More substance abuse with severe mental illness

Rates of smoking, drinking, and drug use are significantly higher among people who have psychotic disorders than among those in the general population. (Credit: wakingphotolife:/Flickr)

Among people with severe psychiatric illness, more than 75 percent are regular smokers, 30 percent engage in binge drinking, and about half regularly use marijuana and other illicit drugs.

The findings are of particular concern, researchers say, because individuals with severe mental illness are more likely to die younger than people without severe psychiatric disorders.

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“These patients tend to pass away much younger, with estimates ranging from 12 to 25 years earlier than individuals in the general population,” says Sarah M. Hartz, assistant professor of psychiatry at Washington University in St. Louis.

“They don’t die from drug overdoses or commit suicide—the kinds of things you might suspect in severe psychiatric illness. They die from heart disease and cancer, problems caused by chronic alcohol and tobacco use.”

Published in JAMA Psychiatry, the study analyzed smoking, drinking, and drug use in nearly 20,000 people, including 9,142 psychiatric patients diagnosed with schizophrenia, bipolar disorder, or schizoaffective disorder.  Schizoaffective disorder is characterized by psychotic symptoms such as hallucinations, delusions, and mood disorders such as depression.

The investigators also assessed nicotine use, heavy drinking, heavy marijuana use, and recreational drug use in more than 10,000 healthy people without mental illness.

The researchers found that 30 percent of those with severe psychiatric illness engaged in binge drinking, defined as drinking four servings of alcohol at one time. In comparison, the rate of binge drinking in the general population is 8 percent.

Mental illness trumps everything

Among those with mental illness, more than 75 percent were regular smokers. This compares with 33 percent of those in the control group who smoked regularly. There were similar findings with heavy marijuana use: 50 percent of people with psychotic disorders used marijuana regularly, versus 18 percent in the general population. Half of those with mental illness also used other illicit drugs, while the rate of recreational drug use in the general population is 12 percent.

“I take care of a lot of patients with severe mental illness, many of whom are sick enough that they are on disability,” Hartz says. “And it’s always surprising when I encounter a patient who doesn’t smoke or hasn’t used drugs or had alcohol problems.”

The study also shows that once a person develops a psychotic illness, protective factors such as race and gender don’t have their typical influence.

Previous research indicates that Hispanics and Asians tend to have lower rates of substance abuse than European-Americans. The same is true for women, who tend to smoke, drink, and use illicit drugs less often than men.

“We see protective effects in these subpopulations,” Hartz says. “But once a person has a severe mental illness, that seems to trump everything.”

Permissive psychiatric wards?

That’s particularly true with smoking. During the last few decades, smoking rates have declined in the general population. People over 50 are much more likely than younger people to have been regular smokers at some point in their lives.

For example, about 40 percent of those over 50 used to smoke regularly. Among those under 30, fewer than 20 percent have been regular smokers. But among the mentally ill, the smoking rate is more than 75 percent, regardless of the patient’s age.

“With public health efforts, we’ve effectively cut smoking rates in half in healthy people, but in the severely mentally ill, we haven’t made a dent at all,” Hartz says.

Until recently, smoking was permitted in most psychiatric hospitals and mental wards. Hartz believes that many psychiatrists decided that their sickest patients had enough problems without having to worry about quitting smoking, too.

There also were concerns about potential dangers from using nicotine-replacement therapy, while continuing to smoke since smoking is so prevalent among the mentally ill. Recent studies, however, have found those concerns were overblown.

The question is whether being more aggressive in trying to curb nicotine, alcohol and substance use in patients with severe psychiatric illness can lengthen their lives. Health professionals who treat the mentally ill need to do a better job of trying to get them to stop smoking, drinking, and using drugs, Hartz says.

“Some studies have shown that although we psychiatrists know that smoking, drinking, and substance use are major problems among the mentally ill, we often don’t ask our patients about those things.

“We can do better, but we also need to develop new strategies because many interventions to reduce smoking, drinking, and drug use that have worked in other patient populations don’t seem to be very effective in these psychiatric patients.”

Source: Washington University in St. Louis