Alcohol abuse, depression, and suicidal behavior in schizophrenia

The Relationship Between Depressive Symptoms and Psychological Variables in Patients With Schizophrenia

INTRODUCTION

Depressive symptoms are common in schizophrenia and can be seen at any stage of the disease. Although various models have been proposed to explain the development of depression in schizophrenia, studies investigating related psychological factors are scarce and the studies that have been done usually focus on only a small number of possible factors.

OBJECTIVE

The goal of this study was to investigate the predictability of some psychological factors on depression in patients with schizophrenia. For this purpose, patients with high and low depression scores were compared.

METHODS

Two groups of individuals with schizophrenia, with (n=29) and without (n=31) depression, as determined by scores on the Calgary Depression Scale in Schizophrenia, were compared using a sociodemographic data form, the Positive and Negative Syndrome Scale (PANSS), the Beck Anxiety Inventory, the Rotter Internal-External Locus 2024 of Control Scale, the Multidimensional Scale of Perceived Social Support, and the Stress Coping Styles Scale.

RESULTS

No differences were found between the 2 groups in terms of sociodemographic and clinical characteristics, social support scores, and coping styles. Statistically significant differences were found between the groups on the PANSS positive, negative, and general psychopathology subscales, in PANSS total scores, in anxiety scores, and in locus of control scores.

CONCLUSIONS

This study showed that high levels of negative, positive, and general psychopathological symptoms, external locus of control, and high anxiety scores may be predictive of depression in individuals with schizophrenia. Studies that examine psychological factors in larger patient groups may provide the opportunity to detect and target these factors earlier in the course of schizophrenia, thereby reducing morbidity and mortality.

Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs) and schizophrenia. This systematic review and meta-analysis estimated prevalence rates of SUDs in epidemiological and treatment-seeking patients diagnosed with schizophrenia or first episode psychosis.

METHODS

A literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2017 inclusive. Prevalence of co-morbid SUDs and schizophrenia were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Combining like studies was dictated how authors reported substance use.

RESULTS

There were 123 included articles with a total sample size of 165,811 subjects that yielded six epidemiological studies, 11 national or state case-registry studies, 20 large cohort studies and 86 clinical studies using in- or out-patient samples. The prevalence of any SUD was 41.7%, followed by illicit drugs (27.5%), cannabis (26.2%), alcohol (24.3%) and stimulant use (7.3%). Meta-analysis showed the pooled variance of any SUD in males was 48% which was significantly higher than that for females with schizophrenia (22.1%, OR 3.43, 95% CI 3.01, 3.92). Patients with SUD had an earlier age of onset of schizophrenia. Meta-regression showed prevalence increased over time for illicit drugs but not for other substances, including alcohol.

CONCLUSIONS

The meta-analysis revealed that SUDs in schizophrenia is highly prevalent and rates have not changed over time. This indicates SUD are difficult to treat in this patient population and there is an urgent need for more informative studies to help develop better prevention, detection and treatment of SUDs in persons with schizophrenia and co-morbid disorders.

OPUS study: Suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis

Background

Patients with first-episode psychosis comprise a high-risk group in terms of suicide.

Aims

To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness.

Method

A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual.

Results

During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness.

Conclusions

Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.

Prevalence, patterns, associated factors and severity of substance use among psychotic patients in southern Thailand

Co-occurring substance use in psychotic patients causes many subsequences including increased illness severity, decreased medication compliance, higher relapse rates, more hospitalizations, and legal problems. We aim to investigate the prevalence, patterns, associated factors and severity of substance use risk among psychotic patients in southern Thailand. Psychotic out-patients were screened with the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST) for their history of substance use in the past three months and categorized as None-to-Low Risk (NLR) or Moderate-to-High Risk (MHR) levels. Multivariate logistic regression was used to examine the associated factors of substance use risk-level. The associations between substance use risk-level and emotional and behavioural symptoms, functional status and family functional status were examined using multivariate linear regression analysis. Of 663 participants screened, 322 (48.6%) used at least one substance in the past three months. Tobacco was the most common substance used (47.2%). The factors associated with a higher risk of any substance use were male gender, young age group, low level of education, being employed and being diagnosed with schizophrenia. A higher number of emotional and behavioural symptoms was significantly associated with higher substance use risk-level. In conclusion, the prevalence of substance use in psychotic patients was high and associated with their emotional and behavioural symptoms. Recommendations for implementation of screening and early intervention programs of substance-related problems in psychotic patients are important for preventing unwanted outcomes.

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.

The Concept of Schizophrenia: From Unity to Diversity

After over 100 years of research without clarifying the aetiology of schizophrenia, a look at the current state of knowledge in epidemiology, genetics, precursors, psychopathology, and outcome seems worthwhile. The disease concept, created by Kraepelin and modified by Bleuler, has a varied history. Today, schizophrenia is considered a polygenic disorder with onset in early adulthood, characterized by irregular psychotic episodes and functional impairment, but incident cases occur at all ages with marked differences in symptoms and social outcome. Men’s and women’s lifetime risk is nearly the same. At young age, women fall ill a few years later and less severely than men, men more rarely and less severely later in life. The underlying protective effect of oestrogen is antagonized by genetic load. The illness course is heterogeneous and depressive mood the most frequent symptom. Depression and schizophrenia are functionally associated, and affective and nonaffective psychoses do not split neatly. Most social consequences occur at the prodromal stage. Neither schizophrenia as such nor its main symptom dimensions regularly show pronounced deterioration over time. Schizophrenia is neither a residual state of a neurodevelopmental disorder nor a progressing neurodegenerative process. It reflects multifactorial CNS instability, which leads to cognitive deficits and symptom exacerbations.

Psychiatric Comorbidity in Patients from the Addictive Disorders Assistance Units of Galicia: The COPSIAD Study

The objective of this study is to assess the prevalence of psychiatric comorbidity in patients under treatment within the addictive disorders assistance units of Galicia (Spain).

MATERIAL AND METHODS

A total of 64 healthcare professionals performed clinical diagnosis of mental disorders (on DSM IV-TR criteria) in 2300 patients treated throughout March 2010 in 21 addictive disorders assistance units.

RESULTS

56.3% of patients with substance abuse/dependency also showed some other mental disorder, 42.2% of patients suffering from at least an Axis I condition and 20.2% from some Axis II condition. Mood and anxiety disorders and borderline and antisocial personality disorders were the most frequent disorders in both axes.

CONCLUSIONS

A high comorbidity was found between mental and substance use disorders (SUD) in patients seen at the addictive disorders assistance units of Galicia.

Duration of assertive community treatment and the interpretation of routine outcome data

OBJECTIVE

Statistical inferences based on routine outcome monitoring data are susceptible to biases. Because this process may be influenced by differences in attrition and treatment duration, we wished to gain an insight into the relationship between treatment duration and clinical outcome.

METHOD

We enrolled 569 assertive community treatment (ACT) team patients. As part of a six-monthly routine outcome monitoring (ROM) procedure, we used the Global Assessment of Functioning (GAF) scale, the Health of the Nation Outcome Scales (HoNOS), and a scale to assess their treatment motivation and satisfaction with services. Duration of ACT showed that treatment duration was short for 292 patients [≤ three ROM assessments; 11.6 months (SD = 6.1)], medium for 191 [four to six ROM assessments; 26.9 months (SD = 7.3)], and long for 86 [≥ seven ROM assessments; 44.06 months (SD=7.1)]. Chi-square and ANOVA were used to compare patient characteristics and baseline values across different treatment duration groups, and structural equation modelling was used to unravel interdependencies between the baseline and outcome variables.

RESULTS

More patients receiving long-term ACT were diagnosed with a psychotic disorder and/or substance abuse than those whose treatment was shorter. Patients whose treatment lasted longer had worse baseline GAF and HoNOS scores than those whose treatment was shorter. Structural equation modelling showed that the interdependencies between determinants and outcome variables (concerning the relationships between both identical and non-identical variables over time) were different for each of the treatment duration categories.

CONCLUSIONS

Patients in ACT teams with different treatment durations constitute distinguishable groups with different outcomes. This should be taken into account when using outcome data for benchmarking purposes.

Alcohol Use Disorders Identification Test (AUDIT) scores are elevated in antipsychotic-induced hyperprolactinaemia

Hyperprolactinaemia in antipsychotic treated patients with schizophrenia is a consequence of D2 receptor (DRD2) blockade. Alcohol use disorder is commonly comorbid with schizophrenia and low availability of striatal DRD2 may predispose individuals to alcohol use. In this pilot study we investigated whether hyperprolactinaemia secondary to pharmacological DRD2 blockade was associated with alcohol use disorder in 219 (178 males and 41 females) patients with schizophrenia. Serum prolactin determinations were made in patients diagnosed with schizophrenia and maintained on antipsychotic agents. Clinical assessment included demographics, family history and administration of the AUDIT (Alcohol Use Disorders Identification Test). Higher AUDIT scores were associated with prolactin-raising antipsychotic medication (n=106) compared with prolactin-sparing medication (n=113). Risperidone (n=63) treated patients had higher AUDIT scores and prolactin levels than those on other atypical antipsychotics (n = 113). Across the entire sample, patients with a prolactin greater than 800 mIU/L had higher AUDIT scores and were more likely to exceed the cut-off score for harmful and hazardous alcohol use. These differences were not explained by potential confounds related to clinical features and demographics, comorbidity or medication side-effects. These data suggest that by lowering dosage, or switching to another antipsychotic agent, the risk for alcohol use disorder in those with schizophrenia may be reduced. This hypothesis requires testing using a prospective methodology.

Significant relationship between lifetime alcohol use disorders and suicide attempts in an Australian schizophrenia sample

OBJECTIVE

Suicide and attempted suicide are common in individuals with schizophrenia, and evidence exists for a link between substance use disorders and suicidality in this disorder. However, alcohol has not been consistently implicated. We examined the relationship between substance use disorders and suicide attempts in schizophrenia.

METHODS

We recruited a schizophrenia sample in Australia (n = 821) for genetic analyses. We analysed demographic and clinical variables, including substance use disorders, and their relationship to suicide attempts using generalised equation modelling.

RESULTS

A significant association was identified between lifetime alcohol abuse/dependence and suicide attempts (OR = 1.66; 95% CI, 1.23 to 2.24; p = 0.001) after adjustment for potential confounders, but not between cannabis abuse/dependence and suicide attempts, nor between other illicit drug abuse/dependence and suicide attempts. Polysubstance abuse/dependence was also not implicated.

CONCLUSIONS

These results suggest that the presence of alcohol abuse/dependence may be a risk factor for suicide attempts in individuals with schizophrenia, independent of comorbid substance abuse/dependence.

Depressive symptoms in schizophrenic patients

Distinction between true negative and depressive symptoms in schizophrenia is difficult. In the present study we seek to establish the psychological profile of depression-prone schizophrenic patients. We addressed the issue by comparing the expression of psychological indices, such as the feelings of being in control of events, anxiety, mood, and the style of coping with stress in depressive and non-depressive schizophrenics. We also analyzed the strength of the association of these indices with the presence of depressive symptoms. A total of 49 patients (18 women and 31 men, aged 23-59) were enrolled into the study, consisting of a self-reported psychometric survey. We found that the prevalence of clinically significant depression in schizophrenic patients was 61%. The factors which contributed to the intensification of depressive symptoms were the external locus of control, anxiety, gloomy mood, and the emotion-oriented coping with stress. We conclude that psychological testing may discern those schizophrenic patients who would be at risk of depression development and may help separate the blurred boundaries between depressive and negative symptoms of schizophrenia.

Schizophrenia: still Kraepelin's Dementia Praecox?

Summary

Asking whether E. Kraepelin's early dementia praecox and disease concepts (1896) are still valid today, we condensed his early theory into four theses:1) schizophrenia is a disease entity, distinguishable from affective psychosis. 2) It is caused by a specific neuropathology. 3) It usually manifests itself in adolescence or early adulthood. 4) Underlying schizo- phrenia is a progressive disease process that leads to defects and dementia.

Having tested whether Kraepelin's dementia praecox and modern schizophrenia are actually comparable, we studied 1) how schizophrenia and depression are linked or separable in terms of symptoms, risk factors and illness course from onset until five years after first treatment contact. The analyses are based on a population-based sample of 130 first admissions because of schiz- ophrenia, 130 age- and sex-matched first admissions because of unipolar depressive disorder and 130 “healthy” population con- trols from the study area. 2) Results will be presented that, though not very specific, confirm Kraepelin's farsighted hypothesis of a neuropathological basis of the disorder. In this context it will be discussed whether the brain changes are developmental or degenerative in origin. 3) The distribution of age of onset extends far into old age. In a sample of 1109 consecutive first admis- sions because of nonaffective psychosis from the total age range it was shown that age-dependent developmental factors mod- ify certain components of symptomatology linearly and significantly. The main risk factors, too, significantly change with age. 4) Long-term course was examined in three studies of epidemiologically recruited first-episode samples: Study 1 included five cross sections over 5 years, Study 2 was a prospective pre-post-comparison over 12 years supplemented by a retrospective assessment of the illness course (IRAOS) and Study 3 encompassed 10 cross sections over fifteen years. Finally, the disease concept of schizophrenia, as it presents itself in the light of current knowledge, will be outlined and compared with Kraepelin's earlier and later view of the disorder.

Declaration of Interest

the paper is based on a lecture (Lettura magistrale) presented at the SIEP Sesto Congresso Nazionale, “Gli Esiti della Schizofrenia - Trattamenti, Pratica nei Servizi, Valutazione” in Sirmione, November 6-8, 2003. Unfortunately, the illustrations shown there and some 20 % of the relevant references could not be included in this printed ver- sion for lack of space. This paper was written within the framework of the German Research Network on Schizophrenia and was funded by the German Federal Ministry for Education and Research BMBF (grant 01GI 0236). The ABC study was supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) as part of the Special Research Branch (Sonderforschungsbereich) 258 at the Central Institute of Mental Health until December 1998. From January 1999 to Sept. 2002 it was continued to be funded by the DFG.

Alcohol use disorders, nicotine dependence, and co-occurring mood and anxiety disorders in the United States and South Korea-a cross-national comparison

BACKGROUND

The strong comorbidity between substance use disorders (SUDs) and mood and anxiety disorders has been well documented. In view of lack of research findings addressing the co-occurrence of SUDs and mood and anxiety disorders, this study examined the pattern of comorbidity of alcohol use disorders (AUDs) and nicotine dependence (ND) between 2 culturally diverse countries, the United States and South Korea.

METHODS

Using the nationally representative samples of the U.S. and Korean general populations, we directly compared rates and comorbidity patterns of AUDs, ND, and mood and anxiety disorders between the 2 countries. We further examined the rates and the comorbidity pattern among individuals with AUDs who sought treatment in the last 12 months. Twelve-month prevalence rates were derived to estimate country differentials, and odds ratios (ORs) and 95% confidence intervals were estimated to measure the strength of comorbid associations while adjusting for all sociodemographic characteristics in multivariate logistic models specific to each country.

RESULTS

The 12-month prevalence rates of AUDs, ND, and any mood disorder and any anxiety disorder were 9.7, 14.4, 9.5, and 11.9% among Americans, whereas the corresponding rates were 7.1, 6.6, 2.0, and 5.2% among Koreans. These rates were significantly greater (except for any AUD) among Americans than among their Korean counterparts. With respect to comorbidity, both countries showed comparable patterns that the prevalence rates of mood and anxiety disorders were consistently the highest among persons with alcohol dependence (AD). Also, a disparate pattern was observed in Korea that the prevalence rates of mood and anxiety disorders were generally lower among individuals with ND than among those with alcohol abuse and AD. Furthermore, despite significantly greater prevalence of AD in Korea (5.1%) than in the United States (4.4%), alcohol-dependent Americans were 4 times (OR = 3.93) more likely to seek treatment compared to their Korean counterparts.

CONCLUSIONS

Our results indicated that the prevalence of AD in Korea was substantially greater than that in both Western and other Asian countries, suggesting a maladaptive pattern of alcohol use in Korea, which is different from the general use pattern of other East Asian countries. The low rate of treatment utilization among Koreans might be attributable to perceived social stigma toward SUDs or mental health problems despite the fact that the Korean government offers national health insurance.

The Effectiveness of Supported Employment in People With Dual Disorders

OBJECTIVE: This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder. METHODS: A secondary data analysis was conducted drawing from four randomized controlled trials comparing IPS supported employment to conventional vocational rehabilitation programs for severe mental illness, and focusing on the 106 clients with a recent (past 6 months) substance use disorder. Competitive work outcomes were tracked across an 18-month follow-up period. Analyses compared the IPS and comparison vocational programs on cumulative work over the 18 months, including attainment of work, hours and weeks worked, job tenure, wages earned, and days to first job. RESULTS: In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up. CONCLUSIONS: The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with a dual disorder.

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

Reprint of "Understanding comorbidity between substance use, anxiety and affective disorders: broadening the research base"

In this paper, we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders; 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus on the effects on comorbidity of primary and secondary prevention interventions for substance use, anxiety, affective and conduct disorders among children and adolescents; and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.

Understanding comorbidity between substance use, anxiety and affective disorders: broadening the research base

In this paper, we argue that the research base for understanding comorbidity between substance use and other mental disorders needs to be broadened. We specifically advocate for: 1) more prospective epidemiological studies of relationships between alcohol and other drug use disorders and anxiety and mood disorders; 2) greater use of twin study designs to disentangle shared genetic and environmental contributions to comorbidity; 3) prospective neuroimaging studies of the effects of early and sustained alcohol and drug use on the developing adolescent brain; 4) a greater focus on the effects on comorbidity of primary and secondary prevention interventions for substance use, anxiety, affective and conduct disorders among children and adolescents; and 5) better evaluations of the impact of treatment upon persons with comorbid substance use and other mental disorders.

Prevalence and correlates of comorbidity 8 years after a first psychotic episode

OBJECTIVE

While rates and correlates of comorbidity have been investigated in the early course of psychosis, little is known about comorbidity in the medium-to-longer term or its relationship with outcome.

METHOD

A total of 182 first-episode psychosis (FEP) patients who met DSM-IV criteria for a current psychotic disorder 8 years after index presentation were grouped according to concurrent comorbidity [no concurrent axis I disorder; concurrent substance use disorder (SUD); other concurrent axis I disorder; concurrent SUD and other axis I disorder]. Outcomes were compared between groups controlling for relevant covariates.

RESULTS

As much as 39% met criteria for one or more concurrent axis 1 diagnoses. Comorbidity was associated with greater severity of general psychopathology, but not with measures of functioning, treatment or negative symptoms.

CONCLUSION

Specific combinations of comorbid disorders may influence patterns of psychotic symptomatology. Routine examination of axis I disorders is warranted in the ongoing management of psychosis.

Reasons for increased substance use in psychosis

Around half of all patients with schizophrenia are thought to abuse drugs or alcohol and there is good evidence to suggest that they have poorer outcomes than their non substance using counterparts. However, despite more than twenty years of research there is still no consensus on the aetiology of increased rates of substance use in people with psychosis. There is a clear need to understand the reasons for such high rates of substance use if treatments designed to help patients abstain from substance use are to be successful. This paper provides an update of the literature examining the reasons for substance use by people with psychosis, and includes a comprehensive review of the self report literature. The main theories as to why people with psychosis use substances are presented. There is evidence to suggest that cannabis may have a causal role in the development of psychopathology but not for other substances. The self report literature provides support for an 'alleviation of dysphoria' model of substance use but there is little empirical support for the self medication hypothesis, or for common factor models and bidirectional models of comorbidity. It is likely that there are multiple risk factors involved in substance use in psychosis and more work to develop and test multiple risk factor models is required.

An unholy alliance: substance abuse and social exclusion among assertive outreach patients

OBJECTIVE

To investigate the relationship between social exclusion and outcomes of mentally ill patients with substance abuse problems receiving assertive outreach treatment in London.

METHOD

Analysis was conducted on data on 580 patients from the 'Pan-London Assertive Outreach Study (PLAO)'. Data were collected using clinician-rated scales of alcohol and drug abuse in the last 6 months before baseline. Outcomes - hospitalization and compulsory hospitalization- were assessed over a 9-month follow-up period.

RESULTS

The analysis identified a group of patients with substance abuse who suffer from social exclusion and forensic problems (n = 77, 15.8%), and had poorer outcomes than the rest of the patients in terms of hospitalization (52% vs. 36% respectively) and compulsory (39% vs. 22% respectively) hospitalization.

CONCLUSION

There is a distinct group of patients whose treatment requires social inclusion and forensic expertise. Future research into which model of service is suitable for these patients and in what setting is recommended.

Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders

The long-term courses of people with schizophrenia and of those with substance use disorder have been studied separately and extensively. The long-term course of clients with co-occurring schizophrenic and substance use disorders has, however, not been examined. This article reports 10-year outcomes for 130 clients with co-occurring schizophrenic and substance use disorders in the New Hampshire Dual Diagnosis Study. In addition, we report on 6 "recovery outcomes," identified by dual diagnosis clients, as examples of positive coping behaviors. Longitudinal data were modeled using generalized estimating equation (GEE) methods. Participants improved steadily over 10 years in the outcome domains of symptoms, substance abuse, institutionalization, functional status, and quality of life. Further, at the 10-year follow-up, substantial proportions were above cutoffs selected by dual diagnosis clients as indicators of recovery: 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non-substance abusers; and 58.3% expressed overall life satisfaction. These 6 outcomes were only weakly interrelated over time, suggesting that recovery, as defined by clients, is a multidimensional concept. Overall, the 10-year findings on recovery outcomes provide a hopeful long-term perspective for dual diagnosis clients.

Three-year recovery outcomes for long-term patients with co-occurring schizophrenic and substance use disorders

Little is known about the expected treatment outcomes of patients with co-occurring schizophrenic and substance use disorders. This paper reports 3-year outcomes for 152 patients with schizophrenia or schizoaffective disorder and substance use disorders, all of whom received integrated dual disorders treatments in the New Hampshire Dual Diagnosis Study. Outcomes are defined as positive coping behaviors identified by consumers as indicators of recovery. Participants improved steadily in terms of controlling symptoms of schizophrenia, actively attaining remissions from substance abuse, increasing competitive employment, increasing social contacts with non-substance abusers, and improving life satisfaction. Though successful in reducing hospitalization and homelessness, they did not increase time in independent living situations. Outcomes were only weakly interrelated, suggesting that recovery is a multidimensional concept. Neither psychotic diagnosis (schizophrenia vs. schizoaffective disorder) nor substance abuse diagnosis (alcohol vs. other drug disorder vs. both) was related to outcomes. However, these patients with co-occurring schizophrenic and substance use disorders did significantly less well than patients with co-occurring bipolar and substance use disorders in terms of hospitalization, independent living, and quality of life. Overall, the findings provide a hopeful long-term perspective for dual diagnosis patients.

Suicidality and psychosis: the predictive potential of symptomatology and insight into illness

Recent research indicates that suicidal ideation and intent effect the majority of psychotic patients, a large proportion of whom eventually complete suicide. Some evidence suggests that psychotic symptomatology and awareness of the disorder may increase the suicidal risk in this patient population. This study investigated the predictive potential of insight into illness, years of treatment, recent traumatic stress, and depressive, manic, cognitive, anxiety, and psychotic symptomatology in the genesis of suicidality with psychotic patients. Results showed that increased insight into illness, fewer years of treatment, and more severe depressive symptoms each significantly heightened patients' risk of suicidality. Research and practice implications of these findings are discussed.

Characteristics of schizophrenic patients with a history of suicide attempt

OBJECTIVE The aim of this study was to evaluate the suicide attempt history among schizophrenic patients and compare their sociodemographic and clinical characteristics with schizophrenic patients without a history of suicide attempt. METHOD Sixty schizophrenic patients according to DSM-IV criteria were included in the study. Half of the patients were in acute phase and receiving inpatient treatment, while the other half were in stable phase and outpatients. The sample was subdivided into two subsamples according to the presence/absence of lifetime suicidal attempts. RESULTS History of suicide attempt was found in 27 (45%) of the patients. The rate of having suicidal ideation, depression, paranoid type schizophrenia and first-degree relatives with psychiatric disorder was high among the group with suicide attempt history. Depression and insight scores were high and PANSS Negative symptoms subscale score was low among the patients with suicide attempt history. There were no significant differences between the two groups according to the scores of PANSS Positive symptoms and General Psychopathology subscales. CONCLUSION The high rate of suicide attempt history in our sample suggests that risk of suicide has to be determined and protective measures have to be taken while planning inpatient and outpatient treatment of these patients. Suicide attempt history is a risk factor for suicide ideation and is also related to depressive symptoms and high insight score and low negative symptoms score.

Life satisfaction and suicidal attempts among persons with schizophrenia

The relationship between subjective quality of life (QOL) and suicide attempts in patients with schizophrenia has been understudied. The current study tested the hypothesis that QOL is negatively associated with a history of suicidality of patients with schizophrenia. QOL, as measured by the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), was investigated in 227 inpatients with DSM-IV diagnosis of schizophrenia with and without a lifetime history of suicide attempts. The statistical analysis included analysis of variance (ANOVA), t tests, and analysis of covariance (ANCOVA). The patients who had attempted suicide multiple times were less satisfied with regard to a larger number of life domains than the nonattempters and the single attempters. The differences in QOL remained significant after adjusting for psychiatric history and current psychopathology variables, e.g., age of onset of the disorder, number and length of hospitalizations, and positive, negative, and depressive symptoms. Dissatisfaction with QOL in general and with reference to four specific domains was associated with repeated suicide attempts. Clinicians should include QOL in the evaluation of patients with schizophrenia that are suspected to be suicidal.

Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review

OBJECTIVE

To review the available literature on depressive symptomatology in schizophrenia in order to establish a diagnostic algorithm of depressive syndromes in schizophrenia.

METHOD

A literature search was performed using PubMed and Medline. Additional information was gained by cross-referencing from papers found in the database. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. Depressive symptoms were classified with respect to their temporal relationship to acute psychotic symptoms before the background of nosological entities as operationalized by Diagnostic Statistical Manual IV (DSM IV).

RESULTS

Depression is a common and devastating comorbid syndrome in patients suffering from schizophrenic disorder. The paper summarizes the relevant diagnostic steps to guide the clinician towards therapeutic interventions, which differ depending on the nature of the depressive syndrome.

CONCLUSION

Differentiating depressives states in schizophrenia has consequences in terms of choosing therapeutic strategies. An algorithm which leads the practitioner to a reliable diagnosis and in consequence to a valid therapy is presented.

Suicide and schizophrenia

Suicide and suicide attempts occur at a significantly greater rate in schizophrenia than in the general population. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at two to five times that rate. Demographically associated with suicidality in schizophrenia are being young, being early in the course of the illness, being male, coming from a high socioeconomic family background, having high intelligence, having high expectations, not being married, lacking social supports, having awareness of symptoms, and being recently discharged from the hospital. Also associated are reduced self-esteem, stigma, recent loss or stress, hopelessness, isolation, treatment non-compliance and substance abuse. Clinically, the most common correlates of suicidality in schizophrenia are depressive symptoms and the depressive syndrome, although severe psychotic and panic-like symptoms may contribute as well. This review specifically explores the issue of depression in schizophrenia, in relation to suicide, by organizing the differential diagnosis of this state and highlighting their potentially treatable or correctable causes. This differential diagnosis includes both acute and chronic disappointment reactions, the prodrome of an acute psychotic episode, neuroleptic induced akinesia and akathisia, the possibility of direct neuroleptic-induced depression, negative symptoms of schizophrenia, and the possible co-occurrence of an independent depressive diathesis. The potential beneficial roles of 'atypical' antipsychotic agents, including both clozapine and more novel agents, and adjunctive treatment with other psychopharmacological medications are considered, and the important roles of psychosocial factors and interventions are recognized.

Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden

The purpose of the current study is twofold: (a) to provide an overall synthesis of recent research on substance abuse in schizophrenia and (b) to present findings in a Swedish patient sample. Studies conducted since 1990 have found a wide range of abuse prevalence rates, with male gender and younger age as primary correlates. Less certainty exists regarding substance abuse as an independent risk factor for schizophrenia and its further impact on illness course. In a sample of 87 patients attending a psychiatric clinic in Malmö, lifetime prevalence of substance abuse was 48.3%, with abuse debut primarily preceding first contact for psychotic symptoms. Significant correlates of abuse were male gender, family history of substance abuse, and increased rates of hospitalization and criminality, with poorer outcome found in previous as well as current abusers. Alcohol abuse, either solely or in combination with other substances, was the main type of substance abuse. Although the specific factors (social, behavioural, genetic) that predispose schizophrenic patients to substance abuse remain unclear, the predominantly male profile of abusers might suggest a link between substance abuse and the poorer clinical outcome frequently observed, especially in male schizophrenic patients.

Treating substance abuse in the context of severe and persistent mental illness: clinicians' perspectives

Patients with comorbid substance use and major mental disorders are treated frequently in the mental health system. Treatment models relevant for this subset of patients have emerged in recent years, however, few have been validated empirically and so relatively few sites benefit from this treatment development activity. Important additional sources of information about good treatment practices are the clinicians who have adopted the treatment of patients with dual disorders as a specialty. We conducted four focus groups (N = 12) with clinicians who were nominated by their peers as experienced and/or expert in treating persons with comorbid substance use and psychiatric disorders. Discussions followed a four-part outline that included (a) general questions about training and experience with the population, (b) preferred treatment methods, (c) motivational issues, and (d) recommendations to the field. Participants were trained in a variety of mental health disciplines and pursued substance abuse treatment credentials or other educational experiences outside of their primary training programs. Their treatment approaches emphasized psychoeducation, a good therapeutic relationship, and the need to be flexible regarding methods and goals. Abstinence was the preferred goal among most clinicians; even so, they expressed a pragmatic flexibility and other views consistent with the principles of harm reduction. Clinicians tended to respond to patients' ambivalent motivational states by addressing the consequences of behaviors in a nonconfrontive style; they also made use of positive incentives and external support. A number of recommendations were made to improve treatment, including greater institutional and programmatic support for the unique needs of this population.

Using randomized controlled trials to evaluate socially complex services: problems, challenges and recommendations

BACKGROUND: Following the lead of evidence-based medicine, practice based on effectiveness research has become the new gold standard of contemporary public policy. Studies of this sort are increasingly demanded to evaluate services provided by mental health, social services and criminal justice systems. AIMS: The paper questions whether the simple randomized controlled trial (RCT) paradigm as applied in clinical trials can be used "off the rack" to evaluate socially complex service (SCS) interventions. These are services that are characterized by complex, diverse and non-standardized staffing arrangements; ambiguous protocols; hard-to-define study samples and unevenly motivated subjects and dependence on broader social environments. The difficulty of ensuring precise protocols, equivalent groups (tied to a meaningful target population) and neutral and equivalent trial environments under real world conditions are explored, as are the implications of not achieving standardization and equivalence. METHODS: Limitations of effectiveness research as a research tool and information source are examined by comparing the assumptions underpinning the simple RCT to the characteristics of SCS interventions, as illustrated by programs targeted to mentally disordered offenders in Britain. RESULTS: SCSs violate the assumptions underpinning the simple RCT model in ways that draw into sharp question the validity, reliability and generalizability of inferences of SCS trials. DISCUSSION: The RCT is not a panacea. Effectiveness research of SCS interventions that is based on the RCT model is unlikely to yield valid, reliable and generalizable inferences without becoming more complex in design and more sensitive to issues of selection bias, unmeasured variables and endogeneity. Ten recommendations are offered for stylizing the RCT design to the characteristics of socially complex services. IMPLICATIONS: It remains an empirical issue whether RCT-based services effectiveness research can inform mental health policy. Without major design innovations, it is more likely that the information generated by this research will have limited practical use, especially if the RCT model is unable to control for the effect of social complexity and the interaction between social complexity and dynamic systemic change. Scientific evaluations of services make clinical and economic sense so long as they are designed to meet the challenges of the services of which they promise greater knowledge.

Suicide in patients hospitalized for schizophrenia: 1913-1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Complications of severe mental illness related to alcohol and drug use disorders

In this chapter we review research on the relationships between substance use disorder and 11 domains of adjustment for people with severe mental illness. Studies are divided into correlational research and prospective, longitudinal research, with greater weight given to those in the latter category. The weight of the evidence indicates that substance abuse severely complicates severe mental illness in the following domains: relapse of psychiatric illness, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, and medication noncompliance. We discuss the limits of causal inference in these studies and the possible mechanisms that relate substance abuse to various complications.

Housing for persons with co-occurring mental and addictive disorders

Homelessness is a far too common outcome for persons with dual diagnoses. This chapter discusses existing housing barriers and suggests housing, treatment, and support services responsive to population need.

Rates and correlates of suicide attempts in first-admission psychotic patients

The relationship of attempted suicide to demographic characteristics, current and lifetime psychiatric diagnoses, clinical history, and current symptoms was assessed in a sample of 184 recently hospitalized psychotic patients. Forty-three patients (23%) had an attempt history, and 28 (15% of sample; 65% of attempters) made an attempt during the episode for which they were hospitalized. Demographic characteristics did not distinguish attempters from nonattempters. Variables significantly associated with having ever attempted suicide were current diagnosis of unipolar major depressive disorder but not bipolar; lifetime major depressive episode; a history characterized by a less acute onset, lower pre-admission psychosocial functioning, and episodes of physical violence; and a symptom picture characterized by greater depression, hopelessness, negative symptoms, hallucinations and less thought disorder. Those with a current attempt had significantly higher rates of lifetime history of major depression and less physical violence than those with past attempts only. The potential importance of the data for predicting future suicidal acts is discussed.

Suicidal ideation in postpsychotic depression

Although approximately 10% of schizophrenics commit suicide, little is known about the clinical correlates of this behavior. This study investigated the relationships between suicidal ideation, anxiety, and psychosis in a group of schizophrenic and schizoaffective patients with operationally defined cases of postpsychotic depression. Psychosis contributed to the variance in suicidal ideation over and above the effects of depression and anxiety. Treatment and research implications of this finding are discussed.