Precipitation and determination of the onset and course of schizophrenia by substance abuse — a retrospective and prospective study of 232 population-based first illness episodes
Introduction
The abuse of illegal drugs, such as cannabis, amphetamines, cocaine and hallucinogens, more rarely opioids, is more frequent in persons with schizophrenia than in other mental patients or in the general population (Smith and Hucker, 1994, Mueser et al., 1992a, Kovasznay et al., 1997). According to a metaanalysis of US studies every third person diagnosed with schizophrenia has an alcohol problem (Cuffel, 1992).
The frequency of abuse as well as the type and amount of the substances abused depend on the duration of exposition, e.g. length of illness and availability of the substances of abuse in the population studied. The overall lifetime prevalence of alcohol abuse ranges from 12.3 (Alterman et al., 1981) to 42.8% (Barbee et al., 1989), that of cannabis abuse from 35 to 60% (Negrete et al., 1986). DeLisi et al. (1991) found a lifetime prevalence of 35% for drug abuse among 100 first-episode cases of schizophrenia in the State of New York. Soyka et al. (1993) found a lifetime prevalence of 21.8% for drug abuse among patients with recent-onset schizophrenia and of 42.9% among chronic patients in Bavaria/Germany. The corresponding figures for alcohol abuse were 17.4 and 34.6%, respectively. In chronic schizophrenia multiple abuse of different drugs and alcohol is wide spread (Drake et al., 1989, Rosenthal et al., 1994).
Finally, as Mueser et al., 1992a, Mueser et al., 1992b pointed out, contributing to the high variation in the rates reported are also methodological flaws frequent in the studies, such as non-uniform instruments of assessment, small sizes and lack of representativity of the samples studied.
Valid results on substance abuse in schizophrenia can only be obtained by studying sufficiently large representative samples of persons with a diagnosis of schizophrenia, by collecting precise data on the duration of both the illness and substance abuse and by comparing these cases with matched controls drawn from the same population of origin. To find out whether schizophrenia is triggered by substance abuse schizophrenia precise data on the time of onset of both the disorder and substance abuse are needed (Lieberman and Bowers, 1990, Linszen et al., 1994).
Section snippets
Materials, methods and hypotheses
The design of the present study, which consists of a retrospective and a prospective part, is shown in Fig. 1.
The retrospective part of the study relied on a population-based sample of 232 first episodes of broadly defined schizophrenia (ICD-9: 295, 297, 298.3 and 298.4) (=86% of consecutive first admissions) in age range 12–59 years from a semi-rural, semi-urban German population of about 1.5 million (Mannheim, Ludwigshafen, Heidelberg, Rhine-Neckar-District and Eastern Palatinate) (for a
Results
Of the 232 first-episode patients at first admission (mean age: 30 years) 55 had a lifetime history of alcohol abuse and 33 a lifetime history of drug abuse. That yielded a lifetime prevalence rate of 23.7% for alcohol abuse among schizophrenics, compared with 12.3% among controls, and a lifetime prevalence rate of 14.2% for drug abuse among schizophrenics compared with 7% among controls (Hambrecht and Häfner, 1996a, Hambrecht and Häfner, 1996b) and, hence, an odds ratio of 2 for both types of
Discussion
Our study confirmed that the abuse of illegal drugs — in the population studied especially of cannabis — and the abuse of alcohol, starting somewhat later, set in at a surprisingly early stage in schizophrenia. As many as 82.7% of the schizophrenic patients with a history of drug abuse and 72.7% of those with a history of alcohol abuse had taken up the habit in the initial stage of schizophrenia before the first psychiatric contact. The age of onset of schizophrenia is significantly lower for
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