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

Examining healthcare professionals' beliefs and actions regarding the physical health of people with schizophrenia

BACKGROUND

People with schizophrenia have a higher premature mortality risk compared with the general population mainly due to cardiovascular disease (CVD). Despite this, people with schizophrenia are less likely to access physical health services or have their physical health investigated and monitored.

AIMS

To examine the beliefs and actions of mental health professionals regarding the physical health of people with schizophrenia.

METHOD

Two hundred and fifty-five healthcare professionals who support people with schizophrenia within Greater Manchester Mental Health NHS Foundation Trust (GMMH), United Kingdom and Pennine Care NHS Foundation Trust (PCFT), United Kingdom took part. Beliefs and actions were assessed using a self-administered questionnaire, which was constructed around two primary domains (1) CVD risk factors; and (2) physical health interventions. Descriptive statistics were reported and responses between different healthcare professional groups were compared.

RESULTS

The overwhelming majority of participants were aware of established CVD risk factors with 98% identifying family history of CVD, 98% for smoking and 96% for high blood pressure. Most participants believed nearly all healthcare professionals were responsible for monitoring the physical health of people with schizophrenia, regardless of job speciality. There were 67% of participants who reported delivering an intervention to improve sedentary behaviour for people with schizophrenia. However, awareness of government and NHS recommended lifestyle interventions were low.

CONCLUSIONS

This study found good knowledge regarding many established CVD risk factors but little clarity regarding who is responsible for monitoring the physical health of people with schizophrenia and how often brief lifestyle interventions are being implemented.

Predicting factors for non-suicidal self-injury in patients with schizophrenia spectrum disorders and the role of substance use

Non-suicidal self-injury (NSSI) has been shown as a characteristic feature in many clinical populations in recent years and schizophrenia is one of the most common psychiatric disorders which is associated with NSSI. In this study, we aimed to investigate predictors of NSSI in patients with schizophrenia spectrum disorders (SSD) and the role of lifetime substance use disorder (SUD). A sample of 165 patients with a diagnosis of SSD who were in remission participated in the study. Lifetime NSSI was assessed using the Inventory of Statements About Self-injury (ISAS). Lifetime SUD were evaluated. Logistic regression analysis was conducted to predict NSSI. SUD was found to be related to NSSI in patients with SSD, and it was associated with an approximately fourfold increase in the risk of NSSI. The rates of lifetime SUD in our sample and in the NSSI (+) group were 38.2 % and 55.6 %, respectively. The most commonly abused substances among patients with NSSI were cannabis and synthetic cannabinoids. The prevalence of NSSI was 43.6 % in our sample. 'Self-cutting' was the most common type and 'affect regulation' was the most common function of NSSI. One of the most significant risk factors for NSSI was a previous history of suicide attempts. SUD appears to be a significant predictor of NSSI in patients with SSD. Further investigation of treatable risk factors such as SUD which are related to NSSI is needed. It is also essential to screen SSD patients for NSSI due to the probable relation to high risk of suicide.

A Qualitative Systematic Review of Caregivers' Experiences of Caring for Family Diagnosed with Schizophrenia

Objective: To synthesise qualitative research that explored caregivers' experiences of caring for family diagnosed with schizophrenia.Methods: Electronic databases including PsycINFO, PubMed, CINAHL and Scopus were searched to identify relevant journal articles published from 2000 to March 2019. Quality was assessed and thematic synthesis of the qualitative research evidence undertaken. Papers were screened and independently appraised by two reviewers using The Critical Appraisal Skills Programme (CASP) for Qualitative Studies Checklist. The review was guided by Thomas and Harden's framework for thematic synthesis of qualitative research evidence.Results: The breadth of information across the 43 papers was noteworthy. Review of the findings noted that almost all of what was discussed fell into three broad themes: the 'feelings' of the caregiver towards their role, the patient and others, including the health system; the 'impacts' of the diagnosis and their caregiving role on the caregiver; and the 'needs' of the caregiver to improve the patient's quality of life and thereby the caregiver's quality of life. Within needs also came recommendations for future changes.Conclusion: Studies have shown that the caregiving process is a complex one, with both negative and positive emotional reactions, societal barriers, such as stigma and isolation, and unmet needs, such as timely, relevant and helpful information. Meeting the needs identified by caregivers has the capacity to address the impacts of the illness and caregiving and thereby reduce the negative feelings associated with the caregiver role.

Early onset of cannabis use and violent behavior in psychosis

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

From apathy to addiction: Insights from neurology and psychiatry

The tendency to engage in addictive behaviors has long been tied to the actions of the dopamine system. Early theories were based on the fact that all addictive drugs and behaviors (such as gambling) increase dopamine levels in the striatum, and the evidence that dopamine signaled reward or reward prediction error. However, with a changing emphasis of addiction away from purely pharmacological models that emphasize tolerance and withdrawal, towards one of behavioral dyscontrol, is there still a place for abnormal dopamine signaling in addiction? Here we recast the dopamine theory of addiction based on the idea that tonic dopamine may index a continuous phenotype that goes from apathy to impulsivity and compulsivity. Higher tonic dopamine signaling would make individuals vulnerable to drug reinforcement and cue-induced craving. We relate this to computational models of dopamine signaling, and review clinical and neuroimaging evidence from Parkinson's Disease, schizophrenia and bipolar disorder in support of this model.

The COVID-19 Global Pandemic: Implications for People With Schizophrenia and Related Disorders

The coronavirus disease-19 (COVID-19) global pandemic has already had an unprecedented impact on populations around the world, and is anticipated to have a disproportionate burden on people with schizophrenia and related disorders. We discuss the implications of the COVID-19 global pandemic with respect to: (1) increased risk of infection and poor outcomes among people with schizophrenia, (2) anticipated adverse mental health consequences for people with schizophrenia, (3) considerations for mental health service delivery in inpatient and outpatient settings, and (4) potential impact on clinical research in schizophrenia. Recommendations emphasize rapid implementation of measures to both decrease the risk of COVID-19 transmission and maintain continuity of clinical care and research to preserve safety of both people with schizophrenia and the public.

Temperament and Character Profile and Its Clinical Correlates in Male Patients with Dual Schizophrenia

Personality traits are relevant in understanding substance use disorders (SUD) and schizophrenia (SZ), but few works have also included patients with dual schizophrenia (SZ+) and personality traits. We explored personality profile in a sample of 165 male patients under treatment, using the Temperament and Character Inventory-Revised. The participants were assigned to three groups of 55 patients each, according to previous diagnosis: SUD, SZ- and SZ+ (without/with SUD). We analyzed their clinical characteristics, relating them to personality dimensions. The SUD and SZ+ groups scored higher than SZ- in Novelty/Sensation Seeking. SZ- and SZ+ presented higher Harm Avoidance and lower Persistence than the SUD group. SZ+ patients showed the lowest levels of Self-directedness, while SZ- and SZ+ had higher scores in Self-transcendence than the SUD group. Several clinical characteristics were associated with personality dimensions depending on diagnosis, and remarkably so for psychiatric symptoms in the SZ- and SZ+ groups. The three groups had a maladaptive personality profile compared to general population. Our results point to different profiles for SUD versus SZ, while both profiles appear combined in the SZ+ group, with extreme scores in some traits. Thus, considering personality endophenotypes in SZ+ could help in designing individualized interventions for this group.

Schizophrenia

BACKGROUND

The lifetime prevalence of schizophrenia is 1%. Schizophrenia is among the most severe mental illnesses and gives rise to the highest treatment costs per patient of any disease. It is characterized by frequent relapses, marked impairment of quality of life, and reduced social and work participation.

METHODS

The group entrusted with the creation of the German clinical practice guideline was chosen to be representative and pluralistic in its composition. It carried out a systematic review of the relevant literature up to March 2018 and identified a total of 13 389 publications, five source guidelines, three other relevant German clinical practice guidelines, and four reference guidelines.

RESULTS

As the available antipsychotic drugs do not differ to any great extent in efficacy, it is recommended that acute antipsychotic drug therapy should be sideeffect- driven, with a number needed to treat (NNT) of 5 to 8. The choice of treatment should take motor, metabolic, sexual, cardiac, and hematopoietic considerations into account. Ongoing antipsychotic treatment is recommended to prevent relapses (NNT: 3) and should be re-evaluated on a regular basis in every case. It is also recommended, with recommendation grades ranging from strong to intermediate, that disorder- and manifestation-driven forms of psychotherapy and psychosocial therapy, such as cognitive behavioral therapy for positive or negative manifestations (effect sizes ranging from d = 0.372 to d = 0.437) or psycho-education to prevent relapses (NNT: 9), should be used in combination with antipsychotic drug treatment. Further aspects include rehabilitation, the management of special treatment situations, care coordination, and quality management. A large body of evidence is available to provide a basis for guideline recommendations, particularly in the areas of pharmacotherapy and cognitive behavioral therapy.

CONCLUSION

The evidence-based diagnosis and treatment of persons with schizophrenia should be carried out in a multiprofessional process, with close involvement of the affected persons and the people closest to them.

Does cannabis use predict psychometric schizotypy via aberrant salience?

Cannabis can induce acute psychotic symptoms in healthy individuals and exacerbate pre-existing psychotic symptoms in patients with schizophrenia. Inappropriate salience allocation is hypothesised to be central to the association between dopamine dysregulation and psychotic symptoms. This study examined whether cannabis use is associated with self-reported salience dysfunction and schizotypal symptoms in a non-clinical population. 910 University students completed the following questionnaire battery: the cannabis experience questionnaire modified version (CEQmv); schizotypal personality questionnaire (SPQ); community assessment of psychic experience (CAPE); aberrant salience inventory (ASI). Mediation analysis was used to test whether aberrant salience mediated the relationship between cannabis use and schizotypal traits. Both frequent cannabis consumption during the previous year and ASI score predicted variation across selected positive and disorganised SPQ subscales. However, for the SPQ subscales 'ideas of reference' and 'odd beliefs', mediation analysis revealed that with the addition of ASI score as a mediating variable, current cannabis use no longer predicted scores on these subscales. Similarly, cannabis use frequency predicted higher total SPQ as well as specific Positive and Disorganised subscale scores, but ASI score as a mediating variable removed the significant predictive relationship between frequent cannabis use and 'odd beliefs', 'ideas of reference', 'unusual perceptual experiences', 'odd speech', and total SPQ scores. In summary, cannabis use was associated with increased psychometric schizotypy and aberrant salience. Using self-report measures in a non-clinical population, the cannabis-related increase in selected positive and disorganised SPQ subscale scores was shown to be, at least in part, mediated by disturbance in salience processing mechanisms.

The overall and sex- and age-group specific incidence rates of cancer in people with schizophrenia: a population-based cohort study

AIMS

Decades of research show that people with schizophrenia have an increased risk of death from cancer; however, the relationship between schizophrenia and cancer incidence remains less clear. This population-based study investigates the incidence of seven common types of cancer among people with a hospital diagnosis of schizophrenia and accounting for the effects of age, sex and calendar time.

METHODS

This population-based study used 1990-2013 data from three nationwide Swedish registries to calculate the incidence (in total, by age group and by sex) of any cancer and of lung, oesophageal, pancreatic, stomach, colon, (in men) prostate and (in women) breast cancer in 111 306 people with a hospital diagnosis of schizophrenia. The incidence in people with diagnosed schizophrenia was compared with the incidence in the general population. Risk estimates accounted for the effects of calendar time.

RESULTS

In 1 424 829 person-years of follow-up, schizophrenia did not confer an overall higher cancer risk (IRR 1.02, 95% CI 0.91-1.13) but was associated with a higher risk for female breast (IRR 1.19, 95% CI 1.12-1.26), lung (IRR 1.42, 95% CI 1.28-1.58), oesophageal (IRR 1.25, 95% CI 1.07-1.46) and pancreatic (IRR 1.10, 95% CI 1.01-1.21) and a lower risk of prostate (IRR 0.66, 95% CI 0.55-0.79) cancer. Some age- and sex-specific differences in risk were observed.

CONCLUSIONS

People with schizophrenia do not have a higher overall incidence of cancer than people in the general population. However, there are significant differences in the risk of specific cancer types overall and by sex calling for efforts to develop disease-specific prevention programmes. In people with schizophrenia, higher risk generally occurs in those <75 years.

Schizophrenia and the retina: Towards a 2020 perspective

BACKGROUND

Differences between people with schizophrenia and psychiatrically healthy controls have been consistently demonstrated on measures of retinal function such as electroretinography (ERG), and measures of retinal structure such as optical coherence tomography (OCT). Since our 2015 review of this literature, multiple new studies have been published using these techniques. At the same time, the accumulation of data has highlighted the "fault lines" in these fields, suggesting methodological considerations that need greater attention in future studies.

METHODS

We reviewed studies of ERG and OCT in schizophrenia, as well as data from studies whose findings are relevant to interpreting these papers, such as those on effects of the following on ERG and OCT data: comorbid medical conditions that are over-represented in schizophrenia, smoking, antipsychotic medication, substance abuse, sex and gender, obesity, attention, motivation, and influences of brain activity on retinal function.

RESULTS

Recent ERG and OCT studies continue to support the hypothesis of retinal structural and functional abnormalities in schizophrenia, and suggest that these are relevant to understanding broader aspects of pathophysiology, neurodevelopment, and neurodegeneration in this disorder. However, there are differences in findings which suggest that the effects of multiple variables on ERG and OCT data need further clarification.

CONCLUSIONS

The retina, as the only component of the CNS that can be imaged directly in live humans, has potential to clarify important aspects of schizophrenia. With greater attention to specific methodological issues, the true potential of ERG and OCT as biomarkers for important clinical phenomena in schizophrenia should become apparent.

Staging and profiling for schizophrenia spectrum disorders: Inter-rater reliability after a short training course

OBJECTIVE

Clinical staging and profiling have been proposed as a new approach in order to refine the diagnostic assessment of schizophrenia spectrum disorders. However, only limited evidence is available for the inter-rater reliability of the clinical staging and profiling model. The aim of the present study was therefore to determine the inter-rater reliability of the clinical staging and profiling model for schizophrenia spectrum disorders, and to investigate whether a short course can improve inter-rater reliability.

METHODS

Consecutively recruited inpatients with schizophrenia spectrum disorders were included between January 2015 and January 2016 (study 1), and between March 2018 and October 2018 (study 2). By contrast with the assessors in study 1, all the assessors in study 2 were trained in clinical staging and profiling. We used the clinical staging model proposed by McGorry and identified profile characteristics. Inter-rater reliability was measured using the Intraclass Correlation Coefficient (ICC).

RESULTS

The ICC score for clinical staging in study 1 was moderate (0.578). It improved considerably in study 2 (0.757). In general, the ICC scores for the profile characteristics in studies 1 and 2 ranged from poor to sufficient (0.123-0.781).

CONCLUSION

This study demonstrated that inter-rater reliability in clinical staging was sufficient after training. However, inter-rater reliability for clinical profile characteristics was highly variable. The general implementation of the clinical staging model for schizophrenia spectrum disorders is therefore feasible but clinical profile characteristics should be used with caution.

The relationship between hopelessness and risk factors for early mortality in people with a lived experience of a serious mental illness

The purpose of this study was to explore the relationships between self-reported hopelessness and risk factors for premature mortality in people with serious mental illness (SMI). Data were extracted from the 2014 Health Center Patient Survey (N = 5,592). Having a diagnosis of SMI was significantly associated with self-reported hopelessness. Hypertension or high blood pressure, congestive heart failure, and chronic obstructive pulmonary disorder were significantly associated with self-reported hopelessness. Higher levels of hopelessness were found to be significantly associated with increased alcohol consumption. Hopelessness may be an important dimension of health in people with SMI.

Sexual health of women with schizophrenia: A review

Women with schizophrenia experience low rates of sexual satisfaction and high rates of sexual dysfunction. They are at high risk for adverse sexual health outcomes including unplanned pregnancies, induced abortions, and human immunodeficiency virus (HIV), and face higher rates of sexual violence and various forms of intimate partner violence. This review explores the complex and intersecting biopsychosocial risk factors that explain these outcomes among women with schizophrenia, including factors related to the illness itself, antipsychotic medications, medical and psychiatric comorbidities, stigma, childhood trauma, and social determinants of health including poverty and housing instability. Sexual health interventions designed to help women with schizophrenia achieve pleasurable and safe sexual experiences, free of coercion, discrimination and violence are few and far between, suggesting opportunities for future development in this area.

Prevalence of comorbid substance use in major depressive disorder in community and clinical settings, 1990-2019: Systematic review and meta-analysis

BACKGROUND

Comorbidity between Substance Use Disorders (SUDs) and major depression is highly prevalent. This systematic review and meta-analysis aimed to estimate the prevalence of SUDs in subjects diagnosed with a major depressive disorder (MDD) in community, inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2019. Prevalence of co-morbid SUDs and MDD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 48 articles identified by electronic searches with a total sample size of 348,550 subjects that yielded 14 unique epidemiological studies, 2 national case registry studies, 7 large cohort studies and 20 clinical studies using in- or out-patients. The prevalence of any SUD in individuals with MDD was 0.250. Maximum prevalence was found with alcohol use disorder (0.208), followed by illicit drug use disorder (0.118) and cannabis use disorder (0.117). Meta-analysis showed the pooled variance of any AUD in men with MDD was 36%, which was significantly higher than that for females with MDD (19%, OR 2.628 95% CI 2.502, 2.760).

CONCLUSIONS

Few studies were published over the last decade so current prevalence rates of SUD in MDD are needed. Meta-analysis revealed that SUDs in MDD are highly prevalent and rates have not changed over time. The persistently high prevalence suggests there is an urgent need for more informative studies to help develop better prevention and treatment options for reducing prevalence of SUDs in persons with major depression and co-morbid disorders.

Neurocognition and social cognition training as treatments for violence and aggression in people with severe mental illness

Aggressive and violent behavior, including both verbal and physical aggression, have considerable adverse consequences for people with schizophrenia. There are several potential causes of violent behavior on the part of people with severe mental illness, which include intellectual impairments, cognitive and social-cognitive deficits, skills deficits, substance abuse, antisocial features, and specific psychotic features. This review explores the interventions that have been tested to this date. Computerized Cognitive Training (CCT) or Computerized Social-Cognitive Training (CSCT) have been associated with reductions in violence. Combined CCT and CSCT have been found to improve social cognition and neurocognition, as well as everyday functioning when combined with rehabilitation interventions. These interventions have been shown to reduce violence in schizophrenia patients across multiple environments, including forensic settings. The reductions in violence and aggression have manifested in various ways, including reduced violent thinking and behavior, reduced physical and violent assaults, and reduced disruptive and aggressive behaviors. Effects of cognitive training may be associated with improvements in problem-solving and the increased ability to deploy alternative strategies. The effect of social cognition training on violence reduction appears to be direct, with improvements in violence related to the extent of improvement in social cognition. There are still remaining issues to be addressed in the use of CCT and CSCT, and the benefits should not be overstated; however, the results of these interventions are very promising.

Comorbidity Profiles of Psychotic Patients in Emergency Psychiatry

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

Cannabidiol for the treatment of psychosis among patients with schizophrenia and other primary psychotic disorders: A systematic review with a risk of bias assessment

Current treatments for primary psychotic disorders include antipsychotics, some of which have significant side effects or suboptimal efficacy. Cannabidiol is a cannabinoid with potential antipsychotic properties. This systematic review examines the use of cannabidiol as an antipsychotic treatment for primary psychotic disorders. CINAHL, EBM, EMBASE, MEDLINE and PubMed databases were searched from 1970 to 2019 for experimental and observational studies evaluating the antipsychotic and cognitive modulation properties of cannabidiol in individuals with psychotic disorders. There were eight eligible studies evaluating the antipsychotic potential of cannabidiol, involving a total of 210 participants. Due to study heterogeneity, we present the extracted data on general psychopathology, positive and negative symptoms, cognition and functioning outcomes as a narrative synthesis. We found limited evidence supporting antipsychotic efficacy for cannabidiol and none supporting its benefits for cognition or functioning. Cannabidiol treatment had an advantageous side effect profile compared to other antipsychotics and was well tolerated across studies. Observational studies had a higher risk of bias than experimental studies. Factors potentially contributing to variability in outcome results included cannabidiol dosage, treatment duration, use as an adjunctive treatment and participant inclusion criteria, which warrant further investigation to determine whether cannabidiol can be effective as a treatment for psychosis.

Once-Monthly Long-Acting Injectable Aripiprazole for the Treatment of Patients with Schizophrenia and Co-occurring Substance Use Disorders: A Multicentre, Observational Study

AIM

To evaluate the efficacy and impact of long-acting injectable (LAI) aripiprazole in patients with schizophrenia with a coexisting substance use disorder (SUD).

PATIENTS AND METHODS

A multicenter, observational, descriptive and retrospective study was conducted in patients with a DSM-5 diagnosis of schizophrenia who had a coexisting SUD and were treated with LAI-aripiprazole. Disease severity was evaluated with the Clinical Global Impression (CGI) severity scale for schizophrenia, daily functioning and disability were evaluated with the World Health Organisation Disability Assessment Scale (WHODAS-2.0), and the severity of the addiction was evaluated with the Severity of Dependence Scale (SDS).

RESULTS

The sample included 40 patients. Overall, after 6 months of treatment with LAI-aripiprazole at a dose of 400 mg/4 weeks in 77.5% of the patients, we observed significant improvement in the psychopathological symptoms, with a reduction of over 30% in the scores of the five CGI-severity scales. The WHODAS-2.0 mean (standard deviation) score was also significantly reduced from 57.6 (8.2) to 42.3 (4.3) points (p < 0.001). Regarding SUDs, after 6 months of treatment, substance use was stopped in 5 of the 9 patients with cocaine use disorder and in 3 of the 16 patients with alcohol abuse disorder. A significant reduction in the severity of the dependence was observed only in the subgroups of participants with cocaine and alcohol use disorders.

CONCLUSION

Our study suggests that once-monthly LAI-aripiprazole retains its antipsychotic efficacy in patients with schizophrenia and a coexisting SUD and could be useful for the management of cocaine or alcohol use disorders in this population.

Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder

Schizophrenia and schizoaffective disorder are schizophrenia spectrum disorders that cause significant disability. Among individuals who have schizophrenia or schizoaffective disorder, alcohol use disorder (AUD) is common, and it contributes to worse outcomes than for those who do not have co-occurring substance use disorder. Common neurobiological mechanisms, including dysfunction in brain reward circuitry, may explain the high rates of co-occurrence of schizophrenia and AUD or other substance use disorders. Optimal treatment combines pharmacologic intervention and other therapeutic modalities to address both the psychotic disorder and AUD. Further research on the etiology of these co-occurring disorders and on treatment of affected individuals is needed.

Comparison of the effectiveness of a 12 step substance use recovery program on quality of life

Substance-related disorders can adversely impact quality of life. This study assessed a 12 step program on health-related quality of life for Iranian individuals seeking to recover from substance use. The study used a quasi-experimental, two group, three stage, pre- and post-test design and collected data at baseline, and at 1 and 3 months' post-intervention. The treatment group comprised 35 participants in a 12 step program with a non-equivalent comparison group of individuals admitted to addiction treatment centers. Physical and mental health quality-of-life domains were assessed using the Short Form 36 Health Survey Questionnaire. The treatment group improved in all aspects of health-related quality of life. The treatment group improved compared to the comparison group for two of eight quality of life dimensions - physical functioning and role limitations due to emotional problems - at 1 month post-intervention. There were additional improvements at 3 months' follow up in six of eight quality-of-life subscales compared to the comparison group. The benefits to quality of life related to mental health recovery extended beyond the treatment program, indicating that the program principles were effectively implemented in daily life.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.

Coping Strategies in Male Patients under Treatment for Substance Use Disorders and/or Severe Mental Illness: Influence in Clinical Course at One-Year Follow-Up

Coping strategies have an impact on substance use disorders (SUD), relapses, and clinical variables, but knowledge on this area is scarce. We explored the coping strategies used during treatment in patients with dual diagnosis (DD), SUD, and severe mental illness (SMI), and the relation with clinical course and relapses at one-year follow-up. A sample of 223 patients was divided into three groups depending on diagnosis: DD (N = 80; SUD with comorbid schizophrenia or major depressive disorder), SUD only (N = 80), and SMI only (N = 63; schizophrenia or major depressive disorder). MANCOVA analyses reflected differences in self-criticism and problem avoidance, with a higher use of these in the DD and SUD groups. The coping strategies used differed depending on the presence/absence of a SUD, but not depending on psychiatric diagnosis. At one-year follow-up, social support was the only strategy that predicted the presence of relapses in DD patients with schizophrenia (positively), and in SMI patients with major depressive disorder (negatively). Thus, social support was associated with relapses, but the relationship was different depending on psychiatric diagnosis. Further studies should analyze the implications of social support as a coping strategy in different mental disorders, as well as its usefulness in individualized interventions.

Sex Differences in Clinical and Functional Outcomes among Patients Treated in an Early Intervention Service for Psychotic Disorders: An Observational Study

OBJECTIVE

It has been shown that men with a longstanding psychotic disorder have worse clinical and functional outcomes than women. Our objectives were to examine whether these sex differences are also present among patients treated in an early intervention service (EIS) for psychosis and to determine if these differences are related to risk factors other than sex.

METHOD

Patients (N = 569) were assessed for demographic/clinical characteristics at entry and for symptoms/functioning over 2 years of treatment. Clinical outcomes included remission of positive, negative, and total symptoms. Functional outcomes included good functioning and functional remission. Logistic regression models examined the relationship between sex and outcomes after 1 and 2 years of treatment while controlling for the influence of other risk factors.

RESULTS

Men reported to be less educated and have a longer duration of untreated psychosis, poorer childhood and early adolescent premorbid functioning, higher rates of substance abuse/dependence disorders, greater severity of baseline negative symptoms, and poorer baseline social/occupational functioning than women. Women were more likely to achieve symptom remission than men after 2 years of treatment (negative odds ratio [OR], 1.69; 95% confidence interval [CI], 1.02 to 2.78; total OR, 1.79; 95% CI, 1.08 to 2.98). Women were also more likely than men to exhibit good functioning (OR, 1.61; 95% CI, 1.04 to 2.49) after 1 but not after 2 years of treatment. These results did not persist after controlling for other risk factors that could confound these associations (i.e., childhood premorbid functioning and age at onset of psychosis).

CONCLUSIONS

Sex differences seen in outcomes among patients treated in an EIS for psychosis may be largely influenced by the disparity of other risk factors that exist between the 2 sexes.

Δ9-Tetrahydrocannabinol During Adolescence Attenuates Disruption of Dopamine Function Induced in Rats by Maternal Immune Activation

The combination of prenatal, such as maternal infections, and postnatal environmental insults (e.g., adolescent drug abuse) increases risks for psychosis, as predicted by the two-hit hypothesis of schizophrenia. Cannabis abuse during adolescence is widespread and is associated with increased risk of psychoses later in life. Here, we hypothesized that adolescent Δ⁹-tetrahydrocannabinol (THC) worsens the impact of prenatal maternal immune activation (MIA) on ventral tegmental area (VTA) dopamine cells in rat offspring. Additionally, since substance abuse disorder is particularly prevalent among schizophrenia patients, we also tested how VTA dopamine neurons in MIA offspring respond to acute nicotine and cocaine administration. We used a model of neurodevelopmental disruption based on prenatal administration of the polyriboinosinic-polyribocytidilic acid [poly (I:C)] in rats, which activates the maternal immune system by mimicking a viral infection and induces behavioral abnormalities and disruption of dopamine transmission relevant to psychiatric disorders in the offspring. Male offspring were administered THC (or vehicle) during adolescence (PND 45–55). Once adult (PND 70–90), we recorded the spontaneous activity of dopamine neurons in the VTA and their responses to nicotine and cocaine. MIA male offspring displayed reduced number, firing rate and altered activity pattern of VTA dopamine cells. Adolescent THC attenuated several MIA-induced effects. Both prenatal [poly (I:C)] and postnatal (THC) treatments affected the response to nicotine but not to cocaine. Contrary to our expectations, adolescent THC did not worsen MIA-induced deficits. Results indicate that the impact of cannabinoids in psychosis models is complex.

Effects of chronic physical illness on treatment outcomes among patients with schizophrenia

PURPOSE OF REVIEW

Previous research has demonstrated the high prevalence of medical comorbidity and multimorbidity among patients with schizophrenia. However, little is known regarding the potential effects of chronic physical illness (CPI) on schizophrenia treatment outcomes. In the present report, we aim to provide an updated review of the relevant literature.

RECENT FINDINGS

We searched MEDLINE for studies published between 2017 and 2018. After screening 683 articles, we included six studies of adequate quality. Five of these studies reported significant associations between several CPIs and different schizophrenia treatment outcomes, whereas the remaining study did not. Significant effects were low to moderate in size. CPIs with significant effects on treatment outcomes included metabolic syndrome, cardiovascular disease, and asthma. No significant effects were observed for diabetes, chronic obstructive pulmonary disease, hepatitis, hypertension, hyperlipidemia, or lung conditions. One study reported a significant association between the total number of CPIs and the overall number of psychiatric rehospitalizations.

SUMMARY

In addition to increasing the risk of premature mortality, accumulating evidence indicates that various CPIs affect schizophrenia treatment outcomes. Thus, researchers and healthcare practitioners should increase efforts to raise awareness regarding the importance of physical health among patients with schizophrenia. Further high-quality studies are required, particularly those targeting the potential effects of individual CPIs.

The impact of substance use on treatment as a compulsory patient

OBJECTIVES

This paper considers the impact of having a diagnosis of substance use disorder on the utilisation of compulsory orders under the Victorian Mental Health Act (2014).

METHODS

We analysed the subsequent treatment episodes over 2 years of people who had been on a community treatment order for at least 3 months and determined the odds of a further treatment order if there was a diagnosis of substance use at or about the time the index community treatment order ended.

RESULTS

An additional diagnosis of a substance use disorder was coded in 47.7% and was associated with significantly increased odds of a subsequent treatment order in the following 2 years for those with a main diagnosis of schizophrenia (AOR = 3.03, p<0.001) and 'other' disorders (AOR = 11.60, p=0.002). Those with a main diagnosis of mood disorder had a significant increase in odds for an inpatient treatment order if there was an additional substance use disorder diagnosis (AOR = 3.81, p=0.006).

CONCLUSIONS

Having an additional diagnosis of substance use disorder was associated with increased likelihood of being placed on an order. This study supports greater emphasis being given to treatment of substance use concurrently with that of mental illness.

Selective allosteric modulation of muscarinic acetylcholine receptors for the treatment of schizophrenia and substance use disorders

Muscarinic acetylcholine receptor (mAChRs) subtypes represent exciting new targets for the treatment of schizophrenia and substance use disorder (SUD). Recent advances in the development of subtype-selective allosteric modulators have revealed promising effects in preclinical models targeting the different symptoms observed in schizophrenia and SUD. M₁ PAMs display potential for addressing the negative and cognitive symptoms of schizophrenia, while M₄ PAMs exhibit promise in treating preclinical models predictive of antipsychotic-like activity. In SUD, there is increasing support for modulation of mesocorticolimbic dopaminergic circuitry involved in SUD with selective M₄ mAChR PAMs or M₅ mAChR NAMs. Allosteric modulators of these mAChR subtypes have demonstrated efficacy in rodent models of cocaine and ethanol seeking, with indications that these ligand may also be useful for other substances of abuse, as well as in various stages in the cycle of addiction. Importantly, allosteric modulators of the different mAChR subtypes may provide viable treatment options, while conferring greater subtype specificity and corresponding enhanced therapeutic index than orthosteric muscarinic ligands and maintaining endogenous temporo-spatial ACh signaling. Overall, subtype specific mAChR allosteric modulators represent important novel therapeutic mechanisms for schizophrenia and SUD.

Treatment of substance use disorders with co-occurring severe mental health disorders

PURPOSE OF REVIEW

To provide an update of treatment for substance use in patients with co-occurring substance use disorders (SUD) and mental health disorders (dual diagnosis) with a focus on both pharmacological and psychosocial interventions.

RECENT FINDINGS

A total of 1435 abstracts were identified, of which we selectively reviewed 43 for this narrative review. There is emerging evidence, both clinical and neurobiological, that clozapine is a more efficacious antipsychotic in treatment of individuals with schizophrenia and SUD. The use of depot atypical antipsychotic paliperidone palmitate in this population is also promising. Although valproate remains the treatment of choice in individuals with bipolar disorder and SUD, present evidence suggests that lithium and quetiapine may not be effective in this population. Naltrexone is the most effective anticraving agent in individuals with severe mental illness (SMI) and comorbid alcohol use disorders. The use of opioid substitution therapy in individuals with SMI and comorbid opioid use disorders is also associated with favorable outcomes. Varenicline shows promise in patients with SMI who smoke tobacco. Psychosocial interventions should be instituted early in the course of treatment. They should ideally be high intensity and based on established therapies used for SUD.

SUMMARY

The paucity of systematic studies in individuals with co-occurring mental health disorders and SUD remains a concern, given the enormous burden that they pose. However, there are a number of studies which have evaluated interventions, both psychosocial and pharmacological, which show promise and can guide clinical practice. VIDEO ABSTRACT: http://links.lww.com/YCO/A49.

The prevalence and clinical correlates of cannabis use and cannabis use disorder among patients with bipolar disorder: A systematic review with meta-analysis and meta-regression

Bipolar disorder (BD) is commonly associated with comorbidities, especially substance use disorders. In light of this, the present review aimed to investigate the prevalence and clinical correlates of cannabis use in BD. Studies evaluating the prevalence of cannabis use among patients with BD and studies reporting a dichotomous sample of patients with cannabis use compared to those without the use were included. Meta-analyses using random-effects models were performed, and sources of heterogeneity were explored using meta-regression. The search resulted in 2918 publications, of which 53 were included. The prevalence of cannabis use was 24% (95%CI:18-29; k = 35; n = 51,756). Cannabis use was significantly associated with being younger, male, and single; having fewer years of education and an earlier onset of affective symptoms; and lifetime psychotic symptoms, suicide attempts, and use of tobacco, alcohol, and other substances. In conclusion, cannabis use present in almost one-quarter of patients with BD and is associated with factors that are highly relevant for both clinical practice and public health.

Efficacy, acceptability and tolerability of antipsychotics in patients with schizophrenia and comorbid substance use. A systematic review and meta-analysis

Patients with schizophrenia and substance related comorbidity or substance induced psychotic disorder are difficult to treat. Although the prevalence of a comorbid substance use is approximately 40% in schizophrenia, such patients are usually excluded from clinical trials. We therefore performed a random-effects meta-analysis of all randomized controlled antipsychotic drug trials in this patient subgroup. We searched multiple databases up to May, 2018. The primary outcome was the reduction of substance user; secondary outcomes were craving, mean reduction of substance use, overall change in schizophrenia symptoms, positive and negative symptoms, response, dropouts, quality of life, social functioning, weight gain, sedation, prolactin, extrapyramidal side effects and use of antiparkinsonian medication. We identified 27 references from 19 RCTs published from 1999 to March 2017 including 1742 participants. The most frequent types of substance abuse were cannabis (8 studies) and cocaine (6 studies) use/dependence. Clozapine was superior to other antipsychotics for reduction of substance use and risperidone to olanzapine for craving. Olanzapine, clozapine and risperidone showed superiority for symptom reduction compared to some other drugs. When reported, results of side-effects followed known patterns. The evidence-base is considerable (19 RCTs), however, firm conclusions cannot be drawn due to small sample sizes of individual studies and insufficient reporting.

Integrating Treatment for Co-Occurring Mental Health Conditions

Given the high co-occurrence between alcohol use disorder (AUD) and mental health conditions (MHCs), and the increased morbidity associated with the presence of co-occurring disorders, it is important that co-occurring disorders be identified and both disorders addressed in integrated treatment. Tremendous heterogeneity exists among individuals with co-occurring conditions, and factors related to both AUD and MHCs, including symptom type and acuity, illness severity, the chronicity of symptoms, and recovery capital, should be considered when recommending treatment interventions. This article reviews the prevalence of co-occurring AUD and MHCs, screening tools to identify individuals with symptoms of AUD and MHCs, and subsequent assessment of co-occurring disorders. Types of integrated treatment and current challenges to integrate treatment for co-occurring disorders effectively are reviewed. Innovative uses of technology to improve education on co-occurring disorders and treatment delivery are also discussed. Systemic challenges exist to providing integrated treatment in all treatment settings, and continued research is needed to determine ways to improve access to treatment.