The association of cannabis use with quality of life and psychosocial functioning in psychosis

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.

Exploring the Interactions Between Psychotic Symptoms, Cognition, and Environmental Risk Factors: A Bayesian Analysis of Networks

BACKGROUND AND HYPOTHESIS

Psychotic disorders (PDs) have huge personal and societal impact, and efforts to improve outcomes in patients are continuously needed. Environmental risk factors (ERFs), especially modifiable risk factors, are important to study because they pose a target for intervention and prevention. No studies have investigated ERFs, cognition, and psychotic symptoms together in a network approach.

STUDY DESIGN

We explored interactions between 3 important ERFs (tobacco smoking, cannabis use, and childhood trauma), 6 cognitive domains, and 3 dimensions of symptoms in psychosis. From the Genetic Risk and Outcome of Psychosis (GROUP) cohort, we used data from patients, siblings, and healthy controls to construct networks using Bayesian analyses of all 12 variables. We constructed networks of the combined sample and of patients and siblings separately.

STUDY RESULTS

We found that tobacco smoking was directly associated with cognition and psychotic symptoms. The cognitive variable processing speed was the most central node, connecting clusters of psychotic symptoms and substance use through the variables of positive symptoms and tobacco smoking. Comparing the networks of patients and siblings, we found that networks were relatively similar between patients and siblings.

CONCLUSIONS

Our results support a potential central role of processing speed deficits in PDs. Findings highlight the importance of integrating tobacco smoking as potential ERFs in the context of PDs and to broaden the perspective from cannabis discontinuation to smoking cessation programs in patients or people at risk of PDs.

Shaping tomorrow's support: baseline clinical characteristics predict later social functioning and quality of life in schizophrenia spectrum disorder

PURPOSE

We aimed to explore the multidimensional nature of social inclusion (mSI) among patients diagnosed with schizophrenia spectrum disorder (SSD), and to identify the predictors of 3-year mSI and the mSI prediction using traditional and data-driven approaches.

METHODS

We used the baseline and 3-year follow-up data of 1119 patients from the Genetic Risk and Outcome in Psychosis (GROUP) cohort in the Netherlands. The outcome mSI was defined as clusters derived from combined analyses of thirteen subscales from the Social Functioning Scale and the brief version of World Health Organization Quality of Life questionnaires through K-means clustering. Prediction models were built through multinomial logistic regression (ModelMLR) and random forest (ModelRF), internally validated via bootstrapping and compared by accuracy and the discriminability of mSI subgroups.

RESULTS

We identified five mSI subgroups: "very low (social functioning)/very low (quality of life)" (8.58%), "low/low" (12.87%), "high/low" (49.24%), "medium/high" (18.05%), and "high/high" (11.26%). The mSI was robustly predicted by a genetic predisposition for SSD, premorbid adjustment, positive, negative, and depressive symptoms, number of met needs, and baseline satisfaction with the environment and social life. The ModelRF (61.61% [54.90%, 68.01%]; P =0.013) was cautiously considered outperform the ModelMLR (59.16% [55.75%, 62.58%]; P =0.994).

CONCLUSION

We introduced and distinguished meaningful subgroups of mSI, which were modestly predictable from baseline clinical characteristics. A possibility for early prediction of mSI at the clinical stage may unlock the potential for faster and more impactful social support that is specifically tailored to the unique characteristics of the mSI subgroup to which a given patient belongs.

Contingency Management for Dually Diagnosed Inpatients with Psychosis

Contingency management (CM) is an evidence-based treatment method in substance abuse treatment. However, little is known about its efficacy in dually diagnosed patients with psychosis and in inpatient settings. Therefore, the aim of this study is to investigate the efficacy of CM for dually diagnosed patients with psychosis in an inpatient setting. Furthermore, we investigate the effect of the nature of the reward used (cash vs. prize) on the efficacy of CM. We made use of an 8-week fish-bowl CM intervention by means of a within-subject reversal design with three treatment phases (baseline-intervention-follow-up). Sixty-seven patients were included in this study, of whom thirty-four completed the protocol. The results show no effect of CM on abstinence nor an interaction with clinical or demographic variables. Cash money is as effective as prizes. Future research should further investigate the effect of psychosis and treatment setting on the efficacy of CM, with special attention for Patient Report Experience and Outcome Measures (PREM/PROM).

The relationship between substance use and self-reported aspects of social functioning in patients with a psychotic disorder

BACKGROUND

In patients with a psychotic disorder, rates of substance use (tobacco, cannabis, and alcohol) are higher compared to the general population. However, little is known about associations between substance use and self-reported aspects of social functioning in patients with a psychotic disorder.

METHODS

In this cross-sectional study of 281 community-dwelling patients with a psychotic disorder, linear regression models were used to assess associations between substance use (tobacco, cannabis, or alcohol) and self-reported aspects of social functioning (perceived social support, stigmatization, social participation, or loneliness) adjusting for confounders (age, gender, and severity of psychopathology).

RESULTS

Compared to nonsmokers, both intermediate and heavy smokers reported lower scores on loneliness (E = -0.580, SE = 0.258, p = 0.025 and E = -0.547, SE = 0,272, p = 0.046, respectively). Daily cannabis users reported less social participation deficits than non-cannabis users (E = -0.348, SE = 0.145, p = 0.017). Problematic alcohol use was associated with more perceived social support compared to non-alcohol use (E = 3.152, SE = 1.102, p = 0.005). Polysubstance users reported less loneliness compared to no users (E = -0.569, SE = 0.287, p = 0.049).

CONCLUSIONS

Substance use in patients with psychosis is associated with more favorable scores on various self-reported aspects of social functioning.

Assessing Cannabis Use in People with Psychosis

Introduction: Cannabis use is common in people with psychotic disorders and is associated with the exacerbation of symptoms, poor treatment adherence, and an increased risk of relapse. Accurate assessment of cannabis use is thus critical to the clinical management of psychosis. Discussion: Cannabis use is usually assessed with self-report questionnaires that were originally developed for healthy individuals or people with a cannabis use disorder. Compared to these groups, the pattern of cannabis use and the associated harms in patients with psychosis are quite different. Moreover, in people with psychosis, the accuracy of self-reported use may be impaired by psychotic symptoms, cognitive deficits, and a desire to conceal use when clinicians have advised against it. Although urinary screening for delta-9-tetrahydrocannabinol is sometimes used in the assessment of acute psychotic episodes, it is not used in routinely. Cannabis use could be assessed by measuring the concentration of cannabinoids in urine and blood, but this is rarely done in either clinical settings or research. Conclusion: Using quantitative biological measures could provide a more accurate guide to the effects of use on the disorder than asking patients or using questionnaires.

Financial dissatisfaction in people with psychotic disorders - A short report on its prevalence and correlates in a large naturalistic psychosis cohort

Psychotic disorders have a strong negative impact on multiple aspects of daily life, including people's financial situation. This exploratory study examines the level of financial dissatisfaction and its correlates in a large cohort of people with psychotic disorders. Data from the first assessments of people with psychotic disorders (n = 5271) who were included in the Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS; 2006-2020), which is conducted in the northern Netherlands, were used. The Manchester Short Assessment of Quality of Life (MANSA) was used to measure financial dissatisfaction. In addition, sociodemographic and psychiatric characteristics, substance use and global and social functioning were assessed. One-fifth to one-third of people with psychotic disorders report financial dissatisfaction, fluctuating over the year in which they were assessed. These proportions are considerably higher than in the general population. Cannabis and other substance use were associated with higher levels of financial dissatisfaction (small to medium effect). The other significant associations showed (very) small effect sizes. Therefore, we conclude that financial dissatisfaction in people with psychotic disorders appears to be relatively independent of other demographic and psychiatric characteristics, and global and social functioning. These findings are an important first step for increasing knowledge on financial dissatisfaction among people with psychotic disorders. The findings can also contribute to raising awareness about the topic for healthcare professionals working in this field.

Cannabis and Psychosis

Psychosis and cannabis use may overlap in multiple ways in young people. Research suggests that cannabis use increases risk for having psychotic symptoms, both attenuated (subthreshold) and acute. Cannabis use may also exacerbate psychosis symptoms among young people with underlying psychosis risk and psychotic disorders. Although there are suggestions for treating co-occurring psychosis and cannabis use in young people (e.g., incorporating cannabis use assessment and treatment strategies into specialized early psychosis care), there are many gaps in clinical trial research to support evidence-based treatment of these overlapping concerns.

How to quit cannabis when you have a mental illness: study from the perspective of patients who have successfully quit

AIMS AND METHOD

Research regarding quitting cannabis use often excludes patients with severe mental illness (SMI). We investigated facilitating and impeding factors in SMI patients and their advice to others, using semi-structured interviews with 12 SMI-patients, who were daily cannabis users for ≥12 months and had fully stopped using for ≥6 months.

RESULTS

Seeking distraction, social contacts in personal environment, avoiding temptation and support from professionals were facilitating factors in stopping. Impeding factors were withdrawal symptoms, user environment, experiencing stress and user's routine. Advice to other patients included to just do it, seek support from others, quit 'cold turkey' and acknowledge that cannabis use is a problem. Advice to mental health professionals is to discuss cannabis use from the start of treatment.

CLINICAL IMPLICATIONS

It is important to inform patients that cannabis use has negative consequences and limits the effects of treatment. Do not judge cannabis use or force the patient to stop.

Avatar Intervention for Cannabis Use Disorder in Individuals with Severe Mental Disorders: A Pilot Study

Cannabis use disorder (CUD) is a complex issue, even more so when it is comorbid with a severe mental disorder (SMD). Available interventions are at best slightly effective, and their effects are not maintained over time. Therefore, the integration of virtual reality (VR) may increase efficacy; however, it has not yet been investigated in the treatment of CUD. A novel approach, avatar intervention for CUD, uses existing therapeutic techniques from other recommended therapies (e.g., cognitive behavioral methods, motivational interviewing) and allows participants to practice them in real-time. During immersive sessions, participants are invited to interact with an avatar representing a significant person related to their drug use. This pilot clinical trial aimed to evaluate the short-term efficacity of avatar intervention for CUD on 19 participants with a dual diagnosis of SMD and CUD. Results showed a significant moderate reduction in the quantity of cannabis use (Cohen's d = 0.611, p = 0.004), which was confirmed via urinary quantification of cannabis use. Overall, this unique intervention shows promising results. Longer-term results, as well as comparison with classical interventions in a larger sample, are warranted through a future single-blind randomized controlled trial.

Discontinuing cannabis use: Symptomatic and functional outcomes in people with an established psychotic disorder

For people with psychotic disorders, the negative outcomes associated with continuing cannabis use would suggest that discontinuing such use may be beneficial for their symptomatic and functional recovery. However, existing evidence that discontinuation is associated with better clinical outcomes is inconsistent and it remains unclear whether discontinuing use is associated with improvements in outcomes for people with an established psychotic disorder. In this 3-5-year longitudinal study we examined baseline and follow-up symptomatic and functional profiles of 371 people with an established psychotic disorder, comparing those who continued to use cannabis with those who discontinued use after baseline assessment. At follow-up, one third (33.3 %) of baseline cannabis users had discontinued use. Discontinuation was associated with significantly lower odds of past-year hallucinations and a mean improvement in level of functioning (Personal and Social Performance Scale) compared to a decline in functioning in continuing users. No significant differences in severity of negative symptoms were observed. With few longitudinal studies examining symptomatic and functional outcomes for people with established psychotic disorders who continue to use cannabis compared to those who discontinue use, our findings that discontinuing cannabis was associated with significant clinical improvements fill gaps in the evidence-base.

Cannabis and Psychosis

Psychosis and cannabis use may overlap in multiple ways in young people. Research suggests that cannabis use increases risk for having psychotic symptoms, both attenuated (subthreshold) and acute. Cannabis use may also exacerbate psychosis symptoms among young people with underlying psychosis risk and psychotic disorders. Although there are suggestions for treating co-occurring psychosis and cannabis use in young people (e.g., incorporating cannabis use assessment and treatment strategies into specialized early psychosis care), there are many gaps in clinical trial research to support evidence-based treatment of these overlapping concerns.