Diagnosis of Alcohol Use Disorders in Schizophrenia

Transcription

1 VOL. 16, NO. 1, 1990 Diagnosis of Alcohol Use Disorders in Schizophrenia by Robert E. Drake, Fred C Osher, Douglas L. Noordsy, Stephanie C Hurlbut, Gregory B. league, and Malcolm S. Beaudett Abstract Alcohol use disorders are common comorbid conditions in schizophrenia, and their presence is associated with poor adjustment and poor treatment response. Standard alcohol assessment instruments have not been' validated for use with schizophrenic patients, and several authors have questioned the validity of these patients' selfreports. A reliable and valid screening procedure for assessing alcohol use is needed. The present study used the following three methods to evaluate a rural sample of 75 outpatients with DSM-IU-R schizophrenia or schizoaffective disorder: (1) clinical records; (2) research interviews using standard alcohol assessment instruments; and (3) case managers' ratings. In addition, consensus diagnoses, determined by combining information from all three methods with intensive case reviews, were used to determine the sensitivity and specificity of the other approaches. As expected, clinical evaluations frequently missed alcohol problems. Research interviews and case managers' ratings differentiated between alcoholic and nonalcoholic schizophrenic patients and were highly correlated. Case managers' ratings, which incorporated longitudinal observations of behavior and collateral reports as well as interview data, were more sensitive measures of current alcohol use disorders thanresearchinterviews. Subjects frequently manifested alcoholrelated problems that interfered with community adjustment without the full dependence syndrome, suggesting that schizophrenic patients may be particularly vulnerable to negative effects of alcohol. The course of schizophrenia is frequently complicated by alcohol use. Freed (1975) reviewed studies published before 1975 and found that the reported prevalence of alcohol abuse in schizophrenia ranged from 3 to 63 percent. More recent U.S. studies have determined that between 14 and 47 percent of treated schizophrenic patients have alcohol use disorders (McLellan and Druley 1977; Alterman et al. 1981; OTarrell et al. 1983; Barbee et al. 1989; Drake et al. 1989) or are frequent, heavy users of alcohol (Test et al. 1985, 1990). The Epidemiologic Catchment Area (ECA) studies have documented the high comorbidity of alcohol use disorders and schizophrenia in community samples (Boyd et al. 1984). Aggregated data from the five ECA sites showed that schizophrenia occurred four times as frequently in alcoholics as in nonalcoholics (Helzer and Pryzbeck 1988). Though some recent studies highlight the tendency of schizophrenic patients to abuse psychotomimetic drugs (Schneier and Siris 1987), alcohol is probably the dmg they most frequently abuse (Barbee et al. 1989; Drake et al. 1989; Test et al. 1989). Alcohol use disorders in schizophrenia have been associated with several aspects of poor adjustment and poor outcome including delusions (Barbee et al. 1989), hallucinations (Noordsy et al., submitted for publication), depressive symptoms (Drake et al. 1989), disruptive behaviors (Alterman et al. 1980; Drake et al. 1989), assaultiveness (Yesavage and Zarcone 1983), poor self-care (Alterman et al. 1980; Drake et al. 1989), housing instability and Reprint requests should be sent to Dr. R.E. Drake, West Central Services, 2 Whipple Place, Lebanon, NH

2 58 SCHIZOPHRENIA BULLETIN homelessness (Drake et al. 1989; Osher et al., in preparation), treatment noncompliance (Alterman et al. 1980; Drake et al. 1989), increased rates of other drug abuse (Barbee et al. 1989; DTake et al. 1989; Test et al. 1989), and increased rates of rehospitalization (Drake et al. 1989). The cross-sectional nature of existing studies and the strong associations of other drug abuse and medication noncompliance with alcohol abuse preclude causal inferences. Comparing studies is difficult because of the widely differing methodologies used. One reason for the variability in methods and findings is the lack of standardization in assessing alcohol use among schizophrenic patients. A reliable and valid assessment procedure is needed for clinical and research purposes (Ridgely et al. 1987; Toland and Moss 1989). In the absence of such a procedure, many studies have relied on clinicians' ratings, nonstandard instruments, or self-reported amounts of drinking, while others have used standard instruments without validation. Clinical diagnoses are generally insensitive measures of alcohol use disorders when compared with structured research interviews (McLellan and Druley 1977; Ananth et al. 1989). However, neuropsychological deficits decrease the accuracy of interview reports (Skinner and Sheu 1982), and schizophrenic patients may not be competent reporters of problems occasioned by alcohol. Two studies have found that structured interviews of schizophrenic patients failed to detect problematic drinking that was observed longitudinally by clinicians (Alterman et al. 1984; Test et al. 1989). Some authors (Safer 1987; Drake and Wallach 1989) have advocated using longitudinal behavioral observations and collateral information to assess substance abuse in psychiatric patients. Confidence in assessing alcohol use is generally heightened by using several approaches concurrently and establishing concordance among them (Skinner 1984), a procedure that has thus far been neglected in studies of schizophrenia. More specifically, studies have not yet compared standard alcohol assessment instruments and case managers' ratings. Diagnosis is widely acknowledged to be difficult when both substance abuse and psychiatric symptoms are present (Lehman et al. 1989; Weiss and Mirin 1989). Several authors have attempted to validate alcohol use assessments in schizophrenic patients. Alterman et al. (1984) examined patients with clinically determined dual diagnoses of schizophrenia plus alcoholism in relation to research diagnostic interviews. Of patients with clinically determined dual diagnoses, 81 percent met lifetime diagnostic criteria for alcoholism and 69 percent met criteria for both disorders. Using a 5-point scale based on the severity of alcohol-related problems, Drake et al. (1989) found that trained clinicians were able to rate the alcohol use of schizophrenic patients with high interrater reliability and that their ratings were correlated with previous hospital diagnoses of alcoholism. Test et al. (1989) compared schizophrenic patients' selfreports of amount and frequency of alcohol use, and their judgments of whether their drinking was problematic, with assessments made by their case managers. Patients were less likely to report frequent drinking than their case managers were (27 vs. 46 percent), and heavy drinkers among them were less likely than case managers to label their drinking as problematic (50 vs. 93 percent). For the most part, standard alcohol assessment instruments have been validated with primary alcoholics and not with dually diagnosed psychiatric patients. One exception, the Michigan Alcoholism Screening Test (MAST; Selzer 1971), has been used extensively with psychiatric patients. Although generally quite reliable and valid as a screening tool for primary alcoholics, it has been found to have good sensitivity (88-98 percent) but poor specificity (36-89 percent) with psychiatric patients (Hedlund and Vieweg 1984). Its overall accuracy may therefore be unacceptably low whenever the ratio of nonalcoholics to alcoholics is high. Recently, Toland and Moss (1989) found that the MAST failed to differentiate between alcoholic and nonalcoholic schizophrenic patients. Although their alcoholic group scored higher on the MAST (mean ± SD ±12.8 for alcoholic schizophrenic patients vs. 8.1 ± 9.1 for nonalcoholic schizophrenic patients), the difference was not statistically significant in their small sample (20 in each group). Several false positives were attributed to confusion on specific items, such as whether hallucinations and hospitalizations were due to heavy drinking or schizophrenia, and to the instrument's failure to differentiate between recent and remote alcohol problems. The validity of clinical diagnosis of alcoholism as the criterion variable was not addressed. As part of our clinical research program on dual diagnosis (Teague et al. 1989), we compared several methods for assessing alcohol use in schizophrenia: clinical evaluations during hospitalizations, direct

3 VOL. 16, NO. 1, patient interviews using standard alcohol assessment instruments, and case managers' ratings. Our sample of rural schizophrenic patients used alcohol much more frequently than other drugs (Osher et al., in preparation) and thus afforded an opportunity to examine alcohol use uncomplicated by the polydrug abuse that frequently occurs among urban schizophrenic patients (Breakey et al. 1974; Drake et al. 1989). Another advantage was that the sample was followed closely by clinical case managers who had low caseloads, training in substance abuse assessment, opportunity to make frequent behavioral observations in the community, and access to collateral information from families, community contacts, and other caregivers. Methods Sample. The subjects for this study were schizophrenic outpatients treated by West Central Services, a comprehensive community mental health center in rural New Hampshire that is affiliated with Dartmouth Medical School. All active outpatient cases during 1987 with a clinical diagnosis of schizophrenia or schizoaffective disorder were considered for the study. Two research psychiatrists (R.E.D. and F.C.O.) screened hospital and mental health center records and interviewed clinically diagnosed schizophrenic patients to verify their diagnoses by DSM-III-R (American Psychiatric Association 1987) criteria. To increase confidence in the diagnoses of schizophrenia, we excluded patients for whom psychotic symptoms appeared only in association with substance abuse. Fifteen patients with inaccurate or questionable diagnoses were eliminated. The remaining 79 patients with definite DSM-III-R schizophrenia or schizoaffective disorder were asked to participate in an interview about the role of alcohol and other drugs in their lives. Four patients, two of whom were considered alcohol abusers by their case managers, declined to participate. The final study sample of 75 patients had a mean age (± SD) of 43.6 (± 14.3) years. The sample was 48.0 percent male and 52.0 percent female. Only 14.7 percent of the sample were married; 60.0 percent were single, and 25.3 percent were separated, divorced, or widowed. Only 12.0 percent were competitively employed. Past hospitalization history, measured as total time spent in any mental hospital before the interview, ranged from a few months to 40 years (mean ± SD ± 77.6 months). The distribution of DSM-III-R diagnoses was as follows: schizophrenia, 89.3 percent (n = 67); and schizoaffective disorder, 10.7 percent (n = 8). Procedures and Measures. Alcohol use was independently assessed from three parallel perspectives: (1} clinical records, (2) research interviews using standard assessment instruments, and (3) ratings by clinical case managers. Information from the three perspectives was combined with intensive case review to produce consensus diagnoses. Clinical records. All available hospital discharge summaries were examined to determine whether alcohol-related problems had ever been diagnosed or detected during a hospital admission. Previous hospital discharge summaries were used as a measure of clinical practice instead of mental health center records because hospital records are relatively independent of the case manager's perspective. Since hospitalizations occurred throughout the course of illness, clinical records were considered a lifetime measure. Five patients without discharge summaries were omitted from the analyses using this variable. The other 70 patients had a mean (± SD) number of discharge summaries available of 4.2 (± 3.1). We used a 3-point scale to indicate the rate of identification of alcohol use as a problem: never, once, and more than once. From previous work (Helzer et al. 1978; Robins et al. 1982; Ananth et al. 1989), we expected clinical records to underestimate secondary diagnoses of alcohol use disorders. Ginical records were therefore used to estimate the relative sensitivity of more structured approaches. Research interviews. Each subject was interviewed for approximately 1 hour by one of the authors who was without knowledge of other assessments. The completed research interviews, recorded verbatim, were reviewed independently by two raters to assign DSM-III-R diagnoses: no disorder, alcohol abuse, or alcohol dependence. Interrater agreement between the two independent raters on a subset of 15 randomly selected interviews was 100 percent for current and lifetime diagnoses. Research interviews included the following structured sections: 1. Alcohol Dependence Scale (ADS): This 47-point scale consists of 25 multiple-choice questions and emphasizes the dependence syndrome, including compulsive drinking, loss of control, use of external supports to stop drinking, and frequent

4 60 SCHIZOPHRENIA BULLETIN withdrawal symptoms (Horn et al. 1984). The ADS refers to the previous 12 months and does not yield diagnoses. Instead, scores on the ADS are interpreted using the following cutoff points: no evidence of dependence (0), low level of dependence (1-13), moderate level of dependence (14-21), substantial level of dependence (22-30), and severe level of dependence (31-47). 2. CAGE: This 4-point scale consists of four questions that define the mnemonic: Have you felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)? (Mayfield et al. 1974). Subjects who answer positively to two or more items are highly likely to have a lifetime alcohol problem (King 1986). 3. Michigan Alcoholism Screening Test (MAST): The MAST is a 24-item, 53-point scale developed as a brief screening instrument (Selzer 1971). As with the CAGE, the MAST does not refer to a specific time period and therefore gathers lifetime information. A score of 5 or more on the MAST indicates alcoholism; a score of 4 is suggestive of alcoholism; and a score of less than 4 indicates nonproblematic drinking. 4. Other: The interview included questions about the use of other drugs (marijuana, cocaine, speed, barbiturates, d-lysergic acid diethylamide, phencyclidine, and narcotics) in the past 12 months, use and misuse of medications prescribed by physicians, and current and lifetime amounts of consumption of alcohol and other drugs. We asked in detail about how nonpsychotic and psychotic symptoms were affected by alcohol and other drugs (Noordsy et al., submitted for publication). We also asked patients if they considered themselves alcoholic and if they thought that alcohol caused them problems. Ratings by clinical case managers. A 5-point case manager rating scale was developed as a research instrument for clinical case managers to assess the extent of alcohol-related problems among severely ill psychiatric patients in the community (Drake et al. 1989; Drake and Wallach 1989). An earlier version showed high interrater reliability and concurrent validity (Drake et al. 1989). Ratings of none (- 1), mild (= 2), moderate (- 3), severe (= 4), and extremely severe (=5) are anchored descriptively on the basis of severity of alcohol-related problems (see Appendix A). Mild indicates nonproblematic drinking; moderate indicates problematic drinking and corresponds to DSM- Hl-R alcohol abuse; and severe and extremely severe, which correspond to DSM-IH-R alcohol dependence, denote more serious symptoms and consequences. Case managers made current and lifetime ratings on the basis of knowledge of their clients' alcohol use during the previous 12 months and over their lifetimes, respectively. The k coefficients of interrater reliability, established by comparing ratings by clinical case managers and a team psychiatrist on a subset of 15 patients, were 055 (current) and 0.72 (lifetime). Consensus diagnosis. To establish a reference standard, we explicitly examined diagnostic disagreements between the case managers' ratings and direct interview ratings. Our research team determined the sources of disagreement and reached consensus diagnoses by first reviewing all clinical and research records, and then reviewing the cases with the entire treatment team. This procedure was used to assign current and lifetime diagnoses according to DSM-U1-R. Data Analyses. Because several of our measures of alcohol use consist of rank-ordered scales with small numbers of rating categories, we used Kendall's T-C to measure the strength of association between scales. Kendall's T-C provides a conservative but valid measure of association for these types of data (Norusis 1987). The distinction between alcohol abuse and dependence has been controversial (Schuckit et al. 1985), and definitional criteria for abuse and dependence have been changed substantially from DSM-HI to DSM- III-R (Rounsaville and Kranzler 1989). The current distinction has not been validated in schizophrenia. Our data (Osher et al., in preparation) show few differences in adjustment between schizophrenic patients with alcohol abuse and those with alcohol dependence. Furthermore, for the purpose of planning treatment, identifying patients with alcohol use disorders (abuse or dependence) is probably the critical task (Osher and Kofoed 1989). We therefore focused our analyses on the detection of alcohol use disorder, defined as a DSM-III-R diagnosis of abuse or dependence. Results Identification of Problem Drinkers. Table 1 summarizes rates of identification of problem drinkers (not all scales yield diagnoses) from different perspectives and using different scales. Depending on the approach, between 7 and 53 percent of the sample were identified as having a drinking problem. Rates of identification vary less when separated into measures of current and lifetime alcohol use.

5 VOL. 16, NO. 1, Table 1. Frequencies of alcohol problems Measure Current alcohol use ADS Interview DSM-III-R rating Case manager rating Consensus DSM-III-R rating Lifetime alcohol use Hospital identification CAGE MAST Interview DSM-III-R rating Case manager rating Consensus DSM-III-R rating Total n Alcohol n Cases above and below threshold problems (%) No alcohol problems n (%) Note. ADS - Alcohol Dependence Scale. MAST - Michigan Alcoholism Screening Test. The following cutoffs were used: ADS > 14, DSM-III-R ratings > 2, case manager rating > 3, hospital identification > 2, CAGE > 2, and MAST > 5. According to consensus diagnoses, 19 patients (25.3 percent) had a current DSM-III-R diagnosis of alcohol use disorder; 10 (13.3 percent) of these met criteria for dependence and 9 (12.0 percent) for abuse. Few subjects were identified as having moderate dependence by the ADS. The complete interview identified nearly three times as many problem drinkers as the ADS, and case managers identified an even larger proportion of subjects as problem drinkers. According to consensus lifetime diagnoses, 38 patients (50.7 percent) met DSM-III-R criteria for alcohol use disorders; 27 (36 percent) had been dependent, and 11 (14.7 percent) had been abusers. For subjects with lifetime consensus diagnoses, only half were identified as having an alcohol problem by even one hospital discharge summary. The CAGE, case managers' ratings, and complete interviews identified more problem drinkers and yielded similar rates. The MAST identified the highest rate of alcohol use disorders. Agreement Between Measures. Table 2 shows that our various measures of alcohol use were highly interrelated. As expected, measures of current use were strongly correlated with each other (Kendall's T-C correlations between 0.44 and 0.60), and measures of lifetime use were highly correlated (correlations between 0.41 and 0.80), as compared with lower but still significant correlations between measures of current and lifetime use (correlations between 0.22 and 0.49). Thus, despite the use of a conservative measure of association (Kendall's T-C), these relationships were quite strong. With the case managers' 5-point scale collapsed into DSM-III-R diagnostic categories (no disorder, abuse, and dependence), the case manager and interview ratings agreed on 66 of 75 subjects (88.0 percent) for current diagnoses and on 57 of 75 subjects (76.0 percent) for lifetime diagnoses. Kendall's T-C correlations were 0.41 (p < 0.001) and 0.61 (p < 0.001), respectively. Consensus Diagnoses. Our investigations to determine the sources of disagreements and to establish consensus diagnoses revealed different results for current and lifetime assessments. For current alcohol use disorder, there were six disagreements on the distinction between no disorder and abuse, and all were resolved in consensus diagnoses of abuse. Only one patient's drinking was underestimated by the case manager but identified as abuse by interview; the case manager for this case was new, and both case records and more experienced team members quickly identified the patient as an abusive drinker. Five patients were identified as alcohol abusers by case managers but not by the complete interview. In each case, the patient denied problematic drinking at interview, but alcohol-related problems were identified by clinical records, reports from families and communities, and staff consensus. In other words, 26.3 percent of those with current alcohol use disorders (5 of 19) denied or significantly minimized their alcohol-related problems at interview. There were three disagreements on the distinction between abuse and dependence, and all were

6 62 SCHIZOPHRENIA BULLETIN Table 2. Intercorrelations of alcohol measures Current measures ADS Interview Case manager Consensus Lifetime measures Hospital identification CAGE MAST Interview Case manager Measures of current alcohol use Interview DSM-/"-R diagnosis 0.46' Case manager rating 0.51' 0.44' Consensus DSM-III-R diagnosis 0.45' 0.46' 0.60' Hospital Identification ' 0.31' 0.31' Measures of lifetime alcohol use CAGE 0.26* ' 0.29' 0.44' MAST 0.35' 0.36' 0.40' 0.39' 0.48' 0.66' Interview DSM-III-R diagnosis 0.41' 0.35' 0.45' 0.40' 0.41' 0.60' 0.79' Case manager rating Note. Full scales were used for all analyses. All correlations determined by Kendall's T-C. ADS - Alcohol Dependence Scale. MAST - Michigan Alcoholism Screening Test. 'p< »p<0.01. resolved in consensus diagnoses of dependence. In each case the case manager had rated the patient as an abusive drinker because of minimal recent alcohol-related problems, but the patient easily met DSM-IU-R criteria for dependence on the basis of the information elicited at interview; case reviews substantiated the dependence diagnoses. For lifetime alcohol use disorder, there were 11 disagreements pertaining to the distinction between no disorder and abuse, and all were resolved in the direction of consensus diagnoses of abuse. For eight of these subjects, past abusive drinking was well documented in the clinical record; the other three subjects' past abuse was known to more senior clinicians but not well documented in the clinical record. Of these 11 subjects, 4 were missed by interview because the patient denied past abuse, and 7 were missed by case managers, in part because their drinking histories were remote. Of seven cases in which the two perspectives disagreed on the distinction between abuse and dependence, three were given consensus diagnoses of abuse and four of dependence by case review. The case manager's rating was rejected in five of the seven cases, often because case managers' knowledge of remote drinking histories was found to be incomplete. 0.36' 0.36' 0.49' 0.46' 0.44' 0.60' 0.66' 0.65' Consensus DSM-III-R diagnosis 0.41' 0.33' 0.49' 0.43' 0.46' 0.68' 0.76' ' Self-Diagnosis and Denial. Despite significant correlations between consensus diagnoses and self-diagnoses (Kendall's T-C = 0.22, p < 0.001, and 0.28, p < 0.001, respectively, for current and lifetime diagnoses), the sensitivity of self-diagnosis was low. Of the 19 subjects with current alcohol use disorders according to consensus diagnoses, only 3 (15.8 percent) reported that they were definitely alcoholic and 5 (26.3 percent) that they were possibly alcoholic; 11 (57.9 percent) reported that they definitely were not alcoholic. Of 38 subjects with lifetime alcohol use disorders, 5 (13.2 percent) considered themselves definitely alcoholic, 6 (15.8 percent) possibly alcoholic, and 27 (71.0 percent) not alcoholic. When asked if alcohol caused them problems, 8 of 19 subjects

7 VOL. 16, NO. 1, (42.1 percent) with current alcohol use disorders denied problems, 2 (10.5 percent) reported possible problems, and 9 (47.4 percent) reported definite problems. The correlation between this variable and current alcohol use disorder was nonsignificant (Kendall's T-C = 0.12), in part because several subjects with lifetime but not current alcohol use disorders reported that alcohol caused them problems. Of 38 subjects with lifetime alcohol diagnoses, 14 (36.8 percent) denied problems, 4 (10.5 percent) reported possible problems, and 20 (52.6 percent) reported definite problems. The relationship between acknowledging alcohol-related problems and lifetime alcohol use disorder was highly significant (Kendall's T-C , p = ). Sensitivity and Specificity. Table 3 gives the sensitivity and specificity of various measures of alcohol use disorder in relation to our consensus diagnoses (abuse and dependence combined). For assessing current alcohol use disorder, the ADS showed poor sensitivity until its cutoff point was dropped so low that specificity became poor. Although ^e MAST shewed moderate sensitivity, both the MAST and the CAGE are lifetime measures and had low specificity for identifying current disorder because of the large number of false positives identified on the basis of past disorders that were currently in remission. The complete interview ratings showed moderate sensitivity but high specificity. Case managers' ratings provided a more sensitive estimate of current alcohol use disorder than interview measures, even when several measures were combined. Specificity was also high. Lifetime alcohol use disorder was missed at a high rate by hospital evaluations. Only half of our subjects with lifetime diagnoses were noted to have an alcohol problem on even one discharge summary. The CAGE had greater sensitivity but still identified less than threefourths of the lifetime disorders. The MAST identified a relatively high proportion of alcohol use disorders, but specificity was only moderate. When the MAST cutoff point was raised to 10, specificity improved but sensitivity dropped. Ratings based on the complete interview identified approximately the same number of lifetime disorders as case managers' ratings, and both measures again showed extremely high specificity. Discussion Our results are in accord with other recent studies in several respects. First, schizophrenic patients have high rates of problematic drinking or alcohol use disorders (OTarrell et al. 1983; Test et al. 1985, 1989; Barbee et al. 1989; Drake et al. 1989). Second, clinical records typically provide an insensitive measure of secondary diagnoses such as alcohol use Table 3. Sensitivity and specificity of alcohol measures Measure (cutoff) Current alcohol use ADS severe (> 31) ADS substantial (> 22) ADS moderate (> 14) ADS low (> 5) ADS low (> 1) CAGE (> 2) MAST (> 5) Interview DSM-III-R diagnosis Case manager rating Total n Lifetime alcohol use Hospital identification (at least once) Hospital identification (more than once) CAGE (> 2) MAST (> 5) MAST (> 10) Interview DSM-III-R diagnosis Case manager rating Total n Sensitivity n t (%) Specificity n Note. ADS - Alcohol Dependence Scale. MAST - Michigan Alcoholism Screening Test. 'Percentages based on a total n of 32 (5 subjects had no disctiarge summaries). (%) too.o

8 64 SCHIZOPHRENIA BULLETIN disorders (McLellan and Druley 1977; Helzer et al. 1978; Robins et al. 1982; Ananth et al. 1989). Third, clinicians who work closely with schizophrenic patients over time can identify problematic drinking that is denied by patients themselves (Test et al. 1989), even on structured diagnostic interviews (Alterman et al. 1984). Several of our findings are new. The wide variability in rates of identified problem drinkers that resulted from using different approaches and making the distinction between current and lifetime prevalence may explain some of the differences between studies in the literature. In particular, our data suggest that studies in which alcohol use is assessed by self-report or interview may misclassify a significant proportion of alcoholic schizophrenic patients as nonalcoholic. One problem with self-reports and interviews is that they depend upon face validity. Schizophrenic patients may deny alcohol-related problems for various reasons, including psychological defenses, neuropsychological impairments that decrease their ability to perceive the relationships between drinking and adjustment difficulties, and the tendency to provide socially desirable answers. Subjective experience data indicate that schizophrenic patients are often aware of the short-term sedative and anxiolytic effects of alcohol but not the long-term adverse effects on adjustment (Bergman and Harris 1985; Test et al. 1989; Noordsy et al., submitted for publication). Whether schizophrenic patients deny alcohol-related problems more than others with alcohol use disorders is uncertain. What is increasingly dear is that case managers who provide and coordinate community care are in a unique position to aggregate behavioral observations and collateral reports regarding alcohol-related problems. Although collateral reports of drinking often underestimate the extent of drinking (Midanik 1982; Skinner 1984), collaterals in most studies are not able to monitor problems across situations and time as are clinical case managers. Trained case managers are able to make reliable and valid assessments of current alcohol use (Drake et al. 1989) and to make diagnoses that are more sensitive and at least as specific as those attained with structured interviews. In this sense, our data support current clinical approaches that use intensive case management as a central intervention in assessing and treating substance abuse among young adults with mental illness and substance abuse problems (National Institute of Mental Health 1987; Osher and Kofoed 1989; Teague et al. 1989), among homeless alcoholics (National Institute on Alcohol Abuse and Alcoholism 1988), and among the homeless mentally ill (Goldfinger and Chafetz 1984). Current definitions of alcohol use disorder emphasize two related dimensions the alcohol dependence syndrome and alcohol-related problems (Edwards 1986). Our data suggest that assessment criteria in both of these dimensions may need to be modified for schizophrenic patients. Though alcohol-related problems were common in our sample, the full dependence syndrome was not. Schizophrenic patients may be particularly sensitive to the effects of alcohol and may encounter problems such as illness decompensation without developing the full dependence syndrome. This is consistent with previous findings that schizophrenic alcoholics have fewer symptoms of alcoholism than nonschizophrenic alcoholics (Alterman et al. 1984) and that relatively small amounts of drinking predict negative outcomes in schizophrenia (Drake et al. 1989). Typical alcoholrelated problems for schizophrenic patients include increased symptoms, disruptive behavior, housing instability, and treatment noncompliance (Drake et al. 1989; Osher et al., in preparation) rather than the familial and vocational problems typical of nonschizophrenic alcoholics. In assessing the consequences of alcohol use, difficulties that are relevant for schizophrenia should be emphasized. Standard instruments may not suffice. Thus, for example, several items on the MAST are typically not applicable to schizophrenic patients; others are confusing because of the need to attribute consequences to alcohol rather than to schizophrenia; and important behaviors such as ability to adhere to a psychosocial rehabilitation program or a medication regimen are not covered. The central concern is with how alcohol affects the schizophrenic illness and the subject's community adjustment. Therefore, the key to assessing alcohol use in schizophrenia is identifying interaction effects by careful longitudinal evaluation. Conclusions Alcohol use disorders are common, clinically significant, comorbid diagnoses in schizophrenia. Diagnosing alcohol use disorders in the context of schizophrenic illness is

9 VOL. 16, NO. 1, difficult, in part because schizophrenic patients develop alcoholrelated problems without the full dependence syndrome and do not recognize the relationships between alcohol use and adjustment difficulties. Standard assessment instruments may not provide adequate sensitivity and specificity for schizophrenic patients. Assessment should focus on the interactions between alcohol use and the schizophrenic patient's adjustment to community living. Supplementation of self-report and interview data by longitudinal observations and collateral data is frequently necessary. Case managers may be ideally situated to gather and synthesize behavioral observations and collateral reports across time and situation, and they are able to make reliable and valid assessments of current alcohol use. References Alterman, A.I.; Ayre, F.R.; and Williford, W.O. Diagnostic validation of conjoint schizophrenia and alcoholism. Journal of Clinical Psychiatry, 45: , Alterman, A.I.; Erdlen, F.R.; McLellan, A.T.; and Mann, S.C. Problem drinking in hospitalized schizophrenic patients. Addictive Behaviors, 5: , Alterman, A.I.; Erdlen, F.R.; and Murphy, E. Alcohol abuse in the psychiatric hospital population. Addictive Behaviors, 6:69-73, American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: The Association, Ananth, ].; Vandewater, S.; Kamal, M.; Brodsky, A.; Gamal, R.; and Miller, M. Missed diagnosis of substance abuse in psychiatric patients. Hospital & Community Psychiatry, 40: , Barbee, J.G.; Clark, P.D.; Craqanzano, M.S.; Heintz, G.C.; and Kehoe, C.E. Alcohol and substance abuse among schizophrenic patients presenting to an emergency service. Journal of Nervous and Mental Disease, 177: , Bergman, H.C., and Harris, M. Substance abuse among young adult chronic patients. Psychosocial Rehabilitation Journal, 9:49-54, Boyd, J.H.; Burke, J.D.; Gruenberg, C.E.; Holzer, C.E.; Rae, D.S.; George, L.K.; Karno, M.; Stoltzman, R.; McEvoy, L.; and Nestadt, G. Exclusion criteria of DSM-HI. Archives of General Psychiatry, 41: , Breakey, W.R.; Goodell, H.; Lorenz, P.C.; and McHugh, PR. Hallucinogenic drugs as precipitants of schizophrenia. Psychological Medicine, 4: , Drake, R.E.; Osher, EC; and Wallach, M.A. Alcohol use and abuse in schizophrenia: A prospective community study. Journal of Nervous and Mental Disease, 177: , Drake, R.E., and Wallach, M.A. Substance abuse among the chronic mentally ill. Hospital & Community Psychiatry, 40: , Edwards, G. The alcohol dependence syndrome: A concept as stimulus to inquiry. British Journal of Addiction, 81: , Freed, E.X. Alcoholism and schizophrenia: The search for perspectives. Journal of Studies on Alcohol, 36: , Goldfinger, S.M., and Chafetz, L. Developing a better service delivery system for the homeless mentally ill. In: Lamb, H.R., ed. The Homeless Mentally III: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Press, pp Hedlund, J.L., and Vieweg, B.W The Michigan Alcoholism Screening Test (MAST): A comprehensive review. Journal of Operational Psychiatry, 15:55-65, Helzer, J.E.; Clayton, P.J.; and Pambakian, R. Concurrent diagnostic validity of a structured psychiatric interview. Archives of General Psychiatry, 35: , Helzer, J.D., and Pryzbeck, T.R. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment. Journal of Studies on Alcohol, 49: , Horn, J.L.; Skinner, H.A.; Wanberg, K.W.; and Foster, F.M. Alcohol Dependence Scale (ADS). Toronto: Addiction Research Foundation of Ontario, King, M. At risk drinking among general practice attenders: Validation of the CAGE questionnaire. Psychological Medicine, 16: , Lehman, A.F.; Myers, P.; and Corty, E. Assessment and classification of patients with psychiatric and substance abuse syndromes. Hospital & Community Psychiatry, 40: , Mayfield, D.; McCleod, G.; and Hall, P. The CAGE questionnaire: Validation of a new alcoholism screening questionnaire. American Journal of Psychiatry, 131: , McLellan, A.T., and Druley, K.A.

10 66 SCHIZOPHRENIA BULLETIN Non-random relation between drugs of abuse and psychiatric diagnosis. Journal of Psychiatric Research, 13: , Midanik, L. The validity of selfreported alcohol consumption and alcohol problems: A literature review. British Journal of Addiction, 77: , National Institute on Alcohol Abuse and Alcoholism. Synopses of Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health. Synopses of Community Support Program Demonstration Projects Re: Young Adults With Mental Illness and Substance Abuse Problems. Rockville, MD: Community Service Systems Branch, Division of Education and Service Systems Liaison, NTMH, Noordsy, D.L.; Drake, R.E.; Osher, EC; Teague, G.B.; Hurlbut, S.C.; and Beaudett, M.S., "Alcohol in Schizophrenia: Subjective Experiences." Submitted for publication. Norusis, M.J. The SPSS Guide to Data Analysis. Chicago: SPSS Inc., OTarrell, T.J.; Connors, G.J.; and Upper, D. Addictive behaviors among hospitalized psychiatric patients. Addictive Behaviors, 8: , Osher, EC; Drake. R.E.; Hurlbut, S.C.; Noordsy, D.L.; Beaudett, M.S.; and Teague, G.B. "Correlates of Alcohol and Drug Use in a Rural Sample of Schizophrenics." In preparation. Osher, EC, and Kofoed, L.L. Treatment of patients with both psychiatric and psychoactive substance use disorders. Hospital & Community Psychiatry, 40: , Ridgely, M.S.; Osher, EC; and Talbott, S.A. Chronically Mentally III Young Adults With Substance Abuse Problems: Treatment and Training Jsswes. Rockville, MD: Alcohol, Drug Abuse, and Mental Health Administration, Robins, L.N.; Helzer, J.E.; and Ratdiff, K.S. Validity of the Diagnostic Interview Schedule, Version II: DSM-II1 diagnoses. Psychological Medicine, 12: , Rounsaville, B.J., and Kranzler, H.R. The DSM-HI-R diagnosis of alcoholism. In: Tasman, A.; Hales, R.E.; and Frances, A.J., eds. Review of Psychiatry. Vol. 8. Washington, DC: American Psychiatric Press, pp Safer, D. Substance abuse by young adult chronic patients. Hospital & Community Psychiatry, 38: , Schneier, F.R., and Siris, S.G. A review of psychoactive substance use and abuse in schizophrenia: Patterns of drug choice. Journal of Nervous and Mental Disease, 175: , Schuckit, M.A.; Zisook, S.; and Mortola, J. Clinical implications of DSM-III diagnoses of alcohol abuse and alcohol dependence. American Journal of Psychiatry, 142: , Selzer, M.L. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127:89-94, Skinner, H.A., Assessing alcohol use by patients in treatment. In: Smart, R.E.; Cappell, H.; Glaser, F.B.; Israel, Y.; Kalant, H.; Schmidt, W.; and Sellers, M., eds. Research Advances in Alcohol and Drug Problems. Vol. 8. New York: Plenum Publishing Company, Skinner, H.A., and Sheu, W.J. Reliability of alcohol use indices: Lifetime drinking history and the MAST. Journal of Studies on Alcohol, 42: , Teague, G.; Mercer-McFadden, C; and Drake, R.E. Dual diagnosis and continuity of care: New Hampshire's integrated initiatives for dual diagnosis patients. Tie-Lines, 6:1-3, Test, M.A.; Knoedler, W.H.; Allness, D.J.; and Burke, S.S. Characteristics of young adults with schizophrenic disorders treated in the community. Hospital & Community Psychiatry, 36: , Test, M.A.; Wallisch, L.S.; Allness, D.J.; and Ripp, K. Substance use in young adults with schizophrenic disorders. Schizophrenia Bulletin, 15: , Toland, A.M., and Moss, H.B. Identification of the alcoholic schizophrenic: Use of clinical laboratory tests and the MAST. Journal of Studies on Alcohol, 50:49-53, Weiss, R.D., and Mirin, S.M. The dual diagnosis alcoholic: Evaluation and treatment. Psychiatric Annals, 19: , Yesavage, J.A., and Zarcone, V. History of drug abuse and dangerous behavior in inpatient schizophrenics. Journal of Clinical Psychiatry, 44: , 1983.

11 VOL. 16, NO. 1, Acknowledgments This research was supported by USPHS grants 1-R01-AA from the National Institute on Alcohol Abuse and Alcoholism and 1-R18-MH from the National Institute of Mental Health (NIMH), and NIMH Research Scientist Development Award 1-K02-MH The authors thank Drs. Arthur Alterman and Michael Appendix A: Case Manager Rating Scale for Alcohol Use Disorder Wallach for their comments on an earlier draft of this manuscript. The Authors Robert E. Drake, M.D., Ph.D., is Associate Professor of Psychiatry; Fred C. Osher, M.D., is Assistant Professor of Clinical Psychiatry; Douglas L. Noordsy, M.D., is Please rate your client's use of alcohol over the past year according to the following scale. You should weigh evidence from self-report, interviews, behavioral observations, and collateral reports (family, group home, day center, community, etc.) in making this rating. 1 = none. Client has not used alcohol during this time interval. D2" mild. Client has used alcohol during this time interval, but there is no evidence of persistent or recurrent social, occupational, psychological, or physical problems related to use and no evidence of recurrent dangerous use. D 3 - moderate. Client has used alcohol during this time interval and there is evidence of persistent or recurrent social, occupational, psychological, or physical problems related to use or evidence of recurrent dangerous use. Problems have persisted for at least 1 month. For example, recurrent alcohol use leads to disruptive behavior and housing problems. Adjunct Assistant Professor of Clinical Psychiatry; and Gregory B. Teague, Ph.D., is Assistant Professor of Clinical Psychiatry, Dartmouth Medical School, Hanover, NH. Stephanie C. Hurlbut, B.A., is Psychology Graduate Student, University of Missouri-Columbia, Columbia, MO. Malcolm S. Beaudett, M.D., is Staff Psychiatrist, Hampstead Hospital, Hampstead, NH. 4 = severe. Meets criteria for moderate plus at least three of the following: greater amounts or intervals of use than intended, much of time spent obtaining or using alcohol, frequent intoxication or withdrawal interferes with other activities, important activities given up because of alcohol use, continued use despite knowledge of alcoholrelated problems, marked tolerance, characteristic withdrawal symptoms, and alcohol used to relieve or avoid withdrawal symptoms. For example, drinking binges and preoccupation with drinking have caused client to <kop out of job training and nondrinking social activities. 5 = extremely severe. Meets criteria for severe plus related problems are so severe that they make noninstitutional living difficult. For example, constant drinking leads to disruptive behavior and inability to pay rent so that client is frequently reported to police and seeking hospitalization.