Substance Use Disclosure in Schizophrenia: You Can Ask, But They Might Not Tell

Leslie Citrome, MD, MPH


January 03, 2014

Under-reporting of Drug Use Among Individuals With Schizophrenia: Prevalence and Predictors

Bahorik AL, Newhill CE, Queen CC, Eack SM
Psychol Med. 2014;44:61-69

Study Summary

Bahorik and colleagues examined data from 1042 individuals with schizophrenia who participated in screening/baseline procedures for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and who completed self-rated assessments of substance use and underwent laboratory drug testing for cannabis, cocaine and methamphetamine. The investigators found that 38% of participants tested positive for drug use on laboratory measures, but 58% of this group did not report it.

Logistic regression models confirmed that patients who were most likely to conceal their use tended to be older and presented with greater neurocognitive deficits. Patients who accurately reported drug use tended to have greater involvement with the criminal justice system. Illness severity and psychopathology were not associated with whether patients disclosed drug use.


Perhaps most surprising is that illness severity and psychopathology (including insight, as measured by the Insight and Treatment Attitude Questionnaire) were not associated with disclosure of drug use. The patients who accurately reported their drug use tended to have greater involvement with the criminal justice system. The investigators speculate that a history of legal involvement rendered the patients desensitized to and less fearful of disclosing their drug use, so they tended to be more likely to accurately report substance use.

If fear of disclosing substance use is a possibility, perhaps a useful strategy would be to reinforce that this question is being asked to fully understand the individual circumstances of the person being assessed, and is not in any way meant to be judgmental or stigmatizing. As the study authors state, "Establishing a positive therapeutic alliance before asking patients to complete self-rated assessments of their drug use may additionally help to increase overall disclosure rates in this population."

In this study, the most consistent predictor of under-reported drug use was neurocognitive impairment. It would be of interest to find out whether cognitive remediation would increase a person's ability or willingness to disclose substance use.

The facts are that substance use among persons with schizophrenia is high, their use can seriously confound a diagnostic assessment, and knowing about drug use is critically important in selecting the optimal course of treatment. We must ask, and patients should be encouraged to tell.



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