Demographic and clinical correlates of substance use disorders in first episode psychosis

Exposotypes in Psychotic Disorders

Psychiatry lags in adopting etiological approaches to diagnosis, prognosis, and outcome prediction compared to the rest of medicine. Etiological factors such as childhood trauma (CHT), substance use (SU), and socioeconomic status (SES) significantly affect psychotic disorder symptoms. This study applied an agnostic clustering approach to identify exposome clusters "Exposotypes (ETs)" and examine their relationship with clinical, cognitive, and functional outcomes. Using data from individuals with psychotic disorders (n=1,350), and controls (n=623), we assessed the relationship between the exposotypes and outcomes. Four exposotypes were identified: ET1 characterized by high CHT and SU; ET2, high CHT; ET3, high SU; ET4, low exposure. Compared to ET4, ET1 demonstrated higher positive and general symptoms, anxiety, depression, impulsivity, and mania; ET2 had higher anxiety, depression, and impulsivity; ET3 had better cognitive and functional outcomes with lower negative symptoms. Intracranial volume was largest in ET3, and smallest in ET2. No group differences in schizophrenia polygenic risk scores were found. The age of onset was 5 years earlier in ET1 than in ET4. These findings provide insight into the complex etiological interplay between trauma, and SU, as well as their unique effects on clinical symptoms, cognition, neurobiology, genetic risk, and functioning.

Substance Use Disorder Among Patients with Primary Mental Illnesses in Southwestern Uganda

Objective: Substance use is common among people with primary mental illness especially schizophrenia and bipolar disorder compared to the general population and complicates treatment outcomes. Methods: We enrolled 385 patients with primary mental illnesses in southwestern Uganda between June and August 2022. We collected information on alcohol and cannabis use, social support, religiosity, adherence to treatment and sociodemographic characteristics. We run a logistic regression model to determine the factors associated with substance use disorder. Results: At multivariable analysis, being male (AOR = 13.61, 95% CI [3.66-50.63]: p <.001) and prior history of cannabis/alcohol use (AOR = 34.95, 95% CI [8.80-138.72]: p < .001) were significantly associated with substance use disorder while adherence to treatment was against substance use disorder (AOR = 0.27, 95% CI [0.09-0.83]: p = .03). Conclusions: Adherence to treatment is protective against substance use disorder among people with mental illness. Interventions aiming at preventing substance use disorder among people with mental illness should aim at promoting adherence to treatment.

What is schizophrenia - symptomatology

Schizophrenia is a highly heterogenous disorder with substantial interindividual variation in how the illness is experienced and how it presents clinically. The disorder is composed of primary symptom clusters-positive symptoms, negative symptoms, disorganization, neurocognitive deficits, and social cognitive impairments. These, along with duration, severity, and excluding other possible etiologies, comprise the diagnostic criteria for the disorder outlined in the two commonly used diagnostic classification systems-the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition, Text Revision and the International Classification of Diseases, 11th Revision. These primary symptoms as well as accessory symptoms (mood disturbances, anxiety, violence) and comorbidities (substance use, suicidality) bear upon each other to varying degrees and impact functional outcomes. The following review presents two patient cases illustrating the clinical heterogeneity of schizophrenia, the natural history of the illness and diagnosis, followed by the current understanding of the primary symptom clusters, accessory symptoms, and comorbidities. In addition to noting symptom prevalence, onset, and change over time, attention is paid to the impact of symptoms on functional outcome.

History of tobacco smoking and alcohol use can predict the effectiveness of electroconvulsive therapy in individuals with schizophrenia: A multicenter clinical trial

BACKGROUND

Current research has found that factors such as gender, age, and family history can predict the efficacy of electroconvulsive therapy (ECT) in individuals with schizophrenia. In our clinical practice, we anecdotally observed that tobacco smokers and alcohol drinkers with schizophrenia seemed to respond more effectively to ECT than non-smokers and non-drinkers. The current study aimed to examine whether history of tobacco smoking or alcohol consumption serve as indicators for predicting therapeutic efficacy of ECT in individuals with schizophrenia.

METHODS

A total of 481 individuals receiving ECT combined with antipsychotic medication (ECT + AP medication) completed a two-week (six sessions of ECT) follow-up; 106 individuals receiving only antipsychotic medication (AP medication) also completed a two-week follow-up. Smoking, alcohol consumption, and AP medication usage was recorded for these individuals. Severity of psychotic symptoms was assessed using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

ECT + AP medication: Compared to schizophrenic individuals without a history of smoking (non-smokers), those with a history of smoking (smokers) showed a high decrease in negative symptoms (36.96% vs 24.76%; F = 5.974, p = 0.015). While, compared to individuals without a history of alcohol consumption (non-drinkers), those with a history of alcohol consumption (drinkers) showed a high decrease in positive symptoms (48.90% vs 41.47%; F = 5.074, p = 0.025). AP medication: No differences were found in symptom reduction between smokers and non-smokers or between drinkers and non-drinkers (p > 0.05).

CONCLUSIONS

Smoking history in schizophrenic individuals independently predicts better improvement in negative symptoms after ECT, while alcohol consumption history independently predicts better improvement in positive symptoms after ECT. This is a clinically significant finding.

Substance Use Within Trials of Psychological Interventions for Psychosis: Sample Inclusion, Secondary Measures, and Intervention Effectiveness

INTRODUCTION

Current clinical guidelines recommend that patients with co-occurring psychosis and alcohol or substance use disorders (A/SUD) receive evidenced-based treatment for both disorders, including psychological intervention for psychosis. However, the efficacy of such treatments for individuals with co-occurring psychosis and A/SUD is unclear.

STUDY DESIGN

Randomized controlled trials (RCTs) of psychological interventions for psychosis were systematically reviewed, to investigate how alcohol and substance use has been accounted for across sample inclusion and secondary measures. Findings from trials including individuals with co-occurring alcohol or substance use issues were then narratively summarized using the Synthesis Without Meta-Analysis guidelines, to indicate the overall efficacy of psychological interventions for psychosis, for this comorbid population.

STUDY RESULTS

Across the 131 trials identified, 60.3% of trials excluded individuals with alcohol or substance use issues. Additionally, only 6.1% measured alcohol or substance use at baseline, while only 2.3% measured alcohol or substance use as a secondary outcome. Across trials explicitly including individuals with alcohol or substance use issues, insufficient evidence was available to conclude the efficacy of any individual psychological intervention. However, preliminary findings suggest that psychoeducation (PE) and metacognitive therapy (MCT) may be proposed for further investigation.

CONCLUSION

Overall, co-occurring alcohol and substance use issues have been largely neglected across the recent RCTs of psychological interventions for psychosis; highlighting the challenges of making treatment decisions for these individuals using the current evidence base.

Antipsychotic Use and Psychiatric Hospitalization in First-Episode Non-affective Psychosis and Cannabis Use Disorder: A Swedish Nationwide Cohort Study

BACKGROUND AND HYPOTHESIS

There is a paucity of research on treatment outcomes of patients with psychosis and cannabis use disorder (CUD). We aimed to compare the effectiveness of antipsychotics in reducing the risk of hospitalization in patients with first-episode psychosis (FEP) and co-occurring CUD.

STUDY DESIGN

We utilized a nationwide Swedish cohort of patients with longitudinal register data from the year 2006 to 2021. Participants were patients with FEP and co-occurring CUD (n = 1820, 84.73% men, mean age 26.80 years, SD 8.25 years). The main outcome was hospitalization due to psychotic relapse. Hospitalization due to any psychiatric disorder or substance use disorder (SUD) were examined as secondary outcomes. Within-individual Cox regression models were used to study these associations.

STUDY RESULTS

Use of any antipsychotic was associated with a 33% risk reduction of psychotic relapse (aHR = 0.67; 95% CI 0.60-0.75). Clozapine (0.43; 0.29-0.64), long-acting injectable (LAI) formulations of risperidone (0.40; 0.22-0.71), aripiprazole (0.42; 0.27-0.65), and paliperidone (0.46; 0.30-0.69) were associated with the lowest risk of relapse. The association between the LAI formulation of olanzapine and hospitalization due to psychosis was statistically non-significant (0.61; 0.35-1.05). Clozapine was associated with an 86% risk reduction of hospitalization due to SUD (0.14; 0.05-0.44). Of oral non-clozapine antipsychotics, aripiprazole was associated with the lowest risk of hospitalization due to psychotic relapse (0.61; 0.45-0.83).

CONCLUSIONS

These findings support the use of clozapine, LAI formulations of second-generation antipsychotics other than olanzapine, or oral aripiprazole to prevent hospitalization in FEP and co-occurring CUD.

Motivation and Pleasure Deficits Undermine the Benefits of Social Affiliation in Psychosis

In psychotic disorders, motivation and pleasure (MAP) deficits are associated with decreased affiliation and heightened functional impairment. We leveraged a transdiagnostic sample enriched for psychosis and a multi-method approach to test the hypothesis that MAP deficits undermine the stress-buffering benefits of affiliation. Participants completed the Social Affiliation Enhancement Task (SAET) to cultivate affiliation with an experimental partner. Although the SAET increased perceived affiliation and mood, individuals with greater negative symptoms derived smaller emotional benefits from the partners, as indexed by self-report and facial behavior. We then used the Handholding fMRI paradigm, which combines threat-anticipation with affiliative physical contact, to determine whether MAP deficits undermine the social regulation of distress. Individuals with greater MAP deficits showed diminished neural 'benefits'-reduced dampening of threat-elicited activation-from affiliative touch in key frontoparietal nodes of the Dorsal Attention Network. In short, MAP symptoms disrupt the emotional and neuroregulatory benefits of affiliation.

Tobacco, Alcohol, and Drug Use Among Young Adults with Serious Mental Illness

To inform early intervention, this study describes correlates of substance use among young people with serious mental illness (SMI) enrolled in integrated care in community mental health settings. 227 adults ages 18-35 were assessed for clinical characteristics and substance use. Logistic regressions were used to describe relationships between substance use and participant characteristics. Over a third (38.9%) reported daily cannabis, 15.9% past month other illicit drug, 13.5% frequent/heavy alcohol and 47.4% any of these; 50.2% reported daily tobacco smoking and 23.3% current vaping. Daily cannabis and tobacco were the most common combination. Alcohol, drug, and cannabis with tobacco were associated with higher mental health symptoms but not with emergency room or hospital utilization. Cannabis and other substance use was common and associated with higher symptoms but not with greater hospital utilization, suggesting that early intervention could prevent long-term negative consequences.

Prevalence, demographics and clinical characteristics of Internet addiction among Chinese adolescents with schizophrenia

Introduction

Several studies have reported that Internet addiction (IA) is more prevalent in the psychiatric disorder population. However, the prevalence of IA and its relationship with clinical variables among Chinese adolescents with schizophrenia is unclear. This study sought to investigate the prevalence of IA and its clinical correlates in Chinese adolescents with schizophrenia, which has not yet been reported.

Methods

Seven hundred and six inpatient adolescents with schizophrenia were recruited. All patients underwent Young's Internet Addiction Test (IAT) to measure Internet addiction, as well as the Positive and Negative Syndrome Scale (PANSS) for psychopathology.

Results

Our results showed that 186 patients had a total IAT score of 50 or more, bringing the prevalence of IA to 26.3%. Girls (21.7%, 92/424) were less likely to have combined IA than boys (33.3%, 94/282). Compared to those patients without IA, patients with IA had better socioeconomic status, higher probability of living in the city, higher levels of depressive symptoms, excited symptoms, and lower levels of concrete symptoms and PANSS total scores (all p<0.05). Further binary logistic regression analysis indicated that good socioeconomic status, living in the city and PANSS total scores were significantly associated with IA. In addition, correlation analysis showed significant correlations between IA total score and the following parameters: good socioeconomic status, living in the city, negative subscore, concrete subscore, depression subscore, excited subscore and PANSS total score (Bonferroni corrected all p <0.05).

Conclusion

The results of this study indicate that the prevalence of IA in Chinese adolescents with schizophrenia is higher than that in the general population. Several demographic and clinical variables are risk factors for IA in adolescents with schizophrenia.

Contingency Management for Dually Diagnosed Inpatients with Psychosis

Contingency management (CM) is an evidence-based treatment method in substance abuse treatment. However, little is known about its efficacy in dually diagnosed patients with psychosis and in inpatient settings. Therefore, the aim of this study is to investigate the efficacy of CM for dually diagnosed patients with psychosis in an inpatient setting. Furthermore, we investigate the effect of the nature of the reward used (cash vs. prize) on the efficacy of CM. We made use of an 8-week fish-bowl CM intervention by means of a within-subject reversal design with three treatment phases (baseline-intervention-follow-up). Sixty-seven patients were included in this study, of whom thirty-four completed the protocol. The results show no effect of CM on abstinence nor an interaction with clinical or demographic variables. Cash money is as effective as prizes. Future research should further investigate the effect of psychosis and treatment setting on the efficacy of CM, with special attention for Patient Report Experience and Outcome Measures (PREM/PROM).

Substance use and self-poisoning in schizophrenia: 11-year findings from a national clinical survey of suicide in mental health patients in the UK

Suicide is the leading cause of unnatural death among people with schizophrenia. Substance use is a highly prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. However, no studies have examined changes in the frequency of substance use or self-poisoning in those who died by suicide over time. Knowing this could support more tailored approaches to reducing specific risk factors and access to means in those with schizophrenia who are at risk of suicide. We conducted an 11-year observational study on a clinical survey of people with schizophrenia in the UK who died by suicide within 12 months of contact with mental health services between 2010 and 2020 (n = 2718). Overall, alcohol, cannabis and stimulants were the most frequently reported substances. The odds of lifetime use significantly increased over time for cannabis, stimulants, heroin, and benzodiazepines. There were differences in socio-demographic, behavioural and clinical factors between those with recent and historical alcohol and drug use before death. Deaths by hanging, jumping and self-poisoning were the most common suicide methods. Though deaths by hanging significantly increased over time, deaths by self-poisoning significantly decreased, especially by means of psychotropic medication and opioids. To improve risk management, clinical efforts should focus on identifying and treating people with schizophrenia using specific substances. Nationwide initiatives for improving safety in prescribing could be contributing to reduced risks of suicide via self-poisoning in this group.

Sex differences in prevalence and clinical correlates of internet addiction among Chinese adolescents with schizophrenia

BACKGROUND

Patients with schizophrenia (SCZ) exhibit sex differences in various aspects, and patients with SCZ have a high prevalence of internet addiction (IA). However, sex differences in IA among patients with SCZ mostly remain unstudied, particularly in Chinese adolescent patients with SCZ. This study investigated sex differences in prevalence, risk factors, and clinical correlates of IA among Chinese adolescent patients with SCZ.

METHODS

A total of 706 adolescent patients with SCZ were enrolled in this study using a cross-sectional design and a convenience sampling method. Demographics and clinical data of the patients were collected using a standardized clinical assessment form. The Positive and Negative Syndrome Scale (PANSS) and the Young's Internet Addiction Test were used to evaluate psychopathological symptoms and IA respectively.

RESULTS

Overall, the prevalence of IA among Chinese adolescent patients with SCZ was 26.30% (95% CI: 23.09-29.60%). In Chinese adolescents with SCZ, there was a sex difference in the comorbidity of IA (males: 33.33% vs. females: 21.69%). Binary logistic regression analysis showed that IA was significantly predicted by good socioeconomic status in male and female patients with SCZ. City of living and PANSS total score were associated with IA in male patients with SCZ. In contrast, hospitalization rate and depression score were associated with IA in female patients with SCZ.

CONCLUSION

Our study suggests sex differences in clinical correlates of IA in Chinese adolescent patients with SCZ. An additional longitudinal study is required to confirm the findings of the present study.

The Ethics of Risk Prediction for Psychosis and Suicide Attempt in Youth Mental Health

OBJECTIVE

To identify potential clinical utility of polygenic risk scores (PRS) and exposomic risk scores (ERS) for psychosis and suicide attempt in youth and assess the ethical implications of these tools.

STUDY DESIGN

We conducted a narrative literature review of emerging findings on PRS and ERS for suicide and psychosis as well as a literature review on the ethics of PRS. We discuss the ethical implications of the emerging findings for the clinical potential of PRS and ERS.

RESULTS

Emerging evidence suggests that PRS and ERS may offer clinical utility in the relatively near future but that this utility will be limited to specific, narrow clinical questions, in contrast to the suggestion that population-level screening will have sweeping impact. Combining PRS and ERS might optimize prediction. This clinical utility would change the risk-benefit balance of PRS, and further empirical assessment of proposed risks would be necessary. Some concerns for PRS, such as those about counseling, privacy, and inequities, apply to ERS. ERS raise distinct ethical challenges as well, including some that involve informed consent and direct-to-consumer advertising. Both raise questions about the ethics of machine-learning/artificial intelligence approaches.

CONCLUSIONS

Predictive analytics using PRS and ERS may soon play a role in youth mental health settings. Our findings help educate clinicians about potential capabilities, limitations, and ethical implications of these tools. We suggest that a broader discussion with the public is needed to avoid overenthusiasm and determine regulations and guidelines for use of predictive scores.

The transition to Schizophrenia spectrum disorder from a first psychotic episode that did or did not appear to be induced by substance use

The first years following a first-episode psychosis (FEP) are crucial. This retrospective cohort study investigates the evolution of first-episode psychosis (FEP), including substance-induced psychosis (SIP), and explores factors influencing the diagnostic conversion to Schizophrenia or Schizophrenia Spectrum Disorders (SSD). Diagnoses of patients discharged from Basurto University Hospital's inpatient psychiatry unit between January 2002 and December 2016 were reviewed. Sociodemographic, clinical, and substance use data, including cannabinoids, opioids, amphetamines, cocaine, and alcohol, were collected. The analysis utilized descriptive statistics, Kaplan-Meier survival curves, and Cox regression. Among 341 patients, 64.8% were male, with a mean age of 33.8 years. Psychiatric family history was present in 33.4% of cases, and cannabis was the most commonly used substance (78.9%). Of the patients, 52.8% received subsequent diagnoses of Schizophrenia or SSD, with 86.9% of these cases occurring within the first five years. No significant differences were observed between patients diagnosed with SIP and other diagnoses in terms of sociodemographic, clinical characteristics, or progression to Schizophrenia or SSD. However, use of cannabis (compared to use of another substance or polysubstance use) was associated with a higher risk to conversion (HR 1.96; p = 0.001). These findings underscore the importance of addressing substance use and treatment adherence in FEP.

Differences in Patterns of Stimulant Use and Their Impact on First-Episode Psychosis Incidence: An Analysis of the EUGEI Study

BACKGROUND

Use of illegal stimulants is associated with an increased risk of psychotic disorder. However, the impact of stimulant use on odds of first-episode psychosis (FEP) remains unclear. Here, we aimed to describe the patterns of stimulant use and examine their impact on odds of FEP.

METHODS

We included patients with FEP aged 18-64 years who attended psychiatric services at 17 sites across 5 European countries and Brazil, and recruited controls representative of each local population (FEP = 1130; controls = 1497). Patterns of stimulant use were described. We computed fully adjusted logistic regression models (controlling for age, sex, ethnicity, cannabis use, and education level) to estimate their association with odds of FEP. Assuming causality, we calculated the population-attributable fractions for stimulant use associated with the odds for FEP.

FINDINGS

Prevalence of lifetime and recent stimulant use in the FEP sample were 14.50% and 7.88% and in controls 10.80% and 3.8%, respectively. Recent and lifetime stimulant use was associated with increased odds of FEP compared with abstainers [fully adjusted odds ratio 1.74,95% confidence interval (CI) 1.20-2.54, P = .004 and 1.62, 95% CI 1.25-2.09, P < .001, respectively]. According to PAFs, a substantial number of FEP cases (3.35% [95% CI 1.31-4.78] for recent use and 7.61% [95% CI 3.68-10.54] for lifetime use) could have been prevented if stimulants were no longer available and the odds of FEP and PAFs for lifetime and recent stimulant use varied across countries.

INTERPRETATION

Illegal stimulant use has a significant and clinically relevant influence on FEP incidence, with varying impacts across countries.

Pathways Through Early Psychosis Care for U.S. Youths From Ethnically and Racially Minoritized Groups: A Systematic Review

OBJECTIVE

The authors of this systematic review examined service utilization and outcomes among youths from ethnoracially minoritized groups after the youths initiated treatment for a psychotic disorder-that is, the youths' "pathway through care." Also examined were potential moderating variables in pathways through care for these youths at the clinic, family, and cultural levels. The goal was to describe methodologies, summarize relevant findings, highlight knowledge gaps, and propose future research on pathways through care for young persons from ethnoracially minoritized groups who experience early psychosis.

METHODS

The PubMed, PsycInfo, and Web of Science literature databases were systematically searched for studies published between January 1, 2010, and June 1, 2021. Included articles were from the United States and focused on young people after they initiated treatment for early psychosis. Eighteen studies met inclusion criteria.

RESULTS

Sixteen of the 18 studies were published in the past 5 years, and 11 had an explicit focus on race and ethnicity as defined by the studies' authors. Studies varied in terminology, outcomes measures, methodologies, and depth of analysis. Being an individual from an ethnoracially minoritized group appeared to affect care utilization and outcomes. Insufficient research was found about potential moderating variables at the clinic, family, and cultural levels.

CONCLUSIONS

Studies of pathways through care for persons from minoritized groups warrant further funding and attention.

A systematic review of digital interventions for smoking cessation in patients with serious mental illness

Tobacco smoking is highly prevalent among patients with serious mental illness (SMI), with known deleterious consequences. Smoking cessation is therefore a prioritary public health challenge in SMI. In recent years, several smoking cessation digital interventions have been developed for non-clinical populations. However, their impact in patients with SMI remains uncertain. We conducted a systematic review to describe and evaluate effectiveness, acceptability, adherence, usability and safety of digital interventions for smoking cessation in patients with SMI. PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group Specialized Register were searched. Studies matching inclusion criteria were included and their information systematically extracted by independent investigators. Thirteen articles were included, which reported data on nine different digital interventions. Intervention theoretical approaches ranged from mobile contingency management to mindfulness. Outcome measures varied widely between studies. The highest abstinence rates were found for mSMART MIND (7-day point-prevalent abstinence: 16-40%). Let's Talk About Quitting Smoking reported greater acceptability ratings, although this was not evaluated with standardized measures. Regarding usability, Learn to Quit showed the highest System Usability Scale scores [mean (s.d.) 85.2 (15.5)]. Adverse events were rare and not systematically reported. Overall, the quality of the studies was fair to good. Digitally delivered health interventions for smoking cessation show promise for improving outcomes for patients with SMI, but lack of availability remains a concern. Larger trials with harmonized assessment measures are needed to generate more definitive evidence and specific recommendations.

Alcohol drinking in male patients with chronic schizophrenia: prevalence and its relationship to clinical symptoms

Background

It is common practice to associate schizophrenia (SCZ) patients with substance use. The most commonly used substances in China are tobacco and alcohol. However, few studies have focused on alcohol consumption itself in patients with SCZ. Thus the purpose of this study was to detect the prevalence of alcohol use and associated clinical factors in Chinese patients with SCZ.

Methods

A total of 616 male inpatients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for SCZ participated in this study. A detailed questionnaire, including data on alcohol consumption was used to collect demographic and clinical information on all patients. The five-factor model of the positive and negative syndrome scale (PANSS) was adopted to assess psychiatric symptoms.

Results

In this study, 31.49% of SCZ inpatients had a history of alcohol use, and 82.9% of these patients abstained from alcohol use after the onset of SCZ. Compared to nondrinkers, patients who drank were more likely to smoke (p = 0.004), more likely to have suicide attempts (p = 0.002) and suicidal ideation (p = 0.001), more severe positive (p < 0.001) and depressive symptoms (p = 0.034), but less severe negative symptoms (p = 0.04).

Conclusion

These findings suggest that alcohol use is common during the lifetime of SCZ patients and that alcohol use may be associated with clinical symptoms in SCZ patients.

Adult use of highly-potent Δ9-THC cannabis concentrate products by U.S. state cannabis legalization status, 2021

BACKGROUND

Compared to plant/flower cannabis products, cannabis concentrates have higher average potency of delta-9-tetrahydrocannabinol (Δ9-THC), which may be associated with greater likelihood of cannabis-related harms. Information on factors associated with use of cannabis concentrates is needed.

METHODS

Respondents were 4,328 adult past-7-day cannabis users from all 50 U.S. states and Washington DC (DC) who participated in an online 2021 survey. Using logistic regression to generate adjusted odds ratios (aOR), we investigated whether participants in states that enacted recreational cannabis laws (RCL, 12 states plus DC [treated as a state], n = 1,236) or medical cannabis laws (MCL-only, 23 states, n = 2,030) by December 31, 2020 were more likely than those in states without cannabis laws (no-CL, 15 states, n = 1,062) to use cannabis concentrate products in the prior 7 days.

RESULTS

Most participants (92.4%) used plant material in the prior 7 days; 57.0% used cannabis concentrates. In RCL, MCL and no-CL states, concentrate use was reported by 61.5%, 56.6%, and 52.5%, respectively. Compared to participants in no-CL states, odds of using cannabis concentrate products were greater among those in RCL states (aOR = 1.47; CI = 1.17-1.84) and MCL-only states (aOR = 1.29; CI = 1.08-1.55). Whether states had legally-authorized dispensaries had little effect on results.

CONCLUSION

Results suggest that individuals in MCL-only and RCL states are more likely to use cannabis concentrate products. Determining mechanisms underlying these results, e.g., commercialization, could provide important information for prevention. Clinicians should be alert to patient use of concentrates, especially in MCL-only and RCL states. Continued monitoring is warranted as additional states legalize cannabis use.

Risk for alcohol use problems in severe mental illness: Interactions with sex and racial/ethnic minority status

BACKGROUND

Alcohol use disorder (AUD) is exceedingly common among individuals with bipolar disorder and schizophrenia. However, studies on alcohol use in psychiatric illness rely largely on population surveys with limited representation of severe mental illness (SMI); schizophrenia and bipolar disorder.

METHODS

Using data from the Genomic Psychiatry Cohort (GPC) (Pato MT, 2013), associations of bipolar disorder and schizophrenia with alcohol use problems were examined in a diverse US based sample, considering the influence of self-described race (African Ancestry (AA), European Ancestry (EA), or Latinx Ancestry (LA)), sex, and tobacco use. Participants answered alcohol use problem items derived from the CAGE instrument, yielding a summed "probable" alcohol use disorder (pAUD) risk score.

RESULTS

This study included 1952 individuals with bipolar disorder with psychosis (BDwP), 409 with bipolar disorder without psychosis (BD), 9218 with schizophrenia (SCZ), and 10,416 unaffected individuals. We found that SMI (BDwP, BD, SCZ) was associated with elevated AUD risk scores (B = 0.223, p < 0.001), an association which was strongest in females, particularly those of AA and LA, and in tobacco users. Schizophrenia was associated with the greatest increase in pAUD score (B = 0.141, p < 0.001). pAUD risk scores were increased among participants with bipolar disorder, with greater increases in BDwP (B = 0.125, p < 0.001) than in BD without psychosis (B = 0.027, p < 0.001).

LIMITATIONS

Limitations include reliance on self-report data, screening items for AUD, voluntary recruitment bias, and differences in race/sex distribution between groups, which were statistically adjusted for in analytic models.

CONCLUSIONS

SMI is associated with risk for AUD, particularly among females from racial minority groups, smokers, and those with psychotic disorders.

An integrated substance use treatment model for young adults with first-episode psychosis: A naturalistic pilot evaluation

AIM

Approximately 50% of individuals with first-episode psychosis meet criteria for a substance use disorder and these concurrent disorders are associated with worse long-term outcomes. Psychosocial interventions, including motivational interviewing as well as cognitive and behavioural therapies, have shown some evidence for effective treatment in substance use disorders; however, there is a paucity of existing studies that have successfully examined these interventions in first-episode psychosis.

METHODS

Participants (n = 64) received the concurrent disorders intervention, which included individual support alongside participation in at least one of two groups: a 4-week Motivational Engagement group utilizing motivational interviewing (n = 59) and an 8-week Relapse Prevention Training group emphasizing skill acquisition, which some participants entered directly (n = 5) and some participants entered following completion of the Motivational Engagement group (n = 16).

RESULTS

Participants who completed the Motivational Engagement group (n = 59) demonstrated significantly increased motivation to change substance use (d = -.0.58; t = -3.02, p < .01) and significantly decreased substance use frequency (d = 0.65; t = 3.26, p < .01). For participants who completed the Relapse Prevention Training group (n = 21), substance use frequency significantly decreased (d = 0.92; t = 3.46, p < .01) and self-efficacy in one's ability to maintain substance use changes significantly increased (d = -0.85; t = -3.59, p < .01).

CONCLUSIONS

This pilot evaluation suggests that motivational interviewing and relapse prevention skills training are acceptable and feasible interventions in the treatment of substance use disorders in young adults with first-episode psychosis.

Circadian functioning and quality of life in substance use disorder patients with and without comorbid schizophrenia

Sleep disturbances are strongly linked with mental diseases such as substance use disorder (SUD) or schizophrenia (SZ) which can have a detrimental impact on quality of life (QOL), especially when both disorders are comorbid (dual disorder). In absence of studies about both circadian characteristics and QOL in patients with SUD and comorbid SZ (SUD + SZ), we examined a sample of 155 male under treatment, 75 with SUD + SZ and 80 only with SUD. Circadian functioning was evaluated by chronotype, social jet-lag and sleep quality (using the Pittsburgh Sleep Quality Index, PSQI), while the QOL was obtained by the World Health Organization's Quality of Life Questionnaire (WHOQOL)-BREF. SUD + SZ patients were more evening type than SUD, and this chronotype was linked to polydrug use in total sample and SUD + SZ group. We observed that the comorbidity did not lead to worse sleep quality in the SUD and SUD + SZ patients. QOL was poorer in SUD + SZ patients, who showed a negative association of Physical health, Psychological health and Social relationship with suicide attempts and severity of SZ. Lastly, patients with worse QOL also reported poorer sleep quality suggesting that treatment could include circadian adjustments along with a focused approach to lifestyle improvement.

Association of polymorphic variants of <i>GRIN2A</i> and <i>GRIN2B</i> genes with alcohol and tobacco abuse in patients with schizophrenia

Aim. To compare the frequency of genotypes for polymorphic variants of GRIN2A and GRIN2B genes in patients with schizophrenia and addictive behavior (alcohol / tobacco abuse) and in patients with schizophrenia without addictive behavior in the Slavic population of the Tomsk region.

Materials and methods. The study included 219 inpatients with the established diagnosis of schizophrenia who received treatment in the clinics of Mental Health Research Institute and Tomsk Clinical Psychiatric Hospital. A history of alcohol / tobacco abuse was identified during a clinical interview and objective data collection. DNA was isolated from peripheral blood leukocytes by standard phenol – chloroform extraction.

15 single nucleotide polymorphisms (SNPs) in the GRIN2A gene and 9 polymorphisms in the GRIN2B gene were selected for genotyping. Allelic variants were determined by real-time polymerase chain reaction (PCR) with specific primers. The SPSS 17.0 software package was used for statistical data processing. The distribution of genotype frequency was assessed using the Pearson’s χ2 test with the Yates’ correction and the Fisher’s exact test.

Results. Significant differences in the allele frequency for the rs9788936 polymorphism in the GRIN2A gene (χ2 = 4.23, p = 0.04) and for the rs10845838 polymorphism in the GRIN2B gene (χ2 = 4.27, p = 0.04) were reveled between the groups of patients with and without alcohol abuse. It was found that the polymorphic variant rs8049651 of the GRIN2A gene had a clear association (F = 8.06, p = 0.029) with the development of tobacco addiction in patients with schizophrenia.

Conclusion. The study identified the association between alcohol abuse and the rs9788936 polymorphism in the GRIN2A gene and the rs10845838 polymorphism in the GRIN2B gene in patients with schizophrenia. The association between the rs8049651 and rs7190619 polymorphisms in the GRIN2A gene and the development of tobacco abuse in patients with schizophrenia was revealed.

Cognitive functioning and cannabis use in first-episode psychosis

AIM

Cannabis use is common in people with psychotic disorders. However, the effect of cannabis on cognition in psychosis remains unclear. Our study investigates relationships between the history of cannabis use and cognitive performance in patients with first-episode psychosis (FEP) during a one-year follow-up.

METHODS

The present study included FEP (N = 91) and control (N = 61) groups. Cannabis use was evaluated with a self-report questionnaire, clinical assessment, and medical records during a lifetime and 12 months prior to the treatment onset (recent). Symptoms of psychosis and anxiety were evaluated on the brief psychiatric rating scale. Negative symptoms were assessed using the scale for the assessment of negative symptoms. Cognitive tests were used to evaluate neurocognition (summarized in the g factor) and social cognition. Crude regression analyses for the g factor included variables of cannabis use as independent variables. Full regression models were controlled for gender, education, and clinical symptoms.

RESULTS

In the FEP group, men used cannabis more frequently than women. In the crude regression model for FEP patients, never having used cannabis was associated with a better neurocognitive profile at 12 months. In the full model, more severe anxiety symptoms were associated with better neurocognition at two months, and less severe negative symptoms were associated with better neurocognition at 12 months. Cannabis use was not associated with social cognition. No associations between cognitive performance and cannabis use emerged in the controls.

CONCLUSION

Negative and affective symptom severity in FEP was associated with cognitive performance to a greater degree than a lifetime history of cannabis use.

Clinical characteristics and treatment outcomes of patients with newly diagnosed schizophrenia: A 4-year single-center experience in Saudi Arabia

Objectives

Understanding how local “psychiatry clinic” characteristics shape research findings is essential for applying research into evolution, outcomes, and costs of mental health. However, a paucity of “psychiatry clinics” details has implications for the interpretation and utilization of this research.

Methods

We reviewed data of 746 patients with new‐onset schizophrenia on antipsychotic monotherapy seen over four years in an “adult psychiatry clinic” at Jazan Health, Saudi Arabia. Protocol‐driven interviews and investigations were recorded prospectively and extracted from the medical records for the study. Summary statistics and logistic regression analyses were applied to assess patients' characteristics and outcomes.

Results

The median patient age was 32 (IQR 27‐39) years. Of patients, 589 (79.0%) were male, and 679 (91.0%) had a low‐level education. The median follow‐up duration was 51.4 (IQR 27.4‐96.3) weeks. The most used initial antipsychotic drugs were olanzapine (48.8%), haloperidol (13.9%), and aripiprazole (11.3%). The numbers of patients who retained the initial drug at 24 and 52 weeks were 539 (72.3%) and 325 (43.6%), respectively. The initial drug was changed in 246 (33.0%) patients. The median time to initial drug change was 43.9 (IQR 14.8‐85.0) weeks. The logistic regression demonstrated that male sex (P < 0.004), young adult age group (P < 0.027), predominant positive symptoms (P < 0.021), treatment with haloperidol (P < 0.024), and khat use (P < 0.006) were significant factors for drug change.

Conclusions

This clinical records study demonstrated substantial individual variations in characteristics and in responding to initial antipsychotic medication. Insight into these findings will facilitate the planning for comprehensive research programs.

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.

A comparative study of complete blood count inflammatory markers in substance-free acute psychotic disorder and substance-induced psychosis

AIM

Recent studies showed a compare complete blood count (CBC) with its related measurements, including neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelet to lymphocyte ratio, are a simple and affordable test for inflammatory markers. The aim of this controlled study is to compare CBC inflammatory markers in substance-induced psychosis (SIP) and substance-free acute psychotic disorder (SF-APD) and to evaluate whether these CBC inflammation values can be used in diagnosis.

METHODS

This retrospective study was conducted with the data of 76 SF-APD patients (including 60 cases of first-episode psychosis [FEP]), 98 SIP patients (including 48 cases of FEP), and 32 controls.

RESULTS

Patients with SF-APD and SIP had higher white blood cell counts, neutrophil and monocyte counts, and MLR than controls. An increased NLR was more distinct in SF-APD, while an increased MLR was observed in APD (both SF and SI) and FEP groups more than in the controls. A receiver operating characteristic analysis showed that the NLR could contribute to the identification of SF-APD (52.6% sensitivity and 12.5% specificity, area under curve [AUC] = 0.704, 2.47 cutoff value) while an MLR could contribute to the identification of APD (70.1% sensitivity and 12.5% specificity, AUC = 0.842) as well as FEP (71.3% sensitivity and 12.5% specificity AUC = 0.831) with 0.26 cutoff value.

CONCLUSIONS

An NLR and MLR might be of interest for inflammatory processes involved in acute and first-episode psychotic events, regardless of substance involvement.

Use of highly-potent cannabis concentrate products: More common in U.S. states with recreational or medical cannabis laws

BACKGROUND

Highly-potent cannabis products, e.g., concentrates, entail greater risks of cannabis-related harms than lower-potency products such as plant or flower material. However, little information is available on whether individuals in U.S. states with recreational cannabis laws (RCL) or medical cannabis laws (MCL) are more likely than individuals in U.S. states without cannabis legalization (no-CL) to use highly-potent forms of cannabis.

METHODS

Cannabis-using adults in a 2017 online survey (N = 4064) provided information on state of residence and past-month cannabis use, including types of products used, categorized as low-potency (smoked or vaped plant cannabis) or high-potency (vaping or dabbing concentrates). Multivariable logistic regression models generated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for use of high-potency cannabis products by state cannabis legalization status (RCL, MCL, no-CL).

RESULTS

Compared to participants in no-CL states, participants in RCL states had greater odds of using high-potency concentrate products (aOR=2.61;CI=1.77-3.86), as did participants in MCL-only states (aOR=1.55;CI=1.21-1.97). When participants in RCL states and MCL states were directly compared, those in RCL states had greater odds of using high-potency concentrate products (aOR=1.69;CI=1.27-2.42).

DISCUSSION

Although the sample was not nationally representative and the cross-sectional data precluded determining the direction of effect, results suggest that use of high-potency cannabis concentrates is more likely among those in RCL states. Clinicians in RCL states should screen cannabis users for harmful patterns of use. Policymakers in states that do not yet have RCL should consider these findings when drafting new cannabis laws, including the specific products permitted and how best to regulate them.

Introspective accuracy for substance use across a year of treatment for first episode psychosis

Substance use exacerbates psychosis, mania, depression, and poor functioning in people with first episodes of psychosis (FEP) and is associated with poor treatment outcomes, even when it does not reach the level of a formal disorder. Impaired insight and substance use are common issues that may interfere with treatment outcomes among people experiencing FEP, yet both are treatable. Improvements in these domains are associated with better outcomes. Low insight could increase risk for substance use by impairing the ability to self-appraise and assess consequences. Introspective accuracy (IA) is understudied in this area and is one way of considering self-appraisal. This study is an archival review using data collected from NAVIGATE, a coordinated specialty care program treating people with FEP. IA was operationalized as the difference between clinician and client ratings of substance use. We tested whether IA changed over one year of treatment and whether those changes occurred alongside changes in symptoms and illness self-management. No changes in IA were detected in relation to illness self-management. Changes in IA for substance use occurred midway through treatment-individuals with greater symptom remission had more overconfident IA. Prior research on insight has shown a paradox where greater insight accompanies more symptoms. However, past research has also shown a relationship between IA and functional outcomes, like illness self-management, and that overconfidence in one domain can positively bias clinician ratings in another. Our findings suggest either a positive bias for ratings associated with overconfident IA or an insight paradox type effect.

A systematic review and meta-analysis of sex differences in cannabis use disorder amongst people with comorbid mental illness

BACKGROUND

While males are more likely diagnosed with cannabis use disorder (CUD), females are more susceptible to developing and maintaining CUD. Yet, for both sexes, CUD is associated with high rates of comorbid mental illness (MI).

OBJECTIVES

To identify and compare sex differences in the prevalence of comorbid CUD amongst individuals with/without MIs.

METHODS

This systematic review generated pooled odds ratios (OR) and 95% confidence intervals (CI) from 37 studies (including clinical trials, cohort, and case-control studies) among individuals with and without MIs, quantifying sex differences in rates of comorbid CUD. A meta-analysis was also completed.

RESULTS

In the CUD-only group, males were twice as likely to have CUD than females (OR = 2.0, CI = 1.9-2.1). Among MIs, males were more likely than females to have CUD comorbid with schizophrenia (OR ~2.6, CI = 2.5-2.7) and other psychotic, mood, and substance use disorders (1> OR <2.2, CI = 0.7-2.6). The reverse association (females > males) was observed for anxiety disorders and antisocial personality disorder (OR = 0.8, CI = 0.7-1.0). Among females, MIs increased the likelihood of having CUD, except for psychotic disorders and depression. A meta-analysis was inconclusive due to high heterogeneity across studies. Thus, comparisons across MI groups were not possible.

CONCLUSION

While males are more likely to be diagnosed with CUD, there are important sex differences in the prevalence of CUD across MI diagnoses that should be taken into account when approaching CUD prevention and determining treatment efficacy.

Schizophrenia and substance use disorder: Characteristics of coexisting issues in a forensic setting

BACKGROUND AND AIMS

Recent research has identified higher prevalence of offending behavior in patients with comorbid schizophrenia spectrum disorder (SSD) and substance use disorder (SUD) compared to patients with SSD only and to the general population. However, findings on the subgroup of patients with SUD, SSD and offending behavior in forensic psychiatric care are scarce and inconsistent. The present study used machine learning to uncover more detailed characteristics of offender patients in forensic psychiatric care with comorbid SSD and SUD.

METHODS

Using machine learning algorithms, 370 offender patients (91.6 % male, mean age of M = 34.1, SD = 10.2) and 558 variables were explored in order to build three models to differentiate between no substance use disorder, cannabis use disorder and any other substance use disorder. To counteract the risk of overfitting, the dataset was split, employing variable filtering, machine learning model building and selection embedded in a nested resampling approach on one subset. The best model was then selected and validated on the second data subset.

RESULTS

Distinguishing between SUD vs. no drug use disorder yielded models with an AUC of 70 and 78. Variables assignable to demographics, social disintegration, antisocial behavior and illness were identified as most influential for the distinction. The model comparing cannabis use disorder with other substance use disorders provided no significant differences.

CONCLUSIONS

From a clinical perspective, offender patients suffering from schizophrenia spectrum and comorbid substance use disorder seem particularly challenging to treat, but initial differences in psychopathology will dissipate over inpatient treatment. Our data suggest that offender patients may benefit from appropriate treatment that focuses on illicit drug abuse to reduce criminal behavior and improve social integration.

Psychosocial interventions for people with a first episode psychosis: between tradition and innovation

PURPOSE OF REVIEW

Assessing recent evidence on psychosocial interventions for people with first episode psychosis (FEP).

RECENT FINDINGS

Family interventions (FI) reduce relapse rates, whilst cognitive behavioural therapy (CBT) shows a moderate effect in improving positive psychotic symptoms. Vocational interventions (VI) appear to be worthy of implementation within early intervention for psychosis (EIP) teams, but it is still unclear what is the most cost-effective strategy for their delivery. Promising interventions, which need more careful evaluation, focus on substance misuse, physical health comorbidities, improvement of social participation, peer support and the potential of new technologies.

SUMMARY

The first five years after the onset of psychotic symptoms are a 'critical period' in which psychosocial interventions can be particularly influential in determining prognosis. Traditional EIP interventions have different effectiveness profiles, i.e., FI reduce relapse rates, CBT has a moderate effectiveness on overall and positive symptoms and VI can improve educational and employment-related functioning. Newer interventions show promise on important targets for FEP treatment but require higher-quality evaluations. Decisions on which interventions to implement within EIP teams should be informed by high-quality evidence, but difficult choices will have to be made based on costs, professionals and technologies available, and local priorities.

Discontinuity of psychiatric care for patients with schizophrenia, relation to previous psychiatric care and practice variation between providers: a retrospective longitudinal cohort study

BACKGROUND

Patients with schizophrenia need continuous integrated healthcare, but many discontinue their treatment, often experiencing adverse outcomes. The first objective of this study is to assess whether patient characteristics or treatment history are associated with discontinuity of psychiatric elective care. The second objective is to assess whether practice variation between providers of psychiatric care contributes to discontinuity of elective care.

METHODS

A large registry-based retrospective cohort of 9194 schizophrenia patients, who were included if they received elective psychiatric care in December 2014-January 2015. Logistic regression models were used to identify predictive factors of discontinuity of care. The dependent variable was the binary variable discontinuity of care in 2016. Potential independent predictive variables were: age, sex, urbanization, and treatment history in 2013-2014. Practice variation between providers was assessed, adjusting for the case mix of patients regarding their demographic and care utilization characteristics.

RESULTS

12.9% of the patients showed discontinuity of elective psychiatric care in the follow-up year 2016. The risk of discontinuity of care in 2016 was higher in younger patients (between age 18 and 26), patients with a history of receiving less elective psychiatric care, more acute psychiatric care, more quarters with elective psychiatric care without antipsychotic medication, or receiving no elective treatment at all. No evidence for practice variation between providers was found.

CONCLUSIONS

Our findings show that the pattern of previous care consumption is an important prognostic factor of future discontinuity of elective care. We propose that previous care consumption can be used to design strategies to improve treatment retention and focus resources on those most at risk of dropping out.

Individuals with schizophrenia who act violently towards others profit unequally from inpatient treatment-Identifying subgroups by latent class analysis

BACKGROUND

People with schizophrenia show a higher risk of committing violent offenses. Previous studies indicate that there are at least three subtypes of offenders with schizophrenia.

OBJECTIVES

Employing latent class analysis, the goals of this study were to investigate the presence of homogeneous subgroups of offender patients in terms of remission in psychopathology during inpatient treatment and whether or not these are related to subtypes found in previous studies. Results should help identify patient subgroups benefitting insufficiently from forensic inpatient treatment and allow hypotheses on possibly more suitable therapy option for these patients.

METHODS

A series of latent class analyses was used to explore extensive and detailed psychopathological reports of 370 offender patients with schizophrenia before and after inpatient treatment.

RESULTS

A framework developed by Hodgins to identify subgroups of offenders suffering from schizophrenia is useful in predicting remission of psychopathology over psychiatric inpatient treatment. While "early starters" were most likely to experience remission of psychopathology over treatment, "late late starters" and a subgroup including patients from all three of Hodgins' subgroups in equal proportions benefited least. Negative symptoms generally seemed least likely to remit.

CONCLUSION

Psychiatric treatment may have to be more tailored to offender patient subgroups to allow them to benefit more equally.

Problem Gambling Associated with Aripiprazole: A Nested Case-Control Study in a First-Episode Psychosis Program

BACKGROUND

Aripiprazole has been linked to cases of problem gambling (PBG), but evidence supporting this association remains preliminary. Additionally, data specific to PBG in individuals with first-episode psychosis (FEP) receiving aripiprazole are limited to a few case reports, even though aripiprazole is widely used among this population that might be especially vulnerable to PBG.

METHODS

To examine this association, a nested case-control study was conducted in a cohort of 219 patients followed at a FEP program located in the Quebec City, Quebec, Canada, metropolitan area. Fourteen cases meeting the PBG criteria according to the Problem Gambling Severity Index were identified and matched for gender and index date to 56 control subjects.

RESULTS

In the univariable conditional logistic regression analysis, the use of aripiprazole was associated with an increased risk of PBG (odds ratio [OR] 15.2; 95% confidence interval [CI] 2.1-670.5). Cases were more likely to have a prior gambling history (either recreational or problematic) than controls at admittance in the program; they were also more frequently in a relationship and employed. After adjustment for age, relationship status, employment and Cluster B personality disorders, the use of aripiprazole remained associated with an increased risk of PBG (OR 8.6 [95% CI 1.5-227.2]).

CONCLUSIONS

Findings from this study suggest that FEP patients with a gambling history, problematic or not, may be at increased risk of developing PBG when receiving aripiprazole. They also highlight the importance of systematically screening for PBG all individuals with psychotic disorders, as this comorbidity hinders recovery. While the results also add credence to a causal association between aripiprazole and PBG, further prospective studies are needed to address some of the limitations of this present study.

Systematic epidemiological and clinical comparisons across all 12 DSM-IV psychotic diagnoses in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS)

BACKGROUND

Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.

METHODS

The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.

RESULTS

Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.

CONCLUSIONS

There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.

A Neurodevelopment Approach for a Transitional Model of Early Onset Schizophrenia

In the last decades, the conceptualization of schizophrenia has dramatically changed, moving from a neurodegenerative process occurring in early adult life to a neurodevelopmental disorder starting be-fore birth, showing a variety of premorbid and prodromal symptoms and, in relatively few cases, evolving in the full-blown psychotic syndrome. High rates of co-occurring different neurodevelopmental disorders such as Autism spectrum disorder and ADHD, predating the onset of SCZ, and neurobio-logical underpinning with significant similarities, support the notion of a pan-developmental disturbance consisting of impairments in neuromotor, receptive language, social and cognitive development. Con-sidering that many SCZ risk factors may be similar to symptoms of other neurodevelopmental psychi-atric disorders, transition processes from child & adolescent to adult systems of care should include both high risk people as well as subject with other neurodevelopmental psychiatric disorders with different levels of severity. This descriptive mini-review discuss the need of innovative clinical approaches, re-considering specific diagnostic categories, stimulating a careful analysis of risk factors and promoting the appropriate use of new and safer medications.

Alcohol Use Disorder and Its Associate Factors Relating to Patients with Severe Mental Disorders Attending Psychiatric Follow-Ups in Northwest Ethiopia

BACKGROUND

Patients with mental disorders have high rates of co-existing alcohol use disorder and vice versa. Alcohol use disorder has emerged as a major challenge to intervene patients with severe mental disorders. It is under-recognized and has not been investigated well in low-income countries like Ethiopia. The aim of this study was to assess the prevalence and associate factors of alcohol use disorder among patients with severe mental disorders attending psychiatric follow-ups at the University of Gondar comprehensive specialized hospital, northwest Ethiopia.

METHODS

A total of 384 patients with severe mental disorders selected by a systematic random sampling technique took part in the interviews for this cross-sectional study. The alcohol use disorder identification test was used to assess the problem. Univariate and multivariate binary logistic regressions were computed to examine the associated factors. An adjusted odds ratio with a 95% confidence interval (CI) was used for reporting the result.

RESULTS

The prevalence of alcohol use disorder among patients with severe mental disorders was 36.2%. Of the participants, 23.5%, 8.6%, and 4.1% had hazardous, harmful alcohol drinking and alcohol dependency, respectively. In the multivariate analysis, male sex, younger age, psychotic and bipolar disorder diagnoses, having poor social support, moderate and high perceived stress, and current tobacco smoking were factors significantly associated with alcohol use disorder.

CONCLUSION

The prevalence of alcohol use disorder among patients with severe mental disorders was found to be high. Early intervention and integrating treatment services for co-existing mental disorders and alcohol use disorder is important. The special treatment, where it is offered for young male patients and those with the diagnosis of psychotic and bipolar disorders, is recommended to promote the uptake of alcohol and mental health treatment services.

Estimated Proportions and Characteristics of National Survey Respondents Reporting New Diagnoses of Schizophrenia or Other Psychoses in the Past Year as Compared With Prior Years

Epidemiologic data on first-episode psychosis is limited due to the infrequency of cases in the general population. This study uses the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309) to examine population-based estimates of early psychosis based on adults who report a first-time diagnosis of schizophrenia from a doctor in the past year and compares them with those receiving diagnoses in previous years. Altogether, 60 respondents reported past-year schizophrenia (170 per 100,000) or 6.7% of 901 with any reported schizophrenia. Mean age was 41.4 ± 2.1, and they reported significantly higher rates of any past-year substance use disorder (44.7%) than individuals diagnosed in previous years (27.7%), specifically alcohol use disorder. Compared with other samples (many of which excluded older adults), this study suggests that early psychosis may affect older populations more than previously recognized, but comorbidity with substance use disorders showed similar elevations.

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.

Problematic Drug Use Among Outpatients With Schizophrenia and Related Psychoses

Background: Problematic drug use is common among psychiatric patients and is linked with poorer course and outcomes of illness. The aim of this study is to assess the prevalence of problematic drug use, and to explore its sociodemographic correlates and associations with health behaviors and outcomes among outpatients with schizophrenia and related psychoses in Singapore. Methods: Data from 397 individuals who were aged 21-65 years and were seeking treatment for schizophrenia and related psychoses in the outpatient clinics of a tertiary psychiatric hospital were analyzed. The Drug Abuse Screening Test (DAST-10) was used to assess problematic drug use. Information on sociodemographics, smoking status, alcohol use, symptoms severity and quality of life were collected. Multivariable logistic regressions were conducted to explore correlates and associations of problematic drug use. Results: The prevalence of problematic drug use was 5.8% (n = 23) in the sample, and 10.6% (n = 42) of the participants reported having problematic drug use and/or problematic alcohol use. More males than females reported having problematic drug use (p = 0.021), and also problematic drug and/or alcohol use (p = 0.004). Significant associations were observed between problematic drug use and smokers with nicotine dependence, and with physical health domain of quality of life. Individuals with greater symptom severity were approximately twice as likely to have problematic drug use and/or alcohol use. Conclusion: While the prevalence of problematic drug use in this sample population is relatively lower compared to other countries, there is a considerable number who might be at risk. Routine screening and close monitoring of drug use is recommended as part of psychiatric assessment, particularly among males and patients with nicotine dependence.

Cannabis Use, Cannabis Use Disorder, and Comorbid Psychiatric Illness: A Narrative Review

BACKGROUND

The landscape of attitudes, legal status and patterns of use of cannabis is rapidly changing in the United States and elsewhere. Therefore, the primary aim of this narrative review is to provide a concise overview of the literature on the comorbidity of cannabis use and cannabis use disorder (CUD) with other substance use and psychiatric disorders, and to use this information to accurately guide future directions for the field.

METHODS

A literature review of PubMed was conducted for studies relating to cannabis use, CUD, and a co-occurring psychiatric disorder. To provide an overview of representative data, the literature review focused on national-level, population-based work from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and National Survey on Drug Use and Health (NSDUH) surveys. Considering rapidly changing cannabis laws, recent (past five-year) studies were addressed.

RESULTS

A strong body of literature shows associations between cannabis use and CUD with other drug use, psychosis, mood disorders, anxiety disorders, and personality disorders. The strongest evidence of a potential causal relationship exists between cannabis use and psychotic disorders. While some evidence shows potential directionality between cannabis use and mood and anxiety disorders, results are inconsistent. Studies have established higher rates of CUD among those with personality disorders, but little about the specifics of this relationship is understood.

CONCLUSIONS

Although the general population in the United States increasingly perceives cannabis to be a harmless substance, empirical evidence shows that cannabis use is associated both with CUD and comorbid psychiatric illness. However, there is mixed evidence regarding the role of cannabis in the etiology, course, and prognosis of a co-occurring disorder across all categories of psychiatric disorders. Future research should expand on the existing body of literature with representative, longitudinal data, in order to better understand the acute and long-term effects of cannabis on comorbid psychiatric illness.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

Assessment of coexisting psychosis and substance misuse: complexities, challenges and causality

Substance misuse worsens the prognosis for people suffering psychosis and places them at risk of being denied appropriate mental health service interventions. To increase the chances of its success, the plan of management for patients with coexisting psychosis and substance misuse should be based on a valid formulation of their problems, which in turn is dependent on the clinician having (a) a thorough understanding of the bidirectional and changing ways that substance use and mental illness symptoms can interact, (b) an awareness of their own biased implicit assumptions about causality in explaining these interactions and (c) a framework for assessment and formulation. This article addresses these three areas with reference to the evidence base and to clinical experience in a way that guides mental health clinicians in the assessment of patients with coexisting psychosis and substance misuse.

Early onset of cannabis use and violent behavior in psychosis

BACKGROUND

Although evidence from psychosis patients demonstrates the adverse effects of cannabis use (CU) at a young age and that the rate of CU is high in subgroups of young violent patients with psychotic disorders, little is known about the possible effect of the age of onset of CU on later violent behaviors (VB). So, we aimed to explore the impact of age at onset of CU on the risk of displaying VB in a cohort of early psychosis patients.

METHOD

Data were collected prospectively over a 36-month period in the context of an early psychosis cohort study. A total of 265 patients, aged 18-35 years, were included in the study. Logistic regression was performed to assess the link between age of onset of substance use and VB.

RESULTS

Among the 265 patients, 72 had displayed VB and 193 had not. While violent patients began using cannabis on average at age 15.29 (0.45), nonviolent patients had started on average at age 16.97 (0.35) (p = 0.004). Early-onset CU (up to age 15) was a risk factor for VB (odds ratio = 4.47, confidence interval [CI]: 1.13-20.06) when the model was adjusted for age group, other types of substance use, being a user or a nonuser and various violence risk factors and covariates. History of violence and early CU (until 15) were the two main risk factors for VB.

CONCLUSIONS

Our results suggest that early-onset CU may play a role in the emergence of VB in early psychosis.

Comorbidity Profiles of Psychotic Patients in Emergency Psychiatry

Objectives: Individuals with psychotic symptoms presenting to emergency psychiatry often have comorbid symptoms, such as substance misuse, depression, and anxiety. Many will also have symptoms linked to previous traumatic experiences such as impulsivity, often found in comorbid personality disorders. Although various studies have looked at specific comorbid symptoms, little is known regarding how these symptoms co-exist in individuals with psychotic symptoms and their link with social functioning. The primary objective of the present study was to identify comorbidity profiles among individuals seeking emergency room services for psychotic symptoms. The secondary objective was to investigate the relationship between comorbid symptoms and social functioning deficits in this same population. Methods: Data from 546 individuals seeking psychiatric help for psychotic symptoms was collected within the Signature Project (large data bank) in a psychiatric emergency. Participants answered brief measures of symptoms of alcohol/substance misuse (AUDIT, DAST), depression (PHQ-9), anxiety (STAI-6), childhood trauma (CEVQ), impulsivity (UPPS) and social functioning deficits (WHODAS). For this study, symptom measures and social functioning at baseline were used. Results: Cluster analyses conducted using three different methods revealed a consensus of five classes of comorbid presentations. Class 1 (n = 90) grouped people who had a high score for childhood trauma, with fairly high scores for anxiety and depression. Class 2 (n = 176) included people with mostly psychotic symptoms with little comorbid presentation across other measures. Class 3 (n = 81) grouped people with the highest anxiety and depression scores as well as high drug use and impulsivity. Individuals in Class 4 (n = 87) had the highest scores on alcohol and substance abuse, as well as high impulsivity. Class 5 (n = 112) grouped people with very low anxiety and depression scores but average trauma, alcohol, and substance misuse scores. Linear regressions revealed an association between social functioning, and depression, anxiety, and childhood trauma. Conclusions: Comorbid presentations of individuals with psychosis are frequent and diverse. Depression and anxiety, in particular, worsen social functioning deficits in people with psychotic symptoms. Given their impact on functioning, psychiatric treatments should address these comorbidities during hospitalization, as well as when followed in the community.