Addressing the Bidirectional Impact of Schizophrenia and Substance Use Disorders

Joshua Kaufman, MD, medical director of Behavioral Health and Medical Integration at Capital District Physicians' Health Plan, explained the bidirectional relationship between schizophrenia and substance use disorders in an interview with The American Journal of Managed Care®. As an expert with board certification in general, adult, and addiction psychiatry, Kaufman delved into some of the challenges that can arise when treating patients with chronic psychotic symptoms that intersect with substance use.

These conditions are highly comorbid, with prevalence rates of comorbidity reaching as high as 80%, particularly with substances like tobacco, alcohol, and cannabis. Patients with schizophrenia may use substances to alleviate psychotic symptoms or cope with medication side effects, such as those from antipsychotics, which can have significant motor and metabolic effects, he explained. Conversely, substance use exacerbates symptoms of schizophrenia, complicates treatment adherence, and increases the risk of medical comorbidities like cardiovascular disease and diabetes.

"Aside from worsening symptoms, [substance use] can also increase the risk of nonadherence, either to treatment or to medications, because if patients are intoxicated throughout the day, or significantly intoxicated, this can impede their ability to attend treatment, including taking medications," Kaufman said in the interview. And then, I think one point I definitely want to mention is also the implication that both schizophrenia and substance use disorders increase the risk of developing medical comorbidities."

Treatment challenges arise from low medication adherence, limited access to specialized care addressing both disorders simultaneously, and frequent hospital admissions for acute episodes or detoxification. Historically, treatment approaches have been siloed, forcing patients to prioritize one disorder over the other due to provider expertise limitations or resource constraints in dual-focused care facilities. This approach has contributed to high rates of relapse, mortality, and health care costs associated with managing these complex conditions, he explained.

"At the intersection, as well, having these comorbid conditions increases the risk of relapse or substance use disorders, for reasons I mentioned before," Kaufman said. "And then, just in general, data has shown that having comorbid schizophrenia and substance use disorder increases the risk of mortality relative to having just one of the disorders, which is obviously very, very important because this is leading to deaths that are earlier in life than would otherwise happen."

Kaufman emphasized the need for integrated treatment models that address both schizophrenia and substance use disorders comprehensively, explaining that these models could benefit from value-based payment systems that incentivize providers to deliver more holistic care, potentially improving outcomes and reducing the economic burden associated with these intertwined health challenges.