CLINICAL HANDBOOK OF SCHIZOPHRENIA

464 VI. SPECIAL POPULATIONS AND PROBLEMSalso have physical disorders and a complex web of social, financial, legal, housing, andoccupational issues. It is time that we recognize this complexity by using a different term.Significant practical issues are raised by this complexity. Which problem should beaddressed first? Which ones are critical to overall recovery?In some cases, the mental disorder may be secondary to the substance use, and treatingthe latter can resolve the former. However, this is not strictly a group with independent,co-occurring disorders. For most people with both psychosis and an SUD, the problemsare linked by threads of mutual influence. For example, symptom exacerbation ismore likely after greater cannabis use, but higher cannabis use is also more likely whensymptoms are worse.A more complex or multifaceted treatment is not necessarily the answer—especiallyif treatment strategies simultaneously impose high memory or performance demands onparticipants. Focusing on one current treatment target that is likely to produce the mostimpact on the total set of problems may be a better approach. An example of a potentialtarget with multiple impacts is increasing positive, nondrug activities: This potentiallyaffects not only the time spent on substance use and total amount consumed but also addressesdysphoria and perhaps social contact. Another example, employment, offers multipleopportunities for pleasure and increased functioning, provides a strong reason forsubstance control, and is inconsistent with substance use over most of the week. Multiimpacttreatment targets need to be identified for each individual and tailored to his orher current status and valued goals.Priority Setting Requires a Balance of Frequency, Severity,and AcceptabilityThe most commonly used drugs are not necessarily the ones with greatest impact on psychoticsymptoms, physical health, or social functioning. Injected or smoked drugs andillegal drugs of unknown content or potency, of course, pose particular risks. Hallucinogensand amphetamines have particularly strong effects on symptoms, as can cannabis,but as I already noted, nicotine and alcohol are by far the most commonly used substances.As a result, the latter drugs have the greatest impact in the population withsevere mental disorders, just as they do in the general population. There are sometimesdifficult priority issues relative to substances: Should we focus on the substances that mostcommonly affect clients, or on those that have the greatest impact on individual users?Clearly, there is not a single answer to this question, but initial work with individualclients is usually more productive if it focuses on substances about which they are alreadyconcerned. One substance that scores high on both frequency and risk is also a commonfocus of client concern. Nicotine is not only the most common substance used by peoplewith psychoses (up to 80% smoke cigarettes according to surveys) but it is also the greatestsingle contributor after suicide to excess mortality and morbidity in psychosis. Nicotineuse is often neglected as a treatment target—perhaps because of high rates of smokingby staff, because of its use in the past to calm or reward clients, or because there islittle evidence that it exacerbates psychotic symptoms. In fact, nicotine moderates negativesymptoms, improving cognitive performance in particular. However, the additionaldopamine release and faster drug metabolism seen in smokers mean that up to 50% moreof the older antipsychotics is needed for effective symptom control. Cigarette smoking isa noncontentious target for many consumers, because of exposure to public campaignson the dangers of smoking, and because it is not subject to the same opprobrium as illegalsubstance use. Nicotine should not be neglected in assessment and intervention forcomorbidity.