Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician
7.4 Major clinical issues with psychosis and alcohol use
Table of contents
- Acknowledgments
- Abbreviations
- Preface
- Introduction
1. Levels of evidence- 2. Management of people with comorbidity of mental disorders and substance use
- 3. The common drug groups
- 4. Tobacco
- 5. Depression and substance use
- 6. Anxiety disorders and substance use
7. Psychosis (schizophrenia and bipolar disorder) and substance use- 7.1 Psychosis
- 7.2 Comorbidity with Psychosis
- 7.3 Major clinical issues with psychosis and cannabis/ hallucinogen use
- 7.4 Major clinical issues with psychosis and alcohol use
- 7.5 Major clinical issues with psychosis and opioid use
- 7.6 Major clinical issues with psychosis and stimulant (including methampetamine) use
- 7.7 Major clinical issues with psychosis and benzodiazepine use
- 7.8 Major clinical issues with psychosis and inhalent/ solvent use
- 8. Personality disorders and substance use
- 9. Eating disorders and substance use
- 10. Somatoform disorders and substance use
- 11. Gambling and substance use
- 12. Brain injury, mental disorders and substance use
- 13. Bibliography
- 14. Appendices
- People with psychosis have high rates of alcohol use disorders.
- As alcohol has several negative effects on psychosis and interacts with medications used for the treatment of psychosis, its use should be minimised.
- There is evidence suggesting that clozapine is effective in reducing alcohol consumption as well as controlling psychosis in those with comorbid alcohol use and psychosis.
- Individuals with psychosis also respond well to adjunctive treatment for alcohol dependence.
7.4.1 Effects of alcohol on psychotic disorders
- People with psychosis have high rates of alcohol use disorders. Alcohol is one of the most commonly used substances in people with psychosis(1, 2, 21, 251, 265, 268, 298).
- Alcohol may worsen or increase psychotic symptoms(15, 298, 299).
- The duration of alcohol use is associated with depression in people who have bipolar disorder(281).
- Disinhibition together with poorly controlled psychotic symptoms may lead to inappropriate or dangerous behaviours.
- There is increased general morbidity in those with psychosis and alcohol use disorders(267):
- Alcohol can increase the risk of tardive dyskinesia(2).
- Alcohol impairs delayed recall, attention, working memory, and vigilance to a greater extent inthose with psychosis compared to people without psychosis(299, 300).
7.4.2 Interactions between alcohol and therapeutic agents for psychotic disorders
- Alcohol can exacerbate the sedative effects of antipsychoticsx(2).
- There do not appear to be any safety issues for the use of acamprosate in this population and, at present, there are no known interactions with antipsychotics(2).
- Disulfiram at high doses may trigger psychotic symptomsxx(301).
- Alcohol can exacerbate the sedative effects of any sedative agents (including tricyclic antidepressants and mirtazepine, and benzodiazepines) used to treat associated depression(2) and anxiety in psychosisx.
- Alcohol toxicity may occur through:
- The inhibition of CYPs by sedative antidepressant involved in the metabolism of alcoholx(133).
- An increase in sedation as a result of combinations of alcohol and benzodiazepinesx.
7.4.3 Management approaches to comorbid psychotic disorders and alcohol use
- People with psychosis should be discouraged from using alcohol for the above mentioned reasons.
- There is evidence suggesting that clozapine is effective in reducing alcohol consumption as well as controlling psychosis in those with comorbid alcohol use and psychosis**(267, 270, 296).
- Individuals with psychosis also respond well to adjunctive treatment of alcohol dependence(302):
- Naltrexone as an adjunctive therapy has been shown to reduce drinking in individuals with psychosis and does not appear to have a negative impact on the actions of concurrently administered antipsychotics***(303).
- As people with psychosis and comorbid substance use are at increased risk of morbidity and are more prone to risk taking, individuals need to be aware of the implications of using naltrexone for emergency pain management(2).
- Patients on naltrexone therapy should be advised to carry a medical warning card or bracelet which states they will not respond to opioid analgesia (obtainable from Bristil Myers Squibb on 1800 067 567).
- Preliminary studies suggest that disulfiram can result in decreasing alcohol consumption in those living with psychosis and may be an effective adjunctive therapy to concurrently administered antipsychotics*(2, 15, 304).
- Naltrexone and disulfiram appear to be equally efficacious in reducing alcohol consumption when used as an adjunctive therapy to antipsychotics in people with psychosis***(302).
- Acamprosate is yet to be studied in individuals with comorbid psychosis and alcohol dependence. However, there do not appear to be any safety issues for its use in this population and its use is worth considering(1, 2).
- Naltrexone as an adjunctive therapy has been shown to reduce drinking in individuals with psychosis and does not appear to have a negative impact on the actions of concurrently administered antipsychotics***(303).
- Benzodiazepines used for acute alcohol withdrawal should be monitored closely and minimised for outpatient use(2). Benzodiazepine use should be restricted to short-term symptomatic use only, as those with an existing substance use disorder are at a greater risk of misusing benzodiazepines(196).
