Lisa B. Dixon

Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes

Comorbid substance abuse disorders have emerged as one of the greatest obstacles to the effective treatment of persons with schizophrenia. Estimates of the prevalence of such comorbidity vary, but as many as half of persons with schizophrenia may suffer from a comorbid drug or alcohol disorder. Younger age, male gender, and lower educational attainment are associated with greater risk for addiction. Persons with schizophrenia and comorbid addiction tend to have an earlier onset of schizophrenia than do those without comorbid addiction. Research does not support a link between specific symptoms of schizophrenia and choice of abused drugs. Rather, drug choice is correlated with the pattern of ambient drug use in the community. Comorbid substance disorders are associated with a variety of poorer outcomes, including increased psychotic symptoms, poorer treatment compliance, violence, housing instability and homelessness, medical problems (including human immunodeficiency virus infection), poor money management, and greater use of crisis-oriented services that result in higher costs of care. Considerable progress has been made over the past decade in understanding the need to integrate substance abuse treatment and mental health treatment to provide more effective care for this population.

Recent developments in family psychoeducation as an evidence-based practice.

Among potential resources for people with serious mental illnesses (SMI) and their families, professionally delivered family psychoeducation (FPE) is designed to engage, inform, and educate family members, so that they can assist the person with SMI in managing their illness. In this article, we review research regarding FPE outcomes and implementation since 2001, updating the previous review in this journal (McFarlane, Dixon, Lukens, & Lucksted, Journal of Marital and Family Therapy 2003; 29, 223). Research on a range of FPE variations continues to return mostly positive effects for adults with schizophrenia and increasingly, bipolar disorder. More recent studies include functional outcomes as well as the more common relapse and hospitalization. FPE research involving adults with other diagnoses is increasing, as is FPE research outside the United States In both cases, uneven methodologies and multiple FPE variations make drawing conclusions difficult, although the core utility of access to information, skill building, problem solving, and social support often shines though. Since the previous review, several FPE programs for parents of children or youth with mood disorders have also been developed, with limited research showing more positive than null results. Similarly, we review the developing inquiry into early intervention and FPE, short-form FPE, and cost studies involving FPE. The second half of the article updates the paradox of FPEs evidence base versus its persistently low use, via recent implementation efforts. Multiple challenges and facilitating factors across healthcare systems and financing, individual programs and providers, family members, and consumers shape this issue, and we conclude with discussion of the need for empirical evaluation of implementation strategies and models.

Consumers as Staff in Assertive Community Treatment Programs

The last decade has witnessed the increasing importance of consumers as providers of mental health services. Assertive Community Treatment (ACT) teams and ACT variants, with their emphasis on rehabilitation and support in the clients natural environment, have hosted consumer-professional collaborations. The authors discuss one such program in which an ACT program for homeless mentally ill adults employed consumer advocates (CAs). Consumer advocates were found to have a service profile similar to other staff. Further, there is suggestive evidence that the employment of CAs created a more positive attitude toward persons with mental illness. Issues of role definition, boundaries, support with supervision and the importance of CAs experiences with mental illness are discussed.

Consumer satisfaction with inpatient psychiatric treatment among persons with severe mental illness

Consumer satisfaction with inpatient care is an important component of quality of care and a recovery-oriented system of care. This study assessed association of patient, demographic and process of care variables with inpatient satisfaction focusing on modifiable service delivery factors. Participants were 136 people with psychotic or affective disorders recruited from VA inpatient units who were interviewed with an extensive assessment. Staff teaching efforts regarding medication, illness management, substance abuse, outpatient treatment and living skills were significantly associated with greater levels of satisfaction with care, controlling for demographic and clinical variables. This may reflect value consumers place on staff time, attention and communication. Teaching may enhance self-efficacy and hope thereby facilitating recovery.

Changes in psychopathology and dyskinesia after neuroleptic withdrawal in a double-blind design

The goal of this study was to assess the time course of change in psychopathology and dyskinesia after neuroleptic withdrawal. Fifteen DSM-III schizophrenic patients were abruptly withdrawn in a double-blind fashion from stable haloperidol treatment. Weekly ratings of dyskinesia and psychopathology were performed for 4 weeks post-withdrawal. There was an overall increase in dyskinesia ratings over the 4-week period (p < 0.05) beginning in week 2, with dyskinetic movements of the fingers showing the most significant increase (p < 0.001). There were no overall changes in psychopathology, though the group appeared to be bimodal with 6 of the 15 patients showing a significant relapse in psychotic symptoms. Neither baseline TD nor psychotic relapse significantly interacted with change in TD over time. These schizophrenic patients showed an increase in global dyskinesia rating early within four weeks of neuroleptic withdrawal. This time course did not appear to be associated with reemergence of psychopathology which occurred later. A significant minority of patients relapsed within this time period. This suggests the relative safety of brief periods of neuroleptic withdrawal for carefully selected patients in a controlled setting with specific goals (e.g., for evaluation or in preparation for clozapine) and the need to further understand who is at risk for rapid relapse.

Comorbid bulimia nervosa and schizophrenia

OBJECTIVEnDespite literature citing the frequency of abnormal eating behavior in persons with schizophrenia, little attention has been paid to the comorbidity of eating disorders and schizophrenia. This case review explores the comorbidity of bulimia nervosa and schizophrenia and its possible clinical implications.nnnMETHODnThe authors present four case reports of women with rigorously diagnosed schizophrenia who have eating-disordered behavior.nnnRESULTSnThe first case describes a woman whose bulimia nervosa clearly preceded the onset of her schizophrenia. The second and third cases describe women who have many characteristics and risk factors for bulimia nervosa and whose bulimic symptoms significantly interact with psychotic symptoms. The fourth case describes a woman with bulimic behavior which is clearly responsive to psychosis. She does not have a history and behavioral profile of true bulimia nervosa.nnnDISCUSSIONnThese case reports extend support to a model that schizophrenia and bulimia may coexist in a complex, interactive fashion with important clinical implications.

Cigarette smoking in community-dwelling patients with schizophrenia in China

This study examined the prevalence of cigarette smoking and its socio-demographic and clinical characteristics in Chinese schizophrenia patients. A sample of 540 community-dwelling patients (female/male: 50.4% vs. 49.6%) with schizophrenia was interviewed using standardized assessment instruments. The patients basic socio-demographic and clinical data including smoking were collected. The prevalence of cigarette smoking was 28.5% in the whole sample, and 53.6% and 4.0% for men and women, respectively. In univariate analyses, male sex, use of first generation antipsychotics (FGAs) and alcohol consumption were significantly associated with smoking. In multiple logistic regression analysis, male sex, alcohol consumption, older age and lower level of education were independently associated with smoking. The prevalence of smoking in Chinese schizophrenia patients is considerably lower than most figures reported from Western settings. The dramatic differences between males and females underscore the influence of cultural norms on smoking.

Clozapine Use in Schizophrenia: Findings of the Research on Asia Psychotropic Prescription (REAP) Studies from 2001 to 2009:

Objective: Optimizing treatment and outcomes for people with schizophrenia requires understanding of how evidence-based treatments are utilized. Clozapine is the most effective antipsychotic drug for treatment-refractory schizophrenia, but few studies have investigated trends and patterns of its use over time internationally. This study examined the prescription patterns of clozapine and its demographic and clinical correlates in Asia from 2001 to 2009. Method: Clozapine prescriptions were collected in a sample of 6761 hospitalized schizophrenia patients in nine Asian countries and regions using a standardized protocol and data collection procedure. Results: Overall, the proportion of patients receiving clozapine prescriptions was stable across the three surveys from 2001 to 2009, ranging from 14.5% to 15.9%. However, the rates and patterns observed within different regions and countries at each survey differed considerably. Clozapine use decreased significantly over time in China, while it increased in Korea and Singapore. Multiple logistic regression analysis revealed that patients taking clozapine were significantly younger, had a higher dose of antipsychotic drugs in chlorpromazine equivalents, were more likely to be female, had fewer extrapyramidal symptoms, and had more negative symptoms, admissions and weight gain in the past month than those not receiving clozapine. Conclusion: The variability in overall rates and changes in prescription rates over time in these samples suggest that factors other than psychopharmacological principles play an important role in determining the use of clozapine in schizophrenia in Asia.

Pharmacological Treatment of Schizophrenia and Co-Occurring Substance Use Disorders

Substance abuse among individuals with schizophrenia is common and is often associated with poor clinical outcomes. Comprehensive, integrated pharmacological and psychosocial treatments have been shown to improve these outcomes. While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring sub-stance use disorders, this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic. This article focuses on and reviews studies involving US FDA-approved medications for co-occurring substance abuse problems among individuals with schizophrenia.Comprehensive treatment for individuals with schizophrenia and co-occurring substance use disorders must include specialized, integrated psychosocial intervention. Most approaches use some combination of cognitive-behavioural therapy, motivational enhancement therapy and assertive case management. The research on antipsychotic and other pharmacological treatments is also reviewed, as well as psychosocial treatments for individuals with schizophrenia and cooccurring substance use disorders, and clinical recommendations to optimize care for this population are offered.

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.