What is the issue?

  1. What you need to know about concurrent schizophrenia and substance use
  2. Why do people with schizophrenia use substances?
  3. What is the impact of using substances on someone who has a psychotic illness?
  4. What are some common misconceptions about concurrent schizophrenia and substance use?
  5. Which came first, the schizophrenia or the substance use?
  6. Information on specific substances
  7. What is the impact on family and friends?
  8. Can people recover?

Families can play a crucial role in helping a person with schizophrenia and substance use problems (NOTE: words in blue are listed in Glossary) to manage their illness effectively. Families are often the main support network for a person who is struggling with psychosis, schizophrenia and substance use problems.

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

The combination of mental illness and substance use disorder is often called "concurrent disorders" or "co-occurring disorders" in Canada, and in the United States is called "dual diagnosis".

About 50% of people diagnosed with schizophrenia will also have problems with substance use and/or dependence. About half of youth who are experiencing a first episode of psychosis have or will develop a substance use disorder1. This makes substance use a common concern of the family and friends of people with schizophrenia or psychotic disorders.


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

Because substance use problems are so common among people with psychotic disorders like schizophrenia, families need to be alert to the earliest signs of problem substance use. If such signs are missed or ignored, the consequences can be serious, including relapse and hospitalization, difficult family relationships, loss of employment or entitlement to benefits, financial hardship, and or incarceration.

Even though it is so common, many people with concurrent schizophrenia and problem substance use have fallen through the cracks of the health care system. Mental health services may refuse treatment to a person with an active drug or alcohol addiction, and addiction professionals may believe that a person cannot recover from problem substance use 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, and sometimes being refused treatment by either system.

There is, however, 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.

In the context of concurrent schizophrenia and substance use, it is helpful to think about the impact of using substances on the person's functioning and quality of life rather than focusing on defining their use as abuse, misuse, dependence or addiction. This impact is further described in section C.


b) Why do people with schizophrenia use substances?

Same reasons as other people

Research has shown that 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 intensified for a person with schizophrenia as a result of decreased vocational, recreational and interpersonal opportunities, as well as the distress and disempowerment associated with having a mental illness4. Some say that people with schizophrenia use substances to cope with symptoms of mental illness.

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

Risk factors

There are common 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 biological or genetic factors8.

People with concurrent disorders have described their own experiences with alcohol and other drugs and their pathways to recovery. Stories and Experiences. Generally, they 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 hopelessness.9

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 disorder.10



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.11

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 safety.12

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 use14

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


d) What are some common misconceptions about concurrent schizophrenia and substance use?

When a person has mental illness and is also using substances, their situation risks being misunderstood, and they may not get the timely help they need. A person with a substance use problem, their friend or a family member may think the beginning symptoms of mental illness are "just the drugs," that is, a reaction that will go away when the drug use stops.

On the other hand, some families may neglect to mention their relative's problem drug or alcohol use to health care professionals because they believe it is a symptom that will clear up once the person receives treatment for the mental illness. Others view drinking or drug use as the best "leisure" activities a person with serious mental illness can expect15.

What is the true picture?

In fact, substance abuse is just as devastating for people with mental illness as it is for other people, if not more so. People with concurrent disorders can get caught up in a vicious cycle that involves multiple living problems resulting from poverty, lack of support systems, isolation, physical illness, housing difficulties, disrupted family functioning and interpersonal relationships, and negative experiences with previous treatment.

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 their behaviour more challenging.


Signs that your family member may have problem substance use

You may notice your relative:

• Is spending more time acquiring and using substances, and less time in their usual activities;
• Has greater financial difficulties
    - the cost of using substances can become significant
    - in some cases substance use can lead to job loss, which creates further financial problems
• Becomes more agitated, hostile or aggressive
• Experiences more frequent and intense psychotic episodes
• Stops taking prescribed medications
• Misses appointments
• Gets kicked out of school
• Loses their job
• Has 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 your relative is going through is an ongoing psychosis or a temporary reaction to drug use. Often families prefer to interpret the changes in their family member's behaviour as a passing problem of substance use rather than as a sign that there may be serious mental health problems developing.

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, the schizophrenia or the 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.16

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 more serious than for someone who does not have this vulnerability.


f) Information on specific substances:

People 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, cocaine.17 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 abuse 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, remembering) difficulties associated with the illness18.

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 cause their psychotic symptoms to temporarily get worse. Therefore, smoking cessation strategies that include nicotine replacement methods sometimes work better than those that do not.19 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 medication, it increases depression, a major problem for those 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.


g) What is the impact on family and friends?

When a member of the 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

It is normal for families to experience a range of reactions, challenges, and emotions. Everyone's reaction will differ, depending not only on their relationship with the ill person, but also on their own personality and coping skills.

One reaction, which can be common to both the person with the illness and those involved in his or her life, is loss and grief.

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 member20.

The next section "What can I do to help?" will explore some of the ways you can help your family member. In the section after that, called "What do I need as a caregiver?", you'll find ideas, information and tools to help you take care of yourself.


h) Can people recover?

Recovery from schizophrenia and other psychotic disorders is more challenging for people who also abuse substances, and the issues faced by families of people with both disorders can be more complex and confusing than for those with mental illness or substance use problems alone21.

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 recovery22.

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 that they experience. Families can help by engaging in their own recovery process, while being as supportive, understanding and as patient as possible as their loved one finds their way. People who are recovering tell how important it is to have someone who believes in them and maintains hope.

In the next section we will provide ideas and examples of ways families can support recovery.


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 Arber 1998; Forchuk et al. 1997.
5 Kessler et al. 1997; Lohr & Flynn 1992; Siegfried 1998
6 Mental Illness Fellowship of Australia. Mental Illness fact Sheet Series. Understanding Dual Diagnosis: mental illness and substance use
7 Kessler et al. 1997; Forchuk et al. 1997; Siegfried 1998
8 http://www.heretohelp.bc.ca/publications/factsheets/concurrent.shtml
9 Drake, R. and Wallach, M. Psychiatric Services. Vol. 51. No. 9. Sept. 2000
10 http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/sbm011v1
11 http://www.psychosissucks.ca/epi/index.cfm?action=substanceuse
12 Mental Illness Fellowship of Australia: Understanding dual diagnosis: Mental Illness and substance use
13 Centre for Addiction and Mental Health. Concurrent Disorders: A Resource for Families. Pilot Version 2006. Pg. 148.
14 Excerpted from Session 8 of Strengthening Families Together, Schizophrenia Society of Canada, 2004
15 BC Partners for Mental Health and Addictions Information. Concurrent Disorders: Addictions and Mental Disorders. 2006 www.heretohelp.bc.ca
16 Concurrent Substance use and Mental Health Disorders: An Information Guide, CAMH, 2004
17 Green, A. & Sherwood Brown, E. Comorbid Schizophrenia and Substance Abuse. J Clin Psychiatry (67(9) 2006
18 http://www.schizophrenia.com/smokereport.htm
19 http://www.nimh.nih.gov/publicat/schizoph.cfm
20 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
21 Mental Illness Fellowship of Australia. Mental Illness fact Sheet Series. Understanding Dual Diagnosis: mental illness and substance use.
22 Drake, R. Ten-year recovery outcomes for clients with co-occurring Schizophrenia and Substance Use Disorders. Schizophrenia Bulletin, July 2006