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Comorbid substance use disorder is common in patients Sendreprintrequeststo Dr. R. Drake, Psychiatric Research Or., 2 Whipple
with schizophrenia (Regier et al. 1990) and is associated Race, Lebanon, NH 03766; email: RobatE.Drake@Daitinouthxdu.
441
Schizophrenia Bulletin, Vol. 26, No. 2, 2000 R.E. Drake et al.
history of comorbid substance use disorder (only seven two-thirds (66.2%) of those with drug use disorder also had
had a current disorder) improved on clozapine as much as current alcohol use disorder.
those without substance abuse comorbidity. On the basis
of the low rate of substance abuse observed during cloza- Treatments. All participants in the study received treat-
pine therapy and a small number of retrospective inter- ments in dual-disorder programs in the seven participating
views, they speculated that clozapine may have reduced mental health centers. The interventions included medica-
cravings. Finally, in a recent, retrospective survey, tion management, case management, and rehabilitation
Zimmet et al. (2000) reported that among 36 patients with
442
Effects of Clozapine on Alcohol and Drug Use Disorders Schizophrenia Bulletin, Vol. 26, No. 2,2000
Tune-Line Follow-Back (TLFB; Sobell et al. 1980) and Procedures. Patients were referred by clinicians, families,
the alcohol and drug use sections from the Addiction or themselves between 1989 and 1992. They were evalu-
Severity Index (ASI; McLellan et al. 1980); (2) urine drug ated for study criteria by reviews of clinical records and
toxicology screens in our laboratory using Enzyme research interviews with the SCID. All participants gave
Multiplied Immunoassay Technique (EMIT, from Syva- written informed consent. They were assessed for sub-
Behring); and (3) clinician ratings using the Alcohol Use stance use and psychiatric symptoms through independent
Scale (AUS), the Drug Use Scale (DUS), and the research interviews, clinician ratings, and laboratory tests
Substance Abuse Treatment Scale (SATS). The TLFB
443
Schizophrenia Bulletin, Vol. 26, No. 2, 2000 R.E. Drake et al.
tinued clozapine because of side effects before the last fol- average scores while not taking clozapine, using paired t
lowup interview. Of the four who discontinued clozapine, tests. These analyses excluded patients who were taking
three were on the medication for less than 1 month. clozapine throughout their 3 years in the study because
To examine baseline differences, we compared the 29 they had no off-clozapine scores. Table 1 shows that
patients who began clozapine after entering the study and patients significantly improved while taking clozapine in
continued on the medication to the end of the study with terms of stage of substance abuse treatment, severity of
the 118 patients who had either no exposure to clozapine alcohol abuse, severity of drug abuse, and days of alcohol
(n = 115) or only brief exposure (n - 3). The two groups use, but not days of drug use.
Within-Group Analysis. To conduct a within-group Between-Group Analysis. Since most of the patients in
analysis of patients who took clozapine, we compared the within-group analysis began taking clozapine during
their average scores while taking clozapine with their the middle of the study and remained on clozapine at the
Table 1. Within-group comparison of patients' substance abuse while taking and while not taking
clozapine
Variable n1 Off clozapine2 On clozapine3 t P
Stage of substance abuse
treatment4 34 4.0411.25 5.3511.41 5.14 0.0001
444
Effects of Clozapine on Alcohol and Drug Use Disorders Schizophrenia Bulletin, Vol. 26, No. 2, 2000
Figure 1. Mean number of days of alcohol consumption during consecutive 6-month periods before
and after starting clozapine
60
to
Assessmant Point 1
jfl°14|
t+1
|n'10|
t+2 t+3
All patients had alcohol use disorder at study entry, t refers to the 6-month period in which each person started on clozapine. t-1 refers
to the 6-month period prior to to, and t=1 refers to the 6-month period after to.
3-year followup, their improvement could be related to Another measure of the effectiveness of clozapine is
maturation or substance abuse counseling. To examine the proportion of patients with active disorder at baseline
this possibility, we compared all patients taking clozapine who attain remission (AUS or DUS score < 3) after start-
with those not on clozapine during each interval, using ing clozapine. Among the 105 patients with alcohol use
mixed-effects analyses with clozapine status as a time- disorder, 79.0 percent of the 19 patients taking clozapine
varying independent variable. We included as a covariate at the end of the study were in remission, compared with
baseline the patient's SATS score, which was the only sig- only 33.7 percent of the 86 patients not on clozapine (x2 =
nificant covariate among our baseline variables. 13.07, df = l,p = 0.001). Remission of alcohol use disor-
Clozapine use produced a significant main effect on der was related neither to the alcohol abuse versus depen-
all five outcomes: improved stage of substance abuse dence distinction nor to the presence of comorbid drug
treatment (F = 8.89, df = 1,147, p = 0.003), decreased use disorder. Among the 65 patients with drug use disor-
severity of alcohol abuse (F = 8.68, df = 1,104, p - der, 63.6 percent of the 11 patients taking clozapine
0.004), decreased days of alcohol use (F = 14.42, df = attained remission of the drug use disorder, whereas only
1,104, p = 0.0002), decreased severity of drug abuse (F = 29.6 percent of the 54 patients not taking clozapine were
16.83, df= 1,64, p - 0.0001), and decreased days of drug in remission at the end of the study (x 2 = 4.62, df = \,p =
use (F = 14.35, df=\,(A,p = 0.0003). Time effects were 0.032).
also significant for each variable. T tests for group differ-
ences at each assessment point were generally significant Relationships Between Changes in Alcohol Use and
whenever there were sufficient numbers of patients on Symptoms. Because the relationship between clozapine
clozapine. The specific pattern of mean differences for use and reductions in alcohol use could be related to the
days of alcohol use is depicted in figure 2, which indicates well-documented effects of clozapine on positive or nega-
again a stable reduction related to clozapine. Figure 2 also tive psychotic symptoms, we examined the covariation of
reveals little improvement for patients who did not take overall changes in BPRS thought disorder and BPRS
clozapine. Neither main effects for case management anergia factor scores with reductions in alcohol use.
group assignment nor interactions between group assign- Patients who began clozapine during the study experi-
ment and clozapine use were significant enced nonsignificant reductions in symptoms of thought
445
Schizophrenia Bulletin, Vol. 26, No. 2, 2000 R.E. Drake et al.
Figure 2. Mean number of days of alcohol consumption in the past 6 months for clozaplne users
and nonusers1
90
n = 105
80
a
r
- |
•
A
•L. |
£ 50 ' n = 9 6 "•"
n =93
Jt
• clozaplne
O 40 • no ctoz
1I 11
o
o
j\ = 17J
< 30
n = 1
10
baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.
1
The study group includes patients with schizophrenia/schizoaffective disorder and alcohol use disorder at baseline (n = 105). Group
sizes at each assessment point are indicated above each bar.
disorder and anergia as a group mean (see table 1). in a dual-disorder treatment program cannot be deter-
Reductions in the severity of alcohol abuse were not sig- mined from our data. However, Zimmet et al. (2000) have
nificantly correlated with reductions in symptoms of reported similar rates of improvement of substance use
thought disorder (r = 0.005, n = 29, ns), but decreased disorder in relation to clozapine use in a different treat-
alcohol severity was strongly correlated with decreases in ment setting that did not emphasize dual-disorder treat-
symptoms of anergia (r = 0.52, n = 32, p = 0.002). ment Moreover, our data reveal little reduction of alcohol
use among the nonclozapine patients, suggesting that
clozapine may have been more effective than the psy-
Discussion chosocial interventions.
The findings reported here were not based on a ran-
Among this group of patients with schizophrenia or domized clinical trial design. Although causal inferences
schizoaffective disorder and co-occurring current sub- should be cautious, our data offer much stronger evidence
stance use disorder, clozapine use was strongly related to than previous case reports and a single retrospective sur-
progress in substance abuse treatment, decreased severity vey for the effects of clozapine on psychoactive substance
of alcohol abuse, decreased days of alcohol use, and use because of the large study group, the use of a compar-
remission of alcohol use disorders. The findings related to ison group that received similar psychosocial interven-
other drugs (primarily cannabis) were similar but less tions, and the prospective, independent, multimodal
consistent and were based on a small number of patients. assessments of substance use. Nevertheless, changes in
All of these patients were participating in dual-disor- substance abuse could have been related to readiness for
der treatment programs that combined psychosocial inter- change when starting clozapine or some other underlying
ventions for mental illness and substance abuse, and the factor. We are currently beginning studies employing a
overall group improved significantly during the 3 years of prospective design with random assignment to clozapine
the study. In this context of active dual-disorder treatment treatment to confirm the findings reported here.
and high rates of remission, those patients who began tak- If clozapine is truly more effective than typical neu-
ing clozapine clearly made greater progress in substance roleptics in reducing substance use disorder in patients
abuse treatment than other patients. Whether or not these with schizophrenia and schizoaffective disorder, the find-
patients would have improved without also participating ing may have important theoretical and clinical implica-
446
Effects of Clozapine on Alcohol and Drug Use Disorders Schizophrenia Bulletin, Vol. 26, No. 2, 2000
tions. From a theoretical perspective, the beneficial effects tients with severe mental illness. Psychological
of clozapine on alcohol use disorder in conjunction with Assessment, 9:422-428, 1997.
reductions in anergia symptoms suggest that clozapine Carey, K.B.; Cocco, K.M.; and Simons, J.S. Concurrent
might have a different effect on the brain reward system validity of clinicians' ratings of substance abuse among
than typical antipsychotic drugs (Green et al. 1999). psychiatric outpatients. Psychiatric Services, 47:842-847,
Clozapine has been demonstrated to improve negative as 1996.
well as positive symptoms of schizophrenia (Kane et al.
Chouljian, T.L.; Shumway, M.; Balancio, E.; Dwyer, E.V.;
447
Schizophrenia Bulletin, Vol. 26, No. 2, 2000 R.E. Drake et al.
Drake, R.E.; Teague, G.B.; and Warren, S.R. New in patients with chronic schizophrenia. Biological
Hampshire's dual diagnosis program for people with Psychiatry, 37:550-552, 19956.
severe mental illness and substance abuse. Addiction and McHugo, G.J.; Drake, R.E.; Burton, H.L.; and Ackerson,
Recovery, 10:35-39, 19906. T.H. A scale for assessing the stage of substance abuse
George, T.P.; Semyak, MJ.; Ziedonis, D.M.; and Woods, treatment in persons with severe mental illness. Journal of
S.W. Effects of clozapine on smoking in chronic schizo- Nervous and Mental Disease, 183:762-767, 1995.
phrenic outpatients. Journal of Clinical Psychiatry, McLean, R.A.; Sanders, W.L.; and Stroup, W.W A unified
448
Effects of Clozapine on Alcohol and Drug Use Disorders Schizophrenia Bulletin, Vol. 26, No. 2, 2000
schizophrenia and substance abuse. Journal of Nervous on Alcohol Abuse and Alcoholism grant AA-08341. The
and Mental Disease, 185:463-465, 1997. authors gratefully acknowledge the assistance of the fol-
Wolford, G.L.; Rosenberg, S.D.; Oxman, T.E.; Drake, lowing individuals in the execution of this work: Lindy
R.E.; Mueser, K.T.; Oxman, T.E.; Hoffman, D.; Vidaver, Fox, Joan Packard, Theimann Ackerson, Keith Miles,
R.M.; Luckoor, R.; and Carrieri, K.L. Evaluation of meth- Barbara Helmstetter, and Rosemarie Wolfe. Thanks also
ods for detecting substance use disorder in persons with to Kim T. Mueser for comments on an earlier draft.
severe mental illness. Psychology of Addictive Behaviors,
449
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