Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.     

The expanding indications for clozapine.

Clozapine is increasingly being used for clinical indications in addition to treatment-resistant schizophrenia; this article reviews the relevant literature. The first section reassesses the risks associated with clozapine treatment, particularly agranulocytosis. The next section discusses its use for schizophrenia in patients who are treatment resistant, not treatment resistant, and intolerant of traditional drug treatments. Subsequent sections address its use in mood disorders, neurologic conditions, comorbid substance abuse, aggressive behavior, and childhood schizophrenia. Each includes the initial rationale for the use of clozapine in the disorder, a critical evaluation of the relevant literature, and theories as to why clozapine's unique pharmacodynamic profile may be efficacious for the specific condition. This body of literature suggests clozapine may be an effective treatment for a wide range of disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrated services for treatment of schizophrenic substance abusers: demographics, symptoms, and substance abuse patterns

We have previously described a model of outpatient integrated treatment for patients with comorbid psychoactive substance use disorders and schizophrenia (PSUD/S)(1). Here we review relevant literature on comorbidity and outline the rationale for integrated services. Further, we describe results from 3 related studies: First, we document the approximate incidence of PSUD among a heterogeneous group of 602 schizophrenic inpatient admissions to our hospital. Second, we describe in greater detail the psychiatric symptoms and patterns of substance abuse among a subsample of 106 inpatients with PSUD/S, contrasting them with 112 patients with PSUD and mixed psychotic disorders, but who are not schizophrenic. Third, we present a prospective research project and describe a sample of 30 patients with PSUD/S, detailing demographic characteristics, psychiatric symptoms and substance abuse history. Attention is given to current issues in the differential diagnosis of patients with PSUD/S using standardized instruments.     

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial bebavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anti-beta-crystallin antibodies (mouse) or sera from humans with age-related cataract are cytotoxic for lens epithelial cells in culture

Although the motivation to quit using substances is an important prognostic and treatment-matching factor in substance abuse treatment, there is limited information on motivation to quit among individuals with schizophrenia. This study used the five-stages-of-change model to evaluate the motivational levels of 497 individuals with schizophrenia or schizoaffective disorder in an outpatient mental health clinic. Rates of substance abuse, motivation levels to quit each specific substance, and correlates to motivational levels were evaluated. At least one substance use disorder was diagnosed in 224 of the subjects (45%); however, there was significant variability among the caseloads of the outpatient division teams. The patients in the triage/acute services and community outreach teams had substance abuse rates of about 70 percent. Most subjects had low motivation to quit substances, and the rates varied according to substance (range of 41% for opiates to 60% for cocaine). Treatment-matching strategies are suggested in the motivation-based treatment model.     

Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders

BACKGROUND: The aim of this study was to explore patterns and clinical correlates of psychiatric comorbidity in patients with schizophrenia spectrum disorders and mood spectrum disorders with psychotic features. METHOD: Ninety-six consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Psychopathology was assessed by the SCID-P, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, and Hopkins Symptom Checklist. Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders. RESULTS: The total lifetime prevalence of psychiatric comorbidity in the entire cohort was 57.3% (58.1% in schizophrenia spectrum disorders and 56.9% in mood spectrum psychoses). Overall, panic disorder (24%), obsessive-compulsive disorder (24%), social phobia (17.7%), substance abuse (11.5%), alcohol abuse (10.4%), and simple phobia (7.3%) were the most frequent comorbidities. Within the group of mood spectrum disorders, negative symptoms were found to be more frequent among patients with psychiatric comorbidity than among those without comorbidity, while such a difference was not detected within the group of schizophrenia spectrum disorders. Social phobia, substance abuse disorder, and panic disorder comorbidity showed the greatest association with psychotic features. An association between earlier age at first hospitalization and comorbidity was found only in patients with unipolar psychotic depression. Patient self-reported psychopathology was more severe in schizophrenia spectrum patients with comorbidity than in those without, while such a difference was less pronounced in mood spectrum psychoses. CONCLUSION: These findings suggest that psychiatric comorbidity is a relevant phenomenon in psychoses and is likely to negatively affect the phenomenology of psychotic illness. Further studies in larger psychotic populations are needed to gain more insight into the clinical and therapeutic implications of psychiatric comorbidity in psychoses.     

Psychiatric morbidity among adults in The Netherlands: the NEMESIS-Study. II. Prevalence of psychiatric disorders. Netherlands Mental Health Survey and Incidence Study

OBJECTIVE: To determine the prevalence of psychiatric disorders in non-institutionalised Dutch adults. DESIGN: Cross-sectional. SETTING: Trimbos Institute, Utrecht, the Netherlands. METHODS: A representative sample of 7076 adults (18-64 years) in the Netherlands' population were interviewed in 1996 to determine the prevalence of mental disorders ever, in the previous 12 months and in the previous month. Objectives and study design are described in the previous article (1997: 2448-52). The 'Composite international diagnostic interview' (CIDI) was used to assess the following mental disorders according to Diagnostic and statistical manual of mental disorders, 3rd revised edition (DSM-III-R): affective disorders, anxiety disorders, eating disorders, schizophrenia and other non-affective psychoses, substance dependence and substance abuse. RESULTS: Mental disorders were common in the general population: the prevalence 'ever' of all disorders was 41.2%, the 12-month prevalence 23.5%, without sex differences. Depression, anxiety disorders and alcohol abuse and dependence showed high prevalence and comorbidity. The prevalence 'ever' of schizophrenia and other non-affective psychoses was low (0.4%).     

The self-medication hypothesis of substance use disorders: a reconsideration and recent applications

The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.     

An examination of gender and racial differences among Missouri insanity acquittees

This study examines gender and racial differences among Missouri insanity acquittees, which included 42 African American females, 279 African American males, 63 Caucasian females, and 458 Caucasian males. Significant differences across the four groups were not found in age, current marital status, a diagnosis of borderline intellectual functioning/mental retardation, committing crimes of assault and burglary, and whether insanity acquittees ever received conditional releases to reside in the community. Some variations across the four gender/race categories were related to race (diagnoses of schizophrenia, mood disorders, and other Axis I diagnoses), but variations were more frequently related to gender (whether ever married; diagnoses of substance abuse, sexual disorders, antisocial personality disorder, borderline personality disorder, and any personality disorder; committing crimes of murder, sexual offenses, and serious offenses; and current residential status). African American males were identified as being an at-risk population. They were the most likely to have a schizophrenia diagnosis, a substance abuse diagnosis, an antisocial personality disorder diagnosis, and to be hospitalized on the survey date. Implications for treatment and future research are explored.     

ESR and U-series analyses of teeth from the palaeoanthropological site of Hexian, Anhui Province, China

Male substance abuse patients with posttraumatic stress disorder (PTSD) (SA-PTSD; N = 140) were compared to patients with only substance use disorders (SA-only; N = 1,262), and those with other Axis I diagnoses (SA-PSY; N = 228) on changes during substance abuse treatment. Diagnoses were determined by chart review, and patients completed questionnaires assessing coping, cognitions, and psychological distress. Although SA-PTSD patients improved on outcomes during treatment, they showed less benefit relative to SA-only patients. At discharge, SA-PTSD patients reported less use of effective coping styles, and endorsed more positive beliefs about substance use than SA-only patients. They had more psychological distress than SA-only and SA-PSY patients. More counseling sessions devoted to substance abuse and family problems, and increased involvement in 12-step activities partially counteracted the negative effects of having a PTSD diagnosis on several outcomes. SA-PTSD patients reported fewer psychological symptoms at discharge in programs that were high in support and order/organization.     

Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions

An emerging body of research on the physical and sexual abuse of seriously mentally ill (SMI) women documents a high incidence and prevalence of victimization within this population. While causal links are not well understood, there is convergent evidence that victimization of SMI women is associated with increased symptom levels, HIV-related risk behaviors, and such comorbid conditions as homelessness and substance abuse. These abuse correlates may influence chronicity, service utilization patterns, and treatment alliance. This article reviews the research literature on the prevalence, symptomatic and behavioral correlates, and treatment of abuse among SMI women, particularly women with schizophrenia. Within each topic, we discuss relevant research findings, limitations of available studies, and key questions that remain unanswered. We also discuss mechanisms that may underlie the relationship between trauma and schizophrenia-spectrum disorders. We conclude by outlining directions for future research in this area.     

Pneumonitis after radiotherapy of bronchial carcinoma: incidence and influencing factors

The main purpose of the study was to describe the characteristics of homeless psychiatric patients, and to compare the treatment they are offered to that offered to domiciled patients by the psychiatric services. Another purpose was to analyse the prevalence of homelessness among psychiatric patients before and after the introduction of community mental health centres in Copenhagen. Cross-sectional studies were conducted in two intervention and two control districts before and after introduction of the new treatment modalities. In 1991, 80 of 1008 patients (8%) were homeless. Male sex, young age, living on general welfare, schizophrenia and alcohol or substance abuse were the factors that most markedly differentiated homeless from domiciled patients. Compared with the treatment of domiciled patients, the homeless were more likely to be offered no further treatment after consultation in a psychiatric emergency and, if admitted, they were more likely to be placed in locked wards, given compulsory medication, and medicated with depot neuroleptics. The homeless were also less likely to be offered psychotherapy and consultation with a social worker. Schizophrenia and alcohol or substance abuse characterised the majority of the patients discharged homeless. In the intervention districts, the number of homeless patients in contact with the psychiatric services was found to increase at the same rate as the number of all patients in contact with the psychiatric services. In the control districts, no changes in prevalence of homeless patients or other patients in contact with the psychiatric services occurred. It is concluded that homeless psychiatric patients comprise a difficult patient group, with problems of schizophrenia, substance abuse and lack of motivation for treatment. It is recommended that special efforts be made to create housing facilities that fit the needs of different types of homeless patients, and that the homeless mentally ill are assisted in obtaining and maintaining an acceptable housing situation.     

Perception of natural fluctuations in peak flow in asthma: clinical severity and psychological correlates

OBJECTIVE: This review focused on empirical research that addressed the effectiveness of service models for the care of patients with personality disorders. METHOD: Services discussed included those delivering acute care, such as crisis and emergency services and acute psychiatric hospitalization; continuing care, such as outpatient services, day hospital treatment, and assertive community treatment programs; and other community programming, such as integrated treatment for comorbid substance abuse and psychoeducational interventions for families of patients with personality disorders. The review focused on studies that included patients with personality disorders, and it measured outcomes relevant to patients with personality disorders. Evidence from randomized controlled trials was highlighted. RESULTS: Few systematic studies of acute services were available. Community programming can decrease the risk of suicide attempts and reliance on inpatient admissions. Services must develop methods of ensuring compliance with treatment. Assertive community treatment for Axis II patients should be developed, implemented, and tested. Comprehensive programming for patients with personality disorders must include integrated treatment for substance abuse and family psychoeducational programs. CONCLUSION: Promising new models of care for patients with personality disorders are ready for testing and wider application.     

Group treatment for substance abuse in schizophrenia

OBJECTIVES: A review of the relevant research suggests a need to develop an appropriate, effective, and replicable treatment to help individuals with schizophrenia and substance abuse problems. This pilot study describes a biweekly group specifically designed to help the individual with both schizophrenia and substance abuse. The components of the group were support, psychoeducation, and skills training. Attention was also paid to the stage of recovery. METHOD: Eighteen subjects attended the group and were assessed pregroup. Thirteen subjects completed a 1-year follow-up, and 5 subjects were assessed between 3 and 6 months. RESULTS: At the follow-up assessment, 8 subjects (44%) were abstinent. CONCLUSIONS: This type of treatment appears to be effective for reducing substance abuse in this population.     

Contingency management is especially efficacious in engendering long durations of abstinence in patients with sexual abuse histories.

Exposure to sexual victimization is prevalent among persons with substance use disorders (SUDs). Contingency management (CM) treatments utilize concrete and relatively immediate positive reinforcers to retain patients in treatment and reduce substance use, and CM may have particular benefits for patients with histories of sexual victimization. Using data from three randomized trials of CM (N = 393), this study evaluated main and interactive effects of sexual abuse history and treatment condition (standard care versus CM) with respect to during treatment outcomes (retention, proportion of negative urine samples submitted, and longest duration of abstinence) and abstinence at a nine-month follow-up. Compared to patients without sexual abuse histories (N = 316), those with sexual abuse histories (N = 77) submitted a significantly higher proportion of negative samples in treatment. In CM, but not in standard care, patients with sexual abuse histories achieved significantly longer durations of abstinence during treatment than those without sexual abuse histories. Although sexual abuse history was not associated with abstinence at nine-month follow-up evaluations, longest duration of abstinence during treatment was significantly associated with this long-term outcome. Results suggest that SUD patients with sexual abuse histories may accrue particular benefits during CM treatment that are associated with long-term abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Functional associations among trauma, PTSD, and substance-related disorders

This review article presents several potential functional pathways which may explain the frequent co-occurrence of PTSD and substance abuse disorders in traumatized individuals. Emerging empirical studies which have examined these potential pathways are reviewed, including studies on relative order of onset, PTSD patients' perceptions of various drug effects, comparisons of PTSD patients with and without comorbid substance use disorders, and correlational studies examining the relations between severity of specific PTSD symptom clusters and substance disorder symptoms. Research on the acute and chronic effects of alcohol and other drugs on cognitive and physiological variables relevant to PTSD intrusion and arousal symptoms is reviewed to highlight ways in which these two sets of PTSD symptoms might be functionally interrelated with substance abuse. Finally, based on these findings, recommendations are made for the treatment of individuals with comorbid PTSD-substance use disorders.     

Prevalence and severity of substance use disorders and onset of psychosis in first-admission psychotic patients

BACKGROUND: Past studies have found inconsistent evidence that substance use disorders are related to earlier onset of schizophrenia or more severe symptoms. This study examines prevalence and severity of current substance use disorders and onset of psychotic illness in a multi-facility sample. METHODS: Data are from the Suffolk County Mental Health Project, an epidemiological study of first admission psychosis. The SCID and instruments measuring symptomatology, personality and background characteristics were administered. Respondents were stratified into three groups: (a) no life-time substance diagnosis; (b) in remission or reporting current mild use at admission; and (c) current moderate-severe substance abuse at admission. RESULTS: Using the SCID severity rating, 17.4% of males and 6.2% of the females had moderate or severe current substance abuse, while 41.5% of males and 68.2% of females had no lifetime substance diagnosis. In almost all cases categorized as moderate-severe, the substance diagnosis predated onset of psychosis. Females categorized as moderate-severe have an earlier age of onset of psychosis than did females in the other groups. There were only slight differences in symptom severity among the groups but more marked antisocial behaviour in the moderate-severe group. Variables discriminating the moderate-severe from non-abuse groups were BPRS thought disturbance, adult anti-social behaviour and current cigarette smoking for males and adult anti-social behaviour and child-teen antisocial behaviour for females. CONCLUSIONS: Severity of substance abuse does not appear to be a pivotal correlate of the early features of psychotic illness.     

Immunolocalization of BMP-6, a novel TGF-beta-related cytokine, in normal and atherosclerotic smooth muscle cells

OBJECTIVES: The study replicated methods used in an earlier study to determine the prevalence of dissociative disorders among patients with substance use disorders and to examine demographic characteristics and history of childhood abuse among patients with and without dissociative comorbidity. METHODS: A total of 100 inpatients who were completing a substance abuse treatment program at a VA medical center were interviewed using the Dissociative Disorders Interview Schedule, which diagnoses dissociative disorders. Two additional screening measures of dissociative symptoms were used, as well as an instrument to measure IQ. RESULTS: Fifteen percent of the sample were diagnosed as having a dissociative disorder. Compared with patients without a dissociative disorder, the patients with a dissociative disorder had significantly higher median scores on the two screening measures, indicating more dissociative experiences and the presence of five distinct symptom clusters. The two groups did not differ in history of childhood abuse or IQ. CONCLUSIONS: The results support earlier findings suggesting that patients with substance abuse disorder should be routinely screened for dissociative symptoms and disorders.     

Substance use disorder and posttraumatic stress disorder comorbidity: Addiction and psychiatric treatment rates.

This study compares substance use disorder (SUD) patients with and without a comorbid diagnosis of posttraumatic stress disorder (PTSD) on their use of addiction and psychiatric services over the 6-month period before an inpatient substance abuse admission. Compared with non-PTSD patients, PTSD patients had a greater number of hospital overnights for addiction treatment. Given no significant between-groups differences on any substance use indexes, PTSD patients apparently overuse costly inpatient addiction services. Despite their greater rates of psychiatric comorbidity, PTSD patients did not receive treatment for psychiatric problems at greater rates than did non-PTSD patients. Among PTSD patients, use of PTSD treatment was low. Assessment of psychiatric comorbidity and referral to treatment targeting co-occurring PTSD and other disorders are suggested as possible ways to reduce the high treatment costs associated with SUD-PTSD comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A longitudinal study of drug and alcohol use by psychosis-prone and impulsive-nonconforming individuals.

The rates of substance use and abuse are higher among psychotic patients and antisocial individuals than in the general population. In a 10-year longitudinal study, psychosis-prone individuals identified by the Perceptual Aberration (L. J. Chapman, J. P. Chapman, M. L. Raulin, 1976) and Magical Ideation (Per-Mag) scales (M. Eckblad & L. J. Chapman, 1983), and individuals with antisocial traits, identified by the Impulsive Nonconformity (Noncon) scale (L. J. Chapman et al., 1984), exceeded a control group on rates of substance use disorders. As hypothesized, the Per-Mag group demonstrated preferential patterns of substance use similar to those reported for schizophrenic patients. Participants who scored deviantly on both the Per-Mag and Noncon scales were at especially heightened risk for substance use disorders. Psychosis proneness at the initial screening predicted substance abuse at the follow-up evaluation, but substance abuse at the initial interview did not predict later clinical psychosis or psychoticlike experiences. (PsycINFO Database Record (c) 2010 APA, all rights reserved)