Substance Use Disorders Among Schizophrenic Individuals:


Psychotherapeutic Interventions


Evaristo O. Akerele, M.D.


Columbia University


New York, New York
I Introduction {Slide 2}


   A.  This lecture is aimed at healthcare practitioners.


1.      Medical students

2.      Psychiatric residents

3.      Others such as psychiatric nurses, social workers, etc.


B. The material relates to substance use disorders among schizophrenic individuals and covers  {Slide 3}

1.      Prevalence

2.   Consequences of use

3.   Etiology

4.   Psychotherapeutic interventions

5.   Limitations

6.   Conclusions


II Prevalence


A. The Major sources of epidemiological studies include: {Slide 4}

          1. The Epidemiological Catchment Area (ECA) study (1).

              2. The National Comorbidity Survey (NCS)(2).

             3. Emergency room data (3).

      4.  National Household Survey(4)

      B. Lifetime Risks {Slide 5}

             1. Schizophrenia: 1%

 2. Alcohol dependence: 12% for men and 5% for women

3. Cocaine dependence: 2% (4)

4. Nicotine dependence: 28% of men and women

 5. Marijuana dependence: 5% (4)

C. Lifetime risks for dependence on alcohol, illicit substances, and nicotine is     elevated    in schizophrenic individuals (2){Slide 6}

             1. Nicotine dependence: 70% (5, 6)

             2. Alcohol dependence: 37%

             3. Marijuana dependence: 23%

             4. Cocaine dependence: 13%


D.  There was a pattern of increase in drug use detected in schizophrenic individuals admitted to the ER from 1984 to 1996. {Slide 7}

            1. Cocaine use has increased from 0 to 73%

2. Marijuana use from 0 to 27%

3. Opiate use has not changed (11%) 




III Consequences of Use {Slide 8}

A. Subsections here first review problems in heavy repetitive use of the substance       (i.e. dependence) in the general population, and then cite special issues in schizophrenic individuals

      B. Alcohol {Slide 9}

 1. Intoxication produces poor judgement, anger, violence, and impaired coordination (7)

 2. These same problems have enhanced dangers in schizophrenics because:

a. Alcohol reduces the efficacy of antipsychotics by inducing hepatic enzymes.

b. In an already potentially violent population, alcohol further increases the odds of violent behavior.

  3. Chronic repetitive heavy use (dependence) increases the risk for:

              a. Cancers (8)

              b. Brain damage resulting in cognitive impairment (9).

              c. Cardiac disease (10, 11)

              d. Severe depression with suicidal ideas (12)

               e. Hallucinations

               f. Delirium tremens


 4. Special issues relating to schizophrenics include {Slide 10}:

               a. Relatively small amounts of alcohol adversely affects psychiatric stability.

               b.  Alcohol can increase cognitive deficits in schizophrenics and enhance depression.


C. Cocaine and amphetamines increase risk for {Slide 11}:

1.      Myocardial infarction

2.      Arrythymias

3.      Cerebrovascular accident

4.      Crack lung

5.      Paranoia

6.      Mood swings

7.      Reduced dopamine uptake

 8. Special issues relating to schizophrenic individuals include {Slide 12}:

a. Financial and housing difficulties due to poor money management (13).

b. Drug free schizophrenics may already have difficulty due to impaired cognition, paranoia and society’s perception. This is aggravated decompensation of a fragile mental state when substances are used

c. Frequent re-hospitalizations, poor treatment compliance (14) (15) (16). This naturally follows an inability to remain cognitively intact as a result of substance use.

d.      Less satisfying family relationships (17). These individuals already have limitations in social skills. The use of substances further aggravates this or results in the loss of the few learned skills.

e.  Increased odds of violent behavior (16). With the addition of substances psychiatric symptoms fluctuate rapidly. These substances aggravate paranoia, resulting in a potentially more violent individual.

e.       A higher risk of HIV infection than nonusers (18). Both schizophrenia and substance use place individuals at risk of physical and sexual abuse, with concomitant increased risk of sexually transmitted diseases.

     D.  Combined cocaine and alcohol  (cocaethylene) use, may result in

1.      Direct toxic effects on the myocardium

2.       Additive effect on locus coerleus, increased risk of panic

3.      Increased in duration of blood pressure elevation

4.      Increased cocaine use and liking

IV Etiology {Slide 13}

A.  Possible genetic crossovers between substance use disorders and schizophrenia

                  1. Substance dependence and schizophrenia are both genetically influenced.

2. Both substance use disorders and schizophrenia involve serotonin and dopamine systems.

3. Both frequently coexist. 40% of schizophrenics are substance dependent.

4. Dopamine is implicated in substance use through its,

            a. Presence in the prefrontal area

            b. Reward system

  5. Thus genes that impact on these neurochemicals might increase the risk for both types of disorders.

B. Drugs of abuse might be sought out and problems develop in an attempt to deal with the side effects of antipsychotic medications. The possible use of substances to help alleviate  symptoms of schizophrenia.

 1. Cocaine could give more energy, focus and reduce neuroleptic induced side effects. (19) (20, 21) (22). This is only transiently effective (23).

2. Alcohol and other depressants could decrease social inhibition and facilitate entry into drug abusing peer groups (19), albeit at substantial personal costs.

                  3.  Nicotine may improve ability to focus attention.

       4.  However, empirical support for the self-medication hypothesis is lacking

  C.  Availability: for many patients, availability seems to be the key issue(24) (25).

Like the general population, schizophrenics tend to use the more readily available drugs most often. Schizophrenics may have even more time to spend in the streets since a significant proportion do not work.

D. Impulsivity and reinforcing effects: high levels of impulsivity (26) and the reinforcing effects of the addictive substance may contribute to continued drug use. In this respect schizophrenics are no different from the general population.       

V Psychotherapeutic Interventions (27){Slide 14}

            Treatment of all substance misusing individuals, including those with schizophrenia, can be divided into four phases (28, 29). {Slide 15}:

       1. Engagement when the patient is in precontemplation.

       2. Persuasion when the patient is in contemplation.

3. Active treatment when the patient is ready to accept help (action).

4. Relapse prevention when the individual is trying to maintain sobriety.

5. These are all particularly difficult to apply in schizophrenics due to,

a. Limitations such as cognitive impairment,

b. Aggravation of psychiatric illness due to substance use

c. Greater need for socioeconomic support even during relapse prevention.

B.  Motivativational Enhancement Therapy (MET) {Slide 16}.

1. Definition: a therapeutic intervention aimed at shifting the balance from ambivalence to a desire to be substance free.

2.  Modality:

a.       Counseling approach for initiating behavioral change by helping individuals to resolve ambivalence about engaging in treatment and stopping drug use.

b.      Non-confrontational methods to take advantage of the internal drive to change (30) (31).

c.       Patient-centered style and stimulus for self-exploration needs to be modified for people with substance dependence and schizophrenia (32).

       3.  Principles: {Slide 17}

                        a.  Expression of empathy.

b.  Development of discrepancy. This aims to enable the individual to see the difference between his/her current situation and ultimate goals.

                        c.  Avoidance of argumentation.

                        d.  Rolling with the resistance.

e. Supporting self-efficacy. This involves teaching the individuals that they can recognize and their own resources to work towards abstinence. For example substance free supportive family members/friends.

4. Controlled Studies: In one study(33) 1,726 patients were randomly assigned to coping skills (CS), motivational enhancement (MET) and 12-step facilitation (TSF). Results;

a.       Those with high anger levels at the outset seemed to have better drinking outcomes if they got MET.

b.      Those with low anger levels at the outset seemed to do better with TSF.

c.       All three were equally effective in improving drinking behavior.


5. Utility: it is most useful in the engagement, persuasion and active phases of treatment.

6. Limitation: schizophrenic individuals may have alogia, which makes them far less motivated than substance abusers in the general population. More effort required for therapist.


C. Here is an example of MET. Briefly describe a patient. A schizophrenic patient comes in describes the lack of understanding from his wife. She wants a divorce. He feels she has never really tried to  understand his illness and how these medications make him feel like a “zombie.” “I don’t get that feeling when I use cocaine.” “I am trying to give up cocaine but she is not giving me a chance.” You can empathize by saying, “this must be difficult for you, especially as you are trying to stop using drugs.” Begin discussing his goals prior to drug use. .Conclude with “so most of your mental health and relationship problems since your drug use started.” He may argue and say “no not really.” Avoid trying to argue to prove him wrong. Move to the next phase. Suggest that he could start weekly sessions at the clinic. He may say “Oh I really cannot with this stiffness right now.” Roll with the resistance, suggest other medications that adequately reduce the unpleasant effect. Encourage him to ask for his wife’s assistance. She may have a change of heart if he invites her to his therapy sessions.

D.      Program for assertive community treatment (PACT).

1.      Definition: provision of maximum socioeconomic support necessary to assist patient in treatment.

2.      Modality: teams work 24 hours a day, 7 days a week to deliver treatment.

3.      Principles in PACT{Slide 18}:

a.       Emphasizing strengths: the patients' strengths in adapting to community life.

b.      Providing support and consultation: enhancing the patients' natural support networks.

c.       Providing outreach: flexibility and phase specific treatment, attempts are made to tailor substance abuse interventions to the patient's stage of change (34). 

4. Controlled studies:

            Reduces length of hospitalization; improves living conditions.

            a. 100 ER patients (35) randomized to PACT or usual services: at 3 months fewer symptoms, more satisfaction, and 1.2 versus 9.3 hospital days. Fewer lost to follow-up (6% vs. 29%).

            b. at two years (N=115) (36) PACT patients had fewer hospital days (5.2 versus 44.2 in the controls) (37) (38).

5.  Utility:  most useful in the engagement/persuasion phase of treatment and for individuals with no social network.

6.  Limitation: difficult to apply to schizophrenic substance dependent persons because many programs do not have necessary resources.

   E. Contingency management {Slide 19}:

1. Definition: a therapeutic intervention that uses provision of reward to change maladaptive behavior.

2. Modality: reduce substance use by providing alternative reinforcers during abstinence.

3. Principle:  relies on principles and conceptual framework of operant conditioning (39)A promising approach currently being adapted for schizophrenic individuals (40) (41).

4.  Four controlled Studies: 

a.  Used positive reinforcement (money) to significantly reduce cocaine use in two cocaine dependent schizophrenics(41)

b. Cigarette abstinence was greater during positive reinforcement than at both baselines time periods(42)

c. Positive reinforcement for reducing marijuana use among schizophrenics revealed similar results (43)

d. Positive reinforcement in reducing alcohol consumption among alcohol dependent schizophrenics. Reduced the proportion of drinks from a baseline mean of 55% to 10% which was maintained at 6 and 12-month follow-up.     (44) (45)

5. Utility: A promising approach being adapted for schizophrenic individuals (40) (41).  It is most useful in the active phase of treatment.

6. Limitation: Patients are likely to revert to previous behavior pattern after the reinforcer has been removed.

  F. 12-Step Groups {Slide 20}:

1.  Definition: Twelve AA-like stages of treatment to achieve and maintain abstinence.

2.  Modality: Self-motivation, and peer support (46).

3.   Principle: encourages 12-step abstinence based approach. Controlled/moderating drinking is not considered possible. The philosophy is “once an alcoholic, always an alcoholic.”

4.   Controlled studies:

a.        631 previously untreated alcoholics randomized AA vs professional inpatient/outpatient therapy. Follow up 1-8years. Number of AA meetings positively related to abstinence.  AA did better overall (47).

b.      One year follow up of veterans: AA was more strongly related to outcomes than outpatient attendance (48).

5. Utility: Especially useful in the active phase. Modified twelve-step (49) accepts members who are taking psychotropic medication.

6. Limitations:

a.       Problematic for schizophrenia: do not tolerate confrontations and emotionally charged situations (50).

b.      Some AA groups do not accept need for psychotropic medications.

c.       Schizophrenics can be seen as odd/paranoid and this may result in rejection by the group.

    G. Relapse Prevention {Slide 21}:

1.   Definition: seeks to stop the return to previously acquired maladaptive behavior 

2.  Modality: Person changes cognitive/behavior response to boredom and negative pressure (51) (52). “I can do other enjoyable things with a more positive group”

3.  Principle: Individuals learn to identify, participate and correct problematic behaviors that might increase substance abuse (e.g. boredom and negative peer pressure as risk factors for relapse).

a. Learning techniques: practice and role-playing, feedback, homework, and positive reinforcement (30).  Practices through role modeling.

b. Self-determination: relies on self-determination and motivation.

4.   Controlled Studies: efficacy up to one-year post treatment (51).

5.    Utility:  most useful in the maintenance phase of treatment.

6. Limitation: schizophrenics may have difficulty remembering triggers. Development of model adapted to their needs is necessary.

VI Limitations of Current Psychotherapeutic Interventions {Slide 22}

  1. Inadequate number of controlled studies.
  2. Difficulty in applying these modalities to schizophrenics with substance use disorders.

VII Conclusion {Slide 23}

A.     Substance use by schizophrenics is a major public health issue.

B.     Well-controlled trials for psychosocial treatment approaches are currently inadequate.

C.     Well-tailored interventions that take into account the special needs of these schizophrenic substance abusers are necessary.

D.     Psychosocial factors might have a significant impact on treatment outcome.






















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