Use of legal drugs by psychiatric outpatients: Benefits, costs, and change

Abstract

Caffeine, nicotine, and alcohol use by persons with a severe mental illness occurs frequently but is poorly understood. We used qualitative methods to elicit information regarding the functional relationships between legal substance use and its antecedents and consequences. This report summarizes responses provided by 37 psychiatric outpatients who participated in focus groups and key informant interviews regarding the use and functions of alcohol, caffeine, and nicotine. We describe major themes regarding positive and negative consequences, triggers for use, change efforts, and offer observations regarding substance use in this under-served population. Licit Substance Use Among Psychiatric Outpatients: A Qualitative AnalysisCaffeine, nicotine, and alcohol are used extensively by persons with severe mental illnesses (SMI), often at rates that far exceed rates found in the general population. Test, Wallisch, Allness, and Ripp (1989) reported that 86% of their patients with schizophrenia drank coffee, averaging 6 cups per day; this quantity has been associated with caffeine withdrawal and related disorders (American Psychiatric Association, 1994). In contrast, only 9% of the general population consumes as much caffeine (Greden, Fontaine, Lubetsky, & Chamberlain, 1978). Excessive caffeine use can have deleterious effects on mental status, increasing anxiety and depression (Greden et al., 1978;Winstead, 1976), and exacerbating psychotic symptoms in persons with schizophrenia (Carey & Carey, 1989;Mikkelsen, 1978).As many as three-quarters of patients with schizophrenia smoke (Goff, Henderson, & Amico, 1992;Ziedonis, Kosten, Glazer, & Frances, 1994) compared to one-quarter of the general population. In addition to the established risks for cancer and heart disease, additional deleterious effects may accrue for smokers receiving psychiatric treatment. Cigarette smoking increases hepatic enzyme action, hastening the elimination of drugs that depend on hepatic metabolism, thereby reducing plasma concentration of some therapeutic drugs (Perry, Miller, Arndt, Smith, & Holman, 1993). Persons with schizophrenia who smoke have also received higher ratings of positive symptoms (Goff et al., 1992;Ziedonis et al., 1994). Although cause and effect relationships are not clear, nicotine may exacerbate psychotic symptoms and reduce the effectiveness of antipsychotic medications.Alcohol use by the SMI is also common. Among persons diagnosed with schizophrenia, onethird meet criteria for an alcohol use disorder, representing an odds ratio of 3.3. Similar odds ratios for alcohol use disorder range from 1.9 among persons with mood disorders (22%) to 1.5 for persons with anxiety disorders (18%; Mueser, Bellack, & Blanchard, 1992 Drake, Osher, & Wallach, 1989), exacerbation of delusions and hallucinations (Noordsy et al., 1991) and depressive symptoms (Cuffel & Chase, 1994). Larger studies have also confirmed that comorbid alcohol abuse increases the likelihood of violent behavior (Swanson, 1993) among persons with a SMI.Drinking ...

“Clozapine makes me quite drowsy, so when I wake up in the morning those first cups of coffee are really handy”: an exploratory qualitative study of excessive caffeine consumption among individuals with schizophrenia

“…Overall, participants’ decision making around caffeine consumption (based on the risk of harm and perceived social desirability) appears similar to the hypotheses for these behaviours offered by previous studies [2,9]. These studies suggest that individuals with a mental illness largely consume caffeine to self-medicate and reduce side effects of medication.…”

“…Participants from both studies identified ‘increased alertness’ and ‘taste’ as a factor that influenced their caffeine consumption. Significantly more participants from the current study than the study by Carey et al [2] identified cravings (expressed as needing or wanting caffeine) as a motivating factor for consumption. It is unknown whether these motivations are consistent with those of the general population, as we were unable to identify any qualitative studies that have explored these factors among community samples.…”

“…While no direct measures of abuse/dependence were administered among interview participants, the average caffeine consumption of coffee drinkers within the sample was 523 mg per day (which is considered a ‘significant health risk’ [2,3]), and half of participants reported feeling that they had minimal control over their caffeine consumption, with some indicating an inability to live without caffeine. For example:…”

Reasons for substance use among people with psychotic disorders: Method triangulation approach.

“…They also found that drinking alcohol for social reasons, such as social facilitation, was important for people with psychiatric disorders, and that nicotine was primarily used to help with negative affect (Carey et al, 1999b).…”

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“…For example, research indicates that individuals diagnosed with schizophrenia are more likely to misuse alcohol and six times more likely to use street drugs [6,7]. While the exact reason for these findings remains unknown, it has been established that the use of socially acceptable legal drugs such as caffeine, nicotine, and alcohol can contribute to the development of mental illness [8].…”