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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Schizophr Res. Author manuscript; available in PMC Nov 1, 2012.
Published in final edited form as:
PMCID: PMC3195925
NIHMSID: NIHMS316895

ACCURACY OF SELF-REPORTED MEDICAL PROBLEMS IN PATIENTS WITH ALCOHOL DEPENDENCE AND CO-OCCURRING SCHIZOPHRENIA OR SCHIZOAFFECTIVE DISORDER

Abstract

Background

Schizophrenia and alcohol dependence (AD) are both major risk factors for a variety of medical problems, yet little is known about the medical status of patients in whom both conditions coexist.

Objective

To assess accuracy of self-reported medical problems and to compare the accuracy reports in patients with schizophrenia or schizoaffective disorder and co-occurring AD compared to patients with AD only and to controls. Our hypothesis was that medical problems are under-reported in patients with co-occurring disorders, possibly due to the combination of alcohol use and symptoms of schizophrenia.

Methods

Self-reported medical diagnoses were recorded and compared to medical records obtained from all area hospitals in 42 patients with schizophrenia and AD, 44 patients with schizoaffective disorder and AD, 41 patients with AD only, and 15 control subjects. Patients underwent a medical history, physical examination, and review of medical records.

Results

Patients with schizophrenia or schizoaffective disorder and co-occurring AD underreported their medical problems significantly more than patients with AD only and controls. Accuracy of self report was significantly lower in patients with schizophrenia-spectrum disorders plus co-occurring alcohol dependence than in AD alone or in controls. The most commonly underreported diagnoses included coronary artery disease, chronic renal failure, seizure disorder, hyperlipidemia, asthma and hypertension.

Discussion

In order to detect potentially unreported medical conditions in patients with co-occurring schizophrenia/schizoaffective disorder and alcohol dependence, the use of targeted screening questionnaires is recommended in addition to physical examination and thorough review of medical records.

Keywords: alcohol, schizophrenia, schizoaffective disorder, medical illness, self-report

1. INTRODUCTION

Schizophrenia has been described as a “life-shortening disease” (Capasso et al. 2008, Colton and Manderscheid, 2006, Lambert et al. 2003). In the United States life expectancy is significantly shorter and mortality rates are significantly higher for patients with schizophrenia, compared to the general population. Over one-third of patients with schizophrenia meet criteria for an alcohol use disorder (AUD) – over three times the prevalence in the general population (D’Souza et al. 2006, Green and Brown 2006, Jeste et al. 1996, Regier et al. 1990). Excluding nicotine, AUDs are the most common co-occurring substance use disorders (SUDs) in schizophrenia (Drake and Mueser, 2002).

It has been estimated that more than 50% of patients with schizophrenia have another medical diagnosis (Mitchell and Malone, 2006). The most prevalent medical problems in this population include diabetes (Dixon et al. 1999, Muir-Cohrane, 2006), hyperlipidemia (Lambert et al. 2003), obesity (Lambert et al. 2003, Goff et al. 2005), COPD (Carney et al. 2006), cardiovascular disease (notably hypertension) (Lambert et al. 2003, McCradie et al. 2003), and hepatitis (Lambert et al. 2003, Carney et al. 2006, Nasrallah 2005). Shorter life expectancy is due mainly to cardiovascular disease (CVD) (Fleischhacker et al. 2008) associated with the frequent occurrence of low HDL, high triglyceride levels (Nasrallah et al. 2006), smoking and substance abuse (Green et al. 2007).

AUDs increase the likelihood of developing a wide range of medical problems (De Alba et al. 2004, Liskow et al. 2000). Excessive alcohol use affects numerous body systems including the nervous, gastrointestinal, hematopoietic, cardiovascular, and endocrine systems. Heavy alcohol use is also associated with an increased risk of cancer.

Schizophrenia and alcohol use disorders are therefore both independent major risk factors for a variety of medical problems. Patients with schizophrenia and co-occurring SUDs have higher morbidity than patients with schizophrenia alone (Dickey et al. 2002, Batki et al. 2009). Medical conditions may go unrecognized and undertreated, placing this patient population at a higher risk. General health care may be neglected in these patients (Nasrallah et al. 2006, De Alba et al. 2004, Liskow et al. 2000) because of barriers between mental health and general health services, stigma, cognitive problems due both to substance use and to schizophrenia, and problems with adherence (Meyer and Nasrallah 2003, Druss, 2002, Druss and Rosenheck 1998). Inadequate recognition of medical illness and poor access to care may contribute to the high morbidity and mortality of patients with schizophrenia and AUD, compared to the general population (Dixon et al. 1999, Nasrallah et al. 2006, Batki et al. 2009).

The aim of the present study was to assess and compare accuracy of self reported medical problems in patients with schizophrenia or schizoaffective disorder plus AD, patients with AD and in control subjects. We also aimed to identify the most commonly underreported medical diagnoses. We examined possible relationships between accuracy of self report and demographic variables, alcohol and other substance use severity, psychiatric symptom severity, and number of verified medical diagnoses. Our hypothesis was that self-report of medical history is less accurate in patients with co-occurring alcohol dependence and schizophrenia/schizoaffective disorder compared to those with alcohol dependence only or to controls..

2. METHODS

2.1. PARTICIPANTS

We obtained data from a total of 142 participants enrolled in two NIAAA-funded parent studies. The first study was a double-blind, placebo controlled trial of directly monitored naltrexone treatment for alcohol dependence in schizophrenia (Batki et al. 2009). Participants were 86 patients with schizophrenia or schizoaffective disorder, and co-occurring alcohol dependence, recruited from community mental health clinics in Syracuse, New York. Forty-four had schizoaffective disorder and 42 had schizophrenia. We analyzed baseline data collected during the screening phase. The second study was designed to examine genetic biomarkers of ethanol-induced brain damage in non-treatment seeking patients with alcohol dependence (N=41), and controls recruited from the community (N=15). All patients in both parent studies provided informed consent.

2.2. ACCURACY OF SELF-REPORT

All patients underwent a detailed structured medical history, physical examination, and review of all available medical records. Medical records were requested going back 6 months prior to the time of enrollment in the two parent studies. Self-reported medical problems were documented and compared to problems obtained from medical records (outpatient clinic charts, inpatient discharge summaries, and emergency room visit records) requested from all local hospitals in the Syracuse metropolitan area. Accuracy was calculated as percent of verified medical conditions reported in patients who had at least one medical condition. The numerical difference between verified and self reported medical diagnoses was determined for each subject as a measure of underreporting of medical problems.

2.3. DEMOGRAPHIC VARIABLES

Baseline demographic data included age, gender, race, level of education, and employment status.

2.4. MEASURES OF ALCOHOL AND SUBSTANCE USE

Alcohol and substance use and diagnoses were assessed with the Timeline Follow-Back (TLFB) interview (Sobell et al. 1985) and the Structured Clinical Interview for DSM-IV (SCID) (First et al. 2001).

2.5. MEASURES OF PSYCHIATRIC SEVERITY

Schizophrenia symptoms were assessed by the Positive and Negative Syndrome Scale (PANSS) (Kay et al. 1987). Interviewers were certified by the PANSS Institute. Diagnosis of schizophrenia vs. schizoaffective disorder was determined using the SCID. Severity of depression was assessed with the Calgary Depression Scale for Schizophrenia [CDSS] in patients with schizophrenia or schizoaffective disorder (Addington et al. 1993).

2.6. STATISTICAL ANALYSES

Statistical analyses were performed using IBM SPSS (Statistical Package for Social Sciences), version 18 software (IBM Co., Somers, NY). All tests employed two-tailed alpha to reject the null of 0.05. Wilcoxon signed ranks test was applied to compare number of medical diagnoses reported vs. number of verified medical diagnoses in each subject (measure of underreporting). Kruskal-Wallis test was used to compare accuracy of self report between groups (schizophrenia/AD vs. schizoaffective/AD vs. AD vs. control patients). Mann-Whitney U-test was used to compare underreporting in each group. Pairwise association (Spearman’s rho coefficient) was performed using the data of 142 subjects to assess the association between accuracy of self report and the following measures:

  1. demographic variables: age, gender, years of education, and employment status
  2. alcohol and other substance use variables: number of drinking days/month, number of standard drinks/week, number of cigarettes/week, cocaine use (number of days/moth), cannabis use (number of days/moth)
  3. variables describing severity of psychiatric symptoms: PANSS positive, negative, and general scores, the PANSS composite index (positive minus negative scale score) Calgary Depression Scale for Schizophrenia
  4. number of total verified medical diagnoses.

3. RESULTS

Demographic data, number of verified and reported medical diagnoses, psychiatric symptom severity and alcohol and substance use are summarized in Table 1. The majority of patients with schizophrenia, schizoaffective disorder, and alcohol dependence were middle-aged, male, Caucasian, single, unemployed and supported on welfare or disability payments. Control patients included a higher proportion of women, were more likely to be employed and smoked less. PANSS positive and negative scores were moderately low in the schizophrenia/schizoaffective disorder patients as compared to the inpatient standard used as a normative group in PANSS manual (Kay et al. 2006).

Table 1
Socio-demographic and clinical characteristics

Patients with alcohol dependence drank significantly more than controls and patients with schizophrenia/AD. Schizoaffective patients drank significantly more than patients with schizophrenia. There was no significant difference in drinking severity between schizoaffective/AD vs. AD patients. Patients with schizoaffective disorder and AD had significantly more verified medical problems (on average, 3.3) compared to controls, patients with schizophrenia/AD, and patients with alcohol dependence only (Table 1.).

Subjects with alcohol dependence, schizophrenia/AD or schizoaffective disorder/AD underreported their medical problems. The number of self-reported medical problems was significantly lower than the actual verified number of diagnoses in subjects with schizophrenia/AD (Wilcoxon test p=0.001), schizoaffective disorder/AD (Wilcoxon test p<0.001), and alcohol dependence only (Wilcoxon test p=0.039). By contrast, control subjects accurately reported nearly all (98%) of their medical problems. Patients with schizophrenia plus AD and with schizoaffective disorder plus AD were significantly less accurate in reporting medical conditions than either patients with AD alone (p=0.027 and p<0.001, respectively) or controls (p=0.043 and p=0.002, respectively) (Mann-Whitney U test). There was no significant difference in accuracy between patients with AD alone and controls.

Although accuracy of self-report was significantly lower in schizophrenia/schizoaffective disorder plus AD, accuracy was independent of measures of alcohol and other substance abuse severity or psychosis severity (PANSS scores), as well as of age, gender, employment, and education. Accuracy of self-report correlated negatively with the total number of verified medical diagnoses in patients with alcohol dependence, schizophrenia/AD and schizoaffective disorder/AD. Results of the association analyses are summarized in Table 2.

Table 2
Correlation analyses between under-reporting of medical diagnoses and demographics, medical illness burden, alcohol and addiction severity and psychiatric severity.

The most commonly underreported medical diagnoses in patients with schizophrenia/AD and schizoaffective disorder/AD were coronary artery disease (5 of 5, 100% not reported), chronic renal failure (2 of 2, 100% not reported), osteoarthrosis and degenerative disk disease (6 of 12, 50% not reported), seizure disorder (2 of 6, 33% not reported), gastro-esophageal reflux disease (6 of 21, 29% not reported), hyperlipidemia (4 of 18, 22% not reported), asthma (3 of 19, 16% not reported), and hypertension (5 of 37, 14% not reported).

4. DISCUSSION

The aim of the present study was to assess accuracy of self-report of medical problems in patients with schizophrenia or schizoaffective disorder and co-occurring alcohol dependence compared to patients with alcohol dependence only, and to controls. In contrast with the previously reported high accuracy of self-reported drug and alcohol use in research settings (Dennis et al. 2004), self-report regarding medical problems was of limited accuracy in patients with alcohol dependence only, and was significantly less accurate in patients with co-occurring schizophrenia/AD and schizoaffective disorder/AD. Even though patients in this study reported the majority of their medical problems, a substantial portion of their chronic medical conditions was unreported. While patients with co-occurring schizophrenia-spectrum disorder and AD were more inaccurate in reporting medical problems than those with AD only, accuracy of self report did not correlate significantly with measures of alcohol use and psychosis severity but did correlate negatively with number of medical diagnoses. The lack of significant correlation between accuracy of self-report and selected measures psychosis and substance use severity in this small cohort does not rule out the potential influence of psychosis and substance use severity on accuracy.

The strengths of the present study are that medical problems and substance use disorders were thoroughly assessed through different means: physical examination, laboratory tests, self report, diagnostic interviews and comprehensive review of medical records. Since the Syracuse metropolitan area has only five major medical centers, it was possible to obtain medical records from all area hospitals, and the chance of missing important diagnoses was therefore low. Study measures were carried out by trained medical research staff, who evaluated patients in a highly structured format, possibly leading to greater accuracy than everyday clinical practice. Weaknesses of this study are the limited cohort size and cross-sectional nature, and the absence of a schizophrenia-only control group. Another important limitation is the presence of multiple significant demographic differences between the control group and patient groups.

Physicians are often unaware of the numerous chronic medical conditions present in patients with schizophrenia-spectrum disorders and alcohol dependence. Our findings indicate that the combination of these disorders is associated with less accurate reporting of medical problems than controls and even patients with alcohol dependence alone. Therefore, self-report may not reliable in these patients, especially if they have multiple medical problems. We recomend performing a physical examination and reviewing all available medical records thoroughly when treating patients with schizophrenia-spectrum disorders and co-occurring alcohol dependence. The use of targeted screening forms including questions about the commonly-occurring medical illnesses found in this population (Batki et al., 2009) may aid in improving the medical care of these vulnerable patients.

Footnotes

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