Abstract
Use and addiction of illicit Psychoactive Substances (PAS) by people with Severe Mental Disorders (SMD) can affect diagnosis, treatment, clinical development and prognosis. This study evaluated 110 inpatients with SMD. Life use of marijuana was 38%, cocaine 27% and crack 8%. 30.9% was addicted to illicit PAS. The comorbid patients were mostly men, younger, had family history of PAS use and low adherence to treatment. SMD was present for 4 years and PAS addiction for 7 years in average; in 71% of cases, PAS addiction preceded the Mental Disorder. A better understanding and strategies to approach this cooccurrence are need.
Keywords: Comorbidity; Mental Disorder; Substance-Related Disorders
Introduction
Problems related to the use of Psychoactive Substances (PAS) represent a severe public health problem worldwide. About 250 million people use illicit drugs annually, and 11.8% use PAS in a problematic way [1]. The use by some subpopulations is particularly worrisome, especially for people with Severe Mental Disorders (SMD), who have higher rates of use than the general population and individuals with mild mental illnesses [2].
The occurrence of comorbidity can affect the diagnosis, treatment, clinical development and prognosis, leading to a greater susceptibility to clinical, social and legal problems.
This study evaluated the prevalence of use and addiction of illicit PAS among inpatients with SMD, and compared the sociodemographic and clinical profile of patients with and without this comorbidity.
Methods
Cross-sectional study, which includes all patients consecutively admitted in 2014 to the Psychiatric Unit in the University General Hospital at the State University of Campinas (PU-HC/UNICAMP), by SMD diagnosis. The Alcohol Smoking and Substance Involvement Screening Test (ASSIST) was applied to evaluate drug use, and the Mini International Neuropsychiatric Interview (MINI) was used for diagnostic confirmation. The variables evaluated were: sex, ethnicity, age, marital status, level of education, occupational situation, reason for hospitalization, adherence to treatment, number of previous hospitalization episodes and duration of hospitalization, medication used during hospitalization and family antecedents. The data was inserted in a database from the SPSS software.
To assess the relationship between the categorical variables and to compare the groups Comorbidity with Substance addiction (C) and Non-Comorbidity (NC), the Chi-square or Fisher’s Exact were used (for expected values under 5). The level of significance adopted for the statistic tests was of 5% (p ‹ 0.05).
The research was approved by the Research Ethics Committee of the State University of Campinas (protocol CAAE18644513.9.0000.5404).
Results
During the studied period, 118 patients were admitted at PUHC/ UNICAMP, 4 were excluded due to severe cognitive limitation, 2 patients evaded, and 2 patients refused to participate in the research. Among the 110 patients assessed, most were Caucasian (73.6%); almost half (46.6%) were unemployed, 34.2% were employed and 7% were retired. The main diagnoses were Schizophrenia (35.9%), Bipolar Disorder (27.1%) and Depressive Disorder (24.5%).
The rate of illicit PAS use in a lifetime was 38.3% for marijuana, 27.3% cocaine and 8.2% crack. Almost 1 in every 3 (30.9%) were addicted on some illicit drug, from which 61.7% marijuana, 14.7% cocaine, 8.8% crack and 26.4% were addicted on multiple PAS. The patients, who presented comorbidity of PAS addiction and SMD, were younger, most of them male, with low adherence to treatment and family history of PAS use. In 71.4% of cases the drug addiction preceded the SMD. The average duration of addiction was 7.2 years and of SMD was 4.1 years (Table 1).
Variable
C (n=34)
NC (n=76)
Total (n=110)
p-value
Average Age, (SD)
29,32 (14,75)
35,25 (16,65)
33,42(16,25)
0,055
Age (Median, min-max)
23,5(14,0-68,0)
31,0(8,0-74,0)
30,0(8,0-74,0)
Male
82,3%
55,2%
63,6%
0,0063
Education
Incomplete Elementary School
29,4%
37,3%
34,5%
0,446
Incomplete High School
29,4%
16%
20%
Complete High School
23,5%
26,6%
25,4%
Higher Education
17,6%
20%
19%
Marital Status
Married
11,7%
30,6%
24,5%
0,105
Divorced
17,6%
13,3%
14,5%
Single
70,5%
56%
60%
Non-adherence to treatment
70,5%
43,4
51,8%
0,008
Number of hospitalization episodes (Average, SD)
3,0(3,81)
2,3(1,9)
2,5(2,64)
0,945
Number of hospitalization episodes (Median, min-max)
1,5(1,0-20,0)
2,0(1,0-10,0)
2,0(1,0-20,0)
Duration of HC hospitalization (Average, SD)
35,8(21,36)
37,7(21,99)
36,5(20,9)
0,773
Psychiatric Medication in hospitalization (Average, SD)
4,0(1,7)
3,9(1,7)
4,0(1,7)
0,88
History of Suicide Attempt
32,3%
42,1%
39%
0,332
Family History of SUD
90,9%
60,5%
69,7%
0,001
Family History of Mental Disorder
71,8%
75%
74%
0,735
SD= Standard Deviation; Min=Minimum; Max=Maximum; SUD=Substance Use Disorder.
Table 1: Comparison between Comorbidity (C) and Non-Comorbidity patients (NC).
Discussion
Because it is an acute hospitalization Unit in a university hospital, the population was composed of severe patients, as presented by the diagnoses, hospitalization time and the average of 2.5 psychiatric admissions in a lifetime, an elevated number considering the average age of 33 years old. The patients were mainly single, with low level of education and had high unemployment rate, which suggests the impact of the severity of their Mental Disorder.
The rate of illicit drug use in a lifetime (38.3% of marijuana, 27.3% of cocaine and 8.2% of crack) was much higher than the general Brazilian population (8% marijuana, 4% cocaine and less than 1% crack) [3]. These data are bi-directionally alarming. On one hand, because of the potential contribution of PAS consumption in the emergence and aggravation of mental disorders. On the other hand, it is known that in individuals with SMD, even in small doses and casually, PAS consumption can produce worse consequences if compared with people without such disorders.
The frequency of illicit drug addiction in patients with SMD was 30.9%, similar to the rates of comorbidity detected in the international literature in studies with inpatients, with a variation of 17.7% to 35% [4], however, much higher than addiction rates among the Brazilian population. Approximately one fourth of these patients were dependent on multiple PAS and it is known that this pattern exposes them more to risks, social harm, worse adherence to treatment and suicide. The combination of a family history of PAS use and comorbidity may be related to genetic and environmental factors, which make both situations vulnerable.
Studies have pointed out to the increase in prevalence of Mood Disorders and Schizophrenia in heavy PAS users. Particularly, the association between the use of Cannabis in adolescence and the development of psychosis in the beginning of adulthood has been being consolidated [5]. In the present study, substance use preceded mental disorders for most patients, occurring with an average of 3 years before. Although the study design does not allow to establish a causality relation, it points to the need for national follow-up studies that corroborate with the associations that have been being found in international studies.
Although this research was made with severe patients, which represents a limitation in data extrapolation for populations of patients with mild mental disorders, or in other treatment contexts, the difficulty in managing this comorbidity is maintained in several care contexts.
The co-occurrence of consumption or addiction of illicit PAS in people with SMD imposes a clinical challenge to the mental health teams, who mostly receive specialized training to be able to approach unique conditions, but rarely for treatment of comorbid conditions. Brazilian health services frequently split care, neglecting the detection of psychopathologic symptoms, which tend to be credited to the use of PAS among drug addicts, and do not even detect drug consumption in people with SMD. Both situations compromise the therapeutic plan, makes pharmacological management difficult due to the risk of interactions with the PAS and brings limitations to harm reduction approaches and psychoeducation measures for the patient and their families. All these difficulties can negatively affect the prognosis and life quality of people who already deal with suffering and stigma. This scenario imposes the necessity of face the use of illicit psychoactive substances by people with severe mental disorders in a realist way, training mental health teams to approach this comorbidity and building a broad care network adapted to each patient’s necessities.
Acknowledgment
The authors would like to thank the team and the residents in the Psychiatric Unit at the University Hospital at the State University of Campinas.
References
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- Laranjeira R, Madruga CS, Pinsky I, Caetano R, Mitsuhiro SS, Caetano R, et al. II Levantamento Nacional de Álcool e Drogas (LENAD)-2012. São Paulo: Instituto Nacional de Ciência e Tecnologia para Políticas Públicas de Álcool e Outras Drogas (INPAD). UNIFESP. 2014.
- Lai HM, Sitharthan T. Exploration of the Comorbidity of Cannabis Use Disorders and Mental Health Disorders among Inpatients Presenting to All Hospitals in New South Wales, Australia. Am J Drug Alcohol Abuse. 2012; 38: 567-574.
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