Comorbid non-alcohol substance misuse among people with schizophrenia: epidemiological study in central London.

BACKGROUND: Few epidemiological studies have assessed the extent and nature of comorbid non-alcohol substance misuse in people with schizophrenia in the community in the UK. AIMS: To study the extent and nature of comorbid non-alcohol substance misuse in people with schizophrenia in central London. METHOD: Subjects were identified in an epidemiological census survey of South Westminster. Standardised assessment of each subject included demographic data, ratings of mental state and movement disorder and questioning about drug and alcohol misuse. RESULTS: Individuals with schizophrenia or related psychoses were identified (n=352) and 57 (16%) reported a lifetime history of non-alcohol substance misuse. Age and gender were the main variables relevant to the extent and pattern of misuse. Self-reported non-alcohol substance misuse showed no significant relationship with a range of outcome measures. CONCLUSIONS: The high proportion of subjects reporting non-alcohol substance misuse is comparable with figures from the USA. The reports of lifetime misuse most commonly referred to cannabis, psychostimulants, LSD, opiates and anticholinergics. Misuse was concentrated in those younger than 36 years and was reported more often by males.

Novel antipsychotics, extrapyramidal side effects and tardive dyskinesia.

A common and serious drawback of the conventional antipsychotics is their association with a range of motor disturbances: acute extrapyramidal symptoms, including parkinsonism, acute akathisia and acute dystonia; and chronic motor problems such as tardive dyskinesia, chronic akathisia and tardive dystonia. In addition to physical disability directly related to abnormal movements, the acute movement disorders can cause considerable subjective discomfort and distress, and are frequently cited as a reason for poor compliance with medication, at least during acute treatment. They can also confound clinical assessment of mental-state phenomena because of symptom overlap with the psychotic illness being treated. The results of clinical trials of the newer antipsychotic drugs such as clozapine, risperidone, olanzapine, amisulpride, quetiapine and sertindole suggest a lower liability for acute extrapyramidal symptoms than conventional antipsychotic drugs such as haloperidol and chlorpromazine. The relative liability of each of the newer drugs to cause acute extrapyramidal side effects is not known, as they have been available for a relatively short time and there is a paucity of direct comparative studies. Evidence is accumulating that those patients exhibiting acute extrapyramidal side effects are at greater risk of developing tardive dyskinesia, which raises the hope that the newer antipsychotic drugs may also be associated with less tardive dyskinesia in the longer term. Encouraging data are already available for clozapine, which appears to have a low incidence of tardive dyskinesia, and therapeutic value in a proportion of established cases of tardive dyskinesia and tardive dystonia. Here we review the available data on atypical antipsychotics and adverse motor effects.

Detecting comorbid substance misuse among people with schizophrenia in the community: a study comparing the results of questionnaires with analysis of hair and urine.

Substance misuse among people with schizophrenia is thought to be common and to adversely affect the outcome of the illness. The shortcomings of studies in this area include patient samples that are not epidemiologically-based, and methods for detecting substance misuse that have serious limitations. We investigated the frequency and severity of substance misuse among people with schizophrenia living in the community in London. Interviews were conducted with a community-based sample of 39 people with schizophrenia aged 35 years or less, living in Inner London. The assessments included ratings of psychopathology, movement disorders and substance misuse, and co-informant histories. Urine and hair specimens were analysed for a range of substances. Urine samples were collected from 37 patients and hair samples were provided by 36 patients. Comorbid substance misuse was reported or detected in 63% of the sample. The information elicited using a structured questionnaire for both informants and subjects represented an under-estimate of psychostimulant misuse and opiate misuse compared with the results obtained by hair or urine analysis. Hair analysis revealed that 12 (33%) of those patients providing samples had covertly abused amphetamines, opiates or cocaine in the previous 3 months. The study demonstrated that hair analysis is a well-tolerated, sensitive test for substance misuse. The technique has several advantages over questionnaires and urine analysis for clinical and research purposes. Further applications include the assessment of comorbid substance use in particular groups of patients with schizophrenia, such as during first-episode or psychotic relapse, or those with forensic problems or apparent resistance to treatment.

How to distinguish between the neuroleptic-induced deficit syndrome, depression and disease-related negative symptoms in schizophrenia.

A major challenge in the clinical assessment of schizophrenia is the differentiation between depressive features, negative symptoms and neuroleptic side effects, including the adverse subjective experiences associated with this medication. The problems include the degree of symptom overlap, and the lack of precise operational definitions, particularly for negative symptoms and the putative, neuroleptic-induced deficit syndrome. The diagnostic process is further confounded by the need to discriminate between primary negative symptoms as persistent, enduring deficits, and social and emotional withdrawal secondary to positive symptoms, or related to depressive features or drug effects such as sedation and the bradykinesia component of parkinsonism. To distinguish between these elements is likely to require careful observation of patients with schizophrenia, over time, by trained raters using appropriate rating scales for depression and negative symptoms that are sensitive to change. Ratings of patients' subjective experiences regarding mood and awareness of behavioural and cognitive deficits should also be included. The associations between the subjective data and the objective ratings of depression, negative symptoms and drug side effects may help with clinical discrimination in these areas of dysfunction and with the refinement of their phenomenological descriptions.

Personality disorder and police section 136 in Westminster: a retrospective analysis of 65 assessments over six months.

Section 136 of the 1983 Mental Health Act empowers the police to detain those suspected of being mentally ill in public places. The current study is a retrospective analysis of those occurring within Westminster, London, over a six-month period. A high rate of referral was found. In those individuals assessed, schizophrenia was the commonest diagnosis, but personality disorder provided the largest number of assessments. This was due to the propensity of the latter individuals to present on multiple occasions. Those with personality disorders were significantly less likely to be placed under further sections of the Mental Health Act, less likely to be admitted to hospital and more likely to re-present under a further section 136. The inability of the current system to address these individuals' needs is a cause for concern.