Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder.

The relationship between history of specific types of substance abuse (alcohol, stimulants, cannabis, hallucinogens, narcotics) and demographic and diagnostic variables was evaluated in a large (n = 263) sample of schizophrenic, schizoaffective, major depression and bipolar disorder patients. Prevalence rates were also compared with rates observed in a previous study (1983-1986) conducted using the same methods. Demographic characteristics (gender, age, race, educational level) were strong predictors of type of substance abuse. Patients with a history of cocaine abuse had fewer prior hospitalizations, suggesting that less impaired psychiatric patients may be more prone to illicit substance abuse. Diagnoses were not related to most types of substance abuse, although there was a trend for bipolar patients to have a history of alcohol abuse. The results demonstrate the importance of matching groups on demographic characteristics when exploring diagnostic differences in preference to abuse specific types of substances.     

Substance abuse in bipolar disorder

Background: High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized.

Methods: Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted.

Results: Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations.

Conclusions: Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.     

Substance abuse and first-episode schizophrenia-spectrum disorders. The Danish OPUS trial

Aim: To evaluate whether integrated treatment (given by OPUS), in comparison with standard treatment, significantly reduced the number of patients with substance abuse and improved clinical and social outcome in the group of substance abusers after 2 years. Methods: A total of 547 patients with first‐episode schizophrenia‐spectrum disorders were included in the study, 275 randomly assigned to OPUS treatment and 272 to standard treatment. OPUS treatment consisted of assertive community treatment with family involvement and social skills training. Standard treatment offered contact with a community mental health centre. Main outcome measure was reduction in comorbid substance abuse. Results: At 2‐year follow up, 42 (17.3%) patients from OPUS and 40 (20.7%) patients from standard treatment met criteria for substance abuse (odds ratio=0.5, 95% confidence interval 0.3–1.0). OPUS treatment compared with standard treatment significantly reduced negative and disorganized symptoms in the substance abuser group. Patients with substance abuse in the OPUS treatment spent significantly fewer days in hospital during the 2‐year period than patients given standard treatment (109 days vs. 167 days) and adhered to treatment significantly more often. Conclusions: Results from this trial indicate that integrated treatment given by OPUS reduced substance abuse and improved clinical outcome in the substance abuser group. Supplementing the OPUS treatment with therapeutic programmes for patients with a comorbid substance abuse would probably further improve outcome.     

Reasons for substance use in schizophrenia

Abuse of and de pendence 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.     

Comorbid substance abuse and neurocognitive function in recent-onset schizophrenia

Despite the high prevalence of comorbid substance use disorder (SUD) up to 65% in schizophrenia there is still few knowledge about the influence of substance abuse on neurocognitive function. In a prospective design we recruited 68 patients (aged 18–40 years) diagnosed as recent-onset schizophrenia or schizoaffective disorder consecutively admitted to hospital. The patients received standardized psychopathological evaluation of schizophrenic symptoms [Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Negative Symptoms (SANS)], depressive symptoms [Montgomery Asberg Depression Rating Scale, (MADRS)] and global ratings [Clinical Global Impressions Scale (CGI), Global Assessment of Functioning Scale (GAF)]. Out of this sample 44 subjects underwent after stabilization (4–6 weeks after admission) neuropsychological investigation focusing on early information processing (Trail-Making-Test A, Digit Span), visuo-spatial ability (Corsi Block Tapping), verbal fluency (Verbal Fluency Test, semantic and letter category), and executive functioning and cognitive flexibility [Trail-Making-Test B, Wisconsin Card Sorting Test (WCST)]. About 36% of patients reported drug abuse [European Addiction Severity Index (EuropASI)] with a high prevalence for cannabis. Compared with nonabusers the sample of substance abusers was younger, predominantly male and had lower socioeconomic status. Attentional impairment according to the SANS subscale was less in abusers than in nonabusers on admission, no other psychopathological differences could be detected. Schizophrenic patients without substance abuse demonstrated significantly better performance only in a few neurocognitive tasks (Verbal Fluency, letter category and at trend level Digit Span, backwards), while there tended to be an advantage for substance abusers in executive functioning (WCST, not significant). These results are consistent with other studies of first-episode patients. The lack of higher cognitive disturbance in young schizophrenic patients with comorbid substance abuse may encourage clinicians to develop integrated treatment programmes using cognitive strategies of drug therapy.     

Attitudes about schizophrenia from the pilot site of the WPA worldwide campaign against the stigma of schizophrenia

Background: A series of surveys were conducted to assess the attitudes of the public, and other groups, toward those with schizophrenia. The aim of these surveys was to aid in the planning and evaluation of the WPA anti-stigma initiative in Alberta, Canada. Method: A questionnaire was devised and administered via telephone to over 1,200 individuals in three Alberta cities, and in paper and pencil format to 40 members of the Schizophrenia Society of Alberta and 67 medical students. Results: In contrast to some earlier findings, “loss of mind” was rated to be more disabling than any other handicapping condition. In general, respondents showed a relatively sophisticated understanding of schizophrenia and a higher level of acceptance than might have been predicted. Nonetheless, this acceptance was not as high for situations where closer personal contact was likely, and fears of dangerousness continue to be associated with schizophrenia. The majority of respondents, however, felt that treatment aided those with schizophrenia, expressed support for progressive programmes for the mentally ill, and stated that they would be willing to pay higher taxes so that programming could be improved. Conclusions The results do not support the utility of a broad approach for an anti-stigma campaign, but rather suggest a more specific focus, such as perceived dangerousness. Accepted: 17 June 2002     

Patients' and their relatives' causal explanations of schizophrenia

Background: Previous studies with schizophrenia patients and their relatives which have been carried out in the western part of Germany and in Austria have demonstrated a strong tendency towards assuming psychosocial stress as a cause of schizophrenia. The question arises as to whether patients with schizophrenia and their relatives in the eastern part of Germany (former German Democratic Republic) share these beliefs. Methods: Problem-centered interviews were conducted with 100 schizophrenia patients living in the catchment area of the university hospital who were in psychiatric outpatient treatment. Thirty-six relatives were also interviewed at the same time. Results: Both patients and relatives most frequently reported psychosocial stress as a cause of the illness. Sixty-two per cent of the patients and 86 % of the relatives reported more than one cause. However, the majority of them did not explicitly link these causes to one another. Discussion: Similarities between the results of this study and those of previous studies prevail. However, there are some differences with regard to the role attributed to socialisation and society. Whereas there is a stronger tendency to hold the family responsible for the illness in the West, in the East the social conditions are more frequently considered to be of etiological relevance. Inconsistencies between patients' and relatives' beliefs and the results of psychiatric research on the causes of schizophrenia suggest a need to provide specific psychoeducation for both. Received: 28 October 2002 / Accepted: 4 November 2002 Correspondence to Dr. Anita Holzinger     

The temporal relationship between schizophrenia and crime

Background Little is known about the temporal relationship between illness onset and the possible beginning of a criminal career among people with schizophrenia, even though criminality, especially violent criminality, has been shown to be more common among people with schizophrenia than among people in general. Aim: The aim of this study was to analyse the temporal relationship between registered crime and contact to the psychiatric hospital system. Method: This is a register-based study merging data on the psychiatric career with criminal records. Results: Among the males with schizophrenia, 37% started a criminal career and 13% had committed first violent crime before first contact with the psychiatric hospital system. Conclusion: The criminality committed before first contact to the psychiatric hospital system is substantial, especially among males with schizophrenia. Accepted: 22 February 2003 Correspondence to Runa Munkner, MD     

Hospital and community-based care for patients with chronic schizophrenia in Hong Kong

Background: There have been few studies on the impact of de-institutionalization on psychiatric patients' lives in Chinese culture. The objectives of the present study were: (1) to compare quality of life (QOL) of Chinese patients with schizophrenia living in three different treatment settings (hospital, long-stay care home and half-way house) in Hong Kong, and (2) to identify factors associated with patients' subjective well-being. Method: A matched-group design was used. Subjects (n = 204) living in the three treatment settings were matched according to age, sex, educational level, marital status, length of psychiatric illness and number of previous psychiatric admissions. Multiple measures for the evaluation of QOL included the Satisfaction With Life Scale (SWLS), WHO Quality of Life Measure-Abbreviated version-Hong Kong (WHOQOL-BREF-HK), Life Event List (LEL) and the Global Assessment Scale (GAS). Psychiatric symptoms were evaluated with the Brief Psychiatric Rating Scale (BPRS). Results: Significant differences in objective QOL indices (global level of functioning, number of life events and income) between subjects staying in hospital and community-based residential services were found in favour of the less restrictive community settings. However, with respect to global life satisfaction, subjects preferred the more secure settings despite their restrictiveness. Predictors of subjective well-being were educational level, negative life events and the BPRS items of somatic concern, anxiety and guilt feelings. The impact of negative life events on subjective well-being decreased over time. Conclusion: In a cohort of Chinese patients with chronic schizophrenia, community-based treatment settings had a positive impact on objective QOL indices but not on subjective well-being. Negative life events, education level, and the BPRS items of somatic concern, anxiety and guilt feelings were predictors of subjective well-being which seemed to adapt to external circumstances over time. Accepted: 1 October 2002 Correspondence to Dr. G. S. Ungvari     

Reasons for the diagnostic discordance between clinicians and researchers in schizophrenia in the Northern Finland 1966 Birth Cohort

Background: The diagnosis of schizophrenia by clinicians is not always accurate in terms of operational diagnostic criteria despite the fact that these diagnoses form the basis of case registers and routine statistics. This poses a challenge to psychiatric research. We studied the reasons for diagnostic discordance between clinicians and researchers. Methods: The Northern Finland 1966 Birth Cohort (n = 11,017) was followed from mid-gestation to the end of the 31st year. Psychiatric outcome was ascertained through linkage to the national hospital discharge register containing clinical diagnoses made by the attending physician. The hospital notes of all subjects admitted to hospital during the period 1982–1997 due to psychiatric disorder were reviewed and 475 research, operational DSM-III-R diagnoses were formulated. Results: Ninety-six cases met operational criteria for schizophrenia. Fifty-five (57 %) had concordant diagnoses: both the clinical and research diagnoses were schizophrenia. Forty-one (43 %) had discordant diagnoses: the clinical diagnosis was other than schizophrenia (mainly schizophreniform or other psychosis). Discordant cases were more likely to be older at onset, experience a shorter treatment duration, fewer treatment episodes, and to have a comorbid diagnosis mental retardation. Conclusions: Clinicians do not make the diagnosis of schizophrenia as often as the application of operational criteria would suggest they should. The discordance between clinical diagnosis and the research, operational diagnosis is especially likely in cases having late onset and few contacts to psychiatric hospital. Accepted: 12 December 2002 Correspondence to Kristiina Moilanen, MD     

Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia

Background: The aim of this study was to explore the characteristics and efficacy of psychoeducational family intervention for persons with schizophrenia in rural China. Methods: A cluster randomised controlled trial of psychoeducational family intervention for families experiencing schizophrenia (three groups, 326 cases) was conducted in Xinjin County, Chengdu. Treatment groups consisted of family intervention and medication, medication alone, and a control. Results: The results showed a gain in knowledge, a change in the relatives' caring attitudes towards the patients, and an increase in treatment compliance in the psychoeducational family intervention group (p < 0.05, 0.001). Most importantly, the relapse rate over 9 months in this group (16.3 %) was half that of the drug-only group (37.8 %), and just over one-quarter of that of the control group (61.5 %) (p < 0.05). Antipsychotic drug treatment and families' attitudes towards patients after the 9-month follow-up were significantly associated with clinical outcome (p < 0.05). Conclusions: In rural China, family intervention should focus on improving the relatives' recognition of illness, the caring attitude towards the patients, treatment compliance, relapse prevention, and the training of the patients' social functioning. This trial, one of the largest in the literature, has shown that psychoeducational family intervention is effective and suitable for psychiatric rehabilitation in Chinese rural communities. Received: 16 April 2002 / Accepted: 29 August 2002 Correspondence to Mao-Sheng Ran, M. D., Ph. D.     

An empirical comparison of substance and alcohol dependence patterns in the homeless in Madrid (Spain) and Los Angeles (CA,USA)

Background Alcohol and drug use continue to figure heavily in the experience of the contemporary homeless population. The comparison among pattern of use plays a central role in the cross-cultural view of this topic. This article shows the results of comparing the data concerning alcohol and other drug abuse and dependence among the homeless population of Madrid (Spain) and Los Angeles (USA). Methods Data come from two studies carried out independently in each city. Both studies used a comparable methodology which included the same inclusion and diagnostics criteria, representative sampling methods and similar diagnostic structured interviews. In the present study, the data from these two studies are combined in a unique database which allows global and item-to-item comparison between the two studies. Results The results show different sociodemographic profiles for each city. Once controlled for the sociodemographic differences (age, education, current employment status and marital status), the life and 12-month prevalence rates of alcohol and other drug disorders (DSM-III-R) are also different. There are also significant differences in social, emotional and health problems associated with the consumption of alcohol and other drugs. The Madrid and LA samples also present differences in the time patterns of the beginning of the homelessness situation and the onset of alcohol- and drug-related disorders. Conclusions The pattern of results is discussed in the light of the differences in both socioeconomic and cultural among Madrid and Los Angeles which might explain, in turn, differences in the homelessness situation as well as in the alcohol and other drug use patterns. Accepted: 27 February 2002     

Cognitive functions and psychopathological symptoms in early-onset schizophrenia

Type and extent of objectively tested cognitive impairments (attention, verbal fluency, nonverbal reasoning) and their association with self-ratings (Paranoia Depression Scale; Frankfurt Complaint Questionnaire) and clinical assessments (Brief Psychiatric Rating Scale, Scales for the Assessment of Positive Symptoms and Negative Symptoms) of psychopathological symptoms were studied in a sample of 74 adolescents primarily suffering from chronic schizophrenia (DSM-III-R; mean duration of illness = 3.4 years), including 15 patients with a very early onset (<14 years). Special consideration was given to the differentiation between positive and negative symptoms. In cross-sectional analyses, the schizophrenic adolescents were remarkably impaired in both cognitive functions (attention, reasoning) and psychopathological measures (BPRS, SANS, SAPS). However, factor analysis yielded orthogonal factors for cognitive and psychopathological parameters, and canonical correlation analyses did not find a significant correlation between these two areas. As the degree of objectively measured cognitive impairment in chronic schizophrenic adolescents cannot be predicted by the severity of individual psychopathological symptoms, a multidimensional evaluation of the symptomatology seems to be appropriate. Moreover, premorbid disturbances (motor and/or language developmental disorders) and onset characteristics (age, pattern, subdiagnosis), and their relationship to cognitive impairments were investigated. Premorbid disturbances were confirmed as risk factors for the subsequent occurrence of cognitive impairments. Accepted: 23 August 1999     

Differences in substance abuse patterns: multiple drug abuse alone versus schizophrenia with multiple drug abuse.

OBJECTIVE: To compare the lifetime consumption patterns of patients with schizophrenia and multiple substance abuse and multiple substance abusers without schizophrenia. METHOD: Two hundred and thirty in-patients of a specialized rehabilitation facility for young drug abusers were assessed with regard to their lifetime consumption patterns of 16 different classes of psychoactive drugs. While 110 patients had no diagnosis of a schizophrenic disorder, 120 patients had a comorbidity of multiple substance abuse and schizophrenia. RESULTS: Comorbid patients reported a higher lifetime consumption of hallucinogens, whereas multiple substance abusers without schizophrenia showed a higher lifetime consumption rate of cocaine. CONCLUSION: The differences found in lifetime consumption patterns between comorbid patients and substance abusers without psychotic disorder do not support the so-called self-medication hypothesis. Instead, the differences in lifetime consumption of certain drugs might be a result of lower social competence and standing in schizophrenic patients and lower ability to procure certain illicit drugs.     

Substance dependence among those without symptoms of substance abuse in the World Mental Health Survey

The World Health Organization (WHO) World Mental Health (WMH) Survey Initiative uses the Composite International Diagnostic Interview (CIDI). The first 13 surveys only assessed substance dependence among respondents with a history of substance abuse; later surveys also assessed substance dependence without symptoms of abuse. We compared results across the two sets of surveys to assess implications of the revised logic and develop an imputation model for missing values of lifetime dependence in the earlier surveys. Lifetime dependence without symptoms of abuse was low in the second set of surveys (0.3% alcohol, 0.2% drugs). Regression‐based imputation models were built in random half‐samples of the new surveys and validated in the other half. There were minimal differences for imputed and actual reported cases in the validation dataset for age, gender and quantity; more mental disorders and days out of role were found in the imputed cases. Concordance between imputed and observed dependence cases in the full sample was high for alcohol [sensitivity 88.0%, specificity 99.8%, total classification accuracy (TCA) 99.5%, area under the curve (AUC) 0.94] and drug dependence (sensitivity 100.0%, specificity 99.8%, TCA 99.8%, AUC 1.00). This provides cross‐national evidence of the small degree to which lifetime dependence occurs without symptoms of abuse. Imputation of substance dependence in the earlier WMH surveys improved estimates of dependence.     

Role of family in alcohol and substance abuse

Abuse is a family disease, which requires joint treatment of family members. Family is an important part of the diagnosis and treatment chain of alcohol and substance abuse. Abuse of alcohol and substance is a response to fluctuations in the family system. In consideration of interactions within the system, it seems an important requirement that the clinician involves, and maintains the presence of, the family in its entirety in the treatment process. A family often needs as much treatment as the family member who is the abuser of alcohol or a substance. In this regard, participation of the family in the treatment process as group members and by assuming a supportive role are assets in terms of preventing relapse, and extending clean time, and also very important for solving conflicts that give rise to abuse of alcohol or substances. Accordingly, it is important to know the family structure and its role in the treatment process. This article covers a review of family systems separately in terms of alcoholism and substance abuse.     

Integrating Services for Schizophrenia and Substance Abuse

Over the past decade, several studies have attempted to determine whether integrating psychiatric and substance abuse treatment leads to better outcome for patients with comorbid schizophrenia and substance use disorders. A recent (1999) Cochrane Review (1) analyzed the effectiveness of prospective randomized studies of integrated treatment approaches, and concluded that there was no clear evidence for superiority of integrated treatment. This paper describes one such integrated treatment approach, in Beth Israel Medical Center's COPAD (Combined Psychiatric and Addictive Disorders) program. We summarize findings from an initial outcome study and a recent replication study; and describe clinical and research issues relevant to this population. Our data suggests the benefits of integrated treatment for patients with addictive disorders and schizophrenia, at least with regard to treatment retention. Clinical issues for such patients include identification of patients at risk, proper assessment and treatment planning, decision-making about mainstreaming vs. referral to specialized programs, and the importance of initial engagement and ongoing reengagement in successful treatment.     

Cannabis and schizophrenia: a longitudinal study of cases treated in Stockholm County

By means of the Stockholm County inpatient care register we identified all cases treated with a diagnosis of cannabis dependence and psychosis, not necessarily at the same occasion, during 1971–1983. By scrutinizing medical records, we evaluated the diagnosis according to DSM-III-R and we assessed the history of substance abuse as well as the psychiatric history and clinical course. We identified 229 cases during the follow-up; 112 of these cases (49%) fulfilled the DSM-III-R criteria for schizophrenia. The majority of the schizophrenics had prominent positive symptoms and a sudden onset of disease, and 69% of the cases had a record of heavy cannabis abuse at least 1 year before onset of psychotic symptoms. The high number of verified DSM-III-R cases of schizophrenia in this cohort and the temporal relation between cannabis abuse and schizophrenia further support the hypothesis that cannabis abuse may be a risk factor for schizophrenia. We confirmed previous observations that cannabis-associated schizophrenia often has a sudden onset and prominent positive symptoms.