DÄ internationalArchive41/2015Effective and Neurobiologically Sound
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Integrated treatment in comorbid schizophrenic psychosis and addiction disorders strengthens patients’ motivation to remain abstinent and their satisfaction with the treatment, and reduces their consumption behavior in the short term. This is the conclusion of a randomized clinical study reported by Gouzoulis-Mayfrank and colleagues in this issue of Deutsches Ärzteblatt International (1).

The study is of particular importance because psychiatric therapeutic research is still far too often oriented towards individual cases of single-diagnosis functional impairments, which is clinically neater but rare in practice. In reality, about half of all patients who develop psychosis also experience a comorbid addition disorder—mostly tobacco or alcohol dependence—at least once in their lives (2). This large group of patients with a dual diagnosis presents a great challenge to conventional psychiatric or addiction-therapeutic services because of the multiple interactions between symptoms (3, 4).

Psychosis and comorbid alcohol dependence

Evidence from international studies shows that the occurrence of alcohol problems in patients with schizophrenic psychosis is associated with a relatively poorer treatment outcome and rather tends to take a chronic course (5, 6). Neurobiologically this is plausible: according to the multidimensional approach to neurobiological psychiatric research that is the subject of current discussion (7), there are indications that people with alcohol addiction and patients with schizophrenic psychosis have reduced neuronal activation in the so-called reward circuit (ventral striatum) when confronted with environmental stimuli that predict a reward at a later time (8).

These changes in the expectation of being rewarded, which are different in terms of detail, can be intensified in a setting of comorbid addiction disorder and schizophrenic psychosis and can result in even more pronounced impairments of a person’s emotional state (9).

In routine clinical practice it is important to know that in persons with alcohol dependence, reduced dopaminergic function occurs after detoxification, which is apparently made worse by administration of neuroleptic drugs, which makes such patients more prone to relapse (10). Unfortunately, detailed studies of the adverse effects of neuroleptic treatment in patients with combined psychosis and alcohol dependence are lacking. The available studies were conducted in alcohol-dependent persons without psychotic comorbidity and indicate that the medication that is given as standard treatment for schizophrenic psychosis may have a negative effect on the course of the addiction disorder (9, 10).

Consumption of cannabis and stimulants in psychotic disorders

An additional common comorbid dependence in persons with psychoses relates to cannabis consumption and, more rarely, stimulants (6), which was also observed in the present study. The interactions between psychotic symptoms and cannabis consumption are extraordinarily complex (3): on the one hand, productive psychotic symptoms can exacerbate after cannabis consumption, but, on the other hand, patients have occasionally described favorable effects on negative symptoms, such as anhedonia (11).

Such effects have implications for patients’ adherence to treatment, their motivation to remain abstinent, and their quality of life. Special problems arise for treatment planning, which may be countered by an easy-access integrated treatment approach, which the Gouzoulis-Mayfrank working group developed years ago, and which includes psychoeducational and behavioral therapeutic elements (3).

As this approach was established in a general psychiatric hospital, it can easily be transferred and implemented into routine clinical practice in other hospitals.

Follow-up care is important, however, as the most important therapeutic effect of the intervention is a reduction in consumption behaviors, which in the present study was observed after 3 months, but not after 6 and 12 months. Because of the complex symptoms, this was rather what was to be expected.

Establishing person-centered integrated treatments

As the authors rightly point out, their precedent-setting study militates against the widespread therapeutic nihilism and supports the idea of setting up person-centered integrated treatment programs with psychosocial and psychotherapeutic elements, which take the complex impairment patterns of our patients seriously and treat them accordingly.

Mutual interactions between psychosis and comorbid addiction

The study by Gouzoulis-Mayfrank and colleagues (1) illustrates the difficulties in dealing with patients with psychosis and comorbid addiction. However, the results give no reason to succumb to fatalism: although doctors and patients should not set their hopes too high, something can be done—for example, by applying manual-based treatment, such as used by Gouzoulis-Mayfrank et al.

The most important step is to recognize the dual burden on the patients and to not see one disorder as a secondary outcome of the other. The crucial approach is to understand the coexistence of the two disorders and their resulting mutual interactions as an independent problem.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Corresponding auhtor
Prof. Dr. med. Dr. phil. Andreas Heinz
Klinik für Psychiatrie u. Psychotherapie
Charité – Universitätsmedizin Berlin
Campus Mitte (CCM)
Charitéplatz 1
10117 Berlin, Germany
andreas.heinz@charite.de

Cite this as:
Heinz A, Majić T: Effective and neurobiologically sound: integrative therapy in patients with psychosis and addiction. Dtsch Arztebl Int 2015; 112: 681–2.
DOI: 10.3238/arztebl.2015.0681

1.
Gouzoulis-Mayfrank E, König S, Koebke S, Schnell T, Schmitz-Buhl M, Daumann J: Trans-sector integrated treatment in psychosis and addiction—a randomized controlled study of a motivational, cognitive behavioral therapy program under standard hospital treatment conditions. Dtsch Arztebl Int 2015; 112: 683–91 VOLLTEXT
2.
Regier DA, Farmer ME, Rae DS, et al.: Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264: 2511–8 CrossRef CrossRef MEDLINE
3.
Gouzoulis-Mayfrank E: Komorbidität Psychose und Sucht: Grundlagen und Praxis; Mit Manualen für die Psychoedukation und Verhaltenstherapie. Berlin, Heidelberg, New York: Springer 2007.
4.
Chambers RA, Krystal JH, Self DW: A neurobiological basis for substance abuse comorbidity in schizophrenia. Biol Psychiatry 2001; 50: 71–83 CrossRef
5.
Dixon L: Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res 1999; 35: 93–100 CrossRef
6.
Mueser KT, Yarnold PR, Rosenberg SD, Swett C Jr, Miles KM, Hill D: Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull 2000; 26: 179–92 CrossRef
7.
Insel T, Cuthbert B, Garvey M, et al.: Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010; 167: 748–51 CrossRef MEDLINE
8.
Hägele C, Schlagenhauf F, Rapp M, et al.: Dimensional psychiatry: reward dysfunction and depressive mood across psychiatric disorders. Psychopharmacology (Berl.) 2015: 232: 331–41 CrossRef MEDLINE PubMed Central
9.
Heinz A: Dopaminergic dysfunction in alcoholism and schizophrenia-psychopathological and behavioral correlates. Eur Psychiatry 2002; 17: 9–16 CrossRef
10.
Wiesbeck GA, Weijers HG, Lesch OM, Glaser T, Toennes PJ, Boening J: Flupenthixol decanoate and relapse prevention in alcoholics: results from a placebo-controlled study. Alcohol Alcohol 2001; 36: 329–34 CrossRef
11.
Gill KE, Poe L, Azimov N, et al.: Reasons for cannabis use among youths at ultra high risk for psychosis. Early Interv Psychiatry 2015; 9: 207–10 CrossRef MEDLINE
Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, Campus Mitte: Prof. Dr. med. Dr. phil. Heinz
Psychiatric University Hospital Charité at St. Hedwig Hospital, Berlin: Dr. med. Majić
1.Gouzoulis-Mayfrank E, König S, Koebke S, Schnell T, Schmitz-Buhl M, Daumann J: Trans-sector integrated treatment in psychosis and addiction—a randomized controlled study of a motivational, cognitive behavioral therapy program under standard hospital treatment conditions. Dtsch Arztebl Int 2015; 112: 683–91 VOLLTEXT
2.Regier DA, Farmer ME, Rae DS, et al.: Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264: 2511–8 CrossRef CrossRef MEDLINE
3. Gouzoulis-Mayfrank E: Komorbidität Psychose und Sucht: Grundlagen und Praxis; Mit Manualen für die Psychoedukation und Verhaltenstherapie. Berlin, Heidelberg, New York: Springer 2007.
4.Chambers RA, Krystal JH, Self DW: A neurobiological basis for substance abuse comorbidity in schizophrenia. Biol Psychiatry 2001; 50: 71–83 CrossRef
5.Dixon L: Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res 1999; 35: 93–100 CrossRef
6.Mueser KT, Yarnold PR, Rosenberg SD, Swett C Jr, Miles KM, Hill D: Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull 2000; 26: 179–92 CrossRef
7.Insel T, Cuthbert B, Garvey M, et al.: Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010; 167: 748–51 CrossRef MEDLINE
8.Hägele C, Schlagenhauf F, Rapp M, et al.: Dimensional psychiatry: reward dysfunction and depressive mood across psychiatric disorders. Psychopharmacology (Berl.) 2015: 232: 331–41 CrossRef MEDLINE PubMed Central
9.Heinz A: Dopaminergic dysfunction in alcoholism and schizophrenia-psychopathological and behavioral correlates. Eur Psychiatry 2002; 17: 9–16 CrossRef
10.Wiesbeck GA, Weijers HG, Lesch OM, Glaser T, Toennes PJ, Boening J: Flupenthixol decanoate and relapse prevention in alcoholics: results from a placebo-controlled study. Alcohol Alcohol 2001; 36: 329–34 CrossRef
11.Gill KE, Poe L, Azimov N, et al.: Reasons for cannabis use among youths at ultra high risk for psychosis. Early Interv Psychiatry 2015; 9: 207–10 CrossRef MEDLINE