Clinical Aspects of Substance Abuse in Persons With Schizophrenia Juan C Negrete, MD, FRCPC1 Objective: To review the current knowledge on the problem of psychoactive substance abuse by persons with schizophrenia, with particular attention to issues of direct relevance to clinical practice. Method: The author examined the literature from the last 2 decades and data from studies in which he was involved. Results: Schizophrenia sufferers show an elevated liability for substance abuse. Such comorbidity may derive from self-medication attempts, a common neuropathology for ad- diction and schizophrenia, the psychotogenic properties of certain drugs, or the influence of environmental factors. Among schizophrenia patients receiving treatment, substance mis- use is associated with more severe symptoms and poorer therapeutic response. The pres- ence of a chronic psychosis impedes treatment of the substance problem in traditional, nonpsychiatric addiction programs. Better outcomes are observed in integrated therapy services, where patients receive appropriate care for both conditions. Conclusion: Dual-pathology patients need comprehensive care with appropriate pharma- cotherapy and psychosocial interventions. This treatment can be best provided within the context of a continuing care psychiatric service.
Information on funding and support and author affiliations appears at the end of thearticle. Highlights
· Schizophrenia sufferers show an elevated liability for substance abuse. · Among schizophrenia patients receiving treatment, substance misuse is associated with more
severe symptoms and poorer therapeutic response.
· Better outcomes are observed in integrated therapy services, where patients receive appropriate
Key Words: dual disorders, schizophrenia, self-medication, pharmacotherapy, integrated treatment
It has been repeatedly confirmed that persons with schizo- Itisalsowellknownthatpersonswithschizophreniapresent
phrenia have an abnormally high risk of developing sub-
rates of tobacco use (between 70% and 90%) that are well
stance use disorders (that is, abuse or dependence) during the
above those of the general population and also above the rates
course of their lives (1). The excessive probability revealed by
observed in persons with anxiety disorders or depression (al-
the Epidemiological Catchment Area (ECA) study, a
though depression sufferers present the second-highest rates)
general-population household survey, is 3.6 times that for al-
cohol, 5 times that for cannabis, 6.5 times that for opiates, and13 times that for cocaine (2).
W Can J Psychiatry, Vol 48, No 1, February 2003
Clinical Aspects of Substance Abuse in Persons With Schizophrenia Risk of Occurrence
first is that substance use is perpetuated by the need to soothe
The highest rates of addiction comorbidity are found in clini-
or correct psychological deficits or distress. Such distress is
cal samples gathered from outreach programs and emergency
believed to arise largely from primary self-regulation defects,
or walk-in services attending to less stable, more severely af-
or ego-function impairments, that manifest themselves as in-
flicted subjects (4). However, it must be noted that substance
ability to tolerate negative affects, to maintain interpersonal
abuse frequency is not evenly distributed across demographic
relationships, to have a sense of personal identity, or to care
categories within single samples of schizophrenia patients,
for oneself. The second assumption is that substance use is not
nor is it evenly distributed among the different locations from
random; it is determined by a preference for drugs whose spe-
which the data were gathered. Rather, the prevalence profile
cific pharmacologic action best remedies particular individual
among these individuals follows closely the age and sex dif-
ego-function defects. The self-medication construct thus de-
ferences observed in the population at large: younger and
fines addiction as the consequence of a negative reinforce-
male schizophrenia sufferers outrank older and female ones
ment mechanism: the reward comes from impeding the
(1,5). Similarly, rates reported in the US are well in excess of
occurrence of undesirable psychological states or, if they are
rates found in German (6), French (7), British (8), or Canadian
inevitable, from decreasing the pain and discomfort they
(9) samples, particularly in regard to cocaine abuse. It there-
fore seems that, as in the general population, the risk of addic-
Such reinforcing benefits may indeed incline schizophrenia
tion disorders occurring among persons with schizophrenia
sufferers to use drugs. This is perhaps the most convincing ex-
depends on environmental conditions such as drug availabil-
planation for the high rates of tobacco smoking among this
ity and local drug culture. Most of the US data, for instance,
population: nicotine is likely to decrease psychological leth-
pertain to patients seen in public facilities. These patients
argy and feelings of depletion, to ameliorate negative symp-
come mainly from within the Department of Veterans Affairs
toms, and to enhance cognitive functions that are diminished
network, which may be catering to a population preselected
by the illness. Nicotine may even decrease the severity of neu-
for high risk of illegal substance misuse.
roleptic drug extrapyramidal side effects (EPSEs) (12). How-
One interesting finding that emerged from a Montreal study of
ever, schizophrenia sufferers also present excess rates of
persons with chronic schizophrenia is that the prevalence of
cannabis and cocaine use. These substances are known to
tobacco smoking, the most widespread drug problem in this
worsen delusional and hallucinatory symptoms—untoward
particular population, covaries with prevalence of alcohol
effects that may be caused by the drugs’ dopaminergic proper-
drinking (5). Of course, that is also the case in samples without
ties on the mesolimbic system. Of course, dopamine activa-
psychosis (10). However, alcohol-abusing schizophrenia suf-
tion also occurs in the mesocortical projections and in the
ferers have been found to present nearly twice the rate of
prefrontal cortex itself. This particular action potentially alle-
smoking (88.4 %) than do the single-diagnosis patients (49.5
viates negative symptoms and may thus remedy what certain
%). This suggests that the early tobacco dependence mani-
authors have described as “the reward-deficiency syndrome,”
fested by persons with schizophrenia—it precedes alcohol
an anomaly believed to afflict persons with schizophrenia
abuse in nearly every case—can be considered as a precursor
(13). It could therefore be postulated that the resulting less-
of a more general and indiscriminate addiction proclivity.
ened anhedonia, facilitated social interaction, and other suchstimulating effects do constitute a reward powerful enough to
Causation
counteract the aversive positive symptoms caused by these
An explanation for the excessive prevalence of substance
drugs. Surveys of clinical samples support this interpretation:
abuse among persons with schizophrenia and the higher-
when asked to describe their subjective experiences with each
than-expected rates of schizophrenic disorders in people with
drug category, schizophrenia sufferers consistently report that
a lifetime history of addiction could be that the mere occur-
cannabis and cocaine decrease “depression,” although they
rence of one such disorder facilitates the development of the
increase suspiciousness and distrust (14). Similarly, it is pos-
other. In other words, schizophrenia may play an etiological
sible that activating dopaminergic function may diminish the
role in substance abuse, or substance abuse may lead to
negative mood correlates of neuroleptic-induced parkinson-
ism—a property that should additionally reinforce use of
Schizophrenia may lead to addiction through self-medication
these drugs among schizophrenia patients receiving
behaviour (11). This is a nonspecific explanation that applies
equally well to most persisting psychological disturbances,
Lately, however, widespread acceptance of the self-
including other Axis I categories and several personality dis-
medication hypothesis is being challenged by the proponents
orders, all of which are associated with elevated rates of
of a “primary addiction” theory of comorbidity. This theory
chemical addiction. This hypothesis has 2 basic premises. The
contends that individuals with schizophrenia suffer from a
W Can J Psychiatry, Vol 48, No 1, February 2003
The Canadian Journal of Psychiatry—In Review
nonspecific avidity for drugs that parallels their psychotic ill-
Phenomenology
ness and may even be independent of it. According to this in-
It seems well established now that, when they coexist, both
terpretation, the inclination of persons with dual pathology to
addiction and schizophrenia present a more problematic clini-
abuse psychoactive substances is an additional symptom of
cal picture with a less favourable outcome, compared with
the basic neuropathology underlying schizophrenia itself. In
their occurence in isolation. Substance-abusing schizophrenia
other words, both schizophrenia and substance abuse share a
sufferers fare more poorly than their nonabusing counterparts
common pathophysiology. A review by Chambers and others
in just about every clinical parameter or measure. Similarly,
details a wide range of neuroscience observations supporting
when compared with addiction patients who do not suffer
the primary addiction theory (15). These authors conclude
from psychosis, addiction patients with chronic psychosis are
that some primary abnormalities in the hippocampal forma-
known to experience considerably more difficulties in terms
tion and in the frontal cortex exist in schizophrenia sufferers
of psychosocial consequences, access to treatment, and thera-
—abnormalities that facilitate the positive reinforcing effects
of drug reward and reduce the individual’s ability to inhibit
Some features that characterize the clinical picture of schizo-
drug-seeking behaviour. This preexisting neuropathology is
phrenia when it co-occurs with substance abuse are as
thought to lead to brain responses that facilitate the rapid de-
velopment of compulsive drug use patterns, providing a short-cut in the path to addiction, as it were. Goldstein and
1. Earlier outbreak of psychotic symptoms. This finding is
Volkow’s report on brain-imaging studies observes that drug
consistent across many clinical surveys (1). On average,
users experience abnormally high activation in the orbitofron-
schizophrenia sufferers with a lifetime history of substance
tal cortex and the cingulate gyrus areas of the brain during
use disorders come to the attention of psychiatric services sev-
craving and acute intoxication (16). The authors conclude that
eral years earlier than do those without such history. Of
these anomalies represent the neurobiological basis of im-
course, it is quite probable that toxic prompting accelerates
paired inhibition, a major feature of addictive behaviour.
the clinical manifestation of the psychotic illness. However,the significant association brought to light by these surveys
Another explanation for the excessive co-occurrence of ad-
could also be caused by a heightened proclivity to use drugs
diction and schizophrenia is the possibility that drugs may
among individuals with more rapidly developing psychosis.
trigger the clinical expression of the psychotic disease. Thisview is supported by epidemiologic and clinical findings dem-
2. More severe productive symptoms. This is another undis-
onstrating that drug use among youth is associated with a
puted finding recorded in a wide variety of studies. When
higher risk of developing psychosis in subsequent years
compared with single-diagnosis schizophrenia patients, indi-
(17,18); that two-thirds of subjects with first-episode schizo-
viduals with dual disorders are more likely to engage in vio-
phrenia and comorbid addiction used drugs in the premorbid
lent behaviour (22). In fact, comorbid substance abuse
or prodromal phases, prior to the appearance of the first posi-
explains most of the variance in violent occurrences between
tive symptoms (19); and that drug use by schizophrenia pa-
schizophrenia sufferers and control subjects without psycho-
tients in remission is associated with a greater risk of early
sis (23). Substance abuse is associated also with higher
positive-symptom scores; particularly in regard to delusionaland hallucinatory disturbances (24,25).
However, incidence rates for schizophrenia have not in-creased in the last 30 years, whereas the prevalence of drug
3. Poorer therapeutic response and less favourable course of
abuse has grown exponentially throughout the world. It there-
illness. Several studies have shown that substance-abusing
fore seems unlikely that drug abuse by itself suffices to cause
schizophrenia patients do not benefit from treatment as much
the clinical manifestation of a schizophrenic disease.
as their nonabusing counterparts (1,26). Their remission ratesare lower, their psychotic symptoms recur more readily, they
Other causes of comorbidity are to be found in the high-risk
require more inpatient treatment, their employment record is
social settings where many persons with schizophrenia are
poorer, they tend to receive more welfare assistance, their
constrained to live. The variance in prevalence rates across
housing and accommodations pattern is more unstable, and
demographic categories suggests that such external factors
they make more visits to the emergency room. All this occurs
also play an important role in the causation of dual disorders.
in the context of a lesser observance of treatment programs,
Access to drugs and the environmental prompting to which
for they also tend to miss more clinic appointments and day-
many schizophrenia sufferers are exposed cannot be ignored
program sessions and to comply less with the prescribed phar-
(21). This is especially the case in urban settings, where many
schizophrenia patients live in conditions of high social pathol-ogy, homelessness, and transient accommodations; that is, in
4. Less severe negative symptoms? Some clinical research
settings where drug circulation is particularly heavy.
findings suggest this feature, but it is not as well established an
W Can J Psychiatry, Vol 48, No 1, February 2003
Clinical Aspects of Substance Abuse in Persons With Schizophrenia
observation as are the previous ones. Some authors have
traditional addiction services are clearly unable to attend to
found a negative linear correlation between amount of canna-
the dual pathology. Conversely, most continuing care psychi-
bis use and negative-symptom scores (28). A similar finding
atric services, where most of these patients are usually seen,
emerged in a clinical survey conducted by the present author,
do not adequately treat the addiction problem. In fact, the sub-
but the significant difference was seen only in patients aged 35
stance use disorder often remains totally untreated (32).
years or under. The negative-symptom ratings did not seem tobe influenced by drug use status in the older subjects with
Treatment Programs
chronic psychosis (29). Perhaps the greater severity of nega-
It is now generally accepted that substance use disorders in
tive symptoms characteristic of the more advanced illness
those with chronic psychosis cannot be properly treated using
stages causes a “ceiling effect,” whereby the assessment in-
a parallel approach, wherein each disorder is dealt with sepa-
struments are no longer able to detect differences between
rately by 2 different care systems. There is a growing aware-
ness of the need to integrate treatment within a single,
Other authors have reported that persons with schizophrenia
comprehensive program that offers patients with dual disor-
who use drugs present a more functional premorbid personal-
ders all the therapy they need from care providers who are
ity and appear to be have better interpersonal skills than do
properly qualified to attend to both the addiction and the psy-
those in the nonusing comparison group (30). However, this
chiatric illness. Given the multiple and special needs of pa-
observation was reported in a sample of patients who were
tients with chronic psychosis, it is rather obvious that such
mostly using cocaine—a group likely to have been prese-
combined treatment programs can only be set up within psy-
lected for better social efficacy, because cocaine is considera-
chiatric services, particularly services that offer long-term,
bly more difficult to procure than alcohol, nicotine, or even
This integrated approach has already been tested through ran-
The psychotic comorbidity confers some peculiar characteris-
domized controlled studies (34,35) and found to be superior to
tics on the picture of addiction and has a significant negative
standard treatments in most outcome measures: there is better
participation and treatment retention, less drug and alcoholuse, higher quality-of-life scores, more stable housing, and
1. Chaotic, polymorphous, and opportunistic substance abuse.
higher ratings in general levels of functioning.
In addition to the most frequently abused substances (nico-tine, alcohol, and cannabis) (5), many persons with schizo-
The essential elements of a well-organized integrated therapy
phrenia misuse drugs that are rather unknown outside the
program include open-ended continuity of care; assertive case
clientele of psychiatric services; for instance, the anticholiner-
management; on-site addiction treatment, including special-
gic agents prescribed to treat EPSEs. They also resort to over-
ized pharmacotherapy; psychiatric therapy that is mindful of
the-counter preparations such as cough and decongestant syr-
the addiction comorbidity; supervised, safe housing; and oc-
ups, which contain codeine, other opioids, or sympathomi-
metic stimulants. Many of these patients can only afford to use
The better-designed programs provide the resources neces-
drugs when they receive their monthly allowance or when
sary to attend to dual-pathology patients through all the con-
they obtain them from someone else. This results in intermit-
tingencies of their condition: acute detoxification and
tent heavy binges, often with acute consequences that require
psychiatric stabilization inpatient services when necessary;
immediate intervention (that is, emergency room visits). It is
longer-term residential rehabilitation for selected patients in a
not uncommon for these patients to take whatever substance is
therapeutic community model, with adequate psychiatric
available to them, without discrimination.
monitoring and care; and continuing ambulatory treatment,
2. Limited motivation. Because of the rather deprived and
the mainstay of the program. A dual-disorder program is best
simple existence they lead, many of these patients see little
need to significantly change their habits. They do not readily
1. Engagement. the initial period, in which the main goal is to
see substance abuse as threatening their quality of life or as
secure a stable and persisting affiliation with the program,
impeding their pursuit of personal goals (31).
regular attendance, compliance with the essential require-
3. Limited access to treatment. Patients with psychosis are of-
ments, and a minimum degree of participation. This phase
ten deemed ineligible for admission into addiction-treatment
could last for months or years, and it is important to keep in
programs, most of which have no psychiatric resources or in-
sight the primary goals, even at the expense of tolerating the
put. Even if accepted, however, these patients are not well
patient’s initial lack of readiness to address the substance
served in time-limited programs that rely heavily on intensive
abuse problem. The following is an example of the therapy
and indiscriminate group interventions, because such
W Can J Psychiatry, Vol 48, No 1, February 2003
The Canadian Journal of Psychiatry—In Review
4. Maintenance and relapse prevention phase. Both schizo-
· in-depth assessment of psychiatric and addiction status
phrenia and addiction are chronic disorders that require con-tinuous, open-ended treatment. Of course, treatment intensity
· fine-tuned psychiatric pharmacotherapy
and the frequency of contacts can be considerably scaled back
once the patient has shown steady remission. However, the
· positive reinforcement (rewards) for participation
program must always provide the conditions for easy reentryinto active care if patients are either lapsing or fully relapsed.
In fact, the most likely treatment course is one of repeated in-
terventions over time, and the occasional readmission should
be seen as the norm. The following are examples of curricu-
an accessible recreational or leisure management program
lum components in the program designed to help maintain
2. Persuasion. In this second phase, well-engaged patients are
· continuing individual case management, with close moni-
exposed to ongoing motivational therapies at different levels,
toring of occupational and leisure activities and housing
both individually with the case manager and in “dual prob-
lem” group discussions. The goal at this point is to help pa-
tients better understand their particular substance abuse
problems and set goals for therapy. Ideally, the work in this
emergency plan to be observed by patients, next of kin,and program staff in case of relapse
phase leads to the patient’s accepting addiction therapy. Someintervention modalities in this phase are as follows:
· time-limited relapse prevention therapy sessions (that is,
· continuing monitoring of the patient’s psychiatric and ad-
diction condition, including longitudinal charting of cri-
· open-ended, therapist-led support sessions
ses and treatment events (for example, adapted health
records, monthly Addiction Severity Index [ASI] scoring
continuing participation in a peer-support group
[36], timeline follow-back record [37], and urine toxicol-ogy screening)
Specific Pharmacotherapy Issues Patients in treatment who have psychosis and who smoke to-
· drug and mental illness education for patients and signifi-
bacco or cannabis are exposed to the enzyme-induction prop-
erties of the smoke components and may experience an
accelerated clearance of neuroleptic and antidepressant drugs
· systematic motivational enhancement work (39)
(43). Therefore, the blood concentrations of these medica-tions may not attain therapeutic levels at regular dosages.
· introduction of “maintenance and change” program tracks
Conversely, they may increase rapidly following smoking
3. Active addiction treatment. In this phase, the therapeutic
activities involve patients who have opted for effecting thenecessary changes in their alcohol and drug habits and see
It is argued that neuroleptics with strong D2 receptor–binding
themselves as needing therapy for that specific purpose. To
affinity may contribute to perpetuating substance abuse in
that end, the program could offer the following interventions:
persons with schizophrenia. Such a pharmacologic property
does lead to receptor upregulation and supersensitivity (44),thus enhancing drug reward and positive reinforcement, and
· optimized psychiatric and addiction pharmacotherapy
causes more severe EPSEs—another incentive to use drugs. It
· continuous clinical and laboratory monitoring
is therefore recommended that schizophrenia sufferers with
dual diagnosis be treated with atypical neuroleptics (44). Sev-
psychiatric case management, individual addiction coun-selling, and housing and social support control
eral clinical-outcome reports support this view (13,45,46).
The use of opiate receptor agonists such as buprenorphine andmethadone (47,48) is considered to be safe and useful in both
· goal setting and a scaled goal-attainment reward program
detoxification and narcotic maintenance therapies for opiate
· dual-diagnosis cognitive-behavioural therapy (CBT) ses-
addiction in schizophrenia patients. No untoward effects have
been reported to date. The same can be said for opiate antago-
· dual-diagnosis social-skills training (41)
nist therapy (that is, naltrexone) in cases of opiate addictionand alcoholism. Disulfiram must be used with caution in per-
· peer support and 12-step program integration
sons with schizophrenia, for in addition to its prime target,
· prevocational counselling and work placement support
acetaldehyde dehydrogenase, it inhibits dopamine beta-
W Can J Psychiatry, Vol 48, No 1, February 2003
Clinical Aspects of Substance Abuse in Persons With Schizophrenia
hydroxylase, an enzyme involved in the conversion of dopa-
inability to sit still through a long meeting. Most do not iden-
mine and noradrenaline, and may thus increase delusional and
tify with the social loss stories of other group members (for
hallucinatory activity (44). There is still not enough informa-
example, loss of marriage, job, property, or driving permit),
tion on the performance of acamprosate in cases of comorbid
because they have seldom attained a similar status in life.
alcoholism and schizophrenia and, in particular, on whether it
Conversely, when self-help sessions are attended by peers and
has any negative interaction with antipsychotic therapy. This
the experience of mental illness is part of the discussion
drug has undergone extensive trials in Europe and the US (49),
agenda, patients with dual disorders appear to engage more
but patients with psychosis appear to have been excluded from
readily and derive the expected benefits (55).
the samples studied so far. Bupropion and nicotine-replacement therapy (that is, the transdermal patch), used to
The main goal of motivational therapy is to help advance the
achieve cessation of smoking, are apparently safe and effec-
process of change, to coach those who abuse substances into
tive in patients with chronic psychosis. Several trials have re-
becoming more consciously aware of the nature and extent of
the problems at hand, and to empower them to decide volun-tarily to make the necessary effort and accept help. Such an
Another issue of considerable clinical importance is the deci-
approach is obviously more effective when the clients are able
sion to initiate a preventive course of pharmacotherapy in
to recognize the costs and untoward consequences of not mak-
young people who have suffered brief, substance-induced
ing the change, when they are capable of formulating goals for
psychotic episodes. Continuing neuroleptic treatment as a
themselves, and when they can muster the necessary energy to
preventive measure has been recommended for persons who
pursue their goals. This is often not the case with persons who
meet criteria for ultrahigh risk (51). It seems the right course if
suffer chronic and severe mental illness. Dual-disorder moti-
the brief psychotic outbreak occurs in a context of family his-
vational therapists must deal with individuals who often see
tory of schizophrenia and if the young person already presents
nothing wrong with their drug practices and cannot perceive
other prodromal symptoms. However, other voices strongly
the advantage of quitting. Such patients have low levels of en-
advise caution, on the grounds that the reliability and specific-
ergy and a certain inability to become enthused with the idea
ity of the prodromal syndrome have not yet been satisfactorily
of goal attainment (56). They may also be cognitively im-
paired. Despite all these limitations, evidence is accumulatingto the effect that the motivation enhancement approach does
Psychotherapy Issues
yield positive results in this population and that it should be
Motivational interviewing, CBT, relapse-prevention skills
training, and the 12-step mutual-help programs are the mostwidely used approaches in the psychotherapy of addiction. Allhave been tried in dual-disorder treatment programs, but it is
Conclusions
clear that some specific modifications are required to adapt
Chronic schizophrenia and substance abuse are significantly
those interventions to the particular conditions of the patient
associated in terms of risk for occurrence and underlying
neuropathology. This clinical reality cannot be overlooked;
The Alcoholics Anonymous (AA) program is the most heav-
for it is both neglectful and self-defeating to treat one of these
ily subscribed treatment resource. It is a significant compo-
disorders while ignoring the other. Emerging evidence points
nent in the therapy curriculum for the vast majority of
to the significant advantage of treating both disorders con-
addiction-treatment centres in North America. It offers a
jointly, in an integrated manner. Given that both illnesses fol-
time-honoured contribution to treatment success—one that is
low a chronic and recurrent course, that their clinical
supported by empirical evidence (53). Most dual-disorder
management calls for a high level of psychiatric expertise, and
treatment services encourage or require their clients to be-
that there is often a need to access hospital facilities within a
come involved in this program, but as Noordsy and others
continuing care model, integrated programs can be developed
have found (54), schizophrenia patients experience signifi-
most adequately within psychiatric services that provide com-
cant difficulties adjusting to it: few attend, despite efforts by
referring clinicians, although attendance is better for patientswith fewer negative symptoms. Most resent confrontation and
Funding and Support
the dismissal of their justification for drinking (that is, mentalsymptoms) as an attempt to “deny” alcoholism. Many are un-
This paper includes data from research funded by the Cana-
comfortable in large groups, feeling watched, different, and
dian Psychiatric Research Foundation and Health Canada’s
out of place among people who do not suffer from psychosis.
Health Research Development Program, in which the author
Some are embarrassed by their own restlessness and their
W Can J Psychiatry, Vol 48, No 1, February 2003
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Clinical Aspects of Substance Abuse in Persons With Schizophrenia Résumé : Aspects cliniques de l’abus de substances psychoactives chez les personnes souffrant de schizophrénie Objectif : Examiner les connaissances actuelles au sujet du problème d’abus de substances psychoac- tives chez les personnes souffrant de schizophrénie, en portant une attention particulière aux questions qui relèvent directement de la pratique clinique. Méthode : L’auteur a examiné la documentation des vingt dernières années et des données d’études auxquelles il a participé. Résultats : Les personnes souffrant de schizophrénie affichent un risque élevé d’abus de substances. Cette comorbidité peut découler de tentatives d’automédication, d’une neuropathologie commune à la toxicomanie et à la schizophrénie, des propriétés psychotogéniques de certains médicaments ou de l’influence de facteurs environnementaux. Parmi les patients schizophrènes qui reçoivent un traite- ment, l’abus de substances est associé à des symptômes plus graves et à une piètre réponse au traite- ment. La présence d’une psychose chronique empêche le traitement du problème d’abus de substances dans des programmes classiques non psychiatriques pour toxicomanie. On observe de meilleurs résul- tats dans des services thérapeutiques intégrés, où les patients reçoivent les soins appropriés pour les deux affections. Conclusion : Les patients souffrant d’une double pathologie ont besoin de soins complets avec phar- macothérapie adéquate et interventions psychosociales. Ce traitement est mieux prodigué dans le cadre d’un service de soins psychiatriques continus.
W Can J Psychiatry, Vol 48, No 1, February 2003
13Clinical Aspects of Substance Abuse in Persons With Schizophrenia
21Are There Cognitive and Behavioural Approaches Specific to The Treatment of Pathological Gambling?
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