Cannabis use and symptom severity in individuals at ultra high risk for psychosis: a meta-analysis

Occasional cannabis use is associated with higher premorbid functioning and IQ in youth at clinical high-risk (CHR) for psychosis: Parallel findings to psychosis cohorts

BACKGROUND

Neurocognitive deficits have been widely reported in clinical high-risk for psychosis (CHR) populations. Additionally, rates of cannabis use are high among CHR youth and are associated with greater symptom severity. Cannabis use has been sometimes shown to be associated with better neurocognition in more progressed psychosis cohorts, therefore in this study we aimed to determine whether a similar pattern was present in CHR.

METHODS

CHR participants ages 12-30 from the North American Prodromal Longitudinal Study (NAPLS-3) (N = 698) were grouped according to: "minimal to no cannabis use" (n = 406), "occasional use" (n = 127), or "frequent use" (n = 165). At baseline, cannabis use groups were compared on neurocognitive tests, clinical, and functional measures. Follow-up analyses were used to model relationships between cannabis use frequency, neurocognition, premorbid, and social functioning.

RESULTS

Occasional cannabis users performed significantly better than other use-groups on measures of IQ, with similar trend-level patterns observed across neurocognitive domains. Occasional cannabis users demonstrated better social, global, and premorbid functioning compared to the other use-groups and less severe symptoms compared to the frequent use group. Follow-up structural equation modeling/path analyses found significant positive associations between premorbid functioning, social functioning, and IQ, which in turn was associated with occasional cannabis use frequency.

DISCUSSION

Better premorbid functioning positively predicts both better social functioning and higher IQ which in turn is associated with a moderate cannabis use pattern in CHR, similar to reports in first-episode and chronic psychosis samples. Better premorbid functioning likely represents a protective factor in the CHR population and predicts a better functional outcome.

Cue-Reactive Phenomenology Mediates the Relationship Between Positive Schizotypy and Cue-Reactive Urge to Gamble in Poker-Machine Gamblers

Although ubiquitous in numerous nightlife cultures, poker-machines present a high risk for problematic use and addiction. Previous research has demonstrated that gambling cues (e.g., flashing lights) can activate gambling urges in poker-machine gamblers. However, the processes that contribute to the maintenance of cue-reactive urges to gamble remain unclear. Consequently, the present study explored whether positive schizotypy predicted gambling urge, and whether cue-reactive altered state of awareness, cue-reactive altered time sense, and cue-reactive absorption mediated this relationship. Seventy adults aged between 19 and 68 (M = 48.86, SD = 12.82) participated in an online cue-reactivity experiment. Participants first completed the Problem Gambling Severity Index and the Unusual Experiences subscale of the Short Oxford-Liverpool Inventory of Feelings and Experiences. Subsequently, at three time points (i.e., baseline, directly after a neutral cue, and directly after a gambling cue) participants completed the Altered State of Awareness, Altered Time Sense, and Absorption subscales of the Phenomenology of Consciousness Inventory and a visual analogue scale measuring cue-reactive urge to gamble. It was found that positive schizotypy was significantly positively correlated with cue-reactive urge to gamble. Additionally, cue-reactive altered state of awareness, cue-reactive altered time sense, and cue-reactive absorption mediated this relationship. The theoretical, clinical and practical implications are discussed.

Compensatory thickening of cortical thickness in early stage of schizophrenia

Brain structural abnormality has been observed in the prodromal and early stages of schizophrenia, but the mechanism behind it is not clear. In this study, to explore the association between cortical abnormalities, metabolite levels, inflammation levels and clinical symptoms of schizophrenia, 51 drug-naive first-episode schizophrenia (FES) patients, 51 ultra-high risk for psychosis (UHR), and 51 healthy controls (HC) were recruited. We estimated gray matter volume (GMV), cortical thickness (CT), concentrations of different metabolites, and inflammatory marks among four groups (UHR converted to psychosis [UHR-C], UHR unconverted to psychosis [UHR-NC], FES, HC). UHR-C group had more CT in the right lateral occipital cortex and the right medial orbito-frontal cortex (rMOF), while a significant reduction in CT of the right fusiform cortex was observed in FES group. UHR-C group had significantly higher concentration of IL-6, while IL-17 could significantly predict CT of the right fusiform and IL-4 and IL-17 were significant predictors of CT in the rMOF. To conclude, it is reasonable to speculate that the increased CT in UHR-C group is related to the inflammatory response, and may participate in some compensatory mechanism, but might become exhaustive with the progress of the disease due to potential neurotoxic effects.

The risk of cannabis use disorder is mediated by altered brain connectivity: A chronnectome study

The brain mechanisms underlying the risk of cannabis use disorder (CUD) are poorly understood. Several studies have reported changes in functional connectivity (FC) in CUD, although none have focused on the study of time-varying patterns of FC. To fill this important gap of knowledge, 39 individuals at risk for CUD and 55 controls, stratified by their score on a self-screening questionnaire for cannabis-related problems (CUDIT-R), underwent resting-state functional magnetic resonance imaging. Dynamic functional connectivity (dFNC) was estimated using independent component analysis, sliding-time window correlations, cluster states and meta-state indices of global dynamics and were compared among groups. At-risk individuals stayed longer in a cluster state with higher within and reduced between network dFNC for the subcortical, sensory-motor, visual, cognitive-control and default-mode networks, relative to controls. More globally, at-risk individuals had a greater number of meta-states and transitions between them and a longer state span and total distance between meta-states in the state space. Our findings suggest that the risk of CUD is associated with an increased dynamic fluidity and dynamic range of FC. This may result in altered stability and engagement of the brain networks, which can ultimately translate into altered cortical and subcortical function conveying CUD risk. Identifying these changes in brain function can pave the way for early pharmacological and neurostimulation treatment of CUD, as much as they could facilitate the stratification of high-risk individuals.

Symptomatic and Functional Outcomes Among Individuals at High Risk for Psychosis Participating in Step-Based Care

Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).

A systematic evidence map of the association between cannabis use and psychosis-related outcomes across the psychosis continuum: An umbrella review of systematic reviews and meta-analyses

While the legal status and public perception of cannabis are currently changing in many countries, one of the important considerations from a public health viewpoint is its potential association with adverse health outcomes such as the development of psychosis. We conducted an umbrella review of systematic reviews and meta-analyses using the AMSTAR-2 to assess the quality of included reviews. We further created an evidence map to visualize and facilitate the overview of the published evidence synthesis on the association between cannabis use and all psychosis-related outcomes and risk moderators in healthy, high-risk, and clinical populations. Overall, we found 32 systematic reviews and meta-analyses. Based on a synthesis of current evidence, cannabis use is associated with subclinical psychosis states (psychotic-like experiences) and traits (schizotypal personality) in the healthy population, as well as earlier onset and development of psychosis. An association with the clinical-high-risk state for psychosis, attenuated psychosis symptoms and transition to psychosis in this population could not be confirmed. An association between cannabis use and psychosis outcomes in patients with psychotic disorder could solely be confirmed regarding relapse. Whether causal effects underlie those associations has not sufficiently been addressed in the evidence synthesis to date.

Cannabis use influences disorganized symptoms severity but not transition in a cohort of non-help-seeking individuals at-risk for psychosis from São Paulo, Brazil

BACKGROUND

Cannabis use is associated with an increased risk of developing a psychotic disorder. However, in individuals with at-risk mental states for psychosis (ARMS) this association is not clear, as well as the impact of cannabis use on symptom severity. The objective of this study was to evaluate the association of cannabis use patterns and ARMS risk status, transition to psychotic and psychiatric disorders, and psychopathology.

METHOD

A sample of 109 ARMS and 197 control individuals was drawn from the general population. Lifetime, maximum and current amount of cannabis use were assessed with the South Westminster modified questionnaire. Participants were followed-up for a mean of 2.5 years and reassessed for transition to any psychiatric disorder.

RESULTS

There were no differences between ARMS and controls regarding lifetime use, current amount of use, or maximum amount of cannabis use. There were also no differences between those who transitioned to a psychiatric disorder and those who did not regarding cannabis use variables. In ARMS individuals, cannabis use was significantly related to disorganization symptoms.

CONCLUSION

The results of this study suggest that cannabis plays a role in the psychopathology of ARMS individuals, leading to more severe symptomatology.

Assessing evidence supporting cannabis harm reduction practices for adolescents at clinical high-risk for psychosis: a review and clinical implementation tool

Cannabis use is consistently associated with both increased incidence of frank psychotic disorders and acute exacerbations of psychotic symptoms in healthy individuals and people with psychosis spectrum disorders. Although there is uncertainty around causality, cannabis use may be one of a few modifiable risk factors for conversion to psychotic disorders in individuals with Clinical High Risk for Psychosis (CHR-P) syndromes, characterized by functionally impairing and distressing subthreshold psychotic symptoms. To date, few recommendations beyond abstinence to reduce adverse psychiatric events associated with cannabis use have been made. This narrative review synthesizes existing scientific literature on cannabis' acute psychotomimetic effects and epidemiological associations with psychotic disorders in both CHR-P and healthy individuals to bridge the gap between scientific knowledge and practical mental health intervention. There is compelling evidence for cannabis acutely exacerbating psychotic symptoms in CHR-P, but its impact on conversion to psychotic disorder is unclear. Current evidence supports a harm reduction approach in reducing frequency of acute psychotic-like experiences, though whether such interventions decrease CHR-P individuals' risk of conversion to psychotic disorder remains unknown. Specific recommendations include reducing frequency of use, lowering delta-9-tetrahydrocannabinol content in favor of cannabidiol-only products, avoiding products with inconsistent potency like edibles, enhancing patient-provider communication about cannabis use and psychotic-like experiences, and utilizing a collaborative and individualized therapeutic approach. Despite uncertainty surrounding cannabis' causal association with psychotic disorders, cautious attempts to reduce acute psychosis risk may benefit CHR-P individuals uninterested in abstinence. Further research is needed to clarify practices associated with minimization of cannabis-related psychosis risk.

Correlates of substance use in a large naturalistic cohort of young people with early and emerging psychosis

BACKGROUND

Substance use remains a barrier to recovery for young people accessing early intervention services for psychosis. While correlates of use have been explored in populations experiencing a first episode of psychosis (FEP), sample sizes have been small and less research assesses cohorts at ultrahigh risk of psychosis (UHR).

METHODS

This study uses data from a naturalistic cohort including UHR and FEP participants (N = 1252) to elucidate clinical correlates of use in the past 3 months of any illicit substance, amphetamine-type stimulants (ATS), cannabis, and tobacco. Moreover, network analysis based on use of these substances and additionally alcohol, cocaine, hallucinogens, sedatives, inhalants, and opioids was completed.

RESULTS

Young people with FEP used substances at significantly higher rates than those at UHR. High concurrence of use was seen between substances. In the FEP group, participants who had used any illicit substance, ATS, and/or tobacco had increased positive symptoms and decreased negative symptoms. Young people with FEP who used cannabis had increased positive symptoms. In the UHR group, participants who had used any illicit substance, ATS, and/or cannabis in the past 3 months showed decreased negative symptoms compared to those who had not.

CONCLUSION

A distinct clinical picture of more florid positive symptoms and alleviated negative symptoms seen in those who use substances in the FEP group appears muted in the UHR cohort. Treating young people at UHR in early intervention services represents the earliest opportunity to address substance use early to improve outcomes.

Understanding the Mechanisms of Action and Effects of Drugs of Abuse

AIM

Drug abuse and addiction are major public health concerns, with millions of people worldwide affected by the negative consequences of drug use. To better understand this complex issue, a review was conducted to examine the mechanisms of action and effects of drugs of abuse, including their acute and chronic effects, the symptoms of abstinence syndrome, as well as their cardiovascular impacts.

METHODS

The analyzed data were obtained after surveying an electronic database, namely PubMed, with no time limit, grey literature sources, and reference lists of relevant articles.

RESULTS

The review highlights the different categories of drugs of abuse, such as opioids, stimulants, depressants, hallucinogens, and cannabis, and discusses the specific ways that each drug affects the brain and body. Additionally, the review explores the short-term and long-term effects of drug abuse on the body and mind, including changes in brain structure and function, physical health problems, and mental health issues, such as depression and anxiety. In addition, the review explores the effects of drug abuse on cardiovascular health, focusing on electrocardiogram changes. Moreover, the analysis of relevant literature also highlighted possible genetic susceptibility in various addictions. Furthermore, the review delves into the withdrawal symptoms that occur when someone stops using drugs of abuse after a period of chronic use.

CONCLUSION

Overall, this review provides a comprehensive overview of the current state of knowledge on drug abuse and addiction. The findings of this review can inform the development of evidence-based prevention and intervention strategies to address this critical public health issue.

The impact of early factors on persistent negative symptoms in youth at clinical high risk for psychosis

Introduction

Persistent negative symptoms (PNS) are described as continuing moderate negative symptoms. More severe negative symptoms have been associated with poor premorbid functioning in both chronic schizophrenia and first episode psychosis patients. Furthermore, youth at clinical high risk (CHR) for developing psychosis may also present with negative symptoms and poor premorbid functioning. The aim of this current study was to: (1) define the relationship between PNS and premorbid functioning, life events, trauma and bullying, previous cannabis use, and resource utilization, and (2) to examine what explanatory variables best predicted PNS.

Method

CHR participants (N = 709) were recruited from the North American Prodrome Longitudinal Study (NAPLS 2). Participants were divided into two groups: those with PNS (n = 67) versus those without PNS (n = 673). A K-means cluster analysis was conducted to distinguish patterns of premorbid functioning across the different developmental stages. The relationships between premorbid adjustment and other variables were examined using independent samples t-tests or chi square for categorical variables.

Results

There was significantly more males in the PNS group. Participants with PNS had significantly lower levels of premorbid adjustment in childhood, early adolescence, and late adolescence, compared to CHR participants without PNS. There were no differences between the groups in terms of trauma, bullying, and resource utilization. The non-PNS group had more cannabis use and more desirable and non-desirable life events.

Conclusion

In terms of better understanding relationships between early factors and PNS, a prominent factor associated with PNS was premorbid functioning, in particular poor premorbid functioning in later adolescence.

Neurobehavioral risk factors influence prevalence and severity of hazardous substance use in youth at genetic and clinical high risk for psychosis

Background

Elevated rates of alcohol, tobacco, and cannabis use are observed in both patients with psychotic disorders and individuals at clinical high risk for psychosis (CHR-P), and strong genetic associations exist between substance use disorders and schizophrenia. While individuals with 22q11.2 deletion syndrome (22qDel) are at increased genetic risk for psychosis, initial evidence suggests that they have strikingly low rates of substance use. In the current study, we aimed to directly compare substance use patterns and their neurobehavioral correlates in genetic and clinical high-risk cohorts.

Methods

Data on substance use frequency and severity, clinical symptoms, and neurobehavioral measures were collected at baseline and at 12-month follow-up visits in two prospective longitudinal cohorts: participants included 89 22qDel carriers and 65 age and sex-matched typically developing (TD) controls (40.67% male, Mage = 19.26 ± 7.84 years) and 1,288 CHR-P youth and 371 matched TD controls from the North American Prodrome Longitudinal Study-2 and 3 (55.74% male; Mage = 18.71 ± 4.27 years). Data were analyzed both cross-sectionally and longitudinally using linear mixed effects models.

Results

Controlling for age, sex, and site, CHR-P individuals had significantly elevated rates of tobacco, alcohol, and cannabis use relative to TD controls, whereas 22qDel had significantly lower rates. Increased substance use in CHR-P individuals was associated with increased psychosis symptom severity, dysphoric mood, social functioning, and IQ, while higher social anhedonia was associated with lower substance use across all domains at baseline. These patterns persisted when we investigated these relationships longitudinally over one-year. CHR-P youth exhibited significantly increased positive psychosis symptoms, dysphoric mood, social functioning, social anhedonia, and IQ compared to 22qDel carriers, and lower rates of autism spectrum disorder (ASD) compared to 22qDel carriers, both at baseline and at 1 year follow-up.

Conclusion

Individuals at genetic and CHR-P have strikingly different patterns of substance use. Factors such as increased neurodevelopmental symptoms (lower IQ, higher rates of ASD) and poorer social functioning in 22qDel may help explain this distinction from substance use patterns observed in CHR-P individuals.

Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes: A Public Mental Health-Oriented Evidence Review

Objective: Cannabis use is increasingly normalized; psychosis is a major adverse health outcome. We reviewed evidence on cannabis use-related risk factors for psychosis outcomes at different stages toward recommendations for risk reduction by individuals involved in cannabis use. Methods: We searched primary databases for pertinent literature/data 2016 onward, principally relying on reviews and high-quality studies which were narratively summarized and quality-graded; recommendations were developed by international expert consensus. Results: Genetic risks, and mental health/substance use problem histories elevate the risks for cannabis-related psychosis. Early age-of-use-onset, frequency-of-use, product composition (i.e., THC potency), use mode and other substance co-use all influence psychosis risks; the protective effects of CBD are uncertain. Continuous cannabis use may adversely affect psychosis-related treatment and medication effects. Risk factor combinations further amplify the odds of adverse psychosis outcomes. Conclusions: Reductions in the identified cannabis-related risks factors-short of abstinence-may decrease risks of related adverse psychosis outcomes, and thereby protect cannabis users' health.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

Substance use and psychotic-like experiences in young people: a systematic review and meta-analysis

This study aimed to systematically review and synthesise the available evidence on the prevalence and associations between psychotic-like experiences (PLEs) and substance use in children and adolescents aged ⩽17 years, prior to the typical age of development of prodromal symptoms of psychosis. As substance use has been associated with earlier age of psychosis onset and more severe illness, identifying risk processes in the premorbid phase of the illness may offer opportunities to prevent the development of prodromal symptoms and psychotic illness. MEDLINE, PsycINFO, and CINAHL databases were searched for chart review, case-control, cohort, twin, and cross-sectional studies. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist, and pooled evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Searches identified 55 studies that met inclusion criteria. Around two-in-five substance users reported PLEs [rate = 0.41, 95% confidence interval (CI) 0.32-0.51; low quality evidence], and one-in-five with PLEs reported using substances (rate = 0.19, 95% CI 0.12-0.28; moderate-to-high quality evidence). Substance users were nearly twice as likely to report PLEs than non-users [odds ratio (OR) 1.77, 95% CI 1.55-2.02; moderate quality evidence], and those with PLEs were twice as likely to use substances than those not reporting PLEs (OR 1.93, 95% CI 1.55-2.41; very low quality evidence). Younger age was associated with greater odds of PLEs in substance users compared to non-users. Young substance users may represent a subclinical at-risk group for psychosis. Developing early detection and intervention for both substance use and PLEs may reduce long-term adverse outcomes.

Cannabis use and attenuated positive and negative symptoms in youth at clinical high risk for psychosis

Cannabis use is more prevalent among youth at clinical high-risk (CHR) for psychosis than healthy controls (HC). There is mixed evidence as to whether cannabis use is associated with increased severity of attenuated psychotic symptoms (APS) or whether current cannabis use is associated with the transition to psychosis. This study aims to assess cannabis use differences between CHR youth and HC and the impact of cannabis use on APS, clinical status, and transition to psychosis. Participants were from the North American Prodrome Longitudinal Study-3, a prospective longitudinal study including 710 individuals, age 12-30, meeting criteria for a psychosis risk syndrome based on the Structured Interview for Psychosis-Risk Syndromes, and 96 HC. Cannabis use, frequency, and severity of use were assessed with the Alcohol Use Scale/Drug Use Scale. Current and past cannabis use disorders were assessed with the Structured Clinical Interview for DSM-5. Compared to HC, CHR individuals reported significantly increased lifetime cannabis use, during the past six months, and at baseline; greater frequency and severity of cannabis use; and increased prevalence of cannabis use disorder. Relative to CHR youth without cannabis use, CHR cannabis users had significantly higher ratings on baseline grandiosity and lower 12-months social anhedonia. Severity of cannabis was unrelated to clinical status at 2-years, and it did not differentiate CHR individuals who transitioned to psychosis from those who did not. However, a major limitation was that the current number of CHR cannabis users was small, and survival analyses resulted in a smaller power than the 80 % recommended.

Trajectories of adolescent psychotic-like experiences and early cannabis exposure: Results from a Finnish Birth Cohort Study

BACKGROUND

Longitudinal studies examining the effect of cannabis exposure (CE) on the prognosis of adolescents with psychotic-like experiences (PLEs) are scarce. We examined trajectories of mental health in adolescents with PLEs and cannabis exposure.

METHODS

The Northern Finland Birth Cohort 1986 (n = 6552) with linkage to nationwide register data was used. Information on lifetime cannabis exposure was collected when participants were aged 15/16. Register-based outcome data on diagnoses made in clinical practice were obtained until age 33. Logistic regression was used to study the association of PLE/CE patterns and subsequent psychiatric disorders. The group with neither PLEs nor CE was utilized as the reference group. Parental psychiatric disorders, family structure, sex, frequent alcohol intoxications, daily smoking and illicit substance use other than cannabis were adjusted for.

RESULTS

In all, 6552 subjects (49.2 % males) were included in analysis. PLEs with cannabis exposure were associated with any psychiatric disorder (OR = 2.59; 95 % CI 1.82-3.68), psychotic disorders (OR = 3.86; 95 % CI 1.83-8.11), mood disorders (OR 4.07; 95 % CI 2.74-6.04), depressive disorders (OR = 4.35; 95 % CI 2.93-6.48), anxiety disorders (OR = 2.06; 95 % CI 1.34-3.17) and substance use disorders (OR = 2.26; 95 % CI 1.13-4.50) compared to reference group. Effect sizes were greater for group with both PLEs and cannabis use than for group with PLEs only.

CONCLUSIONS

Early-onset cannabis use is an adverse prognostic marker for adolescents with PLEs after extensive confounder control including other substance use.

Antipsychotics are related to psychometric conversion to psychosis in ultra-high-risk youth

BACKGROUND

The prescription of antipsychotics outside overt psychotic conditions remains controversial, especially in youth where it is relatively widespread. Furthermore, some studies seem to indicate that antipsychotic exposure in individuals at ultra-high-risk (UHR) for psychosis is associated with higher conversion rates. This study was set up to test whether the inter-current prescription of antipsychotics in UHR patients was related to the psychometric threshold for a diagnosis of psychosis.

METHODS

The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 125 UHR participants. Standard psychometric criteria were used to quantify conversion to psychosis. Kaplan-Mayer and Cox proportional hazard survival analysis were applied to determine the impact of having or not received the prescription of an antipsychotic drug.

RESULTS

Over the study period 30 (24%) subjects received the prescription of an antipsychotic. In the sample, there were 31 participants (25%) who had reached the psychometric threshold for conversion to psychosis after 2 years of treatment. UHR people who received a prescription of antipsychotics during the first 2 years of treatment were statistically more likely to reach the psychometric threshold for conversion to psychosis on the BPRS: Hazard ratio = 3.03 (95%CI: 1.49-6.16); p = .003.

CONCLUSION

This finding supports the hypothesis that the prescription of antipsychotics within UHR cohorts is to be considered a red flag for higher incipient risk of conversion to psychosis.

Cannabis use, self-perceived risk, perceived peer approval and parental attitudes among youth at clinical high-risk for psychosis

AIM

Cannabis use is associated with greater likelihood of psychosis. The relationship between attitudes about cannabis and use has not been examined in youth at clinical high-risk (CHR) for psychosis. Additionally, the shifting legal landscape can provide a valuable context for evaluating use and related attitudes.

METHODS

This study included 174 participants (44 CHR, 43 healthy control [HC] youth-parent dyads). Youth completed measures of self-reported cannabis use confirmed with a urinalysis, self-perceived risk and perceived peer attitudes. Parents reported attitudes about youth use. Legalization occurred halfway during a 5-year study in Colorado, providing an opportunity to cross-sectionally examine its role in use and attitudes.

RESULTS

Frequency of youth reporting cannabis use was significantly higher in CHR (69%) than control group (30%). Use in CHR group was associated with higher perceived peer approval (r = .57), increased parental permissiveness (r = .28) and lower self-perceived risk (r = -.26). Comparing samples participating pre and post-legalization, use remained stable within each group. Group differences in parental permissiveness shifted; trend toward decrease in permissiveness in CHR group (η²_partial  = .07) and a significant increase in HCs (η²_partial  = .16) were observed. Post-legalization, use in CHR group correlated with higher perceived peer approval (r = .64), lower self-perceived risk (r = -.51) and higher parental permissiveness (r = .35, trend).

CONCLUSIONS

Taken together, results indicate a relationship between self and peer/parental attitudes about cannabis and use in youth at CHR for psychosis. These factors are important to consider within the legalization context given the changes in parental attitudes and a stronger association between use and attitudes in this group post-legalization.

Conditional release and cannabis use: Concerns and challenges for community reintegration

This article, which serves as a perspective review, delves into the complexities of cannabis use among individuals preparing for or already on conditional release (CR). These complexities include an association between cannabis use and mental illness and dealing with the fact that the use of illicit substances, such as cannabis, is against CR rules, leading to potential revocation. A focus of this article is the deleterious effects cannabis and synthetic derivatives of cannabis can have for individuals on CR. The article concludes with six-specific recommendations for managing cannabis use in this population with a focus on careful and detailed risk assessments that considers the relationship between substance use and dangerousness, the role of protective factors, the need for a detailed conditional release plan, inpatient and community-based interventions aimed at increasing individual autonomy, and education on the dangers of cannabis use for both the treatment team and the insanity acquittee.

Do schizotypy features predict cannabis problems in partnered community adults?

Schizotypy and its associated features-negative schizotypy, disorganization, and positive schizotypy-are correlated with increased cannabis use. Yet, it is unclear whether cannabis users with schizotypy are at greater risk of developing cannabis problems. Individuals with elevated schizotypy may be particularly vulnerable to cannabis problems. It is important to understand this association given the unknown harms of chronic cannabis use. Data for these analyses were drawn from a larger investigation of cannabis use in adult romantic relationships. Participants were community adults (N = 366; M Age = 24.6, SD = 3.1) who reported regular use of cannabis. Participants completed baseline surveys measuring cannabis use frequency, problems, and schizotypy. Follow-up assessments of cannabis problems and frequency were completed 4-, 7- and 10-months post-baseline. Multiple regression was used to test the effect of schizotypy-measured using the Schizotypal Personality Questionnaire-Brief (SPQ-B, Raine & Benishay, 1995)-on cannabis use problems controlling for 30-day cannabis use. At baseline, disorganization and positive schizotypy were associated with cannabis use, primarily for women. Results revealed that with cannabis use frequency in the model, the Disorganization subscale of the SPQ-B predicted cannabis problems at baseline and all 3 follow-up assessments. Results are consistent with research suggesting that those exhibiting odd behaviors report more problematic cannabis use. Future research may further this line of inquiry with a focus on longitudinal, reciprocal relationships among schizotypy features, cannabis use, and cannabis problems.

Establishing a clinical service to prevent psychosis: What, how and when? Systematic review

The first rate-limiting step to successfully translate prevention of psychosis in to clinical practice is to establish specialised Clinical High Risk for Psychosis (CHR-P) services. This study systematises the knowledge regarding CHR-P services and provides guidelines for translational implementation. We conducted a PRISMA/MOOSE-compliant (PROSPERO-CRD42020163640) systematic review of Web of Science to identify studies until 4/05/2020 reporting on CHR-P service configuration, outreach strategy and referrals, service user characteristics, interventions, and outcomes. Fifty-six studies (1998-2020) were included, encompassing 51 distinct CHR-P services across 15 countries and a catchment area of 17,252,666 people. Most services (80.4%) consisted of integrated multidisciplinary teams taking care of CHR-P and other patients. Outreach encompassed active (up to 97.6%) or passive (up to 63.4%) approaches: referrals came mostly (90%) from healthcare agencies. CHR-P individuals were more frequently males (57.2%). Most (70.6%) services accepted individuals aged 12-35 years, typically assessed with the CAARMS/SIPS (83.7%). Baseline comorbid mental conditions were reported in two-third (69.5%) of cases, and unemployment in one third (36.6%). Most services provided up to 2-years (72.4%), of clinical monitoring (100%), psychoeducation (81.1%), psychosocial support (73%), family interventions (73%), individual (67.6%) and group (18.9%) psychotherapy, physical health interventions (37.8%), antipsychotics (87.1%), antidepressants (74.2%), anxiolytics (51.6%), and mood stabilisers (38.7%). Outcomes were more frequently ascertained clinically (93.0%) and included: persistence of symptoms/comorbidities (67.4%), transition to psychosis (53.5%), and functional status (48.8%). We provide ten practical recommendations for implementation of CHR-P services. Health service knowledge summarised by the current study will facilitate translational efforts for implementation of CHR-P services worldwide.

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

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

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.

Persistent cannabis use as an independent risk factor for violent behaviors in patients with schizophrenia

Although recent studies have shown a moderately strong association between cannabis use and violence among people with severe mental disorders, the direction of this association has not been investigated prospectively in a population with schizophrenia. Therefore, this study aims to determine, using cross-lag models, whether a temporal relationship between cumulative cannabis use and violence exists in a population with schizophrenia. The authors reported findings covering an 18-month period from a randomized, double-blind clinical trial of antipsychotic medications for schizophrenia treatment. Among the 1460 patients enrolled in the trial, 965 were followed longitudinally. Although persistent cannabis use predicted subsequent violence, violence did not predict cannabis use. The relationship was therefore unidirectional and persisted when controlling for stimulants and alcohol use. Finally, a significant body of evidence suggests a link between persistent cannabis use and violence among people with mental illnesses. Studies to further investigate the mechanisms underlying this association should be conducted.

Cannabis use in individuals at clinical high-risk for psychosis: a comprehensive review

PURPOSE

The objectives of this review were to understand the prevalence of cannabis use and how cannabis is associated with transition to psychosis, symptoms, cognition, trauma and family history in clinical high risk (CHR) for psychosis individuals.

METHOD

A systematic literature review was conducted to find studies that examined cannabis use in CHR individuals, with no limitations on the geographical area, and included publications up to November 2018. Studies were screened for inclusion based on detailed criteria, and data were extracted on cannabis use and associated outcomes. A quantitative synthesis by meta-analysis was performed where appropriate, otherwise, a qualitative synthesis was conducted.

RESULTS

Overall, 36 studies met inclusion criteria with an average age of 20.1 years and 58.4% males. Prevalence of lifetime cannabis use was 48.7%, whereas current cannabis use was 25.8% and the prevalence of cannabis use disorder/abuse or dependence was 14.9% across the studies. All cannabis use results had statistically significant heterogeneity ranging from 75.7 to 92.8%. The most commonly reported association with cannabis use was transition to psychosis, although the pooled relative risk (RR) was not statistically significant (RR = 1.11, 95% confidence interval = 0.89-1.37). For all other outcomes including symptoms, cognition, trauma, and family history, the evidence was limited, and therefore, the results were synthesized qualitatively.

CONCLUSION

Almost half of CHR individuals have ever used cannabis. However, cannabis use has not been thoroughly researched regarding frequency and dose of use, and how other factors, such as symptoms, are associated with cannabis in CHR individuals.

Cannabis and psychosis: revisiting a nineteenth century study of 'Indian Hemp and Insanity' in Colonial British India

BACKGROUND

In nineteenth-century British India, concern regarding large numbers of asylum patients with 'Indian Hemp Insanity' led to establishment of the Indian Hemp Drugs Commission. The exotic cannabis plant was widely used in pharmacopeia and a source of government revenue. The Commission was tasked with determining the public health risks of cannabis use, particularly mental illness. This analysis of the Commission report seeks to highlight the status of 1892 cannabis research and compare it with current evidence for medical and recreational cannabis use.

METHODS

Detailed historiographic review of the Indian Hemp Drugs Commission Report (1892).

RESULTS

In 1892, heavy cannabis use was considered to have been associated with severe mental illness (7.3% of asylum patients; 12.6% of patients with diagnoses). About two-thirds were children and young adults with higher relapse rates. Risk increased with early cannabis use and a family history of mental illness. Cannabis psychosis was found to have a shorter trajectory and better prognosis than other mental illnesses in the asylums. Different cannabis potency and modes of consumption had different effects. Occasional cannabis use was felt to have medicinal benefits for some. Appendices provided symptoms and demographic characteristics of cannabis-induced mental illness.

CONCLUSION

This important nineteenth-century study observed frequency and dose-related effects of cannabis on mental health, particularly psychotic symptoms in young people with a previous or hereditary risk of mental illness. Pathophysiological observations were consistent with current knowledge. As one of the most systematic and detailed studies of the effects of cannabis of the time it foreshadowed contemporary cannabis issues.

Substance use disorders before, at and after first episode psychosis hospitalizations in a young national Swedish cohort

BACKGROUND

Comorbidity between Substance use disorders (SUD) and psychotic disorders is common but the temporal relation of the first episodes of SUD and psychosis and how it affects the disorders has not been extensively investigated.

METHODS

A nation-wide cohort (n = 2494) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Psychiatric hospitalizations were followed from birth until up to 5 years after the first psychosis hospitalization. Risk factors for new SUD or psychosis hospitalization after the index hospitalization were analyzed by Cox regression.

RESULTS

30 % of the cases had SUD hospitalizations in the 5 years before or as a comorbid diagnosis at the first psychosis hospitalization. An additional 9% had a first SUD hospitalization in the five years after. The incidence of SUD hospitalizations increased year by year before and decrease year by year after the index hospitalization. The hazard ratio for a new SUD hospitalizations after the index hospitalization was significantly higher (hazard ratio 6.7, p-value<0.001) in cases with SUD before or at the index hospitalization compared to in cases without previous SUD. In cases with previous SUD, there was a strong association (p < 0.001) between a new psychosis hospitalization and a new SUD hospitalization the year after the index hospitalization, indicating that SUD may continue to aggravate the psychotic disorder in this group.

CONCLUSIONS

SUD is very common before a first hospital treated psychosis. The SUD likely aggravates early psychotic disorders in many cases.

Medicinal cannabis for psychiatric disorders: a clinically-focused systematic review

BACKGROUND

Medicinal cannabis has received increased research attention over recent years due to loosening global regulatory changes. Medicinal cannabis has been reported to have potential efficacy in reducing pain, muscle spasticity, chemotherapy-induced nausea and vomiting, and intractable childhood epilepsy. Yet its potential application in the field of psychiatry is lesser known.

METHODS

The first clinically-focused systematic review on the emerging medical application of cannabis across all major psychiatric disorders was conducted. Current evidence regarding whole plant formulations and plant-derived cannabinoid isolates in mood, anxiety, sleep, psychotic disorders and attention deficit/hyperactivity disorder (ADHD) is discussed; while also detailing clinical prescription considerations (including pharmacogenomics), occupational and public health elements, and future research recommendations. The systematic review of the literature was conducted during 2019, assessing the data from all case studies and clinical trials involving medicinal cannabis or plant-derived isolates for all major psychiatric disorders (neurological conditions and pain were omitted).

RESULTS

The present evidence in the emerging field of cannabinoid therapeutics in psychiatry is nascent, and thereby it is currently premature to recommend cannabinoid-based interventions. Isolated positive studies have, however, revealed tentative support for cannabinoids (namely cannabidiol; CBD) for reducing social anxiety; with mixed (mainly positive) evidence for adjunctive use in schizophrenia. Case studies suggest that medicinal cannabis may be beneficial for improving sleep and post-traumatic stress disorder, however evidence is currently weak. Preliminary research findings indicate no benefit for depression from high delta-9 tetrahydrocannabinol (THC) therapeutics, or for CBD in mania. One isolated study indicates some potential efficacy for an oral cannabinoid/terpene combination in ADHD. Clinical prescriptive consideration involves caution in the use of high-THC formulations (avoidance in youth, and in people with anxiety or psychotic disorders), gradual titration, regular assessment, and caution in cardiovascular and respiratory disorders, pregnancy and breast-feeding.

CONCLUSIONS

There is currently encouraging, albeit embryonic, evidence for medicinal cannabis in the treatment of a range of psychiatric disorders. Supportive findings are emerging for some key isolates, however, clinicians need to be mindful of a range of prescriptive and occupational safety considerations, especially if initiating higher dose THC formulas.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Cannabis Use and the Risk for Psychosis and Affective Disorders

Objective: This review discusses the relationship between cannabis use and psychotic, bipolar, depressive, and anxiety disorders, as well as suicide. It summarizes epidemiological evidence from cross-sectional and long-term prospective studies and considers possible etiological mechanisms. Methods: Systematic reviews and methodologically robust studies in the field (from inception to February 2019) were identified using a comprehensive search of Medline, PsychINFO, and Embase and summarized using a narrative synthesis. Results: Consistent evidence, both from observational and experimental studies, has confirmed the important role of cannabis use in the initiation and persistence of psychotic disorders. The size of the effect is related to the extent of cannabis use, with greater risk for early cannabis use and use of high-potency varieties and synthetic cannabinoids. Accumulating evidence suggests that frequent cannabis use also increases the risk for mania as well as for suicide. However, the effect on depression is less clear and findings on anxiety are contradictory with only a few methodologically robust studies. Furthermore, the relationship with common mental disorders may involve reverse causality, as depression and anxiety are reported to lead to greater cannabis consumption in some studies. Pathogenetic mechanisms focus on the effect of tetrahydrocannabinol (THC, the main psychoactive ingredient of cannabis) interacting with genetic predisposition and perhaps other environmental risk factors. Cannabidiol (CBD), the other important ingredient of traditional cannabis, ameliorates the psychotogenic effects of THC but is absent from the high-potency varieties that are increasingly available. Conclusions: The evidence that heavy use of high-THC/low-CBD types of cannabis increases the risk of psychosis is sufficiently strong to merit public health education. Evidence of similar but smaller effects in mania and suicide is growing, but is not convincing for depression and anxiety. There is much current interest in the possibility that CBD may be therapeutically useful.

[Cannabis use in subjects at ultra high risk for psychosis]

Cannabis use is widespread among people at ultra-high risk (UHR) for psychosis. The causal link as well as the temporal link between cannabis use and further occurrence of psychosis in UHR people remain inconclusive. Current science data supported an increased risk of transition to psychosis in cannabis users who are genetically predisposed to psychosis. This risk would be even greater in the presence of a family history of psychosis, in case of a strong use and an early onset use. Several models have been cited to explain the link between cannabis use and the subsequent onset of psychosis or prepsychotic states: cannabis-induced modifications of some brain structures, a dysregulation of the hypothalamic-pituitary axis and an alteration of normal neurological development via the endocannabinoid system. Cannabis represents a modifiable risk for psychosis. Current interventions aim to reduce or stop the cannabis use in order to reduce the risk of transition to psychosis.

Investigating how perceived risk and availability of marijuana relate to marijuana use among adolescents in Argentina, Chile, and Uruguay over time

AIMS

Amid changing marijuana policies in the Southern Cone, we examined relationships between marijuana-related risk factors and marijuana use among adolescents in Argentina, Chile, and Uruguay from 2001 to 2016.

METHODS

Using cross-sectional surveys from 8^th, 10^th, and 12^th graders and weighted time-varying effect models, we estimated associations between perceived risk (no/low risk versus moderate/great risk) and perceived availability (easy/very easy versus difficult/very difficult/not able to obtain) of marijuana, and any past-month marijuana use.

RESULTS

In all countries, marijuana use increased over time and adolescents who perceived no/low risk and easy availability had higher odds of use. In Argentina, the bivariate risk/use association weakened from 2001 (OR = 15.24, 95%CI = 9.63, 24.12) to 2004 [OR = 3.86 (2.72, 5.48)] and strengthened until 2011 [OR = 8.22 (7.56, 10.30)]; the availability/use association strengthened from 2005 [OR = 5.32 (4.05, 6.98)] to 2009 [OR = 20.77 (15.57, 27.70)] and weakened until 2014 [OR = 11.00 (9.11, 13.27)]. In Chile, the risk/use association weakened from 2001 [OR = 7.22 (6.57, 7.95)] to 2015 [OR = 5.58 (4.82, 6.48)]; the availability/use association weakened from 2001 [OR = 5.92 (4.96, 7.06)] to 2015 [OR = 4.10 (3.15, 5.34)]. In Uruguay, the risk/use association weakened from 2003 [OR = 34.22 (22.76, 51.46)] to 2016 [OR = 6.23 (4.96, 7.83)]; the availability/use association weakened from 2005 [OR = 29.13 (13.39, 63.39) to 2007 [OR = 9.42 (3.85, 23.07)], and strengthened until 2016 [OR = 22.68 (12.03, 42.76)].

CONCLUSIONS

Overall, the association between risk and use weakened in all countries, suggesting risk perceptions became a weaker determinant of marijuana use. Perceived availability remained strongly associated with use and may become an increasingly important driver of use (particularly in Uruguay and Argentina).

Predictors of Transition to Psychosis in Individuals at Clinical High Risk

PURPOSE OF REVIEW

Current research is examining predictors of the transition to psychosis in youth who are at clinical high risk based on attenuated psychotic symptoms (APS). Determining predictors of the development of psychosis is important for an improved understanding of mechanisms as well as the development of preventative strategies. The purpose is to review the most recent literature identifying predictors of the transition to psychosis in those who are already assessed as being at risk.

RECENT FINDINGS

Multidomain models, in particular, integrated models of symptoms, social functioning, and cognition variables, achieve better predictive performance than individual factors. There are many methodological issues; however, several solutions have now been described in the literature. For youth who already have APS, predicting who may go on to later develop psychosis is possible. Several studies are underway in large consortiums that may overcome some of the methodological concerns and develop improved means of prediction.

'At risk mental state' clinics for psychosis - an idea whose time has come - and gone!

At Risk Mental State (ARMS) clinics are specialised mental health services for young, help-seeking people, thought to be at ultra-high risk of developing psychosis. Their stated purpose is to reduce transitions from the ARMS state to clinical psychotic disorder. Reports of ARMS clinics provide 'evidence-based recommendations' or 'guidance' for the treatment of such individuals, and claim that such clinics prevent the development of psychosis. However, we note that in an area with a very well-developed ARMS clinic (South London), only a very small proportion (4%) of patients with first episode psychosis had previously been seen at this clinic with symptoms of the ARMS. We conclude that the task of reaching sufficient people to make a major contribution to the prevention of psychosis is beyond the power of ARMS clinics. Following the preventative approaches used for many medical disorders (e.g. lung cancer, coronary artery disease), we consider that a more effective way of preventing psychosis will be to adopt a public health approach; this should attempt to decrease exposure to environmental factors such as cannabis use which are known to increase risk of the disorder.

Individual Differences and Psychosis-Risk Screening: Practical Suggestions to Improve the Scope and Quality of Early Identification

Approaches to identifying individuals at clinical high-risk (CHR) for psychosis currently do not carefully weigh considerations around individual differences. Effective identification depends on awareness of factors beyond psychopathology as it is reflected in the current literature, such as sensitivity to idiographic circumstances and individual differences. The inability to address contextual factors when employing the status quo method of identification likely contributes to the unacceptably poor accuracy when identifying people at CHR. Individual differences related to factors such as culture, race, comorbidity, and development likely play an important role in accurate identification, and have the potential to improve the validity of approaches intended to identify this population. Tailored approaches to assessment based on an awareness of context, identity, setting, and preferences of clients are possible, and customizing assessment efforts accordingly may be useful for accurate identification of people at CHR. Highlighting the potential for the existing early identification paradigm to marginalize or misunderstand certain groups, we describe how effective identification and ethical diagnosis require sensitivity to individual differences writ large. We suggest that recognizing the importance of these factors advances a more inclusive and accurate approach to identification.

Prevalence of non-psychotic disorders in ultra-high risk individuals and transition to psychosis: A systematic review

Despite the growing interest in the prodromes of psychosis, the proper identification of those Ultra High Risk (UHR) subjects who will convert to psychosis remains an unresolved issue. It remains to be fully understood whether the risk of transition to psychosis is incremented by the concomitant presence of non-psychotic symptoms. We performed a systematic review in order to estimate: prevalence rates of non-psychotic disorders in UHR individuals and whether any comorbid disorder impacts on the risk of transition to frank psychosis. The review was conducted using the PRISMA guidelines by searching PubMed until August 2017. The inclusion criteria were: studies with appropriate definition of UHR/ ARMS (At Risk Mental States for psychosis); cross-sectional design (for prevalence rates) or longitudinal design (for transition rates to psychosis); adolescents and/or adults; specified instrument/interview for the diagnosis of mental disorder/symptoms. We included 46 English-language articles. We found that non-psychotic symptoms are a prevalent concern in UHR individuals, and this is true for all comorbid disorders examined. None of the mental disorder examined appear to be a marker for transition to psychosis. Our systematic review found that the great majority of UHR individuals actually has a highly prevalent clearly defined, above-the-threshold mental disorder that should constitute the primary focus of intervention.

Patterns in adolescent cannabis use predict the onset and symptom structure of schizophrenia-spectrum disorder

This study investigated adolescent cannabis use as a risk factor for schizophrenia spectrum disorder (SSD). Motives for early cannabis use and resulting usage patterns were examined alongside clinical measures of SSD onset and symptomatology. Participants (N = 178) were recruited for two samples, 1: healthy controls (HC) with cannabis use, 2: schizophrenia patients (SSD) with cannabis use. Structured interviews of participants and family informants were used to obtain diagnostic and biographical information. Factor-analysis of reported motives for initiating cannabis use produced four groups; sedation, stimulation, social pressure, and recreation. Regression analyses revealed significant relationships between these groups and SSD. Most notably, reason group factor scores predict SSD risk as well as schizotypal symptom severity. Findings also indicate that these factors follow a hierarchical structure, which explains their relative involvement in increased SSD risk. We suggest that adolescent cannabis use both hastens the onset and amplifies the severity of SSD. In response we propose a model for identifying at risk individuals, predicting the onset and severity of SSD, and potentially mitigating the associated psychiatric impairments.

US Epidemiology of Cannabis Use and Associated Problems

This review provides an overview of the changing US epidemiology of cannabis use and associated problems. Adults and adolescents increasingly view cannabis as harmless, and some can use cannabis without harm. However, potential problems include harms from prenatal exposure and unintentional childhood exposure; decline in educational or occupational functioning after early adolescent use, and in adulthood, impaired driving and vehicle crashes; cannabis use disorders (CUD), cannabis withdrawal, and psychiatric comorbidity. Evidence suggests national increases in cannabis potency, prenatal and unintentional childhood exposure; and in adults, increased use, CUD, cannabis-related emergency room visits, and fatal vehicle crashes. Twenty-nine states have medical marijuana laws (MMLs) and of these, 8 have recreational marijuana laws (RMLs). Many studies indicate that MMLs or their specific provisions did not increase adolescent cannabis use. However, the more limited literature suggests that MMLs have led to increased cannabis potency, unintentional childhood exposures, adult cannabis use, and adult CUD. Ecological-level studies suggest that MMLs have led to substitution of cannabis for opioids, and also possibly for psychiatric medications. Much remains to be determined about cannabis trends and the role of MMLs and RMLs in these trends. The public, health professionals, and policy makers would benefit from education about the risks of cannabis use, the increases in such risks, and the role of marijuana laws in these increases.

Cannabis use and symptom severity in individuals at ultra high risk for psychosis: a meta-analysis

OBJECTIVE

We aimed to assess whether individuals at ultra high risk (UHR) for psychosis have higher rates of cannabis use and cannabis use disorders (CUDs) than non-UHR individuals and determine whether UHR cannabis users have more severe psychotic experiences than non-users.

METHOD

We conducted a meta-analysis of studies reporting cannabis use in the UHR group and/or positive or negative symptoms among UHR cannabis users and non-users. Logit event rates were calculated for cannabis use, in addition to odds ratios to assess the difference between UHR and controls. Severity of clinical symptoms in UHR cannabis users and non-users was compared using Hedges' g.

RESULTS

Thirty unique studies were included (UHR n = 4205, controls n = 667) containing data from cross-sectional and longitudinal studies, and randomised control trials. UHR individuals have high rates of current (26.7%) and lifetime (52.8%) cannabis use, and CUDs (12.8%). Lifetime use and CUDs were significantly higher than controls (lifetime OR: 2.09; CUD OR: 5.49). UHR cannabis users had higher rates of unusual thought content and suspiciousness than non-users.

CONCLUSION

Ultra high risk individuals have high rates of cannabis use and CUDs, and cannabis users had more severe positive symptoms. Targeting substance use during the UHR phase may have significant benefits to an individual's long-term outcome.