Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?
ABSTRACT Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income.
We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks.
Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs.
Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.
- [Show abstract] [Hide abstract]
ABSTRACT: Correction of lack of insight in psychiatric patients has the potential to improve both the accuracy of diagnosis and the effectiveness of therapy. Specific aspects of insight include `awareness' by an individual of specific symptoms and behaviours, plus the awareness that such symptoms can be attributed (by the patient) to the presence of a mental disorder. Although this review focuses on adherence with medication, `insight' encompasses far more than just medications and adherence with medication regimens. Impaired or restricted insight may be the result of many factors, including inability to read or to cognitively understand, deficient `health literacy' and the presence of psychopathology such as delusions or hallucinations, among others. While there is a detrimental effect on therapy because of lack of insight, accurate and comprehensive diagnoses may also be negatively affected because the patient may be unable to provide an adequate history enabling the establishment of such a diagnosis. Nonadherence can now be predicted much more accurately, especially with the use of techniques that assess the insight of the patients and their significant others. A variety of management strategies can be implemented effectively with accurate monitoring of medications and treatment-related behaviours, and by measuring adherence and the prediction of nonadherence. Many factors have been identified which are amenable to diagnostic and therapeutic intervention. Among these are the many simple but frequently overlooked issues including the high cost of medication and general or specific health illiteracy sufficient to make understanding medication directions difficult. However, cost-effective education and truly effective collaborations with patients (and significant others) remain major challenges. The ideal programmes for most patients, and especially those with complex problems such as comorbid alcohol or drug use, are the more comprehensive, multidisciplinary rehabilitation programmes. Such comprehensive strategies are probably cost effective in the long term, although few cost analyses been carried out. Nevertheless, there is ample evidence that even patients who are difficult to manage can be effectively treated as inpatients and subsequently as outpatients. Perhaps the most important aspect of insight and adherence is early assessment and planning for those who are at risk of not cooperating with all kinds of therapy, including medication. The assessment and inventory of the positive factors that will facilitate cooperation and adherence to treatment regimens allows therapists to predict insight and adherence and to tailor their interventions and therapies so as to maximise the beneficial outcome.Disease Management and Health Outcomes 01/1998; 4(3):157-175. · 0.36 Impact Factor
Article: Pathways to Assignment of Payees.[Show abstract] [Hide abstract]
ABSTRACT: How clients come to be assigned representative payees and/or conservators to manage their funds is not well understood. We compared clients assigned a payee during a clinical trial of a money management-based intervention to those not assigned payees and examined antecedents to payee assignment. One year after randomization, significantly more clients assigned to the advisor teller money manager (ATM) money management intervention were assigned payees than participants in the control condition (10 of 47 vs. 2 of 43; p = .02); those assigned payees had lower baseline GAF scores and participated more in study therapies. Several ATM clients were assigned payees after third parties paid more attention to clients' finances, and others after having negotiated storage of their funds with the ATM money manager during the study. Assignment of payees appears to be influenced by whether third parties critically attend to how clients' manage funds and by clients' receptiveness to having a payee.Community Mental Health Journal 06/2013; · 1.03 Impact Factor
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ABSTRACT: The community mental health movement of the 1960s enjoyed widespread public support but poorly served its intended target population of seriously mentally ill individuals because: (1) its professional values and technology were, at least initially, not well-oriented toward serving people with severe mental illness; (2) organizational structures linking Community Mental Health Centers with State Mental Health Agencies, State Hospitals, and other relevant service agencies were lacking; (3) ideologically driven aspirations diverted energies and resources into diffuse goals related to the achievement of social justice; and (4) performance objectives were not operationally defined or monitored. Since that time professional technologies and organizational linkages have substantially improved, but there has been a loss of public support for safety net services for the least well off, in part due to a general ascendence of individualist market values, declining civic engagement and reduced support for specialized services for the disadvantaged. A new community mental health movement would be less oriented towards stimulating broad community change, and more narrowly focused on building support among decision makers and the public at large to expand the availability of costly but effective and improved services for people with severe and persistent mental illness.Community Mental Health Journal 03/2000; 36(1):107-24. · 1.03 Impact Factor
Mon Aug 21 012:03:26
Vol. 333 No. 12DISABILITY INCOME, COCAINE USE, AND HOSPITALIZATION AMONG SCHIZOPHRENICS 777
DISABILITY INCOME, COCAINE USE, AND REPEATED HOSPITALIZATION AMONG
SCHIZOPHRENIC COCAINE ABUSERS
A Government-Sponsored Revolving Door?
, M.D., T
, M.D., J
, M.A., J
tal illness are addicted to drugs and alcohol. This comor-
bidity creates additional problems for the patients and for
the clinicians, health care systems, and social-service
agencies that provide services to this population. One
problem is that disability income, which many people with
serious mental illness receive to pay for basic needs, may
facilitate drug abuse. In this study, we assessed the tem-
poral patterns of cocaine use, psychiatric symptoms, and
psychiatric hospitalization in a sample of schizophrenic
patients receiving disability income.
Methods.We evaluated 105 male patients with schizo-
phrenia and cocaine dependence at the time of their ad-
mission to the hospital. They had severe mental illness
and a long-term dependence on cocaine, with repeated
admissions to psychiatric hospitals; many were home-
less. The severity of psychiatric symptoms and urinary
problems for the patients and for the clinicians, health
care systems, and social-service agencies that provide
services to this population. Drug abuse often exacer-
bates psychiatric symptoms and contributes to home-
lessness, violence, and poor compliance with treat-
ment. About half the psychiatric patients in emergency
rooms and inpatient psychiatric programs have prob-
lems that are complicated by substance abuse,
many of these patients have schizophrenia. In a large
the lifetime prevalence of sub-
stance abuse among schizophrenic patients was esti-
mated at 47 percent; the prevalence of cocaine use was
17 percent. In a sample of hospitalized schizophrenic
patients, the overall rate of substance use was 56 per-
cent, and 27 percent of the patients used cocaine.
Cocaine use is particularly destructive in the pres-
ence of schizophrenia, because cocaine is dopaminer-
gic, and excess dopamine has been associated with the
pathophysiology of schizophrenia.
stimulants can exacerbate the course of schizophrenia
by causing dysphoria, insomnia, agitation, and increased
aggressiveness. Abuse of stimulants has also been as-
sociated with an increased rate of psychiatric hospital-
ization. These findings suggest a pattern of repeated
Many patients with serious men-
concentrations of the cocaine metabolite benzoylecgo-
nine were evaluated weekly for 15 weeks.
Results.Cocaine use, psychiatric symptoms, and hos-
pital admissions all peaked during the first week of the
month, shortly after the arrival of the disability payment,
on the first day. The average patient spent nearly half his
total income on illegal drugs.
Conclusions. Among cocaine-abusing schizophrenic
persons, the cyclic pattern of drug use strongly suggests
that it is influenced by the monthly receipt of disability
payments. The consequences of this cycle include the
depletion of funds needed for housing and food, exacer-
bation of psychiatric symptoms, more frequent psychiatric
hospitalization, and a high rate of homelessness. The
troubling irony is that income intended to compensate for
the disabling effects of severe mental illness may have
the opposite effect. (N Engl J Med 1995;333:777-83.)
From the West Los Angeles Veterans Affairs Medical Center and the Depart-
ment of Psychiatry and Behavioral Sciences, UCLA School of Medicine, Los An-
geles. Address reprint requests to Dr. Shaner at the West Los Angeles Veterans
Affairs Medical Center (116A), 11301 Wilshire Blvd., Los Angeles, CA 90073.
Supported by grants from the National Institute of Mental Health (R01
MH48081), the Department of Veterans Affairs (IIR 90-033), and the UCLA Clin-
ical Research Center for Schizophrenia.
ANY patients with severe mental illness are ad-
dicted to drugs and alcohol, creating additional
Cocaine and similar
cycles of emergency hospitalization for acute psychosis
precipitated by drug use.
Many schizophrenic persons receive disability in-
come from the Social Security Administration or, if they
are veterans, from the Department of Veterans Affairs.
This income is intended to cover the basic needs of
people with severe mental illness. Public attention has
recently focused on the troubling possibility that sub-
stance abusers who have no other mental disorder may
use their disability income to purchase drugs.
Congress passed reform legislation to address this is-
sue. Although the debate has centered on people with
a primary diagnosis of substance abuse, the issue also
pertains to those with a primary diagnosis of a severe
mental illness and a secondary diagnosis of substance
Conventional wisdom holds that this problem can be
resolved by appointing a payee who receives and man-
ages disability income on behalf of the disabled person.
Physicians or others who have knowledge of the patient
recommend a payee to the Social Security Administra-
tion or the Department of Veterans Affairs. In practice,
however, this approach routinely breaks down.
can be difficult to find reliable people who are willing
to act as payees for drug abusers with psychotic illness-
es, and some mentally ill patients who are already re-
ceiving disability income avoid treatment rather than
risk losing direct control of their income. As a result,
many people, even those in good treatment programs,
do not have payees. Despite these practical problems,
the payee approach enjoys widespread support.
This approach, however, is based on the assumption
that drug abusers routinely misuse disability payments
Mon Aug 21 012:03:26
778 THE NEW ENGLAND JOURNAL OF MEDICINESept. 21, 1995
to buy drugs — an assumption that has never been test-
ed scientifically. Interviews of cocaine addicts with no
mental disorder other than that related to substance
abuse suggest that the receipt of large sums of money
may lead to recurrent cocaine use.
of cocaine-abusing schizophrenic patients, then month-
ly disability payments will result in monthly cycles of
cocaine use. Because cocaine can worsen the symptoms
of schizophrenia, this pattern of use may lead to similar
cycles of exacerbated symptoms and psychiatric hospi-
talization. In this study, we hypothesized that drug use,
psychiatric symptoms, and hospital admissions would
all peak at the beginning of the month, shortly after the
receipt of a disability payment on the first day of the
If this is also true
Patients were recruited for the study on admission to a large, urban
Veterans Affairs medical center. Data were drawn from a study that
compared the efficacy of two experimental treatment programs for
schizophrenic cocaine abusers. In one program, case managers co-
ordinated separate services for psychiatric disorders and substance
abuse. In the other program, a new treatment unit provided integrat-
ed services for the two disorders. Patients were evaluated by emer-
gency room psychiatrists, hospitalized for several days to three weeks,
and then discharged to outpatient care.
Patients were enrolled in the study if they met the criteria of the
Diagnostic and Statistical Manual of Mental Disorders
vised) (DSM-III-R) for current cocaine dependence and for schizo-
phrenia or schizoaffective disorder.
use of the structured clinical interview for DSM-III-R,
ed by information from collateral interviews and hospital records
whenever possible. All enrolled patients, including those with a diag-
nosis of schizoaffective disorder, met four of the criteria for schizo-
phrenia (characteristic psychosis, functional deterioration, chronic ill-
ness, and exclusion of organic causes). Patients were excluded if all
prior psychotic episodes had occurred only during, or shortly after,
delimited periods of drug use. The study was approved by the medi-
cal center’s institutional review board, and all the subjects gave in-
(third edition, re-
Diagnoses were made with the
Total income, disability income, and expenditures for drugs and
alcohol during the previous month were determined at the time of en-
rollment, with the use of the Addiction Severity Index.
based on a comprehensive, structured interview used widely in sub-
stance-abuse research, and its validity and reliability have been es-
tablished in studies of hospitalized substance abusers.
income included Supplemental Security Income, Social Security Dis-
ability Income, and disability compensation from the Department of
Assessments were made weekly during and after the index hospi-
talization, for a total of 15 weeks. The severity of psychiatric symp-
toms was evaluated with the expanded Brief Psychiatric Rating Scale
(BPRS), a version of the scale that is widely used in psychiatric
research. We used the total score for the principal analysis. In sub-
sequent analyses, five clusters of symptoms (psychosis, anergy, agita-
tion, dysphoria, and hostility) were used. In almost all cases, the
raters were unaware of the subjects’ drug-use status, since they did
not have access to the results of urine tests and did not question the
patients about drug use before assessing their psychiatric symptoms.
On rare occasions, the blinding was unavoidably compromised be-
cause the subject either appeared intoxicated or mentioned recent
Drug use was determined by testing urine samples, collected week-
ly under direct observation. Urine was assayed for cocaine (in the
form of its major metabolite, benzoylecgonine), amphetamine, meth-
The index is
amphetamine, marijuana (in the form of delta-9-tetrahydrocanna-
binol), opiates (in the form of morphine), and phencyclidine. Test-
ing was performed with the fluorescence polarization immunoassay
(TDx, Abbott Laboratories, Abbott Park, Ill.). This assay can detect
the use of cocaine up to five days previously.
zoylecgonine tests were confirmed by high-pressure liquid chroma-
tography with diode-array detection in selected urine samples.
ity control of the immunoassay methods was performed with the use
of high-performance liquid chromatography and diode-array detec-
for benzoylecgonine, morphine, delta-9-tetrahydrocannabinol,
and barbiturates and with the use of gas–liquid chromatography with
amine, and phencyclidine. Values below 100 ng per milliliter were re-
corded as zero.
Because of occasional missing data, data from an average of 10
clinical assessments were available for each of the 105 subjects. The
frequency of attendance at weekly assessments ranged from 86 per-
cent at week 1 to 52 percent at week 15 (median, 74 percent). Occa-
sional missing data did not reflect withdrawal from the study, since
patients might miss an assessment session and then reappear. The
drop in the sample size was linear (about two to three subjects week-
ly) during the 15-week study period, with the exception that the fre-
quency of attendance returned to 84 percent when a comprehensive
clinical assessment was performed at week 12.
The project was affiliated with the UCLA Clinical Research Cen-
ter for Schizophrenia and Psychiatric Rehabilitation, supported by
the National Institute of Mental Health. The center maintains the re-
liability of measurements among many projects through standard-
ized training and quality assurance.
ability were achieved by training five masters’-level psychologists in
the use of the structured clinical interview for DSM-III-R (kappa
0.80 for symptoms and 100 percent agreement on diagnosis)
the expanded BPRS (intraclass correlation coefficient
standardized ratings by senior diagnosticians at the UCLA Clinical
Research Center used as gold-standard criteria. Separate studies of
diagnostic reliability have not been performed among schizophrenic
Positive results of ben-
for amphetamine, methamphet-
High levels of interrater reli-
The percentage of legal income spent on drugs and alcohol, as re-
ported by the subjects, was documented. Many subjects reported
spending more — sometimes considerably more — than their total
legal income on drugs. Thus, the percentage in some cases was well
over 100 percent. Distributions of income and expenses were highly
skewed, so medians were better descriptors than means.
Patterns of monthly drug use were analyzed with repeated-meas-
ures mixed models. Data collected during the first 15 weeks of treat-
ment (i.e., during 4 months for each subject and 2 years for the entire
study sample) were grouped according to 10 three-day intervals
based on the calendar day (i.e., interval 1 was the 1st through the 3rd
days of each month, interval 2 the 4th through the 6th days, and so
on); the 31st of the month was included in interval 10. Thus, data
collected during all months of the study were collapsed into a single
The statistical model for most analyses was an unbalanced, mixed,
linear, main-effects model with repeated measures. The model in-
cluded a fixed effect of the three-day interval (10 three-day intervals)
and random subject and error effects (which were assumed to be in-
dependent). A dichotomous transformation of the results of urine
tests (positive or negative) was analyzed with the generalized esti-
mating equation as described by Liang and Zeger,
cation of a logit link function, binomial error, and exchangeable cor-
relation structure. The overall significance of the fixed effect was
determined with a Wald chi-square test; the program for the gener-
alized estimating equation reports the results of separate robust
z-tests for each of the fixed parameter estimates. For continuous var-
iables, we used the SAS Proc MIXED program, a general, linear,
mixed-model analysis of variance that yields estimates of the maxi-
mal likelihood of the model’s effects, specifying compound symmetry
for the covariance matrix. (The usual autocorrelation one would ex-
pect in sequentially gathered data did not occur, because data were
collapsed into the intervals across months.)
Analyses of cocaine concentrations in positive specimens were per-
with the specifi-
Mon Aug 21 012:03:26
Vol. 333 No. 12DISABILITY INCOME, COCAINE USE, AND HOSPITALIZATION AMONG SCHIZOPHRENICS 779
formed only for the subgroup of subjects who used cocaine at each
time point. These analyses provide information about the amount of
cocaine used when drug use occurred. Because the data were ex-
tremely skewed, they were log-transformed. To check the effect of the
non-normal distribution of data on the analyses, several supplemen-
tary analyses (including analyses of raw and ranked data and of trun-
cated Tobit regression models) were performed. Since the results
were in no case affected by the choice of the analytic method, these
data are not presented here. As in the generalized-estimating-equa-
tion analysis, the overall F test was used to evaluate the significance
of differences among the three-day intervals; separate t-tests were
used for each interval to determine which deviated from the overall
average. To rule out possible confounding effects of other cycles (e.g.,
weekend drug use), the day of the week was included as a categorical
covariate in supplementary analyses of the primary statistical models
of urine-test results. BPRS scores for symptom severity were also an-
alyzed with the general, linear, mixed-model analysis of variance,
with data again grouped into 10 intervals during the month. The de-
pendent variable was the total 24-item BPRS score, with each item
rated on a seven-point Likert scale. Each data point was concurrent
with the result of a urine test, which was either positive or negative
for cocaine. The statistical model in this case was an incomplete
2 (use of cocaine vs. no use)-by-10 (interval) factorial with repeated
measures for each subject (with subjects again treated as a random
design factor in the model).
The ideal way to study the covariation between drug use and hos-
pital admission during each month would have been to examine ad-
mission prospectively, without clinical or experimental intervention.
However, the subjects were in a treatment group specifically designed
to prevent readmission soon after discharge, even when drug use oc-
curred. Thus, we reasoned that the initial hospital admissions, which
occurred before any intervention, could be used to study the variation
in admissions throughout the month. Like the other dependent meas-
ures, these initial admissions were tallied in three-day intervals.
The concurrent and lagged cross-correlations with cocaine concen-
trations were evaluated with a conventional transfer-function model
(with the use of SAS Proc ARIMA software). First-degree autoregres-
sive models characterized both variables. Because the series is very
10), only the first-degree lagged cross-correlations were
A total of 105 patients were enrolled in the study. All
were male and met the DSM-III-R criteria for cocaine
dependence and either schizophrenia or schizoaffective
disorder. The patients had had many psychiatric hospi-
talizations, had used cocaine for many years, and had
used it extensively in the previous month; 34 percent
were homeless (Table 1). The median monthly income
was quite low and consisted almost entirely of disability
income (Table 2). The proportion of monthly income
spent on illegal drugs was high. The percentage of pa-
tients with positive tests for benzoylecgonine (Fig. 1)
differed significantly among the 10 intervals (Wald chi-
0.03). Robust z-tests indicat-
ed that the proportion of patients with positive tests for
cocaine was significantly higher during the second in-
0.01) and third interval (z
0.006) than during the other intervals.
Among the patients with positive tests, the peak ben-
zoylecgonine concentration occurred during the first
three-day interval. The statistical analysis indicated
that the variation in the mean concentration was sig-
nificant among the 10 intervals (F
0.002) (Fig. 2). The actual mean concentrations
were higher than those shown, because the laboratory
analysis had a ceiling value of 150,000 ng per milliliter
(approximately 10 percent of the sample had values at
or above this level). Among the positive urine speci-
mens, the cocaine concentration was significantly high-
er than average in the first two intervals (t
0.035, respectively; df
for both), and significantly lower than average during
the seventh interval — that is, days 19 through 21
0.008). Fewer than 2 percent of
the urine samples had appreciable concentrations of
any of the other illicit drugs tested. With the same
method of analysis, there was no significant variation
in the concentrations of these drugs among the 10 in-
tervals of the month. The tendency for drug use to
increase early in the month did not appear to be an ar-
tifact of weekly cycles. This was determined by per-
forming analyses of the percentage of negative urine
specimens and mean cocaine concentrations with the
addition of the day of the week as a covariate. These
analyses yielded essentially the same results as those
for the three-day intervals.
The analysis of symptom severity (the total BPRS
score) revealed a highly significant main effect of co-
caine use (F
1, 1076; P
nificant interaction between drug use and the interval
0.001) and a sig-
*Plus–minus values are means
Table 1. Characteristics of 105 Schizophrenic Pa-
tients with Substance Abuse.
Race (% of patients)
Marital status (% of patients)
Separated, widowed, or divorced
Homeless (% of patients)
Years of regular cocaine use
Days of cocaine use in the past month
No. of previous psychiatric hospitalizations
*The semi-interquartile range (25th to 75th percentile) is a useful index
of variability when distributions are skewed or truncated.
†Seventy-six subjects received disability income. Nearly all the other
subjects received monthly income from another source, such as the county
welfare program or Aid to Families with Dependent Children.
‡Calculated for each subject rather than by dividing medians.
Table 2. Monthly Income and Expenditures for Il-
legal Drugs and Alcohol among the 105 Schizo-
Total income ($)
Disability income ($)†
Expenditures for illegal drugs ($)
Income spent on illegal drugs
Expenditures for alcohol ($)
Income spent on alcohol (%)‡
Mon Aug 21 012:03:27
780 THE NEW ENGLAND JOURNAL OF MEDICINESept. 21, 1995
3, psychiatric symptoms tended to be more severe when
the urine test for cocaine was positive (top curve) than
when it was negative (bottom curve). However, the dif-
ference was greatest during the earlier intervals, when
the level of cocaine use was maximal. Figure 3 also
shows the average BPRS score without reference to
cocaine use (middle curve). A separate statistical anal-
ysis of that curve indicated a significant variation
among the three-day intervals (F
0.03). Symptoms tended to increase in severity at
the start of the month and were less severe during ap-
proximately the third week. In a sense, this middle
curve represents a weighted function of the other two.
The increase in the severity of symptoms during the
early part of the month was due to the larger number
of patients with positive drug tests at that time. Con-
versely, the reduction in the severity of symptoms dur-
ing the latter half of the month is due to the larger
number of patients with negative tests. The monthly
variation in the severity of symptoms for the sample as
a whole is thus directly attributable to the relative pro-
portions of patients with positive tests for cocaine dur-
ing each interval. Separate analyses of the five BPRS
symptom clusters revealed a significant effect only for
positive psychotic symptoms (hallucinations, delusions,
and conceptual disorganization; F
The pattern of hospitalization appeared to be quite
similar to that observed for cocaine concentrations, with
a clear peak at the start of the month and a trough at
9, 1076; P
0.004). As shown in Figure
about the third week (Fig. 4). Analysis of the relation
between these two variables indicated a significant as-
sociation, with the peak in admissions occurring one in-
terval after the peak in cocaine concentration. The
cross-correlations between the cocaine concentration
and hospital admission were
0.635 with a lag of one interval (t
0.03). Thus, changes in the cocaine concentration
were predictive of changes in the rate of hospitalization
three to five days later.
0.014 concurrently and
In this sample of cocaine-abusing schizophrenic pa-
tients, cocaine use, psychiatric symptoms, and hospi-
talization were temporally related. All three variables
were characterized by peaks early in the month and
troughs late in the month. Psychiatric symptoms were
more severe on the days when cocaine was present in
the urine than on other days. On the average, patients
spent almost half their income on illicit drugs. Because
the cost of board-and-care homes in Los Angeles ap-
proved by the Department of Veterans Affairs (a mini-
mum of $680 per month) exceeded the patients’ medi-
an monthly income, one can surmise that cocaine use
contributed to homelessness by depleting the funds re-
quired for shelter. Our interpretation of the data is that
the increased rate of hospitalization a few days after
the peak in cocaine use resulted from the deleterious
effects of cocaine use, in the form of exacerbated psy-
chiatric symptoms and homelessness.
It is hard to escape the conclusion that this cycle was
facilitated by the arrival of a disability payment on the
first day of each month. An interesting and unexpected
Figure 1. Mean Percentages of Patients with Positive Tests for
Cocaine, According to the Three-Day Interval in the Course of the
The dotted line indicates the mean value (41 percent) for all 10
Patients with Positive Tests (%)
Figure 2. Mean Benzoylecgonine Concentrations in Positive
Specimens, According to the Three-Day Interval in the Course of
The dotted line indicates the mean value (36,852 ng per milliliter)
for all 10 intervals.
Benzoylecgonine Concentration (ng/ml)
Mon Aug 21 012:03:27
Vol. 333 No. 12DISABILITY INCOME, COCAINE USE, AND HOSPITALIZATION AMONG SCHIZOPHRENICS 781
finding was that cocaine use, psychiatric symptoms,
and hospitalization actually began to increase a few
days before the first of the month. This pattern may be
due to a business practice reported by many of the pa-
tients we studied. During the last week of the month,
local drug dealers extend credit to persons who receive
monthly disability income. In a perverse sense, the cer-
tainty of the monthly payments makes these patients
good credit risks.
The markedly poor clinical and social outcomes
among the patients in our study contrast with the rela-
tively good outcomes reported among substance-abus-
ing schizophrenic patients who become abstinent. Two
studies suggest that substance-abusing schizophrenic
patients have better social functioning and a better prog-
nosis than other schizophrenic patients. During periods
of substance abuse, patients with schizophrenia are se-
verely ill, and their symptoms are difficult to manage.
When abstinent, however, such patients have less severe
psychotic symptoms and better social functioning than
those who have never abused substances.
It is important not to overgeneralize these findings,
for several reasons. First, our study was clinical, not ep-
idemiologic, and the sample was not intended to be
broadly representative of schizophrenic persons. Strict-
ly speaking, the results apply only to schizophrenic pa-
tients who abuse cocaine. Most schizophrenic persons
do not abuse cocaine. Moreover, our sample is some-
what atypical of those who do. All the patients were
men. Women who met our enrollment criteria might
have had different characteristics. All our patients were
veterans. As compared with other cocaine-abusing
schizophrenic persons, they probably had histories of
less severe psychiatric disorders and a higher level of
social functioning, at least when they entered the mili-
tary. In addition, most of our patients were black. A ra-
cial distribution similar to that in our study has been
reported in other studies of cocaine abuse. Whether
this distribution reflects socioeconomic status or other
factors associated with race or ethnic group remains
unclear. Second, since the research setting was a
large urban hospital, the findings may not apply to
persons who live in rural areas, where a host of social
and cultural factors, including the availability of drugs,
may be different. Third, the patients entered the study
during a period of exacerbated symptoms and social
problems requiring hospitalization. The mental, physi-
cal, and social condition of our patients may thus not
be typical of that of the overall population of schizo-
phrenic persons, whether or not they are receiving
Our study had several limitations. The increase in
the cocaine concentration preceded the increase in the
proportion of patients with positive tests by a few days.
This suggests that instances of cocaine use very early
in the month involved greater quantities of cocaine.
However, the result is at least partly an artifact of two
aspects of the study method. First, benzoylecgonine
could be detected in the urine up to five days after co-
caine use. Second, patients were tested during sched-
uled appointments that must have occurred at varying
intervals after use. Thus, a patient who used cocaine
would be counted as positive regardless of whether the
Figure 3. Severity of Psychiatric Symptoms According to Cocaine
Use and the Three-Day Interval.
The severity of symptoms was determined on the basis of the
overall score on the 24-item Brief Psychiatric Rating Scale
(BPRS). A higher score indicates more severe symptoms.
Total BPRS Score
Patients using cocaine
Patients not using
Figure 4. Mean Numbers of Psychiatric Admissions According to
the Three-Day Interval.
The dotted line indicates the mean value (10.6 admissions) for
all 10 intervals.
Number of Admissions
Mon Aug 21 012:03:27
782 THE NEW ENGLAND JOURNAL OF MEDICINESept. 21, 1995
urine was sampled immediately or up to five days after
use occurred. However, the measured concentration of
benzoylecgonine would be systematically lower as a
function of how much time had passed since use. Also,
it is unclear whether cocaine use exacerbated psychotic
symptoms directly or indirectly, perhaps through non-
compliance with a medication regimen. Unfortunately,
data on compliance were not available. Patients were
treated with a wide range of antipsychotic medications
in more than a dozen inpatient units and outpatient
clinics, and urine samples were not tested for antipsy-
chotic drugs. Another limitation of the study was that
hospital admissions were index admissions occurring
at the beginning of a 15-week rating period, whereas
data on cocaine use and psychiatric symptoms were ob-
tained subsequently. Finally, the data on income were
based on information provided by the patients them-
selves. To avoid these limitations, future studies should
include a more broadly representative sample, prospec-
tive measures of hospitalization, and objective meas-
ures of both income and medication use. The portion
of disability income spent on food and shelter should
also be determined.
The findings of our study present a dilemma. How
are we to provide for the basic needs of disabled schizo-
phrenic persons without simultaneously facilitating a
cycle of drug abuse and psychiatric hospitalization?
Simply discontinuing the disability payments will not
eliminate drug abuse and might exacerbate hunger and
homelessness. A partial solution may be to direct dis-
ability payments to responsible payees who ensure that
the funds are used for food and shelter. However, even
payees cannot prevent the use of drugs purchased with
funds obtained by other means, such as panhandling.
Therefore, the payee approach must be integrated into
a comprehensive treatment program that addresses
both the psychiatric disorder and the substance abuse
and includes behavioral treatment, case management,
and antipsychotic medications.
evaluating various behavioral interventions, including
the practice of giving patients a small portion of the
monthly disability payment each day, contingent on
their abstinence from cocaine use.
Social Security Handbook
tions, implied or otherwise, are placed on how people
spend their SSI [Supplemental Security Income] bene-
fit” and that SSI is “paid under conditions that are as
protective as possible of people’s dignity.”
suggest that these policies may conflict with one anoth-
er. For cocaine-abusing schizophrenic persons, the mis-
use of disability income intended to compensate for the
disabling effects of schizophrenia can actually make
the illness worse. Instead of protecting the dignity of
patients, direct payment of disability income may de-
prive them of their dignity by initiating a cycle of co-
caine use, exacerbated symptoms, homelessness, and
We are currently
states that “no restric-
We are indebted to Professor David Brillinger, Department of Sta-
tistics, University of California, Berkeley, for his careful review of the
manuscript and comments on the statistical analyses; to Professor
K.Y. Liang, School of Public Health, Johns Hopkins University, Bal-
timore, for giving us the SAS macro for the generalized estimating
equation and providing consultation on its use; to Robert P. Liber-
man, M.D., director, UCLA Clinical Research Center for Schizophre-
nia; and to Meg Racenstein, Kim Boroczi, Mary G. Hannah, and Sun
Sook-Hwang for their assistance in collecting and preparing the data
1. Drake RE, McLaughlin P, Pepper B, Minkoff K. Dual diagnosis of major
mental illness and substance disorder: an overview. New Dir Ment Health
2. Galanter M, Castaneda R, Ferman J. Substance abuse among general psy-
chiatric patients: place of presentation, diagnosis, and treatment. Am J Drug
Alcohol Abuse 1988;14:211-35.
3. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with
alcohol and other drug abuse: results from the Epidemiologic Catchment
Area (ECA) Study. JAMA 1990;264:2511-8.
4. Shaner A, Khalsa ME, Roberts LJ, Wilkins J, Anglin D, Hsieh SC. Unrec-
ognized cocaine use among schizophrenic patients. Am J Psychiatry 1993;
5. Ritz MC, Lamb RJ, Goldberg SR, Kuhar MJ. Cocaine receptors on dopa-
mine transporters are related to self-administration of cocaine. Science
6. Meltzer HY, Stahl SM. The dopamine hypothesis of schizophrenia: a review.
Schizophr Bull 1976;2:19-76.
7. Alterman AI, Erdlen DL. Illicit substance use in hospitalized psychiatric pa-
tients: clinical observations. J Psychiatr Treat Eval 1983;5:377-80.
8. Yesavage JA, Zarcone V. History of drug abuse and dangerous behavior in
inpatient schizophrenics. J Clin Psychiatry 1983;44:259-61.
9. Richard ML, Liskow BI, Perry PJ. Recent psychostimulant use in hospital-
ized schizophrenics. J Clin Psychiatry 1985;46:79-83.
10. Safer DJ. Substance abuse by young adult chronic patients. Hosp Commu-
nity Psychiatry 1987;38:511-4.
11. Brady K, Anton R, Ballenger JC, Lydiard RB, Adinoff B, Selander J. Co-
caine abuse among schizophrenic patients. Am J Psychiatry 1990;147:1164-
12. Tax-subsidized addicts. Wall Street Journal. February 8, 1994:A18.
13. Farrell M. Improving the Social Security Representative Payee Program —
recommendations of the Administrative Conference of the United States.
Ment Phys Disabil Law Rep 1992;16:236.
14. Satel S. Hooked: it’s time to get addicts off welfare. New Republic. May 30,
15. Examining entitlements for the mentally ill. Wall Street Journal. January 28,
16. Wallace BC. Psychological and environmental determinants of relapse in
crack cocaine smokers. J Subst Abuse Treat 1989;6:95-106.
17. Roberts LJ, Shaner A, Eckman TA, Tucker DE, Vaccaro JV. Effectively treat-
ing stimulant-abusing schizophrenics: mission impossible. New Dir Ment
Health Serv 1992;53:55-65.
18. Diagnostic and statistical manual of mental disorders, 3rd ed. rev.: DSM-III-
R. Washington, D.C.: American Psychiatric Association, 1987.
19. Spitzer RL, Williams JBW, Gibbon M, First MB. User’s guide for the struc-
tured clinical interview for DSM-III-R. Washington, D.C.: American Psychi-
atric Press, 1990.
20. McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic
evaluation instrument for substance abuse patients: the Addiction Severity
Index. J Nerv Ment Dis 1980;168:26-33.
21. McLellan AT, Luborsky L, Cacciola J, et al. New data from the Addiction
Severity Index: reliability and validity in three centers. J Nerv Ment Dis
22. Lukoff D, Nuechterlein KH, Ventura J. Manual for the expanded BPRS.
Schizophr Bull 1986;12:594-602.
23. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep
24. Cone EJ, Menchen SL, Paul BD, Mell LD, Mitchell J. Validity testing of
commercial urine cocaine metabolite assays: I. Assay detection times, indi-
vidual excretion patterns, and kinetics after cocaine administration to hu-
mans. J Forensic Sci 1989;34:15-31.
25. Svensson JO. Determination of benzoylecgonine in urine from drug abusers
using ion pair high performance liquid chromatography. J Anal Toxicol
26. Ferrara SD, Tedeschi L, Frison G, Castagna F. Solid-phase extraction and
HPLC-UV confirmation of drugs of abuse in urine. J Anal Toxicol 1992;16:
27. Watts VW, Simonick TF. Screening of basic drugs in biological samples us-
ing dual column capillary chromatography and nitrogen-phosphorus detec-
tors. J Anal Toxicol 1986;10:198-204.
28. Ventura J, Green MF, Shaner A, Liberman RP. Training and quality assur-
ance with the brief psychiatric rating scale: “the drift busters.” Int J Methods
Psychiatr Res 1993;3:221-44.
Mon Aug 21 012:03:27
Vol. 333 No. 12DISABILITY INCOME, COCAINE USE, AND HOSPITALIZATION AMONG SCHIZOPHRENICS 783
29. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas
30. Liang K-Y, Zeger SL. Longitudinal data analysis using generalized linear
models. Biometrika 1986;73:13-22.
31. Dixon L, Haas G, Weiden PJ, Sweeney J, Frances AJ. Drug abuse in schizo-
phrenic patients: clinical correlates and reasons for use. Am J Psychiatry
32. Zisook S, Heaton R, Moranville J, Kuck J, Jernigan T, Braff D. Past sub-
stance abuse and clinical course of schizophrenia. Am J Psychiatry 1992;
33. Lillie-Blanton M, Anthony JC, Schuster CR. Probing the meaning of racial/
ethnic group comparisons in crack cocaine smoking. JAMA 1993;269:993-7.
34. Seale JP, Muramoto ML. Substance abuse among minority populations.
Prim Care 1993;20:167-80.
35. Hartz D, Banys P, Hall SM. Correlates of homelessness among substance
abuse patients at a VA medical center. Hosp Community Psychiatry 1994;
36. Cohen J, Levy SJ. The mentally ill chemical abuser: whose client? New
York: Lexington Books, 1992.
37. Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptual
model, treatment program, and clinical evaluation. Arch Gen Psychiatry
38. Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. In-
centives improve outcome in outpatient behavioral treatment of cocaine de-
pendence. Arch Gen Psychiatry 1994;51:568-76.
39. Social Security Administration. Social Security handbook. 11th ed. Wash-
ington, D.C.: Government Printing Office, 1993:353-4. (DHHS publication
no. (SSA) 65-008.)