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Alcohol dependence and hospitalization in schizophrenia
Schizophrenia Research 38 (1999) 71–75 www.elsevier.com/locate/schres
Alcohol dependence and hospitalization in schizophrenia Lori B. Gerding, Lawrence A. Labbate *, Michael O. Measom, Alberto B. Santos, George W. Arana Medical University of South Carolina and VA Medical Center, Charleston, SC 29401, USA Received 16 May 1998; accepted 7 December 1998
Abstract Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission ( p<0.05). Moreover, patients with alcohol dependence had longer hospital stays ( p<0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment. © 1999 Elsevier Science B.V. All rights reserved. Keywords: Schizophrenia; Alcohol dependence; Medication compliance
1. Introduction Despite apparent optimal treatment, relapse rates for patients with schizophrenia remain disturbingly high. Medication noncompliance has been reported to be as high as 50% in outpatients with schizophrenia (Serban and Thomas, 1974; Young et al., 1986). Factors contributing to noncompliance include complexity or perceived benefits of medication, side-effects, and lack of awareness of mental illness (Diamond, 1983; Amador et al., 1991; McEvoy et al., 1981). * Corresponding author. Tel: +1 843 577 5011 ext. 7234; Fax: +1 843 805 5782. E-mail address: [email protected] (L.A. Labatte)
However, relapse rates are also high for individuals who are compliant with their medication regimen. A recent study evaluating the effects of personal therapy on psychotic relapse in patients with schizophrenia or schizoaffective disorder reported that almost 40% of patients who received usual clinical care and were judged medication compliant (most took fluphenazine or haloperidol decanoate) relapsed during the first year following hospital discharge (Hogarty et al., 1997). Substance abuse is highly prevalent among patients with schizophrenia. The lifetime prevalence of substance abuse among patients with schizophrenia is around 47%, with 34% of patients suffering from alcohol dependence (Regier et al., 1990). Substance abuse can play a major role in
0920-9964/99/$ – see front matter © 1999 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 9 8 ) 0 0 17 7 - 7
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L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
destabilizing patients, worsening delusions (Barbee et al., 1989), depressive symptoms (Drake et al., 1989), and precipitating suicidal (Noriek, 1975), disruptive (Drake et al., 1989; Alterman et al., 1984), or assaultive ( Yesavage and Zarcone, 1983) behaviors; thus contributing to relapse and emergency psychiatric hospitalizations (Drake et al., 1989; Craig et al., 1985), homelessness (Drake et al., 1989; Drake et al., 1991; Lamb and Lamb, 1990), and treatment noncompliance (Alterman et al., 1984; Pristach and Smith, 1990). A recent study evaluated the contribution of substance abuse to hospitalization rates in patients reliably receiving depot neuroleptics for 2 years; patients with active substance abuse had significantly higher re-admission rates than those without active substance abuse (Gupta et al., 1996). That paper presents further evidence linking substance abuse to acute psychiatric hospitalization in patients with clinical diagnoses of schizophrenia who reliably received depot neuroleptics. We wished to follow the method of the study by Gupta el al. and determine if there was a specific association between alcohol dependence and schizophrenia relapse.
2. Method Study subjects were identified through a retrospective review of psychiatric patients treated over a 2-year period (May 1995 through May 1997) in the Ralph H. Johnson Veteran’s Administration Medical Center Outpatient Mental Health Clinic in Charleston, South Carolina, a Dean’s Committee training site of the Medical University of South Carolina. Subjects were included in the study: (1) if patients met DSM IV (American Psychiatric Association, 1994) diagnostic criteria for schizophrenia; (2) if there was archival evidence of 2 years of haloperidol or fluphenazine decanoate injections (outpatients on depot neuroleptics are treated at each appointment by a registered nurse case manager and, as needed, by the attending psychiatrist); (3) if frequency of injections was at least every 3 weeks with fluphenazine or at least monthly with haloperidol; and (4) if they missed less than three total or less than two
sequential injections during the study period. Modal dose and frequency of fluphenazine or haloperidol injections were recorded for each subject. All patients admitted to the psychiatric unit met strict admission criteria: patients had to be considered an acute risk to self or others. Computerized archival inpatient and outpatient records of the identified subjects were further reviewed for a co-occurring clinical DSM IV (American Psychiatric Association, 1994) diagnosis of substance dependence made by the attending psychiatrist (other than nicotine dependence) both during the 2-year period and at times of psychiatric admission. All subjects had urine drug screens as well as blood alcohol concentration performed on admission. Total number of admissions and length of stay per admission were recorded. The inpatient unit was an acute care unit, and there was no substance abuse rehabilitation until patients were discharged. Patients with comorbid diagnoses of schizophrenia and substance abuse were treated similarly on the unit. 2.1. Analysis Chi square analysis was used to compare categorical variables (admitted to hospital with presence or absence of alcohol or other drug dependence). Nonparametric analysis (MannWhitney U test) was used to compare length of admission and number of admissions between patients with and without substance dependence because the distribution of admission and length of stay was not normally distributed. Statistical significance was set at p<0.05. SPSS 6.1 (SPSS, 1995) was used for all analysis.
3. Results Twenty-six male patients (mean age 46 years) were identified as meeting eligibility criteria (most were diagnosed as paranoid subtype). Patients were Caucasian or African American. Fourteen (14) of the 26 study subjects (54%) were hospitalized during the study period. Twelve (12) of the 26 subjects (46%) were identified as carrying a DSM IV clinical diagnosis of alcohol, marijuana
L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
or cocaine dependence. At the time of hospital admission, all patients with a substance dependence diagnosis were using those substances. All of the patients without substance abuse diagnoses had normal urine drug screens. Diagnoses were stable during the study period. Table 1 presents sample demographics and clinical characteristics. Subjects with a DSM IV clinical diagnosis of alcohol dependence were more likely than patients without alcohol dependence to be admitted to the hospital during the 2 years (86% vs 42%; x2=3.9, p<0.05). Marijuana or cocaine dependence was slightly more common among admitted patients, but was not associated with admissions during the study period (36% vs 33%; x2=0.02, p=0.9). Moreover, patients with alcohol dependence were admitted more often (2.3±0.6 (SEM ) vs 0.9±0.4; U=31, p<0.05) and had longer hospital stays (30±11 (SEM ) vs 14±7 days; U=31, p<0.05) than patients without alcohol dependence. Marijuana or cocaine dependence did not predict length of stay (drug: 21±10 (SEM ) vs no drug: 17±8; U=68, p=0.7) or number of admissions (drug: 1.8±0.6 (SEM ) vs no drug: 1.1±0.4; U=61, p=0.6). There was no difference between frequency or dose of decanoate medication between admitted and nonadmitted patients. Mean age was no different between admitted and nonadmitted patients (46.4 vs 45.4, p=0.7). No significant differences in drug or dosage between admitted or nonadmitted patients were found. Race was no different between patients admitted
73
or not admitted or patients with or without substance use diagnoses. Table 2 highlights differences between subjects admitted and those not admitted to the hospital.
4. Discussion This naturalistic study demonstrated that neuroleptic-compliant schizophrenics with substance abuse had a higher rate of hospital admission than a nonsubstance abusing group. This finding is similar to a previous finding (Gupta et al., 1996). Moreover, not only was substance dependence associated with hospitalization, but alcohol dependence was specifically associated with psychotic relapse. The statistically significant association with alcohol use, but not cocaine use, is somewhat surprising considering cocaine’s central dopaminergic effects, and the possible role of dopamine in exacerbating psychosis ( Heinz et al., 1994). Dopamine receptor availability may be reduced in alcoholics ( Volkow et al., 1996) and this neurochemical difference may contribute to the association between alcohol use and schizophrenic exacerbation (Drake et al., 1989). Other neurochemical changes including alterations in excitatory amino acids or GABA ( Yu and Ho, 1990) may be relevant to psychotic exacerbation. One study reported that the use of stimulants had a higher association with relapse and rehospitalization than that associated with alcohol use
Table 1 Demographics and clinical characteristics (n=26) Age mean±SD Number of African Americans, n (%) Admitted to hospital, n (%) Mean admissions, range Admission days, range Number taking haloperidol decanoate, n (%) Mean dose±(SD), frequency in weeks Number taking fluphenazine decanoate, n (%) Mean dose ± (SD), frequency in weeks Alcohol dependence, n (%) and receiving haloperidol decanoate, n and receiving fluphenazine decanoate, n Marijuana or cocaine dependence, n (%) Any substance dependence, n (%)
46±7 16 (62%) 14 (54%) 1.3 (0–6) 18 (0–134) 15 (58%) 137±(51) mg, 3.97 11 (42%) 35±(18) mg, 2.2 7 (27%) 4 3 9 (35%) 12 (46%)
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L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
Table 2 Characteristics of patients admitted and not admitted to the hospital
Haloperidol decanoate, n (%)a Fluphenazine decanoate, n (%) Alcohol dependence, n (%) Marijuana/cocaine dependence, n (%) Any substance dependence, n (%)
Admitted (n=14)
Not admitted (n=12)
p
8 6 6 5 8
7 5 1 4 4
0.95 0.95 0.03 0.8 0.2
(57%) (42%) (42%) (36%) (57%)
(58%) (42%) (8%) (33%) (33%)
a Refers to percent within the ‘Admitted’ or ‘Not admitted’ group.
(Richard et al., 1985), however, neuroleptic compliance was not controlled in that study. The findings of this study suggest that when neuroleptic compliance is controlled, alcohol dependence is a stronger precipitant to hospitalization than is cocaine dependence. Not only were patients with alcohol dependence admitted more often and had longer hospital stays than patients without alcohol dependence, but the presence of marijuana or cocaine dependence was not associated with length of stay or number of admissions during the study period. The small sample size may account for the lack of association between cocaine or marijuana dependence and hospital admissions, and previous studies linking drug abuse with schizophrenia decompensation are not in question. These findings support the association between schizophrenic exacerbation and alcohol dependence. However, the findings must be viewed in light of the limitations of the methods. First, this was a naturalistic retrospective study with a small sample size. Larger samples will be required to confirm these findings. Second, drug selection and dose was determined by clinical and not research protocols. Third, sample selection may have been biased in that patients compliant with depot neuroleptics may be different from other samples, and patients taking other antipsychotics may be at different risk for relapse in association with substance abuse. Fourth, the primary variable of admission to the hospital does not inform us as to symptomatic differences among patients, and symptom severity was not measured by standardized rating instruments. Diagnoses were clinical diagnoses and may have been incorrect, though most studies of schizophrenia rely on clinical diagnosis of schizophrenia alone.
Although we suspect that alcohol use contributes to relapse, it is possible that patients initially became psychotic and then began using alcohol in an effort to decrease their psychotic symptoms. It is difficult to determine the chronology of schizophrenic exacerbation and substance use. The association between alcohol use and psychiatric admission does not imply causality, and alcohol’s effect on psychosis may be complex. Because of the consistency of neuroleptic use, we favor the position that alcohol use strongly contributed to clinical decompensation. Despite the complexity of the cause–effect relationship of substance use and psychotic exacerbation in this population, these findings reaffirm the importance of early substance abuse recognition, intervention, education and treatment. This may lead to decreased hospital admission rates, and reduced treatment costs for the targeted population.
References Alterman, A.I., Ayre, F.R., Williford, W.O., 1984. Diagnostic validation of conjoint schizophrenia and alcoholism. Journal of Clinical Psychiatry 45, 300–303. Amador, X.F., Strauss, D.H., Yale, S.A., Gorman, J.M., 1991. Awareness of illness in schizophrenia. Schizophrenia Bulletin 17, 113–132. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Washington, DC, American Psychiatric Association. Barbee, J.G., Clark, P.D., Crapanzano, M.S., Heintz, G.C., Kehow, C.E., 1989. Alcohol and substance abuse among schizophrenic patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease 177, 400–407. Craig, T.J., Lin, S.P., el-Defrawi, M.H., Goodman, A.B., 1985.
L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75 Clinical correlates of readmission in a schizophrenic cohort. Psychiatric Quarterly 57, 510 Diamond, R.J., 1983. Enhancing medication use in schizophrenic patients. Journal of Clinical Psychiatry 44, 7–14. Drake, R.E., Osher, F.C., Wallach, M.A., 1989. Alcohol use and abuse in schizophrenia; a prospective community study. Journal of Nervous and Mental Disease 177, 408–414. Drake, R.E., Osher, F.C., Wallach, M.A., 1991. Homelessness and dual diagnosis. American Psychology. 46, 1149–1158. Gupta, S., Hendricks, S., Kenkel, A.M., Bhatia, S.C., Haffke, E.A., 1996. Relapse in schizophrenia: is there a relationship to substance abuse? Schizophrenia Research 20, 153–156. Heinz, A., Schmidt, L.G., Reischies, F.M., 1994. Anhedonia in schizophrenic, depressed, or alcohol-dependent patients— neurobiological correlates. Pharmacopsychiatry 27, 7–10. Hogarty, G.E., Kornblith, S.J., Greenwald, D., DiBarry, A.L., Cooley, S., Ulrich, R.F., Carter, M., Flesher, S., 1997. Threeyear trials of personal therapy among schizophrenic patients living with or independent of family, I: Description of study and effects on relapse rates. American Journal of Psychiatry 154, 1504–1513. Lamb, H.R., Lamb, D.M., 1990. Factors contributing to homelessness among the chronically and severely mentally ill. Hospital and Community Psychiatry 41, 301–305. McEvoy, J.P., Aland, J., Wilson, W.H., Guy, W., Hawkins, L., 1981. Measuring chronic schizophrenic patients’ attitudes toward their illness and treatment. Hospital and Community Psychiatry 32, 856–858.
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Noriek, K., 1975. Attempted suicide and suicide in functional psychoses. Acta Psychiatrica Scandinavica 52, 81–106. Pristach, C.A., Smith, C.M., 1990. Medication compliance and substance abuse among schizophrenic patients. Hospital and Community Psychiatry 41, 1345–1348. Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., Goodwin, F.K., 1990. Comorbidity of mental disorders with alcohol and other drug abuse. J. Am. Med. Assoc. 264, 2511–2518. Richard, M.L., Liskow, D.I., Perry, P.J., 1985. Recent psychostimulant use in hospitalized schizophrenics. Journal of Clinical Psychiatry 46, 79–83. Serban, G., Thomas, A., 1974. Attitudes and behaviors of acute and chronic schizophrenic patients regarding ambulatory treatment. American Journal of Psychiatry 131, 91–995. SPSS, 1995. SPSS 6.1 User’s Guide. SPSS, Chicago. Volkow, N.D., Wang, G.J., Fowler, J.S., Logan, J., Gitzemann, R., Ding, Y.S., Pappas, N., Shea, C., Piscani, K., 1996. Decreases in dopamine receptors but not in dopamine transporters in alcoholics. Alcoholism: Clinical and Experimental Research 20, 1594–1598. Yesavage, J.A., Zarcone, V., 1983. History of drug abuse and dangerous behavior in inpatient schizophrenics. Journal of Clinical Psychiatry 44, 259–261. Young, J.L., Zonana, H.V., Shepler, L., 1986. Medication noncompliance in schizophrenia: modification and update. Bull. Am. Acad. Psychiatry Law 14, 105–122. Yu, S., Ho, I.K., 1990. Effects of acute barbiturate administration, tolerance and dependence on brain GABA system: comparison to alcohol and benzodiazepines. Alcohol 7, 261–272.
Alcohol dependence and hospitalization in schizophrenia Lori B. Gerding, Lawrence A. Labbate *, Michael O. Measom, Alberto B. Santos, George W. Arana Medical University of South Carolina and VA Medical Center, Charleston, SC 29401, USA Received 16 May 1998; accepted 7 December 1998
Abstract Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission ( p<0.05). Moreover, patients with alcohol dependence had longer hospital stays ( p<0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment. © 1999 Elsevier Science B.V. All rights reserved. Keywords: Schizophrenia; Alcohol dependence; Medication compliance
1. Introduction Despite apparent optimal treatment, relapse rates for patients with schizophrenia remain disturbingly high. Medication noncompliance has been reported to be as high as 50% in outpatients with schizophrenia (Serban and Thomas, 1974; Young et al., 1986). Factors contributing to noncompliance include complexity or perceived benefits of medication, side-effects, and lack of awareness of mental illness (Diamond, 1983; Amador et al., 1991; McEvoy et al., 1981). * Corresponding author. Tel: +1 843 577 5011 ext. 7234; Fax: +1 843 805 5782. E-mail address: [email protected] (L.A. Labatte)
However, relapse rates are also high for individuals who are compliant with their medication regimen. A recent study evaluating the effects of personal therapy on psychotic relapse in patients with schizophrenia or schizoaffective disorder reported that almost 40% of patients who received usual clinical care and were judged medication compliant (most took fluphenazine or haloperidol decanoate) relapsed during the first year following hospital discharge (Hogarty et al., 1997). Substance abuse is highly prevalent among patients with schizophrenia. The lifetime prevalence of substance abuse among patients with schizophrenia is around 47%, with 34% of patients suffering from alcohol dependence (Regier et al., 1990). Substance abuse can play a major role in
0920-9964/99/$ – see front matter © 1999 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 9 8 ) 0 0 17 7 - 7
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L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
destabilizing patients, worsening delusions (Barbee et al., 1989), depressive symptoms (Drake et al., 1989), and precipitating suicidal (Noriek, 1975), disruptive (Drake et al., 1989; Alterman et al., 1984), or assaultive ( Yesavage and Zarcone, 1983) behaviors; thus contributing to relapse and emergency psychiatric hospitalizations (Drake et al., 1989; Craig et al., 1985), homelessness (Drake et al., 1989; Drake et al., 1991; Lamb and Lamb, 1990), and treatment noncompliance (Alterman et al., 1984; Pristach and Smith, 1990). A recent study evaluated the contribution of substance abuse to hospitalization rates in patients reliably receiving depot neuroleptics for 2 years; patients with active substance abuse had significantly higher re-admission rates than those without active substance abuse (Gupta et al., 1996). That paper presents further evidence linking substance abuse to acute psychiatric hospitalization in patients with clinical diagnoses of schizophrenia who reliably received depot neuroleptics. We wished to follow the method of the study by Gupta el al. and determine if there was a specific association between alcohol dependence and schizophrenia relapse.
2. Method Study subjects were identified through a retrospective review of psychiatric patients treated over a 2-year period (May 1995 through May 1997) in the Ralph H. Johnson Veteran’s Administration Medical Center Outpatient Mental Health Clinic in Charleston, South Carolina, a Dean’s Committee training site of the Medical University of South Carolina. Subjects were included in the study: (1) if patients met DSM IV (American Psychiatric Association, 1994) diagnostic criteria for schizophrenia; (2) if there was archival evidence of 2 years of haloperidol or fluphenazine decanoate injections (outpatients on depot neuroleptics are treated at each appointment by a registered nurse case manager and, as needed, by the attending psychiatrist); (3) if frequency of injections was at least every 3 weeks with fluphenazine or at least monthly with haloperidol; and (4) if they missed less than three total or less than two
sequential injections during the study period. Modal dose and frequency of fluphenazine or haloperidol injections were recorded for each subject. All patients admitted to the psychiatric unit met strict admission criteria: patients had to be considered an acute risk to self or others. Computerized archival inpatient and outpatient records of the identified subjects were further reviewed for a co-occurring clinical DSM IV (American Psychiatric Association, 1994) diagnosis of substance dependence made by the attending psychiatrist (other than nicotine dependence) both during the 2-year period and at times of psychiatric admission. All subjects had urine drug screens as well as blood alcohol concentration performed on admission. Total number of admissions and length of stay per admission were recorded. The inpatient unit was an acute care unit, and there was no substance abuse rehabilitation until patients were discharged. Patients with comorbid diagnoses of schizophrenia and substance abuse were treated similarly on the unit. 2.1. Analysis Chi square analysis was used to compare categorical variables (admitted to hospital with presence or absence of alcohol or other drug dependence). Nonparametric analysis (MannWhitney U test) was used to compare length of admission and number of admissions between patients with and without substance dependence because the distribution of admission and length of stay was not normally distributed. Statistical significance was set at p<0.05. SPSS 6.1 (SPSS, 1995) was used for all analysis.
3. Results Twenty-six male patients (mean age 46 years) were identified as meeting eligibility criteria (most were diagnosed as paranoid subtype). Patients were Caucasian or African American. Fourteen (14) of the 26 study subjects (54%) were hospitalized during the study period. Twelve (12) of the 26 subjects (46%) were identified as carrying a DSM IV clinical diagnosis of alcohol, marijuana
L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
or cocaine dependence. At the time of hospital admission, all patients with a substance dependence diagnosis were using those substances. All of the patients without substance abuse diagnoses had normal urine drug screens. Diagnoses were stable during the study period. Table 1 presents sample demographics and clinical characteristics. Subjects with a DSM IV clinical diagnosis of alcohol dependence were more likely than patients without alcohol dependence to be admitted to the hospital during the 2 years (86% vs 42%; x2=3.9, p<0.05). Marijuana or cocaine dependence was slightly more common among admitted patients, but was not associated with admissions during the study period (36% vs 33%; x2=0.02, p=0.9). Moreover, patients with alcohol dependence were admitted more often (2.3±0.6 (SEM ) vs 0.9±0.4; U=31, p<0.05) and had longer hospital stays (30±11 (SEM ) vs 14±7 days; U=31, p<0.05) than patients without alcohol dependence. Marijuana or cocaine dependence did not predict length of stay (drug: 21±10 (SEM ) vs no drug: 17±8; U=68, p=0.7) or number of admissions (drug: 1.8±0.6 (SEM ) vs no drug: 1.1±0.4; U=61, p=0.6). There was no difference between frequency or dose of decanoate medication between admitted and nonadmitted patients. Mean age was no different between admitted and nonadmitted patients (46.4 vs 45.4, p=0.7). No significant differences in drug or dosage between admitted or nonadmitted patients were found. Race was no different between patients admitted
73
or not admitted or patients with or without substance use diagnoses. Table 2 highlights differences between subjects admitted and those not admitted to the hospital.
4. Discussion This naturalistic study demonstrated that neuroleptic-compliant schizophrenics with substance abuse had a higher rate of hospital admission than a nonsubstance abusing group. This finding is similar to a previous finding (Gupta et al., 1996). Moreover, not only was substance dependence associated with hospitalization, but alcohol dependence was specifically associated with psychotic relapse. The statistically significant association with alcohol use, but not cocaine use, is somewhat surprising considering cocaine’s central dopaminergic effects, and the possible role of dopamine in exacerbating psychosis ( Heinz et al., 1994). Dopamine receptor availability may be reduced in alcoholics ( Volkow et al., 1996) and this neurochemical difference may contribute to the association between alcohol use and schizophrenic exacerbation (Drake et al., 1989). Other neurochemical changes including alterations in excitatory amino acids or GABA ( Yu and Ho, 1990) may be relevant to psychotic exacerbation. One study reported that the use of stimulants had a higher association with relapse and rehospitalization than that associated with alcohol use
Table 1 Demographics and clinical characteristics (n=26) Age mean±SD Number of African Americans, n (%) Admitted to hospital, n (%) Mean admissions, range Admission days, range Number taking haloperidol decanoate, n (%) Mean dose±(SD), frequency in weeks Number taking fluphenazine decanoate, n (%) Mean dose ± (SD), frequency in weeks Alcohol dependence, n (%) and receiving haloperidol decanoate, n and receiving fluphenazine decanoate, n Marijuana or cocaine dependence, n (%) Any substance dependence, n (%)
46±7 16 (62%) 14 (54%) 1.3 (0–6) 18 (0–134) 15 (58%) 137±(51) mg, 3.97 11 (42%) 35±(18) mg, 2.2 7 (27%) 4 3 9 (35%) 12 (46%)
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L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75
Table 2 Characteristics of patients admitted and not admitted to the hospital
Haloperidol decanoate, n (%)a Fluphenazine decanoate, n (%) Alcohol dependence, n (%) Marijuana/cocaine dependence, n (%) Any substance dependence, n (%)
Admitted (n=14)
Not admitted (n=12)
p
8 6 6 5 8
7 5 1 4 4
0.95 0.95 0.03 0.8 0.2
(57%) (42%) (42%) (36%) (57%)
(58%) (42%) (8%) (33%) (33%)
a Refers to percent within the ‘Admitted’ or ‘Not admitted’ group.
(Richard et al., 1985), however, neuroleptic compliance was not controlled in that study. The findings of this study suggest that when neuroleptic compliance is controlled, alcohol dependence is a stronger precipitant to hospitalization than is cocaine dependence. Not only were patients with alcohol dependence admitted more often and had longer hospital stays than patients without alcohol dependence, but the presence of marijuana or cocaine dependence was not associated with length of stay or number of admissions during the study period. The small sample size may account for the lack of association between cocaine or marijuana dependence and hospital admissions, and previous studies linking drug abuse with schizophrenia decompensation are not in question. These findings support the association between schizophrenic exacerbation and alcohol dependence. However, the findings must be viewed in light of the limitations of the methods. First, this was a naturalistic retrospective study with a small sample size. Larger samples will be required to confirm these findings. Second, drug selection and dose was determined by clinical and not research protocols. Third, sample selection may have been biased in that patients compliant with depot neuroleptics may be different from other samples, and patients taking other antipsychotics may be at different risk for relapse in association with substance abuse. Fourth, the primary variable of admission to the hospital does not inform us as to symptomatic differences among patients, and symptom severity was not measured by standardized rating instruments. Diagnoses were clinical diagnoses and may have been incorrect, though most studies of schizophrenia rely on clinical diagnosis of schizophrenia alone.
Although we suspect that alcohol use contributes to relapse, it is possible that patients initially became psychotic and then began using alcohol in an effort to decrease their psychotic symptoms. It is difficult to determine the chronology of schizophrenic exacerbation and substance use. The association between alcohol use and psychiatric admission does not imply causality, and alcohol’s effect on psychosis may be complex. Because of the consistency of neuroleptic use, we favor the position that alcohol use strongly contributed to clinical decompensation. Despite the complexity of the cause–effect relationship of substance use and psychotic exacerbation in this population, these findings reaffirm the importance of early substance abuse recognition, intervention, education and treatment. This may lead to decreased hospital admission rates, and reduced treatment costs for the targeted population.
References Alterman, A.I., Ayre, F.R., Williford, W.O., 1984. Diagnostic validation of conjoint schizophrenia and alcoholism. Journal of Clinical Psychiatry 45, 300–303. Amador, X.F., Strauss, D.H., Yale, S.A., Gorman, J.M., 1991. Awareness of illness in schizophrenia. Schizophrenia Bulletin 17, 113–132. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Washington, DC, American Psychiatric Association. Barbee, J.G., Clark, P.D., Crapanzano, M.S., Heintz, G.C., Kehow, C.E., 1989. Alcohol and substance abuse among schizophrenic patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease 177, 400–407. Craig, T.J., Lin, S.P., el-Defrawi, M.H., Goodman, A.B., 1985.
L.B. Gerding et al. / Schizophrenia Research 38 (1999) 71–75 Clinical correlates of readmission in a schizophrenic cohort. Psychiatric Quarterly 57, 510 Diamond, R.J., 1983. Enhancing medication use in schizophrenic patients. Journal of Clinical Psychiatry 44, 7–14. Drake, R.E., Osher, F.C., Wallach, M.A., 1989. Alcohol use and abuse in schizophrenia; a prospective community study. Journal of Nervous and Mental Disease 177, 408–414. Drake, R.E., Osher, F.C., Wallach, M.A., 1991. Homelessness and dual diagnosis. American Psychology. 46, 1149–1158. Gupta, S., Hendricks, S., Kenkel, A.M., Bhatia, S.C., Haffke, E.A., 1996. Relapse in schizophrenia: is there a relationship to substance abuse? Schizophrenia Research 20, 153–156. Heinz, A., Schmidt, L.G., Reischies, F.M., 1994. Anhedonia in schizophrenic, depressed, or alcohol-dependent patients— neurobiological correlates. Pharmacopsychiatry 27, 7–10. Hogarty, G.E., Kornblith, S.J., Greenwald, D., DiBarry, A.L., Cooley, S., Ulrich, R.F., Carter, M., Flesher, S., 1997. Threeyear trials of personal therapy among schizophrenic patients living with or independent of family, I: Description of study and effects on relapse rates. American Journal of Psychiatry 154, 1504–1513. Lamb, H.R., Lamb, D.M., 1990. Factors contributing to homelessness among the chronically and severely mentally ill. Hospital and Community Psychiatry 41, 301–305. McEvoy, J.P., Aland, J., Wilson, W.H., Guy, W., Hawkins, L., 1981. Measuring chronic schizophrenic patients’ attitudes toward their illness and treatment. Hospital and Community Psychiatry 32, 856–858.
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