The focus of this research is on cultural determinants effects on self-regulation of substance use/abuse among outpatients with schizophrenia, with a focus on data analysis, manuscript writing, publication and grant seeking and submission. This project falls under the Duke C-StARR’s aims in that it will test novel hypotheses on self-regulation, the feasibility of conducting larger studies and the translation of basic science to prevention and treatment programs. In addition, this project meets the C-StARR’s aim to train scientists in multidisciplinary prevention research, through mentorship and training workshops and programs. The knowledge gained in meeting these aims may be used for developing novel substance prevention programs.  This report provides a summary review of three main activities including data analysis, manuscript publication and future direction and grant preparation, all supported by this pilot grant.

There has been little investigation on the role of the cultural determinants, specifically religion/spirituality among individuals living with schizophrenia, and even less research among individuals with comorbidity of substance disorders even though substance use/abuse among the severely mentally ill is high.  Almost half of individuals with schizophrenia have a history of some form of substance abuse-dependence, with the odds of having a substance abuse diagnosis almost 5 times as high as the general population.  Likewise, there is a lack of prevention and treatment programs tailored for individuals with dual diagnoses. Treatments with a spirituality component have been shown to be effective for recovery among individuals with schizophrenia, as the spiritual component of the therapy provides patients with a sense of identity beyond their illness, promoting social connections, therapeutic exploration of value systems, and self-awareness.  Given the success of 12-step programs for addiction, recovery programs with a spiritual component for dual diagnoses may also be effective.  The findings from this research may inform treatment programs and future clinical trials to test the effectiveness of treatment with a spiritual component for dual diagnoses.

Activity 1. Cultural determinants effects on substance use/abuse in schizophrenia: Data was collected (prior to the start of this pilot grant) from 63 outpatients living with schizophrenia using semi-structured in-person interviews comparable to studies conducted in the Psychiatry Department at the University of Geneva, Switzerland. The topics cover the role of religious/spiritual beliefs and practices as a means of coping with illness and its consequences, compatibility with treatment, and role in use/abuse of substances. During the pilot grant period quantitative and qualitative analyses have been conducted, as described in the following paragraphs. The continuing review and amendments to the DUMC IRB have been submitted and approved.

Quantitative Preliminary Analysis: The majority of patients report spirituality and religion are “important” to “essential” in living with severe mental illness. The extent that beliefs help to cope, gain control and provide comfort from the participants’ hardships, difficulties and problems were reported to be relatively high at nearly a mean score of 8 out of 10. More than one-third screen positive for substance abuse (38%).  Two-thirds of the sample report current tobacco smoking while an additional 10 percent report having smoked in the past.  More than one-third report current alcohol use (37%), and past alcohol use (43%).   More than one-tenth report current marijuana use (13%), hard drug use (11%), and prescription drug abuse (11%), while higher rates were reported for past marijuana use (64%), hard drug use (35%) and prescription drug abuse (13%).  The mean age for initial use of tobacco and marijuana was in the teen years while use of hard drugs and abuse of prescription drugs were reported to have started about a decade later. Beliefs were reported to play a larger role in the decision not to use more severe substances than lesser substances: hard drugs (64%); abuse prescription drugs (60%); marijuana (50%); alcohol (40%); and tobacco (18%)).

Factor Analysis and Structural Equation Modeling:
Exploratory factor analysis was conducted to test the latent construct of religiousness/spirituality based on 13 items. The first factor on “beliefs” included the variables of extent of comfort, meaning, importance and control which religious/spiritual beliefs play in living with the illness. The second factor is on “behavior” including frequency of private and public religious/spiritual activities, extent of help from a religious community and spontaneous mention of religion/spirituality as a coping strategy for dealing with the illness.  The third factor contained variables on “conflict between beliefs and treatment” (aspects of treatment measured included medication adherence, therapy, and ease in talking with a clinician about their beliefs). The variables loaded similar to the factor loadings of those found by the Swiss group with some slight differences.  In addition new latent contructs were found for additional variables measuring extent of religious harm experienced and changes in spirituality over a lifetime.  Confirmatory factor analysis (CFA) of these factors was conducted in order to provide fit statistics.  Subsequently the latent construct of these factors on religion/spirituality were put in a structural equation model (SEM) to examine the relationships with substance use/abuse..  The religious latent factors were found to be significantly related to substance abuse, controlling for sociodemographic factors and religious affiliation.  The greater extent of the role of religious/spiritual beliefs and behavior in life, the less substance abuse was reported, while greater conflict was related to more substance abuse.  Being male, with less education and of younger age was also found to be significantly related to substance abuse.  Potential mediators such as self-esteem are being investigated to explain the relationships between the religious latent constructs and substance abuse.  The investigator has participated in statistical workshops on CFA and SEM at SSRI at Duke and at the Odum Institute at UNC-CH and has had consultation with quantitative experts at the C-StARR Methodology and Statistics Core and at Odum.  

Qualitative Analysis:
Qualitative responses have been collected on the protective or facilitating role of beliefs in continuation, cessation or refraining of use of the following substances: tobacco, alcohol, marijuana, hard drugs and prescription drug abuse.  Qualitative analysis has been conducted with two independent coders. Among all the substances overall, approximately one-third of participants report a protective role of beliefs to resist substance use by providing them with tools or guidance to resist substances.  No one reported that their beliefs increased the risk of substance use and only 3 percent reported that their beliefs had no role in use or non-use of substances, while approximately two-thirds reported a reason other than their beliefs for use or non-use of substances.  Emerging themes for how religion/spirituality plays a protective role against substance use/abuse include providing a sense of self-control and responsibility for one’s health.  For example one participant stated “I did not want the drugs no more…it was a hard thing to do…so I started praying…the more I prayed the stronger and closer I…felt like I was getting’ to God…I really believe God took the taste away [for hard drugs].”  Other themes that have emerged include the role of health, quality of life and family influence.

Activity 2. Manuscripts and Publications: A book chapter has been published April 2011.  A book contract has been offered by Springer Academic Press in the Behavioral Sciences Division to produce a full length book titled “Spirituality and sanity: the role of religion and spirituality in living with schizophrenia”.  This would be the first known comprehensive book on review of research and application to treatment on this topic which we are aware of. The book has a section on the role of religion/spirituality in the use of substances among individuals living with schizophrenia.  One manuscript has been resubmitted, three manuscripts are in revision (to be resubmitted July 2011) and one manuscript is in review as listed below: