Extrapyramidal symptoms in substance abusers with and without schizophrenia and in nonabusing patients with schizophrenia

Extrapyramidal symptoms (EPS) such as parkinsonism, dystonia, dyskinesia, and akathisia are conditions of impaired motor function, which are associated with chronic antipsychotic treatment in schizophrenia. In addition, EPS is often exacerbated by psychoactive substance (PAS) abuse, which is frequently observed in this population. Few studies, however, have investigated the contribution of PAS abuse on EPS in PAS‐abusers without comorbid psychosis. This study compared the occurrence of EPS in outpatient schizophrenia patients with (DD group; n= 36) and without PAS abuse (SCZ group; n = 41) as well as in nonschizophrenia PAS abusers undergoing detoxification [substance use disorder (SUD) group; n = 38]. Psychiatric symptoms were measured using the Positive and Negative Syndrome Scale and the Calgary Depression Scale for schizophrenia. Extrapyramidal symptoms were evaluated with the Extrapyramidal Symptoms Rating Scale and the Barnes Akathisia Scale. SUD diagnoses were complemented with urine drug screenings. We found that DD patients exhibited significantly more parkinsonism than SCZ patients. Our subanalyses revealed that cocaine and alcohol abuse/dependence was responsible for the increase in parkinsonism in DD patients. Additionally, we found that SUD individuals exhibited significantly more akathisia than SCZ patients. In these latter individuals, subanalyses revealed that alcohol and cannabis abuse/dependence was responsible for the increase in akathisia. Our results suggest that PAS abuse is a contributor to EPS in individuals with and without schizophrenia. © 2010 Movement Disorder Society.     

Contingency management in opioid substitution treatment

The majority of opiate-dependent patients in substitution treatment show additional substance-related disorders. Concomitant use of heroin, alcohol, benzodiazepines or cocaine compromises treatment success. Concomitant drug use may be treated by using contingency management (CM) which is based on learning theory. In CM, abstinence from drugs, as verified by drug screenings, is reinforced directly and contingently. Reinforcers used in CM studies with substituted patients were, amongst others, vouchers and take-home privileges. Studies in the USA show a medium average effect of CM on drug consumption rates and abstinence. The effects decrease markedly after the end of the intervention. We discuss whether CM is applicable within the German substitution treatment system and how it can be combined with other interventions such as selective detoxification treatments or cognitive-behavioural programmes.     

Anabolic steroid use among substance abusers in treatment.

BACKGROUND: Increasing illicit use of anabolic steroids in adolescent and young adult populations has been reported. To determine the scope of this problem and its relationship to psychoactive substance abuse, we evaluated the prevalence of anabolic steroid use among individuals seeking inpatient treatment for substance abuse. METHOD: A randomized mail survey of 175 inpatient substance abuse treatment directors elicited information regarding the prevalence of anabolic steroid use for inpatients treated in 1989 and the first half of 1990. Additionally, directors were surveyed for experience with DSM-III-R psychoactive substance dependence criteria for anabolic steroid use. RESULTS: Only 19% of centers responding had treated at least one individual using anabolic steroids. Facilities encountering anabolic steroid users reported a prevalence of less than 1% among all admissions. Anabolic steroid users were seen more commonly in privately funded facilities. Directors reported a majority of anabolic steroid users had at least three DSM-III-R psychoactive substance dependence criteria for anabolic steroid use. Treatment directors rarely found anabolic steroid use acknowledged as a problem by users and rarely found anabolic steroid use a primary reason for treatment. CONCLUSION: Users of illicit anabolic steroids may have significant clinical differences compared with users of other psychoactive substances of abuse and dependence.     

An out-patient treatment programme for adolescent substance abusers

This treatment programme is based on the model of Developmental Habilitation being the essence of change for adolescent substance abusers. The practical operation of the programme involves: individual counselling; socialization group; recreational activities; group therapy; parent support group and family counselling. Where possible, it is based on experimental learning (whilst "straight"/"sober") due to the belief that such learning has been forsaken, resulting in a developmental deficit. Therefore, expectations of clients' progress and achievements need to be realistic and related to functional age rather than chronological age. According to clients who have achieved the goal of "living the lifestyle they choose, without the need to use substances" the three most helpful provisions of the programme were: stability; consistency; and realism.     

Affective illness in substance abusers

The evaluation and treatment of substance abusers are complicated tasks, requiring a multifaceted approach. In addition to the patient's substance abuse problems, a substantial minority appear to be suffering from concurrent, nondrug-related psychiatric disorders. The early identification of such individuals allows for the development of specific treatment strategies that address both the substance abuse and the associated nondrug psychopathology. On the other hand, attention to nondrug psychopathology should not preclude our simultaneously addressing the patient's substance abuse problem. Thus, manic depressive patients who are also alcoholic may need a treatment program that includes alcoholism counseling. Alcoholics Anonymous, and chronic administration of disulfiram in addition to lithium carbonate and a supportive psychotherapeutic relationship. As in other areas of medicine, attention to the "whole patient" is the sine qua non of good treatment.     

Treating depression in substance abusers

The literature on the diagnosis and treatment of depression is reviewed to arrive at recommendations for clinical practice, future research, and models of service delivery. The DSM-IV criteria are found to provide a sound basis for diagnosis, and a review of placebocontrolled trials of antidepressant medications among substance-dependent patients suggests medication is effective in the setting of careful diagnosis, preferably during a currently observed abstinent period. Clinical recommendations offered for the approach to patients with co-occurring depression and substance dependence include the following: 1) Initiate treatment for substance dependence and encourage abstinence; 2) Conduct a careful psychiatric history and apply DSM-IV criteria for primary or substance-induced depression; 3) If depression meets diagnostic criteria and persists despite treatment of substance use disorder, treat the depression. Future research should include trials of psychotherapeutic or behavioral treatments, studies of treatment algorithms and of integrated systems of care, and studies of methods for disseminating diagnostic and treatment methods in an effort to diminish traditional boundaries between the skill sets of mental health and substance abuse clinicians.     

Divalproex sodium in substance abusers with mood disorder

BACKGROUND: Substance abuse is a common comorbid illness in patients with mood disorders. Little has been written about the pharmacologic treatment of patients with affective lability and co-occurring substance abuse, however. The following report will describe clinical experience using divalproex sodium in substance-abusing patients with mood disorder. METHOD: Twenty patients admitted to an intermediate-care inpatient substance abuse program were diagnosed with comorbid mood disorder (according to DSM-IV criteria) and treated with divalproex sodium in an open-label, naturalistic trial with no blind. All patients were followed clinically and were assessed using the Clinical Global Impressions scale (CGI) and laboratory studies. RESULTS: Seven patients referred while on divalproex treatment continued to exhibit improved mood. Eleven others had at least 1 week of follow-up, and 10 of these also showed improvement. In 13 cases, divalproex was used safely with other psychiatric medications. Two patients complained of slight tremor, 1 of whom was also taking fluoxetine. Fifteen of 17 patients in whom biochemistry and hematology laboratory studies were completed had unremarkable results; 2 other patients had pretreatment abnormalities, which worsened over the course of treatment. Mean plasma valproate level was 58.53 microg/mL. Mean length of follow-up was 38 days. Mean period of abstinence prior to starting medication was 48 days. Some patients reported decreased cravings, and, by self-report, all patients remained abstinent. CONCLUSION: This report suggests that divalproex sodium is efficacious and safe, both alone and in combination with other psychiatric medications, in treating substance-abusing patients with mood disorder.     

Psychiatric syndromes in adolescent substance abusers

Conduct disorder, major depressive episode, and the combination of attention deficit, hyperactivity, and impulse disorder were the most prevalent diagnoses after detoxification among 57 adolescents consecutively referred to an inpatient facility for treatment of substance abuse and other concurrent psychiatric disorders.     

Sex differences in depressed substance abusers

OBJECTIVE: The main goal of this article is to highlight gender-specific differences in the epidemiology, clinical nature, and treatment responses of comorbid depression and substance abuse. The second goal is to make recommendations for future research in the area of gender-specific aspects of comorbid depression and substance abuse. DATA SYNTHESIS: A literature review was conducted using the keywords sex, gender, depression, and substance use disorders for the time period 1980 to the present. We first outline the well-known sex differences in the epidemiology of depressed substance abusers and discuss the clinical significance of substance abuse in depression. Two distinct ways of understanding the role of substance abuse in depression are presented. The first is the role that depression may play in escalation of substance use, and the second is depression as a common sequela of chronic substance abuse. These 2 manifestations that are not mutually exclusive, often co-occurring in female substance abusers, have important treatment implications. Research on treatment response for the above clinical presentations is discussed followed by a summary of the factors that may influence sex differences in the association between depression and substance abuse. CONCLUSION: Recommendations for future research examining sex differences in animal models of depression, substance abuse, and therapeutic response to medications were made. The need for gender-specific clinical research on the association between depression, stress, and substance abuse is also highlighted.     

Axis II comorbidity in substance abusers

OBJECTIVE: To assess the complex relationship between substance abuse and personality disorders, the authors determined the prevalence of personality disorders in a group of middle-class substance abusers and compared the subjects who had personality disorders with those who did not. METHOD: The subjects were drawn from patients consecutively admitted to an inpatient substance abuse program in a private psychiatric hospital; they were the first 100 who agreed to participate. Substance dependence was diagnosed according to DSM-III-R, and the patients were assessed with the Structured Clinical Interview for DSM-III-R Personality Disorders, Alcohol Use Inventory, MMPI, Health and Daily Living Form, Shipley Institute of Living Scale, and measures of chemical use and life satisfaction. RESULTS: Of the 100 substance abusers, 57 had personality disorders. These patients differed significantly from the 43 patients without personality disorders in several ways: they had greater involvement with illegal drugs, had different patterns of alcohol use, had greater psychopathology, were less satisfied with their lives, and were more impulsive, isolated, and depressed. CONCLUSIONS: Because of the marked differences between the substance abusers with and without personality disorders, a uniform approach to substance abuse treatment may be inadequate.     

Stress hormone responses to corticotropin-releasing hormone in substance abusers without severe comorbid psychiatric disease.

BACKGROUND: Preclinical data indicate a crucial role of stress in the acute effects of drugs of abuse, maintenance of self-administration, and susceptibility to relapse. Stress system activation may serve as a marker for a neurochemical dysfunction with prognostic significance in patients with addiction. METHODS: We tested pituitary adrenocorticotrophin (ACTH) and adrenal cortisol response to ovine corticotropin-releasing hormone (oCRH) to assess the reactivity of the hypothalamic-pituitary-adrenal (HPA) axis in seven nonsubstance-abusing subjects, 31 polysubstance-abusing subjects without depressive symptoms, and seven subjects with substance abuse and depressive symptoms. No subject met diagnostic criteria for depression or other severe psychiatric disease. RESULTS: Compared with normal control subjects, substance abusers showed significantly lower ACTH and cortisol responses over the course of oCRH stimulation (p <.0001). Substance abusers with depressive symptoms showed similarly blunted responses. CONCLUSIONS: Polysubstance abusers with no past or current diagnosis of other Axis I disorders show blunted ACTH and cortisol responses to oCRH administration. The finding of an activated HPA axis in this population suggests an overlapping role of central CRH and HPA axis activation in affective disorders and substance abuse, which is likely to constitute an endocrine milieu necessary for the maintenance of addictive behavior. These data support the role of future therapeutic trials with nonpeptide CRH receptor 1 antagonists in these patients.     

Social networks and psychopathology among substance abusers

The authors studied the social networks and psychopathology of 168 patients with diagnoses of substance abuse. Small network size was correlated with higher scores on the Modified Michigan Alcohol-Drug Screening Test, higher symptom reports on the SCL-90 and the Beck Depression Inventory, and more observed psychopathology according to the Brief Psychiatric Rating Scale. Larger network size was correlated with better functioning according to the Global Assessment Scale and DSM-III axis V. The authors conclude that such symptom complexes as paranoia and phobia may undermine the social networks of substance abusers more than such symptom complexes as anxiety and depression.     

Cognitive-behavioral treatment of older veterans with substance abuse problems

The authors describe the initial cohort of participants in the GET SMART program, an age-specific, outpatient program for older veterans with substance abuse problems. Chief among the program's services is a relapse-prevention intervention consisting of 16 weekly group sessions using cognitive-behavioral (CB) and self-management approaches. Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use, followed by a series of modules to teach coping skills for coping with social pressure, being at home and alone, feelings of depression and loneliness, anxiety and tension, anger and frustration, cues for substance use, urges (self-statements), and slips or relapses. Of the first 110 admissions, more than one-third were homeless, which is indicative of the severity of psychosocial distress of the patients, and more than one-third used illicit drugs. A total of 49 patients completed CB treatment groups and 61 dropped out of treatment. At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters. The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.     

Symptoms and lifetime treatment experiences in psychotic patients with and without substance abuse

The main objective of this study was to compare symptom load and lifetime treatment experiences between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients’ were grouped into two categories based on whether they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used the Positive and Negative Symptom Scale (PANSS) scale to measure symptoms and several scales to measure substance abuse. Parametric tests (independent t-tests) were used to compare continuous variables, and chi-square tests were used to compare frequencies. Positive symptoms, negative symptoms, general psychopathology symptoms and the total score of psychotic symptoms did not differ significantly between the groups with psychosis alone and psychosis with substance abuse. The delusion subscore was significantly higher in the group with psychosis alone (t=?2.3, df=41, P<0.05), and the anxiety subscore was significantly higher in the group with psychosis with substance abuse (t=?2.3, df=41, P<0.05). There were no significant differences in the subscores for negative symptoms. The absence of differences in psychotic symptoms between the two groups with psychosis does not imply a strong relationship between psychotic symptoms and substance abuse. These results do not support the self-medication hypothesis. The higher rates of institutionalization among substance abusers may be explained by mechanisms other than exacerbations of psychotic symptoms, as there are few differences in symptoms among abusers and non-abusers.     

Symptoms and lifetime treatment experiences in psychotic patients with and without substance abuse

The main objective of this study was to compare symptom load and lifetime treatment experiences between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients' were grouped into two categories based on whether they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used the Positive and Negative Symptom Scale (PANSS) scale to measure symptoms and several scales to measure substance abuse. Parametric tests (independent t-tests) were used to compare continuous variables, and chi-square tests were used to compare frequencies. Positive symptoms, negative symptoms, general psychopathology symptoms and the total score of psychotic symptoms did not differ significantly between the groups with psychosis alone and psychosis with substance abuse. The delusion subscore was significantly higher in the group with psychosis alone (t = -2.3, df = 41, P < 0.05), and the anxiety subscore was significantly higher in the group with psychosis with substance abuse (t = -2.3, df = 41, P < 0.05). There were no significant differences in the subscores for negative symptoms. The absence of differences in psychotic symptoms between the two groups with psychosis does not imply a strong relationship between psychotic symptoms and substance abuse. These results do not support the self-medication hypothesis. The higher rates of institutionalization among substance abusers may be explained by mechanisms other than exacerbations of psychotic symptoms, as there are few differences in symptoms among abusers and non-abusers.