Co-Occurring Alcohol Use Disorder and Schizophrenia

Robert E. Drake, M.D., Ph.D., and Kim T. Mueser, Ph.D.

Alcohol use disorder (AUD) is the most common co-occurring disorder in people with schizophrenia. Both biological factors and psychosocial factors are thought to contribute to this co-occurrence. 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. KEY WORDS: comorbidity; AODD (alcohol and other drug dependence); schizophrenia; prevalence; disease susceptibility; disease course; self- medication; reinforcement; dopamine; neurotransmission; social adjustment; treatment complications; combined modality therapy; correlation analysis; literature review

chizophrenia is a severe and dis­ abuse other substances as well. Current related disorder marked by the same abling psychiatric disorder charac­ understanding of contributing factors, symptoms as schizophrenia but lasting Sterized by persistent delusions, correlated problems, effect on course of less than 6 months) also met the criteria hallucinations, disorganized speech, illness, and treatment implications is for an AUD diagnosis at some time disorganized behavior, and negative similar for different substances of abuse. during their lives and that 47 percent symptoms such as the absence of emo­ met the criteria for any substance use tional expression or a lack of motivation disorder (excluding nicotine dependence) or initiative (American Psychiatric Prevalence and (Regier et al. 1990). Rates of substance Association [APA] 1994). Alcohol use Contributing Factors use disorder tend to be higher among disorder1 (AUD) commonly co-occurs males and among people of both genders with schizophrenia. This article reviews Schizophrenia is frequently complicated and all ages in institutional settings, several aspects of AUD among people by comorbid disorders such as medical such as hospitals, emergency rooms, with schizophrenia, including the preva­ illnesses, mental retardation, and sub- lence of this co-occurrence, biological and stance abuse. Substance use disorder is 2The ECA study was a nationwide survey that used DSMÐIV psychosocial factors that contribute to the most frequent and clinically signifi­ criteria to determine the prevalence of psychiatric disorders this relationship, correlated problems cant comorbidity in this population, in the general population and among people in treatment. dually diagnosed people experience, the and alcohol is the most common sub- effects of AUD on the course and out- stance of abuse, other than nicotine ROBERT E. DRAKE, M.D., PH.D., and come of schizophrenia, treatment issues, (nicotine is much more prevalent than KIM T. MUESER, PH.D., are professors in and public policy implications. People any other substance of abuse in this the departments of psychiatry and commu­ with schizophrenia and AUD frequently population) (Cuffel 1996). Undoubtedly, nity and family medicine at Dartmouth the availability of alcohol and the fact Medical School and the New Hampshire- that it is legal contribute to its widespread Dartmouth Psychiatric Research Center, 1The term “alcohol use disorder” in this article refers to the abuse among people with schizophrenia Lebanon, New Hampshire. disorder defined by criteria for alcohol abuse or dependence in the American Psychiatric Association’s Diagnostic and as well as in the general population. Statistical Manual of Mental Disorders, Fourth Edition The Epidemiologic Catchment Area The writing of this paper was supported (DSMÐIV) (APA 1994). The terms “alcohol use disorder” (ECA) study2 found that 33.7 percent by U.S. Public Health Services grants and “alcohol abuse” are used interchangeably in this article.The definitions for these terms vary among studies reviewed of people with a diagnosis of schizophre­ MH–59383 and MH–52872 from the and are frequently based on earlier versions of the DSM. nia or schizophreniform disorder (a National Institute of Mental Health.

Vol. 26, No. 2, 2002 99 jails, and homeless shelters. This holds Roberts 1999). The neurobiology of are available. The first type, cross-sectional true for people with and without schizophrenia is similarly unclear studies, collects data at one point in schizophrenia (Regier et al. 1990). (Chambers et al. 2001). time. The second type, longitudinal The high rates of AUD and other The third hypothesis suggests that studies, collects data at several points substance use disorders in people with people with schizophrenia are especially over a period of time. Cross-sectional schizophrenia appear to be determined vulnerable to the negative psychosocial studies indicate that AUD among people by a complex set of factors (described effects of substance use because the with schizophrenia is associated with below) (Mueser et al. 1998). People schizophrenia syndrome produces im­ numerous manifestations of bad out- with schizophrenia probably use alcohol paired thinking and social judgment comes and poor quality of life (refer- and other drugs for many of the same and poor impulse control. Thus, even red to generally as poor adjustment), reasons as others in society, but several when using relatively small amounts of including increased recurrence of psychi­ biological, psychological, and socioen­ psychoactive substances, these people atric symptoms, psychosocial instability, vironmental factors have been hypothe­ are prone to develop significant substance- other substance use disorders, violence, sized to contribute to this population’s related behavioral problems that qualify victimization, legal problems, medical high rates of substance use disorders. them for a diagnosis of substance use problems such as HIV infection and disorder (Mueser et al. 1998). hepatitis, family problems, and institu­ Biological Factors tionalization in hospitals and jails Psychological and (Drake and Brunette 1998). People with There are three possible biological factors. Socioenvironmental Factors schizophrenia and AUD are particularly First, many clinicians and researchers prone to unstable housing situations have asserted that people with schizophre­ Psychological and socioenvironmental and homelessness. Although these people nia use alcohol and other drugs to self- factors also appear to contribute to the often reject medications and outpatient medicate in an attempt to alleviate the co-occurrence of schizophrenia and AUD. treatment, they nevertheless represent a symptoms of schizophrenia or the side People with schizophrenia and AUD high cost to the treatment system because effects of the antipsychotic medications often report that they use alcohol and they receive a high rate of hospital-based prescribed for schizophrenia (Chambers other drugs to alleviate the general dys­ services—relapse, as well as familial, et al. 2001). Research evidence does phoria of mental illness, poverty, lim­ psychosocial, legal, housing, and other not strongly support this view, however. ited opportunities, and boredom; they crises force them into emergency care For example, alcohol abuse often pre- also report that substance use facilitates (Dickey and Azeni 1996). cedes schizophrenia; specific drugs of the development of an identity and a The common explanation for these abuse are not selected in relation to social network (Dixon et al. 1990). correlated problems is that alcohol use specific symptoms; and various substances An entire generation of adults with causes or exacerbates poor adjustment of abuse produce a range of different schizophrenia in the United States has among people with schizophrenia. Many effects but generally exacerbate rather grown up during the era of deinstitu­ other factors could, however, explain than relieve symptoms of schizophrenia tionalization (Lamb and Bachrach the relationships between AUD and poor (Chambers et al. 2001). 2001). Although residing predominantly adjustment found in cross-sectional stud­ Second, the underlying neuropatho­ in the community rather than in hospi­ ies. For example, schizophrenia patients logical abnormalities of schizophrenia tals, these people still have had limited who abuse alcohol often abuse other (i.e., the abnormalities in the brain that vocational, recreational, and social substances, fail to take medications, and characterize schizophrenia) are thought opportunities (caused by factors such live in stressful circumstances without to facilitate the positive reinforcing effects as illness, stigma, and segregation). a strong support network, as described of substance use (Chambers et al. 2001). Further, they have experienced down- above. They may also have other inherent A common neurological basis for ward social drift into poor urban living differences from schizophrenia patients schizophrenia and for the reinforcing settings, where they are regularly exposed without AUD, thereby confounding effects of substance use may predispose to substance abuse and substance- the comparison between schizophrenia people to both conditions. This common abusing social networks (Lamb and patients with AUD and those without basis involves the dysregulation of the Bachrach 2001). AUD. brain chemical (i.e., neurotransmitter) Researchers are also accumulating dopamine. This would explain why longitudinal data regarding the course people with schizophrenia prefer drugs Correlated Problems and outcome of co-occurring schizophre­ such as nicotine and a class of antipsy­ and the Effects of AUD nia and AUD. Short-term studies last­ chotic medications that increase dopa- on the Course and ing 1 year or less of patients in traditional mine transmission in some areas of the Outcome of Schizophrenia mental health treatment systems indicate brain. Of course, the reinforcing effects that they are prone to negative outcomes, of alcohol use involve multiple neuro­ Two general types of studies of the such as continuing alcohol abuse or transmitter systems, and the mechanisms problems experienced by people with dependence, high rates of homeless­ at work are not yet clear (Koob and co-occurring schizophrenia and AUD ness, disruptive behavior, psychiatric

100 Alcohol Research & Health Alcohol Use and Schizophrenia

hospitalization, victimization, and incar­ abuse services (Bellack and DiClemente Although the need to provide inte­ ceration. For example, one typical study 1999; Onken et al. 1997; Ries 1994). grated, multidisciplinary services is clear, of outpatients with schizophrenia found There is also accumulating research the numerous specific treatments that that those with co-occurring AUD had support for the effectiveness of the are in use or in development need to be higher rates of hospitalization and depres­ integrated treatment approaches that tested regarding their individual effective­ sion compared with those with schizophre­ have evolved over the past two decades ness and their effectiveness in combina­ nia only (Cuffel and Chase 1994). (Drake et al. 1998). tion (Drake et al. 2001). For example, Several studies, including some stud­ Integrated approaches to treatment specific individual, group, family, and ies that tracked participants’ progress for patients with schizophrenia and self-help approaches to integrated treat­ over time (rather than collecting data AUD are generally offered through the ment are described in the literature, but on patients’ histories at some later point) few studies validate or compare these indicate that dually diagnosed people different approaches. Similar comments who become abstinent (compared with pertain to potential psychopharmaco­ those who do not) show more positive logic treatments and to approaches to results in other related areas, such as psychiatric rehabilitation. Several retro­ lower psychiatric symptoms and decreased In practice, patients spective studies indicate that the antipsy­ rates of hospitalization (Drake et al. with co-occurring chotic medication clozapine may be 1996). For example, people in the ECA particularly helpful to patients with study with schizophrenia and AUD mental and schizophrenia and AUD, but the who attained abstinence had decreased mechanisms of action for the effects on rates of depression and hospitalization substance use both illnesses are unclear, and controlled at 1-year followup (Cuffel 1996). In a disorders have rarely research is needed to establish the effi­ long-term followup study of schizophre­ cacy and effectiveness of this treatment nia patients by Drake and colleagues received needed (Green et al. 1999). (1998), those who attained stable absti­ Several approaches to housing, social nence showed dramatic improvements treatments. skills training, vocational services, moneytr in many domains, including decreased management, and supervision have also symptoms, decreased institutionalization, been recommended but not rigorously increased psychosocial stability, and tested. Another important area of inves­ self-reported improvements in quality use of multidisciplinary treatment teams tigation is treatment for those patients of life. These positive findings have that provide outreach, comprehensive who do not respond to standard outpa­ fueled attempts to develop more effec­ services, and stage-wise treatments tient approaches. Clinicians need to tive interventions for AUD among (described below). Outreach is needed know which patients should be offered schizophrenia patients. As described because these patients are often demor­ residential treatments, contingency below, such interventions include those alized and reluctant to engage in treat­ management (i.e., providing positive that integrate treatment for schizophre­ ment. Comprehensive services are vital consequences for desired behaviors and nia and for AUD. because recovery involves building skills withholding those consequences or and supports to pursue a meaningful providing negative consequences for life rather than just managing symptoms undesired behaviors), adjunctive medi­ Treatment or illnesses. Stage-wise treatment assumes cations, money management, or other that patients recover from two serious second-line interventions (i.e., interven­ Historically, the mental health and sub- disorders over time, in stages, and with tions for patients who do not respond to stance abuse treatment systems in the help from treatment providers. Patients standard treatment) (Drake et al. 2001). United States have been separate, and with schizophrenia and AUD generally traditional approaches to treating people pass through four stages of treatment: with co-occurring disorders have involved 1. Engagement, which involves build­ Public Policy parallel or sequential treatment in these ing a trusting treatment relationship separate systems. In practice, patients 2. Persuasion, which entails develop­ Although the testing and refinement of with co-occurring mental and substance ing motivation to manage both illnesses specific interventions, the development use disorders have rarely received needed and pursue recovery of treatment matching, and strategies treatments (Watkins et al. 2001) and 3. Active treatment, which encom­ to overcome nonresponsiveness are have generally experienced poor outcomes passes development of the skills and important issues, progress toward inte­ (Drake et al. 1996; Ridgely et al. 1987). supports needed for illness management grating mental health and substance abuse As a result, there has been widespread and recovery services has been minimal. Barriers endorsement by patients, clinicians, 4. Relapse prevention, which involves exist at all levels (e.g., organizational, administrators, and researchers for inte­ strategies to avoid and minimize the effects financial, and educational) and public grating mental health and substance of relapses (Osher and Kofoed 1989). policy at the Federal, State, regional,

Vol. 26, No. 2, 2002 101 and local levels has thus far failed to pro- chosocial and pharmacological inter­ DRAKE, R.E.; ESSOCK, S.M.; SHANER, A.; ET AL. mote widespread adoption of either ventions also need further development Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services 52: integrated treatments for dual disorders and testing, particularly for patients 469–476, 2001. or other evidence-based practices in the who do not respond to basic integrated mental health and substance abuse treat­ interventions. GOLDMAN, H.H.; GANJU, V.; DRAKE, R.E.; ET AL. Policy implications for implementing evidence-based ment systems (Goldman et al. 2001). practices. Psychiatric Services 52:1591–1597, 2001. Clinicians, patients, and family mem­ bers can advocate for effective services, References GREEN, A.I.; STROUS, R.D.; ZIMMET, S.V.; AND but training and even successful SCHILDKRAUT, J.J. Clozapine for co-morbid sub- American Psychiatric Association (APA). Diagnostic stance use disorder and schizophrenia: Do patients demonstration programs will not be and Statistical Manual of Mental Disorders, Fourth with schizophrenia have a reward deficiency syn­ sustainable if policymakers do not Edition. Washington, DC: APA, 1994. drome that can be ameliorated by clozapine? eliminate restrictions and provide the Harvard Review of Psychiatry 6:287–296, 1999. BELLACK, A.S., AND DICLEMENTE, C.C. Treating incentives and reinforcements for evi­ substance abuse among patients with schizophrenia. KOOB, G.F., AND ROBERTS, A.J. Brain reward cir­ dence-based practices. Psychiatric Services 50:75–80, 1999. cuits in alcoholism. CNS Spectrums 4:23–37, 1999.

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