Preferences of Young Adults With Psychosis for Cannabis-Focused Harm Reduction Interventions: A Cross-Sectional Study: Préférences des jeunes adultes souffrant de psychose pour les interventions de réduction des méfaits axées sur le cannabis : une étude transversale

OBJECTIVES

Cannabis use is common in people with early-phase psychosis (EP) and is associated with worse treatment outcomes. Few targeted interventions for cannabis use behaviour in this population exist, most focusing on abstinence, none focusing on harm reduction. Many people with EP will not seek treatment for their cannabis use with current therapeutic options. Understanding preferences for cannabis-focused harm reduction interventions may be key to improving outcomes. This study aimed to determine preferences of young adults with EP who use cannabis for cannabis-focused harm reduction interventions.

METHODS

Eighty-nine young adults across Canada with EP interested in reducing cannabis-related harms were recruited. An online questionnaire combining conventional survey methodology and two unique discrete choice experiments (DCEs) was administered. One DCE focused on attributes of core harm reduction interventions (DCE 1) and the second on attributes of boosters (DCE 2). We analysed these using mixed ranked-ordered logistic regression models. Preference questions using conventional survey methodology were analysed using summary statistics.

RESULTS

Preferred characteristics for cannabis-focused harm reduction interventions (DCE 1) were: shorter sessions (60 min vs. 10 min, odds ratio (OR): 0.72; P < 0.001); less frequent sessions (daily vs. monthly, OR: 0.68; P < 0.001); shorter interventions (3 months vs. 1 month, OR: 0.80; P < 0.01); technology-based interventions (vs. in-person, OR: 1.17; P < 0.05). Preferences for post-intervention boosters (DCE 2) included opting into boosters (vs. opting out, OR: 3.53; P < 0.001) and having shorter boosters (3 months vs. 1 month, OR: 0.79; P < 0.01). Nearly half of the participants preferred to reduce cannabis use as a principal intervention goal (vs. using in less harmful ways or avoiding risky situations).

CONCLUSIONS

Further research is required to see if technology-based harm reduction interventions for cannabis featuring these preferences translate into greater engagement and improved outcomes in EP patients.

Cannabis use disorder and adverse cardiovascular outcomes: A population-based retrospective cohort analysis of adults from Alberta, Canada

AIM

To measure the association between cannabis use disorder (CUD) and adverse cardiovascular disease (CVD) outcomes.

DESIGN AND SETTING

We conducted a matched, population-based retrospective cohort study involving five linked administrative health databases from Alberta, Canada.

PARTICIPANTS

We identified participants with CUD diagnosis codes and matched them to participants without CUD codes by gender, year of birth and time of presentation to the health system. We included 29 764 pairs (n = 59 528 individuals in total).

MEASUREMENTS

CVD events were defined by at least one incident diagnostic code within the study period (1 January 2012-31 December 2019). Covariates included comorbidity, socio-economic status, prescription medication use and health service use. Using mortality-censored Poisson regression models, we computed survival analyses for time to incident CVD stratified by CUD status. In addition, we calculated crude and stratified risk ratios (RRs) across various covariates using the Mantel-Haenszel technique.

FINDINGS

The overall prevalence of documented CUD was 0.8%. Approximately 2.4% and 1.5% of participants in the CUD and unexposed groups experienced an incident adverse CVD event (RR = 1.57; 95% confidence interval = 1.40-1.77). CUD was significantly associated with reduced time to incident CVD event. Individuals who appeared to have greater RRs for incident CVD were those without mental health comorbidity, who had not used health-care services in the previous 6 months, who were not on prescription medications and who did not have comorbid conditions.

CONCLUSIONS

Canadian adults with cannabis use disorder appear to have an approximately 60% higher risk of experiencing incident adverse cardiovascular disease events than those without cannabis use disorder.

Evaluation of a Cannabis Harm Reduction Intervention for People With First-Episode Psychosis: Protocol for a Pilot Multicentric Randomized Trial

BACKGROUND

Cannabis use is highly prevalent in young people with first-episode psychosis (FEP). Most report cannabis use and are often diagnosed with a cannabis use disorder upon admission to specialized services for psychosis. Cannabis use in this population is associated with worse clinical and psychosocial outcomes, rendering it an important clinical target. Despite this, few cannabis-specific interventions have been developed for FEP and empirically evaluated through randomized controlled trials. Most evaluated interventions have targeted cannabis abstinence, with limited efficacy, but none have centered on harm reduction outcomes for people with FEP who use cannabis. Early intervention services (EIS), the standard of care for FEP, have not successfully addressed problematic cannabis use in people with FEP either. Clinical trials are needed to explore the potential of harm reduction strategies, although these should be preceded by robust pilot studies to establish optimal design and approaches.

OBJECTIVE

Recognizing the need for harm reduction strategies for individuals with FEP who use cannabis and based on research on patients' preferences supporting harm reduction interventions, we developed a mobile app-based cannabis harm reduction intervention for this population. This intervention is called Cannabis Harm-reducing Application to Manage Practices Safely (CHAMPS). Here, we describe the protocol for a multicenter, 2-arm, parallel group, randomized pilot trial evaluating the acceptability of CHAMPS for people with FEP who use cannabis and the feasibility of conducting a full-scale trial in this population using CHAMPS. The impact on key clinical outcomes will also be explored.

METHODS

This pilot trial aims to recruit 100 young people with FEP using cannabis from 6 Canadian EIS clinics. Participants will be randomized in a 1:1 ratio to CHAMPS+EIS or EIS-only. CHAMPS acceptability will be assessed using completion rates for the intervention arm. Trial feasibility will be assessed using a retention rate for randomized participants. Secondary outcomes will explore tendencies of change in the use of protective behavioral strategies and in motivation to change strategies. Exploratory outcomes include cannabis use-related problems, other substance use, the severity of dependence, psychotic symptoms, and health care service use.

RESULTS

Recruitment began in December 2021. Data collection and analysis are expected to be completed in early 2024. Study results describing CHAMPS acceptability and trial feasibility will then be submitted for publication in a peer-reviewed journal.

CONCLUSIONS

CHAMPS uniquely combines evidence-based approaches, patient perspectives, and mobile health technology to support harm reduction in people with FEP who use cannabis. Attaining adequate acceptability and feasibility through this trial may justify further exploration of harm reduction tools, particularly within the context of conducting a larger-scale randomized controlled trial. This pilot trial has the potential to advance knowledge for researchers and clinicians regarding a feasible and user-acceptable research design in the cannabis and early psychosis fields.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04968275, https://clinicaltrials.gov/ct2/show/NCT04968275.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53094.

Assessing research competency development in Canadian psychiatry residency programs: A systematic review and future directions

Objective

We aimed to conduct a systematic review to identify curricular and educational interventions to build research competency among Canadian psychiatry residents and fellows transitioning to the competency-by-design framework.

Methods

The PRISMA guidelines were followed, searching five databases from their inception to February 2023 for relevant evaluation-type studies exploring research competency among psychiatry residents and fellows. We appraised thestudy's quality using the Joanna Briggs Institute's risk of bias tool for observational designs.

Results

Overall, 36 original articles met our inclusion criteria. Surveys (n = 10) showed that participation in scholarly research, quality improvement, or educational projects relevant to psychiatry is needed in most residency programs. However, these vary significantly across programs; few need direct research experience for residency completion. The interventions spanned four categories: externally funded comprehensive research training programs (n = 5); resident research tracks (n = 11); workshops and seminars (n = 7); and specific modules (n = 3). Reported outcomes included overall program ratings, research output, and career trajectory. The quality of most studies was low because of the lack of controls or validated metrics for evaluating outcomes.

Conclusions

While many studies have explored best practices in research curricula, the current literature does not inform competency-based models for Canadian psychiatry residency programs incorporating research training requirements. Further description is needed from Canadian psychiatric training bodies regarding appropriate curricula, milestones, and metrics for evaluating research competencies.

Navigating Evidence, Challenges, and Caution in the Treatment of Stimulant Use Disorders

Amidst the opioid epidemic, harm reduction-oriented approaches have gained traction, including interventions that focus on prescribing pharmaceutical-grade psychoactive substances, such as opioids, instead of illicit versions, intending to mitigate fatal overdose risks arising from the variability in potency and additives found in illicit drugs. Stimulants have increasingly been found in the victims of opioid overdoses, further prompting some to argue for the prescription of stimulant medications for individuals with stimulant use disorders. Yet, the evidence supporting this practice remains insufficient. In this communication, we critically examine the existing evidence, challenges, and cautions surrounding the treatment of stimulant use disorder.

Evaluating preferences for online psychological interventions to decrease cannabis use in young adults with psychosis: An observational study

Innovative technology-based solutions have the potential to improve access to clinically proven interventions for cannabis use disorder (CUD) in individuals with first episode psychosis (FEP). High patient engagement with app-based interventions is critical for achieving optimal outcomes. 104 individuals 18 to 35 years old with FEP and CUD from three Canadian provinces completed an electronic survey to evaluate preferences for online psychological intervention intensity, participation autonomy, feedback related to cannabis use, and technology platforms and app functionalities. The development of the questionnaire was informed by a qualitative study that included patients and clinicians. We used Best-Worst Scaling (BWS) and item ranking methodologies to measure preferences. Conditional logistic regression models for BWS data revealed high preferences for moderate intervention intensity (e.g., modules with a length of 15 min) and treatment autonomy that included preferences for using technology-based interventions and receiving feedback related to cannabis use once a week. Luce regression models for rank items revealed high preferences for smartphone-based apps, video intervention components, and having access to synchronous communications with clinicians and gamification elements. Results informed the development of iCanChange (iCC), a smartphone-based intervention for the treatment of CUD in individuals with FEP that is undergoing clinical testing.

Reducing Cannabis Use in Young Adults With Psychosis Using iCanChange, a Mobile Health App: Protocol for a Pilot Randomized Controlled Trial (ReCAP-iCC)

BACKGROUND

Cannabis use is the most prevalent among adolescents and young adults; frequent consumption is associated with cannabis use disorder (CUD) and psychosis, with a high prevalence (up to 50%) of CUD in individuals with first-episode psychosis (FEP). Early Intervention Services (EIS) for psychosis include face-to-face psychosocial interventions for CUD, because reducing or discontinuing cannabis use improves clinical and health care service use outcomes. However, multiple barriers (eg, staff availability and limited access to treatment) can hinder the implementation of these interventions. Mobile health (mHealth) interventions may help circumvent some of these barriers; however, to date, no study has evaluated the effects of mHealth psychological interventions for CUD in individuals with FEP.

OBJECTIVE

This study describes the protocol for a pilot randomized controlled trial using a novel mHealth psychological intervention (iCanChange [iCC]) to address CUD in young adults with FEP. iCC was developed based on clinical evidence showing that in individuals without psychosis, integrating the principles of cognitive behavioral therapy, motivational interviewing, and behavioral self-management approaches are effective in improving cannabis use-related outcomes.

METHODS

Consenting individuals (n=100) meeting the inclusion criteria (eg, aged 18-35 years with FEP and CUD) will be randomly allocated in a 1:1 ratio to the intervention (iCC+modified EIS) or control (EIS) group. The iCC is fully automatized and contains 21 modules that are completed over a 12-week period and 3 booster modules available during the 3-month follow-up period. Validated self-report measures will be taken via in-person assessments at baseline and at 6, 12 (end point), and 24 weeks (end of trial); iCC use data will be collected directly from the mobile app. Primary outcomes are intervention completion and trial retention rates, and secondary outcomes are cannabis use quantity, participant satisfaction, app use, and trial recruiting parameters. Exploratory outcomes include severity of psychotic symptoms and CUD severity. For primary outcomes, we will use the chi-square test using data collected at week 12. We will consider participation in iCC acceptable if ≥50% of the participants complete at least 11 out of 21 intervention modules and the trial feasible if attrition does not reach 50%. We will use analysis of covariance and mixed-effects models for secondary outcomes and generalized estimating equation multivariable analyses for exploratory outcomes.

RESULTS

Recruitment began in July 2022, and data collection is anticipated to be completed in July 2024. The main results are expected to be submitted for publication in 2024. We will engage patient partners and other stakeholders in creating a multifaceted knowledge translation plan to reach a diverse audience.

CONCLUSIONS

If feasible, this study will provide essential data for a larger-scale efficacy trial of iCC on cannabis use outcomes in individuals with FEP and CUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05310981; https://www.clinicaltrials.gov/ct2/show/NCT05310981.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40817.

Comparative efficacy and safety of pharmacotherapies for alcohol withdrawal: a systematic review and network meta-analysis

BACKGROUND AND AIMS

There have been few head-to-head clinical trials of pharmacotherapies for alcohol withdrawal (AW). We, therefore, aimed to evaluate the comparative performance of pharmacotherapies for AW.

METHODS

Six databases were searched for randomized clinical trials through November 2021. Trials were included after a blinded review by two independent reviewers. Outcomes included incident seizures, delirium tremens, AW severity scores, adverse events, dropouts, dropouts from adverse events, length of hospital stay, use of additional medications, total benzodiazepine requirements, and death. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary ORs and Cohen's d standardized mean differences (SMDs).

RESULTS

Across the 149 trials, there were 10 692 participants (76% male, median 43.5 years old). AW severity spanned mild (n = 32), moderate (n = 51), and severe (n = 66). Fixed-schedule chlormethiazole (OR, 0.16; 95% CI, 0.04-0.65), fixed-schedule diazepam (OR, 0.16; 95% CI, 0.04-0.59), fixed-schedule lorazepam (OR = 0.19; 95% CI, 0.08-0.45), fixed-schedule chlordiazepoxide (OR = 0.21; 95% CI, 0.08-0.53), and divalproex (OR = 0.22; 95% CI, 0.05-0.86) were superior to placebo at reducing incident AW seizures. However, only fixed-schedule diazepam (OR, 0.19; 95% CI, 0.05-0.76) reduced incident delirium tremens. Oxcarbazepine (d = -3.69; 95% CI, -6.21 to -1.17), carbamazepine (d = -2.76; 95% CI, -4.13 to -1.40), fixed-schedule oxazepam (d = -2.55; 95% CI, -4.26 to -0.83), and γ-hydroxybutyrate (d = -1.80; 95% CI, -3.35 to -0.26) improved endpoint Clinical Institute Withdrawal Assessment for Alcohol-Revised scores over placebo. Promazine and carbamazepine were the only agents significantly associated with greater dropouts because of adverse events. The quality of evidence was downgraded because of the substantial risk of bias, heterogeneity, inconsistency, and imprecision.

CONCLUSIONS

Although some pharmacotherapeutic modalities, particularly benzodiazepines, appear to be safe and efficacious for reducing some measures of alcohol withdrawal, methodological issues and a high risk of bias prevent a consistent estimate of their comparative performance.

Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review

OBJECTIVE

This study aims to review the neurobiology and symptomatology of post-acute alcohol withdrawal syndrome (PAWS).

METHOD

We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review of articles from two databases for English-language randomized and nonrandomized studies involving PAWS published between database inception and December 2020.

RESULTS

Twenty-seven studies met inclusion criteria. PAWS involves predominantly negative affect, which develops in early abstinence and can persist for 4-6 months or longer. Symptoms include anxiety, dysphoria, anhedonia, sleep disturbance, cognitive impairment, cravings, and irritability. PAWS symptoms appear to be risk factors for recurrent alcohol consumption. They have been associated with reported neurobiological differences in evoked potentials; measures of orexins, cortisol, serotonin, and pancreatic polypeptides; and neuroadaptation changes in the nucleus accumbens and the prefrontal cortex.

CONCLUSIONS

There is credible evidence to support the concept of PAWS based on this review's findings. There remains a need to develop and test specific criteria for PAWS. High-quality treatment studies involving agents addressing its neurobiological underpinnings are also recommended.

Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review

OBJECTIVE

This study aims to review the neurobiology and symptomatology of post-acute alcohol withdrawal syndrome (PAWS).

METHOD

We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review of articles from two databases for English-language randomized and nonrandomized studies involving PAWS published between database inception and December 2020.

RESULTS

Twenty-seven studies met inclusion criteria. PAWS involves predominantly negative affect, which develops in early abstinence and can persist for 4-6 months or longer. Symptoms include anxiety, dysphoria, anhedonia, sleep disturbance, cognitive impairment, cravings, and irritability. PAWS symptoms appear to be risk factors for recurrent alcohol consumption. They have been associated with reported neurobiological differences in evoked potentials; measures of orexins, cortisol, serotonin, and pancreatic polypeptides; and neuroadaptation changes in the nucleus accumbens and the prefrontal cortex.

CONCLUSIONS

There is credible evidence to support the concept of PAWS based on this review's findings. There remains a need to develop and test specific criteria for PAWS. High-quality treatment studies involving agents addressing its neurobiological underpinnings are also recommended.

Management of Post-Acute Alcohol Withdrawal: A Mixed-Studies Scoping Review

OBJECTIVE

This article reviews research on post-acute alcohol withdrawal syndrome (PAWS) management.

METHOD

We conducted a PRISMA (Preferred Reporting Items for Systematic Revision and Meta-Analyses)-guided scoping review of the published PAWS literature, searching six electronic databases (from their inception through December 2020) for English-language randomized and nonrandomized studies.

RESULTS

A total of 16 treatment studies met the inclusion criteria. The strength of evidence overall for pharmacologic treatments is low, with often only short-term results being reported, small treatment samples used, or inconsistent results found. However, for negative affect and sleep symptoms, more evidence supports using gabapentinoids (gabapentin and pregabalin) and anticonvulsants (carbamazepine and oxcarbazepine). Although preliminary data support acamprosate, there were no controlled trials. Despite an older treatment trial showing some positive data for amitriptyline for mood, the clinical measures used were problematic, and side effects and safety profile limit its utility. Finally, there is no evidence that melatonin and other agents (homatropine, Proproten-100) show PAWS symptoms.

CONCLUSIONS

Although there is some evidence for targeted pharmacotherapy for treating specific PAWS symptoms, there are few recent, robust, placebo-controlled trials, and the level of evidence for treatment efficacy is low.

Strategies to aid self-isolation and quarantine for individuals with severe and persistent mental illness during the COVID-19 pandemic: A systematic review

Background

Individuals with severe and persistent mental illness (SPMI) have a higher risk of contracting COVID‐19 than individuals without SPMI. In combination with physical distancing, hygiene protocols, and vaccines, quarantine and self‐isolation are primary means of viral containment. However, individuals with SPMI may experience more difficulties with mandated quarantine or self‐isolation because of their illness(es), stigma, and marginalization. To date, there is a lack of consensus on strategies that could aid such individuals in completing isolation.

Aim

This review aimed to synthesize evidence for interventions to support self‐isolation and mandated quarantine for COVID‐19 among individuals with SPMIs.

Methods

We followed the PRISMA guidelines, searching 19 electronic databases (9 published literature registries and 10 gray literature sources). We looked for relevant randomized controlled trials, quasi‐experimental studies, and program evaluations of the effectiveness of relevant psychosocial, pharmacological, harm reduction, and addiction management strategies to support isolation settings or quarantine requirements for individuals with any SPMI (e.g., any mental disorder, substance use disorder, or their combination).

Findings

Of 10,298 total records that were located, 5582 were duplicate citations. Upon screening the remaining 4716 unique records by title and abstract, we excluded a further 3562 records. Only one original article met our inclusion criteria after reviewing the full texts of the remaining 1154 citations. To support individuals experiencing homelessness during the COVID‐19 pandemic, San Francisco developed an isolation hotel that reduced COVID‐19 hospital strain for 1009 participants (25% had a mental health disorder and 26% had a substance use disorder). While 81% completed their hotel stay, 48 patients had behavioral health needs that exceeded the hotel's capabilities. No other studies met our review's eligibility criteria. Most articles located by the search simply proposed solutions or discussed the challenges brought by COVID‐19 for people with SPMIs. While some documents went a step further (e.g., shelter guidance documents to support individuals experiencing homelessness), these rarely addressed individuals with SPMIs directly.

Conclusions

This systematic review evaluated evidence from published and gray literature on interventions to support self‐isolation and mandated COVID‐19 quarantine for individuals with SPMIs. Only one study met our inclusion criteria. This study found a beneficial effect of a dedicated isolation hotel for individuals experiencing homelessness and COVID‐19—where approximately 25%–50% of the study sample had a mental or substance use disorder. While there has been an abundance of COVID‐19 protocols in general, information for SPMIs is lacking. As the pandemic continues and we better prepare for future pandemics, developing protocols for supporting SPMIs in this context is imperative.

Individuals with severe and persistent mental illness (SPMI) have a higher risk of contracting COVID‐19 than individuals without SPMI.

This review aimed to synthesize evidence for interventions to support self‐isolation and mandated quarantine for COVID‐19 among individuals with SPMIs.

Only one study met our inclusion criteria. This study found a beneficial effect of a dedicated isolation hotel for individuals experiencing homelessness and COVID‐19—where approximately 25%–50% of the study sample had a mental or substance use disorder.

While there has been an abundance of COVID‐19 protocols in general, information for SPMIs is lacking.

As the pandemic continues and we better prepare for future pandemics, developing protocols for supporting SPMIs in this context is imperative.

Towards competency-based medical education in addictions psychiatry: a systematic review

BACKGROUND

Current curriculum guidelines for addiction training in psychiatry need to be adapted to the competency by design framework to integrate clinical skills in addiction.

OBJECTIVE

We conducted a systematic review to identify curricular and educational interventions to build competency among psychiatry residents and fellows in addiction psychiatry.

METHODS

We followed the PRISMA guidelines, searching five databases from inception to August 2020 for relevant evaluation-type studies exploring addiction psychiatry competency among psychiatry residents and fellows. We appraised study quality using the Joanna Briggs Institute's risk of bias tool for observational designs.

RESULTS

From 1600 records, 17 studies met inclusion criteria. Addiction psychiatry competencies spanned themes involving core knowledge development; attitudinal, communication and leadership skills; screening, assessment, diagnosis; management; and special populations. Examples of effective educational interventions to enhance addiction competency include specific modules for substance use disorders and integrated clinical rotations that simultaneously combine multiple types of skills. Lived experience improved trainee attitudes towards addiction psychiatry.

CONCLUSIONS

While there is current evidence supporting strategies for developing competency in addiction psychiatry, the lack of studies measuring sustained competence over a longer-term follow-up period and the absence of randomized controlled trials limit the overall strength of evidence in this review. Current psychiatry entrustable professional activities (EPAs) involving addiction only partly overlap with curriculum training guidelines and studies identified in this review. These EPAs need to be better identified for training programs, competence in those EPAs better delineated for residents and preceptors, and evaluations should be done to ensure that adequate competence in addictions is attained and sustained.

Chronic bryostatin-1 rescues autistic and cognitive phenotypes in the fragile X mice

Fragile X syndrome (FXS), an X-chromosome linked intellectual disability, is the leading monogenetic cause of autism spectrum disorder (ASD), a neurodevelopmental condition that currently has no specific drug treatment. Building upon the demonstrated therapeutic effects on spatial memory of bryostatin-1, a relatively specific activator of protein kinase C (PKC)ε, (also of PKCα) on impaired synaptic plasticity/maturation and spatial learning and memory in FXS mice, we investigated whether bryostatin-1 might affect the autistic phenotypes and other behaviors, including open field activity, activities of daily living (nesting and marble burying), at the effective therapeutic dose for spatial memory deficits. Further evaluation included other non-spatial learning and memory tasks. Interestingly, a short period of treatment (5 weeks) only produced very limited or no therapeutic effects on the autistic and cognitive phenotypes in the Fmr1 KO2 mice, while a longer treatment (13 weeks) with the same dose of bryostatin-1 effectively rescued the autistic and non-spatial learning deficit cognitive phenotypes. It is possible that longer-term treatment would result in further improvement in these fragile X phenotypes. This effect is clearly different from other treatment strategies tested to date, in that the drug shows little acute effect, but strong long-term effects. It also shows no evidence of tolerance, which has been a problem with other drug classes (mGluR5 antagonists, GABA-A and -B agonists). The results strongly suggest that, at appropriate dosing and therapeutic period, chronic bryostatin-1 may have great therapeutic value for both ASD and FXS.

A Randomized, Double-Blind, Placebo-Controlled, Phase II Study Assessing Safety, Tolerability, and Efficacy of Bryostatin in the Treatment of Moderately Severe to Severe Alzheimer's Disease

BACKGROUND

Bryostatin-activated PKC epsilon pre-clinically induces synaptogenesis, anti-apoptosis, anti-amyloid-β oligomers, and anti-hyperphosphorylated tau.

OBJECTIVES

To investigate bryostatin safety, tolerability, and efficacy to improve cognition in advanced Alzheimer's disease (AD) patients.

METHODS

A double-blind, randomized, placebo-controlled Phase II, 12-week trial of i.v. bryostatin for 150 advanced AD patients (55-85) with MMSE-2 of 4-15, randomized 1:1:1 into 20 μg and 40 μg bryostatin, and placebo arms. The Full Analysis Set (FAS) and the Completer Analysis Set (CAS) were pre-specified alternative assessments (1-sided, p < 0.1 for primary efficacy, and 2-sided, p < 0.05 for pre-specified and post hoc exploratory analyses).

RESULTS

The safety profile was similar for 20 μg treatment and placebo patients. The 40 μg patients showed safety and drop-out issues, but no efficacy. Primary improvement of Severe Impairment Battery (SIB) scores at 13 weeks was not significant (p = 0.134) in the FAS, although in the CAS, the SIB comparison favored 20 μg bryostatin compared to placebo patients (p < 0.07). Secondary analyses at weeks 5 and 15 (i.e., 30 days post-final dosing) also favored 20 μg bryostatin compared to placebo patients. A pre-specified ANCOVA for baseline memantine blocking bryostatin and positive post-hoc trend analyses were statistically significant (2-sided, p < 0.05).

CONCLUSION

Although the primary endpoint was not significant in the FAS, primary and secondary analyses in the CAS, and pre-specified and post-hoc exploratory analyses did favor bryostatin 20 μg compared to the placebo cohort. These promising Phase II results support further trials of 20 μg bryostatin- without memantine- to treat AD.

Canadian Schizophrenia Guidelines: Schizophrenia and Other Psychotic Disorders with Coexisting Substance Use Disorders

OBJECTIVE

Persons with schizophrenia and other psychotic disorders frequently have coexisting substance use disorders that require modifications to treatment approaches for best outcomes. The objectives of this review were to identify evidence-based practices best practices that improve outcomes for individuals with schizophrenia and substance used disorders.

METHOD

We reviewed guidelines that were published in the last 5 years and that included systematic reviews or meta-analyses. Most of our recommendations came from 2 publications from the National Institute for Health and Care Excellence (NICE): the 2011 guidance titled Coexisting Severe Mental Illness (Psychosis) and Substance Misuse: Assessment and Management in Healthcare Settings and the 2014 guidance titled Psychosis and Schizophrenia in Adults: Prevention and Management. We placed these recommendations into the Canadian context to create this guideline.

RESULTS

Evidence supports the inclusion of individuals with coexisting substance use disorders in first-episode psychosis programs. The programs should integrate psychosis and substance use treatments, emphasizing ongoing monitoring of both substance use and patterns and symptoms. The best outcomes are achieved with combined use of antipsychotic medications and addiction-based psychosocial interventions. However, limited evidence is available to recommend using one antipsychotic medication over another or one psychosocial intervention over another for persons with schizophrenia and other psychotic disorders with coexisting substance use disorders.

CONCLUSIONS

Treating persons who have schizophrenia and other psychotic disorders with coexisting substance use disorders can present clinical challenges, but modifications in practice can help engage and retain people in treatment, where significant improvements over time can be expected.

Addiction medicine in Canada: challenges and prospects

In Canada, the qualification of physicians is the jurisdiction of the College of Family Physicians and the Royal College of Physicians and Surgeons. The Colleges have promoted the training of "generalists" in family medicine and "sophisticated generalists" among the traditional specialties, and the development of subspecialties has not been encouraged. Nevertheless, due to the increasing number of family physicians and specialists practicing a range of new subspecialties, including addiction medicine, the College of Family Physicians has recognized special interest or focused practices, whereas the Royal College has recognized, in psychiatry, 3 subspecialties (child, geriatric, forensic) requiring an extra year of training and may offer others a diploma recognition. These new opportunities will shape the training requirements of addiction medicine leading to available certification through the International and American Medical Societies of Addiction Medicine.

Thymosin beta4: structure, function, and biological properties supporting current and future clinical applications

Published studies have described a number of physiological properties and cellular functions of thymosin beta4 (Tbeta4), the major G-actin-sequestering molecule in mammalian cells. Those activities include the promotion of cell migration, blood vessel formation, cell survival, stem cell differentiation, the modulation of cytokines, chemokines, and specific proteases, the upregulation of matrix molecules and gene expression, and the downregulation of a major nuclear transcription factor. Such properties have provided the scientific rationale for a number of ongoing and planned dermal, corneal, cardiac clinical trials evaluating the tissue protective, regenerative and repair potential of Tbeta4, and direction for future clinical applications in the treatment of diseases of the central nervous system, lung inflammatory disease, and sepsis. A special emphasis is placed on the development of Tbeta4 in the treatment of patients with ST elevation myocardial infarction in combination with percutaneous coronary intervention.

A randomized, placebo-controlled, single and multiple dose study of intravenous thymosin beta4 in healthy volunteers

Synthetic thymosin beta 4 (Tbeta4) may have a potential use in promoting myocardial cell survival during acute myocardial infarction. Four cohorts, with 10 healthy subjects each, were given a single intravenous dose of placebo or synthetic Tbeta4. Cohorts received ascending doses of either 42, 140, 420, or 1260 mg. Following safety review, subjects were given the same dose regimen daily for 14 days. Safety evaluations, incidence of Treatment-Emergent Adverse Events, and pharmacokinetic parameters were evaluated. Adverse events were infrequent, and mild or moderate in intensity. There were no dose limiting toxicities or serious adverse events. Pharmacokinetic profile for single dose showed a dose proportional response, and an increasing half-life with increasing dose. Synthetic Tbeta4 given intravenously as a single dose or in multiple daily doses for 14 days over a dose range of 42-1260 mg was well tolerated with no evidence of dose limiting toxicity. Further development for use in cardiac ischemia should be considered.

The impact of opening a smoking room on psychiatric inpatient behavior following implementation of a hospital-wide smoking ban

BACKGROUND

Psychiatric patients are significantly more likely to smoke than mentally healthy persons, presenting a challenge for inpatient psychiatric care when smoking bans are instituted.

OBJECTIVE

To assess the impact of opening a smoking room within a psychiatric unit following a hospital smoking ban.

STUDY DESIGN

A staff survey and a chart review of 180 inpatient admissions before and after the opening of a smoking room.

RESULTS

Patient records revealed no significant differences between recorded indices of disruptive patient behavior before or after the smoking room opening. The staff survey identified a perceived beneficial impact on unit atmosphere, where less time was spent discussing smoking privileges and off-unit privileges were granted more appropriately.

CONCLUSIONS

Implementation of a smoking room failed to reduce indices of disruptive patient behavior. Despite the absence of objective evidence, the attitude among staff was in support of allowing patients to smoke on the unit.

Cigarette smoking, nicotine dependence, and motivation for smoking cessation in psychiatric inpatients

OBJECTIVE

Cigarette smoking is the leading preventable cause of death and disease in Canada, and is disproportionately more frequent among psychiatric patients. Smoking cessation interventions can be successfully implemented with psychiatric patients, yet no Canadian studies have evaluated smoking prevalence, nicotine dependence, and motivation for smoking cessation in psychiatric inpatients. Our study did so to help plan appropriate interventions for these patients.

METHOD

All inpatients aged 18 years or older admitted to acute-care psychiatry units at the Foothills Medical Centre in Calgary, Alberta, during a 6-month period completed a survey involving questions from the Canadian Tobacco Use Monitoring Survey, the Fagerstrom Test for Nicotine Dependence (FTND), the Readiness to Quit Ladder, and the Decisional Balance for Cigarette Smoking. Responses were analyzed for correlation with discharge diagnoses, age, and sex.

RESULTS

Among the total inpatients (n = 342), 211 (62%) completed the survey. Among those, 55% were current cigarette smokers and 17.5% were former smokers. Nicotine dependence (FTND > or = 6) was reported in 45.2% of smokers. Smoking prevalence and nicotine dependence severity was greatest in the substance use disorders (SUD) and psychotic disorders groups. Current smokers endorsed more negative than positive attributes of smoking. Regarding smoking cessation, 51% of patients were precontemplative, 12.7% contemplative, and 36.2% preparatory or action-oriented, despite few receiving advice to quit.

CONCLUSIONS

Cigarette smoking and nicotine dependence are highly prevalent in psychiatric inpatients. However, self-reported motivation for smoking cessation is noteworthy, emphasizing that cessation advice and appropriate follow-up care should be provided to psychiatric inpatients who smoke.

Development of thymosin beta4 for treatment of patients with ischemic heart disease

Thymosin beta 4 (Tbeta4) is a highly conserved, 43-amino acid acidic peptide (pI 4.6) that was first isolated from bovine thymus tissue over 25 years ago. It is present in most tissues and cell lines and is found in high concentrations in blood platelets, neutrophils, macrophages, and other lymphoid tissues. Tbeta4 has numerous physiological functions, the most prominent of which being the regulation of actin polymerization in mammalian nucleated cells and with subsequent effects on actin cytoskeletal organization, necessary for cell motility, organogenesis, and other important cellular events. Recently, Tbeta4 was shown to be expressed in the developing heart and found to stimulate migration of cardiomyocytes and endothelial cells, promote survival of cardiomyocytes (Nature, 2004), and most recently to play an essential role in all key stages of cardiac vessel development: vasculogenesis, angiogenesis, and arteriogenesis (Nature 2006). These results suggest that Tbeta4 may have significant therapeutic potential in humans to protect myocardium and promote cardiomyocyte survival in the acute stages of ischemic heart disease. RegeneRx Biopharmaceuticals, Inc. is developing Tbeta4 for the treatment of patients with acute myocardial infarction (AMI). Such efforts presented will include the formulation, development, and manufacture of a suitable drug product for use in the clinic, the performance of nonclinical pharmacology and toxicology studies, and the implementation of a phase 1 clinical protocol to assess the safety, tolerability, and the pharmacokinetics of Tbeta4 in healthy volunteers. A phase 2 proof of principle clinical trial in AMI patients is in the planning stage and will not be presented at this time.

Brain neuroimaging in cannabis use: a review

In this study, the authors systematically reviewed structural and functional neuroimaging studies of cannabis use. Structural abnormalities generally have not been identified with chronic use. Regular users demonstrate reciprocal changes in brain activity globally and in cerebellar and frontal regions. Abstinence results in decreases, and administration results in increases correlating with subjective intoxication. Chronic use and cannabis administration result in attenuated brain activity in task-activated regions or activation of compensatory regions. Findings correlate partially with neuropsychological data, but generalization is limited by the lack of use of diagnostic criteria, appropriately paired neuropsychological testing or means to better quantify cannabis use and abstinence.

A randomized, open-label pilot comparison of gabapentin and bupropion SR for smoking cessation

This 6-week, randomized, open-label pilot study estimated the treatment effect size of gabapentin (n = 17) compared with bupropion SR (n = 19) for smoking cessation, thereby allowing sample size calculations for a definitive comparison study. The primary outcome measure was smoking cessation. Secondary outcome measures included smoking reduction and withdrawal severity. Gabapentin was less efficacious than bupropion for smoking cessation but was associated with fewer dropouts from adverse effects. Withdrawal severity was less with bupropion. Bupropion remains the first-line non-nicotine pharmacotherapy for smoking cessation. Further study is required to determine if gabapentin has any useful role in smoking cessation. Based on our primary outcome measure, 79 subjects would be required in each treatment group of a two-armed study to achieve 90% power for detecting a difference in efficacy between gabapentin and bupropion.

Preparing psychiatry residents for the certification exam: a survey of residency and exam experiences

OBJECTIVE

To determine which methods best prepare psychiatry residents for the certification exam, and ultimately for practice, to facilitate appropriate residency program curriculum changes.

METHOD

We sent an anonymous survey to all final year (that is, PGY5) Canadian university-affiliated psychiatry residents, regarding frequency and diversity of observed interviews, form of feedback delivery, research and other training experiences, self-perception of preparedness and knowledge base, and management strategies for exam anxiety 6 months before and immediately after the certification exam.

RESULTS

There was a 52% response rate. Residents from across Canada identified the following factors as enabling successful exam completion: regular mock orals supervised by Royal College examiners, clinical experience with exposure to a wide spectrum of pathologies, individual and group study time, and appropriate anxiety management. Preparation for the oral exam involving sample case vignettes with presentation and formulation skills training was considered to be essential but was identified as an area of educational and experiential weakness in some programs.

CONCLUSIONS

To prepare psychiatry residents for successful completion of their certification exam, programs should incorporate regular mock orals observed by Royal College examiners throughout residency training (not just in PGY2 and PGY5). Programs should also incorporate training in case vignettes, training in oral exam skills, and teaching of anxiety-management strategies.

Psychiatric admissions of Asian Canadians to an adolescent inpatient unit

OBJECTIVE

To compare the psychiatric diagnoses for Asian Canadians admitted to an adolescent inpatient unit with those of their white Canadian peers.

METHOD

A literature review was first completed and then followed by a hospital file review of the Asian Canadians admitted over a 5-year period to the adolescent inpatient psychiatric unit. The data extracted (relating to psychiatric diagnosis, age, length of stay, referral source, family type, and gender) were then compared with a random sample of white Canadians admitted to the same unit during the same 5-year time frame.

RESULTS

There were far fewer Asian Canadians admitted than would be expected based on Calgary's demographics. There was equal gender representation among those who were admitted, and they tended to be older and to have a greater preponderance of severe psychiatric symptomatology than their white Canadian peers.

CONCLUSIONS

This paper adds to previous research in emphasizing that ethnocultural factors play a significant role in the utilization of psychiatric services by immigrant populations.