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 Centre for Addictionand Mental Health |
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Meeting the challenge: Integrated treatment tackles co-occurring schizophrenia and substance useCrossCurrentsBy Anne Ptasznik Traditionally, people with concurrent disorders receive separate treatment for mental health and substance use issues, often
resulting in ineffective care. Growing understanding of the complex interaction between mental health and substance use issues
has prompted a move towards evidence-based integrated treatment. Various hypotheses address the link between substance use and schizophrenia, as outlined in a March 2007 study in the American Journal of Psychiatry. According to one hypothesis, a neurobiological vulnerability interacts with environmental stressors, including substance
abuse, to precipitate the onset of schizophrenia or psychotic relapse. Support for this hypothesis comes from recent findings
that vulnerable adolescents who use cannabis may be at greater risk for psychosis. The second hypothesis asserts that people with schizophrenia are more likely to develop substance abuse problems due to the
cumulative risk effects of poor cognitive, social, educational and vocational functioning, as well as poverty, victimization
and familial and social factors. According to the third hypothesis, people with schizophrenia use substances to self-medicate,
in order to reduce symptoms of the disorder or to ease medication side-effects. As these latter two hypotheses have not been substantiated with research, the study authors propose a fourth hypothesis, relating
increased risk to an attempt to correct the dysfunction that occurs with the neurotransmitter dopamine, which studies have
shown to be associated with schizophrenia. Whatever the relationship, one thing is certain – co-occurring substance use and schizophrenia has a particularly deleterious
impact. According to Concurrent Disorders: A Resource for Families, published by the Centre for Addiction and Mental Health (CAMH) in Toronto, people with concurrent disorders are more likely
to end up in jail, have increased relapses and poorer treatment adherence, and have more problems with general health, finances,
housing and personal relationships. They also have increased thoughts of suicide and are more likely to act out. Given these serious potential consequences, effective treatment is crucial, but accurate diagnosis is a challenge. Alison
Gilbart, a registered nurse at the Foothills Medical Centre’s Addiction Centre in Calgary, Alberta, says that among people
with chronic schizophrenia, it can be difficult to determine whether they are experiencing psychotic breakthrough symptoms
or the effects of substance use. The Centre offers an “open group,” which operates on a harm reduction drop-in model. Clients are always welcome and are not
ejected from the program for non-attendance or using substances. “There is a lot of acceptance of where clients are in their
journey,” says Gilbart. The goal is to work towards abstinence, with support from the Centre’s other programs once clients
are more stable. Gilbart stresses the importance of forming organizational partnerships, especially in locations with limited
resources. However, simply engaging people in treatment can be a challenge. Mike Pett, an advanced practice clinician with SPICeD, CAMH’s
new Schizophrenia Program Initiative in Concurrent Disorders, found in his previous position in CAMH’s Concurrent Disorders
Service that there is a subgroup of people with co-occurring schizophrenia and substance use problems who have difficulty
even showing up. “These tend to be those with chronic schizophrenia who may not respond well to medication, are uninterested
in or ambivalent about taking medication or take it irregularly, all of which can be influenced by problematic substance use,”
says Pett. This subpopulation is also characterized by histories of trauma, homelessness, multiple hospitalizations and incarcerations
and chaotic, unstable housing. They often have comorbid diagnoses such as anti-social personality disorder and are at higher
risk of acting out against themselves and others. Pett realized that in order to engage this population, he had to meet them where they were, and liaise with assertive community
treatment (ACT) teams, shelters and community health facilities. He also had to learn about supportive housing, street outreach
engagement strategies, the law and crisis intervention, and had to be ready to give mental status examinations, even in a
coffee shop. This type of assertive outreach and case management will be an important part of integrated treatment through
SPICeD. SPICeD will also offer an “engagement group” in the form of a drop-in breakfast club with guest speakers about concurrent
disorders and field trips for people who have not made a decision to reduce use; a persuasion group, where harm reduction
strategies and motivational interviewing will be used to help clients “get off the fence” and set goals; and action groups,
where clients will develop plans to cut back or become abstinent and practice relapse prevention strategies. The SPICeD team
will also provide consultation and training to inpatient and outpatient programs in CAMH’s Schizophrenia Program, with future
plans to extend consultation and education to community and external agencies. The overall goal of SPICeD, according to Dr. Tony George, clinical director of CAMH’s Schizophrenia Program and Chair in Addiction
Psychiatry at the University of Toronto, will be for all clinicians in the Schizophrenia Program to develop basic skills to
initially assess and initiate treatment of comorbid addictions. Ultimately, the program hopes to develop specialized services,
such as medical withdrawal management tailored to people with comorbid addictions and psychosis and “dual recovery therapies,”
which integrate long-term treatment of comorbid addictions and schizophrenia. Much of the knowledge about the components of effective treatment for this population comes from the work of Dr. Kim Mueser,
a leading expert in concurrent disorders at Dartmouth Medical School in New Hampshire. Mueser says that integrated treatment
begins with collaborative teams that understand how mental health and substance use issues interact. For example, if a person
with schizophrenia is using substances to overcome social limitations, helping them develop stronger interpersonal skills
may affect both issues. Mueser says that the other essential components include the capacity to do assertive outreach to engage people who might not
otherwise be reached; motivational-based or stage-wise interventions, which recognize the importance of the different stages
of readiness; comprehensive treatment, which includes addressing social, housing, medical and family needs; and taking a long-term
perspective rather than placing artificial time limits on how long it takes to recover. Social support from self-help groups,
particularly Dual Recovery Anonymous or Double Trouble, as well as friends and families, is another critical component of
integrated treatment. Mueser has found that clients with family support tend to have a better and quicker course of recovery
from substance use. Evidence-based treatment will get a boost through the latest recommendations from the Schizophrenia Patient Outcomes Research
Team (PORT), funded by the Agency for Health Care Policy and Research and the National Institute of Mental Health in the United
States. The recommendations will be published by the end of the year in Schizophrenia Bulletin. Dr. Lisa Dixon, professor of psychiatry at the University of Maryland School of Medicine, who led the literature
review for PORT, says there was sufficient evidence to recommend that people with schizophrenia and comorbid substance use
should be offered substance use treatment, including motivational enhancement and behavioural strategies that focus on engagement
and treatment, coping skills training and relapse prevention training integrated with mental health care. Improvements in functioning, however, cannot always be attributed to integrated treatment. A study of 10-year outcomes for
people with schizophrenia who received integrated treatment was reported in Schizophrenia Bulletin in 2006. Despite severe and prolonged disabilities, many of them were able to control their schizophrenia symptoms, reduce
episodes of hospitalization and homelessness, obtain employment, achieve success in community functioning and attain a better
quality of life. The authors concluded, however, that the improvements could be attributed to other factors beyond integrated
treatment, such as an increased emphasis on employment and self-help in that area at that time, or the natural course of improvement
that occurs with age. Researchers have also been examining new pharmacological interventions. Naltrexone and acamprosate, which have been proved
effective for alcohol dependence, are now being studied for their use with people who have severe mental illness. Atypical
antipsychotic medications like clozapine may reduce the desire for substances by ameliorating the dopamine dysfunction related
to schizophrenia, according to a 2008 article in the Journal of Substance Abuse Treatment. Ultimately, Mueser stresses that most important in working with this population is helping clients identify an achievable goal, whether it be related to school, work or relationships, so that they have a sense of purpose. He recently met a consumer at a mental health conference who had experienced schizophrenia and substance use issues and had spent significant periods of time homeless, but who was now abstinent for two years and worked part-time. The consumer talked about his experience as a recipient of ACT team services and made it very clear that he needed to acquire housing before he could get sober and allow people to help him work on his substance use issues. “It’s always reasonable to be hopeful about the ability of people to recover,” says Mueser. |
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Last updated: August 21, 2009 4:36 PM Published: February 22, 2010 8:58 PM ID#45557-R |