Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia.

OBJECTIVE: Schizophrenic patients have high rates of cigarette smoking. The authors compared the outcomes of two group psychotherapy programs for smoking cessation in patients with schizophrenia or schizoaffective disorder who were also treated with the nicotine transdermal patch and with either atypical or typical antipsychotic medications. METHOD: Forty-five subjects were randomly assigned to 1) the group therapy program of the American Lung Association (N=17) or 2) a specialized group therapy program for smokers with schizophrenia (N=28) that emphasized motivational enhancement, relapse prevention, social skills training, and psychoeducation. All subjects participated in 10 weeks of treatment with the nicotine transdermal patch (21 mg/day) and 10 weekly group therapy sessions and continued to receive their prestudy atypical (N=18) or typical (N=27) antipsychotic medications. Outcome variables included treatment retention, rate of smoking abstinence, and expired-breath carbon monoxide level. RESULTS: Smoking abstinence rates did not differ in the two group therapy programs. However, atypical antipsychotic agents, in combination with the nicotine transdermal patch, significantly enhanced the rate of smoking cessation (55.6% in the atypical agent group versus 22.2% in the typical group), which was reflected by a significant effect of atypical versus typical agents on carbon monoxide levels. Risperidone and olanzapine were associated with the highest quit rates. CONCLUSIONS: The results suggest that 1) smoking cessation rates with the nicotine transdermal patch are modest in schizophrenia, 2) specialized group therapy for schizophrenic patients is not significantly different from American Lung Association group therapy in its effect on smoking cessation, and 3) atypical agents may be superior to typical agents in combination with the nicotine transdermal patch for smoking cessation in schizophrenia.

Characteristics of participants and nonparticipants in medication trials for treatment of schizophrenia.

OBJECTIVE: The study compared the characteristics of patients who participated in efficacy trials of medications for treatment of schizophrenia with those of the other patients in the clinical population from which the trial participants had been selected. METHODS: Study participants from ten trials of treatment efficacy conducted at a community mental health center in the early and mid-1990s were compared with nonparticipants using data on demographic and diagnostic characteristics and service utilization from the center's administrative database. Six of the trials selected patients with schizophrenia and no concurrent substance use disorder, and four selected patients with dual diagnoses of schizophrenia and a substance use disorder. RESULTS: Compared with nonparticipants, participants in both types of trial were about six to eight years younger, were two to four times less likely to have ever married, and used more services. Participants in trials that selected patients with no substance use disorder were more likely to be high school graduates and were four times more likely to work full time, compared with nonparticipants. Participants in trials that selected patients with dual diagnoses were likely to be minorities and less likely to have medical comorbidities, compared with nonparticipants. CONCLUSIONS: Participants in treatment efficacy trials differed substantially from nonparticipants. Some characteristics of the trial participants, including reduced likelihood of ever having been married and male gender, have been associated with poorer treatment outcomes in earlier studies. Other characteristics, such as younger age and greater likelihood of having graduated from high school and of working full time, have been associated with better outcomes.

Substance abuse and schizophrenia: editors' introduction.

Most individuals with schizophrenia have problems with abuse of substances ranging from licit substances, such as nicotine, to illicit ones, such as cocaine. This comorbidity may reflect self-medication, as well as a biological susceptibility to both disorders. Twin studies have suggested that this biological susceptibility may involve genetic factors. Other biological risk factors may involve the medications used to treat schizophrenia, which may produce symptoms that provoke abuse of drugs to relieve negative symptoms or may even enhance the euphoric response to abused drugs. The articles in this issue address several research areas related to substance abuse and schizophrenia, including the differential diagnosis of schizophrenia and organic disorders induced by substance abuse and the impact of substance abuse on the course of early schizophrenia. The management of substance-abusing schizophrenia patients requires a careful balance of pharmacotherapy and psychotherapies, and atypical antipsychotic agents may be particularly helpful. Psychotherapy needs to focus both on the management of affect and on the adequate monitoring of drug abstinence.

Motivation to quit using substances among individuals with schizophrenia: implications for a motivation-based treatment model.

Although the motivation to quit using substances is an important prognostic and treatment-matching factor in substance abuse treatment, there is limited information on motivation to quit among individuals with schizophrenia. This study used the five-stages-of-change model to evaluate the motivational levels of 497 individuals with schizophrenia or schizoaffective disorder in an outpatient mental health clinic. Rates of substance abuse, motivation levels to quit each specific substance, and correlates to motivational levels were evaluated. At least one substance use disorder was diagnosed in 224 of the subjects (45%); however, there was significant variability among the caseloads of the outpatient division teams. The patients in the triage/acute services and community outreach teams had substance abuse rates of about 70 percent. Most subjects had low motivation to quit substances, and the rates varied according to substance (range of 41% for opiates to 60% for cocaine). Treatment-matching strategies are suggested in the motivation-based treatment model.

Schizophrenia and nicotine use: report of a pilot smoking cessation program and review of neurobiological and clinical issues.

Nicotine use is a major public health problem that increases medical morbidity and mortality. Nicotine's action and the pathobiology of schizophrenic disorders have common neurobiological substrates. Tobacco smoking alters medication blood levels and effectiveness, modifies psychiatric symptoms, and is a clue for other substance abuse. This article presents an evaluation of a smoking cessation program for 24 smokers with schizophrenia. Fifty percent completed the program, 40 percent decreased use by 50 percent, and 13 percent remained abstinent (carbon monoxide verified) for 6 months. Nicotine replacement, motivational enhancement therapy, and relapse prevention behavioral therapy were important components of treatment. Pharmacotherapy strategies of a higher-dose nicotine patch, combining nicotine gum and a patch, and augmentation medication to nicotine replacement should be evaluated in future studies in this population.

Effects of clozapine on smoking in chronic schizophrenic outpatients.

BACKGROUND: The effects of clozapine administration on smoking were examined in chronic schizophrenic outpatients. METHOD: Twenty-nine of 30 schizophrenic outpatients enrolled in a university-affiliated Community Mental Health Center clozapine clinic were retrospectively surveyed by semistructured questionnaire regarding smoking before and after clozapine administration. RESULTS: Smokers comprised 62% (N = 18) of patients, and within this group, there was a significant decrease in reported daily cigarette use during clozapine treatment compared with level of use when patients had been treated with typical neuroleptics (1.67 +/- 1.13 vs. 1.26 +/- 0.72 packs/day, p = .025). CONCLUSION: Clozapine may alter smoking behaviors in chronic schizophrenics.

Psychiatric comorbidity in white and African-American cocaine addicts seeking substance abuse treatment.

OBJECTIVE: Few diagnostic studies have reported rates of psychiatric comorbidity among cocaine addicts according to race. This study examines psychiatric comorbidity in African-American and white cocaine addicts. METHODS: Rates of psychiatric comorbidity were assessed in 263 cocaine addicts seeking substance abuse treatment. The sample included 163 non-Hispanic whites and 100 African Americans. Diagnoses were based on patient interviews using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L). The SADS-L was supplemented to include DSM-III-R criteria for substance abuse or dependence and other psychiatric diagnoses and DSM-III criteria for attention deficit disorder. RESULTS: Overall, 55.7 percent of the cocaine addicts met Research Diagnostic Criteria for a current psychiatric diagnosis, and 73.5 percent met criteria for a lifetime psychiatric diagnosis. Whites and African Americans did not differ significantly in overall psychiatric comorbidity. However, whites had significantly higher rates of life-time major depression, alcohol dependence, attention deficit disorder, and conduct disorder. African-American addicts, particularly women, were more likely to meet criteria for a current diagnosis of phobia. CONCLUSIONS: Psychiatric comorbidity is common among cocaine addicts, and the rates for specific disorders vary by race. Differences in current and lifetime rates should be noted. Cocaine addicts seeking treatment should be assessed for comorbid alcohol dependence and other psychiatric disorders, including anxiety, affective, and personality disorders.

Interactive teaching, medical students, and substance abuse : university and community come together in a new endeavor.

The authors present an innovative approach for providing freshman and sophomore medical students with their initial exposure to the problems of alcohol and other drug abuse. Students in small interactive group seminars teach each other about the major areas of substance abuse: treatment, prevention/education, research, and law enforcement. They are aided by group moderators, by resource professionals, and by recovery teachers as they make field trips, attend 12-step meetings, and get background material. They utilize audiovisuals, role-plays, and programmed patients in a report/debate format. Effects of this seminar on their attitudes have been measured and are presented.

Pharmacotherapy improves treatment outcome in depressed cocaine addicts.

Depression is the most common psychiatric disorder in substance abusers, and results in a poorer prognosis and response to traditional chemical dependence and mental health treatment approaches. This article focuses on the use of pharmacotherapy in the treatment of the cocaine addict with secondary depression and provides general clinical treatment guidelines. It also reports on a study in which depressed, methadone-maintained cocaine addicts were treated in a 12-week placebo-controlled trial that compared two pharmacological agents. Patients were randomly assigned to receive placebo, amantadine (a dopamine agonist) or desipramine (a tricyclic antidepressant). The effects of pharmacotherapy were assessed on program retention, cocaine craving, cocaine usage, and depressed mood. Compared to the placebo-treated patients, it was found that the medication-treated depressed patients had a dramatic decrease in their reported cocaine usage (84% versus 17%) and cocaine craving (48% decrease versus 29% increase). Also, the medication-treated depressed patients dramatically increased the percentage of cocaine-free urines compared to the placebo-treated depressed patients who actually decreased their percentage of cocaine-free urines. A measure of depressive symptoms (Beck Depression Index score) increased 100% for the placebo-treated depressed patients, yet remained stable for the medication-treated depressed patients.

Depression as a prognostic factor for pharmacological treatment of cocaine dependence.

Pharmacotherapy response in depressed (n = 20) vs. nondepressed (n = 74) cocaine-abusing methadone maintenance patients was compared in a 12-week, randomized, double-blind trial using amantadine at 300 mg daily (n = 33), desipramine at 150 mg daily (n = 30), and placebo (n = 31). Starting in Week 3, the depressed patients on medications reported significantly less cocaine usage than the depressed patients who received placebo. By Week 10, the medicated depressed patients (in treatment) reported a 96 percent decrease in cocaine usage and a 68 percent decrease in cocaine craving. During the last 2 weeks of treatment, 42 percent of the urine toxicologies of the medicated depressed patients were cocaine free, compared with only 6 percent of the placebo depressed patients. Also, the placebo nondepressed patients had significantly better treatment outcome compared with the placebo depressed patients. Thus, depression appears to be an important predictor of poor treatment outcome with relapse prevention therapy alone and of good response to cocaine abuse treatment with medication.

Blood flow and functional responses correlate in the ovine neural lobe.

Regional neurohypophyseal and cerebral blood flow were measured in 5 awake unstressed female sheep with radiolabelled microspheres before and after the intracarotid infusion of a 3% NaCl solution. Plasma arginine vasopressin (AVP) levels were concurrently measured by radioimmunoassay. Following intracarotid sodium chloride infusion, neural lobe (but not median eminence) blood flow significantly increased, as did plasma AVP levels. Directed thirst and water-seeking behavior was observed, accompanied by a global increase in cortical blood flow. We conclude that the neuroendocrine response and the behavioral display induced by intracarotid sodium chloride infusion are accompanied by increases in blood flow in selected brain regions.

Choroid plexus blood flow: evidence for dopaminergic influence.

Choroid plexus blood flow was measured in adult female sheep using the radioactive microsphere technique. The response of choroid plexus, renal and cortical blood flow to the infusion of dopamine (11 sheep), haloperidol (7 sheep) and propranolol (6 sheep) were compared. Choroid plexus and renal blood flow significantly increased after dopamine infusion (55% and 49% respectively). Choroid plexus and renal blood flow decreased significantly following haloperidol infusion (-24% and 29% respectively). Cortical blood flow did not significantly change. Propranolol infusion did not significantly change blood flow in these regions. These observations suggest that dopaminergic mechanisms play a role in the regulation of choroid plexus as well as renal blood flow.