Symptomatic and functional outcomes of substance use disorder persistence 2 years after admission to a first-episode psychosis program

Clinical characteristics associated with functioning trajectories following admission to a psychiatric institution: A prospective cohort study of individuals with psychosis

Psychotic disorders can be severely enabling, and functional recovery is often difficult to achieve. Admission to a psychiatric unit represents a key opportunity to implement strategies that will improve functional outcomes. In the current literature, there is a lack of consensus on which factors influence functional recovery. Therefore, the present longitudinal cohort study aimed to identify factors associated with functional trajectories following hospital admission for acute psychosis. A sample of 453 individuals with acute psychosis was extracted from the Signature Biobank database. Participants were followed for up to a year following admission. Various clinical indicators were documented over time. Functional trajectories were calculated based on the World Health Organization Disability Assessment Schedule 2.0. Three groups were identified: "improving", "stable", and "worsening" function. Individuals with a more severe symptomatic presentation at baseline were found to have better functional improve more over time. Over time, individuals in the "improving" and "stable" groups had significant improvements in their psychiatric symptoms. Finally, individuals following a "worsening" functional trajectory initially improved in terms of psychotic symptoms, but it did not persist over time. These results highlight the importance of studying function as a key component of recovery rather than solely focusing on relapse prevention.

Behind the heterogeneity in the long-term course of first-episode psychosis: Different psychotic symptom trajectories are associated with different patterns of cannabis and stimulant use

BACKGROUND

Data-driven classification of long-term psychotic symptom trajectories and identification of associated risk factors could assist treatment planning and improve long-term outcomes in psychosis. However, few studies have used this approach, and knowledge about underlying mechanisms is limited. Here, we identify long-term psychotic symptom trajectories and investigate the role of illness-concurrent cannabis and stimulant use.

METHODS

192 participants with first-episode psychosis were followed up after 10 years. Psychotic symptom trajectories were estimated using growth mixture modeling and tested for associations with baseline characteristics and cannabis and stimulant use during the follow-up (FU) period.

RESULTS

Four trajectories emerged: (1) Stable Psychotic Remission (54.2 %), (2) Delayed Psychotic Remission (15.6 %), (3) Psychotic Relapse (7.8 %), (4) Persistent Psychotic Symptoms (22.4 %). At baseline, all unfavorable trajectories (2-4) were characterized by more schizophrenia diagnoses, higher symptom severity, and longer duration of untreated psychosis. Compared to the Stable Psychotic Remission trajectory, unstable trajectories (2,3) showed distinct associations with cannabis/stimulant use during the FU-period, with dose-dependent effects for cannabis but not stimulants (Delayed Psychotic Remission: higher rates of frequent cannabis and stimulant use during the first 5 FU-years; Psychotic Relapse: higher rates of sporadic stimulant use throughout the entire FU-period). The Persistent Psychosis trajectory was less clearly linked to substance use during the FU-period.

CONCLUSIONS

The risk for an adverse long-term course could be mitigated by treatment of substance use, where particular attention should be devoted to preventing the use of stimulants while the use reduction of cannabis may already yield positive effects.

Perspectives of young adults diagnosed with early psychosis using coordinated specialty care in Texas on substance use and substance use interventions

AIM

Despite known prevalence of substance use (SU) among young people experiencing early psychosis and increasing evidence for the relationship between certain substances (e.g., cannabis) and psychosis, there are no specialized interventions developed for effectively addressing substance use among young people participating in coordinated early psychosis services. This study elicited the perspectives of young people with early psychosis participating in Coordinated Specialty Care (CSC) programs about their substance use, including their motivations and concerns around their use, and their ideas on how to best support young people who are interested in reducing or quitting substance use.

METHODS

We recruited young adults (ages 18 to 30) from CSC programs across Texas through flyers sent to program staff inviting young persons willing to talk about substance use to engage in a 60-90 min person-centered, semi-structured, audio-recorded Zoom interview.

RESULTS

A total of 22 young adults were recruited and 18 completed an interview. Participants described mixed positive and negative responses to substance use, and while many understood the importance of discontinuing substance use, many expressed ambivalence related to social, contextual, mental and physical factors that motivated them to keep using. Participants desired practical substance use information, opportunities to explore their substance use ambivalence in supportive relationships, positive peer communities to support healthy choices, help engage, with work, school, and hobbies, and strategies for addressing psychological and physical pain that did not include substance use.

CONCLUSION

Study findings illuminate what motivates young people with early psychosis to initiate, continue, or cut back on substance use, and ideas for CSC practices for exploring substances and helping young people to reduce substance use.

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

Introduction

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

Methods

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

Results

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

Discussion

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

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.

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.

Substance use Specificities in Women with Psychosis: A Critical Review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A multiple baseline trial of adapted prolonged exposure psychotherapy for individuals with early phase psychosis, comorbid substance misuse, and a history of adversity: A study protocol

Background

Adversity is prevalent among people with psychotic disorders, especially those within the first 5 years of a psychotic disorder, called early phase psychosis. Although adversity can lead to many negative outcomes (e.g., posttraumatic stress symptoms), very few treatments for adversity-related sequelae have been tested with individuals with psychotic disorders, and even fewer studies have specifically tested interventions for people in early phase psychosis. Furthermore, people who misuse substances are commonly excluded from adversity treatment trials, which is problematic given that individuals with early phase psychosis have high rates of substance misuse. For the first time, this trial will examine the outcomes of an adapted 15-session prolonged exposure protocol (i.e., PE+) to observe whether reductions in adversity-related psychopathology occurs among people with early phase psychosis and comorbid substance misuse.

Methods

This study will use a multiple-baseline design with randomization of participants to treatment start time. Participants will complete baseline appointments prior to therapy, engage in assessments between each of the five therapy modules, and complete a series of follow-up appointments 2 months after the completion of therapy. Primary hypothesized outcomes include clinically significant reductions in (1) negative psychotic symptoms measured using the Positive and Negative Syndrome Scale, (2) adversity-related sequelae measured using the Trauma Symptom Checklist-40, and (3) substance use frequency and overall risk score measured with the Alcohol, Smoking, and Substance Involvement Screening Test. We also anticipate that clinically significant reductions in hopelessness and experiential avoidance, measured with the Beck Hopelessness Scale and Brief Experiential Avoidance Questionnaire, the theorized mechanisms of change of PE+, will also be observed. A secondary outcome is a hypothesized improvement in functioning, measured using the Clinical Global Impression and Social and Occupational Functioning Assessment scales.

Discussion

The results of this treatment trial will contribute to the advancement of treatment research for individuals in early phase psychosis who have current substance misuse and a history of adversity, and the findings may provide evidence supporting the use of hopelessness and experiential avoidance as mechanisms of change for this treatment.

Clinical trial registration

Clinicaltrials.gov, NCT04546178; registered August 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04546178?term=NCT04546178&draw=2&rank=1.

A Scoping and Systematic Review of Employment Processes and Outcomes for Young Adults Experiencing Psychosis

Young adults who experience psychosis want to work but are less likely to be employed than their peers. Sixty two studies relating to young adults with psychosis and employment were reviewed following a systematic search of five databases: CINAHL, PsycINFO, MEDLINE, SCOPUS and EMBASE. Publication date ranged from 1973 to 2019 with > 70% between 2010 and 2019. Intervention was considered in 29 papers; critical appraisal revealed 90% of these had moderate to good methodological quality with only three RCTs. Of 11 intervention types "Early Intervention" and "Individual Placement and Support" were most common; both demonstrating positive impact on obtaining employment. The review identified minimal participant perspectives and great variability in: terminology used; the reporting of participant attributes; intervention characteristics and ways employment outcomes were measured. Employment processes identified were preparing for, seeking, obtaining, keeping and re-obtaining employment, with current research efforts focused on obtaining work. More focus is required on keeping and re-obtaining employment.

Lurasidone use in Cannabis-Induced Psychosis: A Novel Therapeutic Strategy and Clinical Considerations in Four Cases Report

BACKGROUND

Lurasidone is an atypical antipsychotic approved for the acute and maintenance treatment of schizophrenia. Recently, lurasidone was also extended FDA approval for adults with major depressive episodes associated with bipolar I disorder (bipolar depression), as either a monotherapy or as adjunctive therapy with lithium or valproate. The use of low doses of atypical antipsychotics is an essential component of early intervention in psychosis, but little has yet been studied on first episode cannabis-induced psychosis. For its particular performance and tolerability, lurasidone is becoming an important option for the treatment of first-episode psychosis in youth. Case presentation four patients experiencing first cannabis-induced psychotic episode were treated with lurasidone. In all patients, there was an improvement in the clinical picture of psychosis. The recovery was positive, not only with the remission of positive and negative symptoms, but also regarding disruptive behaviour, with the return of functioning. All the patients were treated with lurasidone, with a target dose of 74-128 mg/day. No significant side effects were reported.

CONCLUSION

There are non-controlled studies for the use of lurasidone in first episode psychosis cannabis induced. These findings suggest that lurasidone is an atypical antipsychotic beneficial in this clinical picture. Treatment with medium-high doses of lurasidone could be effective and tolerable in this phase of the disorder. Randomized control trials with longer follow-up are recommended to confirm these positive results.

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.

Patients with Schizophrenia Showed Worse Cognitive Performance than Bipolar and Major Depressive Disorder in a Sample with Comorbid Substance Use Disorders

Comorbidity of substance use disorders (SUD) and severe mental illness (SMI) is highly frequent in patients, the most common diagnoses being schizophrenia (SZ), bipolar disorder (BD) and major depressive disorder (MDD). Since comorbidity has its own clinical features, and neurocognitive functioning is not always similar to psychiatric symptoms the present study explores the cognitive performance of patients with dual disorders. A neuropsychological battery of tests was used to assess 120 under treatment male patients, 40 for each group considered (SZ + SUD, BD + SUD and MDD + SUD) who were mainly polyconsumers. Significant differences (with premorbid IQ as a covariate) were found among the groups, with SZ + SUD having a worse performance in attention, verbal learning, short term memory and recognition. The consideration of a global Z score for performance evidenced an impaired neurocognitive pattern for SZ + SUD compared with BD + SUD and MDD + SUD. According to norms, all patients showed difficulties in verbal learning, short-term memory and recognition. Our research indicated that the neurocognitive functioning of dual disorder patients was influenced by the comorbid SMI, with SZ + SUD presenting major difficulties. Future studies should thoroughly explore the role of such difficulties as indicators or endophenotypes for dual schizophrenia disorders, and their usefulness for prevention and treatment.

A naturalistic study on the effectiveness of long-acting antipsychotics in an early intervention program for patients with recent-onset psychosis

AIM

To evaluate the impact of long-acting injectable antipsychotics (LAIs) on the risk of hospitalization and the length of hospitalization in the setting of an early intervention program for patients with recent-onset psychosis.

METHODS

Observational, retrospective study conducted under routine clinical practice conditions. We included all patients admitted from July 2015 to April 2020 to the Early Intervention Program in Psychosis. We analysed the incidence of hospitalization and hospitalization days before and after treatment with LAIs and calculated the incidence rate ratio (IRR). We also compared the outcomes of patients treated with LAIs with those of the patients maintained on oral antipsychotics using a binomial negative regression analysis.

RESULTS

A total of 170 patients were included in the program. Of them, 34 (20%) received LAIs (aripiprazole [n = 22], and paliperidone/risperidone [n = 12]). There was an 89% reduction in the incidence of hospitalizations after treatment with LAIs (IRR 0.11, 95%CI 0.05-0.21; p < .0001). The IRR for LAIs vs. oral antipsychotics was 0.87 (95%CI, 0.24-3.18; p = .829). The presence of a substance use disorder significantly increased the rate of hospitalizations by 123% (IRR 2.23, 95%CI 1.31-3.78). Analyses of hospitalization days showed similar results.

CONCLUSIONS

Our results suggest that LAIs are useful for the management of patients with recent-onset psychosis who fail treatment with oral antipsychotics. Whether LAIs are superior to oral antipsychotics as first-line treatment of patients with early psychosis and/or could play a special role in managing patients with early psychosis and comorbid substance use disorders should be further evaluated.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

The Impact of Adolescent Alcohol Exposure on Nicotine Behavioral Sensitization in the Adult Male Neonatal Ventral Hippocampal Lesion Rat

Nicotine and alcohol use is highly prevalent among patients with serious mental illness, including those with schizophrenia (SCZ), and this co-occurrence can lead to a worsening of medical and psychiatric morbidity. While the mechanistic drivers of co-occurring SCZ, nicotine use and alcohol use are unknown, emerging evidence suggests that the use of drugs during adolescence may increase the probability of developing psychiatric disorders. The current study used the neonatal ventral hippocampal lesion (NVHL) rat model of SCZ, which has previously been shown to have enhanced nicotine behavioral sensitization and, following adolescent alcohol, increased alcohol consumption. Given how commonly alcohol is used by adolescents that develop SCZ, we used the NVHL rat to determine how exposure to adolescent alcohol impacts the development of nicotine behavioral sensitization in adulthood. Male Sprague-Dawley rats underwent the NVHL surgery or a sham (control) surgery and subsequently, half of each group was allowed to drink alcohol during adolescence. Nicotine behavioral sensitization was assessed in adulthood with rats receiving subcutaneous injections of nicotine (0.5 mg/kg) each day for 3 weeks followed by a nicotine challenge session 2 weeks later. We demonstrate that all groups of rats became sensitized to nicotine and there were no NVHL-specific increases in nicotine behavioral sensitization. We also found that NVHL rats appeared to develop sensitization to the nicotine paired context and that adolescent alcohol exposure blocked this context sensitization. The current findings suggest that exposure to alcohol during adolescence can influence behaviors that manifest in the adult NVHL rat (i.e., context sensitization). Interestingly, nicotine behavioral sensitization levels were not altered in the NVHL groups regardless of adolescent alcohol exposure in contrast to prior reports.

A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors

PURPOSES

To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.

METHOD

This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.

RESULTS

Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.

CONCLUSIONS

The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

Preventive interventions targeting cannabis use and related harms in people with psychosis: A systematic review

AIM

While most users will not experience severe adverse health outcomes from cannabis, it can be associated with negative outcomes in people with psychosis. People with psychosis who use cannabis have more severe psychiatric symptoms, higher rates of hospitalization, and diminished psychosocial functioning compared to those who do not use cannabis. Most studies of people with psychotic disorders have focused on cannabis use treatments and only a few on preventive interventions for cannabis. This systematic review aims to evaluate the effectiveness of preventive interventions focusing on cannabis use for people with psychosis.

METHODS

We searched CINAHL Plus, EBM reviews, EMBASE, MEDLINE, PsycInfo and PubMed databases for controlled studies assessing the effects of preventive interventions on cannabis use and related harms in people with psychosis. We conducted the search using a combination of the following concepts: cannabis, psychosis, intervention and prevention. Risk of bias was assessed.

RESULTS

The search yielded 11 460 unique studies. Of these, five studies met our eligibility criteria. None of the studies demonstrated clear efficacy of prevention interventions in reducing cannabis use, and none measured cannabis-related harms. All studies had high risk of bias.

CONCLUSION

The small number of studies and the considerable risk of bias made it difficult to conclude whether any of the existing interventions were promising. With increased acceptance and accessibility of cannabis due to liberalizing cannabis policies, it is imperative to improve the evidence base for preventive interventions, in particular their effectiveness in decreasing the risk of cannabis-related harms in people with psychosis.

Dual Disorders in the Consultation Liaison Addiction Service: Gender Perspective and Quality of Life

Dual disorders (DD) and gender differences comprise an area of considerable concern in patients with substance use disorder (SUD). This study aims to describe the presence of DD among patients with SUD admitted to a general hospital and attended by a consultation liaison addiction service (CLAS), in addition to assessing its association with addiction severity and quality of life from a gender perspective, between 1 January and 30 September 2020. The dual diagnosis screening interview (DDSI), the severity of dependence scale (SDS), and the WHO well-being index were used to evaluate the patients. In the overall sample, DD prevalence was 36.8%, (women: 53.8% vs. men: 32.7%, NS). In both genders the most prevalent DD was depression (33.8%, women: 46.2% vs. men: 30.9%, p = 0.296). Women presented more panic disorders (46.2% vs. 12.7%, p = 0.019) and generalized anxiety (38.5% vs. 10.9%, p = 0.049) than men. When DD was present, women had worse quality of life than men (21.7 vs. 50 points, p = 0.02). During lockdown period 77 patients were attended to and 13 had COVID-19 infection, with no differences in relation to sociodemographic and consumption history variables. The study confirms a high prevalence of DD among patients with SUD admitted to a general hospital for any pathology, and its being associated with worse quality of life, particularly in women.

Unraveling the Association Between Schizophrenia and Substance Use Disorder-Predictors, Mechanisms and Treatment Modifications: A Systematic Review

Individuals with schizophrenia are particularly vulnerable to substance abuse problems. Comorbidity with substance use disorders (SUDs) frequently results in early death and increased dysfunction observed in schizophrenia. This dual diagnosis can be explained through multiple general mechanisms. Tobacco, alcohol, cannabis, and cocaine are substances widely used by individuals with schizophrenia. This study highlights the predictors, mechanisms responsible for the relationship between substance use disorder and schizophrenia and how it can help with the treatment of both disorders. The publications were rigorously reviewed after being found in multiple databases. The study's inclusion criteria were research published within the last five years, publications written in English, full-text availability, and human studies. A total of ten papers were selected for examination from a total of 9,106 articles found using the search method across several databases. This study follows the rules listed within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009. The information gathered from these published studies was used to investigate the elements that contribute to the link between schizophrenia and substance abuse. Here, we evaluate a close relationship between schizophrenia and substance use disorders. The articles studied exhibit a bidirectional association between the two disorders in most individuals. From our analysis, the comorbidity between the two disorders is partially due to shared polygenic liability. Individuals with schizophrenia have dysfunctional Mesocorticolimbic brain reward circuits indicating a history of substance use. An underlying genetic vulnerability to schizophrenia may be triggered by extensive cannabis usage at a young age. A combination of psychological and pharmacological interventions for both disorders can significantly improve the outcome.

Cannabis use and clinical outcome in people with first-episode schizophrenia spectrum disorders over 24 months of treatment

Cannabis use is associated with an unfavourable course of illness in schizophrenia, although several factors may confound this association. In this longitudinal study, we explored the influence of cannabis use on baseline symptom severity and treatment outcomes in 98 patients with first-episode schizophrenia spectrum disorders treated with a long acting injectable antipsychotic over 24 months. Using mixed models for repeated measures, we compared visit-wise changes in psychopathology, social and occupational functioning and quality of life between recent/current cannabis users (n=45) and non-users (n=53). There were no significant group by time interactions for any of our outcomes, and with the exception of poorer functionality in cannabis users at baseline, no significant differences in these domains at baseline or month 24. Also, remission rates were similar. However, more cannabis users met our operationally defined relapse criteria compared to non-users, and more frequent cannabis use over the course of treatment, as assessed by positive urine toxicology testing, predicted relapse. Our results suggest that cannabis users do not have poorer treatment response than non-users in terms of symptom reduction over the 24 months of treatment. However, dose-related risk of relapse remains with ongoing cannabis use, possibly by directly reducing the threshold for psychotic breakthrough.

The Impact of THC and CBD in Schizophrenia: A Systematic Review

Background: People with schizophrenia are more likely to develop cannabis use disorder (CUD) and experience worse outcomes with use. Yet as cannabis is legalized for medical and recreational use, there is interest in its therapeutic potential. Objectives: To conduct a systematic review summarizing the design and results of controlled trials using defined doses of THC and CBD in schizophrenia. Method: A keyword search of eight online literature databases identified 11 eligible reports. Results: One placebo controlled trial (13 stable patients without CUD) found that intravenous THC increased psychosis and worsened learning/recall. Two reports of a functional magnetic resonance (fMRI) study of smoked or oral THC in 12 abstinent patients with schizophrenia and CUD found no change in symptoms and cognition, and an amelioration of impaired resting state brain function in areas implicated in reward function and the default mode network. One 4 week trial in acutely psychotic inpatients without CUD (mean age 30 y) found 800 mg CBD to be similarly efficacious to amisupride in improving psychosis and cognition. Two 6 week studies of CBD augmentation of antipsychotics in stable outpatients reported mixed results: CBD 600 mg was not more effective than placebo; CBD 1,000 mg reduced symptoms in a sample that did not exclude cannabis use and CUD. A brain fMRI and proton magnetic resonance spectroscopy study of single dose CBD in a sample that did not exclude CUD and cannabis use found that CBD improved symptoms and brain function during a learning/recall task and was associated with increased hippocampal glutamate. Discussion: There is substantial heterogeneity across studies in dose, method of drug delivery, length of treatment, patient age, whether patients with cannabis use/CUD were included or excluded, and whether patients were using antipsychotic medication. Conclusion: There is insufficient evidence for an effect of THC or CBD on symptoms, cognition, and neuroimaging measures of brain function in schizophrenia. At this time, research does not support recommending medical cannabis (THC or CBD) for treating patients with schizophrenia. Further research should examine THC and CBD in schizophrenia with and without comorbid CUD and consider the role of CBD in mitigating symptom exacerbation from THC.

A systematic review of longitudinal studies investigating the impact of cannabis use in patients with psychotic disorders

Introduction: Research has established a link between cannabis use and adverse psychotic outcomes in psychosis patients. However, we have yet to determine if this relationship is maintained when controlling for important confounding variables. The following systematic review aims to investigate if the association between cannabis use and psychotic outcomes is preserved when accounting for important confounders, and if discontinued use mitigates any potential negative impacts.Areas covered: The authors conducted an exhaustive search of the MEDLINE database and Google Scholar to identify articles pertaining to the systematic review. Thirty-three articles were retained for meeting the eligibility criteria.Expert opinion: The evidence confirms an overarching pattern of negative psychotic outcomes of cannabis intake in psychosis populations, even when accounting for crucial confounders. Psychosis patients should be informed with evidence-based health information regarding the effects of cannabis use. Clinicians should systematically evaluate cannabis intake patterns in psychosis patients and offer intervention services geared toward reducing problematic consumption. Researchers should record confounding factors in a more systematic manner in future longitudinal investigations while paying careful attention to the potency and dose-response effects of the ingested cannabis. Deciders will need to investigate the impact of cannabis regulations on psychosis populations.

Cannabis use and hippocampal subfield volumes in males with a first episode of a schizophrenia spectrum disorder and healthy controls

BACKGROUND

Both schizophrenia and cannabis use are associated with structural brain changes. The hippocampus is a region of particular interest due to its role in memory and select cognitive functions, impairment of which is a core feature of schizophrenia and has also been observed in substance abuse. This study aimed to explore the effects of recent/current cannabis use on hippocampal subfield volumes in male patients with first-episode schizophrenia spectrum disorders and matched controls.

METHODS

This cross-sectional, case-control study included 63 patients and 58 controls scanned on 3T MRI scanners, with hippocampal segmentation performed using recently validated Freesurfer v6.0 software. Cannabis use status was determined by self and carer report together with urine toxicology screening, and patients were categorised as recent/current users or non-users. We used multivariate analysis of covariance (MANCOVA) with age, scan sequence, scan quality, and total intracranial volume as covariates, with subsequent analysis of variance (ANOVA) to test the effects of diagnosis and cannabis use status on individual hippocampal subfields.

RESULTS

We found a group (patient/control) by cannabis use interaction effect in the subiculum, with decreased volumes observed in the cannabis non-using patients compared to the cannabis using patients, and decreased volumes in the cannabis using controls compared to the cannabis non-using controls.

CONCLUSION

The increased subiculum volume in cannabis using patients compared to cannabis non-using patients raises important questions regarding the pathophysiology of schizophrenia and the role of cannabis use therein.

Employment and relationship outcomes in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies

As employment and relationship status are important long-term outcomes in individuals with a diagnosis of first episode psychosis (FEP) disorders, there is a need to elucidate more accurately the extent of these social deficits in people with FEP. This in turn can aid treatment planning and policy development ultimately ensuring more complete and sustainable recoveries. We carried out a systematic review and meta-analysis of longitudinal studies in FEP reporting on employment and relationship status during the illness course. Random effects meta-analyses and meta-regression analyses were employed. Seventy-four studies were included with a sample totalling 15,272 (range = 20-1724) FEP cases with an average follow-up duration of 8.3 years (SD = 7.2). 32.5% (95%CI = 28.5-36.9) of people with a diagnosis of FEP disorders were employed and 21.3% (95%CI = 16.5-27.1) were in a relationship at the end of follow-up. Studies from high-income countries and Europe had a higher proportion of people in employment at the end of follow-up compared to middle-income nations and non-European countries. The inverse was found for relationship status. The proportion of people with a diagnosis of FEP in employment decreased significantly with longer follow-up. Living with family, being in a relationship at first contact and Black and White ethnicities were identified as significant moderators of these outcomes. These findings highlight marked functional recovery deficits for people with FEP, although cultural factors need to be considered. They support the need for interventions to improve employment opportunities, and social functioning, both in early psychosis and during the longitudinal illness course.

Technology-Based Psychological Interventions for Young Adults With Early Psychosis and Cannabis Use Disorder: Qualitative Study of Patient and Clinician Perspectives

Background

The persistence of cannabis use disorder (CUD) in young adults with first-episode psychosis (FEP) is associated with poor clinical and functional outcomes. Face-to-face psychological interventions are effective in treating CUD. However, their use in early intervention services (EISs) for psychosis is inconsistent because of barriers, including high workload and heterogeneity in training of clinicians and lack of motivation for treatment among patients. Tailoring new technology-based psychological interventions (TBPIs) to overcome these barriers is necessary to ensure their optimal acceptability.

Objective

The aim of this study is twofold: to explore psychological intervention practices and intervention targets that are relevant for treating CUD in individuals with early psychosis and to explore factors related to the development and implementation of a technology-assisted psychological intervention.

Methods

A total of 10 patients undergoing treatment for FEP and CUD in EISs participated in a focus group in June 2019. Semistructured individual interviews were conducted with 10 clinicians working in first-episode clinics in the province of Québec, Canada. A hybrid inductive-deductive approach was used to analyze data. For the deductive analysis, we used categories of promoting strategies found in the literature shown to increase adherence to web-based interventions for substance use (ie, tailoring, reminders, delivery strategies, social support, and incentives). For the inductive analysis, we identified new themes through an iterative process of reviewing the data multiple times by two independent reviewers.

Results

Data were synthesized into five categories of factors that emerged from data collection, and a narrative synthesis of commonalities and differences between patient and clinician perspectives was produced. The categories included attitudes and beliefs related to psychological interventions (eg, behavioral stage of change), strategies for psychological interventions (eg, motivational interviewing, cognitive behavioral therapy, psychoeducation, stress management), incentives (eg, contingency management), general interest in TBPIs (eg, facilitators and barriers of TBPIs), and tailoring of TBPIs (eg, application needs and preferences, outcome measures of interest for clinicians).

Conclusions

This study provides a comprehensive portrait of the multifaceted needs and preferences of patients and clinicians related to TBPIs. Our results can inform the development of smartphone- or web-based psychological interventions for CUD in young adults with early psychosis.

Extracellular vesicles in patients in the acute phase of psychosis and after clinical improvement: an explorative study

Extracellular vesicles (EVs) are cell-derived structures that transport proteins, lipids and nucleic acids between cells, thereby affecting the phenotype of the recipient cell. As the content of EVs reflects the status of the originating cell, EVs can have potential as biomarkers. Identifying EVs, including their cells of origin and their cargo, may provide insights in the pathophysiology of psychosis. Here, we present an in-depth analysis and proteomics of EVs from peripheral blood in patients (n = 25) during and after the acute phase of psychosis. Concentration and protein content of EVs in psychotic patients were twofold higher than in 25 age- and sex-matched healthy controls (p < 0.001 for both concentration and protein content), and the diameter of EVs was larger in patients (p = 0.02). Properties of EVs did not differ significantly in blood sampled during and after the acute psychotic episode. Proteomic analyses on isolated EVs from individual patients revealed 1,853 proteins, whereof 45 were brain-elevated proteins. Of these, five proteins involved in regulation of plasticity of glutamatergic synapses were significantly different in psychotic patients compared to controls; neurogranin (NRGN), neuron-specific calcium-binding protein hippocalcin (HPCA), kalirin (KALRN), beta-adducin (ADD2) and ankyrin-2 (ANK2). To summarize, our results show that peripheral EVs in psychotic patients are different from those in healthy controls and point at alterations on the glutamatergic system. We suggest that EVs allow investigation of blood-borne brain-originating biological material and that their role as biomarkers in patients with psychotic disorders is worthy of further exploration.

Health-Related Quality of Life in Male Patients under Treatment for Substance Use Disorders with and without Major Depressive Disorder: Influence in Clinical Course at One-Year Follow-Up

Health-related quality of life (HRQoL) assessment has interest as an indicator of degree of affectation and prognosis in mental disorders. HRQoL is impaired in both Substance Use Disorder (SUD) and Major Depressive Disorder (MDD), two conditions highly prevalent, although less studied when both are coexisting (SUD + MDD). Hence, we decided to explore HRQoL with the SF-36 survey in a sample of 123 SUD and 114 SUD + MDD patients (51 symptomatic and 63 asymptomatic of depressive symptoms) under treatment. We performed analyses to examine HRQoL among groups, and its predictive value at 3-, 6- and 12-month follow-ups through regression models. Patients with SUD + MDD had worse HRQoL than SUD patients and population norms. For Mental Health, Vitality, and General Health dimensions, lower scores were observed for SUD + MDD regardless the presence/absence of depressive symptoms. For Physical Functioning and Health Change, depressive symptomatology and not the comorbidity of SUD + MDD diagnoses explained HRQoL limitations. At 3-, 6- and 12-month follow-ups we observed two predictors of relapses, General Health for asymptomatic SUD + MDD, and Physical Functioning for SUD. Improving HRQoL in SUD + MDD may be targeted during patient's treatment; future studies should explore the influence of HRQoL on patient's prognosis taking into account the presence/absence of depressive symptomatology.

Adolescent Substance Use and the Brain: Behavioral, Cognitive and Neuroimaging Correlates

Adolescence is an important ontogenetic period that is characterized by behaviors such as enhanced novelty-seeking, impulsivity, and reward preference, which can give rise to an increased risk for substance use. While substance use rates in adolescence are generally on a decline, the current rates combined with emerging trends, such as increases in e-cigarette use, remain a significant public health concern. In this review, we focus on the neurobiological divergences associated with adolescent substance use, derived from a cross-sectional, retrospective, and longitudinal studies, and highlight how the use of these substances during adolescence may relate to behavioral and neuroimaging-based outcomes. Identifying and understanding the associations between adolescent substance use and changes in cognition, mental health, and future substance use risk may assist our understanding of the consequences of drug exposure during this critical window.

Trajectories of occupational and social functioning in people with recent-onset non-affective psychosis enrolled in specialized early intervention services across New York state

BACKGROUND

Despite the benefits of early intervention services for the initial stages of psychosis ongoing impairments in functioning are common.

AIMS

To identify 1-year trajectories of occupational and social functioning in individuals enrolled in OnTrackNY, a statewide program offering early intervention services for recent-onset psychosis in community settings.

METHOD

We included 937 persons with recent-onset psychosis enrolled at 19 programs across New York State. Demographic, social and clinical data was collected at program entry and at 3, 6, 9 and 12 months. We used growth mixture models to identify occupational and social functioning trajectories and examined the association between trajectory class, baseline factors and symptoms during 1-year follow-up.

RESULTS

Four distinct trajectory classes of occupational and social functioning were identified. The converging (58.0%) class had disparate levels of functioning at baseline (low occupational, higher social) which eventually converged. The other classes had high-stable (14.8%), moderate-stable (17.8%) and low-improving (9.4%) trajectories. Female gender, educational attainment and private insurance status were significantly associated with the trajectory characterized by higher functioning, while living alone, homelessness, a longer period from psychosis onset to program enrollment, a schizophrenia diagnosis and cannabis use at enrollment were associated with the poorest trajectory. The differences in severity of symptoms by trajectory class diminished over time.

CONCLUSIONS

Trajectories of occupational and social functioning showed substantial variation, but overall, remained stable or improved during 1-year follow-up. The relationship between symptoms and occupational and social functioning attenuated after the acute treatment phase.

A systematic review of technology-based psychotherapeutic interventions for decreasing cannabis use in patients with psychosis

Persistent use of cannabis in persons with psychosis is associated with poor symptomatic and functional outcomes and increased healthcare costs. Face-to-face psychological interventions (e.g., Cognitive Behavioral Therapy- [CBT], Motivation Enhancement Therapy- [MET]) are widely used in treating problematic cannabis use. We aimed to comprehensively review the efficacy of technology-based psychological interventions (TBPIs) in decreasing cannabis use, the design of TBPIs, and TBPI-related preferences in individuals with psychosis. For the systematic review, we searched six major databases from their inception to November 27, 2019. We included empirical articles of quantitative and qualitative methodologies related to TBPIs in individuals with psychosis and cannabis misuse and used narrative synthesis to report results. Only eight articles were found showing that technology-based motivational and psycho-education interventions and cognitive enhancement therapy were minimally efficient in achieving cannabis abstinence or decreasing frequency of use. Qualitative exploratory methods and participatory action research were used to elicit patient and clinician preferences and TBPIs were tailored accordingly to improve cannabis use related outcomes. Research on TBPIs in individuals with psychosis and cannabis misuse is in its early phases. A significant research effort is needed for the development of adapted interventions for CUD to capitalize on the potential of web-based applications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using machine learning to predict mental healthcare consumption in non-affective psychosis

OBJECTIVE

The main goal of the study was to predict individual patients' future mental healthcare consumption, and thereby enhancing the design of an efficient demand-oriented mental healthcare system by focusing on a patient population associated with intensive mental healthcare consumption. Factors that affect the mental healthcare consumption of service users with non-affective psychosis were identified, and subsequently used in a prognostic model to predict future healthcare consumption.

METHOD

This study was a secondary analysis of an existing dataset from the GROUP study. Based on mental healthcare consumption, patients with non-affective psychosis were divided into two groups: low (N = 579) and high (N = 488) intensive mental healthcare consumers. Three different techniques from the field of machine learning were applied on crosssectional data to identify risk factors: logistic regression, classification tree and a random forest. Subsequently, the same techniques were applied longitudinally in order to predict future healthcare consumption.

RESULTS

Identified variables that affected healthcare consumption were the number of psychotic episodes, paid employment, engagement in social activities, previous healthcare consumption, and met needs. Analyses showed that the random forest method is best suited to model risk factors, and that these relations predict future healthcare consumption (AUC 0.71, PPV 0.65).

CONCLUSIONS

Machine learning techniques provide valuable information for identifying risk factors in psychosis. They may thus help clinicians optimize allocation of mental healthcare resources by predicting future healthcare consumption.

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.

Long-acting antipsychotic medication as first-line treatment of first-episode psychosis with comorbid substance use disorder

AIM

Substance use disorder (SUD) is highly prevalent among patients with first-episode psychosis (FEP) and associated with poor adherence and worst treatment outcomes. Although relapses are frequent in FEP, current literature on long-acting injectable antipsychotics (LAI-AP) use in FEP is scarce and studies often exclude patients with SUD.

OBJECTIVES

To determine the impact of LAI-AP as first-line treatment on psychotic relapses or rehospitalizations in FEP patients with comorbid SUD (FEP-SUD).

METHODS

This is a naturalistic, longitudinal, 3-year prospective and retrospective study on 237 FEP-SUD admitted in two EIS in Montreal, between 2005 and 2012. The patients were divided on the basis of first-line medication introduced, either oral antipsychotics (OAP, n = 206) or LAI-AP (n = 31). Baseline characteristics were compared using χ² test and analysis of variance, and Kaplan-Meier survival analysis was performed on relapse and rehospitalization.

RESULTS

Compared to the OAP group, patients in the LAI-AP group presented worse prognostic factors (eg, history of homelessness). Despite this, the LAI-AP group presented a lower relapse rate (67.7% vs 76.7%), higher relapse-free survival time (694 vs 447 days, P = 0.008 in Kaplan-Meier analysis), and trends for reduced rehospitalization rates (48.4% vs 57.3%) and hospitalization-free survival time (813 vs 619 days, P = 0.065 Kaplan-Meier analysis). Of those receiving OAP as first-line, 41.3% were eventually switched to LAI-AP and displayed worst outcome in relapse and rehospitalization.

CONCLUSION

LAI-AP should be strongly considered as first-line treatment of FEP-SUD patients since this pharmacological option reduces the risk of relapse and rehospitalization even in the individuals with poor prognostic factors.

Homeless youth with first-episode psychosis: A 2-year outcome study

BACKGROUND

Psychosis augments the risk of homelessness, the latter is associated with increased morbidity and mortality. Young adults experiencing first-episode psychosis (FEP) are increasingly recognized as being vulnerable to homelessness. However, data on homeless in youth with FEP are sparse.

OBJECTIVES

To compare symptomatic and functional outcomes in homeless v. never homeless FEP, at admission and two years after admission to an Early Psychosis Intervention Service (EIS).

METHOD

From October 2005 to April 2011, 167 FEP consecutive admissions (aged 18-30 years old), were recruited in a 2-year prospective longitudinal study in an inner city EIS in Montreal, Canada. Socio-demographic characteristics, symptomatic and functional outcomes, as well as treatments and service use data were collected at admission and annually.

RESULT

26% of FEP were homeless, prior or during the follow-up. Attrition rate was similar among the two groups. At baseline, the homeless group were more likely to have childhood abuse, forensic history, non-affective psychosis, negative symptoms, substance use disorder and cluster B personality. Despite the intensive care of EIS, the similarity of illness severity at baseline and medication adherence rate, homeless FEP had poorer 2-year symptomatic and functional outcomes, although having more long-acting injectable antipsychotics (LAI) (vs oral antipsychotics), community treatment order and hospitalizations.

CONCLUSION

Homelessness is a serious and prevalent phenomenon among FEP youth associated with worse symptomatic and functional outcomes. More studies on interventions focusing on potentially modifiable factors (e.g. substance use disorders, social support) are warranted.

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

Background

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

Aim

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

Setting

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

Methods

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

Results

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

Conclusion

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

How to help homeless youth suffering from first episode psychosis and substance use disorders? The creation of a new intensive outreach intervention team

In Canada, about 6,000 youth are homeless every night, many of whom suffer from addiction and psychotic disorders. To facilitate the exit out of homelessness, access to care and to improve psychosis and addiction outcomes, a new intensive outreach intervention team (EQIIP SOL) was created in Montreal (2012). It offers intensive outreach services dedicated to homeless youth suffering from first episode psychosis and addiction (HYFEPA) in addition to an early psychosis intervention service (EIS) in collaboration with the Addiction Psychiatry Unit. Our aim is to describe the characteristics, clinical, functional and housing outcomes of HYFEPA followed by EQIIP SOL. This two years long prospective longitudinal study with all HYFEPA (n = 42) admitted to EQIIP SOL between 2012-2015 reports at multiple time points, clinical (CGI, GAF), functional (SOFAS, work/study, housing autonomy) and substance use disorder (DUS, AUS) outcomes and acute services use (hospitalizations, emergency room visits). We observed that, at baseline, HYFEPA showed poor prognostic factors (eg. cluster B personality, substance use disorders, legal problems, childhood trauma and lower education level). The majority reached housing stability after 6 months and their functioning and illness severity improved with time. This suggests that HYFEPA improve with an intensive outreach intervention team integrated to an EIS.

Non-Genetic Factors in Schizophrenia

PURPOSE OF REVIEW

We review recent developments on risk factors in schizophrenia.

RECENT FINDINGS

The way we think about schizophrenia today is profoundly different from the way this illness was seen in the twentieth century. We now know that the etiology of schizophrenia is multifactorial and reflects an interaction between genetic vulnerability and environmental contributors. Environmental risk factors such as pregnancy and birth complications, childhood trauma, migration, social isolation, urbanicity, and substance abuse, alone and in combination, acting at a number of levels over time, influence the individual's likelihood to develop the disorder. Environmental risk factors together with the identification of a polygenic risk score for schizophrenia, research on gene-environment interaction and environment-environment interaction have hugely increased our knowledge of the disorder.

Microstructural Findings in White Matter Associated with Cannabis and Alcohol Use in Early-Phase Psychosis: A Diffusion Tensor Imaging and Relaxometry Study

Accumulating evidence suggests that brain white matter (WM) abnormalities may be central to the pathophysiology of psychotic disorders. In addition, there is evidence that cannabis use and alcohol use each is associated with WM abnormalities. However, there are very limited data on the effects of these substances on WM microstructure in patients with psychosis, especially for those at the early phase of illness. This project aimed to examine the impact of cannabis use and alcohol use on WM tissue in early-phase psychosis (EPP). WM was investigated in 21 patients with EPP using diffusion tensor imaging (DTI) and transverse relaxation time of tissue water (T2), with the primary outcomes being mean fractional anisotropy (FA) and T2. DTI analyses were performed at the full-brain level using tract-based spatial statistics with both DTI and T2 analysis done within a WM volume of interest (VOI) implicated in psychosis (containing the left superior longitudinal fasciculus). Our findings revealed that younger age of onset of regular alcohol use (more than one drink per week) was associated with lower FA values in the left thalamic radiation and left parahippocampal and left amygdalar WM. More frequent lifetime cannabis use was correlated with increased mean full-brain FA. There was no significant relationship found between FA and alcohol or cannabis use within the VOI. Relaxometry analysis revealed trend-level evidence of shortened T2 with later onset of regular alcohol use and with more frequent cannabis use. This study provides novel data demonstrating cortical and subcortical WM findings related to alcohol use in EPP and is the first to combine DTI and relaxometry, relating to this patient population.

Impact of comprehensive treatment for first episode psychosis on substance use outcomes: A randomized controlled trial

Lifetime co-occurring substance use disorders are common at the time of presentation for treatment of a first episode of primary psychosis and persistent substance use disorder (SUD) leads to poorer outcomes. We assessed whether the NAVIGATE program, a coordinated specialty care service that includes optional substance abuse content reduced substance use compared to usual care in 404 individuals in the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study. Participants were randomized to two years of NAVIGATE (n = 223) or usual care (n = 181) and assessed monthly for substance use. At baseline, over one-half (51.7%) of the participants met criteria for a lifetime SUD, including over one-third with alcohol use disorder (36.4%) and with cannabis use disorder (34.7%). Contrary to our hypothesis, there was no treatment group by time interaction effect on days of self-reported substance use over the two-year follow-up. Participant exposure to the substance abuse component of the NAVIGATE program was low, suggesting that modifications to the program and training method for clinicians may be needed. Further research is needed to determine the most effective strategies for addressing substance use disorders in persons recovering from a first episode of psychosis.

The link between schizophrenia and substance use disorder: A unifying hypothesis

Substance use disorders occur commonly in patients with schizophrenia and dramatically worsen their overall clinical course. While the exact mechanisms contributing to substance use in schizophrenia are not known, a number of theories have been put forward to explain the basis of the co-occurrence of these disorders. We propose here a unifying hypothesis that combines recent evidence from epidemiological and genetic association studies with brain imaging and pre-clinical studies to provide an updated formulation regarding the basis of substance use in patients with schizophrenia. We suggest that the genetic determinants of risk for schizophrenia (especially within neural systems that contribute to the risk for both psychosis and addiction) make patients vulnerable to substance use. Since this vulnerability may arise prior to the appearance of psychotic symptoms, an increased use of substances in adolescence may both enhance the risk for developing a later substance use disorder, and also serve as an additional risk factor for the appearance of psychotic symptoms. Future studies that assess brain circuitry in a prospective longitudinal manner during adolescence prior to the appearance of psychotic symptoms could shed further light on the mechanistic underpinnings of these co-occurring disorders while identifying potential points of intervention for these difficult-to-treat co-occurring disorders.

Unchaining people with mental disorders: medication is not the solution

Chaining of people with mental disorders, and their incarceration and abuse in prisons or mental hospitals, is an affront to psychiatry and humanity. Although mental healthcare always needs attention to cultural and social contexts, this must never be at the cost of allowing human rights violations to go unchallenged. A rights-based approach must enforce well-established international human rights conventions, and scale-up comprehensive community services around the needs and preferences of people affected by mental disorders. Declaration of interest None.

Comparison of health-related quality of life among men with different co-existing severe mental disorders in treatment for substance use

BACKGROUND

Patient-perceived health-related quality of life has become an important outcome in health care as an indicator of treatment effectiveness and recovery for patients with substance use disorder. As no study has assessed health-related quality of life among male patients with substance use disorder and co-existing severe mental illness, we compared health-related quality of life among patients with substance use disorder and the following severe mental illness diagnosis in Barcelona, Spain: schizophrenia, bipolar disorder, major depressive disorder, and examined the associations with clinically related variables. Additionally, we compared results for health-related quality of life in patients with substance use disorder and severe mental illness, with Spanish population norms.

METHODS

We assessed 107 substance use disorder male patients using the 36-Item Short Form Health Survey comparing results across three groups with: comorbid schizophrenia (n = 37), comorbid bipolar disorder (n = 34), and comorbid major depressive disorder (n = 36). Multiple analyses of variance were performed to explore health-related quality of life by the type of co-existing SMI and linear regression analyses examined clinical correlates for the 36-Item Short Form Health Survey dimensions for each group.

RESULTS

There were differences in Physical Functioning, Vitality and the Physical Composite Scale among groups. Poorer Physical Functioning was observed for patients with comorbid schizophrenia (80.13±3.27) and major depressive disorder (81.97±3.11) compared with comorbid bipolar disorder patients (94.26±1.93). Patients with substance use disorder and schizophrenia presented lower scores in Vitality (41.6±2.80) than those with co-existing bipolar disorder (55.68±3.66) and major depressive disorder (53.63±2.92). Finally, results in the Physical Composite Scale showed lower scores for patients with comorbid schizophrenia (51.06±1.41) and major depressive disorder (51.99±1.87) than for those with bipolar disorder (60.40±2.17). Moreover, all groups had poorer health-related quality of life, especially Social Functioning, Role-Emotional and Mental Health, compared with population norms. Different clinical variables (e.g. medical disease comorbidity, severity of addiction, psychiatric symptomatology, suicide attempts, drug relapses) were related to different health-related quality of life dimensions depending on the co-existing severe mental illness.

CONCLUSIONS

Among male patients with substance use disorder, co-existing severe mental illness may influence some health-related quality of life dimensions and clinically related variables. Such differences may require tailored therapeutic interventions.

Specific impact of stimulant, alcohol and cannabis use disorders on first-episode psychosis: 2-year functional and symptomatic outcomes

BACKGROUND

Many studies have concluded that cannabis use disorder (CUD) negatively influences outcomes in first-episode psychosis (FEP). However, few have taken into account the impact of concurrent misuse of other substances.

METHODS

This 2-year, prospective, longitudinal study of FEP patients, aged between 18 and 30 years, admitted to early intervention programs in Montreal, Quebec, Canada, examined the specific influence of different substance use disorders (SUD) (alcohol, cannabis, cocaine, amphetamines) on service utilization, symptomatic and functional outcomes in FEP.

RESULTS

Drugs and alcohol were associated with lower functioning, but drugs had a greater negative impact on most measures at 2-year follow-up. Half of CUD patients and more than 65% of cocaine or amphetamine abusers presented polysubstance use disorder (poly-SUD). The only group that deteriorated from years 1 to 2 (symptoms and functioning) were patients with persistent CUD alone. Outcome was worse in CUD than in the no-SUD group at 2 years. Cocaine, amphetamines and poly-SUD were associated with worse symptomatic and functional outcomes from the 1st year of treatment, persisting over time with higher service utilization (hospitalization).

CONCLUSION

The negative impact attributed to CUD in previous studies could be partly attributed to methodological flaws, like including polysubstance abusers among cannabis misusers. However, our investigation confirmed the negative effect of CUD on outcome. Attention should be paid to persistent cannabis misusers, since their condition seems to worsen over time, and to cocaine and amphetamine misusers, in view of their poorer outcome early during follow-up and high service utilization.

Predictors of functional status at service entry and discharge among young people with first episode psychosis

OBJECTIVE

Most patients with first episode psychosis (FEP) are neither studying nor employed (have a poor functional status) when first accessing care. Knowledge of the characteristics of patients with poor functioning and the features influencing functional status over time may pave the way to better treatment.

METHOD

A medical file audit was used to collect data on premorbid, entry, treatment and 18-month outcome characteristics on 661 FEP patients who consecutively attended the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, between 1998 and 2000. Functional status was ascertained using the modified vocational status index and was rated at baseline (poor or good) and according to its evolution over the treatment period (stable good, stable poor, deteriorating or improved functional status).

RESULTS

52.0% of patients had a poor functional status at service entry. They were more likely to be male with a non-affective psychosis. They also had lower levels of premorbid global functioning and education, and were more likely to have self-reported histories of learning disability, forensic issues, traumatic experiences and substance use. At service entry, they had more severe symptoms and poorer global functioning. 37% of these patients maintained a poor functional status at discharge, and 18% of those with a good functional status at service entry experienced a decline.

CONCLUSIONS

Although psychosocial interventions might assist a young person with FEP with working towards functional goals, for some, the impact of factors such as ongoing substance use and forensic issues on functional status needs to be addressed.