Substance Clarence Chen, Michael
Abuse Among Psychiatric
Balogh, Jack Bathija, Evelyn Howanitz,
The drug use history was obtained for all patients admitted to the inpatient service of a large municipal hospital during a l-month period. A total of 104 patients were evaluated. An inverse relationship was found between the frequency of drug use and the diagnosis of schizophrenia. Approximately one third of the patients were found to be polydrug users, that is, individuals who used at least two types of drugs weekly (e.g., alcohol plus cocaine, heroin plus cocaine, etc.) during the 3 months prior to hospitalization.
Robert Plutchik, and Hope R. Conte
of the polydrug users were males. Patients who scored high in drug use tended to be younger, had more seclusions while on the ward, and had less of a history of drug or alcohol treatment. The drug having the highest frequency of daily use was found to be cocaine. It appears that drug use in general and polydrug use in particular is increasing among psychiatric patients. Copyright 0 1992 by W.B. Saunders Company
Most
T
HE EPIDEMIC of drug abuse in the United States has recently become the subject of considerable public attention. A number of studies in the last three decades have demonstrated that alcohol and drug use and abuse are common in populations of psychiatric patients.“” However, the overall rates of drug abuse, as well as the specific substances most used, vary considerably in different hospital settings, i.e. public, private, or Veteran’s facilities and in different age or socioeconomic Another complicating factor in undergroups. 12-14 standing the effects of drug abuse on psychiatric patients is that the most commonly chosen illicit drugs have changed and gone through several “fads” over the past 30 years, from the popular use of hallucinogenic substances (sometimes called “psychotomimetic?) in the 1960s to the peak of the heroin epidemic in the late 1960s and early 1970s,15to the current use of cocaine and crack.” Clearly there is a need for current empirical observations to elucidate the complex epidemiology of drug use among psychiatric patients. The current study is an attempt to assess quantitatively the prevalence of substance use among patients hospitalized on a general psychiatric service in a major urban area. Further objectives were to identify the types of drugs used, the demographic differences between drugusing and non-drug-using patients, and to relate drug use to psychiatric diagnoses. From the Department of Psychiatry, Albert Einstein College of Medicine, Yeshiva University,Bronx, NY Address reprint requests to Clarence L. Chen, M.D., 123 W 79th St, Suite 209, New York, NY 10024 Copyright 0 I992 by W.B. Saunders Company OOIO-440X19213301-OOOl$O3.OOlO
60
Inpatients
METHOD This study was conducted at a large municipal hospital which serves an inner-city population. The study involved all admissions to the adult inpatient psychiatric wards of the hospital. All of these wards have the same organization and staffing patterns, as well as the same criteria for admission. The study involved all psychiatric admissions to the units during the month of October 1988. A series of standard questions was developed and completed by the primary therapists in all cases while interviewing the patients. Out of a total of 129 admissions, complete data were obtained on 80%. Included were specific questions about demographics, length of stay, employment history, past psychiatric or medical treatment, history of previous drug rehabilitation and admissions, previous suicide attempts, and discharge diagnoses using DSM-III-R nosology and diagnostic criteria. Also included were signs of withdrawal or intoxication during hospitalization, manner of discharge, and incidence of seclusions during hospitalization. In addition, questions were asked about each patient’s drug use history during the past 3 months. A copy of the questionnaire is shown in Fig 1. To arrive at indices of drug use, the following scores were given to the frequency of use of each type of drug: never = 0, rarely = 1, monthly = 2, weekly = 3, and almost daily = 4. Two separate scores were obtained, one for alcohol use, and the other for use of all types of drugs (marijuana, heroin, cocaine, stimulants, sedatives, PCP, and others). A total score was obtained for each patient separately for alcohol use and for drug use, using the sum of the weights cited above. For example, if a patient indicated that he or she used alcohol rarely and use marijuana and sedatives weekly, the patient would get a score of 1 for alcohol use and a score of 6 for other drug use. These indices are measures of drug use. The issue of drug abuse is a more complex question which will be discussed later. RESULTS
The sample of 104 patients consisted of 61% men, 39% women, and 26% white, 41% black, and 33% Hispanic. The mean age for the men was 33.7 years (SD 12.2) and for women was 37.6 years (SD 14.4). The average length of stay was 20 days (SD 25.7). Basic demographic and
Comprehensive Psychiatry, Vol. 33, No. 1 (January/February), 1992: pp 60-64
SUBSTANCE ABUSE IN PSYCHIATRIC
61
PATIENTS
Reviewer Date of Review
BMHCSUBSTANCEABUSESTUDY Ward No.
Chart No.
Name 3. Marital Status
2. Sex
1. Age
___~
Date Admitted 6. Employed:
Treatment
Yes ~
4. Race
W
B
H
A
hospitalization
Yes ~
~
No
No
11. Methadone
13. Residential drug rehab program ~
PrimaryDiagnoses
W
(Lifetime History) [Check all that apply]
10. NA-
9. A.A. ~
~
D
5. L.O.S. (days)
No 7. Previous psychiatric
8. Previous Medical hospitalization
Previous Outpatient
M
Date Discharged Yes _
__
S
Maintenance
~
14. For Alcoholism
~
12. Psychiatric
Outpatient
__
(Use DSM IIIR Code Numbers) At Discharge
At Admission 15. Axis I
16. Axisll
17. Axis II
18. Drug withdrawal
signs during hospital stay? ~
19. Urine (date) ~__
~
20. Urines (dates) __~
~
21. Intoxicated
state in hospital ~
No __~
Yes ~
Uncertain
(+) for
(-),or-
(+) for
(-), or ~ No
Yes ___
Manner of Discharge 22. ~
Administrative’
23. Number of seclusions 24. Suicide in the past? _~
,-AMA;_
planned;
during present hospitalization Yes ~
___
elopement.
_
No (gestures or attempts) Drug Use History Rate of Use in Past Three Months Almost Daily
25. Alcohol
........................................................................
26. Marijuana ..................................................................... 27. Heroin (IV) ................................................................... 28. Heroin (snort) .............................................................. 28. Cocaine (IV) ................................................................. 30. Cocaine (snort). ........................................................... 31. Cocaine (smoke) ......................................................... 32. Stimulants ................................................................... 33. Sedatives.. ................................................................... 34. PCP .............................................................................. 35. Other. ........................................................................... Fig 1.
Study Questionnaire.
Weekly
Monthly
Rarely
Never
62
clinical information concerning the men (N = 63) and women (N = 41) in the patient population shows that there were no significant differences between men and women in age, length of stay, number of seclusions, and number of past suicide attempts. However, men scored significantly higher on use of alcohol (t = 5.10, P < .OOl), and women scored significantly higher on history of alcohol or drug treatment (t = 2.30, P < .05).
In terms of diagnostic distribution, 34% of the patients were given a primary DSM-III-R diagnosis at discharge of schizophrenia, 30% were given a diagnosis of substance abuse, and 14% were diagnosed as having an adjustment disorder. Twenty-two percent of the patients had miscellaneous diagnoses such as major depressive disorder, bipolar disorder, and organic disorder. Twenty-seven percent received a dual diagnosis that included substance abuse at the time of discharge. There was an inverse relationship between the frequency of drug use and the diagnosis of schizophrenia. Seventy-seven percent of the non-drug users had such a diagnosis; 37% of the monodrug users and 26% of the polydrug users were diagnosed as schizophrenic. In other words, schizophrenics tended to either not use drugs, or if they did, to use only one. The patients were divided into three groups on the basis of the extent of their drug and/or alcohol use. Of the total population, 29% were evaluated as non-drug users. Thirty-eight percent were evaluated as being a user of only one type of drug, such as alcohol or crack. The third group consisted of polydrug users and represented 33% of the total population. A drug user was defined as someone who used any type of drug at least weekly during the 3 months prior to hospitalization. A polydrug user was a person who used at least two types of drugs weekly including alcohol during the same time period. Among the polydrug users, 76% were men and 24% were women. In contrast, among the patients not using drugs, approximately 29% were men and 71% were women. Thus, there clearly appears to be a sex difference in the likelihood of use of drugs, with males being about three times more likely to be polydrug users than females. There were no statistically significant differ-
CHEN ET AL
ences among the three groups (polydrug, monodrug, and non-drug) in marital status, ethnic@, employment history, or previous psychiatric or medical hospitalization. Marked differences were found in the frequency of drug use between polydrug users (mean, 8.93) monodrug users (mean, 2.37) and non-drug users (mean, 0.26) (F = 47.57, P < .OOl). There also appears to be an age difference among the three groups. The nondrug users were the oldest group (mean, 38.35 years), while the polydrug users were the youngest, with a mean age of 30.22 years. While not statistically significant, there appears to be a trend for the non-drug users to have the longest length of stay (mean, 25.52 days), while the polydrug users had the shortest length of stay at approximately 15 days. The records of each patient were inspected for evidence of past suicide attempts. It was found that the patients who did, not use drugs had the highest number of previous suicide attempts (mean, 1.83) monodrug users had an intermediate number (mean 1.63), while the polydrug users had the lowest number of previous suicide attempts (mean, 1.30) (F = 8.84, P < .OOl). Another analysis was performed to examine the correlation between the variables. The major findings are as follows: Patients scoring high in drug use during the past 3 months tended to be younger (r = -.35, P < .OOl), to have more seclusions while on the ward (r = + .21, P < .05), had fewer suicide attempts in the past (r = -.39, P < .OOl), and had less of a history of drug or alcohol treatment (r = -.32, P < .OOl). Some of these correlations may result from young people having less opportunity for treatment, or time to make suicide attempts than older people, simply because of the age differential. Other correlations indicated that patients who had more previous drug or alcohol treatment had more suicide attempts in the past (r = .25, P < .05), and were significantly lower in recent alcohol use (r = -.36, P < .OOl). Table 1 shows the frequency of drug use among this sample of psychiatric inpatients. Twenty-three percent of the sample used alcohol daily during the past 3 months, while 36% reported that they never used it. With regard to other street drugs, 13% reported that they used
SUBSTANCE
ABUSE IN PSYCHIATRIC
PATIENTS
63
Table 1. Frequency of Drug Use Among Psychiatric Inpatients Freauencv
Drug
of Use I%1
Never
Rarely
Alcohol
36
22
Monthly 4
Weekly
15
Daily
23
Marijuana
57
19
1
10
13
Heroin (IV)
93
3
0
0
4
Heroin (intranasal)
91
2
1
3
3
Cocaine (IV)
92
2
1
0
5
Cocaine (intranasal)
70
7
5
9
9 15
Cocaine (smoke, “crack”)
66
10
3
6
Stimulants
93
4
2
0
1
Sedatives
92
3
2
0
3
PCP
92
6
1
0
1
marijuana every day, and 15% reported the use of crack daily. However, when all forms of daily cocaine use are combined, the total is the highest found (29%). The overall drug use score (excluding alcohol) could range from 0 to a maximum of 40. It was found that 44% of the patients reported never using street drugs. An additional 21% received scores greater than 8, implying that they used at least two street drugs daily or possibly some assortment of drugs on a less frequent basis. A further analysis was performed on the issue of multiple drug use. All cases were noted of individuals who used one drug daily and a second drug either daily or weekly. Using this more stringent criterion of a polydrug user, it was found that 25% of the patients met this criterion. Of this group, the most common combination of drugs was alcohol plus cocaine (11 instances), followed by marijuana plus cocaine (nine instances). Cocaine plus heroin was reported in seven instances, and alcohol plus marijuana in four. Two instances each of alcohol plus heroin and marijuana plus heroin were also reported. These numbers are not independent, since some patients use as many as three drugs either daily or daily plus weekly. It thus appears that multiple drug use is not an uncommon event. DISCUSSION
Previous research on drug use among psychiatric patients has indicated that somewhere between 30% and 50% of psychiatric inpatients used alcohol or other drugs to the extent that some level of abuse was suspected.4.‘7-‘9In the present study, approximately 71% of the pa-
tients were considered to use alcohol and/or drugs to an appreciable degree. Earlier studies had little to say about polydrug use, while the present one found that approximately one third of the sample consisted of polydrug users. The exact figures obtained concerning levels of drug use depended in part on the definitions of the terms, but even a stringent criterion of polydrug use led to a figure of 25%. This finding in relation to previous publications suggests that drug use in general is increasing among psychiatric patients, as well as polydrug use. Of particular interest is the fact that cocaine (in any of its forms of intake, i.e., intranasal, intravenously, or smoke) has become the number one drug in daily use among psychiatric inpatients prior to hospitalization. While 23% of the patients indicate the daily use of alcohol, 29% indicate the daily use of cocaine. A relatively weak runner-up is marijuana, with 13% of the patients reporting its daily use. These findings are consistent with a New York State Repor? that found a greatly increased use of cocaine throughout the state. The exact figures obtained in the present study may underestimate the true magnitude of the problem in view of some reluctance to report drug use. Another interesting finding of the present survey is the fact that patients diagnosed as schizophrenic tended to use drugs much less than patients with other diagnoses. This confirms a report by Ritzler et al.,” and raises the possibility that drug use may require a relatively high level of ego organization, social skills, and social contacts, in order to maintain the habit on a daily basis. The present results indicate a high probability of drug use among psychiatric inpatients. This implies the need to train psychiatric staff in the assessment, diagnosis, and treatment of such patients. It also implies the need for routine urine screens for drug use. It may also imply the need for specialized psychiatric facilities where such dual-diagnoses patients may be optimally treated. A fmal point that is of great interest concerns the issue of drug use versus drug abuse. DSMIII-R defines drug abuse in terms of the effect of the drug on daily functioning. It also distinguishes between drug abuse (dysfunctional behavior) and drug dependence (withdrawal symp-
64
CHEN ET AL
toms and increased tolerance). The DSM-III-R definition also states that the dysfunctional behavior is caused or exacerbated by the drug use. In the present study, no attempt was made to identify drug abusers; the focus was only on drug use. A major reason for this focus was that all patients on an inpatient service are functionally impaired to some degree, and it is almost impossible to determine whether the impair-
ment is due to drugs, to psychosis, to personality disorders, or to some combination of these. In other words, the term abuse appears to be a moral judgment, rather than a psychiatric description. As presently defined, it does not tell us anything about patterns of drug use. There is a subtle but important interaction between drug use and psychiatric dysfunction. The present study throws some light on this interaction, but clearly more research is needed.
REFERENCES 1. Bukstein OG, Brent D, Kaminer Y. Comorbidity of substance abuse and other psychiatric disorders in adolescence. Am J Psychiatry 1989;146:1131-1141. 2. Craig TJ, Lin SP, E.-Defrawi MH, Goodman AB. Clinical correlates of readmission in a schizophrenic cohort. Psychiatr Q 1985;57:5-10. 3. Davis DI. Differences in the use of substances of abuse by psychiatric patients compared with medical and surgical patients. J Nerv Ment Dis 1984;172:654-657. 4. DeMilio L. Psychiatric syndromes in adolescent substance abusers. Am J Psychiatry 1989;146:1212-1214. 5. Hasin DS, Grant BF. Psychiatric diagnosis of patients with substance abuse problems: a comparison of two procedures, the DIS and the SADS-1. J Psychiatr Res 1987;21:721. 6. Kofoed L, Kania J, Walsh T, Atkinson RM. Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. Am J Psychiatry 1986;143:867-872. 7. Millman RB, Zinberg N, Kaufman E. Alcohol, drug abuse in general psychiatric care. Clin Psychiatry Times 1989;17:1-26. 8. Perkins KA, Simpson JC, Tsuang MT. Ten-year follow-up of drug abusers with acute or chronic psychoses. Hosp Community Psychiatry 1986;37:481-484. 9. Richard ML, Liskow BI, Perry PJ. Recent psychostimulant use in hospitalized schizophrenics. J Clin Psychiatry 1985;46:79-83. 10. Ross HE, Glaser FB, Germanson T. The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry 45:1023-1031,1988. 11. Schneier FR, Siris SG. A review of psychoactive substance use and abuse in schizophrenia: patterns of drug choice. J Nets Ment Dis 1987;175:641-651.
12. Alterman AI, Erdlen DL, Laporte DJ. Effects of illicit drug use in an inpatient psychiatric population. Addict Disord 1982;7:231-242. 13. Fernandez-Pol B, Bluestone H, Mizruchi MS. Innercity substance abuse patterns: a study of psychiatric inpatients. Am J Drug Alcohol Abuse 1988;14:41-50. 14. Galanter M, Casteneda R, Ferman J. Substance abuse among general psychiatric patients: place of presentation, diagnosis, and treatment. Am J Alcohol Drug Abuse 1988;142:211-235. 15. Egan DJ, Robinson DO. Models of a heroin epidemic. Am J Psychiatry 1979;136:1162-1167. 16. Rosenthal R. Crack and the psychiatrist emergency room. New York County District Branch Newsletter Winter 1989-199O;XIII:12-13. 17. Atkinson R. Importance of alcohol and drug abuse in psychiatric emergencies. Calif Med 1973;118:1-4. 18. Crowley T. Chesluk D, Dilts S, Hart P. Drug and alcohol abuse among psychiatric admissions: a multidrug clinical-toxicologic study. Arch Gen Psychiatry 1974;30:1320. 19. Westermeyer J, Walzer V. Sociopathy and drug use in a young psychiatric population. Dis Nerv Syst 1975;36:673677. 20. State of New York Anti-Drug Abuse Strategy Report. 1989, Statewide Anti-Drug Abuse Council, State Capital, Second Floor, Albany, NY 12224. 21. Ritzler BA, Strauss JS, Vanord A, Kokes RF. Prognostic implication of various drinking pattern in psychiatric patients. Am J Psychiatry 1977;134:546-549.
Abuse Among Psychiatric
Balogh, Jack Bathija, Evelyn Howanitz,
The drug use history was obtained for all patients admitted to the inpatient service of a large municipal hospital during a l-month period. A total of 104 patients were evaluated. An inverse relationship was found between the frequency of drug use and the diagnosis of schizophrenia. Approximately one third of the patients were found to be polydrug users, that is, individuals who used at least two types of drugs weekly (e.g., alcohol plus cocaine, heroin plus cocaine, etc.) during the 3 months prior to hospitalization.
Robert Plutchik, and Hope R. Conte
of the polydrug users were males. Patients who scored high in drug use tended to be younger, had more seclusions while on the ward, and had less of a history of drug or alcohol treatment. The drug having the highest frequency of daily use was found to be cocaine. It appears that drug use in general and polydrug use in particular is increasing among psychiatric patients. Copyright 0 1992 by W.B. Saunders Company
Most
T
HE EPIDEMIC of drug abuse in the United States has recently become the subject of considerable public attention. A number of studies in the last three decades have demonstrated that alcohol and drug use and abuse are common in populations of psychiatric patients.“” However, the overall rates of drug abuse, as well as the specific substances most used, vary considerably in different hospital settings, i.e. public, private, or Veteran’s facilities and in different age or socioeconomic Another complicating factor in undergroups. 12-14 standing the effects of drug abuse on psychiatric patients is that the most commonly chosen illicit drugs have changed and gone through several “fads” over the past 30 years, from the popular use of hallucinogenic substances (sometimes called “psychotomimetic?) in the 1960s to the peak of the heroin epidemic in the late 1960s and early 1970s,15to the current use of cocaine and crack.” Clearly there is a need for current empirical observations to elucidate the complex epidemiology of drug use among psychiatric patients. The current study is an attempt to assess quantitatively the prevalence of substance use among patients hospitalized on a general psychiatric service in a major urban area. Further objectives were to identify the types of drugs used, the demographic differences between drugusing and non-drug-using patients, and to relate drug use to psychiatric diagnoses. From the Department of Psychiatry, Albert Einstein College of Medicine, Yeshiva University,Bronx, NY Address reprint requests to Clarence L. Chen, M.D., 123 W 79th St, Suite 209, New York, NY 10024 Copyright 0 I992 by W.B. Saunders Company OOIO-440X19213301-OOOl$O3.OOlO
60
Inpatients
METHOD This study was conducted at a large municipal hospital which serves an inner-city population. The study involved all admissions to the adult inpatient psychiatric wards of the hospital. All of these wards have the same organization and staffing patterns, as well as the same criteria for admission. The study involved all psychiatric admissions to the units during the month of October 1988. A series of standard questions was developed and completed by the primary therapists in all cases while interviewing the patients. Out of a total of 129 admissions, complete data were obtained on 80%. Included were specific questions about demographics, length of stay, employment history, past psychiatric or medical treatment, history of previous drug rehabilitation and admissions, previous suicide attempts, and discharge diagnoses using DSM-III-R nosology and diagnostic criteria. Also included were signs of withdrawal or intoxication during hospitalization, manner of discharge, and incidence of seclusions during hospitalization. In addition, questions were asked about each patient’s drug use history during the past 3 months. A copy of the questionnaire is shown in Fig 1. To arrive at indices of drug use, the following scores were given to the frequency of use of each type of drug: never = 0, rarely = 1, monthly = 2, weekly = 3, and almost daily = 4. Two separate scores were obtained, one for alcohol use, and the other for use of all types of drugs (marijuana, heroin, cocaine, stimulants, sedatives, PCP, and others). A total score was obtained for each patient separately for alcohol use and for drug use, using the sum of the weights cited above. For example, if a patient indicated that he or she used alcohol rarely and use marijuana and sedatives weekly, the patient would get a score of 1 for alcohol use and a score of 6 for other drug use. These indices are measures of drug use. The issue of drug abuse is a more complex question which will be discussed later. RESULTS
The sample of 104 patients consisted of 61% men, 39% women, and 26% white, 41% black, and 33% Hispanic. The mean age for the men was 33.7 years (SD 12.2) and for women was 37.6 years (SD 14.4). The average length of stay was 20 days (SD 25.7). Basic demographic and
Comprehensive Psychiatry, Vol. 33, No. 1 (January/February), 1992: pp 60-64
SUBSTANCE ABUSE IN PSYCHIATRIC
61
PATIENTS
Reviewer Date of Review
BMHCSUBSTANCEABUSESTUDY Ward No.
Chart No.
Name 3. Marital Status
2. Sex
1. Age
___~
Date Admitted 6. Employed:
Treatment
Yes ~
4. Race
W
B
H
A
hospitalization
Yes ~
~
No
No
11. Methadone
13. Residential drug rehab program ~
PrimaryDiagnoses
W
(Lifetime History) [Check all that apply]
10. NA-
9. A.A. ~
~
D
5. L.O.S. (days)
No 7. Previous psychiatric
8. Previous Medical hospitalization
Previous Outpatient
M
Date Discharged Yes _
__
S
Maintenance
~
14. For Alcoholism
~
12. Psychiatric
Outpatient
__
(Use DSM IIIR Code Numbers) At Discharge
At Admission 15. Axis I
16. Axisll
17. Axis II
18. Drug withdrawal
signs during hospital stay? ~
19. Urine (date) ~__
~
20. Urines (dates) __~
~
21. Intoxicated
state in hospital ~
No __~
Yes ~
Uncertain
(+) for
(-),or-
(+) for
(-), or ~ No
Yes ___
Manner of Discharge 22. ~
Administrative’
23. Number of seclusions 24. Suicide in the past? _~
,-AMA;_
planned;
during present hospitalization Yes ~
___
elopement.
_
No (gestures or attempts) Drug Use History Rate of Use in Past Three Months Almost Daily
25. Alcohol
........................................................................
26. Marijuana ..................................................................... 27. Heroin (IV) ................................................................... 28. Heroin (snort) .............................................................. 28. Cocaine (IV) ................................................................. 30. Cocaine (snort). ........................................................... 31. Cocaine (smoke) ......................................................... 32. Stimulants ................................................................... 33. Sedatives.. ................................................................... 34. PCP .............................................................................. 35. Other. ........................................................................... Fig 1.
Study Questionnaire.
Weekly
Monthly
Rarely
Never
62
clinical information concerning the men (N = 63) and women (N = 41) in the patient population shows that there were no significant differences between men and women in age, length of stay, number of seclusions, and number of past suicide attempts. However, men scored significantly higher on use of alcohol (t = 5.10, P < .OOl), and women scored significantly higher on history of alcohol or drug treatment (t = 2.30, P < .05).
In terms of diagnostic distribution, 34% of the patients were given a primary DSM-III-R diagnosis at discharge of schizophrenia, 30% were given a diagnosis of substance abuse, and 14% were diagnosed as having an adjustment disorder. Twenty-two percent of the patients had miscellaneous diagnoses such as major depressive disorder, bipolar disorder, and organic disorder. Twenty-seven percent received a dual diagnosis that included substance abuse at the time of discharge. There was an inverse relationship between the frequency of drug use and the diagnosis of schizophrenia. Seventy-seven percent of the non-drug users had such a diagnosis; 37% of the monodrug users and 26% of the polydrug users were diagnosed as schizophrenic. In other words, schizophrenics tended to either not use drugs, or if they did, to use only one. The patients were divided into three groups on the basis of the extent of their drug and/or alcohol use. Of the total population, 29% were evaluated as non-drug users. Thirty-eight percent were evaluated as being a user of only one type of drug, such as alcohol or crack. The third group consisted of polydrug users and represented 33% of the total population. A drug user was defined as someone who used any type of drug at least weekly during the 3 months prior to hospitalization. A polydrug user was a person who used at least two types of drugs weekly including alcohol during the same time period. Among the polydrug users, 76% were men and 24% were women. In contrast, among the patients not using drugs, approximately 29% were men and 71% were women. Thus, there clearly appears to be a sex difference in the likelihood of use of drugs, with males being about three times more likely to be polydrug users than females. There were no statistically significant differ-
CHEN ET AL
ences among the three groups (polydrug, monodrug, and non-drug) in marital status, ethnic@, employment history, or previous psychiatric or medical hospitalization. Marked differences were found in the frequency of drug use between polydrug users (mean, 8.93) monodrug users (mean, 2.37) and non-drug users (mean, 0.26) (F = 47.57, P < .OOl). There also appears to be an age difference among the three groups. The nondrug users were the oldest group (mean, 38.35 years), while the polydrug users were the youngest, with a mean age of 30.22 years. While not statistically significant, there appears to be a trend for the non-drug users to have the longest length of stay (mean, 25.52 days), while the polydrug users had the shortest length of stay at approximately 15 days. The records of each patient were inspected for evidence of past suicide attempts. It was found that the patients who did, not use drugs had the highest number of previous suicide attempts (mean, 1.83) monodrug users had an intermediate number (mean 1.63), while the polydrug users had the lowest number of previous suicide attempts (mean, 1.30) (F = 8.84, P < .OOl). Another analysis was performed to examine the correlation between the variables. The major findings are as follows: Patients scoring high in drug use during the past 3 months tended to be younger (r = -.35, P < .OOl), to have more seclusions while on the ward (r = + .21, P < .05), had fewer suicide attempts in the past (r = -.39, P < .OOl), and had less of a history of drug or alcohol treatment (r = -.32, P < .OOl). Some of these correlations may result from young people having less opportunity for treatment, or time to make suicide attempts than older people, simply because of the age differential. Other correlations indicated that patients who had more previous drug or alcohol treatment had more suicide attempts in the past (r = .25, P < .05), and were significantly lower in recent alcohol use (r = -.36, P < .OOl). Table 1 shows the frequency of drug use among this sample of psychiatric inpatients. Twenty-three percent of the sample used alcohol daily during the past 3 months, while 36% reported that they never used it. With regard to other street drugs, 13% reported that they used
SUBSTANCE
ABUSE IN PSYCHIATRIC
PATIENTS
63
Table 1. Frequency of Drug Use Among Psychiatric Inpatients Freauencv
Drug
of Use I%1
Never
Rarely
Alcohol
36
22
Monthly 4
Weekly
15
Daily
23
Marijuana
57
19
1
10
13
Heroin (IV)
93
3
0
0
4
Heroin (intranasal)
91
2
1
3
3
Cocaine (IV)
92
2
1
0
5
Cocaine (intranasal)
70
7
5
9
9 15
Cocaine (smoke, “crack”)
66
10
3
6
Stimulants
93
4
2
0
1
Sedatives
92
3
2
0
3
PCP
92
6
1
0
1
marijuana every day, and 15% reported the use of crack daily. However, when all forms of daily cocaine use are combined, the total is the highest found (29%). The overall drug use score (excluding alcohol) could range from 0 to a maximum of 40. It was found that 44% of the patients reported never using street drugs. An additional 21% received scores greater than 8, implying that they used at least two street drugs daily or possibly some assortment of drugs on a less frequent basis. A further analysis was performed on the issue of multiple drug use. All cases were noted of individuals who used one drug daily and a second drug either daily or weekly. Using this more stringent criterion of a polydrug user, it was found that 25% of the patients met this criterion. Of this group, the most common combination of drugs was alcohol plus cocaine (11 instances), followed by marijuana plus cocaine (nine instances). Cocaine plus heroin was reported in seven instances, and alcohol plus marijuana in four. Two instances each of alcohol plus heroin and marijuana plus heroin were also reported. These numbers are not independent, since some patients use as many as three drugs either daily or daily plus weekly. It thus appears that multiple drug use is not an uncommon event. DISCUSSION
Previous research on drug use among psychiatric patients has indicated that somewhere between 30% and 50% of psychiatric inpatients used alcohol or other drugs to the extent that some level of abuse was suspected.4.‘7-‘9In the present study, approximately 71% of the pa-
tients were considered to use alcohol and/or drugs to an appreciable degree. Earlier studies had little to say about polydrug use, while the present one found that approximately one third of the sample consisted of polydrug users. The exact figures obtained concerning levels of drug use depended in part on the definitions of the terms, but even a stringent criterion of polydrug use led to a figure of 25%. This finding in relation to previous publications suggests that drug use in general is increasing among psychiatric patients, as well as polydrug use. Of particular interest is the fact that cocaine (in any of its forms of intake, i.e., intranasal, intravenously, or smoke) has become the number one drug in daily use among psychiatric inpatients prior to hospitalization. While 23% of the patients indicate the daily use of alcohol, 29% indicate the daily use of cocaine. A relatively weak runner-up is marijuana, with 13% of the patients reporting its daily use. These findings are consistent with a New York State Repor? that found a greatly increased use of cocaine throughout the state. The exact figures obtained in the present study may underestimate the true magnitude of the problem in view of some reluctance to report drug use. Another interesting finding of the present survey is the fact that patients diagnosed as schizophrenic tended to use drugs much less than patients with other diagnoses. This confirms a report by Ritzler et al.,” and raises the possibility that drug use may require a relatively high level of ego organization, social skills, and social contacts, in order to maintain the habit on a daily basis. The present results indicate a high probability of drug use among psychiatric inpatients. This implies the need to train psychiatric staff in the assessment, diagnosis, and treatment of such patients. It also implies the need for routine urine screens for drug use. It may also imply the need for specialized psychiatric facilities where such dual-diagnoses patients may be optimally treated. A fmal point that is of great interest concerns the issue of drug use versus drug abuse. DSMIII-R defines drug abuse in terms of the effect of the drug on daily functioning. It also distinguishes between drug abuse (dysfunctional behavior) and drug dependence (withdrawal symp-
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toms and increased tolerance). The DSM-III-R definition also states that the dysfunctional behavior is caused or exacerbated by the drug use. In the present study, no attempt was made to identify drug abusers; the focus was only on drug use. A major reason for this focus was that all patients on an inpatient service are functionally impaired to some degree, and it is almost impossible to determine whether the impair-
ment is due to drugs, to psychosis, to personality disorders, or to some combination of these. In other words, the term abuse appears to be a moral judgment, rather than a psychiatric description. As presently defined, it does not tell us anything about patterns of drug use. There is a subtle but important interaction between drug use and psychiatric dysfunction. The present study throws some light on this interaction, but clearly more research is needed.
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