

CONCLUSIONS

The vulnerability-stress-coping model of schizophrenia suggests possible interpretations of these findings. Group 1 might suffer from the chronic deteriorating influence of cannabis reducing the vulnerability threshold and/or coping resources. Group 2 consists of individuals which are already vulnerable to schizophrenia. Cannabis misuse then is the (dopaminergic) stress factor precipitating the onset of psychosis. Group 3 uses cannabis for self-medication against (or for coping with) symptoms of schizophrenia, particularly negative and depressive symptoms. These patients probably learn to counterbalance a hypodopaminergic prefrontal state by the dopaminergic effects of cannabis. The implications of these very preliminary results include issues of treatment and prognosis, but replication studies are needed.

Addiction and schizophrenia

Epidemiologic studies in the general population and those based on the clinical assessment of schizophrenic populations have revealed a high degree of overlap between schizophrenia and addictive disorders. The abuse of psychoactive substances (including alcohol) throughout life is so frequent (50%) that the possibility of a specific link inevitably arises. Various hypotheses have been suggested to explain the high co-morbidity between schizophrenia and addiction: 1) The social-environmental hypothesis has been developed but studies have provided poor evidence to validate it. 2) The possible shared biological vulnerability between schizophrenia and addictions led researchers to explore common genetic determinants and study the involvement of the dopaminergic and opioid systems in the aetiology of both schizophrenia and the abuse of and dependence on psychoactive drugs. 3) Finally, the theory of self-medication suggests that schizophrenics may be attempting to counter the deficit linked to their disorders by using the substances they take or their dependency-type behaviour to cope with their emotional problems. The clinical profile of schizophrenic addicts does seem to display some distinctive features, such as the high level of depressive co-morbidity, very high nicotine and alcohol dependence, with a very poor prognosis. These patients are difficult to manage; the possibility of pharmacologic interactions between the substances they are taking and neuroleptic medication calls for prudence, and their compliance is also poor. Addictive disorders in schizophrenics are currently a topic of active research intended to lead to identifying specific treatments. The early identification of addictive disorders in schizophrenics should make it possible to limit their development and improve the prognosis.

Cannabis use and psychosis: a review of clinical and epidemiological evidence

OBJECTIVE

This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a 'cannabis psychosis', i.e. a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms.

METHOD

Literature relevant to drug use and schizophrenia is reviewed.

RESULTS

There is limited clinical evidence for the first hypothesis. If 'cannabis psychoses' exist, they seem to be rare, because they require very high doses of tetrahydrocannabinol, the prolonged use of highly potent forms of cannabis, or a preexisting (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia.

CONCLUSIONS

It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of 'self-medication', or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.

Use of Legal Drugs by Psychiatric Outpatients: Benefits, Costs, and Change

Caffeine, nicotine, and alcohol use by persons with a severe mental illness occurs frequently but is poorly understood. We used qualitative methods to elicit information regarding the functional relationships between legal substance use and its antecedents and consequences. This report summarizes responses provided by 37 psychiatric outpatients who participated in focus groups and key informant interviews regarding the use and functions of alcohol, caffeine, and nicotine. We describe major themes regarding positive and negative consequences, triggers for use, change efforts, and offer observations regarding substance use in this under-served population.

Examining an affect regulation model of substance abuse in schizophrenia. The role of traits and coping

Comorbid substance use disorders occur frequently in schizophrenia with significant detrimental effects to clinical outcome. Unfortunately, attempts to identify factors associated with comorbid substance use disorders (beyond demographic characteristics such as gender) have not been successful. This study examined an affect regulation model of comorbid substance use in schizophrenia with a focus on personality traits and coping. It was hypothesized that maladaptive coping and the traits of negative affect (NA) and disinhibition (DIS), but not trait positive affect (PA), would be associated with greater substance use problems. Thirty-nine patients with schizophrenia or schizoaffective disorder completed measures of personality traits, coping, and negative consequences associated with substance use. Traits were differentially associated with coping in that NA and DIS, but not PA, were associated with maladaptive coping including the use of drugs and alcohol to cope with stress. Alternatively, PA, but not DIS or NA, was related to adaptive coping strategies. Individuals high in NA and endorsing the use of drugs and alcohol to cope reported the greatest number of negative consequences from substance use. This finding held after controlling for gender. These results are consistent with an affect regulation model of substance use and suggest the advantage of examining the role of affect, traits, and coping in understanding comorbid substance use in schizophrenia.

Substance abuse treatment for people with schizophrenia

Substance abuse by people with schizophrenia is a serious public health problem that is associated with poor treatment compliance, increased rates of relapse, and disruption of role functioning. There is widespread agreement on the need to integrate psychiatric and substance abuse treatment for this dual disorder, but to date there are no specific treatments with solid empirical support. We first review the primary consequences of substance abuse by people with schizophrenia and then examine what is currently known about their treatment needs. We then describe the special problems faced by this population that interfere with their ability to reduce substance use, with or without treatment. The remainder of the paper focuses on description of a new behavioral treatment we have developed to compensate for the cognitive and motivational deficits that characterize the illness. We describe the development process and present some process data that demonstrate that the intervention is safe and acceptable for people with schizophrenia, and that we are able to train therapists to administer the procedures in a consistent and effective manner. Future studies will examine the effectiveness of the intervention.

A review of the effects of moderate alcohol intake on psychiatric and sleep disorders

In this chapter we discuss the effects of moderate ethanol consumption on the treatment of psychiatric and sleep disorders. A review of the literature on the interactions of ethanol with neurotransmitters and psychotropic medications suggests that although ethanol affects the clinical course of psychiatric and sleep disorders by different mechanisms, it does so principally through perturbations it causes in the balance of central nervous system neurotransmitter systems, which may modify the clinical course of primary psychiatric and sleep disorders and undermine the therapeutic response to psychotropic medications. Neurotransmitter responses may also be manifested clinically by rebound phenomena, akin to a subsyndromal withdrawal, which affect sleep and precipitate anxiety and mood symptoms. In addition, ethanol also modifies the clearance and disposition of a variety of psychotropic metabolites and interferes with their clinical effectiveness. We recommend that most psychiatric patients, and all patients with sleep disorders, should abstain from even moderate ethanol use, as this may adversely affect their clinical course and response to treatment.

Reasons for substance use in schizophrenia

Abuse of and dependence on drugs, alcohol and other substances in schizophrenia are being increasingly recognized and well documented in the literature. It has been suggested that up to 60% of patients with schizophrenia use illicit drugs. A total of 41 subjects who fulfilled DSM-III-R criteria for schizophrenia and substance abuse or dependence were asked to describe their reasons for using such substances, the reasons why they might stop and the subjective effects of the substances. Drugs were reportedly used to increase pleasure, to 'get high' and to reduce depression. However, subjective effects of increased depression and positive symptoms were also reported. These results are considered in the context of potential treatment strategies.

Relationships between symptoms of schizophrenia and substance abuse

Previous work posits that severity of substance abuse and severity of schizophrenic symptoms should be linked by either or both of two mechanisms: self-regulation of symptoms and drug-induced exacerbation of symptoms. Research on these relationships has yielded mixed results. We examined the interrelationships of schizophrenic symptoms and substance abuse in 172 patients with co-occurring disorders. Relationships were weak or nonexistent, without any consistent pattern. Our findings do not support the view that substances are used to self-regulate symptoms. In addition, our results suggest that substance abuse may lead to higher rates of institutionalization through mechanisms other than by exacerbating symptoms.

Substance abuse and the onset of schizophrenia

Up to 60% of chronic schizophrenic patients are reported to abuse alcohol or drugs. This comorbidity raises the question whether one disorder is a consequence of the other. With the structured interview "IRAOS," the onset and course of schizophrenia and substance abuse were retrospectively assessed in a representative first-episode sample of 232 schizophrenic patients. Information by relatives validated the patients' reports. Alcohol abuse prior to first admission was found in 24%, drug abuse in 14%-twice the rates in the general population. Alcohol abuse more often followed than preceded the first symptom of schizophrenia. Drug abuse preceded the first symptom in 27.5%, followed it in 37.9%, and emerged within the same month in 34.6% of the cases. The study demonstrates a remarkable association between first-episode schizophrenia and substance abuse, but a unidirectional causality is not supported, nor is a specific psychotic disorder in comorbid cases.

Internal and external environment of individuals with schizophrenia during alcohol and drug use

Explanations for the high prevalence of alcohol and drug abuse in schizophrenia purport that substance use is related to social-affiliative needs or to symptom regulation. Neither explanation was adequate in describing substance-use episodes in the present longitudinal study. The study involved repeated interviews of 10 individuals with schizophrenia about their internal and external environment during substance use. Qualitative analyses of interview responses showed variability in multiple versus single episodes in a day and categories labeled Activities Prior to Use and Social Context of Use. Individual subject's responses each had a unique pattern that characterized their substance-use episodes.