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

Cariprazine as a maintenance treatment in dual schizophrenia: a 6-month observational study in patients with schizophrenia and cannabis use disorder

Schizophrenia is often associated with substance use disorders, particularly cannabis use disorder (CUD). However, treatments frequently fail to address both conditions simultaneously. This study aimed to evaluate the antipsychotic effectiveness of cariprazine in patients with both schizophrenia and CUD in a real-world setting. A 6-month observational study was conducted on 58 patients diagnosed with schizophrenia and CUD, treated with cariprazine. Antipsychotic effectiveness was measured using the Positive and Negative Syndrome Scale and the Clinical Global Impression-Schizophrenia Scale, along with the Improvement and Severity scales. Cannabis consumption and addiction severity were assessed using the Cannabis Abuse Screening Test and the Severity of Dependence Scale, while functioning was evaluated with the Sheehan Disability Inventory. Cariprazine treatment resulted in significant improvements in schizophrenia symptoms (Positive and Negative Syndrome Scale change: -47.88 points, P  < 0.0001; Clinical Global Impression-Schizophrenia Scale change: -8.26 points, P  < 0.0001). Cannabis use and dependence also decreased (Cannabis Abuse Screening Test change: -7.0 points, P  < 0.0001; Severity of Dependence Scale change: -7.88 points, P  < 0.0001), alongside improvements in functioning (Sheehan Disability Inventory change: -9.48 points, P  < 0.0001). These results suggest that cariprazine is effective for both schizophrenia and CUD, though further research is needed to confirm these findings.

Axis I Psychiatric Disorders and Substance Abuse: A Systematic Review of Neuroimaging Findings

Background/Objectives: The present systematic review analyses the neuroradiological findings in subjects with axis I psychiatric disorders (i.e., bipolar, major depressive, schizophrenic, anxiety, and post-traumatic stress disorders) and comorbid substance use disorder in order to elucidate the organic changes that occur in the brains of people suffering from both conditions. Methods: We analysed and compared the different neuroimaging findings extracted from 93 studies and 10,823 patients; articles were obtained from three databases (Scopus, PubMed [Medline], and the Cochrane Controlled Register of Trials [Central]) and subjected to specific eligibility criteria. We selected articles that assessed patients with axis I psychiatric conditions and a comorbid substance abuse disorder; articles had to report relevant neuroimaging findings and bias was assessed via the Newcastle-Ottawa scale. Results: Significant findings were found on the structure or function of psychiatric patients' brains with comorbid substance abuse, with certain key areas that were further affected by substance use, especially in areas involved in reward processing, with reductions in volume and connectivity and the augmentation of stimuli-related activity. Conclusions: These results present important implications on the current understanding of psychiatric disorders and comorbid substance use, on the importance of neuroradiological tools in the diagnosis and treatment of these disorders, and on the search for potential new targets for the treatment of psychiatric disease and substance addiction.

Modern perspectives on psychoses: dissociation, automatism, and temporality across exogenous and endogenous dimensions

Substance use and the emergence of Novel Psychoactive Substances (NPS) present a significant public health challenge and diagnostic dilemma, particularly in the context of psychosis. The increasing availability of psychoactive substances among youth has led to a rise in Substance Use Disorders (SUDs), with profound implications for mental health. This paper explores the psychopathological distinctions between substance-induced psychoses (SIPs) and endogenous psychoses, such as schizophrenia, from a phenomenological perspective. We emphasize three key aspects: dissociation, mental automatism, and temporality, to elucidate the underlying mechanisms of these conditions. Dissociation, as a psychopathological organizer, is central to exogenous psychoses, particularly those triggered by NPS. This phenomenon leads to a fragmentation of consciousness, detachment from reality, and disintegration of identity, distinct from the spaltung observed in endogenous psychoses. The concept of mental automatism, as theorized by De Clerambault, is also explored, highlighting its role in the early stages of exogenous psychoses, where cognitive disruptions precede delusions and hallucinations. Furthermore, the temporal experience in SIPs is characterized by a disconnection from past and future, trapping individuals in an "eternal present." This contrasts with the fragmented temporality observed in schizophrenia, where patients struggle to maintain a coherent narrative of their lives. The phenomenological approach provides critical insights into the clinical differentiation between SIPs and Primary Psychotic Disorders (PPDs), emphasizing the need for targeted interventions that address the specific temporal and cognitive disruptions in substance-induced conditions. In conclusion, this paper underscores the importance of integrating phenomenological psychopathology into clinical practice, particularly in the face of the evolving landscape of substance use and psychosis. Understanding the distinct psychopathological mechanisms underlying SIPs can inform more accurate diagnoses and effective treatments, ultimately improving patient outcomes in the context of this growing public health issue.

Psychostimulant Substitution Therapy for the Treatment of Stimulant Use Disorders in Patients with Schizophrenia or Schizoaffective Disorder: A Systematic Review

Objective: Co-occurrence of schizophrenia/schizoaffective disorder (SSD) and stimulant use disorder (StUD) is an ongoing clinical problem and can lead to poor outcomes. Although emerging evidence has suggested psychostimulant substitution therapy may result in improved outcomes in those with StUD, the efficacy and safety of psychostimulant substitution therapy for StUD in those with concurrent SSD is uncertain. This review aims to systematically find and assess all available efficacy and safety evidence on the use of prescription psychostimulants in those with co-occurring SSD and StUD. Methods: Electronic searches of MEDLINE, PsycINFO, Embase, Scopus, ClinicalTrials, EU Clinical Trials, and CADTH were conducted from inception to February 27, 2024. Any study design was accepted if they involved the following concepts 1) SSD and StUD and 2) prescription psychostimulants. Given the paucity of trials meeting criteria, outcomes of interest were described qualitatively. Risk of bias was assessed using Q-Coh and ROB2. Results: Only seven articles met criteria, and most of these were case reports and series. The single RCT included was at high risk of bias. Outcomes included abstinence, reductions in non-prescribed stimulant use, psychiatric hospitalizations, levels of craving, improvements in mental health, improvements in psychosocial functioning, adherence to antipsychotic medications, and retention in treatment. Most of the results indicated that psychostimulant substitution therapy in individuals with SSD-StUD was not associated with improved outcomes. Conclusion: Available evidence for treatment of StUD via psychostimulant substitution therapy in individuals with SSD is lacking. More exploration is required for this clinical question to allow for current practice to be backed by evidence.

Randomized Laboratory Study of Single-Dose Cannabis, Dronabinol, and Placebo in Patients With Schizophrenia and Cannabis Use Disorder

BACKGROUND AND HYPOTHESIS

Up to 43% of people with schizophrenia have a lifetime cannabis use disorder (CUD). Tetrahydrocannabinol (THC) has been shown to exacerbate psychosis in a dose-dependent manner, but little research has assessed its effects on schizophrenia and co-occurring CUD (SCZ-CUD). In this double-dummy, placebo-controlled trial (total n = 130), we hypothesized that a modest dose of THC would worsen cognitive function but not psychosis.

STUDY DESIGN

Effects of single-dose oral THC (15 mg dronabinol) or smoked 3.5% THC cigarettes vs placebo in SCZ-CUD or CUD-only on positive and negative symptoms of schizophrenia (only for SCZ-CUD), cognition, and drug experiences assessed several hours after drug administration. SCZ-only and healthy control participants were also assessed.

STUDY RESULTS

Drug liking was higher in THC groups vs placebo. Neither smoked THC nor oral dronabinol predicted positive or negative symptom subscale scores 2 and 5 h, respectively, after drug exposure in SCZ-CUD participants. The oral dronabinol SCZ-CUD group, but not smoked THC SCZ-CUD group, performed worse than placebo on verbal learning (B = -9.89; 95% CI: -16.06, -3.18; P = .004) and attention (B = -0.61; 95% CI: -1.00, -0.23; P = .002). Every 10-point increment in serum THC + THCC ng/ml was associated with increased negative symptoms (0.40 points; 95% CI: 0.15, 0.65; P = .001; subscale ranges 7-49) and trends were observed for worse positive symptoms and performance in verbal learning, delayed recall, and working memory.

CONCLUSIONS

In people with SCZ-CUD, a modest single dose of oral THC was associated with worse cognitive functioning without symptom exacerbation several hours after administration, and a THC dose-response effect was seen for negative symptoms.

Does Cannabis Use Contribute to Schizophrenia? A Causation Analysis Based on Epidemiological Evidence

Cannabis abuse has been linked to acute psychotic symptoms as well as to the development of schizophrenia. Although the association has been well described, causation has not yet been investigated. Therefore, we investigated whether cannabis or cannabinoid use is causal for the development of schizophrenia, conducting a systematic literature review according to the PRISM guidelines. Epidemiological studies and randomized clinical trials investigating the links between cannabis and psychosis-like events (PLE) and schizophrenia were identified (according to PRISM guidelines), and relevant studies were included in a Forest plot analysis. Confounder analysis was performed using a funnel plot, and the Hill causality criteria were used to estimate causation. A total of 18 studies fulfilled the search criteria; 10 studies were included in a forest plot. All studies reported an increased risk for PLE or schizophrenia, and nine of the ten studies, a significant increase; the overall OR was calculated to be 2.88 (CI 2.24 to 3.70), with a twofold-higher risk calculated for cannabis use during adolescence. Confounder effects were indicated by a funnel plot. The Hill criteria indicated a high likelihood for the contribution of cannabis to schizophrenia development. Cannabinoids likely contribute to chronic psychotic events and schizophrenia, especially if taken during adolescence. This effect likely increases with a high cannabis THC concentration and increased frequency of cannabis use, and is stronger in males than in females. This points to the possibility of a selective cannabis toxicity on synaptic plasticity in adolescence, as compared to adult cannabis use. Cannabis use should be regulated and discouraged, and prevention efforts should be strengthened, especially with reference to adolescence.

Comorbid health outcomes in patients with schizophrenia: an umbrella review of systematic reviews and meta-analyses

There is no comprehensive umbrella review exploring the connection between schizophrenia and various health outcomes. Therefore, we aimed to systematically review existing meta-analyses about schizophrenia-associated comorbid health outcomes and validate the evidence levels. We performed an umbrella review of meta-analyses of observational studies to explore comorbid health outcomes in individuals with schizophrenia. Searches were conducted across PubMed/MEDLINE, EMBASE, ClinicalKey, and Google Scholar up to September 5, 2023, targeting meta-analyses of observational studies related to comorbid health outcomes in individuals with schizophrenia. We applied AMSTAR2 for data extraction and quality assessment, adhering to PRISMA guidelines. Evidence credibility was evaluated and categorized by evidence quality. Our protocol was registered with PROSPERO (CRD42024498833). Risk and protective factors were analyzed and presented through equivalent odds ratios (eRR). In this umbrella review, we analyzed 9 meta-analyses, including 88 original articles, covering 21 comorbid health outcomes with over 66 million participants across 19 countries. Patients with schizophrenia showed significant associations with multiple health outcomes, including asthma (eRR, 1.71 [95% CI, 1.05-2.78], class and quality of evidence [CE] = non-significant), chronic obstructive pulmonary disease (1.73 [1.25-2.37], CE = weak), pneumonia (2.63 [1.11-6.23], CE = weak), breast cancer of female patients (1.31 [1.04-1.65], CE = weak), cardiovascular disease (1.53 [1.12-2.11], CE = weak), stroke (1.71 [1.30-2.25], CE = weak), congestive heart failure (1.81 [1.21-2.69], CE = weak), sexual dysfunction (2.30 [1.75-3.04], CE = weak), fracture (1.63 [1.10-2.40], CE = weak), dementia (2.29 [1.19-4.39], CE = weak), and psoriasis (1.83 [1.18-2.83] CE = weak). Our study underscores the imperative for an integrated treatment approach to schizophrenia, highlighting its broad impact across respiratory, cardiovascular, sexual, neurological, and dermatological health domains. Given the predominantly non-significant to weak evidence levels, further studies are needed to reinforce our understanding.

Low Psychological Resilience Predict the Risk for Alcohol Use Disorder in General Population: National Mental Health Survey of Korea 2021

Objective

Prior research has emphasized psychological resilience as a potential protective factor against alcohol use disorder in diverse populations, with limited exploration of its relationship in the general population. This study investigated the association between the lifetime and one-year prevalence of alcohol use disorder and resilience.

Methods

Data obtained from the National Mental Health Survey of Korea 2021 (5,511 participants; 40.7% response rate) encompassed information on alcohol use disorders, resilience, experiences of psychological trauma, and major mental disorders. The analyses compared demographics, psychological trauma, resilience, and the prevalence of major mental disorders based on alcoholism. The contribution of resilience to alcoholism was assessed utilizing Rao-Scott logistic regression, with adjustments made for confounding variables.

Results

Individuals with both lifetime and 1-year alcohol use disorder and dependence exhibited significantly lower levels of resilience on the Connor-Davidson Resilience Scale. Diminished resilience predicted morbidity and persisted even after adjusting for depressive and anxiety disorders, psychological trauma, nicotine use disorders, age, gender, education, income, marital status, and occupation.

Conclusion

Diminished resilience is a prognostic indicator of increased likelihood of both lifetime and current alcoholism in the general population.

Psychiatric antecedents in young patients with first episode psychosis: what relevance for clinical outcomes?

Examining psychiatric antecedents and help-seeking behavior for people with First Episode Psychosis (FEP) could help understand determinants for timely care pathways, decrease the "Duration of Untreated Psychosis" (DUP), and consequently improve their prognosis. The aims of this study were: (1) to calculate the proportion of FEP participants with previous contact with mental healthcare services recruited within a specialized "Early Intervention in Psychosis" service, and (2) to longitudinally compare sociodemographic, clinical, and treatment parameters between FEP patients with and without psychiatric antecedents across a 2-year follow-up period. All participants (aged 12-35 years) were enrolled within the "Parma Early Psychosis" (Pr-EP) program. At baseline, they completed the Health of the Nation Outcome Scale (HoNOS). A mixed-design ANOVA and a Kaplan-Meier survival analysis were used. Of the 489 FEP participants, 204 (41.7%) patients had prior contact with mental health services. In 83% of cases, a care discontinuity was observed. Main psychiatric antecedents at entry were personality disorders (32.8%), anxious-depressive disorder (28.9%), conduct disorder (16.2%), and learning disorder (9.8%). FEP subjects with antecedents were more likely to receive a diagnosis of schizophrenia at baseline. Having previous contact with psychiatric services resulted to be a predictor of poorer clinical and functional outcome. It is very important to carefully monitor mental health suffering and related help-seeking-behavior in young patients typically manifested in their early 20s, especially in terms of psychosis prevention. Particular attention should also be given to service engagement as care continuity within adolescent-adult transition.

Exposotypes in Psychotic Disorders

Psychiatry lags in adopting etiological approaches to diagnosis, prognosis, and outcome prediction compared to the rest of medicine. Etiological factors such as childhood trauma (CHT), substance use (SU), and socioeconomic status (SES) significantly affect psychotic disorder symptoms. This study applied an agnostic clustering approach to identify exposome clusters "Exposotypes (ETs)" and examine their relationship with clinical, cognitive, and functional outcomes. Using data from individuals with psychotic disorders (n=1,350), and controls (n=623), we assessed the relationship between the exposotypes and outcomes. Four exposotypes were identified: ET1 characterized by high CHT and SU; ET2, high CHT; ET3, high SU; ET4, low exposure. Compared to ET4, ET1 demonstrated higher positive and general symptoms, anxiety, depression, impulsivity, and mania; ET2 had higher anxiety, depression, and impulsivity; ET3 had better cognitive and functional outcomes with lower negative symptoms. Intracranial volume was largest in ET3, and smallest in ET2. No group differences in schizophrenia polygenic risk scores were found. The age of onset was 5 years earlier in ET1 than in ET4. These findings provide insight into the complex etiological interplay between trauma, and SU, as well as their unique effects on clinical symptoms, cognition, neurobiology, genetic risk, and functioning.

Discharge Against Medical Advice Among Schizophrenia Patients in Germany: A Multicenter Cross-Sectional Study

BACKGROUND

The objective of this study was to investigate the prevalence of discharge against medical advice (DAMA) among schizophrenia patients in Germany and to identify factors associated with the risk of DAMA.

METHODS

This multicenter cross-sectional study was based on data from the IQVIA hospital database, which contains records from 36 hospitals across Germany. This study included all hospitalizations for patients with a primary or secondary diagnosis of schizophrenia between January 2019 and December 2023. Multivariable logistic regression analyses adjusted for age, sex, primary or secondary schizophrenia diagnosis, as well as codiagnoses, were conducted to assess the associations between demographic and clinical variables and DAMA.

RESULTS

A total of 7663 hospitalization cases (mean age: 49.5 years, 40.6% female) were included in the study. The DAMA rate was 31.1% in patients with schizophrenia as the primary diagnoses and 6.0% in patients with schizophrenia as a secondary diagnosis. Younger age (i.e., adjusted odds ratio (aOR): 7.44; 95% CI: 4.35-12.73 in the age group 18-30; aOR: 6.63; 95% CI: 3.89-11.29 in the age group 31-40; aOR: 5.59; 95% CI: 3.28-9.54 in the age group 41-50), schizophrenia as the primary diagnosis (aOR: 3.61; 95% CI: 3.05-4.26), alcohol-related disorders (aOR: 1.68; 95% CI: 1.38-2.04), and cannabis-related disorders (aOR: 1.43; 95% CI: 1.18-1.72) were significantly associated with an increased risk of DAMA.

CONCLUSIONS

This study highlights the high prevalence of DAMA among hospitalized schizophrenia patients and identifies the important factors (i.e., younger age, alcohol-related disorders, and cannabis-related disorders) associated with DAMA risk. Additional studies are recommended for further exploration into the reasons for DAMA.

Major psychiatric comorbidity among the critically ill: a multi-centred cohort study in Queensland

BACKGROUND

Although comorbid medical diseases are important determinants of outcome among the critically ill, the role of psychiatric comorbidity is not well defined. The objective of this study was to determine the occurrence of psychiatric comorbidity and its effect on the outcome of patients admitted to adult intensive care units (ICU) in Queensland.

METHODS

Admissions among adults to 12 ICUs in Queensland during 2015-2021 were included and clinical and outcome information was obtained through linkages between the ANZICS Adult Patient Database, the state-wide Queensland Hospital Admitted Patient Data Collection, and death registry.

RESULTS

A total of 89,123 admissions were included among 74,513 individuals. Overall, 7,178 (8.1%) admissions had psychiatric co-morbidity with 6,270 (7.0%) having one major psychiatric diagnosis and 908 (1%) having two or more. Individual diagnoses of mood, psychotic, anxiety, or affective disorders were present in 1,801 (2.0%), 874 (1.0%), 3,241 (3.6%) and 354 (0.4%) admissions respectively. Significant differences were observed among the main groups (mood, affective, anxiety, psychotic, or multiple disorders) and those without psychiatric comorbidity with respect to main diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) score, sex, age, and medical comorbidity. Crude 30-day case-fatality rates were significantly lower (5.1%) compared to the general ICU population (10.1%) (p < 0.001). After controlling for confounding variables in the logistic regression model, patients with psychiatric comorbidity were at lower odds of death.

CONCLUSIONS

Psychiatric comorbidity is common among ICU presentations and is associated with a lower risk of death. This association is likely to be more complex than being a simple protective factor, and future research needs to further delineate how psychiatric comorbidity informs outcomes of specific ICU presentations.

Mapping the exposome of mental health: exposome-wide association study of mental health outcomes among UK Biobank participants

BACKGROUND

Dissecting the exposome linked to mental health outcomes can help identify potentially modifiable targets to improve mental well-being. However, the multiplicity of exposures and the complexity of mental health phenotypes pose a challenge that requires data-driven approaches.

METHODS

Guided by our previous systematic approach, we conducted hypothesis-free exposome-wide analyses to identify factors associated with 7 psychiatric diagnostic domains and 19 symptom dimensions in 157,298 participants from the UK Biobank Mental Health Survey. After quality control, 294 environmental, lifestyle, behavioral, and economic variables were included. An Exposome-Wide Association Study was conducted per outcome in two equally split datasets. Variables associated with each outcome were then tested in a multivariable model.

RESULTS

Across all diagnostic domains and symptom dimensions, the top three exposures were childhood adversities and traumatic events. Cannabis use was associated with common psychiatric disorders (depressive, anxiety, psychotic, and bipolar manic disorders), with ORs ranging from 1.10 to 1.79 in the multivariable models. Additionally, differential associations were identified between specific outcomes-such as neurodevelopmental disorders, eating disorders, and self-harm behaviors-and exposures, including early life experiences (being adopted), lifestyle (time spent using computers), and dietary habits (vegetarian diet).

CONCLUSIONS

This comprehensive mapping of the exposome revealed that several factors, particularly in the domains of those previously well-studied were shared across mental health phenotypes, providing further support for transdiagnostic pathoetiology. Our findings also showed that distinct relations might exist. Continued exposome research through multimodal mechanistic studies guided by the transdiagnostic mental health framework is required to better inform public health policies.

Pituitary adenylate cyclase-activating polypeptide plays a role in neuropsychiatric and substance use disorders: sex-specific perspective

The neuropeptide pituitary adenylate cyclase-activating peptide (PACAP) plays a pivotal role in regulating stress, fear, and anxiety responses. Genetic and molecular studies investigating PACAP demonstrate sex-dimorphic characteristics, with females exhibiting increased reactivity of PACAP signaling in neuropsychiatric disorders. Studies expand the role of PACAP to substance use disorders (SUD) by demonstrating modulation of PACAP can lead to neurobiological changes induced by nicotine, ethanol, stimulants and opioids. Given that females with SUD exhibit distinct drug use, relapse, and withdrawal sensitivity relative to males, we hypothesize that the PACAP system contributes to these sex-specific differences. Therefore, we review the role of PACAP in SUD by characterizing the role of PACAP at the molecular, brain regional, and behavioral levels relevant to the addiction cycle. We present literature linking PACAP to neuropsychiatric disorders, which demonstrate the intricate role of PACAP within neuronal signaling and pathways modulating addiction. We hypothesize that females are more particularly susceptible to PACAP-related changes during the intoxication and withdrawal phases of the addiction cycle. Altogether understanding the sex-specific differences in the PACAP system offers a foundation for future studies aimed at developing tailored interventions for addressing SUD.

Characterization of RNA cargo from extracellular vesicles obtained from cerebrospinal fluid and plasma samples in schizophrenia participants and healthy volunteers

Biomarkers that are clinically useful for the diagnosis and treatment of schizophrenia are lacking. Biomarkers are critical tools that reduce the incidence of misdiagnosis, identify subgroups of patients, assist in the proper characterization of patient phenotypes, predict response to treatment or the development of side effects, and can serve as targets for novel therapeutic interventions. In this study, we evaluated small (< 200 nucleotide) and long (> 200 nucleotide) RNAs found in extracellular vesicles (EVs) isolated from the cerebrospinal fluid (CSF) and plasma of individuals with schizophrenia spectrum disorders (SSD) and healthy volunteers (HV). As EVs carry cargo from all tissues in the body, they act as a potential proxy for the tissue of origin, including cells from the brain. We compared the transcriptomic features of EVs from these two biofluids and examined their ability to discriminate between SSD and HV participants, identifying a total of 141 differentially expressed genes, some of which have been previously associated with SSD. Next, we evaluated the potential cell-types that give rise to the SSD-associated CSF RNA cargo, and found the majority were predominantly expressed in excitatory neurons. Our results highlight the potential of EVs as both a source of schizophrenia relevant biomarkers, and molecular insight into disease mechanisms.

Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder

Importance

Interest in and use of hallucinogens has been increasing rapidly. While a frequently raised concern is that hallucinogens may be associated with an increased risk of psychosis, there are limited data on this association.

Objectives

To examine whether individuals with an emergency department (ED) visit involving hallucinogen use have an increased risk of developing a schizophrenia spectrum disorder (SSD).

Design, Settings, and Participants

This population-based, retrospective cohort study (January 2008 to December 2021) included all individuals aged 14 to 65 years in Ontario, Canada, with no history of psychosis (SSD or substance induced). Data were analyzed from May to August 2024.

Exposure

An incident ED visit involving hallucinogen use.

Main Outcomes and Measures

Diagnosis of SSD using a medical record-validated algorithm. Associations between ED visits involving hallucinogens and SSD were estimated using cause-specific adjusted hazard models. Individuals with an incident ED visit involving hallucinogens were compared with members of the general population (primary analysis) or individuals with ED visits involving alcohol or cannabis (secondary analysis).

Results

The study included 9 244 292 individuals (mean [SD] age, 40.4 [14.7] years; 50.2% female) without a history of psychosis, with a median follow-up of 5.1 years (IQR, 2.3-8.6 years); 5217 (0.1%) had an incident ED visit involving hallucinogen use. Annual rates of incident ED visits involving hallucinogens were stable between 2008 and 2012 and then increased by 86.4% between 2013 and 2021 (3.4 vs 6.4 per 100 000 individuals). Individuals with ED visits involving hallucinogens had a greater risk of being diagnosed with an SSD within 3 years compared with the general population (age- and sex-adjusted hazard ratio [HR], 21.32 [95% CI, 18.58-24.47]; absolute proportion with SSD at 3 years, 208 of 5217 with hallucinogen use [3.99%] vs 13 639 of 9 239 075 in the general population [0.15%]). After adjustment for comorbid substance use and mental health conditions, individuals with hallucinogen ED visits had a greater risk of SSD compared with the general population (HR, 3.53; 95% CI, 3.05-4.09). Emergency department visits involving hallucinogens were associated with an increased risk of SSD within 3 years compared with ED visits involving alcohol (HR, 4.66; 95% CI, 3.82-5.68) and cannabis (HR, 1.47; 95% CI, 1.21-1.80) in the fully adjusted model.

Conclusions and Relevance

In this cohort study, individuals with an ED visit involving hallucinogen use had a greater risk of developing an SSD compared with both the general population and with individuals with ED visits for other types of substances. These findings have important clinical and policy implications given the increasing use of hallucinogens and associated ED visits.

Factors of Engagement in Employment or Education Following a First Episode of Psychosis: A Systematic Review and Narrative Synthesis

Despite 75% of people who experience a first episode of psychosis (FEP) reaching clinical remission, this population continue to face lower rates of vocational recovery. This review aimed to identify the factors which help and hinder individuals' employment and post-secondary education engagement post-FEP. Three electronic databases (Psych INFO, Medline and Social Science Database) were searched up to 21st August 2023. Primary research on employment/education status or engagement within FEP populations ages 18-40 were included. A narrative synthesis was applied to the findings. Of the 10,575 articles screened, 18 were included in the final review. Younger age, non-affective psychotic diagnoses and stigma were identified as common barriers to engagement. Ceasing substance use and having family/financial support were reported as facilitators. Conflicting findings were reported as to the impact of positive and negative symptoms. The range of factors emerging from this review highlight several potential barriers and facilitators for individuals seeking employment or further education opportunities post-FEP. This underlines the need for further research into how and why they influence employment and educational outcomes, with a view to improving treatment outcomes by incorporating these factors into care planning.

Modeling diagnostic code dropout of schizophrenia in electronic health records improves phenotypic data quality and cross-ancestry transferability of polygenic scores

Importance

Researchers commonly use counts of diagnostic codes from EHR-linked biobanks to infer phenotypic status. However, these approaches overlook temporal changes in EHR data, such as the discontinuation or "dropout" of diagnostic codes, which may exacerbate disparities in genomics research, as EHR data quality can be confounded with demographic attributes.

Objective

To address this, we propose modeling diagnostic code dropout in EHR data to inform phenotyping for schizophrenia in genomic analyses.

Design

We develop and test our diagnostic dropout model by analyzing EHR data from individuals with prior schizophrenia diagnoses. We further validate model performance on a subset of patients whose diagnoses were attained through chart review. Using PRS-CS and existing GWAS summary statistics, we first extrapolate polygenic weights. Then, we apply our dropout model's outputs to construct a data-driven filter defining our target cohort for measuring polygenic score performance.

Setting

Our analysis utilizes EHR and genomic data from the Million Veteran Program.

Participants

To model diagnostic dropout in schizophrenia, we leverage data from 12,739 patients with a history of schizophrenia, after excluding outliers. For polygenic score analyses, we incorporate data from a potential pool of 8,385 European ancestry and 6,806 African ancestry patients with a history of schizophrenia.

Main outcomes and measures

We compare the performance of our diagnostic dropout model with alternative methodologies both in predicting diagnostic dropout on a holdout set, as well as on chart review labeled data. Using the top differential diagnosis predictors in our model, we select relevant cases by filtering out patients with a prior history of mood or anxiety disorders. We then test the impact of applying different filters for measuring polygenic score performance.

Results

When evaluated on chart review-labeled data, our model improves the area under the precision-recall curve (AUPRC) by 9.6% compared to competing methods. By applying our data-driven filter for schizophrenia, we achieve a 62% increase in the association effect size when transferring a European polygenic score to an African ancestry target cohort.

Conclusions and Relevance

These findings highlight the potential of modeling diagnostic code dropout to enhance the phenotypic quality of EHR-linked biobank data, advancing more equitable and accurate genomics research across diverse populations.

Social defeat predicts the emergence of psychotic-like experiences through the effects on aberrant salience: insights from a network analysis of longitudinal data

BACKGROUND

Psychotic-like experiences (PLEs) are subclinical phenomena that often precede the onset of psychosis and occur in various mental disorders. Social determinants of psychosis and PLEs are important and have been operationalized within the social defeat (SD) hypothesis. The SD hypothesis posits that low social status and exposure to repeated humiliation can lead to imbalanced dopamine neuron activity, and thus increased risk of psychosis. We aimed to assess the role of dynamic interactions between SD components in shaping the occurrence of PLEs using a network analysis.

METHODS

A total of 2241 non-clinical, young adults were assessed at baseline and invited for reassessment after a 6-month follow-up. Self-reports recording the occurrence of PLEs, aberrant salience (AS), depressive, and anxiety symptoms as well as SD characteristics (socioeconomic status, minority status, humiliation, perceived constraints, and domain control) were administered. Two networks were analyzed (the first one covering all baseline measures and the second one with the baseline SD components and follow-up measures of AS and psychopathology).

RESULTS

The SD components were not directly connected to the measures of PLEs in both networks. However, in both networks, SD components were connected to PLEs through a mediating effect of AS. Among SD components, humiliation had the highest bridge centrality across three predefined communities of variables (SD; depressive and anxiety symptoms; AS, and PLEs).

CONCLUSIONS

The findings indicate that SD might make individuals vulnerable to develop PLEs through the mediating effects of AS. Among SD components, humiliation might play the most important role in the development of PLEs.

Oral and Long-acting Injectable Aripiprazole in Severe Mental Illness and Substance Use Disorder Comorbidity: An Updated Systematic Review

BACKGROUND

Co-occurrence of substance use disorders is frequent in patients with mental health disorders is a condition known as "dual diagnosis". The use of substances worsens the prognosis and lowers the quality of life of psychiatric patients. It also increases the risk of hospitalization and suicide rate.

OBJECTIVES

To assess the effects of aripiprazole therapy on substance use and other psychiatric outcomes in dually diagnosed patients.

METHODS

We performed a systematic review conducted on 3 databases PUBMED, SCOPUS, and Web of Science, selecting original studies and analyzing the impact of aripiprazole therapy on dually diagnosed patients. Six hundred and fifty-five articles were founded and, after removing duplicates (n = 274) and applying the exclusion criteria, 12 articles were included in our systematic review.

RESULTS

12 studies were included, among which 6 were Randomized Controlled Trials. The Most frequent psychiatric diagnosis were schizoaffective disorders, schizophrenia, and bipolar disorders. Alcohol and cocaine use disorders were the most used substances. Eleven studies showed a clinical improvement after aripiprazole treatment. 8 studies evaluated craving and found a significant reduction after treatment with aripiprazole. No definitive conclusions can be drawn on substance usage and maintenance of abstinence.

CONCLUSION

The present findings suggest aripiprazole may be associated with reducing substance craving and improving depression, psychosis, and schizoaffective disorders in dually diagnosed patients.

Behavioral Test Scores Could Be Linked to the Protein Expression Values of p62 and GLAST in the Brains of Mice with Neuropsychiatric Disorder-Related Behaviors

Neuropsychiatric disorders are a public health concern, in which diagnosis and prognosis may be based on clinical symptoms that might often diverge across individuals. Schizophrenia is a major neuropsychiatric disorder, which may affect millions worldwide. However, the biochemical alterations of this disorder have not been comprehensively distinguished. In addition, there is less confidence in finding specific biomarkers for neuropsychiatric disorders, including schizophrenia, but rather a specific characteristic behavioral pattern. In general, maternal immune activation is considered to be one of the important factors in the development of neuropsychiatric disorders. Here, a mouse model of neuropsychiatric disorders was created, in which poly I:C, sodium dextran sulfate (DSS), and κ-carrageenan (CGN) were utilized for maternal immune activation during the pregnancies of mother mice. Subsequently, we examined the link between biochemical changes in p62 and/or glutamate aspartate transporter (GLAST) in the brains of offspring mice and the alteration in their experimental behavior scores. Furthermore, a therapeutic study was conducted on these neuropsychiatric disorder model mice using butyric acid, piceid, and metformin. It was found that some molecules could effectively improve the behavioral scores of neuropsychiatric model mice. Importantly, significant correlations between certain behavioral scores and p62 protein expression, as well as between the scores and GLAST expression, were recognized. This is the first report of a significant correlation between pathological behaviors and biochemical alterations in neuropsychiatric disorder model animals. This concept could contribute to the development of innovative treatments to at least ameliorate the symptoms of several psychiatric disorders.

Iowa Gambling Task performance in individuals with schizophrenia: the role of general versus specific cognitive abilities

Objective

We aimed to explore how specific cognitive processes, such as attention and executive functions, account for variance in decision-making measured by Iowa Gambling Task (IGT) performance among individuals with schizophrenia spectrum disorders.

Methods

Adults (N = 65, M age = 25.4) with schizophrenia spectrum disorders participating in a clinical trial (registered at clinicaltrials.gov NCT03048695) completed the IGT, neuropsychological tests of attention, response inhibition, mental flexibility, working memory, and planning, as well as subtests from the Wechsler tests of intelligence to estimate IQ. Associations between performance on specific tasks, a composite score of executive function and attention, and IGT performance measured in two ways, one using the total net score, decks (C+D) - (A+B) and the other as preference for decks with more frequent gains than losses, decks (B+D) - (A+C), were analyzed with correlational and hierarchical regression analysis controlling for estimated IQ and psychotic symptoms, measured by the Positive and Negative Syndrome Scale.

Results

In the regression analyses, the strongest predictor of IGT performance measured as the total net score was estimated IQ (b = 1.43, p <.001). Neither specific cognitive tasks nor the composite score of executive functioning significantly contributed to explaining variance in IGT total net score beyond IQ and symptoms of psychosis. However, IQ and symptoms of psychosis did not predict tendency towards selecting decks with different gain-to-loss frequency, whereas poorer composite executive functioning predicted a pattern of selecting decks A and C with more frequent losses, (b = 8.30, p <.05).

Discussion

The results suggest that both IQ and executive functions contribute to IGT performance, but in distinct ways. Whereas lower IQ may contribute to overall more disadvantageous decision-making, poorer executive functioning may contribute to a more risk-aversive decision-making style. A clinical implication may be that individuals with schizophrenia and lower IQ or poorer executive functioning will have a higher need for support and interventions targeting decision-making.

Parental mental disorders in patients with comorbid schizophrenia and obsessive-compulsive disorder: a nationwide family-link study

Schizophrenia is highly comorbid with obsessive-compulsive disorder (OCD); both conditions share numerous pathophysiological etiologies. We, thus, examined the risk of mental disorders in the parents of probands with schizophrenia, OCD, or both conditions. Between 2001 and 2011, we enrolled a nationwide cohort of 69,813 patients with schizophrenia, OCD, or both. The control cohort included 698,130 individuals matched for demographics. Poisson regression models were employed to examine the risk of six mental disorders in their parents, including schizophrenia, bipolar disorder, depressive disorder, OCD, alcohol use disorder, and substance use disorder. We stratified patients into schizophrenia-only, OCD-only, and dual-diagnosis groups, and the dual-diagnosis group was further divided into schizophrenia-first, OCD-first, and simultaneously diagnosed groups. Compared with controls, the schizophrenia, OCD, and dual-diagnosis groups had higher risks for the six mental disorders in their parents (range of odds ratio [OR] 1.50-7.83). The sub-analysis of the dual-diagnosis group showed that the schizophrenia-first, OCD-first, and simultaneously diagnosed groups had higher odds for schizophrenia, bipolar disorder, depressive disorder, and OCD (range of OR 1.64-6.45) in their parents than the control group; the simultaneously diagnosed and OCD-first diagnosed groups had a higher odds of parental substance use disorder, while the schizophrenia-first diagnosed group had a higher odds of parental alcohol use disorder. The interrelationship between OCD and schizophrenia is linked to bipolar disorder, depressive disorder, alcohol use disorder, and substance use disorder. The results have implications for mental health policy and future research.

Avatar Intervention in Virtual Reality for Cannabis Use Disorder in Individuals With Severe Mental Disorders: Results From a 1-Year, Single-Arm Clinical Trial

Background

The dual diagnosis of cannabis use disorder (CUD) and severe mental disorder (SMD) results in clinically complex individuals. Cannabis use is known to have negative consequences on psychiatric symptoms, medication compliance, and disease prognosis. Moreover, the effectiveness of currently available psychotherapeutic treatments is limited in this population. In this context, our research team developed avatar intervention, an approach using virtual reality as a therapeutic tool to treat CUD in individuals with SMD.

Objective

This pilot clinical trial aimed to evaluate, until the 1-year follow-up, the efficacy of avatar intervention for CUD among 32 participants with a dual diagnosis of SMD and CUD.

Methods

Over the course of the 8 intervention sessions, participants were given the opportunity to enter a dialogue in virtual reality with an avatar representing a person with a significant role in their consumption, who was animated in real time by a therapist. The primary outcomes were the quantity of cannabis consumed and the frequency of use. Secondary outcomes included severity of problematic cannabis use, motivation for change, protective strategies for cannabis use, consequences of cannabis use, psychiatric symptoms, and quality of life. Changes in reported outcomes during the assessment periods before the intervention; postintervention; and 3, 6, and 12 months after the end of the intervention were assessed using a linear mixed-effects model.

Results

Significant reductions were observed in the quantity of cannabis consumed, and these were maintained until the 12-month follow-up visit (d=0.804; P<.001; confirmed by urine quantification). Frequency of cannabis use showed a small significant reduction at the 3-month follow-up (d=0.384; P=.03). Moreover, improvements were observed in the severity of CUD, cannabis-related negative consequences, the motivation to change cannabis use, and the strategies used to mitigate harms related to cannabis use. Finally, moderate benefits were observed for quality of life and psychiatric symptoms.

Conclusions

Overall, this unique intervention shows promising results that seem to be maintained up to 12 months after the end of the intervention. With the aim of overcoming the methodological limitations of a pilot study, a single-blind randomized controlled trial is currently underway to compare the avatar intervention for CUD with a conventional addiction intervention.

RECAPACITA PROJECT: Impact of the New York Convention on capacity modification judgments in persons with severe mental disorders: A comparative study using mixed methodology

In 2013, Spain aligned its capacity modification processes (CM) legislation with the UN Convention on the rights of persons with disabilities, specifically for individuals with severe mental disorders (SMD). The reforms replaced incapacity verdicts with support provision and introduced the term "CM". However, the social impact of these changes remains uncertain. The RECAPACITA project was initiated to generate knowledge on SMD and CM, and this study aims to investigate modifications in CM sentences and associated terminology. Using a qualitative-quantitative methodology, content analysis was conducted on 56 sentences from individuals with SMD. Terminology analysis utilized 19 sentences to achieve information saturation. A comparison was made between sentences prior to 2013 and those spanning 2014 to 2023, analyzing the data through ANOVA and Bonferroni tests (significance level: 0.05). The analysis revealed that psychiatric illness, its evolution, lack of self-governance, and economic management were frequently mentioned aspects in the sentences. However, no significant correlations were found. Qualitatively, mentions of self-governance were more prevalent in sentences before 2013. Conversely, after 2013, there was an increased focus on substances use, lack of insight and medical adherence, and the need for support in daily life. The term "incapable person" appeared in 100% of the sentences, indicating no differences in terminology. The study suggests that current CM sentences provide increasingly individualized information, addressing the specific support needs of individuals. To enhance future legal proceedings, incorporating neuroscience in studying SMD individuals and reconsidering terminology based on Convention guidelines is recommended.

Smoking behavior is associated with suicidality in individuals with psychosis and bipolar disorder: a systematic quantitative review and meta-analysis

Smoking behavior has been well-established to be more prevalent in individuals with psychosis and bipolar disorder compared to the general population. However, reports about higher suicide attempt prevalence of smoking compared to non-smoking patients suggest that smoking behavior may contribute to identifying at-risk groups of patients in a comparatively easy manner. In the present systematic quantitative review, we provide meta-analytical evidence on the smoking and suicide attempt link in 22 studies (k = 27 independent samples; N = 11,452) of patients with psychosis and bipolar disorder. We observed a small meaningful effect of smoking on suicide attempts (OR = 1.70; 95% CI [1.48; 1.95]), indicating that smokers have 1.70 the odds of having reported a suicide attempt compared to non-smokers. This effect generalized across diagnosis type (i.e., schizophrenia vs. bipolar spectrum disorder), sample type (i.e., in-vs. outpatients), and participant sex. However, the observed summary effect appeared somewhat inflated due to publication process-related mechanisms, showing some evidence for effect-inflating publication bias and a decline effect. In all, the presently observed smoking and suicide attempt link appears to be small but meaningful and robust, thus suggesting smoking status represents a useful variable for the identification of at-risk populations for suicide attempts.

The Resurgence of Exogenous Psychosis: A Phenomenological Examination of Substance-Induced Psychopathology

ABSTRACT

The psychopathological manifestations associated with substance use, including induced psychotic experiences, are increasingly relevant but not well-understood within the medical community. Novel psychoactive substances and potentiated old compounds like cannabis and cocaine have emerged as a global concern, especially among adolescents and young adults. Transition rates from substance-induced psychosis (SIP) to persistent psychosis are significant, particularly in cases of cannabis-induced psychosis. Scientific inquiry into induced psychotic phenomena has revealed differences between SIP and primary psychotic disorders, highlighting the risk factors associated with each. The concept of exogenous psychosis, including its toxic variant known as lysergic psychoma, provides valuable insights into the role of external factors in psychosis development. A phenomenological approach characterizes this disruption in perception as a shift in temporal and spatial dimensions, leading to auditory and visual hallucinations. The "twilight state" of consciousness plays a crucial role in the transition from substance use to psychosis, with implications for spatiality, intersubjectivity, and temporality. This complex path to psychosis challenges traditional diagnostic models and underscores the need for a more nuanced understanding of substance-induced psychopathological experiences.

Evaluating the Impact of Motivational Enhancement Therapy on Tobacco Cessation in Schizophrenia: A Comprehensive Review

Tobacco use is markedly prevalent among individuals with schizophrenia, presenting significant challenges to their physical health and psychiatric treatment. This comprehensive review evaluates the impact of motivational enhancement therapy (MET) on tobacco cessation in this population. Schizophrenia, a chronic mental disorder characterized by symptoms such as delusions and hallucinations, is frequently accompanied by high rates of smoking, which exacerbates health risks and complicates treatment regimens. MET, a client-centered approach rooted in motivational interviewing, aims to enhance intrinsic motivation for behavior change through empathetic and non-confrontational therapeutic sessions. This review synthesizes evidence from clinical studies on MET's effectiveness in promoting smoking cessation among individuals with schizophrenia. The review highlights the therapy's strengths, including its adaptability and client-focused nature, which are particularly beneficial for addressing the unique challenges faced by this population. It also discusses the broader health benefits of smoking cessation, such as improved physical health and enhanced efficacy of psychiatric medications. Despite promising results, the review identifies limitations and challenges in applying MET, such as potential barriers to implementation and the need for further research. In conclusion, MET offers a valuable intervention for tobacco cessation in individuals with schizophrenia, with the potential to significantly improve health outcomes and quality of life. Future research should focus on optimizing MET strategies and exploring their broader impacts on this vulnerable population.

An overview of the efficacy and safety of brexpiprazole for the treatment of schizophrenia in adolescents

INTRODUCTION

The onset of psychotic symptoms occurs prior to age 19 in 39% of the patients with schizophrenia. There are limited approved treatment options for adolescents with schizophrenia. Brexpiprazole was approved by the United States Food and Drug Administration (FDA) for treatment of schizophrenia in adolescents in 2022.

AREAS COVERED

Extrapolation of adult data to youth and use of pharmacologic modeling coupled with open long-term safety data were used by the FDA to approve brexpiprazole for adolescent schizophrenia. They were all reviewed herein.

EXPERT OPINION

D2 receptor partial agonist antipsychotic agents are preferred in the early phase of treatment of psychotic disorders. Approval of brexpiprazole in adolescent schizophrenia provides an additional option. Brexpiprazole was approved by the FDA on the basis of extrapolation of adult data without controlled trials in adolescents. This reduces placebo exposure in young people. Two previous agents (asenapine and ziprasidone) approved for adult schizophrenia failed to separate from placebo in adolescent schizophrenia studies; this partially undermines the process of extrapolation. For brexpiprazole, the paucity of data in adolescents relegates it to a second-line agent. More research on brexpiprazole is needed to delineate its relative role in the management of adolescent schizophrenia.

Environmental risk factors for schizophrenia and bipolar disorder from childhood to diagnosis: a Swedish nested case-control study

BACKGROUND

Shared genetic risk between schizophrenia (SCZ) and bipolar disorder (BD) is well-established, yet the extent to which they share environmental risk factors remains unclear. We compare the associations between environmental exposures during childhood/prior to disorder onset with the risk of developing SCZ and BD.

METHODS

We conducted a Swedish register-based nested case-control study using 4184 SCZ cases and 18 681 BD cases diagnosed 1988-2013. Cases were matched to five controls by birth year, birth region, and sex. Conditional logistic regression was used to estimate incidence rate ratios (IRR) for SCZ and BD for each exposure (severe childhood infections, adverse childhood experiences (ACEs), substance use disorders (SUDs), urban birth/longest residence).

RESULTS

All SUD types were associated with very high risk (IRR 4.9-25.5), and all forms of ACEs with higher risk (IRR 1.5-4.3) for both disorders. In the mutually adjusted models, ACEs demonstrated slightly higher risk for BD (SCZ IRR 1.30, 1.19-1.42; BD IRR 1.49, 1.44-1.55), while for SUD, risk was higher for SCZ (SCZ IRR 9.43, 8.15-10.92; BD IRR 5.50, 5.15-5.88). Infections were associated with increased risk of BD (IRR 1.21, 1.17-1.26) but not SCZ. Urban birth and urban longest residence were associated with higher risk of SCZ (IRR 1.19, 1.03-1.37), while only the combination of urban birth and rural longest residence showed higher risk for BD (IRR 1.24, 1.13-1.35).

CONCLUSIONS

There were both shared and unique environmental risk factors: SUDs and ACEs were risk factors for both disorders, while infections were more strongly associated with BD and urbanicity with SCZ.

Rethinking Mental Automatism: De Clérambault's Theory in the Age of Novel Psychoactive Drugs: Psychotropic Effects and Synthetic Psychosis

The widespread use of novel psychoactive substances (NPSs)-defined as new narcotic or psychotropic agents not classified under the Single Convention on Narcotic Drugs of 1961 or the Convention on Psychotropic Substances of 1971-poses a significant challenge to contemporary mental health paradigms due to their impact on psychiatric disorders. This study revisits and expands upon the theory of mental automatism as proposed by Gaëtan Gatian de Clérambault, aiming to elucidate the psychopathological mechanisms underlying substance-induced psychoses (SIP) and their distinction from non-induced psychoses (schizophrenia and related disorders). Through a phenomenological and clinical investigation, we explore the relevance of mental automatism in the development of toxic psychoses, drawing upon the historical and contemporary literature. This research highlights the psychopathological distinctions between induced and non-induced psychoses and the transition mechanisms from acute to chronic psychosis states. De Clérambault's theory, supplemented by Janet, Jackson, and Bonhoeffer's contributions, provides a foundational framework for understanding the genesis of SIP. Our findings suggest that NPS consumption, particularly among adolescents and psychiatric patients, significantly correlates with increased risks of SIP, marked by a transition to chronicity influenced by biological lesions triggered by substance use. Furthermore, we propose a comprehensive framework for SIP, integrating mental automatism, psychopathological distinctions, and transition mechanisms. This framework aims to refine diagnostic criteria and therapeutic approaches, addressing gaps in clinical practice and research. The study underscores the need for a nuanced understanding of SIP, advocating for a paradigm shift in psychiatric assessment and treatment approaches to better address the complexities of substance-induced mental health disorders.

Examining the impact of substance use on hospital length of stay in schizophrenia spectrum disorder: a retrospective analysis

BACKGROUND

Among patients diagnosed with schizophrenia, the presence of substance use poses an aggravating comorbidity, exerting a negative impact on the course of the disease, adherence to therapeutic regimens, treatment outcomes, duration of hospital stays, and the frequency of hospitalizations. The primary objective of the present study is to investigate the relationship between comorbid substance use disorders, antipsychotic treatment, and the length of stay in individuals hospitalized for treatment of schizophrenia.

METHODS

We conducted a retrospective analysis of electronic health records spanning a 12-month period, specifically focusing on adult patients diagnosed with schizophrenia who were discharged from the University Hospital of Psychiatry Zurich between January and December 2019. We documented the number and types of diagnosed substance use disorder, the antipsychotic treatment, the length of stay, and the number of previous hospitalizations for each patient.

RESULTS

Over a third (n = 328; 37.1%) of patients with schizophrenia had comorbid substance use with cannabis being the most frequent consumed substance. Patients with substance use (either single or multiple) were more frequently hospitalized; those with multiple substance use more frequently than those with a single substance use (F(2, 882) = 69.06; p < 0.001). There were no differences regarding the rate of compulsory admission. Patients with no substance use had a lower HoNOS score at discharge (F(2, 882) = 4.06). Patients with multiple substance use had a shorter length of stay (F(2, 882) = 9.22; p < 0.001), even after adjusting for duration of illness, previous hospitalizations, diagnosis, and antipsychotic treatment.

CONCLUSIONS

In patients with schizophrenia, comorbid single or multiple substance use has a relevant negative impact on treatment and thus on the course of disease. Substance use in patients with schizophrenia should therefore receive special attention in order to reduce re-hospitalization rates and improve the clinical outcome.

Impact of gaming disorder on first episode psychosis patients' evolution: Protocol for a multicentered prospective study

AIMS

The objective of this study is to underline the impact of Gaming Disorder on the clinical evolution of patients with First Episode Psychosis. The specific aims of the study are to determine the prevalence of gaming disorder among those patients and assess the consequences of gaming on their clinical trajectory.

METHODS

This is a prospective multicenter cohort study that will enrol 800 patients diagnosed with a first episode psychosis, with a follow-up period of up to 3 years. Using a systematic screening procedure for gaming disorder, the clinical staff will assess patients gaming habits at admission and every 6 months thereafter. Information from patients' medical records will also be extracted using the same timeframe.

RESULTS

The patients' characteristics at admission and during follow-up will be presented in the form of descriptive statistics and compared between different subgroups of patients using uni- and multivariate logistic regression models. Repeated measures ANCOVA will also be performed to analyse the impact of gaming disorders on patients' clinical path as assessed by the Positive and Negative Syndrome Scale and the Clinical Global Impression scale, considering covariates such as psychiatric diagnosis, pharmacological treatment, age, sex/gender, and duration of untreated psychosis.

CONCLUSION

These findings will guide the development of prevention, detection, and treatment strategies for the comorbidity between gaming disorder and first episode psychosis, ultimately improving the patients' recovery.

Modulation of mGlu5 reduces rewarding associative properties of nicotine via changes in mesolimbic plasticity: Relevance to comorbid cigarette smoking in psychosis

RATIONALE

Antipsychotic medications that are used to treat psychosis are often limited in their efficacy by high rates of severe side effects. Treatment success in schizophrenia is further complicated by high rates of comorbid nicotine use. Dopamine D2 heteroreceptor complexes have recently emerged as targets for the development of more efficacious pharmaceutical treatments for schizophrenia.

OBJECTIVE

The current study sought to explore the use of the positive allosteric modulator of the mGlu5 receptor 3-Cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide (CDPPB) as a treatment to reduce symptoms related to psychosis and comorbid nicotine use.

METHODS

Neonatal treatment of animals with the dopamine D2-like receptor agonist quinpirole (NQ) from postnatal day (P)1-21 produces a lifelong increase in D2 receptor sensitivity, showing relevance to psychosis and comorbid tobacco use disorder. Following an 8-day conditioning paradigm, brain tissue in the mesolimbic pathway was analyzed for several plasticity markers, including brain derived neurotrophic factor (BDNF), phosphorylated p70 ribosomal S6 kinase (phospho-p70S6K), and cadherin-13 (Cdh13).

RESULTS

Pretreatment with CDPPB was effective to block enhanced nicotine conditioned place preference observed in NQ-treated animals. Pretreatment was additionally effective to block the nicotine-induced increase in BDNF and sex-dependent increases in cadherin-13 in the ventral tegmental area (VTA), as well as increased phospho-p70S6K in the nucleus accumbens (NAcc) shell found in NQ-treated animals.

CONCLUSION

In conjunction with prior work, the current study suggests positive allosteric modulation of the mGlu5 receptor, an emerging target for schizophrenia therapeutics, may be effective for the treatment of comorbid nicotine abuse in psychosis.

Sociodemographic and treatment-related determinants of recent substance use among adults with comorbid substance misuse and psychotic disorders discharged from substance use treatment

INTRODUCTION

Rates of alcohol and illicit substance use are higher among persons with psychotic disorders relative to the general population. The adverse health and psychological effects of substance use behaviors disproportionately impact persons with psychotic disorders. Prior research has shown that persons with psychotic disorders experience increased difficulty in reducing substance use behaviors, and interventions targeting substance use behavior change among this population have demonstrated limited effectiveness. One reason for this is that little is known about the factors that influence substance use and behavior change among this population. To address these disparities, the present study investigated sociodemographic and treatment-related factors of substance use recurrence among persons with psychotic disorders who received substance use treatment services.

METHODS

Data came from the 2015-2018 Treatment Episode Dataset-Discharges (TEDS-D). TEDS-D collects annual data on adolescent and adult discharges from state-certified substance use treatment centers in the United States. The study conducted all analyses with a subsample of 1956 adult discharges with a psychotic disorder who received services from an outpatient substance use treatment center for at least one month. χ2 tests of independence and multivariable logistic regression analyses were used to examine associations of sociodemographic and treatment-related characteristics with substance use recurrence while in treatment (α < 0.05 analyses). The study presents results from multivariable logistic regression models as adjusted odds ratios (AORs) with 95 % confidence intervals (CI).

RESULTS

Those who were age 50 or older, were referred to treatment by the criminal justice system, and attended substance use self-help groups had lower odds of substance use recurrence while in treatment. Sex, educational attainment, employment status, living situation, type of substance use, and treatment history were not significantly associated with substance use recurrence.

CONCLUSIONS

In designing treatment services, providers should consider whether focusing on sociodemographic, including cultural, factors can affect more positive substance use behavior change and other desired treatment outcomes among those with psychotic disorders and comorbid substance misuse. Further study is needed to identify these factors among specific subpopulations of those with psychotic disorders and substance misuse.

Therapeutic potential of gamma entrainment using sensory stimulation for cognitive symptoms associated with schizophrenia

Schizophrenia is a complex neuropsychiatric disorder with significant morbidity. Treatment options that address the spectrum of symptoms are limited, highlighting the need for innovative therapeutic approaches. Gamma Entrainment Using Sensory Stimulation (GENUS) is an emerging treatment for neuropsychiatric disorders that uses sensory stimulation to entrain impaired oscillatory network activity and restore brain function. Aberrant oscillatory activity often underlies the symptoms experienced by patients with schizophrenia. We propose that GENUS has therapeutic potential for schizophrenia. This paper reviews the current status of schizophrenia treatment and explores the use of sensory stimulation as an adjunctive treatment, specifically through gamma entrainment. Impaired gamma frequency entrainment is observed in patients, particularly in response to auditory and visual stimuli. Thus, sensory stimulation, such as music listening, may have therapeutic potential for individuals with schizophrenia. GENUS holds novel therapeutic potential to improve the lives of individuals with schizophrenia, but further research is required to determine the efficacy of GENUS, optimize its delivery and therapeutic window, and develop strategies for its implementation in specific patient populations.

Patient experiences with a primary care medical home tailored for people with serious mental illness

INTRODUCTION

People with serious mental illness (SMI) have low rates of primary care (PC) use and die years prematurely, mostly because of medical illnesses such as cardiovascular disease or cancer. To meet the needs of these individuals, a novel, specialized patient-centered medical home with care coordination ("SMI PACT") was developed and implemented in PC. This study qualitatively examined patients' experiences with this innovative care model.

METHOD

After implementation of the medical home in 2018, one-on-one semistructured interviews were conducted with 28 patients (32% women, 43% Black, and 25% Hispanic). Interviews were professionally transcribed and coded prior to thematic analysis.

RESULTS

Patients overwhelmingly described positive experiences with SMI PACT because of the qualities of interpersonal communication displayed by SMI PACT staff (e.g., nonjudgment, good listening, patience), structural features of the SMI PACT collaborative care model (e.g., frequent follow-up communication), and other unique aspects of the SMI PACT model tailored for SMI, such as easy-to-understand language. For these reasons, most patients expressed a desire to continue care in SMI PACT. Patients also self-reported improved engagement with their healthcare and self-management of diet, exercise, blood pressure, and diabetes control as a result of SMI PACT participation.

DISCUSSION

Patients enrolled in a specialized PC medical home identified clinician characteristics and behaviors that informed an overwhelmingly positive impression of the program model. Their experiences can guide dissemination of specialized PC models and integrated services for people with SMI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sexually transmitted infections, sexual life and risk behaviours of people living with schizophrenia: systematic review and meta-analysis

BACKGROUND

Sexually transmitted infections (STIs), along with sexual health and behaviour, have received little attention in schizophrenia patients.

AIMS

To systematically review and meta-analytically characterise the prevalence of STIs and sexual risk behaviours among schizophrenia patients.

METHOD

Web of Science, PubMed, BIOSIS, KCI-Korean Journal Database, MEDLINE, Russian Science Citation Index, SciELO and Cochrane Central Register were systematically searched from inception to 6 July 2023. Studies reporting on the prevalence or odds ratio of any STI or any outcome related to sexual risk behaviours among schizophrenia samples were included. PRISMA/MOOSE-compliant (CRD42023443602) random-effects meta-analyses were used for the selected outcomes. Q-statistics, I2 index, sensitivity analyses and meta-regressions were used. Study quality and publication bias were assessed.

RESULTS

Forty-eight studies (N = 2 459 456) reporting on STI prevalence (including 15 allowing for calculation of an odds ratio) and 33 studies (N = 4255) reporting on sexual risk behaviours were included. Schizophrenia samples showed a high prevalence of STIs and higher risks of HIV (odds ratio = 2.11; 95% CI 1.23-3.63), hepatitis C virus (HCV, odds ratio = 4.54; 95% CI 2.15-961) and hepatitis B virus (HBV; odds ratio = 2.42; 95% CI 1.95-3.01) infections than healthy controls. HIV prevalence was higher in Africa compared with other continents and in in-patient (rather than out-patient) settings. Finally, 37.7% (95% CI 31.5-44.4%) of patients were sexually active; 35.0% (95% CI 6.6-59.3%) reported consistent condom use, and 55.3% (95% CI 25.0-82.4%) maintained unprotected sexual relationships.

CONCLUSIONS

Schizophrenia patients have high prevalence of STIs, with several-fold increased risks of HIV, HBV and HCV infection compared with the general population. Sexual health must be considered as an integral component of care.

Prevalence, demographics and clinical characteristics of Internet addiction among Chinese adolescents with schizophrenia

Introduction

Several studies have reported that Internet addiction (IA) is more prevalent in the psychiatric disorder population. However, the prevalence of IA and its relationship with clinical variables among Chinese adolescents with schizophrenia is unclear. This study sought to investigate the prevalence of IA and its clinical correlates in Chinese adolescents with schizophrenia, which has not yet been reported.

Methods

Seven hundred and six inpatient adolescents with schizophrenia were recruited. All patients underwent Young's Internet Addiction Test (IAT) to measure Internet addiction, as well as the Positive and Negative Syndrome Scale (PANSS) for psychopathology.

Results

Our results showed that 186 patients had a total IAT score of 50 or more, bringing the prevalence of IA to 26.3%. Girls (21.7%, 92/424) were less likely to have combined IA than boys (33.3%, 94/282). Compared to those patients without IA, patients with IA had better socioeconomic status, higher probability of living in the city, higher levels of depressive symptoms, excited symptoms, and lower levels of concrete symptoms and PANSS total scores (all p<0.05). Further binary logistic regression analysis indicated that good socioeconomic status, living in the city and PANSS total scores were significantly associated with IA. In addition, correlation analysis showed significant correlations between IA total score and the following parameters: good socioeconomic status, living in the city, negative subscore, concrete subscore, depression subscore, excited subscore and PANSS total score (Bonferroni corrected all p <0.05).

Conclusion

The results of this study indicate that the prevalence of IA in Chinese adolescents with schizophrenia is higher than that in the general population. Several demographic and clinical variables are risk factors for IA in adolescents with schizophrenia.

Promising immunomodulators for management of substance and alcohol use disorders

INTRODUCTION

The neuroimmune system has emerged as a novel target for the treatment of substance use disorders (SUDs), with immunomodulation producing encouraging therapeutic benefits in both preclinical and clinical settings.

AREAS COVERED

In this review, we describe the mechanism of action and immune response to methamphetamine, opioids, cocaine, and alcohol. We then discuss off-label use of immunomodulators as adjunctive therapeutics in the treatment of neuropsychiatric disorders, demonstrating their potential efficacy in affective and behavioral disorders. We then discuss in detail the mechanism of action and recent findings regarding the use of ibudilast, minocycline, probenecid, dexmedetomidine, pioglitazone, and cannabidiol to treat (SUDs). These immunomodulators are currently being investigated in clinical trials described herein, specifically for their potential to decrease substance use, withdrawal severity, central and peripheral inflammation, comorbid neuropsychiatric disorder symptomology, as well as their ability to improve cognitive outcomes.

EXPERT OPINION

We argue that although mixed, findings from recent preclinical and clinical studies underscore the potential benefit of immunomodulation in the treatment of the behavioral, cognitive, and inflammatory processes that underlie compulsive substance use.

A systematic review and meta-analysis of synthetic cathinone use and psychosis

RATIONALE

Synthetic cathinones (SC), commonly referred to as "bath salts", are stimulants resembling the natural alkaloid cathinone found in the khat plant. These substances have the potential to induce serious health risks such as hallucinations, delusions, paranoia and agitation which can lead to substance-induced psychotic disorders. Despite growing concerns, there is a limited understanding of the association between SC consumption and the devolvement of such psychopathologies.

METHODS

We conducted a systematic review to investigate the frequency of substance-induced psychotic disorder (SIPD) and associated conditions in humans following synthetic cathinone consumption. We qualitatively and quantitatively analyzed SC exposure cases.

RESULTS

A total of 32 studies were included, with a diverse range of demographics, synthetic cathinone types, and consumption patterns. The proportion of individuals developing psychotic symptoms was reported at 0.380 (Random-effects model, 95% CI 0.289 - 0.475). Additionally, the significant heterogeneity in diagnostic approaches limited our ability to provide a precise estimate of prevalence.

CONCLUSIONS

Synthetic cathinone consumption is associated with the risk of developing psychotic symptoms as indicated by the prevalence of hallucinations and/or delusions. Due to the lack of information on classifying factors, particularly duration of symptoms, we are unable to conclude synthetic cathinone-induced psychosis. Further research is warranted to elucidate the underlying mechanism linking synthetic cathinone consumption and psychosis. This review underscores the urgency of addressing the growing health risks posed by synthetic cathinone use. Additionally, it highlights the necessity of proper quantification of psychotic symptoms through scales and reporting of classification criteria to accurately diagnose SIPD.

Differential effects of cannabis constituents on schizophrenia-related psychosis: a rationale for incorporating cannabidiol into a schizophrenia therapeutic regimen

Schizophrenia is a serious mental health disorder that confers one of the highest mortality rates of all psychiatric illnesses. Although the disorder's psychotic symptoms are treatable with conventional antipsychotics, they remain incurable. Moreover, medication adherence is poor, and individuals with schizophrenia choose to self-medicate with illicit substances, including cannabis. It is well-established that the delta-9-tetrahydrocannabinol (delta-9-THC) component of cannabis elicits psychotomimetic effects at high doses; worsens schizophrenia-related psychosis; commonly develops into cannabis use disorder in individuals with schizophrenia; and increases the risk of earlier-onset schizophrenia symptoms in those harboring genetic susceptibility. However, individuals with schizophrenia commonly use cannabis and cannabis derivatives such as cannabidiol (CBD). These products seem to alleviate psychotic symptoms and relieve adverse side effects of antipsychotic medications. Therefore, one notion that has gained traction is the potential utility of cannabis-derived cannabidiol (CBD) as adjunct treatment to reduce schizophrenia-associated psychosis and other symptoms. Currently, preclinical and clinical data remain inconclusive. The present review distinguishes the mechanisms underlying schizophrenia-associated vs. cannabis-induced psychosis; reviews the evidence for delta-9-THC-mediated exacerbation vs. CBD-mediated amelioration of schizophrenia-associated psychosis; and describes potential approaches for incorporating CBD into schizophrenia therapeutic regimen in a safe and efficacious manner.

Black family members' cultural beliefs and experiences regarding substance use and misuse by relatives: A focused ethnography

Research explored substance use in Black communities in Canada, but a gap exists about the experiences of Black family members, caring for relatives with substance misuse within the Canadian context. Black family members are defined as African Canadians, Caribbean Canadian or Caribbean Blacks. This paper explores Black family members' beliefs and experiences regarding their relatives' psychoactive substance use and misuse. A focused ethnography was conducted with 26 Black family members with 17 participants originated from various parts of Africa, and nine participants originated from parts of the Caribbean. Participants comprised of mothers (n = 5), fathers (n = 2), step-fathers (n = 1), husbands (n = 1), wives (n = 2), uncles (n = 5), aunties (n = 2), siblings (n = 5), in-laws (n = 2), and guardians (n = 1). Three themes were generated: cultural beliefs and perceptions regarding substance use and misuse of family relatives; "When he starts drinking, hell breaks loose": Perceived impact of substance misuse on family safety and stability; and, the experiences of stigma and the keeping of secrets. Prioritizing public health approaches, such as public policies and campaigns that dismantle stigma and systemic barriers, and increase awareness about substance use and harm reduction interventions among Black communities.

Carepath for overcoming psychosis early (COPE): first 5 years of clinical operation and prospective research in the Cavan-Monaghan early intervention service

OBJECTIVES

As Ireland confronts the many challenges of broadening the introduction of early intervention services (EIS) for first episode psychosis (FEP) as national policy, this article describes Carepath for Overcoming Psychosis Early (COPE), the EIS of Cavan-Monaghan Mental Health Service, and presents prospective research findings during its first 5 years of operation.

METHODS

COPE was launched as a rural EIS with an embedded research protocol in early 2012, following an education programme for general practitioners (GPs). Here, operational activities are documented and research findings presented through to late 2016.

RESULTS

During this period, 115 instances of FEP were incepted into COPE, 70.4% via their GP and 29.6% via the Emergency Department. The annual rate of inception was 24.8/100,000 of population aged > 15 years and was 2.1-fold more common among men than women. Mean duration of untreated psychosis was 5.7 months and median time from first psychotic presentation to initiation of antipsychotic treatment was zero days. Assessments of psychopathology, neuropsychology, neurology, premorbid functioning, quality of life, insight, and functionality compared across 10 DSM-IV psychotic diagnoses made at six months following presentation indicated minimal differences between them, other than more prominent negative symptoms in schizophrenia and more prominent mania in bipolar disorder.

CONCLUSIONS

COPE illustrates the actuality of introducing and the challenges of operating a rural EIS for FEP. Prospective follow-up studies of the 5-year COPE cohort should inform on the effectiveness of this EIS model in relation to long-term outcome in psychotic illness across what appear to be arbitrary diagnostic boundaries at FEP.

Association between psychosis and substance use in Kenya. Findings from the NeuroGAP-Psychosis study

Background

Substance use is prevalent among people with mental health issues, and patients with psychosis are more likely to use and misuse substances than the general population. Despite extensive research on substance abuse among the general public in Kenya, there is a scarcity of data comparing substance use among people with and without psychosis. This study investigates the association between psychosis and various substances in Kenya.

Methods

This study utilized data from the Neuro-GAP Psychosis Case-Control Study between April 2018 and December 2022. The KEMRI-Wellcome Trust Research Programme recruited participants from various sites in Kenya, including Kilifi County, Malindi Sub-County, Port Reitz and Coast General Provincial Hospitals, and Moi Teaching and Referral Hospital, as well as affiliated sites in Webuye, Kapenguria, Kitale, Kapsabet, and Iten Kakamega. The collected data included sociodemographic information, substance use, and clinical diagnosis. We used the summary measures of frequency (percentages) and median (interquartile range) to describe the categorical and continuous data, respectively. We examined the association between categorical variables related to psychosis using the chi-square test. Logistic regression models were used to assess the factors associated with the odds of substance use, considering all relevant sociodemographic variables.

Results

We assessed a total of 4,415 cases and 3,940 controls. Except for alcohol consumption (p-value=0.41), all forms of substance use showed statistically significant differences between the case and control groups. Cases had 16% higher odds of using any substance than controls (aOR: 1.16, 95%CI: 1.05-1.28, p=0.005). Moreover, males were 3.95 times more likely to use any substance than females (aOR:3.95; 95%CI: 3.43-4.56). All the categories of living arrangements were protective against substance use.

Conclusion

The findings of this study suggest that psychotic illnesses are associated with an increased likelihood of using various substances. These findings are consistent with those of previous studies; however, it is crucial to investigate further the potential for reverse causality between psychosis and substance abuse using genetically informed methods.

A whole-brain neuromark resting-state fMRI analysis of first-episode and early psychosis: Evidence of aberrant cortical-subcortical-cerebellar functional circuitry

Psychosis (including symptoms of delusions, hallucinations, and disorganized conduct/speech) is a main feature of schizophrenia and is frequently present in other major psychiatric illnesses. Studies in individuals with first-episode (FEP) and early psychosis (EP) have the potential to interpret aberrant connectivity associated with psychosis during a period with minimal influence from medication and other confounds. The current study uses a data-driven whole-brain approach to examine patterns of aberrant functional network connectivity (FNC) in a multi-site dataset comprising resting-state functional magnetic resonance images (rs-fMRI) from 117 individuals with FEP or EP and 130 individuals without a psychiatric disorder, as controls. Accounting for age, sex, race, head motion, and multiple imaging sites, differences in FNC were identified between psychosis and control participants in cortical (namely the inferior frontal gyrus, superior medial frontal gyrus, postcentral gyrus, supplementary motor area, posterior cingulate cortex, and superior and middle temporal gyri), subcortical (the caudate, thalamus, subthalamus, and hippocampus), and cerebellar regions. The prominent pattern of reduced cerebellar connectivity in psychosis is especially noteworthy, as most studies focus on cortical and subcortical regions, neglecting the cerebellum. The dysconnectivity reported here may indicate disruptions in cortical-subcortical-cerebellar circuitry involved in rudimentary cognitive functions which may serve as reliable correlates of psychosis.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

Schizophrenia and Emergency Medicine

Schizophrenia is a chronic condition characterized by positive symptoms (auditory hallucinations, delusion), negative symptoms (avolition, social withdrawal), and disorganized thoughts/behaviors. Although the pathophysiology is incompletely understood, several neurobiological mechanisms have been proposed. Treatment usually involves antipsychotic medication as well as psychotherapy and supportive services. When evaluating patients in the emergency department, acute safety considerations are paramount. Patients should be assessed for suicide risk, violence risk, inability to care for self, and the risk of being the victim of a crime. Persons with schizophrenia are at an increased risk of substance use and a variety of medical problems.