Schizophrenia and Substance Use

Schizophrenia and substance use tend to be comorbid, that is, they tend to co-occur together.  There is a high rate of occurrence, which creates problems for both the sufferers and the mental health professionals attempting to treat the individuals displaying this comorbidity.  The co-occurrence worsens symptoms and creates confusion when constructing a treatment plan.  There is a need within the mental health community to focus on structuring treatment modalities for these patients.   Mueser, Bellack, & Blanchard (1992) state “drug and alcohol use by schizophrenia patients is one of the most pressing problems facing the mental health system.” 

An attempt to thoroughly describe this pressing problem will be made through explanation of the co-occurrence and a suggested model devised from existing literature.    The demographics for comorbidity will be discussed, the implications of comorbidity for the population experiencing the co-occurrence will be explained, the theories proposed as to why there is such a high probability for comorbidity will be clarified, and finally an intervention model will be introduced focusing on the treatment of dual diagnosis substance abuse and schizophrenic patients.  Before going into detail about the demographics, implications, theories, and intervention, diagnostic definitions must be explain so it is understood what is meant when using specific terminology.     

In order for an individual to be diagnosed with schizophrenia, one must possess six criteria, as characterized in the DSM-IV-TR (American Psychiatric Association [APA], 2000). The individual must have two of the following symptoms for at least one month unless successfully treated before one months period of time: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms.  An exception of only one symptom is required if delusions are bizarre, hallucinations consist of a voice keeping a running commentary on the person’s behavior or thoughts, or if two or more voices are conversing with each other. 

The individual has to experience social and occupational dysfunction in that one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.  The individual has to show continuous signs of the disturbance for at least 6 months with at least one month of symptoms and can include periods of prodromal or residual symptoms.  Schizoaffective disorder and mood disorder with psychotic features have to be ruled out because of a lack of major depressive, manic, or mixed episodes occurring with the active phase symptoms or if mood episodes have occurred during active phase symptoms, their total duration has been shorter relative to the length of the active and residual periods.

The disturbance cannot be due to the direct physiological effects of a substance.  If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if commonly occurring delusions or hallucinations are also occurring for at least one month.  This is the definition that is referred to when schizophrenia is referenced in this paper.

            In academia, the term “substance use” can mean many different things.  It can range anywhere from a single use of a substance to abuse or dependence on a substance (Donovon & Marlatt, 1988).   Abuse refers to the repeated use of a substance.  Dependence refers to the occurrence of tolerance, which is the need to increase in the amount of the substance is necessary to experience similar effects, and withdrawal, which is the experience of negative physiological symptoms due to the absence of the substance (APA, 2000).  For the purpose of this paper, substance use refers to any use of a substance including abuse and/or dependence.

Biological aspects of substance abuse among schizophrenia patients

The prevalence of substance abuse disorders co-occurring with schizophrenia is significantly influenced by the physiopathology of the two problems. Schizophrenia is a severe psychiatric disorder that affects approximately 1% of the general population n the US. The prevalence of alcohol and drug abuse in this population is significantly different from that of the general population. In the US, the prevalence of alcohol abuse in the general population is about 12% while that of other drugs is 2-3%. A considerable difference in the prevalence rates is that almost 50% of all people with schizophrenia suffer from severe co morbid substance related illness at some point in their life. The high prevalence of dual diagnosis for schizophrenia patients has significant implications for medical and psychiatric practice. Patients who have a dual diagnosis of schizophrenia and substance abuse disorders also face significant challenges in relation to treatment and prognosis. The main issue in treating such patient is that the clinicians may focus on treating either the substance abuse problem or the psychiatric disorder hence there is a serious lack of integration. Non integrated treatment modalities have been shown to have poor outcomes for dually diagnosed patients (Volkow, 2009).

An important aspect in understanding the challenge of dual diagnosis for schizophrenia and drug abuse is to assess the pathophysiology of schizophrenia. Schizophrenia involves the disturbance of behavioral, cognitive and emotional processes. It has positive symptoms that may include paranoia, hallucinations, and delusions. The negative symptoms of the disorder are more prevalent and include social avoidance, cognitive deficit, and blunted affect as well as anhedonia. A significant aspect of schizophrenia is that it sometimes results in reduction of brain volume because of the medication, the illness or both. Since the main symptom of schizophrenia is the cognitive deficit, the reductions in brain volume are likely to be seen in the prefrontal cortex or the temporal lobes (George, Vessicchio, et al., 2002).

The four central dopamine systems; tuberoinfundibular, mesolimbic, mesocortical, and nigrostriatal pathways are critical to the cognitive and affective functioning of individuals. The dopamine systems hypothesis of schizophrenia indicates that the dysfunction present is responsible for the ineffective of diagnosed patients to have sufficient cognitive and other functions. The hypothesis does not explain the complexity of schizophrenia in its entirety although it is gaining support from literature. There is increasing evidence that supports DA dysfunction among schizophrenia patients. Studies have shown that the disorder is associated with subcortical mesolimbic DA pathways that are hyperactive in the brain. It is also associated with deficient DA function in the prefrontal cortex. One key aspect of support for this hypothesis is that the effective treatments of the disorder are antagonists that target the DA-D2 receptor. The mesocortical DA is responsible for modulation of executive functioning and working memory (Volkow, 2009). Dysregulation of the pathway is considered responsible for the main symptoms associated with schizophrenia.

Dopamine has a significant effect on motor activity and attention in human beings hence influences the level of stress experienced. Animal tests involving stress levels indicate that it results in release of high levels of DA in the limbic and cortical areas of the brain hence exacerbating the symptoms of schizophrenia (Yin et al., 2002). It is hypothesized that the symptoms result from the high level of demand on the diminished population of dopamine neurons in the brain. Another alternative path of the pathology is that the DA system plays a key role in the pleasure-seeking and reward systems especially D1 and D2 receptors. Many recreational drugs that are abused by patients result in blockage of the DA transporter function. The result is a large increase of dopamine in the synapses, which increases D1 and D2 receptor signaling to mediate reward pathways (Davis, Kahn,  Ko, & Davidson, 1991).

In a recent study by Thompson et al. striatal dopamine release was found to increase in schizophrenia patients. The increase was especially experienced in the precommissural caudate and declined in the ventral straitum for candidates with addiction. The researchers measured the change in amphetamine induced receptor availability in dually diagnosed schizophrenia patients and those with schizophrenia alone. The measurements were conducted suing positron emission tomography. The findings indicated that dual diagnosis patients had greater increase in happiness resulting from drug administration. The patients were also found to have higher levels of energy and overall feeling of well being after the administration of drugs. In both groups, the amphetamine reduced D2 and D3 receptor availability (Wing, Wass, Soh, & George, 2012).

Schizophrenia and substance abuse co-occurrence hypothesis

Doctors and other medical professionals have been interested with the link between schizophrenia and drug abuse. The two main ones that have received much attention in the literature are self medication and addiction vulnerability. The self medication hypothesis posits that drugs and other recreational substances of abuse reduce the psychological suffering of schizophrenia patients. The preference of a patient for a particular drug involves some level of psychopharmacological specifity. The patient sees the drugs of abuse as a treatment for the adverse symptoms of schizophrenia. The hypothesis indicates that drugs preferred because of the relief they provide from negative symptoms such as blunted affect, depression, anhedonia, and cognitive deficits. In this case, drug abuse is a reaction or secondary process to schizophrenia. The dysfunction arising from the illness leads to aversive symptoms that are addressed by the patient through self-medication. The need for self medication does not necessarily arise from the psychiatric condition, but distress and subjective symptoms may not even be associated with the schizophrenia. In some cases, the focus of self medication is the negative symptoms or adverse motor effects of the antipsychotic medication. The hypothesis explains drug addiction among schizophrenia patients through negative reinforcement because they reduce the aversive symptoms of the disorder.

In the recent past, the SMH has drawn significant criticism for its effectiveness in explaining the co-occurrence. The main reason is that supporting literature has focused on self-reported subjective measures, which reduces reliability of the findings and validity of the hypothesis. Schizophrenia patients use drugs in order to alleviate the adverse effects of medication as well as the disorder. Tobacco abuse is common for schizophrenia patients and results in abnormalities of the nicotinic acetylcholine receptor.

In a study conducted by George, Vessicchio, and colleagues (2002), schizophrenia patients who smoked and those who did not were subjected to a study. The focus was on the visuospatial working memory and how it was influenced by smoking abstinence. The effect on smokers with schizophrenia and those without were significantly different with the schizophrenia group experiencing decreased VSWM. The control group, which consisted of individuals without schizophrenia, experienced improvements in VSWM. The study showed that smoking may have beneficial effects on schizophrenia patients. Despite the support provided of the SMH hypothesis by these findings, it is essential to appreciate that cognition is subconscious and the schizophrenia patients may not be able to describe the effects of their habits on such unconscious processes.

Another critical shortcoming of the hypothesis is that when dually diagnosed patients stop using drugs, their psychiatric symptoms improve. The symptoms may remain unchanged, but they do not worsen after complete withdrawal from the drugs. Prospective clinical trials have shown that schizophrenia patients who quit smoking do not have any significant changes in negative or positive symptoms (Weiinberger et al, 2009). A recent clinical trial showed that schizophrenia patients decreased smoking when they switched from being treated with neuroleptics to atypical antipsychotic drugs. In order for the SMH to be supported, the patients would be expected to maintain their daily smoking in response to the change. In fact, the hypothesis suggests that smoking may increase because the hypothesis suggests that substance use is meant to reduce the adverse effects (George et al, 1995).

The addiction vulnerability hypothesis indicates that the presence of schizophrenia may increase vulnerability to drug reinforcement and reward considerations. The reward and reinforcement changes influence the concurrent expressions of the two disorders. The AVH differs in its consideration of drug abuse because it does not positive or negative reasons for co morbid drug addiction. It indicates that the drugs have negative consequences on patients and they become addicted despite the side effects. The theory focuses on the common pathophysiology of drug addiction and schizophrenia as opposed to the positive aspects of the drug in mediating the addiction. The hypothesis considers the two disorders to be similar in their symptoms with common abnormalities. The environment is considered a critical factor in influencing the possibility of developing either of the co morbid diseases. Environmental and genetic factors are critical predisposing factors causing co morbid drug addiction, which may occur before prodromal psychotic symptoms.

Animal studies have presented the best way of assessing the hypothesis because they present data for modeling the co morbidity process. In order to mimic the symptoms of schizophrenia in rats, neo natal ventral hippocampal lesions are used for studies. Rats with NVHL respond more actively to an injection of cocaine and have higher levels of sensitization after a few days. The altered patterns of behavioral sensitization result from the abnormal activation of the brain in schizophrenia, which increases vulnerability to addiction. The schizophrenia tents have a relatively disinhibited state that is associated with a dysfunctional reward circuitry. Dopamine levels continue to rise resulting in a reward feedback that reinforces the use of drugs and subsequent addiction (Chambers, Krystal, & Self, 2001). A schizophrenia patient may be more responsive to the reinforcing and rewarding properties of addiction because of the excess misolimbic functioning.  Another key observation that supports the AVH is that addiction occurs prior to the onset of psychiatric symptoms. A Swedish study involving 45,570 conscripts showed that the risk of schizophrenia in cannabis users was six times higher than that of non users. The explanation of the findings was that cannabis users were more likely to have a predisposition to schizophrenia indicating the common factors underlying both disorders (Andréasson, Allebeck Engström, & Rydberg, 1987).

Demographics

            Common characteristics are found in those that have schizophrenia and use substances (Mueser, Yarnold, Levinson, Singh, Bellack, Kee, Morrison, &Yadalam, 1990).  Those that have the disorder along with substance use tend to share age, socioeconomic status, race, and gender.  Young schizophrenic individuals are more likely to use substances than older sufferers of the disorder, with the mean age of substance users being about 43 years-old compared to non-substance users mean age of about 52 years-old (Duke, Pantelis, & Barnes, 1994).  Individuals with schizophrenia with lower socioeconomic status are more likely to use substances than those of higher socioeconomic statues (Mueser et al. 1990).  White individuals with schizophrenia are more likely to use alcohol and sedatives than black individuals with schizophrenia.  Blacks with schizophrenia are more likely to use cannabis than whites with schizophrenia.  Males suffering from schizophrenia are more likely to use substances than women with the disorder, with males showing up to four times as much usage as women.  Out of the four demographic characteristics, socioeconomic status is the strongest predictor of substance use in the schizophrenic population.

            The prevalence of these demographic characteristics existing for those with schizophrenia suggests that a large denominator in determining if someone with schizophrenia will use substances is environmental factors.  The availability in one’s environment for specific substances due to the prevalence of that substance being used in that specific social environment is a strong indicator for that specific substance being used.

In a study by Rane and Nadkarni (2012) in Goa, India, the focus was on the demographic correlates of alcohol consumption among schizophrenia patients. The study was conducted in a post graduate university teaching hospital that provides tertiary care and mental health services. Recruits for the sample were patients who had attended outpatient services and were treated for schizophrenia for at least 12 months. The authors ascertained the diagnosis of schizophrenia in order to increase reliability of the findings. The study was conducted over a three month period using a structured questionnaire. 1-year drinking prevalence was at 16.8% while hazardous drinking was 12.9%. Most of the respondents preferred beer while 25.5% took Indian made foreign liquor. Among the drinkers, 63.3% drank in bars and had started before the age of 25. 14.3% of the patients drank at home and 11.3% preferred to drink in the morning (Rane & Nadkarni, 2012). Most of the patients who preferred spirits and country liquor were hazardous drinkers and 87.5% of them preferred to drink in the bar.

The patients who reported taking alcohol had more in patient days and stays in mental health wards. They were also more likely to have a longer period of schizophrenia or mental illness in close relatives. The rtes of alcohol consumption in the sample was significantly lower than in the general populations in the US and UK. This indicates a significant effect of culture in the rates of alcohol and substance abuse even in mentally ill patients. The proportion of males who took alcohol was 25.3% compared to females who were 5.3%. The profile of the schizophrenic patient in Goa who takes alcohol is that they are more likely to be male, living alone or in supported housing, economically active, and single or post marital. The higher proportion of male schizophrenics who are dually diagnosed with alcohol dependence has been supported by other studies including Mueser et al (2000) and Margolese, Negrete, Tempier, & Gill (2006). A 1998 study by Fowler, Can, Carter, and Lewis showed that the family is a significant factor in moderating substance use behavior. They found that patients who were single or in post marital stages were more likely to be dually diagnosed, which was similar to the Goa findings (Rane & Nadkarni, 2012). While studies in the US and other countries show that dually diagnosed schizophrenics are more likely to be unemployed, the situation in India was different. The patients who consume alcohol were more likely to be well educated and employed. The possible explanation for the differences is that patients in the US and other developed countries have access to pension, health insurance, and other forms of social security.  In India and other developing economies, such social security may not be available for chronically ill patients reducing their ability to afford alcohol and other drugs of abuse.

Implications of Co morbidity

            It is important to understand the implications of comorbidity of schizophrenia and substance use as the rate of comorbidity is high and the consequences of comorbidity are severe.  Substance use is the highest occurring comorbidity in the schizophrenic population (Cuffel& Chase, 1994).  Studies have indicated that around 47 percent of schizophrenics have lifetime co-occurring substance use (Buckley, Miller, Lehrer, & Castle, 2008).   That is to say those individuals with schizophrenia are 4.6 times more likely to abuse any substance than the general population (Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 1990). Rates of recent use range from 20 to 65 percent (Bellack&DiClemente, 1999).   About 90 percent of schizophrenics use nicotine (Lubman&Berk, 2010), about 47 percent abuse alcohol, around 42 percent use cannabis, around 25 percent use stimulants, about 18 percent use hallucinogens, around 7 percent use sedatives and about 4 percent use narcotics (Mueser et al, 1990). Schizophrenics are three times more likely to use alcohol than the general population (Green, Drake, Brunette, &Noordsy, 2007).    With such high percentages of co-occurrence, the comorbidity of schizophrenia and substance use is thought of as the norm instead of the exception (Buckley et al, 2008).

            There are many implications of comorbidity of schizophrenia and substance use ranging from social to economic to biological.  Individuals with “dual diagnoses are highly prone to… increased symptom severity; increased rates of hospitalization, infectious illness, violence, victimization, homelessness, and nonadherence to medication; and poor overall response to pharmacologic treatment.  Co-occurring substance use disorders contribute substantially to the financial costs and emotional burdens of schizophrenia…” (Green et al. 2008).

            The co-occurrence of schizophrenia and substance use has a tendency of being overlooked and undertreated in mental health facilities (Green et al. 2008).  Because there is a lack of knowledge about the prevalence and proper treatment of the co-occurrence, it goes under-detected.   If it is detected, medical professionals tend to feel overwhelmed when treating psychotic patient with substance problems and that is reflected in the direction of their treatment (Lubman et al. 2010).  Because of unfamiliarity and feelings of inundation, schizophrenia treatment seems to be focused on more so than substance use (Green et al. 2008).  This leads to clinicians prescribing the same medications to schizophrenics with or without substance use issues without research available to know if that specific course of action is beneficial to those patients that also use substances in addition to having schizophrenia (Lubman et al. 2010).

Individuals suffering from both schizophrenia and substance use tend to suffer from poor adjustment (Drake & Brunette, 1998).  They are often more prone to relapse and experience a greater reappearance of psychiatric manifestation.  Along with experiencing an increase in psychotic symptoms, these individuals experience more distressing symptoms of depression (Koskinen, Lohonen, Koponen, Isohanni, &Miettunen, 2009).  Schizophrenic substance users are more likely to use other substances once they start using in general, are likely not to adhere to their prescribed medication regimen, and tend to live stressful lives without a proper support system (Drake et al. 1998).  Schizophrenic substance using individuals are 8 times more likely to not comply with their medication regimen than schizophrenic patients that do not use substances (Owen, Fischer, Booth, & Cuffel, 1996).

            Along with suffering from poor adjustment, schizophrenic substance users suffer from a great deal of negative outcomes from their co-occurring conditions.  Individuals can experience dependence on the substance they are using, unsettling behavior, hospitalization for their symptoms, and imprisonment (Cuffle et al., 1994).  In addition to being hospitalized, patients with schizophrenia that use substances tend to have more admittance and longer periods of hospitalization, which in turn increases their financial burden (Koskinen et al. 2009).

            Schizophrenic patients increase the risk of experiencing negative effects of their disorder from the biological implications of using a substance (Bellack et al. 1999).  Substances tend to elevate levels of activity of dopamine in the brain.  This increases the schizophrenic’s risk of their prescribed psychotic medications being less effective, facing a higher rate of relapse, and their symptoms intensifying.   Substances also increase the chance for noncompliance of the schizophrenic patient in addition to adding stress, which schizophrenic patients are already highly susceptible to.  Also, schizophrenic’s information processing centers are in jeopardy from the disorder and using substances adds to the lack of proper functioning. 

            Specific implications of alcohol have been found in individuals with schizophrenia (Sullivan, Deshmukh, Desmond, Mathalon, Rosenbloom, Lim, &Pfefferbaum, 2000).  In individuals with schizophrenia, lower tissue amounts were found in the cerebellum only when the individual was consuming alcohol.  Comorbid individuals have less hemispheric and vermian gray matter along with larger fourth ventricles than individuals with only one disorder, either alcoholism or schizophrenia (Mathalon, Pfefferbaum, Lim, Rosenbloom, & Sullivan, 2003).  Comorbid individuals experienced greater deficits than alcoholics, even when consuming less alcohol (Sullivan et al. 2000).  These findings indicate that the combination of schizophrenia and alcohol is much more detrimental than by just having schizophrenia or alcoholism alone.

            In cannabis use specifically, those with schizophrenia exhibited a lowered GABA-A mediated short- interval cortical inhibition than schizophrenic patients that had no history of cannabis use (Wobrock, Hasan, Malchow, Wolff-Menzler, Guse, Lang, Schneider-Axmann, Ecker, &Falkai, 2009).   It is also seen with cannabis use that in 74 percent of individuals, the use of the substance preceded the onset of psychotic symptoms (Sevy, Robinson, Napolitano, Patel, Gunduz, Miller, McCormack, Lorell, & Kane, 2010).  This finding illustrates a link between the onset of symptoms and cannabis use that cannot be explained by characteristics of the population or clinical inconsistencies.  Thornicroft (1990) reviewed such findings and concluded that frequent cannabis use increases the risk of developing schizophrenia within 15 years.

In a study by Fazel and colleagues (2009), the adverse effects of co-occurring drug abuse with schizophrenia were addressed using nationwide data in Sweden. The findings of the study indicated that schizophrenia patients had a higher likelihood of being convicted of violent crimes with a prevalence rate of 12-13%. The median time from discharge to offence in the general population was 1132 days and 1214 in a sibling comparison sample. Among the individuals diagnosed of having schizophrenia, there was an increased risk of being involved in violent crime. The odds ratio for the schizophrenia sample was 2.0 when using the general population s the control group. When the unaffected sibling controls were used, the odds ratio was 1.6. The comparison between unaffected siblings and the general population was meant to address the effect of environmental and genetic factors.

The study found evidence of the modification between the co morbidity of substance abuse and schizophrenia on the risk of being convicted for violent crime. The rate of violent crime for individuals diagnosed with schizophrenia and drug abuse was significantly higher than those without the co morbidity. The rate of violent crime for dually diagnosed schizophrenia patients was 27.6% while those without the co morbidity had a rate of 8.5%. The adjusted odds ratio for dually diagnosed patients with drug abuse disorder was 4.4 and 1.2 in cases of schizophrenia without substance abuse (Fazel et all, 2009).

As indicated in different studies, nearly 50% of patients with schizophrenia present with substance abuse disorders. The rate is significantly higher than in the general population indicating that the factors influencing the risk and vulnerability of substance abuse risk in this population are more complex or numerous than the general population. Substance abuse in schizophrenic patients results in poor outcomes in terms of medication adherence, social functioning and mortality (Volkow, 2009). The mechanisms that underlie the co morbidity between drug abuse and schizophrenia are not well understood and may include common as well as drug specific aspects. The neuropathology of schizophrenia increases addiction vulnerability by disrupting the neural substrates that mediate positive reinforcement. Compared to other drugs of abuse, nicotine is the most common among schizophrenia patients. The high prevalence may be associated with the legal status of the substance, but it may also highlight the effect it has on the nicotinic acetylcholine receptors. The self medication hypothesis indicates that nicotine is used to alleviate some of the cognitive deficits that are commonly experienced in schizophrenia (Brunette, Mueser, Xie, & Drake, 1997.

Another commonly abused drug is cannabis sativa, which is associated with more severe clinical outcomes. Recent studies such as Piomelli (2008) using magnetic resonance imaging have shown that loss of gray matter in schizophrenic patients proceeds faster among those using cannabis. The findings of the study indicated that over a five year period, schizophrenic patient who used cannabis had twice as fast loss of gray matter compared to those who abstained. The outcome was not associated with baseline characteristics hence provides support for its adverse effects. In addition to the hedonic effects, the drug is also used for the pharmacological influence of cannabinoids that affect emotional response to stress (Eggan, Hashimoto, & Lewis, 2008).

Genetic and biological factors that predispose individuals to schizophrenia also influence the possibility of drug addiction. Psychosocial factors also play a critical role in the co occurrence of the disorders. Common factors such as poverty, low education levels, peer pressure, unemployment, and the state of the mental health system may account for the co morbidity. Both disorders are adversely influenced by stressors which increase drug consumption and exacerbate the symptoms of schizophrenia. As a result, interventions meant to reduce social stressors to alleviate the symptoms of schizophrenia may also reduce the consumption of drugs and other substances. Dual diagnosis and concurrent drug abuse with schizophrenia contributes heavily to the morbidity and mortality of patients. The adverse consequences of the drugs such as heavy smoking and deaths from poisoning an overdose indicate a need for efficient interventions (Chambers, Krystal, & Self, 2001; Rosen et al., 2008). Another important aspect of the co morbidity between schizophrenia and drug abuse is that some drugs that are abused by schizophrenics target mechanisms that are associated with the metabolic syndrome. In the case of marijuana, the target is cannabinoid receptor, which exacerbates the side effect of the recommended antipsychotic medication.

Purpose of the study

A review of the literature has indicated a need for efficient strategies geared towards addressing the clinical and psychological effects of dually diagnosed schizophrenia and substance abuse. Schizophrenic patients face significant challenges in maintaining good health as well as managing the adverse effects of the disorder. In many cases, use of alcohol and other substances is a strategy for addressing the adverse effects of the disorder or the side effects of the medication. The problem with this strategy is that the self-medication approach does not normally produce positive results. It exacerbates the symptoms in most instances and renders the patients more incapacitated. Some of the adverse outcomes include low adherence to medication, longer periods of hospitalization, and negative symptoms. The current study is meant to provide information on how to address the co morbid conditions that dually diagnosed schizophrenia patients face. It seeks to highlight the effectiveness of group modalities in helping dually diagnosed schizophrenic patients. Different approaches such as motivational interviewing and self help groups have been shown to be significant in aiding drug abuse patients to make the necessary behavioral changes. The focus of this study is to highlight how the group treatment modalities are applicable for dually diagnosed schizophrenia patients. The purpose of the study is to highlight an alternative solution that can be applied in reducing the high prevalence of schizophrenia and drug abuse co morbidity in the US and other countries. Practitioners in psychiatric care need to develop strategies that are effective in addressing all challenges that this vulnerable patient population faces. The purpose of the study is to highlight the relevant information that practitioners should consider in constituting and managing such groups. It will also provide information on how the different strategies such as motivational interviewing and cognitive behavioral therapy can be combined in group treatment of dually diagnosed patients for effectiveness.

Significance of the study

The study is based on the review of current literature that shows a dearth in research on how to integrate drug addiction counseling and treatment for psychiatric disorders in addressing dual diagnosis. Few studies and research have focused on effective ways of integrating such treatments in order to improve the outcomes for the patients who are dually diagnosed with both. The available research also shows that the dually diagnosed schizophrenic patients have significant healthcare problems. The outcomes are adverse for the patients irrespective of the drug of abuse that they use. Another issue is that they are exposed to other risks because of the dual diagnosis since their schizophrenia symptoms are likely to increase and the possibility of poisoning or overdose is significantly higher for them. Non integrated treatment modalities have been shown to have poor outcomes for dually diagnosed patients. The patients need to be provided with integrated treatment strategies that ensure their prolonged well being in relation to social and physical health. Dually diagnosed patients are highly vulnerable to drug addiction and they face a difficult time trying to adopt positive behaviors to enable them deal with the adverse outcomes. In this case, practitioners and clinicians need to develop strategies that allow the patients to take control of their lives and address difficult situations such as social stigma, joblessness, and poor living conditions. By assessing the effectiveness of group interventions for this population of patients, the study will play a critical role in developing literature that is beneficial to psychiatric health practitioners in practitioners in developing efficient modifications for the available treatment modalities for addressing schizophrenia patients with drug addiction problems.

Problem statement

Alcohol and other drugs among people with schizophrenia produce numerous manifestations of poor quality of life and bad outcomes known as poor adjustment. It causes increased recurrence of psychiatric conditions, violence, victimization, homelessness, family problems, HIV, and psychosocial instability among others. Dually diagnosed patients are more prone to homelessness and unstable housing situations, which exacerbate their problems. Schizophrenia patients who have drug abuse problems are unlikely to take medications and outpatient treatment seriously. They present a heavy cost to the health care system because of hospital-based services that they require frequently. The main reason for the correlation is that the abused drugs exacerbate poor adjustment that arises from schizophrenia. The patients also fail to take medication and live in unconventional circumstances with high levels of stress and poor support networks. Longitudinal studies on the co-occurrence have shown that schizophrenia patients with drug abuse problems are more prone to depression, psychiatric symptoms, and hospitalization.

Dual diagnosis of schizophrenia and drug abuse makes patients vulnerable to adverse outcomes in different domains. The patients may experience increased symptom severity, non-adherence to prescription, and poor response to pharmacologic treatment (Dixon, 1999). Substance use disorders contribute considerably to the emotional burden and financial costs of schizophrenia affecting the patients, their families, and the health care system. The co-occurrence of substance abuse and schizophrenia is also experienced among patients without chronic illnesses. Some studies of schizophrenia patients have shown as high as 53% rates of cannabis use disorder. Abuse of cannabis is also associated with an earlier age of onset of schizophrenia as well as elevated risks of developing psychosis (Green, et al., 2004). Use of drugs causes a higher relapse rate for schizophrenia patients after remission of psychotic signs in the initial episode. In effect, when the two disorders co-occur, patients have a higher likelihood of getting adverse effects that are more difficult to treat or manage.

References

Andréasson, S., Allebeck, P., Engström, A., & Rydberg, U. (1987). Cannabis and schizophrenia. A longitudinal study of Swedish conscripts. Lancet, 2:1483-1486.

Brunette, M. F., Mueser, K. T., Xie, H., & Drake, R. E. (1997). Relationships between symptoms of schizophrenia and substance abuse. J Nerv Ment Dis, 185:13–20.

Chambers, R. A., Krystal, J. H., & Self, D. W. (2001). A neurobiological basis for substance abuse comorbidity in schizophrenia. Biol Psychiatry, 50:71–83.

Davis, K. L., Kahn, R. S., Ko, G., & Davidson, M. (1991). Dopamine in schizophrenia: a review and reconceptualization. Am J Psychiatry, 148:1474-1486.

Eggan, S. M., Hashimoto, T., & Lewis, D. A. (2008). Reduced cortical cannabinoid 1 receptor messenger RNA and protein expression in schizophrenia. Arch Gen Psychiatry, 65:772–784

Fazel, S., et al. (2009). Schizophrenia, Substance Abuse, and Violent Crime. Journal of American Medical Association , 301 (19), 2016-2023.

Fowler, I. L., Can, V. J., Carter, N. T., & Lewin T. J. (1998). Patterns of current and lifetime substance use in schizophrenia. Schizophr Bull, 24: 443–55

George T. P., Vessicchio, J. C, Termine A., et al. (2002). Effects of smoking abstinence on visuospatial working memory function in schizophrenia. Neuropsychopharmacology, 26: 75-85.

George, T. P., Sernyak, M. J., Ziedonis, D. M, & Woods, S. W. (1995). Effects of clozapine on smoking in chronic schizophrenic outpatients. J Clin Psychiatry.56:344-346.

George, T. P., Vessicchio, J. C., et al. Effects of smoking abstinence on visuospatial working memory function in schizophrenia. Neuropsychopharmacology, 26: 75-85.

Margolese, H. C., Negrete, J. C,, Tempier, R., & Gill, K. (2006). A 12-month prospective follow-up study of patients with schizophrenia-spectrum disorders and substance abuse: changes in psychiatric symptoms and substance use. Schizophr Res, 83:65–75.

Rane, A., & Nadkarni, A. (2012). Alcohol use in schizophrenia: prevalence, patterns, correlates and clinical outcomes in Goa, India. BJ Psych Bulletin , 36 (10), 257-262.

Rosen, C. S., et al. (2008). Substance abuse-related mortality among middle-aged male VA psychiatric patients. Psychiatr Serv, 59:290–296.

Volkow, N. D. (2009). Substance Use Disorders in Schizophrenia—Clinical Implications of Comorbidity. Schizophrenia Bulletin , 35 (3), 469–472.

Weinberger, D. et al. (2009). Predictors of abstinence and changes in psychiatric symptoms in a pooled sample of smokers with schizophrenia receiving combination pharmacotherapy and behavioral therapy for smoking cessation. J Clin Psychopharmacol. 29: 601-603.

Wing V. C., Wass, C. E., Soh, D. W., & George, T. P. (2012). A review of neurobiological vulnerability factors and treatment implications for comorbid tobacco dependence in schizophrenia. Ann N Y Acad Sci. 2012;1248:89-106.

Yin, D. M., Chen, Y. J., & Sathyamurthy, A, et al. (2002). Synaptic dysfunction in schizophrenia. Adv Exp Med Biol, 970: 493-516.