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Substance abuse in Schizophrenia- a short report
Available online at www.sciencedirect.com
Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
WCPCG-2010
Substance abuse in Schizophrenia- a short report Sobia Haqqia a
M.B.B.S, M.C.P.S, F.C.P.S, Consultant Psychiatrist
Received January 7, 2010; revised February 1, 2010; accepted March 28, 2010
Abstract Background Substance abuse, a common problem worldwide, has been found to be prevalent among patients suffering from Schizophrenia1, 4. Pakistan, a South Asian developing country with a population of 150 million, is no exception. 1, 4 There is a dearth of locally published literature on the prevalence of substance abuse amongst schizophrenic patients and especially in-patients. The present study was done keeping in view these observations with the aim to present findings in a psychiatric inpatient sample at a tertiary care hospital in Karachi, Pakistan. © 2010 Elsevier Ltd. All rights reserved. Keywords: Substance abuse, Schizophrenia, Pakistan
Introduction Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, wherein the person may also suffer from tolerance and withdrawal 2 Schizophrenia is a severe brain disease resulting in substantial loss of reproductive fitness in the past, and it is has a lifetime prevalence close to 1% worldwide and across cultures. It is clear that many individuals who are genetically vulnerable to schizophrenia do not express it, and that schizophrenia is multifactorial, involving genes, environmental factors, their interactions, and hypothesized epigenetic factors. . 3 Studies conducted worldwide since the early1990s have found a wide range of psychoactive substance abuse prevalence rates, with male gender and younger age as the primary correlates. Although, less certainty exists regarding substance abuse as an independent risk factor for schizophrenia and its further impact on illness course.4 There is substantial evidence for substance misuse being a major risk factor for violence and aggression in patients with major mental disorder, especially schizophrenia 19, 20, 21, 22, 23 and seems to be associated with greater use of inpatient services 21 Method Medical records of 50 in-patients, who were admitted with the primary diagnosis of Schizophrenia in the last six months, were reviewed by the author. Result There were 46 male and 4 female patients. 40% patients (n=20) were in the age range of 21-30 years. 1877-0428 © 2010 Published by Elsevier Ltd. doi:10.1016/j.sbspro.2010.07.442
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Sobia Haqqi / Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
46% (n=23) of the patients were married at the time of admission, only 8% (n=4) of the sample had no formal education. Interestingly, only the records of male patients reported a history of substance abuse (n=26) along with their principal diagnosis of schizophrenia. The most commonly reported psychoactive substance was Alcohol (n=15). Cannabis was noted to be the second most commonly used psychoactive substance (n=11). Discussion The results show that 52% of admitted schizophrenics are also substance abusers. This is somewhat higher in comparison with worldwide published data that indicates a lifetime prevalence of drug abuse among first-episode cases of schizophrenia upto 35% 6,15,16,17, and that too more common in male patients, 6, 15,16,17,18 similar to this study. A recent Prospective case control study conducted in Karachi has reported the mean age of onset of schizophrenia to be 23.96 years in females and 24.13 years in males. 24 In the present study, majority of the patients were also young. These findings seem to indicate that substance abuse in the early course of illness determines an earlier onset of schizophrenia and could play a role in increasing the severity of psychosis. Therefore persons incurring a risk of schizophrenia may be warned of the possible relation between substances and psychosis and should be counseled against the use of them. In the present study, 54% of the sample was not married at the time of admission in the psychiatry ward. As Gillis et al 25 has also pointed out, the high-risk individual in Pakistan, as in the United States, is one with ready access to drugs and the social inducements to use them while lacking bonds with societal institutions or value systems which might mitigate against drug use. Further research regarding the psycho-social rehabilitation of the schizophrenic patients post-admission, would be helpful in determining the fate of such patients especially those without a primary support system. 26 In conclusion, the present study indicates that substance abuse is frequent among in-patients with schizophrenia, and could have a considerable effect on symptom presentation; it also seems to precipitate the onset of schizophrenia at an earlier age. These findings, which are in line with other recently published data, underline the need to act early on substance abuse. People at risk of schizophrenia should be warned of the possible relationship between substance abuse and psychosis, and counseled against the use of it. Further research is recommended as the next step for the development of risk management strategies and the evaluation of treatment in people with dual-diagnosis. Acknowledgements The author would like to thank Dr Murad Moosa Khan, Chair, Department of Psychiatry, Aga Khan University Hospital, Karachi. Footnote The author was affiliated with the Department of Psychiatry, Aga Khan University Hospital, Karachi, as a Consultant Psychiatrist, at the time of submission of this manuscript. References Pakistan Narcotic Control Board (PNCB): National Survey on Drug Abuse in Pakistan – 1993. Islamabad 1994. Gelder M, Mayou R, Cowen P: Misuse of Alcohol and Drugs. In Shorter Oxford Textbook of Psychiatry 4th edition. Oxford University Press; 2001:533-79. McGuffin, P.Owen, MJ.Gottesman, II. Eds. Psychiatric Genetics & Genomics (revised). Oxford: Oxford University Press; 2004 E. Cantor-Graae. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophrenia research. Volume 48 issue 1 .69-82. Drug Addiction Highest in Pakistan: International Narcotic Control Board – February 22, 2001
2241
Sobia Haqqi / Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK. Co morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990; 264:2511–2518. Hambrecht M, Hafner H. Cannabis, vulnerability, and the onset of schizophrenia: an epidemiological perpective. Aust N Z J Psychiatry. 2000; 34:468–475. Kosten TR, Ziedonis DM. Substance abuse and schizophrenia: editors' introduction. Schizophr Bull. 1997; 23:181–186. Buckley PF. Substance abuse in schizophrenia: a review. J Clin Psychiatry. 1998; 59:26–30. Sevy S, Robinson DG, Solloway S, Alvir JM, Woerner MG, Bilder R, Goldman R, Lieberman J, Kane J. Correlates of substance abuse in patients with first-episode schizophrenia and schizoaffective disorder. Acta Psichiatr Scand. 2001; 104:367–374. Swofford CD, Kasckow JW, Scheller-Gilkey G, Inderbitzin LB. Substance use: a powerful predictor of relapse in schizophrenia. Schizophr Res. 1996; 20:145–151. Owen RR, Fischer EP, Booth BM, Cuffel BJ. Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatr Serv. 1996; 47:853–858. Hambrecht M, Hafner H. Substance abuse and the onset of schizophrenia. Biol Psychiatry. 1996; 40:1115–1163. Caspari D. Cannabis and schizophrenia: results of a follow-up study. Eur Arch Psychiatry Clin Neurosci. 1999; 249:45–49 Rabinowitz J, Bromet EJ, Lavelle J, Carlson G, Kovasznay B, Schwartz JE. Prevalence and severity of substance use disorder and onset of psychosis in first-admission psychotic patients. Psychol Med. 1998; 28:1411–1419 Buhler B, Hambrecht M, Loffler W, Heiden W, Hafner H. Precipitation and determination of the onset and course of schizophrenia by substance abuse – a retrospective and prospective study of 232 population-based first illness episodes. Schizophr Res. 2002; 54:243–251 U
U
De Lisi LE, Boccio AM, Riordan H, Hoff AL, Dorfman A, Mc Clelland J, Kushner M, Van Eyl O, Oden N. Familial thyroid disease and delayed language development in first admission patients with schizophrenia. Psychiatry Res. 1991; 38:39–50. Cantwell R, Brewin J, Glazebrook C, Dalkin T, Fox R, Medley I, Harrison G. Prevalence of substance abuse in first-episode psychosis. Br J Psychiatry. 1999; 174:50–153. Niaz et al. A Survey of Psychosocial Correlates of Drug Abuse in Young Adults Aged 16-21, in Karachi: Identifying ‘High Risk’ Population to Target Intervention Strategies. Pak j med Sci 2005 Regier, D. A., Farmer, M. E., Rae, D. S., et al (1990) Co morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, 264, 2511-2518. PR Menezes. Drug and alcohol problems among individuals with severe mental illness in south London. The British Journal of Psychiatry 168: 612-619 (1996) E. Cantor-Graae. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophrenia research. Volume 48 issue 1 .69-82 J Smith and S Hucker .Schizophrenia and substance abuse The British Journal of Psychiatry 165: 13-21 (1994). Naqvi
et
al.
Gender
differences
in
age
at
onset
of
Schizophrenia
J Coll Physicians Surg Pak Jun 2005; 15(6):345-8.
HU
UH
Gillis JS , Mubbashar MH . Risk factors for drug abuse in Pakistan: a replication. Psychol Rep. 1995 Feb; 76(1):99-108.
HU
UH
HU
UH
Cuffel, B. J. (1992) Prevalence estimates of substance abuse in schizophrenia and their correlates. Journal of Nervous and Mental Disease, 180, 589-592.
Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
WCPCG-2010
Substance abuse in Schizophrenia- a short report Sobia Haqqia a
M.B.B.S, M.C.P.S, F.C.P.S, Consultant Psychiatrist
Received January 7, 2010; revised February 1, 2010; accepted March 28, 2010
Abstract Background Substance abuse, a common problem worldwide, has been found to be prevalent among patients suffering from Schizophrenia1, 4. Pakistan, a South Asian developing country with a population of 150 million, is no exception. 1, 4 There is a dearth of locally published literature on the prevalence of substance abuse amongst schizophrenic patients and especially in-patients. The present study was done keeping in view these observations with the aim to present findings in a psychiatric inpatient sample at a tertiary care hospital in Karachi, Pakistan. © 2010 Elsevier Ltd. All rights reserved. Keywords: Substance abuse, Schizophrenia, Pakistan
Introduction Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, wherein the person may also suffer from tolerance and withdrawal 2 Schizophrenia is a severe brain disease resulting in substantial loss of reproductive fitness in the past, and it is has a lifetime prevalence close to 1% worldwide and across cultures. It is clear that many individuals who are genetically vulnerable to schizophrenia do not express it, and that schizophrenia is multifactorial, involving genes, environmental factors, their interactions, and hypothesized epigenetic factors. . 3 Studies conducted worldwide since the early1990s have found a wide range of psychoactive substance abuse prevalence rates, with male gender and younger age as the primary correlates. Although, less certainty exists regarding substance abuse as an independent risk factor for schizophrenia and its further impact on illness course.4 There is substantial evidence for substance misuse being a major risk factor for violence and aggression in patients with major mental disorder, especially schizophrenia 19, 20, 21, 22, 23 and seems to be associated with greater use of inpatient services 21 Method Medical records of 50 in-patients, who were admitted with the primary diagnosis of Schizophrenia in the last six months, were reviewed by the author. Result There were 46 male and 4 female patients. 40% patients (n=20) were in the age range of 21-30 years. 1877-0428 © 2010 Published by Elsevier Ltd. doi:10.1016/j.sbspro.2010.07.442
2240
Sobia Haqqi / Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
46% (n=23) of the patients were married at the time of admission, only 8% (n=4) of the sample had no formal education. Interestingly, only the records of male patients reported a history of substance abuse (n=26) along with their principal diagnosis of schizophrenia. The most commonly reported psychoactive substance was Alcohol (n=15). Cannabis was noted to be the second most commonly used psychoactive substance (n=11). Discussion The results show that 52% of admitted schizophrenics are also substance abusers. This is somewhat higher in comparison with worldwide published data that indicates a lifetime prevalence of drug abuse among first-episode cases of schizophrenia upto 35% 6,15,16,17, and that too more common in male patients, 6, 15,16,17,18 similar to this study. A recent Prospective case control study conducted in Karachi has reported the mean age of onset of schizophrenia to be 23.96 years in females and 24.13 years in males. 24 In the present study, majority of the patients were also young. These findings seem to indicate that substance abuse in the early course of illness determines an earlier onset of schizophrenia and could play a role in increasing the severity of psychosis. Therefore persons incurring a risk of schizophrenia may be warned of the possible relation between substances and psychosis and should be counseled against the use of them. In the present study, 54% of the sample was not married at the time of admission in the psychiatry ward. As Gillis et al 25 has also pointed out, the high-risk individual in Pakistan, as in the United States, is one with ready access to drugs and the social inducements to use them while lacking bonds with societal institutions or value systems which might mitigate against drug use. Further research regarding the psycho-social rehabilitation of the schizophrenic patients post-admission, would be helpful in determining the fate of such patients especially those without a primary support system. 26 In conclusion, the present study indicates that substance abuse is frequent among in-patients with schizophrenia, and could have a considerable effect on symptom presentation; it also seems to precipitate the onset of schizophrenia at an earlier age. These findings, which are in line with other recently published data, underline the need to act early on substance abuse. People at risk of schizophrenia should be warned of the possible relationship between substance abuse and psychosis, and counseled against the use of it. Further research is recommended as the next step for the development of risk management strategies and the evaluation of treatment in people with dual-diagnosis. Acknowledgements The author would like to thank Dr Murad Moosa Khan, Chair, Department of Psychiatry, Aga Khan University Hospital, Karachi. Footnote The author was affiliated with the Department of Psychiatry, Aga Khan University Hospital, Karachi, as a Consultant Psychiatrist, at the time of submission of this manuscript. References Pakistan Narcotic Control Board (PNCB): National Survey on Drug Abuse in Pakistan – 1993. Islamabad 1994. Gelder M, Mayou R, Cowen P: Misuse of Alcohol and Drugs. In Shorter Oxford Textbook of Psychiatry 4th edition. Oxford University Press; 2001:533-79. McGuffin, P.Owen, MJ.Gottesman, II. Eds. Psychiatric Genetics & Genomics (revised). Oxford: Oxford University Press; 2004 E. Cantor-Graae. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophrenia research. Volume 48 issue 1 .69-82. Drug Addiction Highest in Pakistan: International Narcotic Control Board – February 22, 2001
2241
Sobia Haqqi / Procedia Social and Behavioral Sciences 5 (2010) 2239–2241
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK. Co morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990; 264:2511–2518. Hambrecht M, Hafner H. Cannabis, vulnerability, and the onset of schizophrenia: an epidemiological perpective. Aust N Z J Psychiatry. 2000; 34:468–475. Kosten TR, Ziedonis DM. Substance abuse and schizophrenia: editors' introduction. Schizophr Bull. 1997; 23:181–186. Buckley PF. Substance abuse in schizophrenia: a review. J Clin Psychiatry. 1998; 59:26–30. Sevy S, Robinson DG, Solloway S, Alvir JM, Woerner MG, Bilder R, Goldman R, Lieberman J, Kane J. Correlates of substance abuse in patients with first-episode schizophrenia and schizoaffective disorder. Acta Psichiatr Scand. 2001; 104:367–374. Swofford CD, Kasckow JW, Scheller-Gilkey G, Inderbitzin LB. Substance use: a powerful predictor of relapse in schizophrenia. Schizophr Res. 1996; 20:145–151. Owen RR, Fischer EP, Booth BM, Cuffel BJ. Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatr Serv. 1996; 47:853–858. Hambrecht M, Hafner H. Substance abuse and the onset of schizophrenia. Biol Psychiatry. 1996; 40:1115–1163. Caspari D. Cannabis and schizophrenia: results of a follow-up study. Eur Arch Psychiatry Clin Neurosci. 1999; 249:45–49 Rabinowitz J, Bromet EJ, Lavelle J, Carlson G, Kovasznay B, Schwartz JE. Prevalence and severity of substance use disorder and onset of psychosis in first-admission psychotic patients. Psychol Med. 1998; 28:1411–1419 Buhler B, Hambrecht M, Loffler W, Heiden W, Hafner H. Precipitation and determination of the onset and course of schizophrenia by substance abuse – a retrospective and prospective study of 232 population-based first illness episodes. Schizophr Res. 2002; 54:243–251 U
U
De Lisi LE, Boccio AM, Riordan H, Hoff AL, Dorfman A, Mc Clelland J, Kushner M, Van Eyl O, Oden N. Familial thyroid disease and delayed language development in first admission patients with schizophrenia. Psychiatry Res. 1991; 38:39–50. Cantwell R, Brewin J, Glazebrook C, Dalkin T, Fox R, Medley I, Harrison G. Prevalence of substance abuse in first-episode psychosis. Br J Psychiatry. 1999; 174:50–153. Niaz et al. A Survey of Psychosocial Correlates of Drug Abuse in Young Adults Aged 16-21, in Karachi: Identifying ‘High Risk’ Population to Target Intervention Strategies. Pak j med Sci 2005 Regier, D. A., Farmer, M. E., Rae, D. S., et al (1990) Co morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, 264, 2511-2518. PR Menezes. Drug and alcohol problems among individuals with severe mental illness in south London. The British Journal of Psychiatry 168: 612-619 (1996) E. Cantor-Graae. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophrenia research. Volume 48 issue 1 .69-82 J Smith and S Hucker .Schizophrenia and substance abuse The British Journal of Psychiatry 165: 13-21 (1994). Naqvi
et
al.
Gender
differences
in
age
at
onset
of
Schizophrenia
J Coll Physicians Surg Pak Jun 2005; 15(6):345-8.
HU
UH
Gillis JS , Mubbashar MH . Risk factors for drug abuse in Pakistan: a replication. Psychol Rep. 1995 Feb; 76(1):99-108.
HU
UH
HU
UH
Cuffel, B. J. (1992) Prevalence estimates of substance abuse in schizophrenia and their correlates. Journal of Nervous and Mental Disease, 180, 589-592.