Drug-related predictors of readmission for schizophrenia among patients admitted to treatment for drug use disorders

Readmission and Dropout in Outpatient Centers: An Analysis of Real-World Data in Patients with Dual-Diagnosis

Substance use disorder treatment faces challenges such as dropout, relapse, and readmission. This study aims to identify factors associated with readmission and those influencing dropout among dual diagnosis (DD) patients (those with both a substance use disorder and another psychiatric disorder) attending outpatient addiction centers. Retrospective cohort study using the electronic health records of 8383 outpatients diagnosed with DD. Bivariate analysis and regression analysis were applied to control for the variables. Age, incarceration for 30 days prior to admission, and specific patterns of consumption increased the likelihood of readmission. Specifically, individuals who reported no substance use in the 30 days before admission or those diagnosed with an opioid or cocaine use disorder were particularly susceptible to readmission. Of the dual diagnoses, patients with personality disorders were more likely to be readmitted. In relation to dropout, opioid dependence and frequency of use were associated with a higher probability of dropout. Patients with poorer adherence to treatment and previous readmissions were also more likely to drop out. Enhancing treatment adherence and reducing dropout and readmission rates poses a challenge in managing patients with DD. Leveraging electronic health records offers enhanced ecological validity concerning the outpatient treatment requirements for such patients. Therapeutic adherence, alongside specific sociodemographic variables and consumption patterns, emerges as pivotal factors in this context. Identifying and understanding these variables facilitates the customization of outpatient treatment strategies to better meet the needs of patients with comorbidities.

Use of antipsychotic medication, benzodiazepines, and psychiatric hospitalization in cannabis-related versus cannabis-unrelated schizophrenia - a nationwide, register-based cohort study

BACKGROUND

Evidence suggests that cannabis may be a causal factor for development of schizophrenia. We aimed to investigate whether use of antipsychotic medication, benzodiazepines, and psychiatric service use differs among patients with schizophrenia depending on whether psychosis was precipitated by a diagnosis of cannabis use disorder (CUD).

METHODS

We utilized the nationwide Danish registries to identify all individuals with an incident diagnosis of schizophrenia from 1995 to 2016. We also collected information on whether first CUD diagnosis preceded schizophrenia and thus defined a group of potentially cannabis-related schizophrenia. We compared the cannabis-related schizophrenia group both with all non-cannabis-related patients with schizophrenia and with non-cannabis-related patients with schizophrenia that were propensity-score matched to cases using a range of potentially confounding variables.

RESULTS

We included 35 714 people with incident schizophrenia, including 4116 (11.5%) that were cannabis-related. In the unmatched-comparison analyses, there were no clear differences over time in use of antipsychotics and benzodiazepines related to whether the diagnosis of schizophrenia was cannabis-related. After propensity-score matching, use of antipsychotics and benzodiazepines was significantly lower among cannabis-related cases of schizophrenia. In the unmatched comparison, the cannabis-related group had significantly more days admitted than the non-cannabis-related group. This was markedly attenuated after propensity-score matching.

CONCLUSIONS

Our findings indicate the importance of considering cannabis-related cases of schizophrenia as a potentially distinct disorder in terms of prognosis. It is unclear, however, if these differences are due to different biological types of schizophrenia being compared or if they rather indicate behavioral differences such as reduced adherence and treatment-seeking.

Psychological factors predicting patients' risk of relapse after enrollment in drug use treatment: A systematic review

BACKGROUND AND AIMS

Despite high rates of relapse after treatment for drug use, to our knowledge there is no systematic literature identifying psychological factors that predict risk of relapse to drug use (excluding alcohol or tobacco). Our aim was to identify psychological factors that predict risk of relapse to drug use after enrollment in drug use treatment. The identification of such factors can support treatment planning and relapse prevention.

METHODS

We searched for peer-reviewed articles published between 2000 and 2023 in PsycINFO, PsycArticles, Web of Science, and PubMed. The inclusion criteria were: peer-reviewed publications, quantitative studies, in English, adult samples, with a prospective design, and analyses of minimum one psychological factor as predictor of relapse to drug use. All authors were involved in abstract and full-text screening, and in assessing risk of bias. The findings are presented in a narrative synthesis and tables are organized by type of drug.

RESULTS

Of 2226 publications initially identified, 45 were eligible. Twenty-three focused on predicting relapse to stimulants, 15 to opioids, and 7 to unspecified drugs. Substance use at baseline was an important factor predicting risk of relapse to opioids, and possibly stimulants. There was an indication that craving and attention problems potentially predict relapse to use of some drugs. Mental health factors (e.g., psychiatric diagnosis) did not predict relapse. Several psychological factors (e.g., cognition, emotion, personality, motivation) were scarcely examined. Over half of the studies had moderate to high risk of bias.

CONCLUSIONS

Based on the 45 studies, few psychological factors predicted risk of relapse to drug use. Higher comparability between studies and more rigorous methodology are necessary in order to derive more precise recommendations that inform and improve clinical practice.

PRE-REGISTRATION

PROSPERO, CRD42020182839.

Cannabis use among patients presenting to the emergency department for psychosis: Associations with restraint use, medication administration, psychiatric hospitalization, and repeat visits

Cannabis use is associated with increased severity of psychotic symptoms and the risk of acute agitation and aggressive behavior in inpatient (IP) and outpatient settings. Whether or not cannabis use is associated with increased acuity of psychosis-related ED presentations and risk of repeat ED visits for psychosis is unclear. In this retrospective study of 2,134 ED visits for acute psychosis, we investigated the risk of physical restraint, parenteral medication administration, psychiatric hospitalization, and recurrent ED visits. We examined ED visits between March 1, 2019 and February 28, 2021 based on urinary Tetrahydrocannabinol (THC) screen status (positive vs negative vs no screen). The risk of physical restraint, parenteral antipsychotic, and benzodiazepine administration was significantly greater in ED visits with a positive THC screen compared to those with a negative or no THC screen. We did not find an association between a positive urinary THC screen and IP hospitalization or the risk of recurrent ED presentation for psychosis within 90 days. These findings suggest that positive urinary THC may predict acute agitation or acuity of symptoms in ED settings and underscores the importance of screening for THC during ED presentations for psychosis.

Patient-, Hospital-, and System-Level Factors Associated With 30-Day Readmission After a Psychiatric Hospitalization

Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

Risk factors for readmission in schizophrenia treated with combined psychoeducation and standard therapy

Background

We conducted a historical cohort study of patients with schizophrenia to identify more robust risk factors at discharge that contribute to readmission within a year.

Methods and Findings

The subjects underwent brief psychoeducation during hospitalization. Multivariate analysis was conducted using factors selected in the univariate analysis. Using logistic regression analysis, the number of hospital admissions (P = .01) and Schedule for Assessment of Insight Japanese version score (P = .04) were identified as risk factors for readmission, with odds ratios of 0.70 and 1.18, respectively.

Conclusions

These results suggest that improvement in insight and early intervention may lead to a more stable community life.

We conducted a historical cohort study of patients with schizophrenia to identify more robust risk factors at discharge that contribute to readmission within a year. The number of hospital admissions and Schedule for Assessment of Insight Japanese version score were identified as risk factors for readmission.

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.

Impact of cannabis use on outcomes of patients admitted to an involuntary psychiatric unit: A retrospective cohort study

INTRODUCTION

Cannabis is associated with an increased risk of mental disorders, including the onset or adverse evolution of schizophrenia, bipolar disorder and depression. The aim of our study was to examine how cannabis use influences length of stay and readmissions in a unit of involuntary care.

METHOD

All patients admitted to one secure adult psychiatry unit in France in 2016 were included (n = 370). Patients were assigned to one of two groups according to detection of urinary tetrahydrocannabinol (THC + or -). Clinical outcomes, such as length of stay and readmissions, were compared between the groups in multivariate analyses.

RESULTS

We identified 130 THC + patients and 240 THC- patients. THC + patients were often young men. In adjusted analyses, THC + status was significantly associated with one-year readmissions (OR = 2.29, p = .0082) and more prescriptions of benzodiazepines (OR = 1.93, p = .02), but not antipsychotics, at discharge.

CONCLUSIONS

Cannabis users seem to have a particular profile in secure units, and are associated with specific diagnoses and treatments, and a higher risk of readmissions. Adapted management strategies might be warranted for these patients.

A Web-Based Program for Cannabis Use and Psychotic Experiences in Young People (Keep It Real): Protocol for a Randomized Controlled Trial

BACKGROUND

Young Australians (16-25 years) have the highest rates of past-month cannabis use in the world. Cannabis use increases the risk of alcohol and other drug disorders and depressive disorders, and has a robust dose-response association with psychotic experiences (PEs) and disorders. PEs are subthreshold positive psychotic symptoms, including delusions and hallucinations, which increase the risk of substance use, depressive or anxiety disorders, and psychotic disorders. Access to effective web-based early interventions targeting both cannabis use and PEs could reduce such risk in young people.

OBJECTIVE

The objective of this study is to determine the efficacy and cost-effectiveness of the Keep it Real web-based program compared to an information-only control website among young cannabis users (16-25 years) with PEs.

METHODS

Participants are recruited online, and consenting individuals meeting inclusion criteria (aged 16-25 years, who have used cannabis in the past month and experienced PEs in the past 3 months) are automatically randomized to either the Keep it Real web-based program (n=249) or an information-only control website (n=249). Both websites are self-guided (fully automated). The baseline and follow-up assessments at 3, 6, 9, and 12 months are self-completed online. Primary outcome measures are weekly cannabis use, PEs, and the relative cost-effectiveness for quality-adjusted life years. Secondary outcomes include other substance use and related problems, PE-related distress, cannabis intoxication experiences, severity of cannabis dependence, depression/anxiety symptoms, suicidality, and mental well-being and functioning.

RESULTS

Recruitment commenced in February 2019, and the results are expected to be submitted for publication in mid-2021.

CONCLUSIONS

This study protocol describes a large randomized controlled trial of a new web-based program for young cannabis users experiencing PEs. If effective, the accessibility and scalability of Keep it Real could help reduce growing public health concerns about the significant social, economic, and health impacts of cannabis use.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618001107213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374800.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15803.

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.

Benzodiazepine abuse, misuse, dependence, and withdrawal among schizophrenic patients: A review of the literature

Patients diagnosed with schizophrenia are at least three times more likely to develop a substance use disorder than controls. These patients are frequently prescribed benzodiacepines as a coadjuvant drug, which have a high potential for addiction. We performed a literature review aiming to gather evidence on various topics concerning the use of benzodiacepines in schizophrenia, with a focus on possible abuse: 1) Prevalence of prescripted and non-prescripted benzodiacepine use among patients, 2) Prevalence of abusers, 3) Effects of long-term benzodiacepine abuse in schizophrenia prognosis, 4) Possible management strategies for benzodiacepine abuse in this population. Our search revealed there is a high variability (up to 20%) in benzodiacepine abuse among patients, with cannabis and stimulants being more frequent, and no clear demographic traits have been identified among these patients. Patients with affective symptoms are more likely to abuse benzodiazepines. Its long-term effects on prognosis have been debated, with some papers hinting at a higher mortality rate. Tapering benzodiacepines has been associated with an improvement in some cognitive functions. Management strategies for potential abuse do not differ greatly for this population, and no specific pharmacological aid can be indicated, but an integral approach is proposed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The role of substance use and adult sexual assault severity in the course of schizophrenia: An epidemiological catchment study of sexual assault victims

BACKGROUND

Childhood trauma increases the risk of schizophrenia, yet the role of adult sexual assault in the course of schizophrenia is unknown. This study aims to examine the associations between substance use and sexual assault severity characteristics with the course of schizophrenia among adult sexual assault victims using an epidemiologic study design.

METHODS

Sexual assault data on all individuals received from 2000 to 2010 (N = 2147) at the Center for Care of Sexual Assault Victims at Wolfson Medical Center, the largest medical center for sexual assault victims in the country, were merged with the Israel National Psychiatric Case Registry, that consisted of lifetime psychiatric hospitalizations of schizophrenia (birth to 6 years post-assault). The associations between substance use and adult sexual assault severity characteristics with hospitalizations were quantified using recurrent events Cox modeling.

RESULTS

Schizophrenia with sexual assault survivors occurred in 117 persons. Cox modeling showed that recurrent psychiatric hospitalizations were associated with younger age, sexual assault at older age, previous diagnosis of psychosis, and drug use shortly before or during the assault. Other assault characteristics (number of assailants, means of subdual, penetration type, perpetrator violence, physical injury of the victim) and immediacy of seeking help had a null association with the course of psychiatric hospitalization. These results replicated in two sensitivity analyses.

CONCLUSIONS

Substance use among victims of sexual assault was associated with an exacerbated course of schizophrenia, pointing to a possibly modifiable risk factor that should be targeted in prevention, assessment, treatment formulation and implementation.

Patient-Level Predictors of Psychiatric Readmission in Substance Use Disorders

Repeated psychiatric readmissions are a particular challenge in the treatment of substance use disorders and are associated with substantial burden for patients and their associates and for healthcare providers. Factors affecting readmission rates are heterogeneous and need to be identified to better allocate resources. Within the Swiss healthcare system, such data on substance use disorder patients are largely missing. Understanding these factors might bear important implications for future healthcare planning. Thus here, we examine risk factors of inpatient readmission. We retrospectively analyzed all admissions to the hospital's department of addictive disorders in the year 2016. Patients included in the study were followed over a period of 1 year after discharge regarding readmissions to the clinic. Besides the demographic, social, and economic data, we extracted data concerning patient history, admission, and discharge as well as clinical data regarding type and number of substances abused and comorbid diagnoses. In order to describe severity of cases, we furthermore included the scores of the Health of the Nation Outcome Scale (HoNOS) at admission and at discharge as documented in the medical database. Of the 554 patients included in the study, 228 (41.2%) were readmitted within 12 months. Previous admissions, concomitant use of different substances, presence of psychosis or mania, and a higher severity score at discharge increased the likelihood of readmission. The odds for readmission were furthermore higher in patients not being married, living alone, and being unemployed. When all (bivariate) statistically significant factors are included into a logistic regression model, the previous number of admissions and the HoNOS clinical score at discharge significantly contributed to this model. Our findings stress that patients with higher symptom load at discharge are prone to be readmitted within 12 months. The same applies for patients with previous admissions. These findings suggest that the development of specific interventions to prevent premature discharge before satisfactory symptom remission, in particular in those patients with previous admissions in their patient history, might help to prevent readmissions.