The Schizophrenia-Cocaine Link: Breaking the Cycle
There are many barriers that can prevent individuals in low-income communities from receiving mental health services, and as a result, a slew of mental illnesses and psychological disorders go untreated (DeCarlo, Kaltman, & Miranda, 2013). Mental illnesses can be debilitating, especially when untreated, potentially interfering with typical daily responsibilities such as maintaining a steady job or caring for children and family. As mental health assistance is less accessible in low-income communities, having an untreated mental illness can feed a vicious cycle of poverty and poor mental health (Breslau, Lane, Sampson, & Kessler, 2008; DeCarlo et al., 2013). One psychological disorder that can be particularly dangerous if left untreated is schizophrenia, especially when it exists in conjunction with cocaine abuse (Power, Dragovic, Jablensky, & Stefanis, 2012). The present paper aims to investigate how lacking mental health services in low-income populations affect individuals with a comorbidity1 of cocaine abuse and schizophrenia within populations where individuals are not likely to seek psychological help. The following will identify the relationship between cocaine and schizophrenia, in terms of cocaine-induced schizophrenia and cocaine addictions among those already diagnosed with schizophrenia, specifically with regard to the lack of mental health care in low-income populations.
Cocaine Abuse and Schizophrenia in Low-Income Communities
According to the DSM-V (2013), schizophrenia is a psychological disorder that consists of “one or more of the following, each present for a significant period of time during a 1-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms, i.e., affective flattening, alogia, or avolition” (American Psychiatric Association, 2013). It is a condition that can deeply affect one’s self-care, personal relationships, and awareness of reality (American Psychiatric Association, 2013). Researchers currently believe that schizophrenia is a genetic disorder; however, there has been some difficulty in explaining the heterogeneity of the disorder (American Psychiatric Association, 2013). One reason for this is that schizophrenia tends to arise as a result of a gene-environment interaction, meaning that genetic predisposition in a schizophrenic patient exists, yet often only comes to the surface as a result of environmental experiences (American Psychiatric Association, 2013).
Because of the gene-environment interaction that must typically occur for an individual to become schizophrenic, the symptoms for which a patient is predisposed lay dormant in the patient’s system for many years before becoming active symptoms (Power et al., 2012). When psychotic symptoms surface early in one’s lifetime, they can become more intense and difficult to treat due to the lack of maturation of the brain, as the human brain does not fully develop until age 25 and schizophrenia tends to develop between ages 15 and 25 (Power et al., 2012). Studies have shown that two major instances that lead to early onset schizophrenia are stressful and traumatic life events and substance abuse (Paparelli et al., 2011; Picken & Tarrier, 2011).
Ninety-eight percent of individuals with schizophrenia report some degree of previous exposure to trauma, such as violence, abuse, and neglect, and 47-65% of individuals with schizophrenia report prior substance abuse (Picken & Tarrier, 2011; Zhornitsky et al., 2012). Incidentally, both trauma and drug abuse are two very prevalent issues in low-income populations (Bassuk, Buckner, Perloff, & Bassuk, 1998; Davis, Ressler, Schwartz, Stephens, & Bradley, 2008). Since low-income environments are often stressful and trauma-ridden, and since people in these communities rarely seek psychological help, some turn to substance abuse as a way to self-medicate, which can lead to the onset of schizophrenic symptoms (Power et al., 2012). The use of cocaine in particular has strong links to the onset of schizophrenia, especially when schizophrenic individuals report using the substance within twelve months prior to the onset of psychotic symptoms (Power et al., 2012). Researchers are still struggling to establish a definitive explanation for cocaine’s ability to induce schizophrenic symptoms in individuals. However, recent studies have shown that cocaine may cause a dysfunction in the prefrontal cortex of the brain, which is a neurological characteristic of schizophrenia (Chambers, Sentir, Conroy, Truitt, & Shekhar, 2012; Tseng, Chambers, & Lipska, 2009).
Nearly 50% of individuals with schizophrenia experience comorbid substance abuse disorder after the initial diagnosis of psychosis, most commonly with cocaine (Atkinson, 1973; Barbee, Clark, Crapanzano, Heintz, & Kehoe, 1989; Serper, Chou, Allen, Pal, & Cancro, 1999; Zhornitsky et al., 2012). As compared to the general population, people with schizophrenia have higher rates of impulsivity, sensation-seeking, and social anhedonia (i.e., disinterest in social contact) (Serper et al., 1999; Zhornitsky et al., 2012). Social anhedonia can cause dissatisfaction with everyday social activities, which can lead to impulsive drug use in order to obtain heightened sensation (Serper et al., 1999; Zhornitsky et al., 2012). Additionally, once cocaine has entered the system of a schizophrenic individual, it increases the positive symptoms (i.e., hallucinations or paranoia) in the patient. This can lead a craving for more cocaine in order to suppress the symptoms (Brady et al., 1990; Cleghorn, Kaplan, Szechtman, Szechtman, & Brown, 1991; Satel & Edell, 1991; Seper et al., 1999; Siegel, 1984).
The comorbidity of schizophrenia and substance abuse, especially cocaine abuse, is currently considered an epidemic by psychological researchers and mental health professionals alike (Jane-Llopis & Matytsina, 2006). The combination of the two disorders has led to significant difficulties in applying traditional treatment for psychotic symptoms (Jane-Llopis & Matytsina, 2006). In fact, the use of cocaine has been shown to increase the intensity of symptoms (Jane-Llopis & Matytsina, 2006; Kelly, Daley, & Douaihy, 2012; Merikangas & Kalaydjian, 2007). As a result, it becomes necessary for a combination of different types of treatment to keep psychotic schizophrenia symptoms under control, along with reducing (or ideally eliminating) the cravings for cocaine (Kelly et al., 2012). Methods include, but are not limited to, psychotherapy, pharmacotherapy, and behavioral therapy (Baker, Hides, & Lubman, 2010; Chen, Barnett, Sempel, & Timko, 2006; Kelly et al., 2012). Despite the fact that schizophrenia is much more common amongst those with lower socioeconomic status (Holzer, Shea, Swanson, & Leaf, 1986), these psychological treatments are significantly less accessible in low-income communities.
Barriers to Mental Health Service Access in Low-Income Communities
There has been an increasing amount of research that demonstrates that individuals in low-income populations do not seek the psychological help necessary for their wellbeing (Chung et al., 2012; Thornicroft, 2012; Walker et al., 1999; Walker et al., 2003). As compared to people in other communities, people in low-income communities endure more chronic stress, including economic strain, neighborhood violence, and prevalent substance abuse(Chung et al., 2012; Thornicroft, 2012). Therefore, poor accessibility to mental health services is especially detrimental in low-income neighborhoods (Chung et al., 2012; Thornicroft, 2012). Further, research shows that chronic-stress environments increase the risk of developing psychological disorders (Lipman & Boyle, 2008; DeCarlo Santiago, Kaltman, & Miranda, 2013). There is a multitude of reasons why low-income individuals may not seek psychological assistance, including financial difficulties, lack of transportation, lack of awareness about mental health treatment, and ethnic differences regarding culture and language.
Many adults in low-income populations have heavy schedules that include both a day job and a night job, leaving little free time for additional appointments (Thornicroft, 2012). Since money is necessary for survival, working takes precedence over psychological care (DeCarlo Santiago, Kaltman, & Miranda, 2013; Thornicroft, 2012). Many of these families are single-parent families in which the parent is unable to afford childcare, and may not have the time to attend psychiatric sessions (Thornicroft, 2012). It is also likely that these individuals cannot afford to pay for mental health services or do not have the health insurance necessary to assist their payments (DeCarlo Santiago et al., 2013; Thornicroft, 2012). A study performed by Sentell and Shumway (2004) found that adults with insurance had double the chance of receiving mental health services compared to adults without insurance, and having a low income is a barrier toward obtaining health insurance. Furthermore, many of these neighborhoods do not have local psychological facilities, thus requiring those in need to travel elsewhere for assistance. If accessible transportation is not available, people may be less likely to seek assistance (DeCarlo Santiago et al., 2013; Thornicroft, 2012).
As discussed earlier, treating schizophrenic patients with a drug addiction requires a combination of different treatment methods. This is necessary, as cocaine addiction and schizophrenia are two very different conditions that need to be addressed separately, to ensure fully effective treatment. It is typically necessary that more than one clinician is involved in the process, as addiction counselors often do not have adequate experience in treating other psychological disorders, and vice versa for general mental health clinicians (Wiechelt, Miller, Smyth, & Maguin, 2011). However, it is important that all clinicians treating an individual communicate with each other about the status of each condition as each condition is related and can affect the progress of the other (Wiechelt et al., 2011). A combination of treatments is even more difficult to attain than one treatment alone. When so many barriers toward mental health care already exist, the multiplicity of treatments necessary to effectively treat schizophrenia and cocaine abuse comorbidity creates yet another complication in the treatment process for individuals in low-income populations (Baker et al., 2010; Kelly et al., 2012).
Lack of knowledge about both mental health and mental health services in low-income communities is also an important consideration. If the peers and family members of low-income individuals have never sought psychological assistance, they may never become aware of available services (DeCarlo Santiago et al., 2013; Thornicroft, 2012). Additionally, studies have found that public schools in low-income neighborhoods rarely discuss the importance of mental health care in their health education classes, so people who grow up in these communities may simply never learn about the major potential benefits of such services, nor how to identify different disorders (Thornicroft, 2012).
Many of the 46.2 million people currently living below the federal poverty line in the United States are ethnic minorities, i.e., 25.6% of Hispanic descent, 27.2% of African descent, and 11.7% of Asian descent (DeNavas-Walt, Proctor, & Smith, 2011). Minority populations face many additional issues pertaining to psychological help. People working in mental health services are predominantly English-speaking, which may not be optimal for minorities who speak different first languages (DeNavas-Walt et al., 2011). According to the US Census (2003), over 13 million Spanish-speaking individuals who live in the United States either speak minimal English or no English at all. As a result, language barriers within the mental health care system presumably prevent minority groups from obtaining appropriate services.
Many minority groups may not be trusting of the people of different backgrounds who work in the mental health field (as they are often considered to be of more privileged groups), simply because they have not interacted with them before (DeNavas-Walt et al., 2011). Interviews with individuals from low-income minority groups have demonstrated that, since more privileged groups have not experienced the same hardships that they have (e.g., financial struggles, neighborhood violence, or structural discrimination), they do not understand their roots and therefore cannot be fully trusted (DeNavas-Walt et al., 2011; Thornicroft, 2012). Additionally, professionals of privileged groups may hold biased or discriminatory attitudes toward minority groups, or they may be uninformed about the cultural norms of an ethnic group, which can negatively affect treatment due to strained interactions between health professionals and those seeking aid (Roysircar, Gard, Hubbell, & Ortega, 2005).
There are 31.3 million people living in the United States without citizenship, many of whom live in low-income communities (US Department of Homeland Security, 2009). Citizens are 125% more likely than non-citizens to receive mental health services (Sentell & Shumway, 2004). Non-citizens have greater difficulty obtaining private health insurance, are ineligible for Medicaid for the first 5 years of living in the United States, and are less familiar with the United States health system as they may not have lived in the country for an extended period of time (Lee & Matejkowski, 2011). Lack of trust or familiarity between mental health professionals and those seeking aid, as well as lack of citizenship, can greatly interfere with the attainment of necessary mental health services in low-income communities.
In order to address the cycle of schizophrenia and comorbid cocaine abuse, it is crucial that mental health services become more readily available for individuals in low-income communities. Individuals with no schizophrenic symptoms, who may have had family members with untreated schizophrenia, may likely experience stressful or traumatic events in their day-to-day lives. These experiences can lead to substance abuse, which may result in the early onset of psychotic symptoms (Breslau et al., 2008; DeCarlo et al., 2013). Lack of resources and poor knowledge about mental health in these populations may cause individuals to neither seek nor receive adequate assistance (DeCarlo Santiago et al., 2013; Thornicroft, 2012). Low-income individuals whose schizophrenic symptoms did not result from trauma or substance abuse are equally unlikely to receive mental health services. Consequently, they may turn to cocaine as a form of self-medication for the disorder, which may worsen their condition (Lawrence, Rasinski, Yoon, & Curlin, 2013).
If mental health providers address the barriers low-income community members face in terms of receiving services to cope with stressful events, fewer people might resort to drug use, which could in turn keep genetic psychological issues dormant. This can be achieved by offering childcare at mental health service facilities, establishing more financial aid for treatment and transportation, and providing competent translators for those whose first language is not English. Additionally, public schools should become more active in teaching about mental health, so that people in low-income populations are well-informed about symptoms to look out for, how to seek treatment, and the resources available to them in their community.
While a significant dearth in these services does exist, it is necessary to point out that there are some organizations attempting to address the barriers between mental health services and low-income community members. One of these organizations is the Multicultural Action Center of the National Alliance of Mental Illness (NAMI), which aims to “eliminate disparities in mental health care for diverse communities, ensure access to culturally competent services and […] help and support people of diverse backgrounds who are affected by serious mental illness” (NAMI, 2013). However, more action should be taken in order to increase accessibility to mental health services to all low-income and minority populations across the country, and organizations such as NAMI should become more ubiquitous in our society. Schizophrenia is an extremely difficult condition to live with, both with and without cocaine addiction, and every step should be taken to improve mental health service access of these individuals.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Atkinson, R. M. (1973). Importance of alcohol and drug abuse in psychiatric emergencies. California Medicine, 118(4), 1-4.
Baker, A. L., Hides, L., & Lubman, D. I. (2010). Treatment of cannabis use among people with psychotic or depressive disorders: A systematic review. The Journal of Clinical Psychiatry, 71(3), 247–254.
Barbee, J.G., Clark, P.D., Crapanzano, M.S., Heintz, G.C., & Kehoe, C.E. (1999). Alcohol and substance abuse among schizophrenia patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease, 177(7), 400-407.
Bassuk, E.L., Buckner, J.C., Perloff, J.N., & Bassuk, S.S. (1998). Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. The American Journal of Psychiatry, 155(11), 1561-1564.
Brady, K., Anton, R., Ballenger, J. C., Lydiard, R. B., Adinoff, B., & Selander, J. (1990). Cocaine abuse among schizophrenic patients. American Journal of Psychiatry, 147(1), 164-1167.
Breslau, J., Lane, M., Sampson, N., & Kessler, R. (2008). Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research, 42(9), 708-716.
Chambers, R. A., Sentir, A. M., Conroy, S. K., Truitt, W. A., & Shekhar, A. (2012). Cortical striatal integration of cocaine history and prefrontal dysfunction in animal modeling of dual diagnosis. Biological Psychiatry, 67(8), 788–792.
Chen, S., Barnett, P. G., Sempel, J. M., & Timko, C. (2006). Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients’ symptom severity. Journal of Substance Abuse Treatment, 35, 95–105.
Chung, J. Y., Frank, L., Subramanian, A., Galen, S., Leonhard, S., & Green, B. L. (2012). A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care. Journal of Nervous and Mental Disease, 200(5), 438-443.
Cleghorn, J.M., Kaplan, R.D., Szechtman, B., Szechtman, H., & Brown, G.M. (1991). Substance abuse and schizophrenia: Effect on symptoms but not on neurocognitive function. Journal of Clinical Psychiatry, 52(1), 26-30.
Davis, R.G., Ressler, K.J., Schwartz, A.C., Stephens, K.J., & Bradley, R.G. (2008). Treatment barriers for low-income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 218-222.
DeCarlo Santiago, C., Kaltman, S., & Miranda, J. (2013). Poverty and mental health: How do low-income adults and children fare in psychotherapy? Journal of Clinical Psychology, 69(2), 115-126.
DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2011). U.S. Census Bureau, Population Reports. Income, Poverty, and Health Insurance Coverage in the United States. Washington, DC.
Holzer, C.E., Shea, B.M., Swanson, J.W., Leaf, P.J. (1986). The increased risk for specific psychiatric disorders among persons of low socioeconomic status. American Journal of Social Psychiatry, 6(4), 259-271.
Jane-Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515–536.
Kelly, T. M., Daley, D. C., & Douaihy, A. B. (2012). Treatment of substance abusing patients with comorbid psychiatric disorders. Addictive Behaviors, 37(1), 11-24.
Lawrence, R. E., Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2013). Physicians’ beliefs about the nature of addiction: A survey of primary care physicians and psychiatrists. The American Journal of Addictions, 22(3), 255-260.
Lee, S., & Matejkowski, J. (2011). Mental health service utilization among noncitizens in the United States: Findings from the National Latino and Asian American study. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 406-418.
Merikangas, K. R., & Kalaydjian, A. (2007).Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Current Opinion in Psychiatry, 20(4), 353–358.
National Alliance of Mental Illness. Multicultural Action Center. (n.d.). Retrieved from http://www.nami.org/Template.cfm?Section=Multicultural_Support.
Picken, A., & Tarrier, N. (2011). Trauma and comorbid posttraumatic stress disorder in individuals with schizophrenia and substance abuse. Comprehensive Psychiatry, 52(5), 490-497.
Power, B. D., Dragovic, M., Jablensky, A., & Stefanis, N. C. (2012). Does accumulating exposure to illicit drugs bring forward the age at onset in schizophrenia?. Australian and New Zealand Journal of Psychiatry, 47(1), 51-58.
Roysircar, G., Gard, G., Hubbell, R., & Ortega, M. (2005). Development of counseling trainees’ multicultural awareness through mentoring English as a second language students. Journal of Multicultural Counseling and Development, 33(1), 17-36.
Satel, S. & Edell, W.S. (1991). Cocaine-induced paranoia and psychosis proneness. American Journal of Psychiatry, 148(12), 1708-1711.
Sentell, T., & Shumway, M. (2004). Language, cultural, and systemic barriers to mental health care among racial and ethnic groups in California: Scope of the problem and implications for state policy. Retrieved from University of California, San Francisco website: http://www.cpehn.org/pdfs/FinalShumwaySentellCPACReport.pdf
Siegel, R.K. (1984). Cocaine smoking disorders: Diagnosis and treatment. Psychiatric Annals, 14(10), 728-732.
Serper, M. R., Chou, J. C., Allen, M. H., Pal, C., & Cancro, R. (1999). Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophrenia Bulletin, 25(2), 387.
Thornicroft, G. (2012). Evidence-based mental health care and implementation science in low and middle-income countries. Epidemiology and Psychiatric Sciences, 21(3), 241-244.
Tseng K. Y., Chambers R. A., & Lipska B. K. (2009). The neonatal ventral hippocampal lesion as a heuristic neurodevelopmental animal model of schizophrenia. Behav Brain Res, 204(2), 295-305.
U.S. Department of Homeland Security. (2009). Interagency Security Committee use of physical security performance measures. Retrieved from http://www.dhs.gov/xlibrary/assets/isc_physical_security_performance_measures.pdf
Van Dorn, R. A., Desmarais, S. L., Young, M. S., Sellers, B. G., & Swartz, M. S. (2012). Assessing illicit drug use among adults with schizophrenia. Psychiatry Research, 200(23), 228-236.
Walker E. A., Gelfand A., Katon W. J., Koss M. P., Von Korff M., Bernstein D., & Russo J. (1999) Adult health status of women with histories of childhood abuse and neglect. Am J Med, 107(4), 332-339.
Walker E. A., Katon W., Russo J., Ciechanowski P., Newman E., & Wagner A. W. (2003). Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry. 60(4), 369-374.
Wiechelt, S. A., Miller, B. A., Smyth, N. J., & Maguin, E. (2011). Associations between post traumatic stress disorder symptoms and alcohol and other drug problems: Implications for social work practice. Practice: Social Work in Action, 23(4), 183-199.
Zhornitsky, S., Rizkallah, E., Pampoulova, T., Chiasson, J. P., Lipp, O., Stip, E., & Potvin, S. (2012). Sensation-seeking, social anhedonia, and impulsivity in substance use disorder patients with and without schizophrenia and in non-abusing schizophrenia patients. Psychiatry Research, 200(2-3), 237-241.