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Blackman G, Dadwal AK, Teixeira-Dias M, Ffytche D. The association between visual hallucinations and secondary psychosis: a systematic review and meta-analysis. Cogn Neuropsychiatry 2023; 28:391-405. [PMID: 37922514 DOI: 10.1080/13546805.2023.2266872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 09/28/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Visual hallucinations are often considered to be suggestive of a secondary cause of psychosis, however, this association has never been assessed meta-analytically. We aimed to compare the presence of visual hallucinations in patients with psychosis due to a primary or secondary cause. METHOD We conducted a meta-analysis of case-control studies directly comparing primary and secondary psychosis. A random-effects model, following the DerSimonian and Laird method, was used to pool studies and generate overall odds ratios (OR), 95% confidence intervals (CI) and prediction intervals (PI). RESULTS Fourteen studies (904 primary and 804 secondary psychosis patients) were included. Visual hallucinations were significantly associated with secondary psychosis (OR = 3.0, 95% CI = 1.7-5.1, p < 0.001) with moderate between-study heterogeneity (I2 = 70%). Subgroup analysis by type of secondary psychosis (organic, drug-induced, mixed) was non-significant. Analysis of the content of visual hallucinations (51 primary and 142 secondary psychosis patients) found hallucinations of inanimate objects were significantly more likely to be associated with secondary psychosis (OR = 0.1, 95% CI = 0.01-0.8, p = 0.03). CONCLUSIONS Visual hallucinations were strongly associated with a secondary cause of psychosis. The presence of visual hallucinations in a patient presenting with psychosis may serve as a potential "red flag" for a secondary cause and warrant further investigation.
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Affiliation(s)
- Graham Blackman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Amber Kaur Dadwal
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maria Teixeira-Dias
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dominic Ffytche
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Visual Perceptual Disorder Clinic, South London and Maudsley NHS Foundation Trust, London, UK
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Shah R, Ghosh A, Avasthi A, Ahuja CK, Khandelwal N, Nehra R. White Matter Microstructure and Gray Matter Volume in Cannabis-Induced Psychosis and Schizophrenia With Cannabis Use. J Neuropsychiatry Clin Neurosci 2022; 34:406-413. [PMID: 35872614 DOI: 10.1176/appi.neuropsych.21070172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study explored the differences in white matter (WM) microstructural integrity and gray matter (GM) volume between cannabis-induced psychosis (CIP) and schizophrenia with cannabis use (SZC). METHODS This cross-sectional study with convenience sampling involved three groups of 20 participants each (CIP, SZC, and a control group without substance use), matched on age, handedness, and education. CIP and SZC were diagnosed with the Psychiatric Research Interview for Substance and Mental Disorders. Diffusion tensor and kurtosis imaging were done, and fractional anisotropy (FA), mean diffusivity, and mean kurtosis were estimated. GM volume was measured with voxel-based morphometry. RESULTS Group comparisons revealed comparable age at initiation and duration and frequency of cannabis use between participants in the SZC and CIP groups. Participants with SZC had lower FA than controls in the anterior and retrolenticular internal capsule limbs, cingulate gyrus hippocampal formation, fornix, and superior fronto-occipital fasciculus (all p<0.05). Participants with CIP had lower FA than controls in the left fornix and right superior fronto-occipital fasciculus but higher FA than those with SZC in the left corticospinal tract (all p<0.05). On morphometry, participants with CIP had greater cerebellar GM volume than those with SZC and greater inferior frontal gyrus volumes than controls (all p<0.05). CONCLUSIONS Widespread WM microstructural abnormalities were observed in participants with SZC, and fewer but significant WM disruptions were observed in those with CIP. Better WM integrity in some WM fiber tracts and greater GM volumes in crucial brain areas among those with CIP may have prevented the transition to schizophrenia.
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Affiliation(s)
- Raghav Shah
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Abhishek Ghosh
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ajit Avasthi
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Chirag K Ahuja
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Niranjan Khandelwal
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritu Nehra
- Department of Psychiatry (Shah, Ghosh, Avasthi, Nehra) and Department of Radiodiagnosis and Imaging (Ahuja, Khandelwal), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Argote M, Sescousse G, Brunelin J, Fakra E, Nourredine M, Rolland B. Association between formal thought disorder and cannabis use: a systematic review and meta-analysis. SCHIZOPHRENIA 2022; 8:78. [PMID: 36175509 PMCID: PMC9523063 DOI: 10.1038/s41537-022-00286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/10/2022] [Indexed: 10/26/2022]
Abstract
AbstractFormal thought disorder (FTD) is a multidimensional syndrome mainly occurring along the psychosis continuum. Cannabis use is known to increase symptoms of psychosis, particularly positive symptoms. However, the impact of cannabis use on FTD in individuals presenting symptoms along the psychosis continuum remains unclear. To address this knowledge gap, we conducted a meta-analysis examining the association between cannabis use and FTD in those individuals. We hypothesized that cannabis would worsen FTD. We conducted a systematic search of the PubMed, ScienceDirect, PsycINFO, Web of Science, Embase and Google Scholar databases up to July 2022. The results were collated through a random-effects model using the statistical software R. Reference lists of included studies were searched for additional relevant publications. Nineteen studies were included, totalling 1840 cannabis users and 3351 non-cannabis users. The severity of FTD was found to be higher in cannabis users (SMD = 0.21, 95%CI [0.12–0.29], p = 0.00009). Subgroup analyses revealed that FTD severity was increased among cannabis users, regardless of the disorder severity: healthy individuals (SMD = 0.19, 95%CI [0.05–0.33], p = 0.02); patients with first-episode psychosis (SMD = 0.21, 95%CI [0.01–0.41], p = 0.04); patients with schizophrenia (SMD = 0.25, 95%CI [0.11–0.38], p = 0.005). Between-group differences were not significant. In line with its already known effect on positive symptoms in psychosis, cannabis use appears to be associated with increased FTD severity all along the psychosis continuum. Future research should consider potential confounding variables such as other substance use disorders and explore how FTD dimensions are impacted by cannabis use.
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Padhi D, Shukla P, Chaudhury S. Sociodemographic and clinical profile of cannabis-induced psychosis: A comparative study. Ind Psychiatry J 2021; 30:S132-S139. [PMID: 34908679 PMCID: PMC8611598 DOI: 10.4103/0972-6748.328804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/19/2021] [Accepted: 05/27/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Cannabis is the most widely used drug in the world. An association between cannabis use and mental illness, in particular psychotic illness, was recognized since long. Various cultures have traditionally used cannabis for different purposes, and continuous increasing use of cannabis is promoting psychosis also. AIM The present study has tried to identify the differences in profile between the two groups and thus proposing possible variables underlying cannabis and psychosis. MATERIALS AND METHODS This cross-sectional descriptive hospital-based study included 50 consecutive cannabis-using patients with psychosis and equal number of age-matched patients with schizophrenia but no cannabis intake. Permission was taken from the institutional ethics committee. All subjects gave written informed consent. Detailed history regarding psychotic symptoms and different parameters of cannabis use were collected from the key informant as well as the patients in the ward. Both the groups' psychotic symptoms were assessed using scale for assessment of the positive symptoms. RESULTS There is no significant difference between both the groups with respect to age. Cannabis-using patients with psychosis showed high symptomatology in the areas of pressure of speech, distractible speech, and clanging. On the other hand, patients with schizophrenia but no cannabis intake showed high symptomatology in the areas of derailment, incoherence, illogicality, and global rating of positive formal thought disorder. CONCLUSION Continuous heavy use of cannabis can induce a psychotic disorder distinct from acute schizophrenia. Cannabis-induced psychosis has distinct demographic, premorbid, and clinical features.
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Affiliation(s)
- Debasish Padhi
- Department of Psychiatry, Rama Medical College, Kanpur, Uttar Pradesh, India
| | - Priyanka Shukla
- Department of Psychology, CSJM University, Kanpur, Uttar Pradesh, India
| | - Suprakash Chaudhury
- Department of Psychiatry, Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil University, Pune, Maharashtra, India
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Hirjak D, Meyer-Lindenberg A, Brandt GA, Dreßing H. [Differential diagnostic distinction between substance-induced and primary psychoses: : Recommendations for general psychiatric and forensic practice]. DER NERVENARZT 2021; 93:11-23. [PMID: 33656571 PMCID: PMC8763934 DOI: 10.1007/s00115-021-01083-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
Substanzinduzierte psychotische Störungen (SIPS) sind häufig und für ca. 25 % der ersten Einweisungen in eine psychiatrische Klinik verantwortlich. Aus klinischer Sicht ist aufgrund ähnlicher psychopathologischer Phänomene die diagnostische Unterscheidung zwischen SIPS und primären (genuinen oder kryptogenen) psychotischen Störungen oft eine Herausforderung. Dieser Umstand wird dadurch erschwert, dass SIPS im Zusammenhang mit Cannabis, Halluzinogenen und Amphetaminen ein erhebliches Risiko des Übergangs in eine primäre psychotische Störung (z. B. Schizophrenie) haben. Im ersten Abschnitt dieser Arbeit werden zunächst zwei exemplarische Fallvignetten aus der allgemeinpsychiatrischen und forensischen Praxis vorgestellt. Danach wird im Sinne einer selektiven Literaturübersicht die Relevanz der differenzialdiagnostischen Unterscheidung beider Störungsbilder aus der Sicht der allgemeinen und forensischen Psychiatrie in Bezug auf Therapie, Prognose und richterliche Entscheidung bezüglich der Unterbringung im Maßregelvollzug (§ 63 vs. § 64 StGB) beleuchtet. Der letzte Abschnitt hat das Ziel, ein strukturiertes Vorgehen zur differenzialdiagnostischen Unterscheidung zwischen SIPS und primären psychotischen Störungen zu erarbeiten. Die in dieser Arbeit dargestellten und diskutierten Konzepte und Befunde sollen klinisch tätigen Psychiatern und Psychologen die Diagnosestellung im allgemeinen und forensischen Kontext erleichtern.
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Affiliation(s)
- Dusan Hirjak
- Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, 68159, Mannheim, Deutschland.
| | - Andreas Meyer-Lindenberg
- Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, 68159, Mannheim, Deutschland
| | - Geva A Brandt
- Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, 68159, Mannheim, Deutschland
| | - Harald Dreßing
- Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, 68159, Mannheim, Deutschland
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Maremmani AGI, Pacini M, Maremmani I. What we have learned from the Methadone Maintenance Treatment of Dual Disorder Heroin Use Disorder patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E447. [PMID: 30717435 PMCID: PMC6388207 DOI: 10.3390/ijerph16030447] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/22/2022]
Abstract
Mental Disorders and Heroin Use Disorder (HUD) often co-occur and constitute correlated risk factors that the authors believe are best considered from a unitary perspective. In this article we review and discuss data collected by the V.P. Dole Research Group in Dual Disorder (V.P. Dole DD-RG) patients according to the following six discussion points: (1) Treatment of personality disorders during Methadone Maintenance Treatment (MMT); (2) Treatment of Mood Disorders during MMT; (3) Treatment of Anxiety Disorders during MMT; (4) Treatment of Psychotic Disorders during MMT; (5) Treatment of violence during MMT; (6) Treatment of Alcohol Use Disorder (AUD) during MMT. In treating Mood Disorder in HUD patients, we must bear in mind the interactions (potentiation and side effects) between psychopharmacology, used substances and agonist opioid medications; the use of psychiatric medications as an anti-craving drug, and the possible use of agonist and antagonist opioid medications in treating the other mental disorders. In treating chronic psychosis in HUD patients, we must consider the potentiation and side effects of antipsychotic drugs consequent on HUD treatment, worsening addiction hypophoria and inducing a more severe reward deficiency syndrome (RDS) in hypophoric patients. Violence and AUD during MMT can benefit from adequate dosages of methadone and co-medication with Sodium gamma-hydroxybutyrate (GHB). The experience of our V.P. Dole DD-RG suggests the following: (a) DD is the new paradigm in neuroscience in deepening our understanding of mental health; (b) To successfully treat DD patients a double competence is needed; (c) In managing DD patients priority must be given to Substance Use Disorder (SUD) treatment (stabilizing patients); (d) Antidepressant use is ancillary to SUD treatment; antipsychotic use must be restricted to acute phases; mood stabilizers must be preferred; any use of Benzodiazepines (BDZs) must be avoided.
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Affiliation(s)
- Angelo G I Maremmani
- Department of Psychiatry, North-Western Tuscany Region NHS Local Health Unit, Versilia Zone, 55049 Viareggio, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
- G. De Lisio, Institute of Behavioral Sciences, 56127 Pisa, Italy.
| | - Matteo Pacini
- G. De Lisio, Institute of Behavioral Sciences, 56127 Pisa, Italy.
| | - Icro Maremmani
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
- G. De Lisio, Institute of Behavioral Sciences, 56127 Pisa, Italy.
- V.P. Dole Dual Disorder Unit, 2nd Psychiatric Unit, Santa Chiara University Hospital, University of Pisa, 56126 Pisa, Italy.
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Singh S, Balhara YPS. A review of Indian research on co-occurring cannabis use disorders& psychiatric disorders. Indian J Med Res 2018; 146:186-195. [PMID: 29265019 PMCID: PMC5761028 DOI: 10.4103/ijmr.ijmr_791_15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND & OBJECTIVES Cannabis is a widely used illicit drug and its use is often associated with co-occurring psychiatric disorders. This systematic review was aimed to provide information on the published Indian studies on co-occurring cannabis use disorders and psychiatric disorders. METHODS An electronic search of available Indian literature using relevant search terms was carried out in May 2015 and 52 articles in English language published from India were included in the current review. RESULTS Studies on cannabis and associated psychotic disorders (n=16) chiefly described acute episodes with predominant positive symptoms, following cannabis use. Some studies (n=6) observed an overall increased prevalence of all psychiatric disorders and symptoms owing to cannabis use, while others (n=14) elaborated on high rates of substance use in those with psychiatric disorders. The effect of cannabis use on cognitive function was the focus of some of the Indian studies (n=7). All these studies barring one had all male subjects, and a single study described the service delivery model for those with dual diagnosis disorders in India. Most of the research used cross-sectional observational design and focussed on treatment-seeking population. INTERPRETATION & CONCLUSIONS A review of Indian literature on cannabis use and its association with psychiatric disorders indicates a high co-prevalence of psychotic disorders, especially in vulnerable individuals as well as high rates of co-occurrence of other psychiatric comorbidities. However, there is limited focus on exploring the aetiological association between cannabis use and psychiatric disorders; understanding the neurobiology of this association and management-related issues.
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Affiliation(s)
- Shalini Singh
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Yatan Pal Singh Balhara
- Department of Psychiatry; National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Wilson L, Szigeti A, Kearney A, Clarke M. Clinical characteristics of primary psychotic disorders with concurrent substance abuse and substance-induced psychotic disorders: A systematic review. Schizophr Res 2018; 197:78-86. [PMID: 29117908 DOI: 10.1016/j.schres.2017.11.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Distinguishing between a primary psychotic disorder with concurrent substance abuse (PPD+SA) and a substance-induced psychotic disorder (SIPD) can be diagnostically challenging. We aimed to determine if these two diagnoses are clinically distinct, particularly in relation to psychopathology. In addition, we aimed to examine the specific clinical features of cannabis-induced psychotic disorder (CIPD) as compared to primary psychotic disorder with concurrent cannabis abuse (PPD+CA) and also to SIPD associated with any substance. METHODS A systematic review of SIPD literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Using strict inclusion criteria, a total of six studies examining SIPD were included in the review (two of which only considered psychosis induced by cannabis alone). The findings did not reveal many consistent differences in psychopathology. However, we did find that that compared to PPD+SA, individuals with SIPD have a weaker family history of psychotic disorder; a greater degree of insight; fewer positive symptoms and fewer negative symptoms; more depression (only in CIPD) and more anxiety. CONCLUSION There remains a striking paucity of information on the psychopathology, clinical characteristics and outcome of SIPD. Our review highlights the need for further research in this area.
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Affiliation(s)
- Lorna Wilson
- Cluain Mhuire Community Mental Health Service, Newtownpark Avenue, Blackrock, Dublin, Ireland.
| | - Attila Szigeti
- DETECT Early Intervention in Psychosis Service, Avila House, Carysfort Avenue, Blackrock Business Park, Dublin, Ireland
| | | | - Mary Clarke
- DETECT Early Intervention in Psychosis Service, Avila House, Carysfort Avenue, Blackrock Business Park, Dublin, Ireland
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Hanna RC, Perez JM, Ghose S. Cannabis and development of dual diagnoses: A literature review. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 43:442-455. [PMID: 27612527 DOI: 10.1080/00952990.2016.1213273] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of cannabis has garnered more attention recently with ongoing efforts at marijuana legalization. The consequences of cannabis use are not clearly understood and remain a concern. OBJECTIVES To review the acute and persistent effects of cannabis use and associations with psychiatric disorders. METHODS Using Pubmed and PsychInfo, we conducted a narrative review of the literature on cannabis and psychiatric comorbidity using the keywords cannab*, marijuana, schizo*, psychosis, mood, depression, mania, bipolar, and anxiety. RESULTS There is substantial evidence of cannabis use leading to other illicit drug use and of an association between cannabis use and psychosis. A few reports suggest an association with bipolar disorder while the association with depression and anxiety disorders is mixed. CONCLUSIONS Whenever an association is observed between cannabis use and psychiatric disorders, the relationship is generally an adverse one. Age at the time of cannabis use appears to be an important factor with stronger associations observed between adolescent onset cannabis use and later onset of psychiatric disorders. Additional studies taking into account potential confounds (such as withdrawal symptoms, periods of abstinence, and other substance use) and moderators (such as age of initiation of cannabis use, the amount and frequency of drug use, prior history of childhood maltreatment, and gender) are needed to better understand the psychiatric consequences of cannabis use.
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Affiliation(s)
- Rebecca C Hanna
- a Department of Psychiatry , UT Southwestern , Dallas , TX , USA
| | - Jessica M Perez
- a Department of Psychiatry , UT Southwestern , Dallas , TX , USA
| | - Subroto Ghose
- a Department of Psychiatry , UT Southwestern , Dallas , TX , USA
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Schoeler T, Monk A, Sami MB, Klamerus E, Foglia E, Brown R, Camuri G, Altamura AC, Murray R, Bhattacharyya S. Continued versus discontinued cannabis use in patients with psychosis: a systematic review and meta-analysis. Lancet Psychiatry 2016; 3:215-25. [PMID: 26777297 DOI: 10.1016/s2215-0366(15)00363-6] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/17/2015] [Accepted: 07/23/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Although the link between cannabis use and development of psychosis is well established, less is known about the effect of continued versus discontinued cannabis use after the onset of psychosis. We aimed to summarise available evidence focusing on the relationship between continued and discontinued cannabis use after onset of psychosis and its relapse. METHODS In this systematic review and meta-analysis, we searched MEDLINE for articles published in any language from the database inception date up until April 21, 2015 that included a sample of patients with a pre-existing psychotic disorder with a follow-up duration of at least 6 months. We used a combination of search terms for describing cannabis, the outcome of interest (relapse of psychosis), and the study population. We excluded studies if continued cannabis use or discontinued cannabis use could not be established. We compared relapse outcomes between those who continued (CC) or discontinued (DC) cannabis use or were non-users (NC). We used summary data (individual patient data were not sought out) to estimate Cohen's d, which was entered into random effects models (REM) to compare CC with NC, CC with DC, and DC with NC. Meta-regression and sensitivity analyses were used to address the issue of heterogeneity. FINDINGS Of 1903 citations identified, 24 studies (16 565 participants) met the inclusion criteria. Independent of the stage of illness, continued cannabis users had a greater increase in relapse of psychosis than did both non-users (dCC-NC=0·36, 95% CI 0·22-0·50, p<0·0001) and discontinued users (dCC-DC=0·28, 0·12-0·44, p=0·0005), as well as longer hospital admissions than non-users (dCC-NC=0·36, 0·13 to 0·58, p=0·02). By contrast, cannabis discontinuation was not associated with relapse (dDC-NC=0·02, -0·12 to 0·15; p=0·82). Meta-regression suggested greater effects of continued cannabis use than discontinued use on relapse (dCC-NC=0·36 vs dDC-NC=0·02, p=0·04), positive symptoms (dCC-NC=0·15 vs dDC-NC=-0·30, p=0·05) and level of functioning (dCC-NC=0·04 vs dDC-NC=-0·49, p=0·008) but not on negative symptoms (dCC-NC=-0·09 vs dDC-NC=-0·31, p=0·41). INTERPRETATION Continued cannabis use after onset of psychosis predicts adverse outcome, including higher relapse rates, longer hospital admissions, and more severe positive symptoms than for individuals who discontinue cannabis use and those who are non-users. These findings point to reductions in cannabis use as a crucial interventional target to improve outcome in patients with psychosis. FUNDING UK National Institute of Health Research.
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Affiliation(s)
- Tabea Schoeler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anna Monk
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Musa B Sami
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ewa Klamerus
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Enrico Foglia
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ruth Brown
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Giulia Camuri
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Robin Murray
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sagnik Bhattacharyya
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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Håkansson A, Johansson BA. Atypical course in severe catatonic schizophrenia in a cannabis-dependent male adolescent: a case report. J Med Case Rep 2015; 9:200. [PMID: 26388066 PMCID: PMC4576396 DOI: 10.1186/s13256-015-0678-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 08/18/2015] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Adolescents with psychoses usually have full recovery from their first psychotic episode, but the first relapse often arises within 2 years of the first episode. Cannabis-related psychoses are difficult to distinguish from schizophrenic psychoses. Here, we describe a particularly severe clinical case, with a first psychotic episode occurring after heavy cannabis smoking, an atypically long symptom-free duration, and a subsequent non-substance-related episode. CASE PRESENTATION A 17-year-old male adolescent of Middle-East origin presented with delusions and hallucinations after extensive cannabis smoking. His first psychotic episode, with paranoid delusions and hallucinations, progressed into severe catatonic symptoms. His symptoms were treated with electroconvulsive therapy and risperidone and he was transferred to a residential substance abuse treatment center. He remained drug-free and non-psychotic for 3.5 years. Given the temporal association with extensive cannabis use, and his full remission of symptoms lasting several years, a cannabis-induced psychosis-though atypically extended-could be suspected. However, after 3.5 years without psychiatric care, and in a drug-free state, our patient again presented with positive psychotic symptoms, possibly induced by a period of severe psychosocial stress. CONCLUSION We here discuss whether a primary schizophrenic episode possibly induced by cannabis can increase the risk of subsequent non-drug-related schizophrenic episodes.
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Affiliation(s)
- Anders Håkansson
- Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, Malmö Addiction Centre, Södra Förstadsgatan 35, Malmö, S-205 02, Sweden.
| | - Björn Axel Johansson
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Malmö, Sweden.
- Office for Healthcare 'Sund', Child & Adolescent Psychiatry, Regional Inpatient Care, Emergency Unit, Malmö, Sweden.
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Soares-Weiser K, Maayan N, Bergman H, Davenport C, Kirkham AJ, Grabowski S, Adams CE. First rank symptoms for schizophrenia. Cochrane Database Syst Rev 2015; 1:CD010653. [PMID: 25879096 PMCID: PMC7079421 DOI: 10.1002/14651858.cd010653.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Early and accurate diagnosis and treatment of schizophrenia may have long-term advantages for the patient; the longer psychosis goes untreated the more severe the repercussions for relapse and recovery. If the correct diagnosis is not schizophrenia, but another psychotic disorder with some symptoms similar to schizophrenia, appropriate treatment might be delayed, with possible severe repercussions for the person involved and their family. There is widespread uncertainty about the diagnostic accuracy of First Rank Symptoms (FRS); we examined whether they are a useful diagnostic tool to differentiate schizophrenia from other psychotic disorders. OBJECTIVES To determine the diagnostic accuracy of one or multiple FRS for diagnosing schizophrenia, verified by clinical history and examination by a qualified professional (e.g. psychiatrists, nurses, social workers), with or without the use of operational criteria and checklists, in people thought to have non-organic psychotic symptoms. SEARCH METHODS We conducted searches in MEDLINE, EMBASE, and PsycInfo using OvidSP in April, June, July 2011 and December 2012. We also searched MEDION in December 2013. SELECTION CRITERIA We selected studies that consecutively enrolled or randomly selected adults and adolescents with symptoms of psychosis, and assessed the diagnostic accuracy of FRS for schizophrenia compared to history and clinical examination performed by a qualified professional, which may or may not involve the use of symptom checklists or based on operational criteria such as ICD and DSM. DATA COLLECTION AND ANALYSIS Two review authors independently screened all references for inclusion. Risk of bias in included studies were assessed using the QUADAS-2 instrument. We recorded the number of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) for constructing a 2 x 2 table for each study or derived 2 x 2 data from reported summary statistics such as sensitivity, specificity, and/or likelihood ratios. MAIN RESULTS We included 21 studies with a total of 6253 participants (5515 were included in the analysis). Studies were conducted from 1974 to 2011, with 80% of the studies conducted in the 1970's, 1980's or 1990's. Most studies did not report study methods sufficiently and many had high applicability concerns. In 20 studies, FRS differentiated schizophrenia from all other diagnoses with a sensitivity of 57% (50.4% to 63.3%), and a specificity of 81.4% (74% to 87.1%) In seven studies, FRS differentiated schizophrenia from non-psychotic mental health disorders with a sensitivity of 61.8% (51.7% to 71%) and a specificity of 94.1% (88% to 97.2%). In sixteen studies, FRS differentiated schizophrenia from other types of psychosis with a sensitivity of 58% (50.3% to 65.3%) and a specificity of 74.7% (65.2% to 82.3%). AUTHORS' CONCLUSIONS The synthesis of old studies of limited quality in this review indicates that FRS correctly identifies people with schizophrenia 75% to 95% of the time. The use of FRS to diagnose schizophrenia in triage will incorrectly diagnose around five to 19 people in every 100 who have FRS as having schizophrenia and specialists will not agree with this diagnosis. These people will still merit specialist assessment and help due to the severity of disturbance in their behaviour and mental state. Again, with a sensitivity of FRS of 60%, reliance on FRS to diagnose schizophrenia in triage will not correctly diagnose around 40% of people that specialists will consider to have schizophrenia. Some of these people may experience a delay in getting appropriate treatment. Others, whom specialists will consider to have schizophrenia, could be prematurely discharged from care, if triage relies on the presence of FRS to diagnose schizophrenia. Empathetic, considerate use of FRS as a diagnostic aid - with known limitations - should avoid a good proportion of these errors.We hope that newer tests - to be included in future Cochrane reviews - will show better results. However, symptoms of first rank can still be helpful where newer tests are not available - a situation which applies to the initial screening of most people with suspected schizophrenia. FRS remain a simple, quick and useful clinical indicator for an illness of enormous clinical variability.
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Affiliation(s)
- Karla Soares-Weiser
- Enhance Reviews Ltd, Central Office, Cobweb Buildings, The Lane, Lyford, Wantage, OX12 0EE, UK. .
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Wilkinson ST, Radhakrishnan R, D'Souza DC. Impact of Cannabis Use on the Development of Psychotic Disorders. CURRENT ADDICTION REPORTS 2014; 1:115-128. [PMID: 25767748 DOI: 10.1007/s40429-014-0018-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The link between cannabis use and psychosis comprises three distinct relationships: acute psychosis associated with cannabis intoxication, acute psychosis that lasts beyond the period of acute intoxication, and persistent psychosis not time-locked to exposure. Experimental studies reveal that cannabis, tetrahydrocannabinol (THC) and synthetic cannabinoids reliably produce transient positive, negative, and cognitive symptoms in healthy volunteers. Case-studies indicate that cannabinoids can induce acute psychosis which lasts beyond the period of acute intoxication but resolves within a month. Exposure to cannabis in adolescence is associated with a risk for later psychotic disorder in adulthood; this association is consistent, temporally related, shows a dose-response, and is biologically plausible. However, cannabis is neither necessary nor sufficient to cause a persistent psychotic disorder. More likely it is a component cause that interacts with other factors to result in psychosis. The link between cannabis and psychosis is moderated by age at onset of cannabis use, childhood abuse and genetic vulnerability. While more research is needed to better characterize the relationship between cannabinoid use and the onset and persistence of psychosis, clinicians should be mindful of the potential risk of psychosis especially in vulnerable populations, including adolescents and those with a psychosis diathesis.
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Affiliation(s)
- Samuel T Wilkinson
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Rajiv Radhakrishnan
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Deepak Cyril D'Souza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA ; Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA ; Schizophrenia and Neuropharmacology Research Group, VA Connecticut Healthcare System, West Haven, CT, USA
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Radhakrishnan R, Wilkinson ST, D'Souza DC. Gone to Pot - A Review of the Association between Cannabis and Psychosis. Front Psychiatry 2014; 5:54. [PMID: 24904437 PMCID: PMC4033190 DOI: 10.3389/fpsyt.2014.00054] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 05/02/2014] [Indexed: 01/01/2023] Open
Abstract
Cannabis is the most commonly used illicit drug worldwide, with ~5 million daily users worldwide. Emerging evidence supports a number of associations between cannabis and psychosis/psychotic disorders, including schizophrenia. These associations-based on case-studies, surveys, epidemiological studies, and experimental studies indicate that cannabinoids can produce acute, transient effects; acute, persistent effects; and delayed, persistent effects that recapitulate the psychopathology and psychophysiology seen in schizophrenia. Acute exposure to both cannabis and synthetic cannabinoids (Spice/K2) can produce a full range of transient psychotomimetic symptoms, cognitive deficits, and psychophysiological abnormalities that bear a striking resemblance to symptoms of schizophrenia. In individuals with an established psychotic disorder, cannabinoids can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness. Several factors appear to moderate these associations, including family history, genetic factors, history of childhood abuse, and the age at onset of cannabis use. Exposure to cannabinoids in adolescence confers a higher risk for psychosis outcomes in later life and the risk is dose-related. Individuals with polymorphisms of COMT and AKT1 genes may be at increased risk for psychotic disorders in association with cannabinoids, as are individuals with a family history of psychotic disorders or a history of childhood trauma. The relationship between cannabis and schizophrenia fulfills many but not all of the standard criteria for causality, including temporality, biological gradient, biological plausibility, experimental evidence, consistency, and coherence. At the present time, the evidence indicates that cannabis may be a component cause in the emergence of psychosis, and this warrants serious consideration from the point of view of public health policy.
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Affiliation(s)
- Rajiv Radhakrishnan
- Department of Psychiatry, Yale University School of Medicine , New Haven, CT , USA
| | - Samuel T Wilkinson
- Department of Psychiatry, Yale University School of Medicine , New Haven, CT , USA
| | - Deepak Cyril D'Souza
- Department of Psychiatry, Yale University School of Medicine , New Haven, CT , USA ; Abraham Ribicoff Research Facilities, Connecticut Mental Health Center , New Haven, CT , USA ; Schizophrenia and Neuropharmacology Research Group, VA Connecticut Healthcare System , West Haven, CT , USA
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Aggarwal M, Banerjee A, Singh SM, Mattoo SK, Basu D. Substance-induced psychotic disorders: 13-year data from a de-addiction centre and their clinical implications. Asian J Psychiatr 2012; 5:220-4. [PMID: 22981049 DOI: 10.1016/j.ajp.2011.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/15/2011] [Accepted: 11/06/2011] [Indexed: 11/28/2022]
Abstract
The relationship between substance use and psychotic disorder has been complex. Alcohol, cannabis, amphetamines, hallucinogens, and phencyclidine have been implicated as a causative factor for psychotic disorders. It is important to differentiate substance induced psychotic disorders (SIPDs) from primary psychotic disorders as management of the two conditions is different. There is paucity of research in the area of SIPD particularly from Asia. The present study was a retrospective study and it determines retrospectively the incidence rate and clinical characteristics of the SIPDs over a period of 13 years. The incidence of SIPDs was found to be 1.4% and all the subjects were males. In the present study, only alcohol and cannabis were implicated as causative agents for SIPDs. The most common type of psychosis was schizophrenia like psychosis, being more common in the cannabis group. The other forms of psychosis included delusional type, hallucinatory type and affective psychosis. 20% of the subjects had a change in diagnosis to either schizophrenia or affective psychosis on follow-up. The present study showed that the presentation of SIPDs is similar to the primary psychotic disorder and this has management implication.
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Affiliation(s)
- Munish Aggarwal
- Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
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Drake RE, Caton CL, Xie H, Hsu E, Gorroochurn P, Samet S, Hasin DS. A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis. Am J Psychiatry 2011; 168:742-8. [PMID: 21454918 PMCID: PMC3768258 DOI: 10.1176/appi.ajp.2011.10071051] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis METHOD Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations. RESULTS Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged. CONCLUSIONS Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.
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Makkos Z, Fejes L, Inczédy-Farkas G, Kassai-Farkas A, Faludi G, Lazary J. Psychopharmacological comparison of schizophrenia spectrum disorder with and without cannabis dependency. Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:212-7. [PMID: 21087649 DOI: 10.1016/j.pnpbp.2010.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 10/02/2010] [Accepted: 11/05/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although incidence of schizophrenia is higher among cannabis users and marijuana is the most common abused drug by adolescents, etiological linkage between schizophrenia and cannabis use is still not clarified. Clinical experiences suggest that regular cannabis user can show similar psychotic episode to schizophrenic disorders but it is still unclear if chronic cannabis use with schizophreniform disorder is a distinct entity requiring special therapy or it can be treated as classical schizophrenia. There are no data available on the comparison of pharmacotherapy between schizophreniform patients with and without cannabis use. METHODS Clinical data of 85 patients with schizophrenia spectrum disorder were analyzed retrospectively. Cannabis use was not reported by 43 persons (Cnbs0 subgroup) and 42 patients used regularly cannabis during at least 1 year (Cnbs1 subgroup). Comparison of anamnesis, family history, social-demographic condition, positive and negative symptoms, acute and long-term therapies recorded by clinical interviews was performed with chi square tests, logistic binary regression and t-tests using SPSS 13.0 for Windows software. RESULTS Men were over-represented in cannabis dependent group while mean age was lower among them compared to Cnbs0 subgroup. Prevalence of suicidal attempt was increased in men without cannabis use (OR = 5.25, p = 0.016). Patients without cannabis use spent more time in hospital (p = 0.026) and smoking was more frequent among them (OR = 1.36, p = 0.047). The chance to get olanzapine for acute therapy and aripiprazol for long term therapy was more than two fold in Cnbs1 subgroup (OR = 2.66, OR = 3.67, respectively). However, aripiprazol was used for acute therapy with significantly lower risk in Cnbs1 subgroup (OR = 0.47, p = 0.023). Olanzapine was administered for long term therapy in a higher dose to Cnbs0 patients (p = 0.040). Also higher dose of risperidon LAI was used in women without cannabis dependency compared to women of Cnbs1 subgroup (p=0.020). Positive and negative symptoms and family history did not differ significantly between the two subgroups. CONCLUSION Although symptom profile was similar, hospitalization time, suicidal anamnesis, smoking habit and also dosage, intensity and lasting of therapy were different between the two subgroups. Further prospective studies are required for the investigation of the clinical and molecular background of this discrepancy in order to determine a relevant protocol of prevention and treatment of the chronic cannabis use related psychotic disorder.
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Affiliation(s)
- Zoltan Makkos
- 1st Department of Psychiatry, Nyírő Gyula Hospital, Budapest, Hungary
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Abstract
BACKGROUND The correlation between cannabis and negative mental health outcomes has been unequivocally established. Nevertheless, there is still a great need to research different dimensions of cannabis-related disorders, among which the study of cannabis-related psychosis is very important. There is a dearth of research regarding phenomenology and effect of abstinence, particularly from India. This study attempts to research the clinical presentation of cannabis-related psychosis and effect of abstinence. AIM The aim of the present study was to document the clinical presentation of cannabis-related psychosis at presentation and after 7 days' abstinence from cannabis. MATERIALS AND METHODS Subjects with psychosis following cannabis use without any other prior or concurrent psychiatric disorder presenting to the outpatient department of a large tertiary care hospital were consecutively recruited for study. They were observed in a drug-free, protected environment for 7 days, during which clinical features were recorded using the Brief Psychiatric Rating Scale (BPRS). RESULTS Twenty male subjects were recruited and phenomenology was evaluated on the BPRS. Items with highest frequencies were unusual thought content (100%), excitement (75%), grandiosity (75%), hallucinatory behavior (70%) and uncooperativeness (65%). The least common symptoms were anxiety (5%), guilt feeling (5%), depressive mood (10%), motor retardation (10%) and blunted affect (30%). Nine subjects (45%) presented with cognitive dysfunction. Affective psychosis was the predominant diagnosis. At the end of 1 week of abstinence from cannabis, there was a significant decrease in scores. Significant improvement was observed in cognitive dysfunction, conceptual disorganization, grandiosity, tension, hostility, hallucinatory behavior and excitement. CONCLUSIONS Cannabis-related psychosis presented with a predominantly affective psychosis and prominent thought disorder, excitement and violence. All subjects showed improvement in symptoms with abstinence from cannabis. A small heterogeneous sample and short duration of observation were the important limitations of this study.
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Affiliation(s)
- Vani Kulhalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029, India
| | - Mohan Isaac
- Community, Culture and Mental Health Unit, School of Psychiatry and Clinical Neurosciences, University of Western Australia, Freemantle, WA 6160
| | - Pratima Murthy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029, India
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Abstract
Recent epidemiological studies and advances in understanding of brain cannabinoid function have renewed interest in the long-recognized association between cannabinoids and psychosis. This chapter presents evidence supporting and refuting the association between cannabinoids and psychosis. Cannabinoids can induce acute transient psychotic symptoms or an acute psychosis in some individuals. What makes some individuals vulnerable to cannabinoid-related psychosis is unclear. Also clear is that cannabinoids can also exacerbate psychosis in individuals with an established psychotic disorder, and these exacerbations may last beyond the period of intoxication. Less clear is whether cannabis causes a persistent de novo psychosis. The available evidence meets many but not all the criteria for causality, including dose-response, temporality, direction, specificity, and biological plausibility. On the other hand, the large majority of individuals exposed to cannabinoids do not experience psychosis or develop schizophrenia and the rates of schizophrenia have not increased commensurate with the increase in rates of cannabis use. Similar to smoking and lung cancer, it is more likely that cannabis exposure is a component cause that interacts with other factors, for example, genetic risk, to "cause" schizophrenia. Nevertheless, in the absence of known causes of schizophrenia, the role of component causes such as cannabis exposure (exogenous hypothesis) is important and warrants further study. There is also tantalizing evidence from postmortem, neurochemical, and genetic studies suggesting CB1 receptor dysfunction (endogenous hypothesis) in schizophrenia that warrants further investigation. Further work is necessary to identify those factors that place individuals at higher risk for cannabinoid-related psychosis, to identify the biological mechanisms underlying the risks and to further study whether CB1 receptor dysfunction contributes to the pathophysiology of psychotic disorders.
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Affiliation(s)
- Deepak Cyril D'Souza
- Department of Psychiatry, Yale University School of Medicine, VA Connecticut Healthcare System, West-Haven, Connecticut 06516, USA
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Abstract
AIM To review information relevant to the question of whether substance-induced mental disorders exist and their implications. DESIGN AND METHOD This paper utilized a systematic review of manuscripts published in the English language since approximately 1970 dealing with comorbid psychiatric and substance use disorders. FINDINGS The results of any specific study depended on the definitions of comorbidity, the methods of operationalizing diagnostic criteria, the interview and protocol invoked several additional methodological issues. The results generally support the conclusion that substance use mental disorders exist, especially regarding stimulant or cannabinoid-induced psychoses, substance-induced mood disorders, as well as substance-induced anxiety conditions. CONCLUSIONS The material reviewed indicates that induced disorders are prevalent enough to contribute significantly to rates of comorbidity between substance use disorders and psychiatric conditions, and that their recognition has important treatment implications. The current literature review underscores the heterogeneous nature of comorbidity.
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Arendt M, Rosenberg R, Foldager L, Perto G, Munk-Jørgensen P. Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: follow-up study of 535 incident cases. Br J Psychiatry 2005; 187:510-5. [PMID: 16319402 DOI: 10.1192/bjp.187.6.510] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies have examined samples of people with cannabis-induced psychotic symptoms. AIMS To establish whether cannabis-induced psychotic disorders are followed by development of persistent psychotic conditions, and the timing of their onset. METHOD Data on patients treated for cannabis-induced psychotic symptoms between 1994 and 1999 were extracted from the Danish Psychiatric Central Register. Those previously treated for any psychotic symptoms were excluded. The remaining 535 patients were followed for at least 3 years. In a separate analysis, the sample was compared with people referred for schizophrenia-spectrum disorders for the first time, but who had no history of cannabis-induced psychosis. RESULTS Schizophrenia-spectrum disorders were diagnosed in 44.5% of the sample. New psychotic episodes of any type were diagnosed in 77.2%. Male gender and young age were associated with increased risk. Development of schizophrenia-spectrum disorders was often delayed, and 47.1% of patients received a diagnosis more than a year after seeking treatment for a cannabis-induced psychosis. The patients developed schizophrenia at an earlier age than people in the comparison group (males, 24.6 v. 30.7 years, females, 28.9 v. 33.1 years). CONCLUSIONS Cannabis-induced psychotic disorders are of great clinical and prognostic importance.
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Affiliation(s)
- Mikkel Arendt
- Aarhus University Hospital, Skovagervej 2, DK-824 0 Risskov, Denmark.
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Kalant H. Adverse effects of cannabis on health: an update of the literature since 1996. Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:849-63. [PMID: 15363608 DOI: 10.1016/j.pnpbp.2004.05.027] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2004] [Indexed: 10/26/2022]
Abstract
Recent research has clarified a number of important questions concerning adverse effects of cannabis on health. A causal role of acute cannabis intoxication in motor vehicle and other accidents has now been shown by the presence of measurable levels of Delta(9)-tetrahydrocannabinol (THC) in the blood of injured drivers in the absence of alcohol or other drugs, by surveys of driving under the influence of cannabis, and by significantly higher accident culpability risk of drivers using cannabis. Chronic inflammatory and precancerous changes in the airways have been demonstrated in cannabis smokers, and the most recent case-control study shows an increased risk of airways cancer that is proportional to the amount of cannabis use. Several different studies indicate that the epidemiological link between cannabis use and schizophrenia probably represents a causal role of cannabis in precipitating the onset or relapse of schizophrenia. A weaker but significant link between cannabis and depression has been found in various cohort studies, but the nature of the link is not yet clear. A large body of evidence now demonstrates that cannabis dependence, both behavioral and physical, does occur in about 7-10% of regular users, and that early onset of use, and especially of weekly or daily use, is a strong predictor of future dependence. Cognitive impairments of various types are readily demonstrable during acute cannabis intoxication, but there is no suitable evidence yet available to permit a decision as to whether long-lasting or permanent functional losses can result from chronic heavy use in adults. However, a small but growing body of evidence indicates subtle but apparently permanent effects on memory, information processing, and executive functions, in the offspring of women who used cannabis during pregnancy. In total, the evidence indicates that regular heavy use of cannabis carries significant risks for the individual user and for the health care system.
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Affiliation(s)
- Harold Kalant
- Department of Pharmacology, Medical Sciences Building, University of Toronto, Toronto, ON, Canada M5S 1A8.
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Abstract
AIM To model the impact of rising rates of cannabis use on the incidence and prevalence of psychosis under four hypotheses about the relationship between cannabis use and psychosis. METHODS The study modelled the effects on the prevalence of schizophrenia over the lifespan of cannabis in eight birth cohorts: 1940-1944, 1945-1949, 1950-1954, 1955-1959, 1960-1964, 1965-1969, 1970-1974, 1975-1979. It derived predictions as to the number of cases of schizophrenia that would be observed in these birth cohorts, given the following four hypotheses: (1) that there is a causal relationship between cannabis use and schizophrenia; (2) that cannabis use precipitates schizophrenia in vulnerable persons; (3) that cannabis use exacerbates schizophrenia; and (4) that persons with schizophrenia are more liable to become regular cannabis users. RESULTS There was a steep rise in the prevalence of cannabis use in Australia over the past 30 years and a corresponding decrease in the age of initiation of cannabis use. There was no evidence of a significant increase in the incidence of schizophrenia over the past 30 years. Data on trends the age of onset of schizophrenia did not show a clear pattern. Cannabis use among persons with schizophrenia has consistently been found to be more common than in the general population. CONCLUSIONS Cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of NSW, NSW 2052, Sydney, Australia.
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Abstract
There has been considerable debate about the reasons for the association observed between cannabis use and psychosis in both clinical and general population samples. Among the hypotheses proposed to explain the association are the following: 1) common factors explain the co-occurrence; 2 cannabis causes psychosis that would not have occurred in the absence of cannabis use; 3) cannabis precipitates psychosis among persons who were vulnerable to developing the disorders; 4) cannabis use worsens or prolongs psychosis among those who have already developed the disorder; and 5) that persons with psychosis are more likely to become regular or problematic cannabis users than persons without psychosis. This article evaluates the evidence on each of these hypotheses, including recent research on the role of the cannabinoid receptor system in schizophrenia. The evidence suggests that common factors do not explain the comorbidity between cannabis use and psychosis, and it is unlikely that cannabis use causes psychosis among persons who would otherwise not have developed the disorder. The evidence is more consistent with the hypotheses that cannabis use may precipitate psychosis among vulnerable individuals, increase the risk of relapse among those who have already developed the disorder, and may be more likely to lead to dependence in persons with schizophrenia.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia, 2502.
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Abstract
OBJECTIVE The existence of cannabis-induced psychosis (CP) remains controversial, partly because of methodological problems. We hypothesize that acute schizophrenia (AS) and CP can have distinct demographic, premorbid and clinical features. METHOD We compared 26 patients with CP to 35 with AS, after their cannabis-consumption status was confirmed by repeated urine screens. Patients with CP were assessed after at least 1 week but not more than 1 month of abstinence. Symptoms were evaluated with the Present State Examination (PSE). RESULTS In group CP, male gender, expansive mood and ideation, derealization/depersonalization, visual hallucinations, and disturbances of sensorium were more frequent than in group AS. Premorbid schizoid personality traits were more frequently associated to AS and antisocial personality traits to CP. CONCLUSION The continuous heavy use of cannabis can induce a psychotic disorder distinct from AS. These two clinical entities share some features but they differ in others.
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Affiliation(s)
- L A Núñez
- Psychiatry Service, Hospital de Navarra, Pamplona, Spain.
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