What is the issue?



The site is for people with schizophrenia, and other psychotic illness, who also have substance use problems. You'll find practical information on effective ways to respond to challenges, and useful tools and links for further information.


a) What you need to know about concurrent schizophrenia and substance use

In Canada, the combination of mental illness and substance use disorder is usually called "concurrent disorders" (NOTE: words in blue are listed in Glossary) and sometimes "co-occurring disorders". In the United States, it is called "dual diagnosis."

Substance use is a common problem for people with schizophrenia or psychotic disorders. About 50% of people diagnosed with schizophrenia will also have problems related to their use of substances, and/or their dependence on substances. About half of youth who are experiencing a first episode of psychosis also have or will develop a substance use disorder1.

The most commonly abused substance among individuals with psychotic disorders and schizophrenia is alcohol, followed by marijuana. Most people with schizophrenia are also dependent on nicotine (70-90 %)2.

In the context of concurrent schizophrenia and substance use, it is helpful to think about the impact of use on a person's functioning and quality of life, rather than focusing on defining use as abuse, misuse, dependence or addiction.

Even though it is so common, many people with schizophrenia and problem substance use have fallen through the cracks of the health care system. If a person with an active drug or alcohol addiction seeks mental health services, they may be refused treatment, and told not to come back until their addiction issues are addressed. If a person with a mental disorder seeks help for problem substance abuse, they may be told by addiction professionals that they cannot recover until their mental disorder is treated3. This has resulted in people with schizophrenia and substance use problems being bounced back and forth between mental health and addictions services, sometimes being refused treatment by either system.

There is now a growing recognition among professionals and health care organizations of the problem of concurrent disorders, and more and more concurrent disorders services are becoming available.



b) Why do people with schizophrenia use substances?


Same reasons as other people

People with schizophrenia and other mental disorders often use drugs and alcohol for the same reasons as everyone else - to feel better or different, to relax and have fun, and to be part of a group. Other reasons for drug use include curiosity or experimentation, to relieve stress, overcome boredom, isolation and inhibitions and to "fit in" socially.

These motivations may be even stronger for a person with schizophrenia because of fewer vocational, recreational and social opportunities, as well as the distress and disempowerment associated with having a mental illness.

Risk factors

There are common risk factors that place people at risk for either substance use or mental health problems, or both: poverty or unstable income, difficulties at school, unemployment or problems at work, isolation, lack of decent housing, family problems, family histories, past trauma or abuse, discrimination, and even biological or genetic factors.4

Explanations particular to people with schizophrenia

There are several possible explanations for why people with schizophrenia use substances at a higher rate than the general population. One theory, called "Primary Addiction Theory" is based on literature that suggests there may be a common cause of both schizophrenia and substance-use disorders. For example, a person could be born with a genetic predisposition to both schizophrenia and substance use, or these could appear together in response to stressors in the environment5. Another possible explanation suggests that the two disorders could develop independently but then, directly or indirectly, they affect one another.

One theory suggests that people with schizophrenia may use substances to 'self-medicate', that is, to cope with the symptoms of their illness, such as anxiety and depression, or the side effects of medication.6,7

Early intervention in psychosis and substance use

Early intervention programs have been shown to be effective in reducing both problem substance use and psychotic symptoms. For people experiencing their first episode of psychosis, early intervention services may help to detect and reduce substance use among before it becomes a more serious disorder8.

People with concurrent disorders have described their own experiences with alcohol and other drugs and their pathways to recovery. Generally, people don't talk about using drugs to "treat" their mental illness, but describe confused attempts to survive the stress of mental illness, the powerlessness of being a "patient", victimization, lack of opportunities and hopelessnes.9



c) What is the impact of using substances on someone who has a psychotic illness?

The use of street drugs or the excessive use of alcohol is harmful to the physical and mental health of all people, but the risks associated with drug use are even greater for people who have experienced psychosis.10

This is best understood by the fact that schizophrenia and substance use interact with one another to make each diagnosis worse. As a result, the combination of these disorders can have serious and negative effects on many areas of people's lives, including work, relationships, health and safety11.

There is increasing evidence that having schizophrenia or other psychotic disorders may make individuals "supersensitive" to the effects of alcohol and other drugs. This means that they will experience more of the negative consequences from even fairly small amounts of alcohol and other drugs.

But substance use in turn affects the course of illness and treatment of people with schizophrenia, even when small amounts of substances are used. People with a serious brain disorder like schizophrenia or other psychotic problems who take illegal drugs and/or abuse alcohol are more likely to have relapses, are more likely to require hospitalization, and are less likely to respond well to treatment.

Substance abuse can reduce the effectiveness of treatment for schizophrenia in a number of ways. It can interfere with the effectiveness of medications used to treat psychosis, and can also contribute to people discontinuing their medication. Substance abuse also reduces the likelihood that people will follow through with their service providers' suggestions for managing their illness.

Impacts of substance use12

For the individual

  • "Increased risk of making the symptoms of a mental illness worse with substance abuse, possibly bringing on an episode of mania or psychosis
  • "Increased risk of suicide
  • "Increased risk of poverty and homelessness
  • "Increased risk of illegal activity and incarceration (jail sentence)
  • "Increased risk of violent behaviour & domestic violence
  • "Increased risk of victimization
  • "Increased risk of unemployment and instability
  • "Loss of support systems
  • "Increased levels of stress
  • "Feelings of shame and guilt
  • "Increased levels of physical health problems (increased risk of contracting diseases like hepatitis or HIV/AIDS through sharing needles or unprotected sex)
  For the family members

  • "Increased family conflict and tension caused by substance abuse; increased levels of confusion, miscommunication, and mistrust; family's attempts to be supportive may then fall apart
  • "Increased levels of stress
  • "Feelings of shame, guilt, and blame
  • "Feelings of anger or frustration
  • "Feeling depressed and/or hopeless
  • "Increased risk of being abused

The risks associated with drug use for a person with psychosis include:
• an increased risk of relapse (return to problem substance use after period of abstinence or controlled use))
• the development of more secondary problems in addition to the substance use problems (including depression, anxiety or memory problems)
• a slower recovery
• more persistent psychotic symptoms



d) What does concurrent schizophrenia and substance use look like?


In addition to some of the changes in behaviour that a psychotic illness can bring about, a person who is also using substances will most likely experience a worsening of their psychiatric symptoms. Substance use can also make people's behaviour more challenging.

Signs that your substance use may be a problem:

You may notice that you:


• Are spending more time acquiring and using substances, and less time in your usual activities;
• Have greater financial difficulties
    - the cost of using substances can become significant
    - in some cases, substance use can lead losing your job, which creates further financial problems
• Are becoming more agitated, hostile or aggressive
• Experience more frequent and intense psychotic episodes
• Have stopped taking your prescribed medications
• Miss appointments
• Have been kicked out of school
• Have difficulty getting or maintaining appropriate housing
    - some supportive housing facilities ban substance use and will evict tenants over problem substance use.

It can be difficult to tell if what you're going through is an ongoing psychosis or a temporary reaction to drug use.
Because it is difficult to distinguish between a toxic psychotic state (brought on by drug use) and a first episode of psychosis, it is always a good idea to seek help from a professional.



e) Which came first, schizophrenia or substance use?


People often wonder: "Which came first: the mental health problem or the substance use problem?" Often it's hard to tell. It is more useful to think of them as independent problems that interact with each other.14

While most researchers do not believe that substance abuse causes schizophrenia, many people who have schizophrenia also abuse alcohol or drugs, and may have particularly bad reactions to certain drugs.

Some stimulating drugs, like amphetamines and cocaine, can actually cause psychosis. When induced by drugs in this way, the result is known as a drug-induced psychosis. This psychosis can last up to a few days, and is often characterized by hallucinations, delusions, memory loss and confusion. This usually results from prolonged or heavy street-drug use; and it responds well to treatment.

Psychosis can also be "drug assisted". For a person who is already at risk for psychosis, some drugs, such as marijuana, can give the process a boost. These drugs "unmask" the person's vulnerability and can trigger the onset of a "drug assisted" psychosis.

On the other hand, problem substance use may follow the onset of a psychotic illness and can be an attempt to deal with certain psychotic symptoms.

The important thing to understand is that for a person who may have a biological predisposition to develop psychosis, the impact of substance use can be be more serious than for someone who does not have this vulnerability.



f) Information on specific substances


People who are living with schizophrenia and other psychotic disorders tend to use substances that are affordable, easily accessible and readily available. The most common substances used by people with schizophrenia and psychotic disorders are alcohol, marijuana, and cocaine15. Prescription drugs like tranquilizers and sleep medication can also be misused.

Sometimes people may use a number of substances. The types of substances people with schizophrenia use may change depending upon what stage they're at in their life. People who are older may not use street drugs as much as alcohol, or they may misuse over-the-counter drugs.

Nicotine and schizophrenia

The most common form of substance use in people with schizophrenia is an addiction to nicotine. People with schizophrenia are addicted to nicotine at three times the rate of the general population (75-90 percent vs. 25-30 percent). As well, people with schizophrenia who smoke tend to smoke at heavier rates than in the general population. Most patients start smoking in their teens, usually before the illness has clearly begun.

The relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. Increasingly, research is suggesting that people with brain disorders like schizophrenia smoke at a higher rate because nicotine provides them some benefit by reducing some of the cognitive (thinking, feeling or remembering) difficulties that are associated with the illness.16

In addition to its known health hazards, several studies have found that smoking interferes with the action of antipsychotic drugs. As a result, people with schizophrenia who smoke may need higher or lower doses of their medication.
Quitting smoking may be especially difficult for people with schizophrenia since nicotine withdrawal can temporarily worsen psychotic symptoms. Therefore, smoking cessation strategies that include nicotine replacement methods may work better than those that do not17. While many people have assumed that it's almost impossible to get a person with schizophrenia to stop smoking, a number of different programs and approaches have been effective. For an example, please see <http://www.sane.org/information/research/the_smokefree_project.html>

Drugs and alcohol

It's often believed that "hard drugs" are more of a problem than marijuana and alcohol. It's true that narcotics like heroin and stimulants such as cocaine or crack and ecstasy are serious problems, and can be dangerous for anyone, especially someone with a psychotic illness. Hallucinogens like mushrooms and LSD are dangerous as well, especially since they can mimic psychosis in those without any underlying vulnerability to psychosis.

But marijuana and alcohol, more commonly available than the "hard drugs", should not be dismissed as harmless. On the contrary, new research is showing that using marijuana can create serious problems for people who are vulnerable to psychosis, and can lead to earlier psychotic relapses in young people recovering from a first episode of psychosis.

Alcohol too creates problems. It can compound the sedating effects of antipsychotic medications, it increases depression, a major problem for people in the early stages of schizophrenia, and it can make it harder for people to stick with their treatment and supports to manage their schizophrenia.

Most people experience a worsening of their schizophrenia symptoms when they are using substances.

For more information about genetic and environmental vulnerability to developing psychosis, please go to Psychosis Sucks at http://www.psychosissucks.ca/epi/whatcausespsychosis.cfm



g) What is the impact on your family and friends?

When a member of a family has schizophrenia and uses substances, everyone is affected, and life can often change quite dramatically for the whole family.

Family members often feel:
• shock and fear
• overwhelmed by stress
• grief and anger
• loss and sadness

The stigma and shame that are unfortunately attached to mental illness and substance use can isolate the family from its community and social support networks.

Having a relative with schizophrenia and substance use problems can put an enormous strain on the family -financially as well as emotionally. The financial strain can come from direct costs, such as specialized treatment services, and indirect costs, such as having to leave employment to help take care of the ill family member18. For more information on the impact of concurrent schizophrenia and substance use on families, and for ideas to help support families, please see another section of this website - Information for Families.



h) Can people recover?


Recovery from schizophrenia and other psychotic disorders is more challenging for people who also abuse substances, and the issues faced these people can be more complex and confusing than for those with mental illness or substance use alone19.

But recovery is possible! New research is showing that, with access to integrated treatment and psychological services for both disorders, along with community supports and services, most people with concurrent schizophrenia and substance abuse can and do recover over time.

People move toward recovery on different paths, so the supports that are needed are different for each individual. Most consumers report that recovery involves reaching their personal goals in life. A range of options such as self-help groups, access to integrated treatment of mental health and substance use problems, vocational and housing support are needed to promote recovery20.

What helps people recover?

The first step to recovery can occur in any number of situations, circumstances and/or events, which may lead a person to seek treatment or a self-help alternative.

Getting enough exercise, rest and eating well are all essential to maintaining recovery. Light exercise, such as a daily walk helps you to feel better physically and helps to counteract the side effects of some medications


It is important to note that recovery occurs as a result of an internal desire to change one's life. Service providers may facilitate but not force this process.

Your family members and friends need to know that recovery can be a long road, full of ups and downs. Families are on their own journey of recovery as they deal with the personal "chaos" and losses they experience. Having the support, understanding and patience of family and friends will be very helpful to you as you move toward recovery.

In the next section we will provide ideas and examples of ways different people have achieved and maintained recovery. We'll explore some of the ways that you can help manage your illness and find support.



Footnotes


1 Best Practices Report on Concurrent Mental Health and Substance Use Disorders Centre for Addiction and Mental Health, 2001
2 National Institute of Mental Health,2006
3 BC Partners for Mental Health and Addictions Information. Concurrent Disorders: Addictions and Mental Disorders. 2006 www.heretohelp.bc.ca
4 http://www.heretohelp.bc.ca/publications/factsheets/concurrent.shtml
5 Kessler et al. 1997; Lohr & Flynn 1992; Siegfried 1998
6 Kessler et al. 1997; Forchuk et al. 1997; Siegfried 1998
7 Mental Illness Fellowship of Australia. Mental Illness fact Sheet Series. Understanding Dual Diagnosis: mental illness and substance use http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/sbm011v1
8 Drake, R. and Wallach, M. Psychiatric Services. Vol. 51. No. 9. Sept. 2000
9 http://www.psychosissucks.ca/epi/index.cfm?action=substanceuse
10 Mental Illness Fellowship of Australia: Understanding dual diagnosis: Mental Illness and substance use
11 Excerpted from Session 8 of Strengthening Families Together, Schizophrenia Society of Canada, 2004
12 Centre for Addiction and Mental Health. Concurrent Disorders: A Resource for Families. Pilot Version 2006. Pg. 148.
13 Concurrent Substance use and Mental Health Disorders: An Information Guide, CAMH, 2004
14 Green, A. & Sherwood Brown, E. Comorbid Schizophrenia and Substance Abuse. J Clin Psychiatry (67(9) 2006
15 http://www.schizophrenia.com/smokereport.htm
16 http://www.nimh.nih.gov/publicat/schizoph.cfm
17 Sarah Hamid-Balma. For Better or Worse: The impact of a child's mental disorder on the family. A review of the Literature. In Visions: B.C's Mental Health and Addictions Journal. Vol. 2. No. 3
18 Mental Illness Fellowship of Australia. Mental Illness fact Sheet Series. Understanding Dual Diagnosis: mental illness and substance use.
19 Drake, R.Ten-year recovery outcomes for clients with co-occurring Schizophrenia and Substance Use Disorders. Schizophrenia Bulletin, July 2006
20 BC Partners for Mental Health and Addictions Information.
21 http://www.heretohelp.bc.ca/publications/toolkits/family_toolkit_m2.pdf www.heretohelp.bc.ca