Patterns of current and lifetime substance use in schizophrenia

Associations of comorbid substance use disorders with clinical outcomes in schizophrenia using electronic health record data

BACKGROUND AND HYPOTHESIS

Schizophrenia and comorbid substance use disorders (SUDs) are associated with poor treatment outcomes but differences between the associations of different SUDs with clinical outcomes are poorly characterized. This study examines the associations of comorbid SUDs with clinical outcomes in schizophrenia using a largescale electronic health record (EHR) database.

DESIGN

Real-world data (RWD) analysis using the NeuroBlu database; de-identified EHR data were analysed. Multivariable logistic regression, Poisson and CoxPH models were used to compare the associations of specific comorbid SUDs with outcome variables.

RESULTS

Comorbid SUD was significantly different on all outcome measures compared to no SUD (U = 1.44e7-1.81e7, all ps < .001), except number of unique antipsychotics (U = 1.61e7, p = .43). Cannabis (OR = 1.58, p < .001) and polysubstance (OR = 1.22, p = .007) use disorders were associated with greater CGI-S. Cannabis (IRR = 1.13, p = .003) and polysubstance (IRR = 1.08, p = .003) use disorders were associated with greater number of unique antipsychotics prescribed, while cocaine (HR = 1.87, p < .001), stimulants (HR = 1.64, p = .024), and polysubstance (HR = 1.46, p < .001) use disorders were associated with a shorter time to antipsychotic discontinuation. Conversely, alcohol use (IRR = 0.83, p < .001), cocaine use (IRR = 0.61, p < .001), opioid use (IRR = 0.61, p < .001), stimulant use (IRR = 0.57, p < .001) and polysubstance use (IRR = 0.87, p < .001) disorders were associated fewer inpatient days.

CONCLUSION

Comorbid SUDs were generally associated with greater CGI-S and poorer clinical outcomes in patients with schizophrenia. Treatment strategies should target not only schizophrenia symptoms but also comorbid SUD to improve management of both conditions.

Scoping Review of Cannabis-Reduction Psychosocial Interventions and Reasons for Use among Young Adults with Psychosis

Objective: No evidence-based intervention effectively reduces cannabis use in young adults with psychosis (YAP). To generate hypotheses about why, a scoping review was conducted to synthesize evidence about motivations for cannabis use and reduction/cessation for YAP and the psychosocial interventions trialed to identify possible gaps between motivations and interventive strategies. Methods: A systematic literature search was conducted in December, 2022. Reviews of titles and abstracts (N = 3,216) and full-texts (n = 136) resulted in 46 articles. Results: YAP use cannabis for pleasure, to reduce dysphoria, and for social and recreational reasons; motivations for cessation include insight about cannabis-psychosis interactions, incompatibility with goals and social roles, and support from social networks. Interventions with at least minimal evidence of efficacy include motivational interviewing, cognitive-behavioral strategies, and family skills training. Conclusions: Authors recommend additional research on mechanisms of change and motivational enhancement therapy, behavioral activation, and family-based skills interventions matched to YAP motivations for use/cessation.

Are Patients with Schizophrenia Reliably Reporting their Cannabis Use? An African Cross-sectional Study

BACKGROUND

Most studies of the prevalence of cannabis use among patients with schizophrenia used a self-report as declared by the patient himself. We hypothesize that patients with schizophrenia did not tell the truth and might underreport their use for many reasons to be discussed later. Indeed, the under-report of cannabis use among these patients can affect the effectiveness of their treatment.

AIMS

To assess the degree of agreement between the prevalence values obtained from patients' reports and the results of the toxicological tests.

METHODS

A cross-sectional study was carried out on 403 patients with schizophrenia. A sociodemographic, psychiatric history and illicit drug use profile was performed for each patient. We assessed the patients with the Positive and Negative Syndrome Scale (PANSS), Calgary Depression score (CDSS), Barratt Impulsiveness Score (BIS-10) and Medication Adherence Rating Scale (MARS). The consumption of cannabis used was confirmed with MINI International Neuropsychiatric Interview (MINI-DSM IV) and using toxicological analysis.

RESULTS

Among the 403 patients who consented to give their urine samples, 49.1% (198/403) tested positive for cannabis, and 41.41% (82/198) underreported their use. The sensitivity and specificity of the questionnaire were 0.58 and 0.74. Based on the comparison between sociodemographic and psychiatric history data of patients who self-report and underreport their cannabis use, no significant difference was observed except for the duration of cannabis use and the score on the medication adherence scale. Moreover, it was found that impulsivity, PANSS score, CDSS score, and the type of schizophrenia are not involved in predicting the underreporting of cannabis use.

CONCLUSION

The rate of patients who under-report cannabis use is important. Therefore, toxicological analysis is becoming relevant for identifying drug use among schizophrenic patients and in the addictive comorbidity research field.

Alcohol use disorder and its determinant factors among patients with schizophrenia attending treatment at mental specialized hospital, Addis Ababa, Ethiopia: A cross-sectional study

Background:

Alcohol use disorder is one of the primary causes of avoidable death, illness, and injury in many societies throughout the world. Although alcohol use disorder can influence the natural history of a disease, disease recurrence, quality of life, and treatment adherence in psychiatric patients, the data on its magnitude is scarce.

Objectives:

This study was aimed to determine the magnitude of alcohol use disorder and its determinants among patients with schizophrenia attending a mental specialized hospital in Addis Ababa, Ethiopia.

Methods:

An institutional-based cross-sectional study was conducted from May 15 to June 15, 2018. An alcohol use disorder identification test was employed among a sample of 414 randomly selected patients with schizophrenia. Alcohol use disorder was categorized as hazardous drinking (Alcohol Use Disorders Identification Test (AUDIT) score of 8–15), harmful drinking (AUDIT score of 16–19), and alcohol dependence (AUDIT score of 20 or above). The data were entered into Epi-Data 3.1 and exported to SPSS 20 for analysis. Logistic regression was fitted to identify factors associated with alcohol use disorder.

Results:

The prevalence of alcohol use disorder was 38.4% (95% confidence interval (CI) 33.7, 42.9). Of this, 22.4% of the patients had hazardous drinking, 8.4% harmful drinking, and 7.6% alcohol dependence. Factors associated with alcohol use disorder were male sex (adjusted odds ratio (AOR) = 5.8, 95% CI 2.55, 13.19), being single (AOR = 3.0, 95% CI 1.63, 5.51), divorced (AOR = 4.3, 95% CI 1.95, 9.47) and widowed (AOR = 3.5, 95% CI 1.39, 8.81), having family history of alcoholism (AOR = 3.8, 95% CI 1.98, 7.19), longer duration of illness (AOR = 3.9, 95% CI 1.83, 8.36), previous history of psychiatric diagnosis (AOR = 2.2, 95% CI 1.1, 4.34), and concomitant use of non-alcoholic substances (AOR = 3.7, 95% CI 2.06, 6.74).

Conclusions:

Almost four in ten patients with schizophrenia had alcohol use disorder. Male sex, single, divorced, and widowed, family history of alcohol use, long duration of illness, previous history of psychiatric diagnosis, and concomitant use of non-alcoholic substances were significantly associated with alcohol use disorder. Continuous counseling of at risk populations about alcohol consumption should be strengthened.

Predictors of controlled prescription drug non-medical and lifetime use among patients accessing public mental health services in Uganda: a cross-sectional study

OBJECTIVES

We determined the prevalence of controlled prescription drug (CPD) non-medical and lifetime use and their predictors among patients at three public psychiatric clinics in Uganda to identify missed care opportunities, enhanced screening priorities, and drug control needs.

METHODS

A cross-sectional survey of 1275 patients was performed from November to December 2018. Interviewer-administered semi-structured questionnaires, desk review guide and urine drug assays were employed. Questionnaire recorded CPD non-medical and illicit drug use history from patients' files, CPD lifetime use and risk factors. Desk review guide recorded recently prescribed drugs in patients' files to corroborate with urine assays. Predictors were analysed by multivariate logistic regression.

RESULTS

From desk review, 145 (11.4%) patients had history of CPD non-medical use and 36 (2.8%) had used illicit drugs. Of 988 patients who provided urine, 166 (16.8%) self-medicated CPDs, particularly benzodiazepines while 12 (1.2%) used illicit drugs. Of those with drug-positive urine, 123 (69.1%) had no documented history of CPD non-medical and illicit drug use. Being an inpatient (OR=10.90, p<0.001) was independently associated with CPD non-medical use. Additionally, being an inpatient (OR=8.29, p<0.001) and tobacco consumption (OR=1.85, p=0.041) were associated with CPD non-medical and illicit drug use combined. Among participants, 119 (9.3%) reported CPD lifetime use, and this was independently associated with education level (OR=2.71, p<0.001) and history of treatment for substance abuse (OR=2.08, p=0.018).

CONCLUSIONS

CPD non-medical use is common among Uganda's psychiatric patients, and more prevalent than illicit drug use. Rapid diagnostic assays may be needed in psychiatric care in resource limited settings. It is necessary to assess how CPD non-medical use impacts mental care outcomes and patient safety. High risk groups like inpatients and tobacco consumers should be prioritised in psychiatric screening.

Endocannabinoid system in trauma and psychosis: distant guardian of mental stability

Central endocannabinoid system (eCBS) is a neuromodulatory system that inhibits potentially harmful, excessive synaptic activation. Endocannabinoid receptors are abundant among brain structures pivotal in different mental disorders development (for example, hippocampus, amygdala, medial-prefrontal cortex, hypothalamus). Here, we review eCBS function in etiology of psychosis, emphasizing its role in dealing with environmental pressures such as traumatic life events. Moreover, we explore eCBS as a guard against hypothalamic-pituitary-adrenal axis over-activation, and discuss its possible role in etiology of different psychopathologies. Additionally, we review eCBS function in creating adaptive behavioral patterns, as we explore its involvement in the memory formation process, extinction learning and emotional response. We discuss eCBS in the context of possible biomarkers of trauma, and in preclinical psychiatric conditions, such as at-risk mental states and clinical high risk states for psychosis. Finally, we describe the role of eCBS in the cannabinoid self-medication-theory and extinction learning.

Substance Use Patterns and Schizophrenia Spectrum Disorders: A Retrospective Study of Inpatients at a Community Teaching Hospital

Background

Schizophrenia is one of the chronic mental illnesses, characterized by delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and cognitive decline. It frequently leads to a lifetime of impairment and disability that span the entire lifespan of the patients. Several epidemiologic studies have shown that schizophrenia spectrum disorders (SSDs) contribute significantly to years lived with disability. Additionally, substance use disorders have been reported to co-occur commonly among patients with SSD (a comorbidity also known as dual diagnosis), attracting notable attention over the past few decades. This dual diagnosis often requires treatment modifications to ensure for best patient outcomes.

Methods

This study was a retrospective review of the electronic medical charts. The patients included in the study were discharged from the psychiatric unit of our hospital between July 1, 2017 and October 31, 2017. Patients were included in the study using three inclusion criteria: 1) age ≥18 years; 2) had a diagnosis of SSD at discharge; and 3) had urine drug screen performed. Sociodemographic and clinical variables were abstracted. Univariate analysis and summary statistics were performed. Bivariate and multivariate analyses were done via logistic regression models to determine the odds ratios (ORs) and corresponding P values (P).

Results

A total of 365 (52.2%) patients had a diagnosis of SSD at discharge. Of these, 349 met the inclusion criteria. The age ranged from 19 to 79 years, with a mean age of 42.2 years, and 76.8% of the patients used substances. Out of the 269 patients who used substances, 199 (74%) used two or more substances. Tobacco use was most prevalent (62.3%), followed by cannabis use (41.5%), alcohol use (40.2%), and cocaine use (27.4%). Patients who reported using tobacco, were more likely to have comorbid alcohol use (OR = 7.24; P = 0.000), cannabis use (OR = 2.80; P = 0.000), cocaine use (OR = 5.00; P = 0.000), and synthetic cannabis (K2) use (OR = 4.62; P = 0.048). Results of the multivariate analyses supported the other findings.

Conclusions

Our study found a high association between schizophrenia spectrum disorders and substance use, with three out of four patients with SSD using a substance. This prevalence is higher than previously reported by other studies. Among those who use substances, about three in four use multiple substances. These point to some interaction between the substances and appear to be heavily influenced by significant social determinants of mental health that continue to plague the community. It is important to establish if a patient with schizophrenia has a comorbid substance use disorder, because addressing both generally leads to better patient outcomes.

Personality Traits in Individuals with the Dual Diagnosis of Psychosis and Substance Use Disorders: A Comprehensive Review and Meta-Analysis

Substance abuse comorbidity is highly prevalent and is linked to detrimental outcomes in individuals with psychotic disorder, but the role of personality traits as the underlying mechanism is being increasingly underscored. This study aimed to profile temperamental risks of comorbid substance use disorder in psychotic disorders by performing meta-analyses on personality trait differences between psychotic disorders with comorbidity (dual diagnosis; DD) and without it (psychotic disorders; PSD). Methods: A systematic review of English articles using PubMed, MEDLINE, Scopus, Google Scholar, and ProQuest Dissertation and Theses. Only original empirical studies including participants with diagnosis of psychotic disorders based on structured diagnostic interviews, with and without substance use disorder evaluated with reliable and valid tests were included. Articles were independently extracted by two authors using predefined data fields, including study quality indicators. All pooled analyses were based on random-effect models. Thirteen studies (N = 885) met our inclusion criteria. All effect-size estimates were calculated based on means and standard deviations of included measures. Separate effect size estimates were obtained for four traits in the UPPS model (negative urgency, low premeditation, low perseverance, sensation seeking), four traits in the HS model (unconscientious disinhibition, negative affect, disagreeable disinhibition, positive affect) and trait anhedonia. Results: Negative urgency (four studies with 262 participants; ES = 0.59; 95% confidence interval [CI] [0.34, 0.84]), low premeditation (five studies with 349 participants; ES = 0.60; 95% CI [0.39, 0.80]), sensation seeking (seven studies with 550 participants; ES = 0.63; 95% CI [0.17, 1.09]) and unconscientious disinhibition (five studies with 291 participants; ES = 0.36; 95% CI [0.13, 0.59]) were elevated in DD than PSD. Heterogeneity of sensation seeking was significant (I² = 86.2%). Conclusions: The findings of the current meta-analysis highlight a unique profile of impulsive and externalizing trait personality domains pertaining to DD. The study emphasizes the importance of emotion regulation interventions targeting impulsivity or negative affect (i.e. negative urgency, low premeditation) in substance abuse comorbidity patients.

A large-scale genome-wide association study meta-analysis of cannabis use disorder

BACKGROUND

Variation in liability to cannabis use disorder has a strong genetic component (estimated twin and family heritability about 50-70%) and is associated with negative outcomes, including increased risk of psychopathology. The aim of the study was to conduct a large genome-wide association study (GWAS) to identify novel genetic variants associated with cannabis use disorder.

METHODS

To conduct this GWAS meta-analysis of cannabis use disorder and identify associations with genetic loci, we used samples from the Psychiatric Genomics Consortium Substance Use Disorders working group, iPSYCH, and deCODE (20 916 case samples, 363 116 control samples in total), contrasting cannabis use disorder cases with controls. To examine the genetic overlap between cannabis use disorder and 22 traits of interest (chosen because of previously published phenotypic correlations [eg, psychiatric disorders] or hypothesised associations [eg, chronotype] with cannabis use disorder), we used linkage disequilibrium score regression to calculate genetic correlations.

FINDINGS

We identified two genome-wide significant loci: a novel chromosome 7 locus (FOXP2, lead single-nucleotide polymorphism [SNP] rs7783012; odds ratio [OR] 1·11, 95% CI 1·07-1·15, p=1·84 × 10-9) and the previously identified chromosome 8 locus (near CHRNA2 and EPHX2, lead SNP rs4732724; OR 0·89, 95% CI 0·86-0·93, p=6·46 × 10-9). Cannabis use disorder and cannabis use were genetically correlated (rg 0·50, p=1·50 × 10-21), but they showed significantly different genetic correlations with 12 of the 22 traits we tested, suggesting at least partially different genetic underpinnings of cannabis use and cannabis use disorder. Cannabis use disorder was positively genetically correlated with other psychopathology, including ADHD, major depression, and schizophrenia.

INTERPRETATION

These findings support the theory that cannabis use disorder has shared genetic liability with other psychopathology, and there is a distinction between genetic liability to cannabis use and cannabis use disorder.

FUNDING

National Institute of Mental Health; National Institute on Alcohol Abuse and Alcoholism; National Institute on Drug Abuse; Center for Genomics and Personalized Medicine and the Centre for Integrative Sequencing; The European Commission, Horizon 2020; National Institute of Child Health and Human Development; Health Research Council of New Zealand; National Institute on Aging; Wellcome Trust Case Control Consortium; UK Research and Innovation Medical Research Council (UKRI MRC); The Brain & Behavior Research Foundation; National Institute on Deafness and Other Communication Disorders; Substance Abuse and Mental Health Services Administration (SAMHSA); National Institute of Biomedical Imaging and Bioengineering; National Health and Medical Research Council (NHMRC) Australia; Tobacco-Related Disease Research Program of the University of California; Families for Borderline Personality Disorder Research (Beth and Rob Elliott) 2018 NARSAD Young Investigator Grant; The National Child Health Research Foundation (Cure Kids); The Canterbury Medical Research Foundation; The New Zealand Lottery Grants Board; The University of Otago; The Carney Centre for Pharmacogenomics; The James Hume Bequest Fund; National Institutes of Health: Genes, Environment and Health Initiative; National Institutes of Health; National Cancer Institute; The William T Grant Foundation; Australian Research Council; The Virginia Tobacco Settlement Foundation; The VISN 1 and VISN 4 Mental Illness Research, Education, and Clinical Centers of the US Department of Veterans Affairs; The 5th Framework Programme (FP-5) GenomEUtwin Project; The Lundbeck Foundation; NIH-funded Shared Instrumentation Grant S10RR025141; Clinical Translational Sciences Award grants; National Institute of Neurological Disorders and Stroke; National Heart, Lung, and Blood Institute; National Institute of General Medical Sciences.

The prevalence and clinical correlates of substance use disorders in patients with psychotic disorders from an Upper-Middle-Income Country

Background

Substance use disorders (SUDs) occur frequently in patients with psychotic disorders and have been associated with various demographic and clinical correlates. There is an absence of research on the prevalence and clinical correlates of SUDs in psychotic disorders in low-and-middle-income countries (LMICs).

Aim

We aimed to determine the prevalence and correlates of SUDs in psychotic disorders.

Setting

Patients attending a large secondary-level psychiatric hospital in Cape Town South Africa.

Methods

We used the Structured Clinical Interview for DSM-IV (SCID-I) to determine psychiatric and substance use diagnoses, depressive, anxiety, obsessive-compulsive and post-traumatic symptoms. We used logistic regression models to determine significant predictors of SUDs.

Results

In total sample (N = 248), 55.6% of participants had any SUD, 34.3% had cannabis use disorders, 30.6% alcohol use disorders, 27.4% methamphetamine use disorders, 10.4% methaqualone use disorders and 4.8% had other SUDs. There were significant associations with male sex for most SUDs, with younger age and Coloured ethnicity for methamphetamine use disorders, and with lower educational attainment for cannabis use disorders. Anxiety symptoms and suicide attempts were significantly associated with alcohol use disorders; a diagnosis of a substance induced psychosis with cannabis and methamphetamine use disorders. Across most SUDs legal problems and criminal involvement were significantly increased.

Conclusion

This study found a high prevalence and wide distribution of SUDs in patients with psychotic disorders, consistent with previous work from high income countries. Given clinical correlates, in individuals with psychotic disorders and SUDs it is important to assess anxiety symptoms, suicidality and criminal involvement.

Cannabinoid receptor CNR1 expression and DNA methylation in human prefrontal cortex, hippocampus and caudate in brain development and schizophrenia

Beyond being one the most widely used psychoactive drugs in the world, cannabis has been identified as an environmental risk factor for psychosis. Though the relationship between cannabis use and psychiatric disorders remains controversial, consistent association between early adolescent cannabis use and the subsequent risk of psychosis suggested adolescence may be a particularly vulnerable period. Previous findings on gene by environment interactions indicated that cannabis use may only increase the risk for psychosis in the subjects who have a specific genetic vulnerability. The type 1 cannabinoid receptor (CB1), encoded by the CNR1 gene, is a key component of the endocannabinoid system. As the primary endocannabinoid receptor in the brain, CB1 is the main molecular target of the endocannabinoid ligand, as well as tetrahydrocannabinol (THC), the principal psychoactive ingredient of cannabis. In this study, we have examined mRNA expression and DNA methylation of CNR1 in human prefrontal cortex (PFC), hippocampus, and caudate samples. The expression of CNR1 is higher in fetal PFC and hippocampus, then drops down dramatically after birth. The lifespan trajectory of CNR1 expression in the DLPFC differentially correlated with age by allelic variation at rs4680, a functional polymorphism in the COMT gene. Compared with COMT methionine¹⁵⁸ carriers, Caucasian carriers of the COMT valine¹⁵⁸ allele have a stronger negative correlation between the expression of CNR1 in DLPFC and age. In contrast, the methylation level of cg02498983, which is negatively correlated with the expression of CNR1 in PFC, showed the strongest positive correlation with age in PFC of Caucasian carriers of COMT valine¹⁵⁸. Additionally, we have observed decreased mRNA expression of CNR1 in the DLPFC of patients with schizophrenia. Further analysis revealed a positive eQTL SNP, rs806368, which predicted the expression of a novel transcript of CNR1 in human DLPFC, hippocampus and caudate. This SNP has been associated with addiction and other psychiatric disorders. THC or ethanol are each significantly associated with dysregulated expression of CNR1 in the PFC of patients with affective disorder, and the expression of CNR1 is significantly upregulated in the PFC of schizophrenia patients who completed suicide. Our results support previous studies that have implicated the endocannabinoid system in the pathology of schizophrenia and provided additional insight into the mechanism of increasing risk for schizophrenia in the adolescent cannabis users.

Cannabis use and outcome of recent onset psychosis

Purpose

To test the hypothesis that recent onset psychotic patients who use cannabis will have psychotic symptoms that are more severe and more persistent than those who do not use cannabis.

Subjects and methods

We carried out a 4-year follow-up study of a cohort of 119 patients with recent onset of psychosis. The patients were divided into four groups according to duration of cannabis use, taking index admission and follow-up as reference points.

Results

Those subjects who persisted in the use of cannabis had more positive (but not negative) symptoms and a more continuous illness at follow-up.

Limitations

The main limitations of the study were: the relatively small sample size, and that the excess of male subjects and the presence of cannabis induced psychosis could have a confusing impact on the interpretation of the results.

Conclusion

It is possible that psychotic patients who use cannabis are at a greater risk of a more continuous illness with more positive symptoms than those who do not.

Comparison of self-reports and biological measures for alcohol, tobacco, and illicit drugs consumption in psychiatric inpatients

Background

Asking psychiatric in-patients about their drug consumption is unlikely to yield reliable results, particularly where alcohol and illicit drug use is involved. The main aim of this study was to compare spontaneous self-reports of drug use in hospitalized psychiatric patients to biological measures of same. A secondary aim was to determine which personal factors were associated with the use of tobacco, alcohol, and illicit drugs as indicated by these biological measures.

Methods

The consumption of substances was investigated using biological measures (urine cotinine, cannabis, opiates, cocaine, amphetamines and barbiturates; blood carbohydrate-deficient transferrin [CDT] and gamma-glutamyl transferase [GGT]) in 486 consecutively admitted psychiatric patients, one day following their hospitalization. Patients’ self-reports of alcohol, tobacco and illicit drugs consumption were recorded. Socio-professional and familial data were also recorded.

Results

The results show a low correlation between biological measures and self-reported consumption of alcohol and illicit drugs. Fifty-two percent of the patients under-reported their consumption of illicit drugs (kappa = .47). Patients with schizophrenia and personality disorders were more likely to disclose their illicit drug consumption relative to patients suffering from mood disorders and alcohol dependence. Fifty-six percent of patients underreported alcohol use, as evaluated by CDT (kappa = .2), and 37% underreported when using the CDT + GGT measure as an indicator. Smoking appeared to be reported adequately. In the study we observed a strong negative correlation between cannabis use and age, a strong correlation between tobacco and cannabis use, and correlations between tobacco, cannabis and alcohol consumption.

Conclusion

This study is the first to compare self-reports and biological measures of alcohol, tobacco and illicit drug uses in a large sample of inpatients suffering from various categories of psychiatric illnesses, allowing for cross-diagnosis comparisons.

Psychoactive substance use among outpatients with severe mental illness: A comparative study

Background

Despite several studies on the prevalence and pattern of substance use in Nigeria, there is little information on substance use in patients diagnosed with serious mental illness (SMI) such as schizophrenia and bipolar affective disorder (BD).

Aim

The aim of the study was to compare the pattern of psychoactive substance use among outpatients with BD and schizophrenia.

Setting

The study was conducted in a neuropsychiatric hospital in Nigeria.

Methods

Seventy five consecutive patients with a MINI-PLUS diagnosis of BD were compared with an equal number of patients obtained by systematic random sampling with a MINI-PLUS diagnosis of schizophrenia.

Results

The respondents with schizophrenia were aged 18–59 years (37.2 ± 9.99) and were predominantly young adult (49, 65.3%), men (46, 61.3%), who were never married (38, 50.7%). Overall, lifetime drug use prevalence was 52%, while for current use, overall prevalence was 21.3%. Participants with BD were aged 18–63 years (36.7 ± 10.29) and were predominantly young adult (53, 70.7%), women (44, 58.7%), who were married (32, 42.7%), with tertiary education (31, 41.3%). Overall, lifetime drug use prevalence was 46.7%, while current overall prevalence was 17.3%. These rates (lifetime and current) for both diagnostic groups are higher than what was reported by the World Health Organization in the global status report of 2014 (0% – 16%). The statistically significant difference between the two diagnostic groups was related to their sociodemographic and clinical variables and psychoactive substance use.

Conclusion

Psychoactive substance use remains a burden in the care of patients diagnosed with schizophrenia and BD. Future policies should incorporate routine screening for substance use at the outpatient department with a view to stemming the tide of this menace.

Gene Expression Profiles Associated with Brain Aging are Altered in Schizophrenia

Existence of aging associated transcriptional differences in the schizophrenia brain was investigated in RNA sequencing data from 610 postmortem Dorso-Lateral Pre-Frontal Cortex (DLPFC) samples in the CommondMind Consortium (CMC) and the psychENCODE cohorts. This analysis discovered that the trajectory of gene expression changes that occur during brain aging differed between schizophrenia cases and unaffected controls. Mainly, the identified gene expression differences between the diagnosis groups shrank in magnitude following 60 years of age. A differential expression analysis restricted to the 40 to 60 year age group identified 556 statistically significant loci that replicated and had highly consistent gene expression fold changes in the two cohorts. An interaction between age and diagnosis in the wider psychENCODE cohort was also detected. Gene set enrichment analysis discovered disruptions in mitochondria, RNA splicing and phosphoprotein gene pathways. The identified differentially expressed genes in the two cohorts were also significantly enriched in genomic regions associated with schizophrenia although no enrichment was observed for differentially expressed genes identified in the 40 to 60 year age group. This work implicates disruptions to the normal brain aging processes in the pathology of schizophrenia and demonstrates the need for age stratification in schizophrenia postmortem brain gene expression studies.

Impact of tobacco, alcohol and cannabis use on treatment outcomes among patients experiencing first episode psychosis: Data from the national RAISE-ETP study

AIM

The primary aim of this study was to examine the effect of recent tobacco, alcohol and cannabis use on treatment outcomes among participants experiencing first episode psychosis (FEP).

METHODS

Secondary data analyses were conducted on 404 participants enrolled in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study. RAISE-ETP investigated the effectiveness of a coordinated specialty care (CSC) intervention for FEP in community mental health agencies in the United States. Generalized estimating equations were used to examine whether recent tobacco smoking, alcohol, and cannabis use at baseline were associated with illness severity, number of antipsychotic pills missed, psychiatric symptoms and quality of life during the 24-month treatment period, after controlling for duration of untreated psychosis and treatment group.

RESULTS

At baseline, roughly 50% (n = 209) of participants reported recent tobacco, 28% (n = 113) alcohol and 24% (n = 95) cannabis use. Tobacco smokers had higher levels of illness severity (β = .24; P < .005), a higher number of missed pills (β = 2.89; P < .05), higher psychiatric symptoms and lower quality of life during treatment relative to non-smokers. Alcohol users had a higher number of missed pills (β = 3.16; P < .05) during treatment and cannabis users had higher levels of illness severity (β = .18; P < .05) and positive symptoms (β = 1.56; P < .05) relative to non-users.

CONCLUSIONS

Tobacco, alcohol and cannabis use are common in youth seeking treatment for FEP. Tobacco smoking was associated with more negative clinical outcomes. These findings have implications for including interventions targeting these areas of substance use within current CSC models.

Epidemiology of hallucinogen use in the U.S. results from the National epidemiologic survey on alcohol and related conditions III

BACKGROUND

Population-based data regarding the epidemiology of hallucinogen use and co-occurring psychiatric disorders is largely absent from the literature. We aim to present findings on the prevalence, sociodemographic correlates, psychiatric comorbidity, treatment utilization, social support and associated disability of hallucinogen use using nationally representative data.

METHOD

We analyzed data from the National Epidemiologic Study on Alcohol and Related Conditions-III (2011-2012, N = 36,309). We conducted multivariate logistic regression analyses in unadjusted and adjusted models in order to explore the odds of psychiatric disorders and associated disability among hallucinogen users.

RESULTS

Prevalence of twelve-month and lifetime hallucinogen use was 0.62% and 9.32%, respectively. Hallucinogen use was found to be significantly associated with mood disorders, anxiety disorders, eating disorders, personality disorders and substance use disorders. Following adjustment, significant associations were retained with several substance use disorders (adjusted odds ratio (AOR) for heroin use disorder = 4.89 (95% CI, 1.90-12.58), personality disorders (AOR = 2.10 (95% CI, 1.81-2.44)), Post-Traumatic Stress Disorder (AOR = 1.86, 95% CI 1.00-3.45) and past suicide attempts (AOR = 1.49, 95% CI 1.21-1.85).

CONCLUSIONS

Lifetime hallucinogen use in the US is prevalent and highly comorbid with other substance use and psychiatric disorders. Hallucinogen Use Disorder is relatively uncommon, with a low risk of development following exposure to hallucinogens. There are significant associations between hallucinogen use and substance use disorders, personality disorders, PTSD and past suicide attempts. The evolving therapeutic utility of this class of substances requires further assessment of short- and long-term risks of use, before large scale clinical application is pursued.

Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs) and schizophrenia. This systematic review and meta-analysis estimated prevalence rates of SUDs in epidemiological and treatment-seeking patients diagnosed with schizophrenia or first episode psychosis.

METHODS

A literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2017 inclusive. Prevalence of co-morbid SUDs and schizophrenia were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Combining like studies was dictated how authors reported substance use.

RESULTS

There were 123 included articles with a total sample size of 165,811 subjects that yielded six epidemiological studies, 11 national or state case-registry studies, 20 large cohort studies and 86 clinical studies using in- or out-patient samples. The prevalence of any SUD was 41.7%, followed by illicit drugs (27.5%), cannabis (26.2%), alcohol (24.3%) and stimulant use (7.3%). Meta-analysis showed the pooled variance of any SUD in males was 48% which was significantly higher than that for females with schizophrenia (22.1%, OR 3.43, 95% CI 3.01, 3.92). Patients with SUD had an earlier age of onset of schizophrenia. Meta-regression showed prevalence increased over time for illicit drugs but not for other substances, including alcohol.

CONCLUSIONS

The meta-analysis revealed that SUDs in schizophrenia is highly prevalent and rates have not changed over time. This indicates SUD are difficult to treat in this patient population and there is an urgent need for more informative studies to help develop better prevention, detection and treatment of SUDs in persons with schizophrenia and co-morbid disorders.

Effectiveness of Integrated Dual Diagnosis Treatment (IDDT) in severe mental illness outpatients with a co-occurring substance use disorder

Integrating substance use disorder treatment with psychiatric treatment is considered more favourable then treating these disorders parallel or sequential, but the evidence base is inconclusive. We examined the effectiveness of Integrated Dual Diagnosis Treatment (IDDT) on substance use in severe mental illness outpatients with substance use disorders. IDDT is a collaborative, multidisciplinary team approach in which motivational interviewing is a key element. In addition, we also examined the effects of IDDT implementation on skills and knowledge of mental health care professionals. A randomized controlled stepped-wedge cluster trial was performed in 6 functional assertive cummunity treatment teams. We included 37 clinicians who were given a three-day IDDT training. Our primary outcome was days of substance use at follow up, 12 months after IDDT implementation. This was assessed in 154 included patients and was measured with the Measurement in the Addiction for Triage and Evaluation. After implementation of IDDT we found a reduction in the number of days patients used alcohol or drugs, but no improvements on other secondary outcomes such as psychopathology, functioning, therapeutic alliance or motivation to change. Also, IDDT training did not seem to improve clinicians' knowledge, attitudes and motivational interviewing skills. Effects on our secondary outcomes may have been limited by the absence of a training effect in our clinicians. Our study clearly underlines the complexity of disseminating IDDT and in particular motivational interviewing.

Online Communication about Depression and Anxiety among Twitter Users with Schizophrenia: Preliminary Findings to Inform a Digital Phenotype Using Social Media

Digital technologies hold promise for supporting the detection and management of schizophrenia. This exploratory study aimed to generate an initial understanding of whether patterns of communication about depression and anxiety on popular social media among individuals with schizophrenia are consistent with offline representations of the illness. From January to July 2016, posts on Twitter were collected from a sample of Twitter users who self-identify as having a schizophrenia spectrum disorder (n = 203) and a randomly selected sample of control users (n = 173). Frequency and timing of communication about depression and anxiety were compared between groups. In total, the groups posted n = 1,544,122 tweets and users had similar characteristics. Twitter users with schizophrenia showed significantly greater odds of tweeting about depression compared with control users (OR = 2.69; 95% CI 1.76-4.10), and significantly greater odds of tweeting about anxiety compared with control users (OR = 1.81; 95% CI 1.20-2.73). This study offers preliminary insights that Twitter users with schizophrenia may express elevated symptoms of depression and anxiety in their online posts, which is consistent with clinical characteristics of schizophrenia observed in offline settings. Social media platforms could further our understanding of schizophrenia by informing a digital phenotype and may afford new opportunities to support early illness detection.

Risk factors of compliance with self-harm command hallucinations in individuals with affective and non-affective psychosis

Clinicians are often left with the difficult task of assessing and managing the risk of violent behaviors in individuals having command hallucinations, which may result in substantial rates of false positive or false negative. Moreover, findings on the association between command hallucinations and suicidal behaviors are limited. In an attempt to better understand compliance to this hallucinatory phenomenon, our objective was to identify the risk factors of compliance with self-harm command hallucinations. Secondary analyses from the MacArthur Study were performed on 82 participants with psychosis reporting such commands. Univariate logistic regression was used to examine the classification value of each characteristic associated with compliance with such commands. Seriousness and frequency of childhood physical abuse, a current comorbid substance use disorder, emotional distress, general symptomatology, history of compliance, and belief about compliance in the future were found to be significant risk factors of compliance with self-harm commands in the week preceding psychiatric inpatient. Multivariate analyses revealed that severity of childhood physical abuse, belief about compliance in the future, and a current comorbid substance use disorder were independent risk factors. The final model showed excellent classification accuracy as suggest by the receiver operating characteristic curve (AUC=0.84, 95% CI: 0.75-0.92, p<0.001). Our results suggest considerable clinical implications in regard to the assessment of risk of compliance to self-harm command hallucinations in individuals with psychosis.

Interactions between cannabis and schizophrenia in humans and rodents

In this review, we provide an overview of the relationship between cannabis use and the development of schizophrenia, using both animal and human studies. We further discuss the potential neural mechanism that may mediate the relationship between cannabis use and schizophrenia symptoms. We finally provide clinical implications and future studies that can further elucidate the relationship between cannabis and schizophrenia.

Risperidone versus other antipsychotics for people with severe mental illness and co-occurring substance misuse

BACKGROUND

Up to 75% of people with serious mental illness (SMI) such as schizophrenia and bipolar disorder have co-occurring substance use disorders (dual diagnosis). Dual diagnosis can have an adverse effect on treatment and prognosis of SMI.

OBJECTIVES

To evaluate the effects of risperidone compared to treatment with other antipsychotics (first-generation and other second-generation antipsychotics) used in people with serious mental illness and co-occurring substance misuse.

SEARCH METHODS

On 6 January 2016 and 9 October 2017, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including trial registers).

SELECTION CRITERIA

We selected randomised trials of risperidone versus any other antipsychotic in people with SMI and substance abuse (dual diagnosis). We included trials meeting our inclusion criteria and reporting useable data. We excluded trials that either did not meet our inclusion criteria or met our inclusion criteria but did not report any useable data.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and selected studies. For included studies, we independently extracted data and appraised study quality. For binary outcomes we calculated the risk ratios (RRs) and their 95% confidence intervals. For continuous outcomes we calculated the mean differences (MDs) and their 95% confidence intervals. We pooled data using random-effects meta-analyses and assessed the quality of evidence, creating a 'Summary of findings' table using the GRADE approach.

MAIN RESULTS

We identified eight randomised trials containing a total of 1073 participants with SMI and co-occurring substance misuse. Seven of these contributed useable data to the review. There was heterogeneity in trial design and measurement. Risperidone was compared to clozapine, olanzapine, perphenazine, quetiapine and ziprasidone. Few trials compared risperidone with first-generation agents. Few trials examined participants with a dual diagnosis from the outset and most trials only contained separate analyses of subgroups with a dual diagnosis or were secondary data analyses of subgroups of people with a dual diagnosis from existing larger trials.For risperidone versus clozapine we found no clear differences between these two antipsychotics in the reduction of positive psychotic symptoms (1 randomised controlled trial (RCT), n = 36, mean difference (MD) 0.90, 95% CI -2.21 to 4.01, very low quality evidence), or reduction in cannabis use (1 RCT, n = 14, risk ratio (RR) 1.00, 95% CI 0.30 to 3.35, very low quality evidence), improvement in subjective well-being (1 RCT, n = 36, MD -6.00, 95% CI -14.82 to 2.82, very low quality evidence), numbers discontinuing medication (1 RCT, n = 36, RR 4.05, 95% CI 0.21 to 78.76, very low quality evidence), extrapyramidal side-effects (2 RCTs, n = 50, RR 2.71, 95% CI 0.30 to 24.08; I² = 0%, very low quality evidence), or leaving the study early (2 RCTs, n = 45, RR 0.49, 95% CI 0.10 to 2.51; I² = 34%, very low quality evidence). Clozapine was associated with lower levels of craving for cannabis (1 RCT, n = 28, MD 7.00, 95% CI 2.37 to 11.63, very low quality evidence).For risperidone versus olanzapine we found no clear differences in the reduction of positive psychotic symptoms (1 RCT, n = 37, MD -1.50, 95% CI -3.82 to 0.82, very low quality evidence), reduction in cannabis use (1 RCT, n = 41, MD 0.40, 95% CI -4.72 to 5.52, very low quality evidence), craving for cannabis (1 RCT, n = 41, MD 5.00, 95% CI -4.86 to 14.86, very low quality evidence), parkinsonism (1 RCT, n = 16, MD -0.08, 95% CI -1.21 to 1.05, very low quality evidence), or leaving the study early (2 RCT, n = 77, RR 0.68, 95% CI 0.34 to 1.35; I² = 0%, very low quality evidence).For risperidone versus perphenazine, we found no clear differences in the number of participants leaving the study early (1 RCT, n = 281, RR 1.05, 95% CI 0.92 to 1.20, low-quality evidence).For risperidone versus quetiapine, we found no clear differences in the number of participants leaving the study early (1 RCT, n = 294, RR 0.96, 95% CI 0.86 to 1.07, low-quality evidence).For risperidone versus ziprasidone, we found no clear differences in the number of participants leaving the study early (1 RCT, n = 240, RR 0.96, 95% CI 0.85 to 1.10, low-quality evidence).For many comparisons, important outcomes were missing; and no data were reported in any study for metabolic disturbances, global impression of illness severity, quality of life or mortality.

AUTHORS' CONCLUSIONS

There is not sufficient good-quality evidence available to determine the effects of risperidone compared with other antipsychotics in people with a dual diagnosis. Few trials compared risperidone with first-generation agents, leading to limited applicability to settings where access to second-generation agents is limited, such as in low- and middle-income countries. Moreover, heterogeneity in trial design and measurement of outcomes precluded the use of many trials in our analyses. Future trials in this area need to be sufficiently powered but also need to conform to consistent methods in study population selection, use of measurement scales, definition of outcomes, and measures to counter risk of bias. Investigators should adhere to CONSORT guidelines in the reporting of results.

Alcohol use in schizophrenia: prevalence, patterns, correlates and clinical outcomes in Goa, India

Aims and method

To explore the patterns of alcohol consumption and its impact on clinical outcomes in schizophrenia in low- and middle-income countries. We performed a cross-sectional survey of 315 patients with schizophrenia and calculated the prevalence of alcohol consumption and alcohol use disorder. The patients' sociodemographic profiles and clinical outcomes, including Brief Psychiatric Rating Scale (BPRS) scores, were compared between abstainers and drinkers using the χ2- andt-tests.

Results

The 1-year prevalence of drinking, hazardous drinking and alcohol dependence was 16.8% (95% CI 12.9–21.4), 5.7% (95% CI 3.4–8.9) and 2.5% (95% CI 1.1–4.9), respectively. Male gender, single or post-marital status, higher education and being economically active were significantly associated with alcohol consumption. Alcohol drinkers were significantly more likely to be on combination psychotropics compared with abstainers. The mean total BPRS score was significantly lower in alcohol drinkers compared with abstainers. Drinking alcohol was associated with fewer deficit symptoms.

Clinical implications

Cultural settings have a significant impact on the prevalence of alcohol use disorder in schizophrenia.

Service innovations

One of the challenges for services in the UK has been how best to meet the needs of those people who experience severe mental health problems and use drugs and alcohol problematically. It is now well-documented in the international literature that the coexistence of severe mental health and substance misuse problems are common (e.g. Regier et al, 1990; Krausz et al, 1996; Menezes et al, 1996; Fowler et al, 1998; Mueser et al, 2000; Graham et al, 2001) and often correlated with a number of adverse outcomes (Smith & Hucker, 1994; Johnson, 1997; Mueser et al, 2000). Integrated treatment approaches developed in the USA for this client group (e.g. Drake & Wallach, 2000; Drake et al, 2001), and although they offer much food for thought and some direction, they could not be wholly imported and implemented in the UK because of significant differences in the contextual factors that guide service provision in the two countries. The challenge in the UK has been to develop effective services that fit with the unique community-based treatment approaches for substance misuse problems and mental health that have developed and historically offered separately and in parallel.

Service innovations

One of the challenges for services in the UK has been how best to meet the needs of those people who experience severe mental health problems and use drugs and alcohol problematically. It is now well-documented in the international literature that the coexistence of severe mental health and substance misuse problems are common (e.g. Regier et al, 1990; Krausz et al, 1996; Menezes et al, 1996; Fowler et al, 1998; Mueser et al, 2000; Graham et al, 2001) and often correlated with a number of adverse outcomes (Smith &amp; Hucker, 1994; Johnson, 1997; Mueser et al, 2000). Integrated treatment approaches developed in the USA for this client group (e.g. Drake &amp; Wallach, 2000; Drake et al, 2001), and although they offer much food for thought and some direction, they could not be wholly imported and implemented in the UK because of significant differences in the contextual factors that guide service provision in the two countries. The challenge in the UK has been to develop effective services that fit with the unique community-based treatment approaches for substance misuse problems and mental health that have developed and historically offered separately and in parallel.

Psychoactive substance use in specialized psychiatric care patients

Objective Life expectancy of psychiatric patients is markedly shorter compared to the general population, likely partly due to smoking or misuse of other substances. We investigated prevalence and correlates of substance use among psychiatric patients. Methods Within the Helsinki University Psychiatric Consortium Study, data were collected on substance use (alcohol, smoking, and illicit drugs) among patients with schizophrenia or schizoaffective disorder (n = 113), bipolar (n = 99), or depressive disorder (n = 188). Clinical diagnoses of substance use were recorded, and information on smoking, hazardous alcohol use, or misuse of other substances was obtained using questionnaires. Results One-fourth (27.7%) of the patients had clinical diagnoses of substance use disorders. In addition, in the Alcohol Use Disorders Identification Test, 43.1% had hazardous alcohol use and 38.4% were daily smokers. All substance use was more common in men than in women. Bipolar patients had the highest prevalence of alcohol use disorders and hazardous use, whereas those with schizophrenia or schizoaffective disorder were more often daily smokers. In regression analyses, self-reported alcohol consumption was associated with symptoms of anxiety and borderline personality disorder and low conscientiousness. No associations emerged for smoking. Conclusions The vast majority of psychiatric care patients have a diagnosed substance use disorder, hazardous alcohol use, or smoke daily, males more often than females. Bipolar patients have the highest rates of alcohol misuse, schizophrenia or schizoaffective disorder patients of smoking. Alcohol use may associate with symptoms of anxiety, borderline personality disorder, and low conscientiousness. Preventive and treatment efforts specifically targeted at harmful substance use among psychiatric patients are necessary.

Pros and Cons of Medical Cannabis use by People with Chronic Brain Disorders

BACKGROUND

Cannabis is the most widely used illicit drug in the world and there is growing concern about the mental health effects of cannabis use. These concerns are at least partly due to the strong increase in recreational and medical cannabis use and the rise in tetrahydrocannabinol (THC) levels. Cannabis is widely used to self-medicate by older people and people with brain disorders such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Alzheimer's disease (AD), Parkinson's disease (PD), bipolar disorder, and schizophrenia.

OBJECTIVE

This review provides an overview of the perceived benefits and adverse mental health effects of cannabis use in people with ALS, MS, AD, PD, bipolar disorder, and schizophrenia.

RESULTS

The reviewed studies indicate that cannabis use diminishes some symptoms associated with these disorders. Cannabis use decreases pain and spasticity in people with MS, decreases tremor, rigidity, and pain in people with PD, and improves the quality of life of ALS patients by improving appetite, and decreasing pain and spasticity. Cannabis use is more common among people with schizophrenia than healthy controls. Cannabis use is a risk factor for schizophrenia which increases positive symptoms in schizophrenia patients and diminishes negative symptoms. Cannabis use worsens bipolar disorder and there is no evidence that bipolar patients derive any benefit from cannabis. In late stage Alzheimer's patients, cannabis products may improve food intake, sleep quality, and diminish agitation.

CONCLUSION

Cannabis use diminishes some of the adverse effects of neurological and psychiatric disorders. However, chronic cannabis use may lead to cognitive impairments and dependence.

A Study of the Impact of Cannabis on Doses of Discharge Antipsychotic Medication in Individuals with Schizophrenia or Schizoaffective Disorder

Patients with schizophrenia or schizoaffective disorder have a high prevalence of comorbid cannabis use disorder (CUD). CUD has been associated with poorer outcomes in patients. We compared doses of antipsychotic medications at the time of discharge from hospital among inpatients with schizophrenia or schizoaffective disorder with or without concurrent cannabis use. We reviewed the medical records of patients (N = 8157) with schizophrenia or schizoaffective disorder discharged from the hospital between 2008 and 2012. The patients were divided into two groups; those with urine drug tests positive for cannabis and those negative for cannabis. Doses of antipsychotic medications were converted to chlorpromazine equivalents. Bivariate analyses were done with Student's t test for continuous variables and χ ² test for categorical variables. Linear regression was carried out to adjust for potential confounders. Unadjusted analysis revealed that the cannabis positive group was discharged on lower doses of antipsychotic medication compared with the cannabis negative group (geometric mean chlorpromazine equivalent doses 431.22 ± 2.20 vs 485.18 ± 2.21; P < 0.001). However, the difference in geometric mean chlorpromazine equivalent doses between the two groups was no longer significant after adjusting for sex, age, race, and length of stay (geometric mean difference 0.99; 95 % CI 0.92-1.10). Though limited by lack of information on duration, amount and severity of cannabis use, as well as inability to control for other non-antipsychotic medications, our study suggests that cannabis use did not significantly impact on doses of antipsychotics required during the periods of acute exacerbation in patients with schizophrenia or schizoaffective disorder.

Characterization of peripheral cannabinoid receptor expression and clinical correlates in schizophrenia

The relationship between cannabinoid receptor signaling and psychosis vulnerability requires further exploration. The endocannabinoid signaling system is extensive, with receptors exerting regulatory functions in both immune and central nervous systems. In the brain, cannabinoid receptors (CBR) directly modulate neurotransmitter systems. In the peripheral lymphocyte, CBRs mediate cytokine release, with dysregulated cytokine levels demonstrated in schizophrenia. mRNA levels of CBRs were measured in human peripheral blood mononuclear cells (PBMCs) obtained from 70 participants (35 non-clinical controls, 35 participants with schizophrenia), who were recruited for the absence of marijuana use/abuse by self-report. Changes in mRNA expression were measured using qRT-PCR. Clinical measurements collected included the MATRICS Cognitive Battery and the Positive and Negative Syndrome Scale. Levels of CB1R and CB2R mRNA in PBMCs were significantly higher in participants with schizophrenia compared to the non-clinical controls. Additionally, CB1R and CB2R mRNA levels correlated with impairments in cognitive processing and clinical symptom severity in multiple domains. These results continue to support dysregulation of particular aspects of the endocannabinoid signaling system in participants with schizophrenia selected for the self-reported absence of marijuana abuse/dependence.

Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study

BACKGROUND

Co-occurring substance use increases the risk of hospitalisation in people with severe mental illness, whereas Assertive Community Treatment (ACT) generally reduces hospitalisation in patients with severe mental illness and high inpatient service use. Because the superiority of ACT over standard services amongst patients with problematic substance use is uncertain, the present study examined inpatient service use amongst patients with and without problematic substance use in the 2 years before and the 2 years after they enrolled into ACT teams.

METHODS

This naturalistic observational study included 142 patients of 12 different ACT teams throughout Norway. The teams assessed the patients upon enrolment into ACT using clinician-rated and self-reported questionnaires. We obtained hospitalisation data from the Norwegian Patient Register for the 2 years before and the 2 years after enrolment into ACT. We used linear mixed models to assess changes in hospitalisation and to explore associations between problematic substance use and changes in hospitalisation, controlling for socio-demographic and clinical characteristics.

RESULTS

A total of 84 (59%) participants had problematic substance use upon enrolment into the ACT teams. In the 2 years after ACT enrolment both participants with and without problematic substance use experienced a reduction in total inpatient days. Those with problematic substance use also had fewer involuntary inpatient days. Exploratory analyses suggested that symptom severity and functioning level interacted with problematic substance use to influence change in total inpatient days.

CONCLUSION

These findings may suggest that ACT teams successfully support people with complex mental health problems in the community, including those with problematic substance use, and thereby contribute to a reduction in inpatient service use.

Cannabis Use Is Associated With Increased Psychotic Symptoms and Poorer Psychosocial Functioning in First-Episode Psychosis: A Report From the UK National EDEN Study

OBJECTIVE

The use of cannabis during the early stage of psychosis has been linked with increased psychotic symptoms. This study aimed to examine the use of cannabis in the 12 months following a first-episode of psychosis (FEP) and the link with symptomatic course and outcome over 1 year post psychosis onset.

DESIGN AND SETTING

One thousand twenty-seven FEP patients were recruited upon inception to specialized early intervention services (EIS) for psychosis in the United Kingdom. Participants completed assessments at baseline, 6 and 12 months.

RESULTS

The results indicate that the use of cannabis was significantly associated with increased severity of psychotic symptoms, mania, depression and poorer psychosocial functioning. Continued use of cannabis following the FEP was associated with poorer outcome at 1 year for Positive and Negative Syndrome Scale total score, negative psychotic symptoms, depression and psychosocial functioning, an effect not explained by age, gender, duration of untreated psychosis, age of psychosis onset, ethnicity or other substance use.

CONCLUSION

This is the largest cohort study of FEP patients receiving care within EIS. Cannabis use, particularly "continued use," was associated with poorer symptomatic and functional outcome during the FEP. The results highlight the need for effective and early intervention for cannabis use in FEP.

Schizophrenia and Suicide Attempts: Findings from a Representative Community-Based Canadian Sample

This study examined factors associated with suicide attempts among those with schizophrenia (n = 101) versus those without (n = 21,643) in a representative sample of noninstitutionalized Canadians. The lifetime prevalence of suicide attempts among persons with schizophrenia was 39.2% versus 2.8% of nonafflicted individuals. After adjusting for sociodemographics, childhood adversities, substance abuse/dependence, depression/anxiety, and chronic pain, those with schizophrenia had 6 times the odds (OR = 6.47) of attempting suicide. Among persons with schizophrenia, suicide attempts were associated with female gender (OR = 4.59), substance abuse/dependence (OR = 6.31), depression (OR = 4.93), and childhood physical abuse (OR = 5.75). Community-dwelling persons with schizophrenia appear to be at high risk for suicide attempts.

Social Stress and Psychosis Risk: Common Neurochemical Substrates?

Environmental risk factors have been implicated in the etiology of psychotic disorders, with growing evidence showing the adverse effects of migration, social marginalization, urbanicity, childhood trauma, social defeat, and other adverse experiences on mental health in vulnerable populations. Collectively, social stress may be one mechanism that could link these environmental risk factors. The exact mechanism(s) by which social stress can affect brain function, and in particular the molecular targets involved in psychosis (such as the dopaminergic (DA) system), is (are) not fully understood. In this review, we will discuss the interplay between social environmental risk factors and molecular changes in the human brain; in particular, we will highlight the impact of social stress on three specific neurochemical systems: DA, neuroinflammation/immune, and endocannabinoid (eCB) signaling. We have chosen the latter two molecular pathways based on emerging evidence linking schizophrenia to altered neuroinflammatory processes and cannabis use. We further identify key developmental periods in which social stress interacts with these pathways, suggesting window(s) of opportunities for novel interventions. Taken together, we suggest that they may have a key role in the pathogenesis and disease progression, possibly provide novel treatment options for schizophrenia, and perhaps even prevent it.

Evaluating the relationship between cannabis use and IQ in youth and young adults at clinical high risk of psychosis

Among people with psychosis, those with a history of cannabis use show better cognitive performance than those who are cannabis naïve. It is unknown whether this pattern is present in youth at clinical high risk (CHR) of psychosis. We evaluated relationships between IQ and cannabis use while controlling for use of other substances known to impact cognition in 678 CHR and 263 healthy control (HC) participants. IQ was estimated using the Vocabulary and Block Design subtests of the Wechsler Abbreviated Scale of Intelligence. Drug and alcohol use severity and frequency were assessed with the Alcohol and Drug Use Scale, and we inquired participants' age at first use. CHR were further separated into early and late age at onset of cannabis use sub-groups, and low-, moderate- and high-frequency sub-groups. No significant differences in IQ emerged between CHR or HC cannabis users vs. non-users, or between use frequency groups. CHR late-onset users showed significantly higher IQ than CHR early-onset users. Age at onset of cannabis use was significantly and positively correlated with IQ in CHR only. Results suggest that age at onset of cannabis may be a more important factor for IQ than use current use or use frequency in CHR.

Relationship between cannabis and psychosis: Reasons for use and associated clinical variables

The mechanism underneath the relationship between cannabis and psychosis remains controversial, for which several hypotheses have been proposed, including cannabis as self-medication and cannabis as a risk for the development of psychosis. The aim of this work was to study the relationship between cannabis and psychosis in first-episode psychosis cannabis users and non-users, and non-psychotic cannabis users. The age at the first psychotic episode, duration of untreated psychosis, psychopathology and reasons for cannabis use were assessed. First-episode psychosis cannabis users showed an earlier age at psychosis onset than non-user patients. No significant differences in symptomatology were found. The distinguishing reasons to use cannabis for patients with first-episode psychosis with respect to non-psychotic users were to arrange their thoughts and deal with hallucinations and suspiciousness. These findings are in agreement with both hypotheses: self-medication and secondary psychosis hypothesis. However, longitudinal prospective cohort studies assessing reasons for cannabis use are needed to investigate both hypotheses and their complementarity.

Factors affecting smoking cessation efforts of people with severe mental illness: a qualitative study

OBJECTIVE

People with severe mental illness are much more likely to smoke than are members of the general population. Smoking cessation interventions that combine counseling and medication have been shown to be moderately effective, but quit rates remain low and little is known about the experiences of people with severe mental illness in smoking cessation interventions. To address this gap in knowledge, we conducted a qualitative study to investigate factors that help or hinder the smoking cessation efforts of people with severe mental illness.

METHODS

We recruited 16 people with severe mental illness who had participated in a clinical trial of two different smoking cessation interventions, one involving nicotine replacement therapy only and the other nicotine replacement therapy combined with motivational interviewing and a peer support group. We conducted open-ended, semi-structured interviews with participants, who ranged in age from 20 to 56 years old, were equally distributed by gender (eight men and eight women), and were predominantly Caucasian (n = 13, 81%). Primary mental illness diagnoses included schizophrenia/schizoaffective disorder (n = 6, 38%), depression (n = 5, 31%), bipolar disorder (n = 4, 25%), and anxiety disorder (n = 1, 6%). At entry into the clinical trial, participants smoked an average of 22.6 cigarettes per day (SD = 13.0).

RESULTS

RESULTS indicated that people with mental illness have a diverse range of experiences in the same smoking cessation intervention. Smoking cessation experiences were influenced by factors related to the intervention itself (such as presence of smoking cessation aids, group supports, and emphasis on individual choice and needs), as well as individual factors (such as mental health, physical health, and substance use), and social-environmental factors (such as difficult life events and social relationships).

CONCLUSIONS

An improved understanding of the smoking cessation experiences of people with severe mental illness can inform the delivery of future smoking cessation interventions for this population. The results of this study suggest the importance of smoking cessation interventions that offer a variety of treatment options, incorporating choice and flexibility, so as to be responsive to the evolving needs and preferences of individual clients.

Prevalence and socio-demographic risk factors associated with psychoactive substance use in psychiatric out-patients of a tertiary hospital in Nigeria

BACKGROUND

The co-morbidity of psychoactive substance use and other mental disorders is a major challenge to the management of both conditions in several parts of the world. There is relative dearth of information on co-morbidity and its predictors in Nigeria. This study determined the prevalence and socio-demographic risk factors associated with psychoactive substance use in the psychiatric out-patients of a tertiary hospital in Nigeria.

STUDY DESIGN

A cross-sectional study.

MATERIALS AND METHODS

From routine clinic visits over a 4-month period, each consecutive 4(th) adult patients (>18 years) who had previously attended the clinic at least for 1 year, completed a socio-demographic and semi-structured drug use questionnaires and interview with the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) to generate substance use diagnosis. Data was analysed using the statistical package for social sciences (SPSS), version 16. Level of significance was set at P < 0.05.

RESULTS

The lifetime prevalence for the use of substance was 29.3%, while that for multiple substances was 17.7%. The most commonly used substances were alcohol, cannabis and tobacco and they were also the ones mostly used in combination with one or the other. A total of 10.1% of the patients had a psychoactive substance use disorder. Being male, married with at least primary education and unemployed were significant risk factors for substance use.

CONCLUSION

Psychoactive substance is common among the psychiatric outpatients of the hospital with males, those with formal education, the married and unemployed being at high risk of substance use.

Reasons for cannabis use in first-episode psychosis: does strength of endorsement change over 12 months?

BACKGROUND

Why patients with psychosis use cannabis remains debated. The self-medication hypothesis has received some support but other evidence points towards an alleviation of dysphoria model. This study investigated the reasons for cannabis use in first-episode psychosis (FEP) and whether strength in their endorsement changed over time.

METHODS

FEP inpatients and outpatients at the South London and Maudsley, Oxleas and Sussex NHS Trusts UK, who used cannabis, rated their motives at baseline (n=69), 3 months (n=29) and 12 months (n=36). A random intercept model was used to test the change in strength of endorsement over the 12 months. Paired-sample t-tests assessed the differences in mean scores between the five subscales on the Reasons for Use Scale (enhancement, social motive, coping with unpleasant affect, conformity and acceptance and relief of positive symptoms and side effects), at each time-point.

RESULTS

Time had a significant effect on scores when controlling for reason; average scores on each subscale were higher at baseline than at 3 months and 12 months. At each time-point, patients endorsed 'enhancement' followed by 'coping with unpleasant affect' and 'social motive' more highly for their cannabis use than any other reason. 'Conformity and acceptance' followed closely. 'Relief of positive symptoms and side effects' was the least endorsed motive.

CONCLUSIONS

Patients endorsed their reasons for use at 3 months and 12 months less strongly than at baseline. Little support for the self-medication or alleviation of dysphoria models was found. Rather, patients rated 'enhancement' most highly for their cannabis use.

Differences between patients with schizophrenia with and without co-occurring methamphetamine use disorders in a Taiwanese public psychiatric hospital

This study aimed to examine the factors related to and the outcomes of schizophrenic patients with co-occurring methamphetamine use disorders (MUDs). All schizophrenic patients discharged from a psychiatric hospital between January 1, 2006, and December 31, 2006, were monitored. This study compared the important demographic and clinical variables between patients with co-occurring MUDs and those without, and postdischarge measured time to rehospitalization during a 1-year period. Seven hundred fifty-six patients were included in this study. Of these patients, 88 (11.6%) reported the use of methamphetamine. Univariate analyses indicated that male sex, low educational level, discharge against medical advice, missed first appointment after discharge, co-occurring other illicit substance use disorder, age (younger), diazepam equivalents prescribed at discharge (higher), number of previous admissions within the past 5 years (higher), and length of hospital stay (longer) were predictive of patients with co-occurring MUDs. There were also significant differences in time to rehospitalization between these two groups during the follow-up periods. Many factors can be identified in schizophrenic patients with co-occurring MUDs. Furthermore, schizophrenic patients with co-occurring MUDs were more likely to be rehospitalized. Future studies in many different mental health systems are needed before these findings can be generalized.

Cognitive functioning associated with stimulant use in patients with non-affective psychosis, their unaffected siblings and healthy controls

BACKGROUND

Little is known about the effect of stimulant use (amphetamines, cocaine, ecstasy) on cognitive functioning in schizophrenia patients. The current study examined (1) whether recency and frequency of stimulant use is associated with cognitive functioning and (2) whether these associations differ between psychotic patients, their unaffected siblings and controls.

METHOD

Participants completed a comprehensive cognitive test battery. Stimulant use was assessed by urinalysis and by the Composite International Diagnostic Interview (CIDI). Using random effects regression models, the main effects of Stimulant Use and the interaction with Diagnostic Status on cognitive functioning were assessed.

RESULTS

The interaction term between Stimulant Use and Diagnostic Status was not significant for any of the cognitive outcome variables, indicating similar effects of stimulant use in all three groups. Recent stimulant users showed more errors deficit in verbal learning in comparison to never users (Cohen's d = -0.60, p < 0.005). Lifetime frequent stimulant use was significantly associated with worse immediate and delayed verbal recall, working memory and acquired knowledge (Cohen's d = -0.22 to -0.29, p < 0.005). Lifetime infrequent stimulant use was not associated with significant cognitive alterations in comparison to never use.

CONCLUSIONS

The presence of cognitive deficits associated with lifetime stimulant use is dependent on the frequency of use, with no observed deficits in infrequent users and modest negative effects in frequent users.

Systematic meta-analysis of outcomes associated with psychosis and co-morbid substance use

OBJECTIVE

To compare the symptoms and social function of patients with psychosis and current substance use to those with psychosis and no history of substance use.

METHOD

The databases EMBASE, MEDLINE and PsycINFO were searched for peer-reviewed publications in English that reported the characteristics of patients with psychotic illness who were current substance users and those who had never used substances. The searches yielded 22 articles that met the inclusion criteria. Meta-analysis was used to compare four key outcome variables: positive symptoms, negative symptoms, depression and social function - and three secondary outcomes: violence, self-harm and hospital admissions.

RESULTS

Current substance-using patients were significantly younger than non-substance-using patients and were more likely to be male, but did not differ in age at onset of psychosis or in their level of education. Current substance users had higher ratings of positive symptoms and were more likely to have a history of violence. Older studies reported a stronger association between current substance use and positive symptoms than more recently published studies. Current substance users did not differ from non-users on measurements of negative symptoms, depressive symptoms, social function, self-harm, or the number of hospital admissions.

CONCLUSION

Current substance users with psychosis may have more severe positive symptoms than patients who have never used substances, but this result should be interpreted with caution because of demographic differences between substance users and non-substance users.

Stress-induced dopamine response in subjects at clinical high risk for schizophrenia with and without concurrent cannabis use

Research on the environmental risk factors for schizophrenia has focused on either psychosocial stress or drug exposure, with limited investigation of their interaction. A heightened dopaminergic stress response in patients with schizophrenia and individuals at clinical high risk (CHR) supports the dopaminergic sensitization hypothesis. Cannabis is believed to contribute to the development of schizophrenia, possibly through a cross-sensitization with stress. Twelve CHR and 12 cannabis-using CHR (CHR-CU, 11 dependent) subjects underwent [(11)C]-(+)-PHNO positron emission tomography scans, while performing a Sensorimotor Control Task (SMCT) and a stress condition (Montreal Imaging Stress task). The simplified reference tissue model was used to obtain binding potential relative to non-displaceable binding (BPND) in the whole striatum, its functional subdivisions (limbic striatum (LST), associative striatum (AST), and sensorimotor striatum (SMST)), globus pallidus (GP), and substantia nigra (SN). Changes in BPND, reflecting alterations in synaptic dopamine (DA) levels, were tested with analysis of variance. SMCT BPND was not significantly different between groups in any brain region (p>0.21). Although stress elicited a significant reduction in BPND in the CHR group, CHR-CU group exhibited an increase in BPND. Stress-induced changes in regional BPND between CHR-CU and CHR were significantly different in AST (p<0.001), LST (p=0.007), SMST (p=0.002), SN (p=0.021), and whole striatum (p=0.001), with trend level in the GP (p=0.099). All subjects experienced an increase in positive (attenuated) psychotic symptoms (p=0.001) following the stress task. Our results suggest altered DA stress reactivity in CHR subjects who concurrently use cannabis, as compared with CHR subjects. Our finding does not support the cross-sensitization hypothesis, which posits greater dopaminergic reactivity to stress in CHR cannabis users, but adds to the growing body of literature showing reduced DA (stress) response in addiction.

"Clozapine makes me quite drowsy, so when I wake up in the morning those first cups of coffee are really handy": an exploratory qualitative study of excessive caffeine consumption among individuals with schizophrenia

BACKGROUND

Research has shown that individuals with schizophrenia use caffeine at higher rates than the general population; however, no qualitative research has been undertaken investigating problematic caffeine use and its effects on this population. This article explores the role of caffeine consumption in the lives of people with schizophrenia through a narrative analysis of the attitudes and beliefs associated with this practice, and how these, in turn, influence caffeine consumption.

METHODS

A qualitative study was undertaken with individuals who had previously scored in either a 'moderate' or 'high' risk category for caffeine use on the Alcohol, Smoking and Substance Involvement Screening Tool (ASSIST). In-depth interviews were undertaken with 20 individuals, and transcripts were analysed thematically to identify prominent perspectives.

RESULTS

Consistent with previous literature, participants' caffeine consumption was driven largely by its stimulating properties; however, participants also identified 'cravings' as an important motivating factor. Participants' behaviours related to caffeine consumption seemed to be tempered by their previous experiences of consumption; if participants had experienced positive effects such as alertness or relaxation in the past, their use was maintained at a similar level or increased. Conversely, participants who anticipated negative consequences often altered their patterns of caffeine consumption; for example, by substituting caffeinated drinks that minimised or ceased their experience of negative side effects for those that directly caused such impacts. Overall, participants largely identified caffeine consumption as a highly meaningful activity, which provided structure to their day and facilitated opportunities for social interaction.

CONCLUSIONS

The inconsistencies between individuals' beliefs about their health and the actual risk of harm associated with health-related behaviours present significant and ongoing challenges for the implementation of relevant and effective strategies for health promotion among individuals diagnosed with mental illness. As a starting point, it would be worthwhile for services engaging with people diagnosed with mental illness, and in particular schizophrenia, to consider implementing caffeine-related health literacy strategies to educate consumers about the risk of excessive caffeine consumption and the interactions between caffeine and antipsychotic medications.