Treating substance abuse in schizophrenia. An initial report.

Schizophrenia patients show alarmingly high rates of substance use disorders. These patients experience neurocognitive and social deficits that make it difficult for them to benefit from effective treatment strategies designed for less-impaired populations. Previously, we described Behavioral Treatment for Substance Abuse in Schizophrenia and discussed how the program was adapted for this population. Here we provide an update of BTSAS, discuss our clinical experience running the intervention, and review how it has changed over five years of development. We present attendance, participation, and substance use data on patients who consented to attend (n = 42), completed (n=14), and dropped out (n = 14) of the program. Outcome data are provided for 14 patients, and comparisons are made between good (n = 5; > or = 67% of urine tests clean from a goal drug over 6 months) and poor (n = 9; < or = 66% of urine tests clean) progress patients. Implications for the treatment are discussed.

Generalization of training effects in schizophrenia.

The primary goal of this study was to investigate transfer of training (generalization) in patients with schizophrenia. We randomly assigned 33 schizophrenia subjects to one of three conditions: training on the Wisconsin Card Sort Test (WCST-T), training on the Halstead Category Test (CAT-T), or no training (No-T). The WCST and CAT were administered to all subjects at baseline. Subjects in the WCST-T and CAT-T groups then received training on the respective test, while the No-T group received additional untrained trials. All participants were subsequently retested on the WCST and CAT, and completed a brief neuropsychological battery. As hypothesized, the WCST-T and CAT-T groups exhibited large improvements on the trained test and moderate improvement on the untrained test, while the No-T group failed to show improvement on either test. These results suggest that the training paradigm did produce generalization, and that the changes were not due to practice effects. The extent of generalization across both training groups was strongly associated with neuropsychological test performance (Spearman's rho=0.56, P<0.05). The implications of these findings for rehabilitation programs were discussed, and recommendations were made for future research.

Drug-use behavior and correlates in people with schizophrenia.

This study examined how illicit drugs were accessed, reasons for drug use, prevalence of emotional, physical, and sexual abuse, psychiatric symptomatology, level of functioning, and the relationship of these factors to substance use in 25 schizophrenia outpatients. To identify unique substance-use behaviors or correlates, this information was compared to 25 substance-abusing outpatients with major affective disorders, and 30 people with schizophrenia alone. Patients largely financed their drug habits with money given by immediate family members, and reported using drugs primarily for social reasons. While all three groups reported high levels of physical, sexual, and emotional abuse, a relationship between emotional abuse and substance use was observed only for people with schizophrenia. There were no differences between the two schizophrenia groups in psychiatric symptoms or level of functioning. The treatment implications of these findings are discussed.

Sex differences in illness presentation, course, and level of functioning in substance-abusing schizophrenia patients.

Studies of gender differences in schizophrenia have concluded that women experience a more benign form of the illness than men as evidenced by later age of illness onset, less debilitating psychiatric symptomatology, fewer psychiatric hospitalizations, and better premorbid and overall functioning. Little research, however, has focused on documenting the potential negative impact of substance use on these clinical outcomes. The purpose of this study was to evaluate gender differences in the effects of substance use on the course and presentation of schizophrenia. Two groups of schizophrenia outpatients were evaluated: 34 with substance-use disorders and 33 with no history of substance-use disorders. Sex comparisons were conducted on rates of current psychiatric symptoms, age of onset, number of previous hospitalizations and ratings of general level of functioning. The results suggest that the more benign course and presentation of illness ordinarily seen in women with schizophrenia become muted when they use substances. The data further suggest that women may be especially vulnerable to the adverse effects of substance use. Collectively, these findings highlight the need for additional research and the development of more effective treatment interventions for this population of women.

A psychological view of people with serious mental illness.

Focusing on a variety of relevant psychological theories, this chapter addresses important elements in the recovery process for people with serious mental disabilities.

Women with schizophrenia and co-occurring substance use disorders: an increased risk for violent victimization and HIV.

Women with serious mental illnesses are at risk for victimization and HIV. Schizophrenia related neurocognitive and social competency deficits exacerbated by the effects of substance abuse may make women with schizophrenia particularly vulnerable. Information processing deficits may impair the ability to identify situations or interpersonal cues signaling danger, and make it difficult to remember and hence avoid, situations, people, or places previously proven dangerous. Social competency deficits interfere with the ability to form lasting relationships, negotiate out of dangerous situations, refuse unreasonable requests, and effectively problem solve. Given the potential increased vulnerability of this population to these negative outcomes, empirically based manualized preventive interventions are greatly needed.

Awareness of substance abuse problems among dually-diagnosed psychiatric inpatients.

This study examines the ability to acknowledge the need for treatment of mental illness and substance abuse problems among dually-diagnosed inpatients before and after an inpatient substance abuse treatment program. A cohort of 264 consecutively admitted patients diagnosed with a mental illness and substance use disorder were entered into a dual diagnosis treatment program. Perceptions of patients diagnosed with a substance-induced mental disorder were compared to those of patients with a primary mental illness regarding their problems and need for treatment before and after the dual diagnosis program. Most patients acknowledged a substance abuse or mental illness problem and need for treatment. Patients with substance-induced mental disorders were more likely to acknowledge a substance use problem and need for treatment (p < .001). After treatment, changes in perception of mental illness were greater for substance-induced mental disorder patients compared to patients with a primary mental illness (p < .001). Persons with more severe substance abuse were more likely to acknowledge a problem and need for treatment. The majority of dually-diagnosed patients admitted with a substance use disorder agreed that substance use was a problem, suggesting that inpatient hospitalization presents a prime opportunity to address addiction in dually-diagnosed patients. The type of mental illness and severity of substance use influenced perceptions of illnesses and treatment readiness and must be considered by the clinician.

Substance abuse treatment for people with schizophrenia.

Substance abuse by people with schizophrenia is a serious public health problem that is associated with poor treatment compliance, increased rates of relapse, and disruption of role functioning. There is widespread agreement on the need to integrate psychiatric and substance abuse treatment for this dual disorder, but to date there are no specific treatments with solid empirical support. We first review the primary consequences of substance abuse by people with schizophrenia and then examine what is currently known about their treatment needs. We then describe the special problems faced by this population that interfere with their ability to reduce substance use, with or without treatment. The remainder of the paper focuses on description of a new behavioral treatment we have developed to compensate for the cognitive and motivational deficits that characterize the illness. We describe the development process and present some process data that demonstrate that the intervention is safe and acceptable for people with schizophrenia, and that we are able to train therapists to administer the procedures in a consistent and effective manner. Future studies will examine the effectiveness of the intervention.

Family members' ratings of the use and value of mental health services: results of a national NAMI survey.

OBJECTIVE: Data from a 1993 survey of families in the National Alliance for the Mentally Ill (NAMI) were analyzed to examine services used by consumers and families' perceptions of the services' value. Data from 1993 and 1976 were compared to document changes. METHODS: A total of 3,099 families responded to a mailed questionnaire that was first used in a 1976 local survey of 89 NAMI members. Respondents indicated which of 11 services had been used by their ill relative in the past two years and rated the services as having "no," "some," or "considerable" value. Chi square tests examined relationships between service use and value and key variables. RESULTS: In 1993 families reported nearly universal use of medications and rated them highest in value. More than 60 percent of the ill relatives had been hospitalized in the past two years, and hospitalization was rated second highest in value. Individual therapy, used by two-thirds of the consumers, also received high ratings. Community services were used by about a third of the consumers; these services were valued less highly than office-based services and medications. Respondents in 1976 reported less use of medication and residential services, more hospitalization, and more use of individual, group, and family therapies. In 1993 all services were valued more highly than in 1976. CONCLUSIONS: The 1993 survey findings showed that more consumers used office-based services and hospitalization than community-based alternatives, and that families rated the former services more highly. Value ratings of community services rose significantly between 1976 and 1993.