Substance use in youth at risk for psychosis

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

Influence of cannabis use on incidence of psychosis in people at clinical high risk

AIMS

Evidence for case-control studies suggests that cannabis use is a risk factor for the development of psychosis. However, there have been limited prospective studies and the direction of this association remains controversial. The primary aim of the present study was to examine the association between cannabis use and the incidence of psychotic disorders in people at clinical high risk of psychosis. Secondary aims were to assess associations between cannabis use and the persistence of psychotic symptoms, and with functional outcome.

METHODS

Current and previous cannabis use were assessed in individuals at clinical high risk of psychosis (n = 334) and healthy controls (n = 67), using a modified version of the Cannabis Experience Questionnaire. Participants were assessed at baseline and followed up for 2 years. Transition to psychosis and persistence of psychotic symptoms were assessed using the Comprehensive Assessment of At-Risk Mental States criteria. Level of functioning at follow up was assessed using the Global Assessment of Functioning disability scale.

RESULTS

During follow up, 16.2% of the clinical high-risk sample developed psychosis. Of those who did not become psychotic, 51.4% had persistent symptoms and 48.6% were in remission. There was no significant association between any measure of cannabis use at baseline and either transition to psychosis, the persistence of symptoms, or functional outcome.

CONCLUSIONS

These findings contrast with epidemiological data that suggest that cannabis use increases the risk of psychotic disorder.

Physical Health in Clinical High Risk for Psychosis Individuals: A Cross-Sectional Study

BACKGROUND

The clinical high risk for psychosis (CHR-P) phase represents an opportunity for prevention and early intervention in young adults, which also could focus on improving physical health trajectories.

METHODS

We conducted a RECORD-compliant clinical register-based cohort study. The primary outcome was to describe the physical health of assessed CHR-P individuals, obtained via Electronic Health Records at the South London and Maudsley (SLaM) NHS Foundation Trust, UK (January 2013-October 2020).

RESULTS

The final database included 194 CHR-P subjects (46% female). Mean age was 23.70 ± 5.12 years. Percentage of tobacco smokers was 41% (significantly higher than in the age-matched general population [24%]). We found that 49% of subjects who consumed alcohol had an AUDIT-C (Alcohol Use Disorder Identification Test) score above 5 (hazardous drinking), with an average score of 4.94 (significantly higher than in the general population [2.75]). Investigating diet revealed low fiber intake in most subjects and high saturated fat intake in 10% of the individuals. We found that 47% of CHR-P subjects met the UK recommended physical activity guidelines (significantly lower than in the general population [66%]). Physical parameters (e.g., weight, heart rate, blood pressure) were not significantly different from the general population.

CONCLUSIONS

This evidence corroborates the need for monitoring physical health parameters in CHR-P subjects, to implement tailored interventions that target daily habits.

Cannabis use, self-perceived risk, perceived peer approval and parental attitudes among youth at clinical high-risk for psychosis

AIM

Cannabis use is associated with greater likelihood of psychosis. The relationship between attitudes about cannabis and use has not been examined in youth at clinical high-risk (CHR) for psychosis. Additionally, the shifting legal landscape can provide a valuable context for evaluating use and related attitudes.

METHODS

This study included 174 participants (44 CHR, 43 healthy control [HC] youth-parent dyads). Youth completed measures of self-reported cannabis use confirmed with a urinalysis, self-perceived risk and perceived peer attitudes. Parents reported attitudes about youth use. Legalization occurred halfway during a 5-year study in Colorado, providing an opportunity to cross-sectionally examine its role in use and attitudes.

RESULTS

Frequency of youth reporting cannabis use was significantly higher in CHR (69%) than control group (30%). Use in CHR group was associated with higher perceived peer approval (r = .57), increased parental permissiveness (r = .28) and lower self-perceived risk (r = -.26). Comparing samples participating pre and post-legalization, use remained stable within each group. Group differences in parental permissiveness shifted; trend toward decrease in permissiveness in CHR group (η²_partial  = .07) and a significant increase in HCs (η²_partial  = .16) were observed. Post-legalization, use in CHR group correlated with higher perceived peer approval (r = .64), lower self-perceived risk (r = -.51) and higher parental permissiveness (r = .35, trend).

CONCLUSIONS

Taken together, results indicate a relationship between self and peer/parental attitudes about cannabis and use in youth at CHR for psychosis. These factors are important to consider within the legalization context given the changes in parental attitudes and a stronger association between use and attitudes in this group post-legalization.

Longitudinal and cross-sectional validation of the WERCAP screen for assessing psychosis risk and conversion

BACKGROUND

The Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen was developed to assess risk for developing psychosis. Its validity has not been investigated in a large population-based study or with longitudinal analyses.

METHODS

825 participants, aged 14-25, were recruited from Kenya. Symptoms were assessed using the WERCAP Screen, as experienced over the prior 3-months (3MO), 12-months (12MO) or lifetime (LIF). ROC curve analysis was used to determine the validity of the WERCAP Screen against the Structured Interview of Psychosis-Risk Syndromes. Longitudinal validity was assessed by comparing baseline p-WERCAP scores in psychotic disorder converters and non-converters, and using ROC curve analysis. Relationship of the p-WERCAP was examined against clinical variables.

RESULTS

ROC curve analyses against SIPS showed an AUC of 0.83 for 3MO, 0.79 for 12MO and 0.65 for LIF psychosis scores. The optimal cut-point on 3MO was a score of >12 (sens: 0.78; spec: 0.77; ppv: 0.41), and >32 for 12MO (sens: 0.71; spec: 0.74; ppv: 0.24). Baseline 3MO scores (but not LIF scores) were higher in converters compared to high-risk non-converters (p = 0.02). 3MO scores against conversion status had an AUC of 0.75, with an optimal cutoff point of >16 (sens: 1.0; spec: 0.53). All p-WERCAP scores significantly correlated with substance use and stress severity. 12 MO scores were most related to cognitive impairment.

CONCLUSIONS

The WERCAP Screen is a valid instrument for assessing psychosis severity and conversion risk. It can be used in the community to identify those who may require clinical assessment and care, and for recruitment in psychosis-risk research.

Perceived racial and social class discrimination and cannabis involvement among Black youth and young adults

BACKGROUND

The current study examines the association of perceived racial and social class discrimination with cannabis involvement among Black youth and young adults.

METHODS

This secondary analysis used data from the Missouri Family Study (MOFAM), a high-risk longitudinal family study of alcohol use disorder, oversampled for Black families. Offspring (n = 806) and their mothers were interviewed by telephone. Cox proportional hazards regression analyzes were used to examine associations of racial and social class discrimination (experienced by offspring and their mothers) with offspring cannabis involvement. Two stages of cannabis involvement were analyzed: timing of 1) initiation and 2) transition from initiation to first cannabis use disorder (CUD) symptom.

RESULTS

The study found that offspring report of experiencing racial (HR: 1.28, CI: 1.01-1.62) and social class discrimination (HR: 1.45, CI: 1.14-1.84) were associated with cannabis initiation in our fully adjusted model. Mothers' report of discrimination predicted a lower hazard of cannabis initiation among offspring (HR: 0.79, CI: 0.64-0.98). Offspring social class discrimination (HR: 2.45, CI: 1.71-3.51) predicted an increased hazard of transition from initiation to first CUD symptom, while offspring racial discrimination (HR: 0.57, CI: 0.39-0.85) was associated with lower hazard of transition in our fully adjusted model.

CONCLUSIONS

As rates for cannabis use among Black youth are disproportionately rising, there is a critical need to identify pathways to its use among Black youth. These findings suggest racial and social class discrimination may be important targets in efforts to prevent cannabis involvement among Black youth and emerging adults.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

Using Experience Sampling Methodology Data to Characterize the Substance Use of Youth With or At-Risk of Psychosis

OBJECTIVES

Psychotic-spectrum disorders emerge during adolescence and early adulthood, which corresponds with the peak period for substance use initiation. Clinical and epidemiological data provide support that substance use is associated with psychotic symptom onset and severity. Experience-sampling methodology (ESM) data may provide additional insight into dynamic associations between substance use and psychotic symptoms. This is one of the first efforts to characterize substance use frequency and dynamic associations with psychotic symptoms and negative affect from ESM data in both clinical high risk (CHR) and early psychosis (EP) individuals.

METHODS

Using ESM, 33 individuals, including 17 with CHR and 16 EP (age range: 15-24), provided information on substance use, negative affect, and psychotic symptoms 6 times a day across a 21-day data collection window. Psychotic symptoms and negative affect included multi-item variables rated on a seven-point Likert Scale. Participants reported recent substance use for 4 drug classes (nicotine, cannabis, depressants, stimulants) via a yes/no item. Descriptive information included data on substance use frequency, and momentary negative affect and psychotic symptoms. Exploratory analyses included multi-level and person-level dynamic structural equation models, which assessed contemporaneous and lagged associations between substance use and symptoms.

RESULTS

Twenty-seven individuals (82%) reported recurrent substance use including stimulants (n = 12, 46%), nicotine (n = 9, 27%), cannabis (n = 6, 18%), and depressants (n = 4, 12%). Individuals with any recurrent substance use indicated usage at 47.7% of answered prompts; stimulants at 23.6%; nicotine at 74.2%; cannabis at 39.1%; and depressants at 20.1%. A multi-level dynamic structural equation model reflected that substance use (any class) was associated with lagged negative affect (β = -0.02, CI: -0.06, < -0.00) but no significant contemporaneous or lagged associations between substance use and psychotic symptoms. Person-level models suggest potentially meaningful inter-individual variability.

CONCLUSIONS

CHR and EP individuals use a range of substances that may both reflect and influence other experiences in daily life experiences. Data reflected moderate to high rates of recurrent substance use with more consistent use within nicotine and cannabis classes. ESM data have the potential to increase our understanding of the dynamic relationships between substance use and symptoms and to inform treatment for individuals in early course psychosis.

Schizotypy, Lifestyle Behaviors, and Health Indicators in a Young Adult Sample

Problematic lifestyle behaviors and high rates of physical illness are well documented in people with schizophrenia, contributing to premature mortality. Yet, there is a notable absence of research examining general lifestyle and health issues in participants at risk for psychosis. This form of research may help identify concerns that exist during prodromal periods related to future outcomes. Accordingly, the current study examined lifestyle and health in a nonclinical sample of 530 young adults with varying levels of schizotypy. Increasing symptom severity was associated with greater somatic symptoms and poorer sleep quality across positive, negative, and disorganized domains. Elevated negative and disorganized symptoms were associated with significantly reduced health-related quality of life, while evidence for reduced engagement in health behaviors was largely limited to those with elevated negative schizotypy. No relationships emerged between symptom presentation/severity and body mass index or substance use, although zero-order correlations suggested an association between disorganized schizotypy and nicotine use. The pattern of relationships in the current study was consistent with findings from the ultra-high risk and clinical literature suggesting that lifestyle and health concerns may exist on a continuum with psychosis. Future research should seek to clarify if these patterns are associated with long-term physical or mental health outcomes.

Exercise interventions in child and adolescent mental health care: An overview of the evidence and recommendations for implementation

Background

The use of physical activity interventions in mental health care for adults has a large academic evidence base and numerous examples of real-world implementation. However, the use of physical activity within mental health care for children and young people (CYP) has received less attention to date.

Methods

A narrative review was conducted to summarize the relevant literature in the area. Online databases were searched using terms synonymous with CYP, exercise, physical health, and mental health. Findings from existing systematic reviews, meta-analyses, meta-syntheses, and consensus statements were reviewed, and used alongside the authors' experience to inform clinical recommendations.

Results

We first discuss the importance of applying physical health interventions in early stages of mental illness for CYP to prevent physical comorbidities and premature mortality in the long term. We then provide a brief summary of the current evidence of the benefits of exercise interventions in CYP with mental illness. We then present our top five recommendations on the implementation of exercise interventions within CYP mental health care.

Conclusion

The key conclusions from this suggest there is an increasingly strong evidence base for the benefits of using physical activity interventions to improve, prevent, and manage physical and mental health outcomes in CYP with mental illness. However, more work needs to be done to improve the evidence base, refine its implementation into standard mental health care, and develop strategies for large-scale dissemination of such interventions across various care and cultural contexts.

The central executive network and executive function in healthy and persons with schizophrenia groups: a meta-analysis of structural and functional MRI

This meta-analysis evaluated the extent to which executive function can be understood with structural and functional magnetic resonance imaging. Studies included structural in schizophrenia (k = 8; n = 241) and healthy controls (k = 12; n = 1660), and functional in schizophrenia (k = 4; n = 104) and healthy controls (k = 12; n = 712). Results revealed a positive association in the brain behavior relationship when pooled across schizophrenia and control samples for structural (pr = 0.27) and functional (pr = 0.29) modalities. Subgroup analyses revealed no significant difference for functional neuroimaging (pr = .43, 95%CI = -.08-.77, p = .088) but with structural neuroimaging (pr = .37, 95%CI = -.08-.69, p = .015) the association to executive functions is lower in the control group. Subgroup analyses also revealed no significant differences in the strength of the brain-behavior relationship in the schizophrenia group (pr = .59, 95%CI = .58-.61, p = .881) or the control group (pr = 0.19, 95%CI = 0.18-0.19, p = 0.920), suggesting concordance.

Psychotic-like experiences among 9,564 Kenyan adolescents and young adults

OBJECTIVE

To investigate the prevalence and characteristics of psychotic-like experiences (PLE) in a large cohort of Kenyan adolescents and young adults.

METHOD

The Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen was used to the study the 12-month prevalence of PLE's among 9,564 Kenyan youths (aged 15-25 yrs), and the rates of psychosis high-risk (HR) and medium-risk (MR) cases, based on cut-off scores. Relationships with clinical, demographic and economic profiles were investigated.

RESULTS

Across all participants, 72% reported having had at least one PLE over the last year. 4.6% and 30.6% were HR and MR based on symptom scores. There were similar PLE rates in females and males. PLE severity correlated with mood (r=0.67), stress (r=0.46), and autistic traits (r=0.18). PLE severity was also related to poverty, lower education attainment, and underemployment. Compared to controls, HR and MR youths were more likely to report lifetime substance use and to have more significant use.

CONCLUSION

Psychosis screening can provide valuable information about individuals and may help identify those who may require clinical assessment and intervention to improve outcomes. This is particularly relevant in many parts of Africa where the resources are limited for treating more advanced illness.

Clinical and functional characteristics of a subsample of young people presenting for primary mental healthcare at headspace services across Australia

PURPOSE

Headspace services provide treatment options to young people seeking mental healthcare. To obtain a better understanding of needs and characteristics of this population, and effectively evaluate services, we require novel youth-specific outcome measures. As part of our broad research program to establish such measures, a sample of young people were recruited and assessed. The study describes (i) methodology used to obtain clinical, functioning, and substance use characteristics of young people presenting to headspace services; and (ii) an overview of these characteristics.

METHODS

Young people presenting to headspace centres were recruited. Multidimensional information was obtained relating to clinical and functional outcomes, demographic information, and lifestyle factors.

RESULTS

1107 young help-seeking individuals were recruited. Participants were most likely young adults aged M = 18.1 years, SD = 3.3, with diagnoses of depression and/or anxiety (76.6%, n = 801), engaged in work and study (84.9%, n = 890), and living with parent(s) (68.9%, n = 736). Impairments in functioning were moderate as indicated by the Social and Occupational Functioning Assessment Scale (M = 65.2, SD = 9.5), substance use was common (alcohol 62.7%, n = 665; illicit substances 30.5%, n = 324), and current suicidal ideation was reported by a third (33.6%, n = 358).

CONCLUSIONS

A broad dataset was obtained providing an insight into key clinical, functional and quality of life characteristics of these individuals. We observed that young people present with complex problems, comorbid diagnoses, moderate levels of symptomatology, impairments in functioning, substance use, and suicidal ideation. This work provides the foundation for our broader research program aiming to develop novel, relevant and youth-specific, change and outcome measures.

Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults

Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

Substance use in youth at-risk for serious mental illness

AIM

The aim of this paper is to describe the substance use of participants who are at-risk for serious mental illness (SMI).

METHOD

The Canadian Psychiatric Risk and Outcome study (PROCAN) is a two-site study of 243 youth and young adults aged 13 to 25 years, categorized into four groups: healthy controls (n = 42), stage 0 (asymptomatic individuals with risk of SMI typically family high risk; n = 41), stage 1a (distress disorder or mild symptoms of anxiety or depression; n = 53) and stage 1b (attenuated syndromes, including bipolar disorder or psychosis; n = 107). Substance use measures were administered at baseline, 6- and 12-months.

RESULTS

At baseline, the most commonly reported substance used in the past month was alcohol (43.6%), followed by cannabis (14.4%) and tobacco (12.4%). There were no significant group differences in use. 42.4% of all participants reported ever using cannabis in their lifetime, whereas 21.4% reported currently using cannabis. There were no group differences in ever having used cannabis. Regarding lifetime substance abuse disorders, cannabis use disorder (5.7%) and alcohol use disorder (4.5%) were the most common and more often reported in stage 1b participants relative to other groups. Furthermore, alcohol, cannabis and tobacco use remained relatively consistent at 6- and 12-month follow-ups when compared to baseline use.

CONCLUSION

Alcohol was the most commonly used substance followed by cannabis and tobacco. Although substance use did not differ between those at different stages of risk, overall prevention strategies are still warranted for youth at-risk for SMI, especially those who are more symptomatic and potentially at greater risk of developing an SMI.

Attenuated Psychotic Symptoms in Adolescents With Chronic Cannabis and MDMA Use

OBJECTIVES

Both substance use, on the one hand, and the first signs of psychosis, on the other, commonly begin in adolescence. Adolescents with substance use disorder (SUD) frequently show recreational use of cannabis and 3,4-methylenedioxymethamphetamine (MDMA). When attenuated psychotic symptoms (APS) occur during the course of SUD, they are commonly attributed to the cannabis use, neglecting the role of other substances abused, such as MDMA in the risk of psychosis.

METHODS

We analyzed retrospective self-reports on APS (Prodromal Questionnaire, PQ-16) and amount of cannabis and MDMA use in n = 46 adolescent psychiatry outpatients with SUD. N = 17 (35%) individuals reported MDMA consume additional to cannabis. Furthermore, we examined the associations of APS with cannabis and MDMA use in stepwise hierarchical regressions while controlling for trauma history, birth complications and gender.

RESULTS

APS were not related to cannabis (B = 0.04, p = 0.842), but to MDMA use (B = 4.88, p = 0.001) and trauma history (B = 0.72, p = 0.001). Gender (B = -0.22, p = 0.767) and birth complications (B = -0.68, p = 0.178) were not associated with APS.

DISCUSSION

Our results indicate that MDMA use additional to cannabis use is associated with APS among adolescent SUD patients. Contrary to our expectations, we did not see an association of cannabis use and APS. We speculate that cannabis increases the risk for psychosis after a longer period of use and in combination with other risk factors, such as trauma history. Clinicians should screen for APS among SUD patients using MDMA and cannabis in order to adapt treatment plans of SUDs. Future research should validate these findings in longitudinal studies including polysubstance use and trauma history.

Cannabis use in individuals at clinical high-risk for psychosis: a comprehensive review

PURPOSE

The objectives of this review were to understand the prevalence of cannabis use and how cannabis is associated with transition to psychosis, symptoms, cognition, trauma and family history in clinical high risk (CHR) for psychosis individuals.

METHOD

A systematic literature review was conducted to find studies that examined cannabis use in CHR individuals, with no limitations on the geographical area, and included publications up to November 2018. Studies were screened for inclusion based on detailed criteria, and data were extracted on cannabis use and associated outcomes. A quantitative synthesis by meta-analysis was performed where appropriate, otherwise, a qualitative synthesis was conducted.

RESULTS

Overall, 36 studies met inclusion criteria with an average age of 20.1 years and 58.4% males. Prevalence of lifetime cannabis use was 48.7%, whereas current cannabis use was 25.8% and the prevalence of cannabis use disorder/abuse or dependence was 14.9% across the studies. All cannabis use results had statistically significant heterogeneity ranging from 75.7 to 92.8%. The most commonly reported association with cannabis use was transition to psychosis, although the pooled relative risk (RR) was not statistically significant (RR = 1.11, 95% confidence interval = 0.89-1.37). For all other outcomes including symptoms, cognition, trauma, and family history, the evidence was limited, and therefore, the results were synthesized qualitatively.

CONCLUSION

Almost half of CHR individuals have ever used cannabis. However, cannabis use has not been thoroughly researched regarding frequency and dose of use, and how other factors, such as symptoms, are associated with cannabis in CHR individuals.

Attention Deficit/Hyperactivity Disorder and risk for non-affective psychotic disorder: The role of ADHD medication and comorbidity, and sibling comparison

Attention Deficit/Hyperactivity Disorder (ADHD) is the most common psychiatric disorder in childhood. It is unclear whether ADHD increases the risk of non-affective psychotic disorder (NAPD). The study included a matched cohort, drawn from all born in Sweden 1987-1991 (n = 548,852). ADHD was defined as ICD diagnosis and/or prescription of ADHD medication. We distinguished between stimulants and non-stimulants, and usage duration (<1 year, 1-2 years and ≥2 years). We calculated odds ratios (OR) with 95% confidence intervals (CI) for NAPD, adjusted for confounders, comorbid autism spectrum disorder (ASD) and substance abuse. ADHD cases were also compared to their unaffected full siblings. We analyzed 18,139 ADHD cases and 72,437 sex and birth year matched controls. NAPD was more common in cases than controls (2.7 and 0.4%, respectively). After adjustment for confounders, ADHD cases had markedly high risk for NAPD (OR: 6.99; 95% CI 6.03-8.10), which attenuated further after adjustment for ASD and substance abuse (OR: 2.57; 95% CI 2.09-3.16). Utilization of ADHD medication increased the risk for NAPD (ORs for change in odds of NAPD for every 5 extra prescriptions of stimulants 1.06 (95% CI 1.02-1.10) and, non-stimulants 1.15 (95% CI 1.01-1.30)). There was no association between usage length of medication and risk for NAPD. The risk was higher in individuals with ADHD than their unaffected siblings (OR: 2.95 (95% CI 2.07-4.20)). Overall, ADHD was associated with elevated risk for NAPD, which is not entirely explained by shared familial factors. The clinical severity leading to medical treatment may also increase NAPD risk. Ethics approval: Approved by the ethical committee in Stockholm, Sweden (dnrs: 2010-1185-31/5 and 2013/1118-32).

Substance use disorders before, at and after first episode psychosis hospitalizations in a young national Swedish cohort

BACKGROUND

Comorbidity between Substance use disorders (SUD) and psychotic disorders is common but the temporal relation of the first episodes of SUD and psychosis and how it affects the disorders has not been extensively investigated.

METHODS

A nation-wide cohort (n = 2494) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Psychiatric hospitalizations were followed from birth until up to 5 years after the first psychosis hospitalization. Risk factors for new SUD or psychosis hospitalization after the index hospitalization were analyzed by Cox regression.

RESULTS

30 % of the cases had SUD hospitalizations in the 5 years before or as a comorbid diagnosis at the first psychosis hospitalization. An additional 9% had a first SUD hospitalization in the five years after. The incidence of SUD hospitalizations increased year by year before and decrease year by year after the index hospitalization. The hazard ratio for a new SUD hospitalizations after the index hospitalization was significantly higher (hazard ratio 6.7, p-value<0.001) in cases with SUD before or at the index hospitalization compared to in cases without previous SUD. In cases with previous SUD, there was a strong association (p < 0.001) between a new psychosis hospitalization and a new SUD hospitalization the year after the index hospitalization, indicating that SUD may continue to aggravate the psychotic disorder in this group.

CONCLUSIONS

SUD is very common before a first hospital treated psychosis. The SUD likely aggravates early psychotic disorders in many cases.

[Cannabis use in subjects at ultra high risk for psychosis]

Cannabis use is widespread among people at ultra-high risk (UHR) for psychosis. The causal link as well as the temporal link between cannabis use and further occurrence of psychosis in UHR people remain inconclusive. Current science data supported an increased risk of transition to psychosis in cannabis users who are genetically predisposed to psychosis. This risk would be even greater in the presence of a family history of psychosis, in case of a strong use and an early onset use. Several models have been cited to explain the link between cannabis use and the subsequent onset of psychosis or prepsychotic states: cannabis-induced modifications of some brain structures, a dysregulation of the hypothalamic-pituitary axis and an alteration of normal neurological development via the endocannabinoid system. Cannabis represents a modifiable risk for psychosis. Current interventions aim to reduce or stop the cannabis use in order to reduce the risk of transition to psychosis.

The Critical Need for Help-Seeking Controls in Clinical High-Risk Research

Despite rapidly growing knowledge of the clinical high-risk (CHR) state for psychosis, the vast majority of case-control studies have relied on healthy volunteers as a reference point for drawing inferences about the CHR construct. Researchers have long recognized that results generated from this design are limited by significant interpretive concerns, yet little attention has been given to how these concerns affect the growing field of CHR research. We argue that overreliance on healthy controls in CHR research threatens the validity of inferences concerning group differences, hinders advances in understanding the development of psychosis, and limits clinical progress. We suggest that the combined use of healthy and help-seeking (i.e., psychiatric) controls is a necessary step for the next generation of CHR research. We then evaluate methods for help-seeking control studies, identify the available CHR studies that have used such designs, discuss select findings in this literature, and offer recommendations for research.

Can youth at high risk of illness progression be identified by measures of rumination and sleep-wake disturbance

AIM

Clinical staging models offer a useful framework for understanding illness trajectories, where individuals are located on a continuum of illness progression from stage 0 (at-risk but asymptomatic) to stage 4 (end-stage disease). Importantly, clinical staging allows investigation of risk factors for illness progression with the potential to target trans-diagnostic mechanisms at an early stage, especially in help-seeking youth who often present with sub-threshold syndromes. While depressive symptoms, rumination and sleep-wake disturbances may worsen syndrome outcomes, the role of these related phenomena has yet to be examined as risk factors for trans-diagnostic illness progression in at-risk youth.

METHODS

This study is a prospective follow-up of 248 individuals aged 12 to 25 years presenting to headspace services with sub-threshold syndromes (stage 1) classified under the clinical staging model to determine transition to threshold syndromes (stage 2). Factor analysis of depression, rumination and sleep-wake patterns was used to identify key dimensions and any associations between factors and transition to stage 2 at follow-up.

RESULTS

At 1 year, 9% of cases met criteria for stage 2 (n = 22). One of three identified factors, namely the factor reflecting the commonalities shared between rumination and sleep-wake disturbance, significantly differentiated cases that transitioned to stage 2 vs those that did not demonstrate transition. Items loading onto this factor, labelled Anergia, included depression severity and aspects of rumination and sleep-wake disturbance that were characterized as introceptive.

CONCLUSIONS

Common dimensions between rumination and sleep-wake disturbance present a detectable trans-diagnostic marker of illness progression in youth, and may represent a target for early intervention.

The psychosis risk timeline: can we improve our preventive strategies? Part 2: adolescence and adulthood

Current understanding of psychosis development is relevant to patients' clinical outcomes in mental health services as a whole, given that psychotic symptoms can be a feature of many different diagnoses at different stages of life. Understanding the risk factors helps clinicians to contemplate primary, secondary and tertiary preventive strategies that it may be possible to implement. In this second article of a three-part series, the psychosis risk timeline is again considered, here focusing on risk factors more likely to be encountered during later childhood, adolescence and adulthood. These include environmental factors, substance misuse, and social and psychopathological aspects.

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DECLARATION OF INTEREST:

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Impact of rurality and substance use on young people at ultra high risk for psychosis

BACKGROUND

Longitudinal research into early intervention for youth at ultra high risk (UHR) for psychosis demonstrates beneficial outcomes including increased treatment compliance and greater participation in education and the workforce. Despite known barriers for rural youth accessing mental health services, research comparing urban and rural UHR youth is lacking. The study included an examination of the impact of substance use on functioning of UHR youth.

METHODS

Youth aged 12 to 25 years were recruited from the urban area of Newcastle or the rural area of Orange, New South Wales, Australia, and identified as UHR by the Comprehensive Assessment of At Risk Mental States. Rural and urban youth were compared on clinical profiles, social and occupational functioning and substance use.

RESULTS

The rural youth showed different help-seeking behaviours and had greater functional impairment than urban youth. Substance use was common across the sample of 57 youth (mean age 16.5 years, 56% female) and a history of hazardous substance use was associated with higher levels of depression. Rural youth (n = 32) were more likely than urban youth to be taking antidepressants at baseline (44% compared with 16%).

CONCLUSION

Different patterns of help seeking by rural UHR youth suggest a need for greater access to psychosis informed primary care early intervention services. Interventions should target functional decline to prevent adverse outcomes such as reduced community participation and unemployment. In addition, interventions for substance use should be a priority for UHR youth, who should also be screened and monitored for depressive symptoms and treated for depression if indicated.

What prevents youth at clinical high risk for psychosis from engaging in physical activity? An examination of the barriers to physical activity

BACKGROUND

Exercise has increasingly been proposed as a healthful intervention prior to and after the onset of psychosis. There is some evidence to suggest that youth at clinical high risk (CHR) for psychosis are less physically active and report more barriers to engaging in exercise; however, there has been relatively limited empirical work documenting this phenomenon, and to date, relationships between physical activity, barriers, and clinical phenomenology have been unclear.

METHODS

CHR (N = 51) and healthy control (N = 37) participants completed a structured clinical interview assessing attenuated psychotic symptoms and substance use, and an exercise survey that assessed current exercise practices, perceived physical fitness, and barriers related to engaging in exercise.

RESULTS

CHR youth engaged in less physical activity, exhibited lower perception of fitness, and endorsed more barriers related to motivation for exercise. The CHR group showed significant negative correlations where lower perceptions of fitness were associated with increased negative, disorganized, and general symptoms. Decreased frequency of activity was related to more barriers of motivation. Interestingly, greater symptomatology in the CHR group was associated with more barriers of self-perception and motivation for engaging in exercise. However, findings suggested a nuanced relationship in this area; for example, increased physical activity was associated with increased substance use.

CONCLUSIONS

The results of the current study support the notion that sedentary behavior is common in CHR youth, and more broadly, provide an impetus to target motivation through supervised exercise and fitness tracking to promote the health and well-being of CHR individuals.

Addiction Vulnerability: Exploring Relationships Among Cigarette Smoking, Substance Misuse, and Early Psychosis

OBJECTIVE

Smoking rates in adolescents at risk for psychosis are significantly greater than in those who are not at risk. Recent research suggests that cigarette smoking in adolescence may be a potential marker of transition to psychosis, although the exact relationship between the two remains unclear. Our aim was to examine whether tobacco smoking is a potential marker of transition to psychosis or subsequent episodes of psychosis, independently of other substance use, or alternatively whether smoking is essentially a general marker of later mental illness episodes.

METHODS

This substudy was conducted as part of an audit of a specialized early psychosis community mental health service, the Psychological Assistance Service (PAS). A multilayered audit over 10 years (January 1997 to December 2007) of PAS presentations was conducted (N = 1997), which documented baseline sociodemographic and clinical characteristics and subsequent illness episodes and service usage. Among clients with baseline smoking status information (n = 421, mean age = 18.3 years), this study examined predictors of transition to or subsequent episodes of psychosis, substance misuse, and affective disorder.

RESULTS

A recent psychosis episode at baseline and receiving ongoing treatment from PAS predicted transition to or subsequent psychosis episodes; however, baseline ultra-high-risk status was not predictive. In addition, baseline smoking/substance misuse status was a significant predictor, with smokers being twice as likely to experience a subsequent episode of psychosis, even after controlling for other baseline comorbidity. Baseline smoking status also independently predicted subsequent substance misuse episodes, but not subsequent affective disorder. Among clients experiencing post-PAS comorbid substance misuse and psychosis, the majority (80.3%) reported smoking at baseline.

CONCLUSIONS

Smoking status at service presentation appeared to function as a general proxy for addiction vulnerability among young help seekers and thereby as a potential marker for the development of severe mental illness (including psychosis) and associated health problems. Routine evaluations of presenting problems need to incorporate comprehensive assessments of early substance misuse and tobacco smoking. Adjunctive lifestyle interventions promoting smoking cessation, physical health, and well-being need to be offered in conjunction with conventional mental health interventions tailored to key presenting problems, recovery, and psychological strengthening.

Examining the physical health and lifestyle of young people at ultra-high risk for psychosis: A qualitative study involving service users, parents and clinicians

Emerging evidence suggests young people at ultra-high risk for psychosis (UHR) are also at-risk for poor physical health, and display high rates of modifiable cardiometabolic risk factors. However, before we can develop effective interventions there is a need to understand factors affecting lifestyle choices in the UHR group. We conducted semi-structured qualitative interviews with 20 UHR individuals (50% male; mean age 21.7), 5 parents (4 mothers, 1 father), and 6 clinicians from early intervention services in the Northwest of England to identify barriers and facilitators to living a healthy lifestyle, including achieving regular exercise, eating well and refraining from excessive substance use. Thematic analysis revealed the main barriers to living a healthy lifestyle related to psychiatric symptoms, beliefs about self, social withdrawal and practical considerations such as accessibility and cost. Provision of social support and promoting autonomy emerged as the two main themes which would facilitate a healthy lifestyle. Promoting physical health in people with emerging symptoms of psychosis is an important, yet neglected area of mental health practice and warrants further investigation. UHR individuals experience numerous barriers to living a healthy lifestyle, and interventions should focus primarily on targeting autonomous motivation and providing social support to facilitate this change.

The epidemiology of alcohol use in Izmir, Turkey: drinking pattern, impairment and help-seeking

PURPOSE

There is no report on various patterns of alcohol drinking and related impairment, help-seeking in Turkey. We investigated the 12-month prevalence and correlates of drinking patterns and alcohol use disorders in the general population of Izmir-Turkey, with further analyses on role impairment and help-seeking.

METHOD

A multi-stage clustered area probability sample of adult household residents in the Izmir Metropolitan Area was assessed using the Composite International Diagnostic Interview 2.1 (n  = 4011). Estimation focused on prevalence and correlates of 12-month drinking pattern and DSM-IV alcohol use disorders. The 12-month drinking pattern included groups of non-regular users, regular non-heavy drinkers, regular heavy drinkers, and alcohol abuse disorder and alcohol dependence. All respondents were questioned about receiving 12-month treatment for any psychological complaints, the route of help-seeking, and were assessed with Short Form-36 for functional impairments. Multinomial logistic regression was used for underlying associations between the covariates and the drinking patterns.

RESULTS

The rate of lifetime alcohol abstinence was 52.3% while the prevalence of past-year users was 14.8%. The 12-month prevalence estimates of regular heavy drinkers, and alcohol abuse disorder and dependence were 2.5%, 3.2 and 1.6%, respectively. Any of the drinking patterns and alcohol use disorders was associated with male gender, and higher levels of education, monthly income and socioeconomic status. Alcohol dependence was associated with mental health impairment but not with physical impairment. The 12-month rates of help-seeking in alcohol abuse and dependence were 11.6 and 16.5%.

CONCLUSION

Although alcohol use disorders are lower than estimates of Western countries, alcohol use constitute a major reason of disability with prominent treatment gap.

Cannabis use and symptom severity in individuals at ultra high risk for psychosis: a meta-analysis

OBJECTIVE

We aimed to assess whether individuals at ultra high risk (UHR) for psychosis have higher rates of cannabis use and cannabis use disorders (CUDs) than non-UHR individuals and determine whether UHR cannabis users have more severe psychotic experiences than non-users.

METHOD

We conducted a meta-analysis of studies reporting cannabis use in the UHR group and/or positive or negative symptoms among UHR cannabis users and non-users. Logit event rates were calculated for cannabis use, in addition to odds ratios to assess the difference between UHR and controls. Severity of clinical symptoms in UHR cannabis users and non-users was compared using Hedges' g.

RESULTS

Thirty unique studies were included (UHR n = 4205, controls n = 667) containing data from cross-sectional and longitudinal studies, and randomised control trials. UHR individuals have high rates of current (26.7%) and lifetime (52.8%) cannabis use, and CUDs (12.8%). Lifetime use and CUDs were significantly higher than controls (lifetime OR: 2.09; CUD OR: 5.49). UHR cannabis users had higher rates of unusual thought content and suspiciousness than non-users.

CONCLUSION

Ultra high risk individuals have high rates of cannabis use and CUDs, and cannabis users had more severe positive symptoms. Targeting substance use during the UHR phase may have significant benefits to an individual's long-term outcome.

Substance Use Profiles Among Juvenile Offenders: A Lifestyles Theoretical Perspective

Base rates of illicit substances such as cocaine, crack cocaine, and heroin are typically low in community-based studies, which often inhibit more complex multivariate analysis. Additionally, single-item measures and aggregate scales mask within-group differences among those showing versatility in their substance use. Latent class analysis was used to model the substance use profiles of adjudicated female ( n = 98) and male ( n = 378) youth. Alcohol, marijuana, acid, mushrooms, ecstasy, cocaine, crack cocaine, heroin, crystal methamphetamine, and nonmedical use of prescription pills were used to define latent profiles of substance use. Three latent classes were identified that were qualitatively different across males and females. Multinomial logistic regression analyses indicated that time spent outside of the home of the biological parents, early substance use, and parental substance abuse were informative of the use of substances such as cocaine, crack cocaine, and heroin. Implications for more individualized treatment strategies are discussed.