Treatment for schizophrenia and substance abuse, treating severe tinnitus - Test Out

Schizophrenia is a chronic, severe, debilitating mental illness characterized by disordered thoughts, abnormal behaviors, and anti-social behaviors. Paranoid-type schizophrenia is distinguished by paranoid behavior, including delusions and auditory hallucinations. A person with disorganized-type schizophrenia will exhibit behaviors that are disorganized or speech that may be bizarre or difficult to understand. Undifferentiated-type schizophrenia is a classification used when a person exhibits behaviors which fit into two or more of the other types of schizophrenia, including symptoms such as delusions, hallucinations, disorganized speech or behavior, catatonic behavior.
When a person has a past history of at least one episode of schizophrenia, but the currently has no symptoms (delusions, hallucinations, disorganized speech or behavior) they are considered to have residual-type schizophrenia.
The diagnosis of schizophrenia is made both by ruling out other medical disorders that can cause the behavioral symptoms (exclusion), and by observation of the presence of characteristic symptoms of the disorder. The doctor may use physical examination, psychological evaluation, laboratory testing of blood, and imaging scans to produce a complete picture of the patient's condition.
Mental health screening and evaluation is an important part of the diagnosis process for schizophrenia.
Antipsychotic medications are the first-line treatment for many patients with schizophrenia. Family psycho-education: It is important to include psychosocial interventions in the treatment of schizophrenia. Assertive community treatment (ACT): Another form of psychosocial intervention includes use of out-patient support groups.
Substance abuse treatment: Many people with schizophrenia (up to 50%) also have substance abuse issues. Social skills training: Patients with schizophrenia may need to re-learn how to appropriately interact in social situations. Supported employment: Many people with schizophrenia have difficulty entering or re-entering the work force due to their condition. Cognitive behavioral therapy (CBT): This type of intervention can help patients with schizophrenia change disruptive or destructive thought patterns, and enable them to function more optimally. Weight management: Many anti-psychotic and psychiatric drugs cause weight gain as a side effect. The prognosis for people with schizophrenia can vary depending on the amount of support and treatment the patients receives.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),1 the diagnosis of alcohol dependence, abuse, or misuse is no different in the presence of another mental illness. In a study focusing on the correlation between addiction and  mental illness, Helzer and Pryzbeck3 found that every psychiatric diagnosis they screened for was more prevalent in the alcoholic respondents while using the same data.
Importantly for psychiatrists, approximately one third of general psychiatry patients and up to 50% of emergency room (ER) patients have presenting problems directly related to addiction.4 Given the high community prevalence of dual diagnosis and the even higher prevalence in treatment populations, psychiatrists should evaluate all of their psychiatric patients for latent or manifest alcohol use disorders (AUDs). The classic stigma of clinical depression, such as mood impairment, hopelessness, and insomnia, are mimicked by the effects of alcohol use.
In a study on depressed individuals who also drink alcohol, Schuckit and colleagues7 delineated two groups: those with independent depression and those with substance-induced major depression. After the psychiatrist explained the depressant and anxiogenic effects of alcohol, Jane immediately agreed to stop drinking alcohol. At this juncture the psychiatrist referred the patient to AA and a therapist skilled in dual-diagnosis treatment and the relapse-prevention model. The problem for the anxious alcoholic remains that alcohol initially treats anxiety, which worsens it later on. Rather than just relieving painful affects when they are overwhelming, drugs and alcohol and the distress they entail  may also be adopted as way of being in control especially when they feel out of control because affects are vague, elusive and nameless.
Due to the numerous potential interactions between alcohol and anxiety, the clinician must focus on treatments that ensure patient safety and bring quick symptom relief. Bipolar disorder co-occurs with alcohol dependence more than any other mental illness.19 In a study of patients with bipolar disorder and alcoholism,20 patients who had primary alcoholism (unrelated to their bipolar disorder) were less likely to experience remission from their alcoholism. The high prevalence and serious consequences of bipolar disorder combined with alcoholism necessitate aggressive treatment for this combination of illnesses. Regarding patients who have suffered from a long-term psychotic disorder, Miles and colleagues29 found alcohol to be the most common substance of abuse (Figure 2). Patients with schizophrenia and other psychotic illnesses must be carefully monitored for their alcohol usage, since alcohol can worsen or even cause psychotic illnesses. Treatment for a schizophrenic using alcohol should focus on avoiding alcohol while maximizing the use of antipsychotics and psychosocial treatments (such as dual diagnosis or addiction-knowledgeable day treatment programs) and assertive case management techniques.
Although all of the personality disorders are affected by the use of alcohol or drugs, borderline personality disorder (BPD)30  is the only disorder which mentions substance abuse per se as one diagnostic criterion. The clinician treating an alcoholic  with a personality disorder must carefully distinguish between psychiatric phenomena caused by alcohol use, versus chronic characterological traits and symptoms independent of alcohol use. ASPD and other Cluster B personality disorders evoke strong negative counter transference in therapists because of the patient’s often dramatic and self-destructive behaviors.
Treatment of the alcohol dependent mentally ill patient should strive toward an integrated approach. Individual therapy for the alcoholic mentally ill individual should start at the supportive rather than the expressive (psychoanalytic) end of the spectrum because the powerful affects generated in expressive therapy can precipitate a slip or full-blown relapse.
Disulfiram, while arguably more effective than naltrexone, does present some problems for the mentally ill alcoholic. Mueser and colleagues40 found that, out of 33 severely mentally ill patients administered disulfiram, 64% experienced remission for at least 1 year. Integrated treatment of the dually diagnosed patients and comorbid AUDs, although challenging, can yield great rewards.
E-newsletter Opt-inSent no more than 2–3 times each month, our E-Newsletter brings you recent findings and commentary from the psychiatric literature. Patients with mental illness constitute a population that can be challenging for any health care provider, but they offer great opportunities for a pharmacist to make a meaningful contribution. Although nonpharmacologic interventions may be perceived as treatment modalities that cannot change the biochemistry of schizophrenia, they can help patients learn how to cope with their illness.
A 2-year randomized study compared the effect of integrated treatment versus standard treatment in 547 newly diagnosed schizophrenia patients.
Most patients with schizophrenia require chronic treatment with medications to control symptoms and achieve remission. Second-Generation Antipsychotics (SGAs): Whereas FGAs work primarily as dopamine-2 receptor antagonists, the mechanisms are much broader for SGAs (also known as atypical antipsychotics).
Improvements in sleep disturbance and agitation may be seen in the first 2 days of antipsychotic therapy; however, the full effect may not be seen for 6 to 8 weeks.
In general, FGAs are more affordable than SGAs, with perphenazine and fluphenazine costing more than other FGAs. Other Medications: Whereas antipsychotics remain the primary pharmacologic treatment for schizophrenia, a number of other medications may be used to augment them. One of the most straightforward algorithms for the treatment of schizophrenia was published by the Texas Department of State Health Services (FIGURE 1). Despite the fact that there is no cure for schizophrenia, providing patients with guideline-based treatments supported by primary literature will afford the best opportunity for controlling the symptoms of their illness.
It is a psychotic disorder, meaning the person with schizophrenia does not identify with reality at times.
The National Institute of Mental Health (NIMH) estimates only 1 in 40,000 children experience the onset of schizophrenia symptoms before the age of 13. People with this type of schizophrenia may vary between extremes: they may remain immobile or may move all over the place. While schizophrenia occurs in only 1% of the general population, it occurs in 10% of people with a first-degree relative (parent, sibling) with the disorder.
Patients with schizophrenia often have overlapping depression and may have suicidal thoughts or behaviors. Many other mental illnesses such as bipolar disorder, schizoaffective disorder, anxiety disorders, severe depression, and substance abuse may mimic symptoms of schizophrenia. Medications are often used in combination with other types of drugs to decrease or control the symptoms associated with schizophrenia. Including family members to support patients decreases the relapse rate of psychotic episodes and improves the person's outcomes.
Support teams including psychiatrists, nurses, case managers, and other counselors, meet regularly with the schizophrenic patient to help reduce the need for hospitalization or a decline in their mental status.
These substance abuse issues worsen the behavioral symptoms of schizophrenia and need to be addressed for better outcomes.


This type of psychosocial intervention helps people with schizophrenia to construct resumes, interview for jobs, and even connects them with employers willing to hire people with mental illness. It can help patients "test" the reality of their thoughts to identify hallucinations or "voices" and ignore them.
Maintaining a healthy weight, eating a well-balanced diet, and exercising regularly helps prevent or alleviate other medical issues. It is intended for general informational purposes only and does not address individual circumstances.
Westreich is clinical associate professor of psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, at the New York University School of Medicine in New York City. Westreich, MD, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine, 550 First Ave, New York, NY 10016.
Alcohol can both cause and exacerbate symptoms and must be treated concurrently with the psychiatric illness. However, when dealing with those suffering from mental illness, the criteria for diagnosing a patient’s problem with alcohol should be quite broad.
Nonetheless, discontinuing alcohol use for the psychiatric patient is often necessary, partly to remove an impediment to effective treatment. Of those who were found to have a mental illness, 22% had a lifetime diagnosis of alcohol abuse or dependence and 15% had a lifetime diagnosis of drug abuse or dependence. The highest associations with alcoholism were mania, antisocial personality disorder, and other substance abuse. Those with an independent, non alcohol-related, depressive condition were more likely to have a close family member with depression, and to be married, caucasian, and female. Allowing a patient to suffer depressive symptoms any longer than necessary while waiting for a firm diagnosis is unnecessary.
In fact, she had never seen a therapist until 6 months after her son was born, when she realized that her sadness had not dissipated and that she was feeling increasingly anxious every day.
The therapist was a cognitive-behavioral specialist and assessed Jane as severely depressed, but in no danger of actually harming herself or her infant. Although Jane felt less alone and beleaguered by her depression, both she and her therapist worried that her anxiety had not abated because her insomnia and low appetite remained.
Such a therapist should be knowledgable about the abundant literature guiding clinician working with dual disorders.10 Several weeks later, the patient was hospitalized for a 3-day detoxification period, after which she continued with an intensive outpatient program, AA, and sertraline. This rapid symptom relief strategy ensures patient compliance with the long-term treatment plan.
On each occasion he was intoxicated, but joked and teased the physicians on call in a pleasant manner, regaling them with long, hilarious tales of his misadventures. During that interview it became clear that Bill’s mother had been diagnosed and successfully treated for bipolar disorder and that his younger brother had symptoms suggestive of bipolar disorder. Another study28 found that among patients with schizophrenia, the lifetime prevalence of alcohol use disorder was in the 50% range.
In addition, Miles and colleagues found that alcohol users were more likely than stimulant users to be older, white, and less likely to have a history of violent behavior. First, alcohol is an easily available, fast-acting agent that quells the fears and pain of becoming psychotic, especially during a first break.
Alcohol withdrawal can mimic the hallucinations of schizophrenia, as can the longer term alcohol-induced psychotic disorder with delusions or hallucinations. Assertive case management techniques involve a clinician engaging with the patient in securing work or education, housing, and structured follow-up with mental health and social services.
Most addicts, irrespective of sociopathic traits, lie and cheat in order to maintain their addiction; however, if the addiction is treated and remits, so does the dishonest behavior.
Alcohol intensifies these self destructive or deceptive behaviors often leading to greater alienation between the patient and others, including therapists. AA, as a peer-led community, does not treat mental illness, but can support the alcoholic in her search for sobriety. Since alcohol exacerbates mental illness, abstinence from alcohol or use reduction significantly improves the patient’s overall level of functioning, and leads to marked, sometimes astonishing improvement. Positive symptoms include disorganized speech or behavior and psychotic characteristics such as delusions or hallucinations. Standard-treatment patients were offered access to a community mental-health center and received minimal home visits; integrated-treatment patients received home visits from an assigned assertive community-treatment team member and were offered family treatment sessions and social-skills training. This class of antipsychotics is associated with movement disorders, including extrapyramidal symptoms (EPS) and tardive dyskinesia (TD).
In addition to having an antagonistic effect on dopamine, SGAs also antagonize norepinephrine and serotonin receptors (TABLE 2). While this often is unavoidable in treatment-resistant patients, the practice may result in adverse events and limited additional efficacy. Although the studies have been small, they have shown some advantage over antipsychotic monotherapy in treating agitation in schizophrenia.
This algorithm is based on evidence when available, and expert consensus where no evidence exists. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Lieberman JA, Stroup TS, McEvoy JP, et al, for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Daily activities such as hygiene, eating, and working may be disrupted or neglected by their disorganized thought patterns.
Family relationships are improved when everyone knows how to support their loved one dealing with schizophrenia. However, people with schizophrenia have a higher death rate and higher incidence of substance abuse. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
Alcohol causes some depressive and anxiety syndromes, worsens others, always impairs sleep, and has harmful interactions with psychiatric medications. In a study of 50 alcoholics, Dorus and colleagues8 found that 66% had Beck Depression Inventory (BDI) scores of >17 within 24 hours of their last drink. Rather than waiting for depressive symptoms to resolve, clinicians should treat both alcoholism and depression simultaneously and in an integrated manner. At follow-up, Jane’s anxiety and insomnia were unchanged, despite her taking a therapeutic dosage of the SSRI. At a deeper level, the use of alcohol may function as a medication, as well as a way for the sufferer to assert control over her emotions. As always, less potentially harmful treatments are preferred initially, including supportive psychotherapy, cognitive-behavioral psychotherapy, hypnosis, and acupuncture. Psychotherapeutic methods can include group therapies with others who suffer from bipolar disorder,23 and relapse-prevention teaching.
At the clinic visit, the outpatient psychiatrist (having been briefed by the detoxification ward psychiatrist) started Bill on a medication regimen including lithium and, subsequently, the antidepressant bupropion. First psychotic breaks are difficult to diagnose and treat, and the addition of alcohol or any other mood-altering substance confuses the issue even further.
Second, alcohol use can be one of the few easy social experiences available to long-term schizophrenics with few friends and impaired social skills. Since all antipsychotics are metabolized by the liver, patients with schizophrenia may need  vigilant monitoring of their liver functioning and a dosage adjustment if they are in liver failure.
However, aggressive treatment of the AUD, can significantly ameliorate these adverse behaviors.
The individual therapy should coordinate peer-led support groups, motivational interviewing approaches, individual psychotherapy, medications, and any necessary group psychotherapy.
Although AA proscribes the use of any mind-altering substance as a substitute for alcohol, AA does not officially comment in any way on appropriate medical or psychiatric treatment, including medication usage. Medications such as benzodiazepines and barbiturates may be used in the acute phase of detoxification. However, 28% of schizophrenic subjects experienced disulfiram reactions, and there was no change in work status.
These benefits, once seen by the clinician and the patient, can be used to promote the behaviors necessary to avoid alcohol, achieve a stable abstinence, and obtain the best possible outcome for the mental illness. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment.
Substance abuse among general psychiatric patients: place of presentation, diagnosis and treatment.

Group therapy for patients with bipolar and substance dependence: results of a pilot study. A pilot open randomized trial of valproate and phenobarbital in the treatment of acute alcohol withdrawal.
The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial. Characterisitics of subgroups of individuals with psychotic illness and a comorbid substance use disorder.
Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. Treatment of persons with dual diagnoses of substance use disorder and other psychological problems, In: McCrady BS, Epstein EE, eds.
The role of self-help programs in the rehabilitation of persons with severe a mental illness and substance use disorders. Absolute neutrophil counts must be monitored weekly for 6 months when therapy is initiated or adjusted, and continuously throughout the course of therapy.1 Risperidone and paliperidone are associated with hyperprolactinemia, leading to acute adverse events such as galactorrhea (spontaneous flow of milk from nipple), amenorrhea (absence of menses), and sexual dysfunction. A randomized multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness.
Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review.
Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Reducing clozapine-related morbidity and mortality: 5 years of experience with the Clozaril National Registry.
Four-week, double-blind, placebo- and ziprasidone-controlled trial of iloperidone in patients with acute exacerbations of schizophrenia. A meta-analysis of head-to-head comparisons of second-generation antipsychotics in the treatment of schizophrenia. Randomized controlled trial of the effect on quality of life of second- and first-generation antipsychotic drugs on schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS I). Effectiveness of clozapine versus olanzapine, quetiapine, and risperidone in patients with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). The efficacy of lamotrigine in clozapine-resistant schizophrenia: a systematic review and meta-analysis. Topiramate add-on treatment in schizophrenia: a randomised, double-blind, placebo-controlled clinical trial. The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2006 update. The person usually has relatively normal intellectual functioning and expression of affect. These behaviors put these people with catatonic-type schizophrenia at high risk because they are often unable to take care of themselves or complete daily activities. When medications are taken regularly and the family is supportive, patients can have better outcomes.
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Thus, a person who drinks any amount of alcohol while receiving psychiatric treatment, especially pharmacologic treatment, should be advised to stop all use of alcohol.
For example, the cessation of drinking should be treated as an essential component of recovery from depression.
Jane informed the psychiatrist that she was a social drinker but the psychiatrist probed more and the interview revealed that Jane’s definition of a social drinker was someone who never drank alone. When asked about her use of alcohol, she became tearful and acknowledged that she had cut down for a few days, but was now drinking at about the same rate.
The Table explains the four classes of anti-anxiety medications that are appropriate for the treatment of anxiety17; their use must be considered on an individual patient basis. However, after four such admissions in a 2-week period, the director of the ER asked for a psychiatric assessment of Bill in order to determine the root cause of his recidivism. Bill and the psychiatrist agreed that they would talk again in 2 days, just prior to Bill’s scheduled discharge. Avoiding premature diagnostic closure in this scenario is even more important than with other psychiatric illnesses: the person misdiagnosed with schizophrenia because of intervening intoxicant use will face a lifetime of attempting to shed the diagnosis and receive the proper treatment.
A period of abstinence from alcohol is important in making definite diagnoses in forming a treatment plan. Since the patient is unavailable for intervention on the chararacterologic issues when alcohol is in the picture, the clinician must first focus on helping the patient abstain from alcohol. A more experienced treatment team would probe for, and if necessary, treat an underlying depression or suicidal thoughts.
However, some members may believe that psychiatric medications are unhelpful and express this during AA meetings.
The benefits shown in the study demonstrated that although disulfiram must be carefully considered for the mentally ill individual, it has a place in the pharmacopoeia. Patients in the integrated-treatment arm showed clinically significant improvement in positive and negative symptoms and substance abuse, but no improvement in depression or suicidal behavior.
Specifically, patients experiencing their first psychotic break will likely respond to much lower doses of antipsychotics and be more sensitive to adverse events than a patient in a more advanced stage of schizophrenia.21 Additionally, it should be noted that the total daily dose of most antipsychotics can be administered once daily if tolerated, and this will improve adherence. Specific psychotherapeutic modalities useful for dually diagnosed patients include relapse-prevention psychotherapy, motivational interviewing, cognitive-behavioral psychotherapy, and social skills training groups. Of course, the addicted individual may not be able to stop his or her alcohol use and may need education about the interaction between addiction and mental illness, treatment of the addictive substance use, or even inpatient treatment of the addiction. In fact, Jane shared a full bottle of wine every evening during and after dinner with her husband. For example, for the patient addicted to alcohol or another addictive substance, non-addictive medications are preferred.
They also arranged for an AA meeting that Bill could attend, escorted by another patient in the clinic who attended the same meeting. Although addicted, personality disordered patients are among the most difficult to treat, their often-astonishing gains when they become sober serve as a reward for the persistent therapist.
A special consideration for the schizophrenic patient is that disulfiram inhibits aldehyde dehydrogenase activity,39 which might cause an increase in synaptic dopamine and a worsened psychosis. Exceptions to this are clozapine, quetiapine, and ziprasidone, which probably will require multiple daily doses to control symptoms. The clinician must modify the treatment regimen on an ongoing basis to address symptoms of alcoholism or mental illness as they appear. This instructive style often involves a paradigm shift for the therapist more attuned to the mental illness alone. Patients expecting the rapid effect for a benzodiazepine will be disappointed if they are prescribed buspirone, which may account for its poor efficacy among addicted people. To his own surprise, Bill enjoyed the AA meeting and was able to engage with several AA members there. Similarly, if the treating physician believes that the patient exhibits self-destructive traits and might provoke a disulfiram reaction intentionally, the medication should not be prescribed. Finally, treatment with multiple antipsychotics should be considered a last resort and avoided if at all possible, as it often provides no additional efficacy and increases the risk of intolerable side effects.
Using research data and case examples, this article provides a model for the treatment of individuals diagnosed with mental illness and AUDs.
Rather than remain neutral or give interpersonal or instructional interpretations, the addiction treater assumes a coaching role, where direct suggestions are made and behavioral change is strongly supported and encouraged.
However, there are some cases where a potentially addictive substance such as benzodiazepine, must be used to treat an anxiety syndrome in an addicted person. These problematic scenarios are extremely rare: most mentally ill alcoholics are candidates for a discussion about disulfiram. In this circumstance, the treating clinician must carefully weigh the risk-benefit profile of the particular medication for a particular patient, and closely monitor the patient for side effects and addictive behaviors. When seen in the ER= several months later for a hand laceration, Bill reported that he was living in a shelter, going to night school classes, and following up with his psychiatric appointments and AA meetings.

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