Substance abuse in first-episode schizophrenic patients: a retrospective study

Remission with or without comorbid substance use disorders in early psychosis: long-term outcome in integrated care (ACCESS III study)

Introduction

Schizophrenia-Spectrum-Disorders are associated with poor long-term outcome as well as disability and often severely affect the lives of patients and their families often from symptom onset. Up to 70% of first episode psychosis (FEP) patients suffer from comorbid substance use disorders (SUD). We aimed at studying the course of illness in FEP patients within evidence-based care, with and without comorbid SUD, to examine how decreased, remitted or persistent substance use impacted rates of a combined symptomatic and functional long-term recovery compared with patients without SUD.

Methods

ACCESS III is an integrated care model for FEP or patients in the early phase of non-affective and affective psychotic disorders. Treatment trajectories of patients, who had been in ACCESS care for 1 year, with and without SUD were compared with regard to the course of illness and quality of life using Mixed Model Repeated Measures (MMRM) and recovery rates were compared using binary logistic regression. Change in substance use was coded as either persistent, decreased/remitted or no use.

Results

ACCESS III was a prospective 1-year study (N = 120) in patients aged 12-29 years. Of these, 74 (61.6%) had a comorbid SUD at admission. There were no group differences regarding the course of illness between patients with or without comorbid SUD or between patients with a substance abuse or substance dependence. The only outcome parameter that was affected by SUD was quality of life, with larger improvement found in the group without substance use (p = 0.05) compared to persistent and remitted users. Using LOCF, 44 patients (48.9%) fulfilled recovery criteria at the endpoint; recovery did not differ based on substance use status.

Discussion

SUD and especially substance dependence are common in psychotic disorders even in FEP patients. Evidence-based integrated care led to long-term improvement in patients with comorbid SUD and rate of recovery did not differ for patients with substance use.

Correlates of substance use in a large naturalistic cohort of young people with early and emerging psychosis

BACKGROUND

Substance use remains a barrier to recovery for young people accessing early intervention services for psychosis. While correlates of use have been explored in populations experiencing a first episode of psychosis (FEP), sample sizes have been small and less research assesses cohorts at ultrahigh risk of psychosis (UHR).

METHODS

This study uses data from a naturalistic cohort including UHR and FEP participants (N = 1252) to elucidate clinical correlates of use in the past 3 months of any illicit substance, amphetamine-type stimulants (ATS), cannabis, and tobacco. Moreover, network analysis based on use of these substances and additionally alcohol, cocaine, hallucinogens, sedatives, inhalants, and opioids was completed.

RESULTS

Young people with FEP used substances at significantly higher rates than those at UHR. High concurrence of use was seen between substances. In the FEP group, participants who had used any illicit substance, ATS, and/or tobacco had increased positive symptoms and decreased negative symptoms. Young people with FEP who used cannabis had increased positive symptoms. In the UHR group, participants who had used any illicit substance, ATS, and/or cannabis in the past 3 months showed decreased negative symptoms compared to those who had not.

CONCLUSION

A distinct clinical picture of more florid positive symptoms and alleviated negative symptoms seen in those who use substances in the FEP group appears muted in the UHR cohort. Treating young people at UHR in early intervention services represents the earliest opportunity to address substance use early to improve outcomes.

Substance use Specificities in Women with Psychosis: A Critical Review

BACKGROUND

Women with schizophrenia or other psychotic disorders differ from male patients in many respects, including psychopathology, prognosis, disease course, and substance use comorbidities. Most studies performed to date to investigate the association between drug use and psychosis have not evaluated gender differences, although this has started to change in recent years.

METHODS

We briefly summarize the available evidence on gender differences in drug use and substance use disorders (SUD) in psychotic patients during the early phases of the psychotic illness and during the course of schizophrenia.

RESULTS

Substance use and SUD are both less prevalent in women, both in the general population and at all phases of the psychotic spectrum. Some studies suggest that SUD may be under diagnosed in female patients, in part due to their more vulnerable profile. Substance use, especially cannabis, may more negatively impact females, especially on the disease course and prognosis. The available data suggest that it may be more difficult to treat SUD in female patients with schizophrenia, which could negatively impact prognosis.

CONCLUSION

Women with concomitant psychotic illness and SUD comprise a highly vulnerable subgroup. This should be considered when selecting the treatment approach, especially in the early phases of the illness, to ensure better outcomes.

Association between formal thought disorder and cannabis use: a systematic review and meta-analysis

Formal 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.

Interaction of sex and cannabis in adult in vivo brain imaging studies: A systematic review

Cannabis has been shown to cause structural and functional neurocognitive changes in heavy users. Cannabis use initiation aligns with brain development trajectories; therefore, it is imperative that the potential neurological implications of cannabis use are understood. Males and females reach neurodevelopmental milestones at different rates making it necessary to consider biological sex in all cannabis and brain-based research. Through use of a systamatic review in accordance with PRISMA guidelines, we aimed to understand the interaction between biological sex and cannabis use on brain-based markers. In total, 18 articles containing a sex-based analysis of cannabis users were identified. While the majority of studies (n = 11) reported no sex by cannabis use interactions on brain-based markers, those that reported findings (n = 8) suggest females may be more susceptible to cannabis’ neurotoxic effects. Unfortunately, a large portion of the literature was excluded due to no sex-based analysis. In addition, studies that reported no sex differences often contained a reduced number of females which may result in some studies being underpowered for sex-based analyses, making it difficult to draw firm conclusions. Suggestions to improve cannabis and sex-based reseach are proposed.

The Development of a Nutrition Screening Tool for Mental Health Settings Prone to Obesity and Cardiometabolic Complications: Study Protocol for the NutriMental Screener

People living with serious mental illness (SMI) experience physical health complications at disproportionate rates to people without an SMI. Unhealthy dietary intake and disordered eating behaviors are key driving factors. There is a lack of valid nutrition-risk screening tools targeted to mental health services, and typically used nutrition-risk screening tools are not suitable for mental health services. This paper details the rationale and study protocol for development and validation of the NutriMental screener, a tool for use in clinical practice to identify service users who are at risk for common nutrition issues experienced by this population group and trigger referral to a specialist clinician. The development process includes five phases. Phase I is the development of nutrition-related domains of interest from screening tools used in mental health services. Phase II involves a literature review and service-user interviews to identify additional domains. Phase III consists of international workshops with relevant clinicians and persons with SMI to gain a consensus on questions to be included in the draft tool. Phase IV involves conducting multinational feasibility and preliminary validation studies. Phase V consists of performing formal validation studies. The development of a nutrition-risk screening tool for mental health services is a necessary step to help rectify the physical-health disparities and life-expectancy gap for people with SMI.

Risk and protective factors of relapse in patients with first-episode schizophrenia from perspectives of health professionals: a qualitative study in northeastern Thailand

Background:  Schizophrenia is a serious mental illness that can relapse after treatments. Risk and protective factors for relapse are dependent on multicultural contexts.

Objective: To identify risk and protective factors related to relapse in first-episode schizophrenia (FES) in northeastern Thailand from perspectives of health professionals.

Methods: This qualitative research collected data from 21 health professional staff members (psychiatric nurses, psychiatrists, psychologists, social workers, occupational therapists and nutritionist) of a tertiary psychiatric hospital of northeastern Thailand who had been involved in mental health care for schizophrenia for at least 5 years by in-depth interviews and group interview using semi-structured interview schedule. Content analyses was used to identify staff perception of factors that put patients at risk of relapse.

Results: Data analyses demonstrated that factors related to relapse in FES patients were drug adherence (drug discontinuation, limited access to new generation drugs, self-dose reduction and skipping medication, and poor insight), family factors (stressful circumstances and family supports), substance abuses (narcotics, addictive substances, caffeinated drinks), concurrent medical illness (insomnia, thyroid diseases, and pregnancy-related hormonal changes), and natural course of disease. 

Conclusion: Factors affecting relapse in FES was not only drug adherence. Family factors, drug abuses, and concurrent health status should be also taken into account. A comprehensive mental health care program should be developed for FES patients in the region.

A Retrospective Study of the Clinical Characteristics Associated with Alcohol and Cannabis use in Early Phase Psychosis

OBJECTIVE

Alcohol and cannabis misuse are common in patients with early phase psychosis (EPP); however, research has tended to focus primarily on cannabis misuse and EPP outcomes, with a relative lack of data on alcohol misuse. This retrospective cross-sectional EPP study investigated the relationship between cannabis, alcohol, and cannabis combined with alcohol misuse, on age, gender, psychotic, depressive and anxiety symptom severity, and social/occupational functioning, at entry to service.

METHODS

Two-hundred and sixty-four EPP patients were divided into 4 groups based on substance use measured by the Alcohol, Smoking and Substance Involvement Screening Test: (1) no to low-level cannabis and alcohol misuse (LU), (2) moderate to high alcohol misuse only (AU), (3) moderate to high cannabis misuse only (CU), and (4) moderate to high alcohol and cannabis misuse (AU + CU).

RESULTS

We found significant between group differences in age (with the AU group being the oldest and AU + CU group the youngest) as well as gender (with the CU group having the highest percentage of men). There were also group differences in positive psychotic symptoms (lowest in AU group), trait anxiety (highest in AU + CU group), and social/occupational functioning (highest in AU group). Further regression analyses revealed a particularly strong relationship between AU + CU group and trait anxiety (3-fold increased odds of clinical trait anxiety for combined misuse of alcohol and cannabis compared to non/low users).

CONCLUSIONS

This study demonstrates the unique demographic and clinical characteristics found in the EPP population at entry to care associated with alcohol and cannabis misuse both separately and in combination. This work highlights the importance of including the assessment of alcohol misuse in addition to cannabis misuse in future treatment guidelines and research.

First-episode psychosis and substance use in Nelson Mandela Bay: Findings from an acute mental health unit

Background

Use of psychoactive substances is a common finding in studies on first-episode psychosis (FEP), and this has prognostic implications. We know very little about psychoactive substance use (SU) among patients with FEP in the Eastern Cape province (EC) of South Africa (SA).

Aim

The study seeks to determine SU prevalence and associated features among inpatients with non-affective FEP in an acute mental health unit (MHU) in Nelson Mandela Bay, EC.

Setting

Researchers conducted a retrospective clinical file review of a 12-month admission cohort of patients with FEP, without a concurrent mood episode, to the Dora Nginza Hospital MHU. Information collected included SU history, psychiatric diagnoses, and demographics. Data were then subjected to statistical analysis.

Methods

Researchers conducted a retrospective clinical file review of a 12-month admission cohort of patients with FEP, without a concurrent mood episode, to the Dora Nginza Hospital MHU. Information collected included SU history, psychiatric diagnoses and demographics. Data were then subjected to statistical analysis.

Results

A total of 117 patients (86 [73.5%] males; 31 [26.5%] females) aged 18–60 years (mean 29 years) met the inclusion criteria. After controlling for missing information, 95 of 117 (81.2%) patients had a history of active or previous SU, 82 of 90 (91.1%) were single and 61 of 92 (66.3%) were unemployed. A significant association was found between SU and unemployment (p < 0.001), as well as male sex (p < 0.001). The most common substances used were cannabis (59.8%), followed by alcohol (57.3%) and stimulants (46.4%).

Conclusion

In keeping with national and international literature, the results of this study showed a high prevalence of substance use in South African patients with first-episode psychosis. The high prevalence of lifetime substance use in this cohort compared to previous studies in South Africa requires further investigation and highlights the urgent need for dual diagnosis services in the Eastern Cape province.

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.

Validation of the Brief Edinburgh Depression Scale (BEDS) in a Mexican population with advanced cancer in a palliative care service

OBJECTIVE

Depression in palliative advanced cancer patients is common, but often goes unrecognized. One of the first steps toward improving detection is the development of tools that are valid in the specific language and setting in which they are to be used. The Brief Edinburgh Depression Scale (BEDS) is a sensitive case-finding tool for depression in advanced cancer patients that was developed in the United Kingdom. There are no validated instruments to identify depression in Mexican palliative patients. Our aim was to validate the Spanish-language version of the BEDS in Mexican population with advanced cancer.

METHOD

We conducted a cross-sectional study with outpatients from the palliative care unit at the Instituto Nacional de Cancerología in Mexico City. The Mexican BEDS was validated against a semistructured psychiatric clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, classification criteria for major depressive disorder. The interviewer was blind to the BEDS score at the time of the assessment.

RESULT

Seventy subjects completed the scale and interview. Women represented 71.4% of the sample and median age of subjects was 56.5 years (range, 20-85 years). The prevalence of major depressive disorder according to the psychiatric interview was 20%. The most valid cutoff for defining a case of depression was a score ≥5 of 18 on the Mexican BEDS, which gave a sensitivity of 85.7% and specificity of 62.5%. The scale's Cronbach's alpha was 0.71.

SIGNIFICANCE OF RESULTS

Major depressive disorder is frequent in Mexican palliative patients. The Spanish-language Mexican version of the BEDS is the first valid case-finding tool in advanced cancer patients in this setting.

Burden of Schizophrenia or Psychosis-Related Symptoms in Adults Undergoing Substance Abuse Evaluation

This study evaluated the biopsychosocial characteristics of adults undergoing substance abuse evaluation with potential schizophrenia/psychotic disorder, or possible schizophrenia/psychosis-like symptoms, compared with those with no schizophrenia/psychosis-like symptoms. A cross-sectional, observational study examined 170,201 adults, aged 18 to 30, who completed the Addiction Severity Index-Multimedia Version (ASI-MV). Approximately 10% were classified as having possible schizophrenia/psychosis-like symptoms or potential schizophrenia/psychotic disorder. These patients were more likely to exhibit moderate to extreme severity on employment, medical, legal, substance use, social, and psychiatric status than nonsymptomatic patients. The potential schizophrenia or psychotic disorder cohort was also more likely to have ever experienced physical abuse (odds ratio [OR] = 4.30, 95% confidence interval [CI] = 4.12-4.48) and/or sexual abuse (OR = 4.32, 95% CI = 4.15-4.51) versus the no schizophrenia/psychosis-like symptoms cohort. Findings support a recommendation for routine screening for mental health issues, particularly schizophrenia/psychosis-like symptoms, for adults entering substance use disorder treatment settings. This may increase the likelihood of appropriate and earlier intervention.

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

BACKGROUND

We assessed the prevalence and correlates of lifetime substance use disorders in people with first episode psychosis using the baseline data from the Recovery After an Initial Schizophrenia Episode (RAISE) Early Treatment Program study.

METHODS

Research staff assessed 404 first episode patients at 34 community mental health centers across the United States with the Structured Clinical Interview for DSM-IV for diagnoses of psychotic and substance use disorders. Logistic regression was used to evaluate the relationships between participant characteristics and lifetime substance use disorders, followed with generalized linear mixed-effects regression models to identify unique predictors of lifetime substance use disorders.

RESULTS

Approximately one-third of participants reported recent alcohol use (36.6%) and cannabis use (30.7%), and one half (51.7%) met criteria for any lifetime alcohol or drug use disorder. Lifetime substance use disorders were associated with male gender, White race, higher excited (hyperactivity, mood lability, impulsivity, hostility, and uncooperativeness), psychotic and depressive symptoms, less impaired cognition, and greater perceived stigma. Gender, race, and excited symptoms were the most consistent unique predictors of lifetime substance use disorders found in multivariate analyses.

CONCLUSIONS

Half of first episode psychosis patients have co-occurring substance use disorders, which are associated with both more severe symptoms and greater perceptions of stigma. Programs aiming to serve these patients must have the skills and clinical strategies to help people with these unique characteristics.

The need for close monitoring of early psychosis and co-occurring substance misuse

Substance misuse is widespread among individuals with early-phase psychotic disorders and is associated with a worse illness course. Thorough assessment of patterns of substance misuse at admission for psychiatric care is often lacking and can compromise the accuracy of a diagnostic assessment that distinguishes between a primary psychosis and one that is substance induced. Given the risk to recovery from psychosis posed by substance misuse, close monitoring of the course and treatment of early-phase psychosis that is accompanied by substance misuse is indicated and could inform the development of more effective dual-diagnosis treatments.

Patterns of Substance Abuse in Offenders With Schizophrenia- Illness-Related or Criminal Life-Style?

Objective: The impact of substance abuse on violent behavior in patients suffering from schizophrenia is well-known. However, the association between the pattern of substance abuse and certain aspects of criminal behavior like the severity of offense, the previous history of violence and the age at onset of the criminal career is still unclear. Method: To assess the relationship between substance abuse, schizophrenia and violent behavior we examined healthy non-offenders; healthy offenders; non-offenders suffering from schizophrenia; and offenders suffering from schizophrenia, with respect to different patterns of substance abuse (none, alcohol only, illicit drugs only, and multiple substances). Results: Healthy offenders as well as offenders and non-offenders suffering from schizophrenia are characterized by increased rates of alcohol and illicit drug abuse. Especially multiple substance abuse appears to lower the threshold of aggression and illegal behavior. This effect is more pronounced in subjects suffering from schizophrenia. In both offender groups the abuse of psychoactive substances is associated with an earlier onset of the criminal career, but has no impact on the severity of the offenses. Conclusion: Our results point to the need for a differentiated view on the contribution of substance abuse to the criminality of subjects suffering from schizophrenia.

Primary psychosis with comorbid drug abuse and drug-induced psychosis: Diagnostic and clinical evolution at follow up

The study reports a follow-up assessment of 48 patients with concomitant drug abuse at the first admission for psychosis. We focused on the diagnostic distinction between primary psychosis with concomitant drug abuse and drug induced psychosis, to observe whether the diagnoses are stable over time and whether the clinical course significantly differs. The study examined 25 primary psychotic disorder with comorbid drug abuse and 23 drug-induced psychotic disorder patients. Diagnostic and psychopathological assessments were made at baseline and at follow-up. Mean follow-up period was 4.96 years. Patients with comorbid Drug Abuse exhibited higher scores in the item Unusual Content of Thought at baseline than drug-induced psychotic disorder patients: 5.48 vs 4.39 while the two patients groups did not differ in any of the BPRS items evaluated at follow-up. The primary psychosis with comorbid drug abuse and the substance induced psychosis groups were similar regarding diagnostic stability, and a diagnosis of schizophrenia at follow-up occurred similarly. There was no evidence that Drug Induced psychotic patients' symptoms tend to improve more after cessation of drug abuse. An earlier age of onset was found in primary psychotic patients, particularly for patients diagnosed as affected by schizophrenia at follow up. These results might reflect the uncertainty of the distinction between Primary and Drug Induced Psychosis and the difficulties in applying the DSM IV-TR criteria for diagnosing comorbid drug use disorders and psychotic disorders.

Differential effects of sex on substance use between first episode psychosis patients and healthy people

BACKGROUND

Substance use in psychosis is an important field of study given that it can be a risk factor for the development of psychosis and can give rise to psychotic symptoms. Studies of substance use in first episode psychosis patients do not frequently assess non-pathological substance consumption among patients, but rather the prevalence of substance abuse or dependence disorders. Moreover, most of these studies do not address the effects of sex in sufficient depth, and the consumption of caffeine or tobacco, which are two of the most frequently used substances, is often not assessed.

OBJECTIVES

The aim of this study was to compare patterns and quantities of substance use between first episode psychosis patients and healthy controls and between men and women, and explore the potential interactive effects between group (patients or controls) and sex.

METHODS

A total of 158 participants (82 first episode psychosis patients and 76 healthy controls) were included in the study. Both adults and adolescents were included in the study. Frequency and amount of use of caffeine, tobacco, alcohol, cannabis, cocaine, hallucinogens, stimulants, and opiates were gathered.

RESULTS

A significant main effect of sex was found for the frequency of use of tobacco (p=.050). Main effects of group were found for the quantity of tobacco (p<.001) and cannabis (p<.001) consumed, as well as main effects of sex for the quantity of alcohol (p=.003) and cannabis (p=.017) consumed. There were also interaction effects between group and sex for the frequency of use of tobacco (p=.005) and cannabis (p=.009), and for the amount of cannabis consumed (p=.049). Qualitative differences between males and females regarding combined substance use are also reported.

CONCLUSIONS

Among patients, men used tobacco more frequently than women, but this sex difference was not the same for the control group, in which women smoked more often than men. Regarding cannabis, men smoked cannabis more frequently and in larger amounts than women, but only in the patients group, whereas no sex differences for cannabis were found for the controls. Main effects of group and sex for tobacco and alcohol, as well as the lack of differences for the frequency and amount of use of caffeine, are also commented. This is the first study to assess the different effects of sex on substance use in first episode psychosis patients and healthy controls.

Brain metabolism in substance-induced psychosis and schizophrenia: a preliminary PET study

INTRODUCTION

The relation between schizophrenia and cannabis abuse has been widely discussed from etiopathogenetic, psychopathological and neurometabolic points of view. Relatively little has been written about the differences between schizophrenia with co-occurrent cannabis abuse and substance-induced psychotic disorder (SIPD). Given these premises, our study aims to investigate the psychopathological and neurometabolic features of these clinical entities.

METHODS

We enrolled patients experiencing an acute psychotic episode, affected either by schizophrenia with or without cannabis abuse (SCZ +/- CA; n = 5 and n = 5, respectively) with recent onset (<5 years of illness) or by SIPD (n = 6), as diagnosed by the Structured Clinical Interview for DSM-IV Axis I. Patients affected by SIPD were all cannabis abusers. All patients were assessed with the PANSS (Positive and Negative Scale for Schizophrenia), urinary toxicological tests and brain 18-FDG-PET scanning in resting condition. Statistical analysis (ANOVA) was performed with Statistical Parametric Mapping SPM8 and Scenium software.

RESULTS

Bilateral hypermetabolism in the posterior cingulum and the precuneus (p < 0.001) was observed in SIPD patients compared to patients with schizophrenia, with or without cannabis abuse.

CONCLUSIONS

Our preliminary PET findings suggest that substance abuse may cause increased brain metabolism in patients with induced psychosis but not in those with schizophrenia. These differences in brain metabolism were found in the posterior cingulum and precuneus, which are two core regions of the default mode network in humans.

Marijuana use in the immediate 5-year premorbid period is associated with increased risk of onset of schizophrenia and related psychotic disorders

OBJECTIVES

Several studies suggest that adolescent marijuana use predicts earlier age at onset of schizophrenia, which is a crucial prognostic indicator. Yet, many investigations have not adequately established a clear temporal relationship between the use and onset.

METHODS

We enrolled 247 first-episode psychosis patients from six psychiatric units and collected data on lifetime marijuana/alcohol/tobacco use, and ages at onset of prodrome and psychosis in 210 of these patients. Cox regression (survival analysis) was employed to quantify hazard ratios (HRs) for effects of diverse premorbid use variables on psychosis onset.

RESULTS

Escalation of premorbid use in the 5years prior to onset was highly predictive of an increased risk for onset (e.g., increasing from no use to daily use, HR=3.6, p<0.0005). Through the analysis of time-specific measures, we determined that daily use approximately doubled the rate of onset (HR=2.2, p<0.0005), even after controlling for simultaneous alcohol/tobacco use. Building on previous studies, we were able to determine that cumulative marijuana exposure was associated with an increased rate of onset of psychosis (p=0.007), independent of gender and family history, and this is possibly the reason for age at initiation of marijuana use also being associated with rate of onset in this cohort.

CONCLUSIONS

These data provide evidence of a clear temporal relationship between escalations in use in the five years pre-onset and an increased rate of onset, demonstrate that the strength of the association is similar pre- and post-onset of prodromal symptoms, and determine that early adult use may be just as important as adolescent use in these associations.

The study of primary psychotic disorders with concurrent substance abuse in terms of their diagnostic stability

BACKGROUND

Co-morbid substance use is common among individuals presenting with symptoms of psychosis. There is a paucity of research in this area.

AIM

To study the longitudinal follow-up of patients over 1-year of first episode psychosis with concurrent substance use in terms of their diagnostic stability.

MATERIALS AND METHODS

Fifty patients having at least one symptom of psychosis at first admission at a General Hospital Psychiatric Unit along with concurrent substance abuse were included and followed up for 1-year. International Classification of Disease-10, diagnostic criteria were used for diagnosis. Semi-structured sociodemographic performa to assess the sociodemographic profile. Brief Psychiatric Rating Scale and Alcohol Use Disorder Identification Test as rating scales were used for the assessment at 6 and 12 months.

RESULTS

Of 50 patients, 31 patients who had a diagnosis of primary psychosis retained their diagnosis at follow-up. The mean age of cases in substance-induced psychosis group was 37.47 years, which was significantly higher than in primary psychosis group at 31.52 years. However, 7 patients of the substance-induced psychosis group required a change in diagnosis to primary psychosis group. The primary psychosis group patients were significantly younger, less educated, had less family support, had greater family mental illness, had more severe symptoms, and less hallucinations.

CONCLUSION

The present study is a forerunner in this area. Salient differences indicated in the study can help in differentiating the diagnosis and in the management of cases. This is particularly relevant in the management setting and for long-term intervention purpose.

Comorbid substance use disorders in schizophrenia: a latent class approach

Schizophrenia is a complex psychiatric disorder with a characteristic disease course and heterogeneous etiology. While substance use disorders and a family history of psychosis have individually been identified as risk factors for schizophrenia, it is less well understood if and how these factors are related. To address this deficiency, we examined the relationship between substance use disorders and family history of psychosis in a sample of 1219 unrelated patients with schizophrenia. The lifetime rate of substance use disorders in this sample was 50%, and 30% had a family history of psychosis. Latent class mixture modeling identified three distinct patient subgroups: (1) individuals with low probability of substance use disorders; (2) patients with drug and alcohol abuse, but no symptoms of dependence; and (3) patients with substance dependence. Substance use was related to being male, to a more severe disease course, and more acute symptoms at assessment, but not to an earlier age of onset of schizophrenia or a specific pattern of positive and negative symptoms. Furthermore, substance use in schizophrenia was not related to a family history of psychosis. The results suggest that substance use in schizophrenia is an independent risk factor for disease severity and onset.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation

OBJECTIVE

Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates.

METHODS

PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression.

RESULTS

Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors.

CONCLUSIONS

Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.

Substance Use in Patients With First-Episode Psychosis: Is Gender Relevant?

OBJECTIVE

Only a few studies in patients with first-episode psychosis have included gender in the study hypothesis or considered this a primary study variable. The aim of this study was to explore the influence of gender in the pattern of substance use in patients with first-episode psychosis.

METHODS

This is a sub-analysis of a randomized open clinical trial that compared 1-year treatment retention rates of patients with first-episode psychosis randomized to haloperidol, olanzapine, quetiapine, risperidone, or ziprasidone. Our sub-analysis included 85 men and 29 women.

RESULTS

Substance use was relatively high among these patients and differed significantly by gender. Men were more likely to use substances overall than women (89.4% for men vs. 55.2% for women), χ(2) = 16.2, df = 1, p <.001, and were also more likely to use alcohol (χ(2) = 13, df = 1, p <.001), cannabis (χ(2) = 9.9; df = 1, p <.002), and cocaine (χ(2) = 10.3; df = 1, p <.001), compared to women. While there were no gender differences in age at first consumption of alcohol or cocaine, men were significantly younger at first consumption of cannabis (M = 16.08 years, SD = 2.1) than women (M = 18.0 years, SD = 3.8), F(1, 59) = 5, p <.02. When analyzed separately by gender, women showed no significant differences in the influence of number of substances used on age at onset of psychosis, F(3, 29) = 1.2, p =.30. However, there was a significant difference among men, with earlier onset of psychosis noted in men consuming multiple substances; F(4, 85) = 5.8, p <.0001. Regarding prediction of age at onset of psychosis, both male gender and the use of a higher number of substances significantly predicted an earlier age at onset of psychosis.

CONCLUSIONS

Our study provides some evidence of gender differences in the pattern of substance use in patients with first-episode psychosis, suggesting the possible need for gender-specific approaches in the interventions performed in these patients. This study is registered as #12610000954022 with the Australian New Zealand Clinical Trials Registry (www.anzctr.org.au).

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.

One year follow-up of alcohol and illicit substance use in first-episode psychosis: does gender matter?

Longitudinal studies on first-episode psychosis (FEP) patients have shown a decrease of substance use disorders (SUDs) over the first years of illness, but there has been less focus on the gender aspect. The present study examines stability of alcohol and illicit substance use, with specific focus on gender, in a one year follow-up investigation of 154 FEP patients (91 men, 63 women) in Oslo, Norway, using criteria for DSM-IV substance use disorder diagnosis, the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT). The results show that cannabis was the most frequently used illicit substance at both times. Significantly more men (34%) than women (13%) had a current illicit SUD at baseline. At follow-up, the rate of illicit SUDs was significantly reduced in men (18%) but not in women (11%). There were no significant gender differences in the rate of current alcohol use disorders (AUD) (men 14%; women 8%) at baseline, and no significant reduction in AUD in any of the genders at follow-up. At follow-up, total AUDIT and DUDIT scores were reduced in men only. In conclusion, the high and persistent rate of SUDs, particularly of cannabis, among men and women during the first year of treatment for psychosis should be addressed in the clinical management of the patients. Female FEP patients who are also substance users may be particularly vulnerable in this regard and warrant closer attention.

Substance use disorders among treatment naïve first-episode psychosis patients

OBJECTIVES

To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India.

METHODS

The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients.

RESULTS

Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen.

CONCLUSION

The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK.

Does substance use disorder affect clinical expression in first-hospitalization patients with schizophrenia? Analysis of a prospective cohort

Although several papers reported a wide range of negative outcomes among patients with both schizophrenia and Substance Use Disorder (SUD), only a few studies evaluated the impact of SUD on psychopathology and thus on the length of first-hospitalization. The aim of the present study was to compare clinical expression of first-episode of schizophrenia between inpatients with and without SUD, giving close attention to the length of stay. One hundred and thirty inpatients at first-episode of schizophrenia were assigned to either SUD or not SUD group depending on SUD diagnosis and were assessed through BPRS at admission, during hospitalization and at discharge. Cross-sectional and longitudinal statistical analysis were performed to investigate differences between groups and also a linear regression was used to evaluate relationship between length of stay and BPRS scores. SUD group showed more disorganization at admission, less marked improvement of symptoms (disorganization, thought disturbance, anergia), and longer hospital stay than not SUD group. Moreover BPRS total score during hospitalization was a significant positive predictor for length of stay. Taken together, these findings suggest that SUD patients have a more severe and drug-resistant expression of schizophrenia, hence, they need longer treatment to achieve the overall symptoms improvement required for discharge.

The brain effects of cannabis in healthy adolescents and in adolescents with schizophrenia: a systematic review

Cannabis is widely used in adolescence; however, the effects of cannabis on the developing brain remain unclear. Cannabis might be expected to have increased effects upon brain development and cognition during adolescence. There is extensive re-organisation of grey (GM) and white matter (WM) at this time, while the endocannabinoid (eCB) system, which is involved in the normal physiological regulation of neural transmission, is still developing. In healthy adolescent cannabis users there is a suggestion of greater memory loss and hippocampal volume changes. Functional studies point to recruitment of greater brain areas under cognitive load. Structural and DTI studies are few, and limited by comorbid drug and alcohol use. The studies of cannabis use in adolescent-onset schizophrenia (AOS) differ, with one study pointing to extensive GM and WM changes. There is an intriguing suggestion that the left parietal lobe may be more vulnerable to the effects of cannabis in AOS. As in adult schizophrenia cognition does not appear to be adversely affected in AOS following cannabis use. Given the limited number of studies it is not possible to draw firm conclusions. There is a need for adequately powered, longitudinal studies.

Substance abuse and smoking among a Canadian cohort of first episode psychosis patients

Individuals experiencing their first psychotic episode report rates of substance and tobacco use that are higher than observed in the general population. In this sample of individuals diagnosed with first episode psychosis, rural/non-rural variations in substance use and smoking behaviour were evaluated. Analyses were performed utilizing data from a sample of individuals enrolled in early intervention programs located throughout the province of Ontario. Based upon population density, two geographical regions were developed: rural and non-rural. Illicit drug use, alcohol consumption, and smoking behaviour were assessed. The total sample consisted of 152 individuals experiencing their first episode of psychosis. Of these individuals, 82 and 70 resided in rural and non-rural areas, respectively. Rural vs non-rural residence was not significantly associated with substance or tobacco use. Regardless of geographical location, early intervention programs for individuals experiencing their first psychotic episode need to incorporate interventions that address substance use.

Substance abuse and psychosis

This article reviews the literature for the most pressing diagnostic and treatment challenges faced in working with adolescents. Diagnosing the treatment interventions required for this population involve psychoeducation, engagement of the patient and family in the treatment process, and use of antipsychotic medications. Cannabis may be a causal risk factor in psychotic illness, and data support recommendations to reduce or cease cannabis use in this population. Treatment strategies are discussed that are effective in adult patients and that may be efficacious for youth to abstain from substances after the resolution of psychotic symptoms.

Do former substance users with psychosis differ in their symptoms or function from non-substance users? A systematic meta-analysis

OBJECTIVE

To compare the symptoms and function of patients with psychosis who have ceased using substances to those who have psychosis but do not have a history of substance use.

METHOD

The databases EMBASE, MEDLINE and PsycINFO were searched for peer-reviewed publications in English reporting the characteristics of patients with psychotic illness who had stopped using substances and those who had never used substances. The searches yielded 20 articles that met the inclusion criteria. Four key outcome variables - positive symptoms, negative symptoms, depression and global function - and four other outcome measures reported in five or more studies were examined using meta-analysis.

RESULTS

Former 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. There were no significant differences between former substance users and non-substance users in ratings of positive symptoms, negative symptoms, depression or global function. Among first-episode patients there was a trend towards former substance users having less severe depressive symptoms than non-substance users. In contrast, among non-first-episode patients, former substance users had significantly more depressive symptoms than non-substance users. In studies rated as being of higher quality, former substance users had significantly less severe positive symptoms than non-substance users.

CONCLUSION

The absence of significant differences between the two groups suggests that a history of substance use is not a poor prognostic indicator for patients who are able to stop using substances.

Factors predicting hostility in outpatients with schizophrenia: 36-month results from the SOHO study

This analysis explored the prevalence, incidence, and predictors of hostility in the European Schizophrenia Outpatient Health Outcomes (EU-SOHO) study. Data were collected at baseline and up to 36 months on the presence of hostility, clinical course and severity, medication compliance, side effects, substance/alcohol abuse, and being a crime survivor. Regression models were fitted to test the association between predictors and the presence of hostility. Hostility prevalence in the 6 months before baseline was 27.9%, and the incidence at 3 years was 14.0%. Variables related to hostility during follow-up were age, male sex, alcohol/substance abuse, tardive dyskinesia, extrapyramidal symptoms, cognitive impairment, noncompliance, and hospitalization. Being a crime survivor, being married, not living independently, and not being in paid employment were associated with hostility at baseline. Clinical and social variables are related to hostility in schizophrenia. Extrapyramidal symptoms and tardive dyskinesia, alcohol/substance abuse, cognitive impairment, medication noncompliance, and hospitalizations are predictors of future hostility.

Prospective study of cannabis use in adolescents at clinical high risk for psychosis: impact on conversion to psychosis and functional outcome

BACKGROUND

Clinical and epidemiological studies suggest an association between cannabis use and psychosis but this relationship remains controversial.

METHOD

Clinical high-risk (CHR) subjects (age 12-22 years) with attenuated positive symptoms of psychosis (CHR+, n=101) were compared to healthy controls (HC, n=59) on rates of substance use, including cannabis. CHR+ subjects with and without lifetime cannabis use (and abuse) were compared on prodromal symptoms and social/role functioning at baseline. Participants were followed an average of 2.97 years to determine psychosis conversion status and functional outcome.

RESULTS

At baseline, CHR+ subjects had significantly higher rates of lifetime cannabis use than HC. CHR+ lifetime cannabis users (n=35) were older (p=0.015, trend), more likely to be Caucasian (p=0.002), less socially anhedonic (p<0.001) and had higher Global Functioning: Social (GF:Social) scores (p<0.001) than non-users (n=61). CHR+ cannabis users continued to have higher social functioning than non-users at follow-up (p<0.001) but showed no differences in role functioning. A small sample of CHR+ cannabis abusers (n=10) showed similar results in that abusers were older (p=0.008), less socially anhedonic (p=0.017, trend) and had higher baseline GF:Social scores (p=0.006) than non-abusers. Logistic regression analyses revealed that conversion to psychosis in CHR+ subjects (n=15) was not related to lifetime cannabis use or abuse.

CONCLUSIONS

The current data do not indicate that low to moderate lifetime cannabis use is a major contributor to psychosis or poor social and role functioning in clinical high-risk youth with attenuated positive symptoms of psychosis.

Age at onset of non-affective psychosis in relation to cannabis use, other drug use and gender

BACKGROUND

Cannabis use is associated with an earlier age at onset of psychotic illness. The aim of the present study was to examine whether this association is confounded by gender or other substance use in a large cohort of patients with a non-affective psychotic disorder.

METHOD

In 785 patients with a non-affective psychotic disorder, regression analysis was used to investigate the independent effects of gender, cannabis use and other drug use on age at onset of first psychosis.

RESULTS

Age at onset was 1.8 years earlier in cannabis users compared to non-users, controlling for gender and other possible confounders. Use of other drugs did not have an additional effect on age at onset when cannabis use was taken into account. In 63.5% of cannabis-using patients, age at most intense cannabis use preceded the age at onset of first psychosis. In males, the mean age at onset was 1.3 years lower than in females, controlling for cannabis use and other confounders.

CONCLUSIONS

Cannabis use and gender are independently associated with an earlier onset of psychotic illness. Our findings also suggest that cannabis use may precipitate psychosis. More research is needed to clarify the neurobiological factors that make people vulnerable to this precipitating effect of cannabis.

Does giving up substance use work for patients with psychosis? A systematic meta-analysis

OBJECTIVE

To assess the extent to which ceasing the use of cannabis or other substances reduces the symptoms and social disability associated with psychotic illness.

METHODS

The electronic databases CINAHL, EMBASE, MEDLINE and PsycINFO were searched for peer-reviewed publications in English that report data about the characteristics of current and former substance-using patients diagnosed with psychotic illnesses. The searches yielded 328 articles, of which 23 studies met the inclusion criteria. Four key outcome variables; positive symptoms, negative symptoms, ratings of depression and global function, and five other measures of outcome that were reported in five or more studies were examined using meta-analysis.

RESULTS

Current substance-using patients were significantly younger than former substance-using patients (standardised mean difference (SMD) = -0.38), but did not differ in age at onset of psychosis, sex, level of education or marital status. Current substance users had higher scores on rating scales of positive symptoms (SMD = 0.29) and depression (SMD = 0.36), and lower scores on global function (SMD = -0.26) when compared with former substance users. There was a significant improvement in the ratings of positive symptoms, mood and global function among patients who stopped using substances during the first episode of psychosis, while improvements in the symptoms of patients with a more established psychotic illness did not reach statistical significance.

CONCLUSION

The results suggest that substance use contributes to both the symptoms and the burden of disability experienced by patients with psychosis. Patients in the early stages of psychotic illness should be informed about the benefits of giving up substances earlier, rather than later in the illness. Psychiatric services should regard the treatment of substance use as an integral part of the treatment of psychotic disorders.

Meta-analysis of self-reported substance use compared with laboratory substance assay in general adult mental health settings

An accurate assessment of substance use is necessary to make a correct psychiatric diagnosis and to provide appropriate treatment. This study uses meta-analysis to establish the strength of the association between self-reported substance use and the results of laboratory substance assay including the testing for specific substances and screening for any substance use in psychiatric hospitals and in community mental health settings. A systematic search for published studies was supplemented by additional data required for meta-analysis provided by several researchers in this field. Using random-effects meta-analysis, we calculated the pooled estimate of the odds ratio of a positive substance assay in patients reporting use or non-use of substances and estimated the sensitivity, specificity, positive predictive value and negative predictive value. Twenty-six studies met the inclusion criteria. Very strong associations were found between self-reported use and positive tests for cannabis [N = 11 studies, odds ratio (OR) = 22.3; 95% confidence interval (CI) = 10.1-49.1], amphetamines (N = 8, OR = 26.6; 95% CI = 7.9-88.9), cocaine (N = 8, OR = 39.7; 95% CI = 16.2-97.2) and opiates (N = 7, OR = 83.5; 95% CI = 26.7-260.7). Strong associations were found between self-reported use of any substance and positive substance screening (N = 15, OR = 7.2, 95% CI = 3.6-14.1) and tests for alcohol use (N = 5, OR = 8.5; 95% CI = 2.5-28.4). Screening for any substance use had a sensitivity of 61% and a specificity of 66%. Testing for individual substances was specific but lacked sensitivity. Screening has the potential to detect clinically relevant substances that would not be reported by the patient, whereas testing for a specific substance has little advantage over self-report. The sensitivity of the substance assay might be improved by obtaining a sample at the earliest opportunity. Consideration should be given to the increased use of substance screening in general adult mental health settings because it could improve the accuracy of psychiatric diagnosis and increase the likelihood of patients receiving treatment for substance use disorders.

Synthetic cannabinoid JWH-018 and psychosis: an explorative study

BACKGROUND

Aroma, Spice, K2 and Dream are examples of a class of new and increasingly popular recreational drugs. Ostensibly branded "herbal incense", they have been intentionally adulterated with synthetic cannabinoids such as JWH-018 in order to confer on them cannabimimetic psychoactive properties while circumventing drug legislation. JWH-018 is a potent cannabinoid receptor agonist. Little is known about its pharmacology and toxicology in humans. This is the first research considering the effects of JWH-018 on a psychiatric population and exploring the relationship between JWH-018 and psychotic symptoms.

METHOD

This paper presents the results of semi-structured interviews regarding the use and effects of JWH-018 in 15 patients with serious mental illness in a New Zealand forensic and rehabilitative service.

RESULTS

All 15 subjects were familiar with a locally available JWH-018 containing product called "Aroma" and 86% reported having used it. They credited the product's potent psychoactivity, legality, ready availability and non-detection in drug testing as reasons for its popularity, with most reporting it had replaced cannabis as their drug of choice. Most patients had assumed the product was "natural" and "safe". Anxiety and psychotic symptoms were common after use, with 69% of users experiencing or exhibiting symptoms consistent with psychotic relapse after smoking JWH-018. Although psychological side effects were common, no one reported becoming physically unwell after using JWH-018. Three subjects described developing some tolerance to the product, but no one reported withdrawal symptoms.

CONCLUSION

It seems likely that JWH-018 can precipitate psychosis in vulnerable individuals. People with risk factors for psychosis should be counseled against using synthetic cannabinoids.

Substance use disorder among people with first-episode psychosis: a systematic review of course and treatment

OBJECTIVE

People experiencing a first episode of psychosis frequently have co-occurring substance use disorders, usually involving alcohol and cannabis, which put them at risk for prolonged psychosis, psychotic relapse, and other adverse outcomes. Yet few studies of first-episode psychosis have addressed the course of substance use disorders and the response to specialized substance abuse treatments.

METHODS

The authors searched MEDLINE, PsycINFO, and other medical databases for English-language articles published between 1990 and 2009. Included studies addressed two research questions. First, do some clients become abstinent after a first episode of psychosis without specialized substance abuse treatments? Second, for clients who continue to use substances after a first episode of psychosis, does the addition of specialized substance abuse treatment enhance outcomes?

RESULTS

Nine studies without specialized substance abuse treatment and five with specialized substance abuse treatment assessed the course of substance use (primarily cannabis and alcohol) after a first episode of psychosis. Many clients (approximately half) became abstinent or significantly reduced their alcohol and drug use after a first episode of psychosis. The few available studies of specialized substance abuse treatments did not find better rates of abstinence or reduction.

CONCLUSIONS

Experience, education, treatment, or other factors led many clients to curtail their substance use disorders after a first episode of psychosis. Specialized interventions for others need to be developed and tested.

Greater white and grey matter changes associated with early cannabis use in adolescent-onset schizophrenia (AOS)

BACKGROUND

Cannabis use is associated with a higher risk of schizophrenia, however, its specific long-term effect on the structure of the brain of adolescent-onset schizophrenic patients remains unclear.

AIMS

To study cognitive and structural (grey and white matter) changes in patients with adolescent-onset schizophrenia (AOS) with early cannabis use (CAN+ve) (more than 3 times/week for at least 6 months) and without cannabis use (CAN-ve) versus controls.

METHOD

An optimised voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) MRI study of 32 adolescents with DSM IV schizophrenia-16 CAN+ve and 16 CAN-ve, and 28 healthy adolescents.

RESULTS

Compared to CAN-ve subjects, CAN+ve subjects showed GM density loss in temporal fusiform gyrus, parahippocampal gyrus, ventral striatum, right middle temporal gyrus, insular cortex, precuneus, right paracingulate gyrus, dorsolateral prefrontal cortex, left postcentral gyrus, lateral occipital cortex and cerebellum. Similar group comparison showed decreased fractional anisotropy (FA) in particular in brain stem, internal capsule, corona radiata, superior and inferior longitudinal fasciculus in CAN+ve patients. No cognitive differences were apparent between CAN+ve and CAN-ve subjects, and both were impaired relative to controls.

CONCLUSION

Cannabis use in early adolescence increases WM and GM deficits in AOS, but does not appear to increase the cognitive deficit associated with this illness.

Psychopharmacological comparison of schizophrenia spectrum disorder with and without cannabis dependency

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.

Prevalence of Substance Use in People With First-Episode Psychosis

OBJECTIVE

People experiencing a first episode of psychosis often have co-occurring substance use, which increases risk of prolonged psychosis and impairs recovery. This article examines the prevalence of substance use in people with first-episode psychosis.

METHODS

The authors searched MEDLINE and other databases for articles published between 1990 and 2009 that described current or lifetime prevalence of substance use, misuse, abuse, or dependence in individuals with first-episode psychosis.

RESULTS

Forty-four unique studies provided information. More than 25% of individuals with first-episode psychosis in reviewed studies indicated current or lifetime alcohol use, lifetime alcohol abuse/dependence, current or lifetime cannabis use, or lifetime cannabis abuse or dependence. For all substances, lifetime prevalence of abuse/dependence was higher than current abuse/dependence.

CONCLUSIONS

Despite variation in assessment methods, findings were generally consistent. Individuals with first-episode psychosis have lower current substance prevalence than lifetime prevalence, suggesting cessation of some substance use prior to seeking treatment for psychosis.

Cannabis use and progressive cortical thickness loss in areas rich in CB1 receptors during the first five years of schizophrenia

Cerebral grey matter volume reductions are progressive in schizophrenia, with larger grey matter volume decreases associated with cannabis use. It is unknown whether this grey matter loss is globally distributed over the entire brain or more pronounced in specific cortical brain regions. Fifty-one patients with recent-onset schizophrenia and 31 matched healthy subjects were included. For all subjects, magnetic resonance imaging scans were obtained at inclusion and at 5-year follow-up. Nineteen patients (ab-)used cannabis but no other illicit drugs; 32 patients and the healthy comparison subjects did not use any drugs during the 5-year follow-up. At follow-up, clinical outcome was measured. To evaluate the local differences in cortical thickness change over five years between the two groups regression analysis was carried out over the cortical surface. At inclusion cortical thickness did not differ between patients and controls and between cannabis-using and non-using patients. Over the follow-up period we found excessive thinning of the right supplementary motor cortex, inferior frontal cortex, superior temporal gyrus, angular gyrus, occipital and parietal lobe in patients relative to controls after controlling for cannabis use. Patients who used cannabis showed additional thinning in the left dorsolateral prefrontal cortex (DLPFC), left anterior cingulate cortex (ACC) and left occipital lobe as compared to those patients that did not use cannabis during the scan interval. First-episode schizophrenia patients who use cannabis show a more pronounced cortical thinning than non-using patients in areas known for their high density of CB1 receptors, such as the ACC and the DLPFC.

Suicide in schizophrenia

Schizophrenia is a disorder with an estimated suicide risk of 4-5%. Many factors are involved in the suicidal process, some of which are different from those in the general population. Clinical risk factors include attempted suicide, depression, male gender, substance abuse and hopelessness. Biosocial factors, such as a high intelligence quotient and high level of premorbid function, have also been associated with an increased risk of suicide in patients with schizophrenia. Suicide risk is especially high during the first year after diagnosis. Many of the suicides occur during hospital admission or soon after discharge. Management of suicide risk includes both medical treatment and psychosocial interventions. Still, risk factors are crude; efforts to predict individual suicides have not proved useful and more research is needed.

Adolescent brain maturation, the endogenous cannabinoid system and the neurobiology of cannabis-induced schizophrenia

Cannabis use during adolescence increases the risk of developing psychotic disorders later in life. However, the neurobiological processes underlying this relationship are unknown. This review reports the results of a literature search comprising various neurobiological disciplines, ultimately converging into a model that might explain the neurobiology of cannabis-induced schizophrenia. The article briefly reviews current insights into brain development during adolescence. In particular, the role of the excitatory neurotransmitter glutamate in experience-dependent maturation of specific cortical circuitries is examined. The review also covers recent hypotheses regarding disturbances in strengthening and pruning of synaptic connections in the prefrontal cortex, and the link with latent psychotic disorders. In the present model, cannabis-induced schizophrenia is considered to be a distortion of normal late postnatal brain maturation. Distortion of glutamatergic transmission during critical periods may disturb prefrontal neurocircuitry in specific brain areas. Our model postulates that adolescent exposure to Δ9-tetrahydrocannabinol (THC), the primary psychoactive substance in cannabis, transiently disturbs physiological control of the endogenous cannabinoid system over glutamate and GABA release. As a result, THC may adversely affect adolescent experience-dependent maturation of neural circuitries within prefrontal cortical areas. Depending on dose, exact time window and duration of exposure, this may ultimately lead to the development of psychosis or schizophrenia. The proposed model provides testable hypotheses which can be addressed in future studies, including animal experiments, reanalysis of existing epidemiological data, and prospective epidemiological studies in which the role of the dose-time-effect relationship should be central.

A retrospective analysis of cannabis use in a cohort of mentally ill patients in Sri Lanka and its implications on policy development

BACKGROUND

Several epidemiological studies have shown that cannabis; the most widely used illegal drug in the world, is associated with schizophrenia spectrum disorders (SSD).

AIMS

To assess the characteristics of cannabis use and its association with SSD in a cohort of psychiatrically ill patients and discuss the implications for policy development

METHODS

This is a retrospective analytical study of a cohort of psychiatric patients who received treatment in the psychiatry unit of the Provincial General Hospital, Ratnapura, Sri Lanka over five years (2000 - 2004). The schizophrenia spectrum disorders defined in this article include schizophrenia and the schizoaffective disorders.

RESULTS

A total of 3644 patient records were analyzed. The percentage of self reported life time cannabis (LTC) use was 2.83% (103, all males). Sixteen percent (576) of the total cohort was diagnosed with SSD by 2009. Male sex and LTC use were significantly associated with SSD (p < 0.01 and 0.001 respectively). In the majority (91.5%), cannabis use preceded the diagnosis. There were 17(16.5%) patients diagnosed as cannabis induced psychosis and 7 (41.2%) of them were subsequently diagnosed as SSD. This group was significantly more likely to have had a past psychiatric consultation, but other demographic and clinical correlates did not differ from the rest of the LTC users.

CONCLUSIONS

Self reported LTC use was strongly associated with being diagnosed with SSD. However we could not identify a particular subgroup of users that are at increased risk to recommend targeted primary prophylaxis. The policy implications of this observation are discussed.