Schizophrenia and Addiction: The Guide to Unraveling Comorbidity and Finding the Path to Recovery

By James Achanyi-Fontem, Executive Director, Cameroon Link, Courtesy of The Centers for Disease Control (CDC)

It’s estimated that approximately 1% of the world’s population is diagnosed with schizophrenia, while the prevalence in the United States is slightly higher with an estimated 1.2% of the population diagnosed with the illness. That’s about 3.2 million Americans as of 2009, with an expected 100,000 people diagnosed annually – or 7.2 in every 1,000 people. The Centers for Disease Control (CDC) offers slightly different statistical estimates, noting, “Worldwide prevalence estimates range between 0.5% and 1%. Age of first episode is typically younger among men (about 21 years of age) than women (27 years). Of persons with schizophrenia, by age 30, 9 out of 10 men, but only 2 out of 10 women, will manifest the illness.” While schizophrenia can impact people throughout their lifespan, it is most commonly diagnosed during early adulthood. In fact, it’s rare for children or older adults to be diagnosed with schizophrenia. The rate of diagnosis for new cases of schizophrenia is highest between the ages of 16 and 25 years with a few differences between males and females: •Men reach peak vulnerability between 18 and 25 years old. •Women reach peak vulnerability between 25 and 30 years old. •Women have a second period of peak vulnerability at around 40 years of age. Schizophrenia is most notably characterized by odd and bizarre behaviors, and it’s these behaviors that often lead to the initial diagnosis. Most experts don’t believe that drug or alcohol abuse causes schizophrenia; it is widely recognized, though, that people with schizophrenia are more likely to abuse alcohol and/or drugs. Substance abuse can make treatments for schizophrenia less effective, however, which can lead to further complications. We’ve created this guide to explore the relationship between schizophrenia and addiction, the impacts of comorbidity, and solutions for overcoming addiction and mental illness to begin the path down the road of recovery. What You’ll Find in This Guide: •What is Schizophrenia? •Schizophrenia and the Prevalence of Substance Abuse •Complications of Comorbidity •Solutions and Treatment Options for Positive Outcomes What is Schizophrenia? In this section we examine schizophrenia, common signs and symptoms, statistics, and disease impacts. While schizophrenia directly affects just a small portion of the population (both in the United States and worldwide), the effects of this devastating mental illness are far-reaching, impacting family and friends in addition to the individual diagnosed with the disease.

Schizophrenia is a serious mental illness, and while there is currently no cure for the disorder, it is treatable with careful management. According to the National Institute of Mental Health, “Schizophrenia is a chronic, severe, and disabling mental disorder characterized by deficits in thought processes, perceptions, and emotional responsiveness.” The NIMH further explains that the symptoms of schizophrenia are generally categorized by “positive” or “negative” symptoms. Positive symptoms include those which are present in people with schizophrenia but not present in people who do not have schizophrenia such as: •Hallucinations •Delusions •Thought disorders Negative symptoms, on the other hand, are characteristics normally present in people without schizophrenia but that those diagnosed with the disease do not exhibit such as: •Avolition (“a lack of desire or motivation to accomplish goals”) •A lack of interest or desire in forming social relationships •Blunted affect and/or emotion Early warning signs of schizophrenia may include: •Intentional social isolation or withdrawal •Suspiciousness of or hostility towards others •An inability to express emotions – such as an inability to cry •Showing emotions inappropriate to the context – such as crying or laughing in unusual circumstances •Forgetfulness and lack of concentration •Using strange words or speaking in an usual manner •Odd or irrational statements The hallmarks of schizophrenia include delusions, hallucinations, disorganized speech, and disorganized behavior. People suffering from schizophrenia may feel paranoid or experience severe anxiety, or they may find it difficult to find the words they’re looking for to communicate, resulting in disorganized speech. While there’s a stigma surrounding schizophrenia, the disease is often manageable with a commitment to long-term (often lifetime) treatment. However, when schizophrenia is undiagnosed or not well managed, the symptoms of the disease may become uncontrollable and create severe disruption not only in the life of the person suffering from the disease, but their family and friends who are plagued with worry and confusion, sometimes not understanding what is happening to the person they know and love.

Schizophrenia and the Prevalence of Substance Abuse In this section we examine the link between schizophrenia and substance abuse as well as the ramifications of substance abuse for those being treated for schizophrenia and the dangers associated with the misuse of drugs and alcohol.

Researchers have long recognized a high prevalence of comorbid (simultaneously occurring) substance abuse among people with schizophrenia, but the cause for this correlation hasn’t been definitively established. That said, most research – and the majority of experts in the field – seem to agree with one hypothesis: that people with schizophrenia turn to substances in an attempt to self-medicate and achieve symptomatic relief. According to a report from the University of Montreal appearing on Europe PMC, “Formulated in a clinical context, in reaction to the psychoanalytic interpretation of addiction as a pleasure seeking pathology, Khantzian’s hypothesis holds that schizophrenic patients use psychoactive substances to relieve their symptoms.” “Various hypotheses have been suggested to explain the high co-morbidity between schizophrenia and addiction,” explains a report from the National Center for Biotechnology Information (NCBI). These hypotheses include: 1.The social-environmental hypothesis, although no studies have provided adequate evidence in support of this hypothesis to date. 2.There’s a possibility that a shared biological vulnerability exists between schizophrenia and addictions. This has led researchers to explore common genetic factors for each condition, such as “the involvement of the dopaminergic and opioid systems in the etiology of both schizophrenia and the abuse of and dependence on psychoactive drugs.” 3.The self-medication theory, described above, which suggests that people suffering from schizophrenia use drugs and/or alcohol in an attempt to “counter the deficit linked to their disorders by using the substances they take or their dependency-type behavior to cope with their emotional problems.” Medscape reports that nearly half of people who suffer from schizophrenia “also present with a lifetime history of substance abuse disorders (SUD),” a significantly higher rate than the incidence of substance abuse disorders in the general population. The most commonly abused substances among people with schizophrenia include (percentage rates represent substance abuse meeting DSM-IV criteria for substance abuse disorder obtained from various studies as reported by Medscape): •Nicotine (28.5%) •Cannabis (50.8%) •Alcohol (43.1-65%) •Cocaine (23%) Addressing comorbid substance abuse among patients with schizophrenia is critical as substance abuse disorder is associated with poor clinical outcomes for people with schizophrenia. Complications of Comorbidity In this section we discuss the complications that arise from comorbidity for people who suffer from schizophrenia and their friends and loved ones as well as provide resources for further reading on the impacts comorbidity can have among those battling this mental illness.

Alcohol Use Disorder (AUD) is the most common comorbid disorder among people with schizophrenia. According to a report from the National Institutes of Health (NIH), “Schizophrenia patients with AUD are more likely to have social, legal, and medical problems, compared with other people with schizophrenia. AUD also complicates the course and treatment of schizophrenia.” Influenced by both biological and psychological and socioenvironmental factors, alcohol use disorder among people with schizophrenia is associated with poor treatment outcomes and diminished quality of life. Those who battle both schizophrenia and AUD are more likely to experience unstable housing conditions or homelessness, and as the report explains, “increased recurrence of psychiatric symptoms, psychosocial instability, other substance use disorders, violence, victimization, legal problems, medical problems such as HIV infection and hepatitis, family problems, and institutionalization in hospitals and jails.” According to the Schizophrenia Bulletin from Oxford Journals, substance abuse comorbidity is so common that it’s largely considered the norm rather than the exception among schizophrenic patients. Substance abuse is associated with a variety of negative consequences, including: •An increase in positive symptoms •A relapse of psychosis •Increased risk of violence •Increased risk of suicide •More medical comorbidities •Legal complications such as an increased risk of incarceration •A greater likelihood of experiencing antipsychotic-related side effects It’s important to note that alcohol-related psychosis is also a possible consequence of alcohol abuse. “Alcohol-related psychosis is a secondary psychosis that manifests as prominent hallucinations and delusions occurring in a variety of alcohol-related conditions. For patients with alcohol use disorder, previously known as alcohol abuse and alcohol dependence, psychosis can occur during phases of acute intoxication or withdrawal, with or without delirium tremens,” explains a report from Medscape. “In addition, alcohol hallucinosis and alcoholic paranoia are 2 uncommon alcohol-induced psychotic disorders, which are seen only in chronic alcoholics who have years of severe and heavy drinking.” However, alcohol-induced psychosis is rare and does not typically follow the same longitudinal course as schizophrenia. Solutions and Treatment Options for Positive Outcomes In this section we discuss treatment options and the path to long-term recovery for patients with schizophrenia. We also provide valuable resources with insights on obtaining adequate treatment and strategies for achieving long-term disease management and improved quality of life.

Individuals who live in low-income communities face obstacles in obtaining mental health services, and left untreated, mental illness can contribute to a vicious cycle making it difficult to secure and maintain gainful employment, care for children and other family members, and contribute to the ongoing cycle of poverty and poor mental health. According to NYU’s Department of Applied Psychology, schizophrenia is one of the most dangerous mental health conditions when inadequately treated, particularly when combined with cocaine use. Improving access to mental health care in impoverished communities is critical for reducing the negative outcomes associated with lack of access to treatment. The University of Maryland Medical Center (UMM) suggests an integrated approach to treatment encompassing: •Motivational interviews to gauge the patient’s commitment to recovery •Antipsychotic medications with careful monitoring and management •Community-based rehabilitation coupled with skills training to improve long-term outcomes •Psychotherapy not just for the patient but their whole family to strengthen family support systems •Cognitive-behavioral therapy aimed at reducing delusions and hallucinations Long-term medication is typically recommended for a period of at least one year, and long-term maintenance medication is frequently used to control symptoms during long-term recovery. Substance abuse reduces the likelihood of medication compliance, however, so these patients should be carefully monitored to ensure ongoing compliance and reduce the risk of relapse. While further research and evaluation is needed to determine the best approach to treating comorbid schizophrenia and substance abuse, an integrated treatment approach is the current widely accepted treatment standard. According to a report appearing in Medscape, a combination of psychosocial interventions with pharmacotherapy typically results in the best possible outcomes. Research continues to evaluate the effect of atypical antipsychotics to treat these patients, and the adjunctive use of naltrexone and similar agents is promising. Psychiatric Times explains the importance of discovering solutions to the clinical challenges associated with treating comorbid substance use disorders among patients with schizophrenia, pointing out the many consequences such as more frequent and longer hospitalizations and increased use of crisis-oriented services (in addition to the consequences discussed earlier in this guide), ultimately resulting in a higher cost of care. “Pharmacologic interventions that have been evaluated (e.g., the medications used to treat alcohol dependence, including disulfiram and naltrexone) seem to have clinical use in this population,” the article explains, concurring with earlier noted studies that state that the use of atypical antipsychotics shows promise for treating substance abuse disorders in comorbid populations. In fact, the first line of treatment for these patients is usually an antipsychotic medication. “It has been hypothesized that if these newer medications are superior in their effects on psychotic symptoms or have fewer adverse effects, they may concomitantly reduce comorbid substance use disorders,” the article further explains. “Another hypothesis suggests that because atypicals have a different pharmacologic profile from conventional antipsychotics and because they target receptors that may play a direct role in the etiology of substance abuse and dependence, they may be especially effective in treating substance use disorders as well as psychosis.” Effectively managing comorbid schizophrenia and substance abuse requires more than pharmaceutical intervention. The best outcomes are achieved through mental health and substance abuse treatments coupled with therapeutic intervention providing patients with the skills and supports they need to manage both comorbid conditions as well as achieve functional goals, resulting in the long-term, comprehensive approach to recovery that results in positive outcomes. While there is no definitive cure for schizophrenia alone or coupled with comorbid substance abuse disorder, the current integrated treatment approach holds promise for patients in enabling them to lead normal lives with ongoing disease management.