Info for service providers

What is the issue?

Defining Concurrent Disorders (CD)
Prevalence of substance use in people who have schizophrenia
Relationship between substance use and schizophrenia
Impact of CD
Signs and symptoms
Best practices in treatment and support

Recovery

a) Defining Concurrent Disorders

Concurrent Disorders (CD) refers to any combination of mental health (NOTE: words in blue are listed in Glossary) and substance use disorders that might affect an individual at the same time.

The concept can be expressed in a number of different ways and the terms "concurrent", "co-occurring" or "dual" are sometimes used interchangeably. However Concurrent Disorders is the term usually used in Canada to express the co-occurrence of a mental, emotional or psychiatric problem with the abuse of alcohol or another psychoactive drug. (The terms Dually Diagnosed or Dual Diagnosis, more commonly used in the United States, usually refer to mental health problems occurring with intellectual or developmental disability.)

Source(s): Best Practices: Concurrent Mental Health and Substance Use Disorders, Health Canada, 2002.

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b) Prevalence of substance use problems in people with schizophrenia

Although estimates vary, conservative estimates suggest that 47% of people with schizophrenia will also have an alcohol or drug abuse problem during their lifetime. Individuals with schizophrenia face roughly three times the risk of alcohol use disorders than the general population and five times the risk of drug use disorders. About half the youth at the first episode of schizophrenia present with or will develop a substance use disorder.

As in the general population, the risk of substance use problems among persons with schizophrenia also depends on environmental conditions such as drug availability and local drug culture.

It has been noted that the prevalence profile for concurrent disorders closely follows the age and sex differences observed in the population at large: younger males with schizophrenia are more likely to abuse substances than older men and women. (Negrete, 2003)

Alcohol and cannabis are the most commonly abused substances, followed by cocaine and amphetamines. In addition, nicotine addiction is estimated at 90% in this population.

Among people in treatment for alcohol or drug abuse, the lifetime prevalence of schizophrenia is also significantly higher than in the general population. In the general population an estimated 1% of people have schizophrenia; in people being treated for alcohol abuse, 4.5% to 6% of people also have schizophrenia, and among those in treatment with drug use disorders, 28% also have schizophrenia.

Source(s):

• Concurrent Disorders Policy Framework,Concurrent Disorders Network of Ontario, 2005
• Clinical aspects of substance abuse in persons with schizophrenia. JC Negrete. Canadian Journal of Psychiatry. 2003 Feb;48(1):14-21.
• Treatment Improvement Protocol (TIP) Series 42. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Center for Substance Abuse Treatment. DHHS : Substance Abuse and Mental Health Services Administration, 2005
• Drug and alcohol use among patients with schizophrenia and related psychoses: levels and consequences. Margolese HC. Malchy L. Negrete JC. Tempier R. Gill K. Schizophrenia Research 2004 Apr;67(2-3):157-66.Link to PubMed abstract: <http://www.ncbi.nlm.nih.gov>

Other resources and links:

• Comorbidity of mental disorders and substance use <http://som.flinders.edu.au/FUSA/PARC/toolkitcomorbidresource.html>. Developed by the Primary Mental Health Care Australian Resource Centre, this site also provides information on shared care, papers on comorbidity, and case examples.

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c) Relationship between substance use problems and schizophrenia

Research has shown that people with schizophrenia and other mental disorders often use drugs and alcohol for the same reasons as everyone else - to feel better or different, to relax and have fun, and to be part of a group.

There are several theories about the relationship between problem substance use and schizophrenia.

A strand of recent research suggests that increased vulnerability to addictive behavior may be related to the impact of schizophrenia on the nervous system. This hypothesis suggests that people with schizophrenia may have a tendency for addictive behavior as a primary disease symptom parallel to, and in many cases independent from, their other symptoms.

Another theory, the super-sensitivity model suggests that people with severe mental illness such as schizophrenia are more sensitive to the effects of alcohol and other drugs due to increased biological vulnerability, and that they experience more negative consequences from relatively small amounts of alcohol or other drugs.

One common hypothesis is that the choice and use of substances is a method of "self-medication", to treat adverse symptoms (particularly anxiety and depression), or medication side effects.

Finally, many people with schizophrenia live in high-risk social settings, and may be transient or homeless. They are therefore more likely to find themselves in settings where drug traffic is high.

Other models have been put forward that might explain the relationship between substance use and mental health problems.

What is clear is that for different groups of people, and even within the same person, multiple factors may come into play.

Source(s):

• The Relationship between substance use and mental health problems, excerpted from Introduction to Concurrent Disorders: A Guide for Counsellors,CAMH, 2005
• Personality characterizations of outpatients with schizophrenia, schizophrenia with substance abuse, and primary substance abuse. Reno RM. Journal of Nervous & Mental Disease 2004 Oct;192(10):672-81.Link to PubMed abstract: www.ncbi.nlm.nih.gov

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d) Impact of substance use on people with schizophrenia

Substance use complicates the course of illness and the treatment of people with schizophrenia, even when relatively small amounts of substances are used.

The use of substances can affect the pharmacodynamics of the medication taken for psychiatric symptoms, and can exacerbate all the symptoms.

People in treatment for schizophrenia who use substances may experience visual or auditory hallucinations, altered emotional responses, thought-disorder or delusions. These symptoms may be a result of or heightened by the interaction between prescribed medication and substances. It can be difficult to differentiate between a psychotic episode that is a result of a mental health condition such as schizophrenia and one that is substance induced. (See Guidelines to assist in differentiating between a primary psychotic and a substance-induced disorder below).

Substance use problems also reduce the likelihood that people will follow the treatment/management plans recommended.

An important implication of the super-sensitivity model is that only a minority of people with concurrent substance use problems and severe persistent mental illness may be able to sustain controlled substance use. This is because even moderate use may result in negative consequences or dramatically increase the risk of more severe substance use. It is important to emphasize to clients that because of their mental illness, they may have an increased biological sensitivity to the effects of alcohol and drugs.

In addition to the impact on symptoms, people who have both schizophrenia and substance use problems:
• are at a higher risk for self-destructive and volatile behaviors;
• may be more vulnerable to homelessness, victimization, poor nutrition;
• are more likely to have inadequate financial resources, a lack of social supports and meaningful daytime activity and be refused access to treatment and services.

Because schizophrenia and substance use disorders tend to be chronic and typically involve multiple relapses and remissions, support for long-term treatment is critical. Treatment may take longer and be more challenging, but recovery is possible.

Source(s):
• Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3922. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005 <http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.75014>

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e) Signs and symptoms of a substance use problem

Warning signs can include a number of subtle physical or behavioral symptoms or a combination of symptoms. For example, individuals may experience physical problems such as insomnia, fatigue, chest pain, cardiac arrhythmia, headaches. When other physical or psychological causes cannot be found, substance use should be considered.

Screening helps to increase or support your suspicion of problem substance use and is generally based on observations about an individual's appearance, behaviour, cognition and their responses to a few simple questions. Read more about Screening and Assessment.

A combination of risk factors, signs and symptoms might indicate that a client or patient with schizophrenia also has a substance use problem. The table below provides a few examples of these:

Risk factors	Signs	Symptoms
younger	frequently missed appointments	physical symptoms (sweats, shakes, chest pain, insomnia etc.)
male	relationship problems	higher affective symptoms (depression/suicidality)
single or never married	financial/legal problems	physical diagnosis (e.g. liver problem, cardiac arrhythmia, etc.)
family history of addiction	disrupted housing	more severe positive symptoms (delusions, hallucinations, etc.)
poverty	poor medication adherence	poorer response to treatment; lower remission rate
precarious housing	job difficulties
social isolation/exclusion	disruptive behaviour/volatility
	frequent visits to emergency departments due to need for immediate intervention
	suspicious injuries

Guidelines to assist in differentiating between a primary psychotic and a substance-induced disorder 

Substance-induced psychotic symptoms can result from intoxication, chronic use or withdrawal. Some examples include: 

• Intoxication with cannabis can induce a transient, self-limiting psychotic disorder characterised by hallucinations and agitation; 

• Use of psychostimulants (eg, amphetamine, methylenedioxymethamphetamine [MDMA] or Ecstasy ) can produce a psychotic picture similar to schizophrenia; 

• Hallucinogen-induced psychosis is usually transient, but may persist if use is sustained; 

• Heavy alcohol use/intoxication has been associated with alcoholic hallucinosis 

• Psychotic symptoms can also occur during withdrawal from a substance (eg, delirium tremens). 

A non-substance-induced psychotic disorder should be considered when: *

• Psychosis precedes the onset of substance use; 

• Psychosis persists for longer than one month after acute withdrawal or severe intoxication; 

• Psychotic symptoms are not consistent with the substance used; 

• There is a history of psychotic symptoms during periods (> one month) of abstinence; 

• There is a personal or family history of a non-substance-induced psychotic disorder.

Source: Substance misuse in patients with schizophrenia: a primary care guide Dan I Lubman and Suresh Sundram MJA 2003; 178 (9) Suppl 5 May: S71-S75 www.mja.com.au

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f) Promising practices in treatment and support

People with concurrent substance use problems and severe and persistent mental illness such as schizophrenia are best treated in an integrated program or system of services that view both disorders as primary and deal simultaneously with both the mental health and substance use problems. Attitudes and approaches that reflect a recovery philosophy can enhance the therapeutic relationship.

Integrated treatment addresses mental health and substance use problems in a coordinated and consistent manner. It requires enduring linkages between service providers or treatment units within a system, or across multiple systems, including mental health and addictions, to facilitate the provision of services to individuals at the local level.

The essential elements of a well-organized integrated therapy program include:

• concurrent disorders assessment
• clinical case management based on stages of treatment
• open-ended continuity of care
• assertive case management
• on-site addiction treatment, including specialized pharmacotherapy that takes into account substance use issues
• a harm reduction approach
• motivational interviewing
• cognitive-behavioral substance use counseling
• concurrent disorders group interventions, including social skills training groups
• self-help liaison (e.g. Double Trouble ; Alcoholics Anonymous)
• work with families including behavioral family therapy and support / psychoeducation
• residential options, including housing

Integrated treatment assumes a close relationship between substance use and mental health problems and that one problem shouldn't be treated in isolation from the other. The concept was developed to respond to the difficulties clients have had - and some continue to have - when navigating between the substance use and mental health systems.

Because one clinician or treatment team takes overall responsibility for blending treatment and support interventions into a coherent package, integrated treatment services shifts the responsibility for navigating and negotiating the complexities of diverse treatment approaches from clients/consumers to the people and agencies that deliver the services.
(Drake and Mueser 2000) (Drake et al, 2004).

When this approach to treatment is coordinated and consistent it should appear seamless to the client. (Health Canada, 2002).

Source(s):
• Treating Concurrent Disorders A Guide for Counsellors - Approaching Concurrent Disorders-CAMH
• Best Practices: Concurrent Mental Health and Substance Use Disorders Research information and recommendations for the screening, assessment, and treatment/support of this population. A resource for managers and staff of mental health, substance abuse, and integrated mental health/substance abuse services. (Health Canada, 2002)
• Negrete, Juan C. (2003). Clinical Aspects of Substance Abuse in Persons with Schizophrenia. Can.J. Psychiatry 48(1), Feb. 2003. 14-21.

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g) Recovery

Recovery from schizophrenia and other psychotic disorders is more challenging for people who also abuse substances. The recovery process can be prolonged, and relapse - the return to active substance use or return of disabling psychiatric symptoms after a period of remission - are likely in the course of recovery.

But recovery is possible. New research is showing that, with access to integrated treatment and psychological services, along with community supports and services, most people with schizophrenia and substance use problems can and do recover over time.

Recovery is defined differently for each individual, but it is generally thought to include a number of factors, including:

• a sense of hopefulness, renewed meaning and purpose
• management of the symptoms of schizophrenia
• remission from substance use problems
• living independently
• having a job
• having friends and social support
• sustaining a good quality of life

Most people report that recovery also involves identifying and achieving their personal goals in life.

People move toward recovery on different paths, and the supports that are needed are different for each individual.

A range of options are needed to promote and sustain recovery. These include access to:
• integrated treatment of mental health and substance use problems
• vocational and housing support
• links to self-help groups
• support for clients to develop illness self-management skills
• positive approaches to working with families that honour their expertise