SUBSTANCE ABUSE IN SCHIZOPHRENICS
Understanding Co-Existing Schizophrenia and Drug Abuse
by Helen Borel, PhD
Ten years ago, Peter F. Buckley, M.D. of the Dept. of Psychiatry at Case Western Reserve University noted - in his review of studies on schizophrenics suffering concommitant substance abuse1 - that "Approximately [50 % of schizophrenics] are also substance abusers at some time during their illness." He went on to assert that, "The motivational drive toward abusive consumption is compounded in individuals with schizophrenia who turn toward substances with reinforcing properties to alleviate aspects of psychosis."
Dr. Buckley further stressed, despite treatment with the traditional antipsychotic drugs prescribed for schizophrenia at the time that, unfortunately, these very ill patients persisted in their harmful use of addictive substances such as alcohol, tobacco and cocaine. He pointed out that Clozaril (R) (clozapine) - a so-called "newer-generation antipsychotic" - showed promise as long as 10 years ago, because of its ability to reduce the use of cocaine, alcohol and cigarettes.
Futhermore, he warns, "[These] patients are notoriously difficult to effectively engage in treatment, and they have a reduced probability of therapeutic response with traditional antipsychotic drugs."
Why Schizophrenics Engage in Substance Abuse
The idea that a pre-existing, genetically-determined, undiagnosed schizophrenia, or a genetic tendency toward that psychosis was inherent prior to substance abuse behavior was initiated by the patient is not controversial. Probably, additionally, the substance abuse itself tips such an individual over the mental balance precipice toward developing schizophrenia. So, the biologic dynamics - in the neurotransmitter (brain chemical) system - of overuse of certain substances plus the vulnerability to schizophrenia may intertwine, rendering the afflicted person doubly victimized.
Self-Medication to Relieve Bad Side Effects of Rx Psych Medications Tremors, Parkinsonian-like movement disorders, and dysphoria (low mood states) are a few of the distressing and often unbearable side reactions of psychiatric drugs prescribed to banish the voices, delusions and other anomalous thought processes that beleaguer schizophrenics. Thus, alcohol and cocaine abuse may be resorted to in order to erase these prescription drug drawbacks. Of course, these substances only compound the schizophrenic's psychotic state.
Multiple Substances of Abuse in Schizophrenia And those who are addicted are generally "polysubstance [multiple substances] abusers," making particularly challenging the assessment of these patients' baseline mental illness underlying their substance abuse behavior.
(1) Nicotine - Over 70% of chronic schizophrenics are nicotine dependent. This is problematic because, in addition to concerns about the respiratory health and cancer risks of smoking, cigarette addiction is considered a "gateway" to the abuse of other agents.
(2) Cocaine - Up to 50% of schizophrenics are cocaine abusers and some researchers provide evidence that these specific schizophrenics could have a somewhat milder form of the psychosis only to be worsened by cocaine abuse.
(3) Alcohol - Up to 60% of former inpatients, who were diagnosed as psychotic, go on to abuse alcohol "for its euphoric, antidepressant, or relaxing effects, " reports Dr. Buckley. What is more, he stresses, "Alcohol abusers...have more florid symptoms, more re-hospitalization, and a poorer long-term outcome."
Negative Treatment Outcomes in Psychotic Substance Abusers
Substance-abusing schizophrenics tend to (a) avoid mental healthcare professionals, (b) refuse to take prescribed antipsychotics, and (c) were much sicker six months after their "dual diagnosis" of substance abuse + psychosis.
Positive Results with Newer, Atypical Rx Antipsychotics
One drug, clozapine, appears to have helped these dually-diagnosed patients a decade ago. And it is still in use today. Particularly because this chemical class has (1) a decreased side-effect profile, (2) the capacity to reduce addictive cravings, and (3) the propensity to induce improved behaviors that reinforce healthier social interactions in this normally socially-averse and behaviorally-bizarre patient population. These beneficial effects incentivize the schizophrenic to stay on the antipsychotic medication clozapine and to cooperate with the necessary monitoring by medical and psychiatric professionals.
Psychotic Substance Abusers...Still a Dire Challenge to Psychiatric and Emergency Medicine Practitioners
Today, other drugs can be useful in treating schizophrenia co-existing with substance abuse. Yet this tenacious co-occurring affliction continues to plague psychiatric divisions of hospital Emergency Rooms, psychiatric inpatient hospitals, and other mental health facilities throughout this country.
A clue to helping such patients recover from substance abuse and comply more easily with their antipsychotic drug regimen is implicit: Psychotic patients require inpatient hospitalization in order to get the comprehensive medical, psychiatric, psychotherapeutic, nutritional, pharmacologic and psych nursing care they so desperately need while they are hearing voices, while they are delusional, while they are unable to take care of themselves, while they are frightened by their illness.
Professional Abandonment of Psychotic Patients Persists
Why such very sick individuals are discharged from inpatient psychiatric care and left to their own devices on the street - or to the untrained, overburdening care of distressed loved ones - is an utter bafflement to me. This is a medical outrage, a psychiatric disgrace inflicted on these helpless psychotics by the movement decades ago "to empty all the mental hospitals" and situate the mentally ill in the community.
That was a noble concept; however, it was meant for those patients who had recovered to a degree where some self-care was possible and where the disabling symptoms were under control. Nevertheless, this wholesale discharge of very ill psychotic persons continues.
I consider this practice an abandonment of patients who are unable to fend for themselves and a blot on the profession of psychiatry. I believe some psychiatrists are discharging such patients because of fee-coverage restrictions by HMOs and other insurers, being constrained by the CEOs of Mental Health Facility conglomerates to get rid of patients once the money pot appears to be drying up. For shame, when a society won't take care of its most fragile citizens!
1. Buckley, M.D., Peter F.: "Substance Abuse in Schizophrenia: A Review," J . Clin. Psychiatry , Vol. 59 (suppl 3) 1998.
(c) copyright 2008 by Dr. Helen Borel. All rights reserved.
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