Addictive Behaviors 32 (2007) 477 490

Do individuals with a severe mental illness experience

greater alcohol and drug-related problems? A test of the
supersensitivity hypothesis
Vivian M. Gonzalez , Clara M. Bradizza, Paula C. Vincent,
Paul R. Stasiewicz, Nicole D. Paas
Research Institute on Addictions, University at Buffalo, The State University of New York, 1021 Main Street, Buffalo,
NY 14206-1016, United States

Abstract

The supersensitivity hypothesis posits that individuals with a severe mental illness (i.e., schizophrenia and bipolar
disorder; SMI) are more likely to be diagnosed with a substance abuse as opposed to a substance dependence
diagnosis, and experience greater negative consequences associated with substance use at lower levels of
consumption, as compared with non-SMI substance abusers. This is the first known study to test this hypothesis with a
control group of non-SMI substance abusing individuals. Forty-two individuals with only a substance use disorder
(SUD-only) and 53 dually diagnosed individuals (DD) were compared on measures of substance use, alcohol and drug
dependence, negative consequences, substance use outcome expectancies, and motivation for change. A third group
of SMI-only individuals (i.e., no SUD; n = 35) were also recruited and all three groups were compared on
psychological symptoms. Substance use, negative consequences, substance use outcome expectancies, motivation for
change, and severity of alcohol and drug dependence were not found to differ significantly between the DD and SUD-
only groups. However, the DD group had significantly greater levels of psychological symptoms, as compared with
the SMI-only and SUD-only groups. Overall, this study does not provide support for the supersensitivity hypothesis.
2006 Elsevier Ltd. All rights reserved.

Keywords: Severe mental illness; Dual diagnosis; Substance abuse; Negative consequences of substance use; Supersensitivity
hypothesis

Corresponding author. Research Institute on Addictions, 1021 Main Street, Buffalo, NY 14203-1016, United States. Tel.: +1
716 8872229; fax: +1 716 9972477.
E-mail addresses: [email protected] (V.M. Gonzalez), [email protected] (C.M. Bradizza),
[email protected] (P.C. Vincent), [email protected] (P.R. Stasiewicz), [email protected] (N.D. Paas).

0306-4603/$ - see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.addbeh.2006.05.012
478 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

1. Introduction

High rates of comorbidity for alcohol and drug use disorders are found among individuals with a severe
mental illness (SMI; i.e., schizophrenia, bipolar disorder). Among individuals with schizophrenia, 40
50% meet diagnostic criteria for a substance abuse disorder (SUD) at some time in their lives; 4.6 times
the rate of alcohol and drug use disorders among the general population (Blanchard, Brown, Horan, &
Sherwood, 2000). Among individuals with bipolar disorder, lifetime prevalence rates of SUDs are the
highest of any diagnostic group: 61% for bipolar I and 48% for bipolar II (Epidemiological Catchment
Area Study; Regier et al., 1990).
Individuals with both an SMI and SUD have higher rates of negative outcomes as compared with
individuals with an SMI and no SUD. Among those with schizophrenia, substance abuse is associated
with higher rates of homelessness (Olfson, Mechanic, Hansell, Boyer, & Walkup, 1999), more frequent
psychiatric hospitalization (Kamali et al., 2000), poorer clinical functioning (Kovasznay et al., 1997),
greater suicidal ideation and attempts (Gut-Fayand et al., 2001; Kamali et al., 2000), and increased
violence when combined with poor medication compliance (Swartz et al., 1998). Similarly, among those
with bipolar disorder, substance abuse is associated with treatment noncompliance (Keck et al., 1998), an
increased rate of hospitalizations (Cassidy, Ahearn, & Carroll, 2001), and a higher rate of suicide attempts
(Dalton, Cate-Carter, Mundo, Parikh, & Kennedy, 2003).
Various explanations have been proposed regarding ways in which substance use may differentially
impact individuals with an SMI, as compared with general samples of substance abusers. The
supersensitivity hypothesis (Mueser, Drake, & Wallach, 1998) suggests that individuals with an SMI
are more likely to experience the negative effects of alcohol and drugs as compared with non-SMI
individuals, at the same level of consumption. Mueser et al. (1998) suggests that this
supersensitivity to the effects of alcohol and drugs may help explain the high rates of comorbidity
among individuals with an SMI. This sensitivity to the effects of alcohol and drugs may in part be due
to the psychobiological vulnerabilities that accompany an SMI, resulting in negative consequences at
relatively low amounts of alcohol or drug use. In addition to a possible biological vulnerability
suggested by the supersensitivity hypothesis, disorder-specific difficulties, such as impaired cognitive
functioning, poor social skills, and poor impulse control, may result in a reduction in the ability to
regulate substance use and in a greater number of negative consequences associated with use (Drake
& Mueser, 2002).
The supersensitivity hypothesis has evolved from observations of the characteristics and course of
SUDs among SMI individuals. For example, it has been suggested that individuals with an SMI display
lower quantities of substance use, while incurring greater problems as compared with non-SMI substance
users (see Mueser et al., 1998, for a review). In addition, it has been proposed that individuals with an SMI
are more likely to be diagnosed with substance abuse than dependence as compared with non-SMI
substance abusers, and are unlikely to be able to maintain moderate alcohol use without developing
negative consequences (Drake & Wallach, 1993). Together, these observations have been interpreted as
indicating intolerance to the amounts of substance use that are often found among SMI individuals with
SUDs. Thus, the mental illness is thought to create a vulnerability to developing negative consequences,
even at low levels of use, thereby making it more likely that an individual with an SMI who uses
substances will meet diagnostic criteria for substance abuse. However, to date, this supersensitivity
hypothesis has not been tested empirically with an appropriate control group of non-SMI substance
abusers.
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 479

The main purpose of this study was to conduct an empirical test of the supersensitivity hypothesis. To
our knowledge, this is the first such test of this hypothesis. Specifically, we examined how aspects of
SUDs such as dependency, problems, and negative consequences differ between a sample of individuals
with an SUD and an SMI, as compared with those who have an SUD but no other major Axis I disorder.
Of particular interest in these comparisons was examining the hypothesis that those who are dually
diagnosed would display greater negative consequences associated with comparable or lower levels of
alcohol or drug use than individuals with solely an SUD. In addition, attitudinal or cognitive factors that
may affect SUDs, such as motivation for change and expectancies regarding the effects of substance use
were examined to determine possible differences in the relationships between these factors and substance
use among SUD individuals with and without an SMI.

2. Method

2.1. Participants

The sample was derived from a study assessing coping skills among individuals with an SMI and an
SUD. Three groups were recruited: (1) 42 individuals with an SUD and no other major Axis I disorder
(SUD-only group), (2) 35 individuals with an SMI (i.e., schizophrenia, schizoaffective, or bipolar
disorders and no SUD; SMI-only group), and (3) 53 individuals with both an SMI and an SUD (dually
diagnosed; DD group). Participants presenting for the study who scored below 23 on the Mini-Mental
State Exam (Folstein, Folstein, & McHugh, 1975) were not included (n = 22) in order to ensure sufficient
cognitive functioning to complete the study tasks.
The SMI-only and DD participants were recruited from a university-affiliated, publicly funded
community mental health center and SUD-only participants were recruited from an outpatient substance
use treatment clinic. Dually diagnosed individuals were attending a treatment program designed to
address both their substance use disorder and mental illness. All DD and SUD-only individuals were
recruited early in treatment from their respective treatment programs. All participants were administered
the computerized Diagnostic Interview Schedule-IV (Robins, Cottler, Bucholz, & Compton, 1995) to
confirm diagnostic status. Participants in the SMI-only group were only used in analyses comparing
groups on psychological symptoms, and were not included in substance-related comparisons. Participants
completed two interview appointments and were compensated $15 following the first appointment and
$30 following the second.
Demographic characteristics of the study groups are shown in Table 1. No significant differences
were found among groups in age or years of education. As expected, the SUD-only group had
significantly higher scores on the Mini-Mental State Exam as compared with DD and SMI-only groups.
There was a significant difference between the groups in the proportion of men and women; the SMI-
only group was comprised of a higher proportion of women, as compared with the SUD-only group,
while the DD group did not differ from either group. The majority of the sample was single (i.e., never
married). Tests of differences between proportions for each marital category revealed that individuals in
the DD group were less likely to have been married or cohabitating than individuals in the SUD-only
group (z = 2.58, p < .05); there were no other significant differences between groups on marital status
variables. As expected, the SUD-only group reported a significantly lower unemployment rate than
either the DD or SMI-only groups. The sample was predominately African-American, with no
480 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

Table 1
Demographic characteristics and psychiatric diagnoses of SUD, DD, and SMI participants
Continuous variables SUD-only (n = 42) DD (n = 53) SMI-only (n = 35) Test
Mean (S.D.) Mean (S.D.) Mean (S.D.)
Age-mean 37.02 (7.41) 37.75 (8.49) 36.43 (9.18) F (2, 127) = .27
Education 12.43 (1.76) 11.62 (2.00) 12.34 (2.34) F (2, 127) = 2.27
Mini-Mental State test 28.29 (1.67) 27.32 (2.06) 27.26 (2.36) F (2, 127) = 3.44

Categorical variables % (n) % (n) % (n)

Gender 2(2) = 6.91
Female 35.7 (15) 50.9 (27) 65.7 (23)
Marital statusa
Single 59.5 (25) 66.0 (35) 71.4 (25)
Married 11.9 (5) 0 5.7 (2)
Divorced/separated/widowed 28.6 (12) 34.0 (18) 22.9 (8)
Race/Ethnicityb 2(2) = 3.90
African-American 54.8 (23) 54.3 (19) 67.9 (36)
White 45.2 (19) 45.7 (16) 26.4 (14)
Latino 0 0 1.6 (1)
Other 0 0 3.8 (2)
Housingc 2(2) = 11.64
Apartment/private house/hotel 95.2 (40) 72.5 (37) 64.7 (22)
Group/halfway home 4.8 (2) 27.5 (14) 35.3 (12)
Employment 2(2) = 35.09
Employed or student 47.6 (20) 3.8 (2) 5.7 (2)
Unemployed 52.4 (22) 96.2 (51) 94.3 (33)
Incomed 2(6) = 19.96
0 to $5500 42.9 (18) 39.6 (21) 20.0 (7)
$550110,000 16.7 (7) 41.5 (22) 62.9 (22)
$10,00120,000 26.2 (11) 15.1 (8) 8.6 (3)
$20,001$40,000 11.9 (5) 3.8 (2) 5.7 (2)
SMI diagnosis 2(1) = 2.93
Schizophrenia/schizoaffective 69.8 (37) 85.7 (30)
Bipolar 30.2 (16) 14.3 (5)
p < .05. p < .01. p < .001.
a
Too few participants were in the married category to allow for chi-square analyses of marital status.
b
Individuals in the Latino and Other categories were not included in the analysis of race/ethnicity as n in these categories
was too small to allow statistical comparisons.
c
Two individuals in both the SMI and SUD groups reported other living arrangements.
d
One respondent in both the SMI and the SUD groups either refused or reported not knowing their income.

significant differences between groups. Income for the sample as a whole tended to be modest, with
the majority making less than or equal to $10,000 in the prior year; SUD-only participants had a
significantly greater gross income than DD and SMI groups. Significantly more SUD-only
participants lived in independent housing (i.e., private residence) as opposed to a group setting
(e.g., group or halfway home) than did DD and SMI-only participants. The DD and SMI-only groups
did not differ in their proportions of individuals with diagnoses of bipolar or schizophrenia/
schizoaffective disorders.
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 481

2.2. Measures

Mini-Mental State Exam (MMSE; Folstein et al., 1975) is a widely used brief cognitive screening
measure that assesses orientation to time and place, attention, short-term memory, visualspatial skills,
and language functioning.
Diagnostic Interview Schedule-IV (DIS-IV; Robins et al., 1995) is a structured diagnostic interview
used to obtain current (i.e., here defined as in the past 12 months) DSM-IV Axis I diagnoses. The
following sections of the DIS were administered to all participants: alcohol use, drug use, depression,
mania, schizophrenia, post-traumatic stress disorder, antisocial personality disorder, agoraphobia, social
phobia, and generalized anxiety disorder.
Timeline Followback (TLFB; Sobell, Maisto, Sobell, & Cooper, 1979) is a calendar-based
retrospective recall interview of daily substance use; a 60-day timeline was used in the current study.
The use of a TLFB method (as opposed to summary measures of consumption) and a 60-day time period
allowed for the estimation of substance use that would capture sporadic, as well as more constant levels of
use. In primary alcohol abusers, the TLFB method has been found to have high testretest reliability
(Sobell et al., 1979) and good concurrent validity (Maisto, Sobell, Cooper, & Sobell, 1982). Significant
positive correlations have been found between the TLFB method and drug urinalysis (Ehrman & Robbins,
1994; Fals-Stewart, O'Farrell, Freitas, McFarlin, & Rutigliano, 2000). The TLFB method has been found
to be a reliable and valid method for use with psychiatric outpatients (Carey, 1997; Carey, Carey, Maisto,
Gordon, & Weinhardt, 2001).
In the present study, DD and SUD-only groups were compared on number of days of drug use,
number of days of alcohol use, average number of drinks per drinking day, and number of heavy
drinking days. Heavy drinking days were considered days with 4 or more drinks for women and 5 or
more for men.
Drug Urinalysis was performed on unsupervised urine samples collected from all participants. Samples
were sent to a DHHS-certified laboratory for analysis where they were screened for the following drugs:
amphetamines, barbiturates, benzodiazepines, cocaine, marijuana, methadone, methaqualone, opiates,
phencyclidine, and propozphene.
Brief Michigan Alcoholism Screening Test (BMAST; Pokorny, Miller, & Kaplan, 1972) is comprised of
10 items assessing alcohol problems that are rated as present (1) or absent (0) in the past 12 months, with
higher scores indicating greater alcohol problems. The BMAST has been shown to be highly correlated
with the longer MAST (Pokorny et al., 1972). The MAST demonstrates good sensitivity and specificity in
identifying alcohol use disorders in psychiatric samples (Teitelbaum & Mullen, 2000) and has
demonstrated good testretest reliability in both psychiatric and community samples (Teitelbaum &
Carey, 2000). The BMAST also demonstrates good specificity in identifying alcohol dependence and
harmful drinking (Cherpitel, 1998).
Drug Abuse Screening Test (DAST-10; Skinner, 1982) is comprised of 10 items relating to problematic
drug use that are rated as present (1) or absent (0) in the past 12 months, with higher scores indicating
greater drug involvement and impairment. In outpatients with an SMI, the DAST-10 has demonstrated
high internal consistency and adequate testretest reliability, as well as criterion validity as demonstrated
by acceptable sensitivity and specificity (Carey, Carey, & Chandra, 2003; Cocco & Carey, 1998; Maisto,
Carey, Carey, Gordon, & Gleason, 2000).
Severity of Dependence Scale (SDS; Gossop et al., 1995) is a 5-item measure of drug dependence, with
items rated on a 4 point-scale from never/almost never (0) to always/nearly always (3) for the past year.
482 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

The SDS has demonstrated high sensitivity and specificity, high internal consistency, and good testretest
reliability (de las Cuevas, Sanz, de la Fuente, Padilla, & Berenguer, 2000; Gossop et al., 1995).
Short-Form Alcohol Dependence Data Questionnaire (SADD; Raistrick, Dunbar, & Davidson, 1983)
is a 15-item measure of alcohol dependence, with items rated on a 4-point scale from never (0) to nearly
always (3) for the past year. The SADD correlates highly with other measures of dependence (Davidson &
Raistrick, 1986).
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996) is
a 19-item measure of motivation for change, with versions to measure drinking (SOCRATES-A) and drug
related (SOCRATES-D) motivation. Items are rated on a 5-point scale from strongly disagree (1) to
strongly agree (5), and there are three subscales: Problem Recognition (7 items), Ambivalence (4
items), and Taking Steps (8 items). The SOCRATES-A has adequate internal consistency and excellent
testretest reliability (Miller & Tonigan, 1996); psychometrics for the drug version have not yet been
reported.
Outcome Expectancy Questionnaire (OEQ; Leigh & Stacy, 1993) is a 34 item scale with subscales to
measure positive and negative outcome expectancies associated with alcohol and/or drug use, rated on a 4
point scale from almost never/never (1) to almost always/always (4).
Inventory of Drug Use Consequences (InDUC; Tonigan & Miller, 2002) is a 50 item measure of
negative consequences of alcohol and other drugs experienced in the past 12 months, with problems rated
as present (1) or absent (0). It is comprised of 5 subscales: Physical, Intrapersonal, Social Responsibilities,
Interpersonal, and Impulse Control. It has been found to have good reliability and to be sensitive to
changes in drug use (Tonigan & Miller, 2002).
Brief Symptom Inventory (BSI; Derogatis, 1993) is a 53-item scale of psychological symptoms
experienced in the past week, rated on a 5-point scale from not at all (0) to extremely (4). The BSI
includes nine symptom dimensions: Somatization, Obsessivecompulsive, Interpersonal Sensitivity,
Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. It has demonstrated
adequate reliability in psychiatric samples (Derogatis, 1993).

2.3. Data analysis

Multivariate analyses of covariance (MANCOVAs), with gender as a covariate, were used to compare
the DD and SUD-only groups on the following substance use disorder related domains: alcohol and drug
use, alcohol and drug dependence, alcohol and drug problems, alcohol motivation for change, drug
motivation for change, alcohol and drug expectancies, and negative consequences associated with alcohol
and drug use. MANCOVAs, with gender as a covariate, also were used to compare DD, SUD, and SMI
groups on psychological symptoms.
Regression analyses were performed to examine possible group differences in the influence of negative
consequences associated with substance use on alcohol and drug expectancies and motivation for change.
Four separate analyses were completed with a composite score formed by combining the InDUC
subscales regressed onto the following dependent variables: (1) drug motivation for change, (2) alcohol
motivation for change, (3) positive expectancies, and (4) negative expectancies, with gender included in
the analyses. Gender was included in analyses as a covariate because it has a potential impact on the
substance-related and psychological variables under investigation and participant groups were not
matched with regards to the numbers of men and women. Analyses were conducted probing for possible
moderating effects of substance use group (DD and SUD-only) on the influence of negative consequences
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 483

on the dependent variables. This was done by adding an interaction term (Group Negative
Consequences) as well as a variable representing group membership in the second step of the regression
analyses.

3. Results

3.1. Substance use and diagnoses

In order to test the hypothesis that individuals with an SMI are more likely to be diagnosed with
substance abuse, as opposed to dependence, separate analyses were conducted for alcohol, cocaine,
and cannabis comparing abuse and dependence diagnoses among SUD-only and DD participants. A
significant difference was found in the distribution of abuse and dependence diagnoses among the 70
individuals meeting criteria for an alcohol use disorder (Fisher's Exact Test, p < .01, r = .36 with
100% (n = 30) of DD and 79.3% (n = 23) of SUD-only participants meeting criteria for dependence as
opposed to abuse. Of the 22 SUD-only and 31 DD participants meeting criteria for a cocaine use
disorder, 100% in each group met criteria for dependence as opposed to abuse. Of the 29 individuals
meeting criteria for a cannabis use disorder, 89.9% (n = 16) of DD and 72.7% (n = 8) of SUD-only met
criteria for dependence, with no significant difference found between groups (Fisher's exact test,
p > .05, r = .20).
The DD and SUD-only groups did not differ in the distribution of alcohol or drug use diagnoses (see
Table 2). These two groups also did not differ in drug urinalysis results (2 (1) = 3.01, p > .05, r = .18 with
23% (n = 9) of SUD and 40% (n = 21) of DD testing positive for at least one illicit drug. Overall, rates of
drug use disorders were high, with the most prevalent being cocaine (54.7%, n = 53) and marijuana
(30.5%, n = 29). Among the DD and SUD-only participants, 36% (n = 34) had solely an alcohol use
disorder, 26% (n = 25) had solely a drug use disorder, and 38% (n = 36) had both an alcohol and a drug use
disorder. Only one gender difference was revealed in substance use diagnoses. More women (71%,
n = 30) met criteria for cocaine abuse or dependence then did men (43%, n = 23; 2 (1) = 7.47, p < .01,
r = .27).
In order to determine whether the DD and SUD-only groups differed with respect to their level of
alcohol and drug consumption, a MANCOVA was conducted on the following substance use variables:
days of alcohol use, average drinks per drinking day, days of heavy alcohol use, and days of drugs use (see

Table 2
Current substance abuse or dependence diagnoses
Substance use SUD-only (n = 42) DD (n = 53) 2 (1) r
diagnosis
% (n) % (n)
Alcohol 71.4 (30) 75.5 (40) .20 .05
Cocaine 52.4 (22) 58.5 (31) .36 .06
Cannabis 26.2 (11) 34.0 (18) .67 .08
Sedativesa 2.4 (1) 9.4 (5) .14
r = Phi coefficient.
a
Fisher's exact test.
484 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

Table 3). Substance use variables were log transformed prior to analyses due to non-normality. No
significant differences were found between DD and SUD-only groups in their recent substance use. In
addition, there were no significant gender differences.
The supersensitivity hypothesis suggests that substance abusing SMI individuals will display lower
rates of substance use as compared with individuals with solely an SUD, and be more likely to be
diagnosed with abuse as opposed to dependence. Contrary to predictions, there were no significant
differences between DD and SUD participants with regards to there recent substance use and DD
participants were not more likely to be diagnosed with abuse as opposed to dependence.
Table 3
Comparisons of substance use disorder groups for recent substance use, associated problems, severity of dependence, negative
consequences, motivation for change, and outcome expectancies
Variables and measures SUD-only (n = 42) DD (n = 53) Multivariate tests Univariate tests 2
Mean (S.D.) Mean (S.D.)
Alcohol and drug use (TLFB-60 days) a F(4,89) = .39, 2 = .04
Days of alcohol use 11.43 (16.96) 7.62 (14.83) F(1,92) = .56 .01
Average drinks per drinking day 6.01 (12.33) 3.91 (6.16) F(1,92) = .06 .00
Days of heavy drinking 6.17 (12.29) 6.51 (14.39) F(1,92) = .00 .00
Days of drug use 5.40 (13.36) 10.06 (19.33) F(1,92) = .96 .01
Alcohol and drug problems F(2,81) = 4.18, 2 = .09
Drug problems (DAST) 4.89 (2.87) 6.63 (2.36) F(1,81) = 8.46 .09
Alcohol problems (BMAST) 4.53 (1.86) 4.67 (2.21) F(1,81) = .14 .00
Alcohol and drug dependence severity F(2,81) = .79, 2 = .02
Alcohol dependence (SADD) 12.03 (9.88) 15.29 (11.78) F(1,81) = 1.57 .02
Drug dependence (SDS) 7.25 (5.21) 7.71 (4.18) F(1,81) = .06 .00
Negative alcohol/drug F(5,80) = .86, 2 = .02
consequences (InDUC)
Physical 5.08 (2.31) 5.84 (2.21) F(1,84) = 1.67 .02
Interpersonal 6.82 (2.93) 7.27 (2.94) F(1,84) = .29 .00
Intrapersonal 6.26 (2.30) 6.67 (1.94) F(1,84) = .52 .01
Impulse Control 6.32 (2.88) 6.84 (3.06) F(1,84) = .52 .01
Social Responsibility 4.58 (2.11) 5.06 (1.99) F(1,84) = .79 .01
Motivation for changeAlcohol F(3,88) = .74, 2 = .02
(SOCRATES)
RecognitionAlcohol 26.63 (9.67) 26.78 (8.49) F(1,90) = .97 .01
Taking StepsAlcohol 33.83 (9.32) 32.69 (8.42) F(1,90) = .03 .00
AmbivalenceAlcohol 14.76 (5.15) 14.23 (4.84) F(1,90) = .56 .01
Motivation for changeDrug F(3,86) = 1.79, 2 = .06
(SOCRATES)
RecognitionDrug 21.28 (12.44) 26.33 (10.24) F(1,88) = 2.87 .03
Taking StepsDrug 27.98 (13.88) 32.98 (9.61) F(1,88) = 2.61 .03
AmbivalenceDrug 12.53 (6.65) 14.25 (5.64) F(1,88) = .88 .01
Alcohol and drug expectancies (EQ) F(2,89) = .27, 2 = .03
Positive 48.61 (10.77) 51.50 (12.32) F(1,90) = 1.33 .01
Negative 31.78 (9.47) 34.90 (8.64) F(1,90) = 1.73 .02
Ns vary due to missing data.
p < .05. p < .01.
a
TLFB variables were log-transformed prior to analyses. Displayed values are the non-transformed means and standard
deviations.
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 485

3.2. Substance problems, severity of dependence, and negative consequences

A MANCOVA revealed a significant difference between DD and SUD-only groups in problems

associated with alcohol and drug use (see Table 3). Univariate analyses revealed that the DD group had a
significantly higher score on the DAST than the SUD-only group, indicating greater problems with drug
use (see Table 3). No significant difference was found for alcohol problems. Women reported greater
problems with drug use (F(1,81) = 12.72, p < .001, 2 = .13), but men and women did not differ in their
reported alcohol problems.
MANCOVAs revealed no significant differences between the DD and SUD-only groups on
measures of alcohol or drug dependence severity, or negative consequences associated with substance
use (see Table 3). While men and women did not differ in their report of experiencing negative
consequences associated with alcohol and drug use, women reported greater severity of drug
dependence (F(1,82) = 5.95, p < .05, 2 = .07).
Based on the supersensitivity hypothesis, it was expected that individuals in the DD group would
exhibit greater alcohol and drug problems, a lower level of substance dependence, and greater negative
consequences due to substance use. Contrary to these predictions, DD participants did not report greater
symptoms of substance dependence severity, experiencing more negative consequences associated with
their substance use, or greater problems associated with alcohol use; however, they did report greater drug
problems.

3.3. Substance use expectancies and motivation for change

MANCOVAs also revealed no significant differences between SUD-only and DD groups in alcohol or
drug motivation for change or in positive or negative expectancies associated with substance use (see
Table 3). No gender differences were found in expectancies or alcohol motivation for change. However,
women reported greater motivation for change for drug use behavior (F(3,86) = 2.80, p < .05, 2 = .09),
with significant differences for all three subscales of the SOCRATES-D.
Regression analyses were used to examine the influence of negative consequences associated with
substance use on substance use expectancies and motivation for change. For both the drinking and the
drug versions of the SOCRATES, high correlations were found between the subscales (r = .72.91);
therefore, composite scores were calculated by summing subscale totals with higher scores indicating
greater motivation for change. Similarly, analyses involving the InDUC resulted in problems with multi-
collinearity; therefore, a composite score was formed by summing subscale scores in order to perform
regression analyses of negative consequences associated with drug and alcohol use.
A simultaneous regression analysis in which negative consequences and gender were regressed onto
alcohol motivation for change was significant (see Table 4). Greater negative consequences were
associated with greater alcohol motivation for change, while gender was not significantly associated with
alcohol motivation for change. Similarly, when negative consequences and gender were regressed onto
drug motivation for change there was a significant relationship such that both greater negative
consequences and female gender predicted greater drug motivation for change (see Table 4).
A simultaneous regression analysis in which negative consequences and gender were regressed onto
negative substance use expectancies also revealed a significant positive association between these
variables (see Table 4). Both negative consequences and gender significantly predicted negative drug and
alcohol expectancies, with women reporting greater negative expectancies than men. A regression
486 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

Table 4
Summary table of regressions analyses of gender and negative consequences associated with substance use predicting motivation
for change and substance use expectancies
Variables R2 B SEB
Alcohol motivation for change .25
Gender 3.94 4.02 .09
Negative consequences .95 .19 .47
Drug motivation for change .27
Gender 14.90 5.06 .28
Negative consequences .99 .24 .39
Negative expectancies .44
Gender 3.38 1.51 .19
Negative consequences .53 .07 .60
Positive expectancies .01
Gender .95 2.48 .04
Negative consequences .10 .12 .10
Gender was dummy coded such that men = 0 and women = 1.
p < .05. p < .01. p < .001.

analysis with positive expectancies and gender regressed onto negative consequences did not reveal a
significant relationship between these variables.
No significant interactions were revealed for group membership for any of the regression analyses;
therefore, DD and SUD-only groups did not differ in their relationship between negative consequences
and dependent variables.

3.4. Psychological symptoms

A MANOVA of the BSI subscales revealed significant differences between SUD-only, DD, and SMI-
only groups (F(18,232) = 4.04, p < .001, 2 = .24; see Table 5). The DD group scored significantly higher
on Somatization, as compared with the other two groups. The DD and SMI-only groups reported

Table 5
Comparison of psychological symptoms, as measured by the BSI, among SUD, DD, and SMI participants
BSI subscales SUD-only (n = 41) DD (n = 52) SMI-only (n = 35) F(2,124) 2
Somatization .54 (.69)b
1.25 (.95)a b
.94 (.77) 7.85 .11
ObsessiveCompulsive .86 (.70)b 1.80 (.85)a 1.51 (.98)a 12.84 .17
Phobic Anxiety .42 (.61)b 1.29 (.88)a 1.08 (1.04)a 10.97 .15
Interpersonal Sensitivity .79 (.82)b 1.83 (.96)a 1.33 (.89)a 14.35 .19
Depression .81 (.92)b 1.63 (1.02)a 1.34 (.99)a 7.93 .11
Anxiety .69 (.69)b 1.56 (.94)a 1.29 (.86)a 10.90 .15
Paranoid Ideation 1.15 (.94)b 1.91 (.86)a 1.48 (.99)a 7.54 .11
Hostility .91 (.86)a 1.41 (1.06)a .61 (.54)b 12.14 .16
Psychoticism .58 (.63)b 1.43 (.85)a 1.32 (.96)a 12.88 .17
Means in the same row with different subscripts are significantly different at the .05 level. Bonferroni corrections applied during
post hoc analyses.
p < .001.
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 487

significantly greater scores for Obsessive-Compulsive Phobic Anxiety, Interpersonal Sensitivity,

Depression, Anxiety, Paranoid Ideation, and Psychoticism than the SUD group. The DD and SUD-
only groups had significantly higher scores for Hostility compared with the SMI-only group. This
multivariate analysis of the BSI also indicated a significant difference between women and men (F(9,116)
= 3.36, p < .001, 2 = .21), with univariate tests of individual subscales revealing that women reported
significantly greater Obsessivecompulsive, Interpersonal sensitivity, and Hostility scores.

4. Discussion

Although it has been posited that DD individuals are more likely to suffer from symptoms of substance
abuse as opposed to substance dependence, this is the first known study to test this hypothesis via an
appropriate comparison group. According to the supersensitivity hypothesis, DD individuals should
evidence higher rates of substance abuse diagnoses and relatively lower rates of dependence diagnoses, as
compared with SUD individuals, due to lower levels of substance use accompanied by higher rates of
associated negative consequences. No support for these posited relationships were found in the current
study. Among individuals with an alcohol use disorder, the DD group actually had higher proportions of
individuals meeting dependence criteria as opposed to abuse.
Dually diagnosed individuals were more similar than different to those with only an SUD with
respect to their substance use and associated factors. Dually diagnosed individuals evidenced
comparable rates of recent substance use (via both self-report and drug urinalysis) and rates of
substance use disorders. These groups also did not differ significantly in their rates of negative
consequences associated with substance abuse or in their severity of substance dependence. Overall, the
hypothesis of a heightened sensitivity to substance use resulting in greater negative consequences was
not supported in this study.
The DD and SUD-only groups did not differ in their motivation to change their alcohol or drug use or
their in alcohol and drug expectancies. These groups also did not differ in the interrelationships of
negative consequences, negative expectancies, and motivation. While SMI individuals are unique in
regards to their cognitive and psychiatric symptoms, these findings suggest that DD and SUD patients are
quite similar in their attitudes and thoughts regarding substance use and motivation for change.
To date, few studies have compared SUD individuals with and without a severe mental illness.
Westermeyer and Schneekloth (1999) conducted one of the few studies comparing SUD individuals with
schizophrenia to an SUD-only group. Groups were compared on demographic characteristics, age at first
use of a variety of substances, duration of use, days of use in the past year, lifetime substance use
diagnoses, and longest period of abstinence. As in the current study, few differences were found between
these groups for alcohol and drugs.
Overall, DD individuals in the present study appear to fare worse with regards to psychological
symptoms than both the SMI-only and SUD-only groups in that all significant differences were in the
direction of the DD group being more symptomatic. In addition, the DD group evidenced higher scores
than the SUD-only group on all subscales, with the exception of the hostility subscale. Both SUD groups
scored significantly higher than the SMI-only group on this subscale. This finding is consistent with
previous research that has found greater levels of violence and aggression in DD individuals in
comparison with those with an SMI only (Soyka, 2000; Swartz et al., 1998). Consistent with their mental
illness diagnoses, DD and SMI-only groups reported higher levels distress on most symptom subscales
488 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

than did the SUD-only group. However, the DD group reported more somatization symptoms (e.g.,
dizziness, nausea, weakness) in comparison with both the SUD-only and SMI-only groups. These
findings suggest that some of the increased psychological symptoms seen among DD individuals may be
due to an additive effect of having an SUD and a severe mental illness.
In the current sample, more women than men met criteria for cocaine abuse or dependence, while no
significant differences were found for alcohol or other drug use disorders. This likely explains the greater
symptoms of dependence and problems with drug use reported by women. Consistent with this finding,
women also reported greater motivation to change their drug use.
There are some limitations with regards to the sample used in the current study. The sample sizes for
each of the groups were limited, resulting in low statistical power to find small differences between
groups; however, as the effect sizes for nonsignificant findings were quite small, statistically significant
differences between groups were unlikely to have been found even with a much larger sample size. The
SUD-only and DD groups were not recruited from the same treatment site, but were instead recruited
from two different treatment centers in the same city and in close proximity to each other. Demographic
comparisons revealed differences between the SUD-only and DD groups with regards to housing,
employment, and income; however, these differences were to be expected given the demographic
characteristics typically found among SMI populations. In the current study, SUD patient groups were
drawn from substance abuse and dual-diagnosis outpatient treatment sites. Therefore, the results may not
generalize to non-treatment seeking individuals or those who use substances but do not meet diagnostic
criteria for abuse or dependence. Also, using a treatment sample may have resulted in a bias towards
dependence as opposed to abuse diagnoses in both the DD and the SUD-only groups, which may have
contributed to the lack of significant findings for abuse and dependence when comparing these groups. It
is also possible that DD individuals were only referred to substance abuse treatment when their
substance use problems were more progressed, possibly owing to a masking of substance abuse
symptoms by psychiatric symptoms. If this were the case, it would result in higher rates of dependence
in this group than is representative of the population. This also could have contributed to the lack of
significant findings found between the groups for diagnoses of abuse and dependence. Alternatively,
SMI individuals may have been more likely to be identified as having a substance use disorder during
their mental health assessments and treatment. If this direction of bias were present, it would have
supported the supersensitivity hypothesis in that DD individuals would have been expected to display
lower rates of dependence diagnoses and symptoms. While our findings do not support the
supersensitivity hypothesis, a population-based epidemiological study would provide a superior test of
the supersensitivity hypothesis by avoiding the potential for bias associated with treatment seeking
populations.
Most efforts to understand comorbidity among individuals with an SMI have involved studying
characteristics of substance abusing participants with an SMI in comparison to those with only an
SMI, or without any comparison group. While considerable evidence has been accrued regarding the
deleterious effect of substance abuse on the course of a severe mental illness, little information exists
regarding how SUDs differ in those with an SMI compared with those without a comorbid severe
mental illness. The results of the current study suggest that negative consequences and problems
associated with SUDs do not differ between those with and without a severe mental illness. In
addition, cognitive and attitudinal factors related to substance use examined in the current study
suggest that SMI and SUD participants were quite similar in their thoughts about substance use and
their self-reported need for change.
 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490 489

References

Blanchard, J. J., Brown, S. A., Horan, W. P., & Sherwood, A. R. (2000). Substance use disorders in schizophrenia: Review,
integration, and a proposed model. Clinical Psychology Review, 20, 207234.
Carey, K. B. (1997). Reliability and validity of the time-line follow-back interview among psychiatric outpatients: A preliminary
report. Psychology of Addictive Behaviors, 11, 2633.
Carey, K. B., Carey, M. P., & Chandra, P. S. (2003). Psychometric evaluation of the Alcohol Use Disorders Identification
Test and Short Drug Abuse Screening Test with psychiatric patients in India. Journal of Clinical Psychiatry, 64,
767774.
Carey, M. P., Carey, K. B., Maisto, S. A., Gordon, C. M., & Weinhardt, L. S. (2001). Assessing sexual risk behaviour with the
Timeline Followback (TLFB) approach: Continued development and psychometric evaluation with psychiatric outpatients.
International Journal of STD & AIDS, 12, 365375.
Cassidy, F., Ahearn, E. P., & Carroll, B. J. (2001). Substance abuse in bipolar disorder. Bipolar Disorders, 3, 181188.
Cherpitel, C. J. (1998). Difference in performance of screening instruments for problem drinking among Blacks, Whites and
Hispanics in an emergency room population. Journal of Studies on Alcohol, 59, 420426.
Cocco, K. M., & Carey, K. B. (1998). Psychometric properties of the Drug Abuse Screening Test in psychiatric outpatients.
Psychological Assessment, 10, 408414.
Dalton, E. J., Cate-Carter, T. D., Mundo, E., Parikh, S. V., & Kennedy, J. L. (2003). Suicide risk in bipolar patients: The role of
co-morbid substance use disorders. Bipolar Disorders, 5, 5861.
Davidson, R., & Raistrick, D. (1986). The validity of the Short Alcohol Dependence Data (SADD) Questionnaire: A short self-
report questionnaire for the assessment of alcohol dependence. British Journal of Addiction, 81, 217222.
de las Cuevas, C., Sanz, E., de la Fuente, J. A., Padilla, J., & Berenguer, J. C. (2000). The Severity of Dependence Scale (SDS) as
screening test for benzodiazepine dependence: SDS validation study. Addiction, 95, 245250.
Derogatis, L. R. (1993). Brief symptom inventory: Administration scoring and procedures manual (3rd ed.). Minneapolis, MN:
National Computer Systems.
Drake, R. E., & Mueser, K. T. (2002). Co-occuring alcohol use disorder and schizophrenia. Alcohol Research & Health, 26,
99102.
Drake, R. E., & Wallach, M. A. (1993). Moderate drinking among people with severe mental illness. Hospital and Community
Psychiatry, 44, 780782.
Ehrman, R. N., & Robbins, S. J. (1994). Reliability and validity of 6-month timeline reports of cocaine and heroin use in a
methadone population. Journal of Consulting and Clinical Psychology, 62, 843850.
Fals-Stewart, W., O'Farrell, T. J., Freitas, T. T., McFarlin, S. K., & Rutigliano, P. (2000). The Timeline Followback reports of
psychoactive substance use by drug-abusing patients: Psychometric properties. Journal of Consulting and Clinical
Psychology, 68, 134144.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of
patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W., et al. (1995). The Severity of Dependence Scale (SDS):
Psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction,
90, 607614.
Gut-Fayand, A., Dervaux, A., Olie, J., Loo, H., Poirier, M., & Krebs, M. (2001). Substance abuse and suicidality in
schizophrenia: A common risk factor linked to impulsivity. Psychiatry Research, 102, 6572.
Kamali, M., Kelly, L., Gervin, M., Browne, S., Larkin, C., & O'Callaghan, E. (2000). The prevalence of comorbid substance
misuse and its influence on suicidal ideation among in-patients with schizophrenia. Acta Psychiatrica Scandinavica, 101,
452456.
Keck, P. E., McElroy, S. L., Strakowski, S. M., West, S. A., Sax, K. W., Hawkins, J. M., et al. (1998). 12-month outcome of
patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry,
155, 646652.
Kovasznay, B., Fleischer, J., Tanenberg-Karant, M., Jandorf, L., Miller, A. D., & Bromet, E. (1997). Substance abuse disorder
and the early course of illness in schizophrenia and affective psychosis. Schizophrenia Bulletin, 23, 195201.
Leigh, B. C., & Stacy, A. W. (1993). Alcohol outcome expectancies: Scale construction and predictive utility in higher order
confirmatory models. Psychological Assessment, 5, 216229.
490 V.M. Gonzalez et al. / Addictive Behaviors 32 (2007) 477490

Maisto, S. A., Carey, M. P., Carey, K. B., Gordon, C. M., & Gleason, J. R. (2000). Use of the Audit and the DAST-10 to identify
alcohol and drug use disorders among adults with a severe and persistent mental illness. Psychological Assessment, 12,
186192.
Maisto, S. A., Sobell, L. C., Cooper, A. M., & Sobell, M. B. (1982). Comparison of two techniques to obtain retrospective reports
of drinking behavior from alcohol abusers. Addictive Behaviors, 7, 3338.
Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness and
Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10, 8189.
Mueser, K. T., Drake, R. E., & Wallach, M. A. (1998). Dual diagnosis: A review of etiological theories. Addictive Behaviors, 23,
717734.
Olfson, M., Mechanic, D., Hansell, S., Boyer, C. A., & Walkup, J. (1999). Prediction of homelessness within three months of
discharge among inpatients with schizophrenia. Psychiatric Services, 50, 667673.
Pokorny, A. D., Miller, B. A., & Kaplan, H. B. (1972). The brief MAST: A shortened version of the Michigan Alcoholism
Screening Test. American Journal of Psychiatry, 129, 342345.
Raistrick, D., Dunbar, G., & Davidson, R. (1983). Development of a questionnaire to measure alcohol dependence. British
Journal of Addiction, 78, 8995.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., et al. (1990). Comorbidity of mental disorders with
alcohol and other drugs. Journal of the American Medical Association, 264, 25112518.
Robins, L. N., Cottler, L. B., Bucholz, K. K., & Compton, W. M. (1995). Diagnostic interview schedule for DSM-IV (DIS-IV). St.
Louis, MO: National Institute of Mental Health.
Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7, 363371.
Sobell, L. C., Maisto, S. A., Sobell, M. B., & Cooper, A. M. (1979). Reliability of alcohol abusers' self-reports of drinking
behavior. Behavior Research and Therapy, 17, 157160.
Soyka, M. (2000). Substance misuse, psychiatric disorders and violent and disturbed behaviour. British Journal of Psychiatry,
176, 345350.
Swartz, M. S., Swanson, J. W., Hiday, V. A., Borum, R. H., Wagner, R., & Burns, B. J. (1998). Violence and severe mental
illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226231.
Teitelbaum, L., & Mullen, B. (2000). The validity of the MAST in psychiatric settings: A meta-analytic integration. Journal of
Studies on Alcohol, 61, 254261.
Teitelbaum, L. M., & Carey, K. B. (2000). Temporal stability of alcohol screening measures in a psychiatric setting. Psychology
of Addictive Behaviors, 14, 401404.
Tonigan, J. S., & Miller, W. R. (2002). The Inventory of Drug Use Consequences (InDUC): Testretest stability and sensitivity to
change. Psychology of Addictive Behaviors, 16, 165168.
Westermeyer, J. J., & Schneekloth, T. D. (1999). Course of substance abuse in patients with and without schizophrenia. The
American Journal on Addictions, 8, 5564.