Amphetamine-induced psychosis: Transition to schizophrenia and mortality in a small prospective sample

Counting the Toll of Inflammation on Schizophrenia-A Potential Role for Toll-like Receptors

Toll-like receptors (TLRs) are a family of pattern recognition receptors (PRRs) that are ubiquitously expressed in the human body. They protect the brain and central nervous system from self and foreign antigens/pathogens. The immune response elicited by these receptors culminates in the release of cytokines, chemokines, and interferons causing an inflammatory response, which can be both beneficial and harmful to neurodevelopment. In addition, the detrimental effects of TLR activation have been implicated in multiple neurodegenerative diseases such as Alzheimer's, multiple sclerosis, etc. Many studies also support the theory that cytokine imbalance may be involved in schizophrenia, and a vast amount of literature showcases the deleterious effects of this imbalance on cognitive performance in the human population. In this review, we examine the current literature on TLRs, their potential role in the pathogenesis of schizophrenia, factors affecting TLR activity that contribute towards the risk of schizophrenia, and lastly, the role of TLRs and their impact on cognitive performance in schizophrenia.

Diagnostic stability in substance-induced psychosis

INTRODUCTION

Substance-induced psychosis (SIP) is the name given to a psychosis that starts in the context of substance abuse but persists for days and weeks with no substance use. There is as yet little knowledge about the longitudinal course of this psychosis, which suggests that significant numbers go on to be diagnosed with a severe mental disorder (SMD). The objective of this study was to analyse the progression of SIP to SMD in our environment and the possible factors that may be involved in that conversion.

MATERIAL AND METHODS

We used a retrospective cohort follow-up design. We reviewed all diagnoses of patients discharged from the psychiatric hospitalisation unit of the University Hospital of Basurto from January 2002 to December 2015 inclusively. In addition to sociodemographic and clinical data, information was collected on the consumption of cannabinoids, opioids, amphetamines, cocaine and alcohol. The data were analysed using descriptive analysis, Kaplan-Meier survival curves and Cox regression.

RESULTS

Of the 116 patients, 78.4% were male, had an average age of 33.0 (SD = 8.9) years and 44.0% were single; 31.0% had a psychiatric family history; the most commonly used substance was cannabis (60.3%), followed by cocaine (40.5%). The cumulative risk of diagnostic conversion to an SMD in 16 years was 41.6% (95%CI: 32.2-52.2) over a mean 36.43 months.

CONCLUSIONS

In interventions in episodes of SIP we must bear in mind that a significant proportion will progress to an SMD in the first three years.

Adderall-Induced Persistent Psychotic Disorder Managed With Long-Acting Injectable Haloperidol Decanoate

Adderall is one of the most commonly prescribed stimulant medications for attention deficit hyperactivity disorder (ADHD). Although safe and effective when clinically indicated at the appropriate dose, stimulant misuse may lead to serious adverse effects. We report a 29-year-old male with a diagnosis of ADHD who took more than the recommended therapeutic dose of Adderall prescribed by his psychiatrist. He subsequently presented with persistent psychotic symptoms, which responded to oral haloperidol. Due to treatment non-compliance with multiple recurring psychiatric hospitalizations, long-acting injectable haloperidol decanoate was considered to improve compliance and prognosis. The patient’s psychosis remained in remission while on the long-acting injectable. In this case study, we highlight the need for future research to identify stimulant misuse risk factors. Randomized clinical trials are needed to determine the effectiveness of long-acting injectable antipsychotic medication in the management of persistent psychosis secondary to stimulant misuse.

Pharmacotherapy treatment of stimulant use disorder

Stimulant use disorder (SUD) is a public health problem in the United States that is associated with increased morbidity and mortality. Psychosocial interventions, such as cognitive behavioral therapy and contingency management, are the main treatment modality for SUDs and no pharmacotherapy is currently FDA approved for this indication. Although some medications show promising data for the treatment of SUD, the evidence remains inconsistent, and the clinical application is limited due to the heterogenicity of the population and the lack of studies in patients with various comorbidities. Selection of pharmacotherapy treatment for methamphetamine intoxication, persistent methamphetamine-associated psychosis with methamphetamine use disorder, and cocaine use disorder in patients with co-occurring OUD are discussed in 3 patient cases.

A latent class analysis of psychiatric symptom profiles associated with past-month methamphetamine use

We explored latent psychiatric symptom profiles associated with methamphetamine use, and examined how these corresponded to diagnoses of schizophrenia (SZ) and methamphetamine-associated psychosis (MAP). We assessed psychiatric symptoms among 160 people who had used methamphetamine in the past month. Psychiatric symptoms were defined as a score of 4+ on Brief Psychiatric Rating Scale (BPRS) items. Diagnoses were made using the Composite International Diagnostic Interview (CIDI). Participants were defined as having MAP if they met symptom criteria for SZ, but symptoms were considered to be always the result of substance use. Latent class analysis identified three classes. Class one (44% of participants) had a low probability of most BPRS symptoms; 4% met criteria for SZ, 51% for MAP. Class two (31% of participants) had a higher probability hallucinations and suspiciousness (37-46%); 72% met criteria for MAP, and 7% for SZ. Class three (25% of participants) had the highest probability for all positive psychotic symptoms (hallucinations, suspiciousness, grandiosity, unusual thought content; 32-82%), and reported activation, conceptual disorganisation, and tension (35% met criteria for SZ and 17% for MAP). We found three distinct classes of psychiatric symptom profiles, two of which showed partial alignment with diagnostic constructs of SZ and MAP.

Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis

Some people who experience substance-induced psychosis later develop an enduring psychotic disorder such as schizophrenia. This study examines the proportion of people with substance-induced psychoses who transition to schizophrenia, compares this to other brief and atypical psychoses, and examines moderators of this risk. A search of MEDLINE, PsychINFO, and Embase identified 50 eligible studies, providing 79 estimates of transition to schizophrenia among 40 783 people, including 25 studies providing 43 substance-specific estimates in 34 244 people. The pooled proportion of transition from substance-induced psychosis to schizophrenia was 25% (95% CI 18%-35%), compared with 36% (95% CI 30%-43%) for brief, atypical and not otherwise specified psychoses. Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with highest rates associated with cannabis (6 studies, 34%, CI 25%-46%), hallucinogens (3 studies, 26%, CI 14%-43%) and amphetamines (5 studies, 22%, CI 14%-34%). Lower rates were reported for opioid (12%), alcohol (10%) and sedative (9%) induced psychoses. Transition rates were slightly lower in older cohorts but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up. Substance-induced psychoses associated with cannabis, hallucinogens, and amphetamines have a substantial risk of transition to schizophrenia and should be a focus for assertive psychiatric intervention.

Diagnostic stability in substance-induced psychosis

INTRODUCTION

Substance-induced psychosis (SIP) is the name given to a psychosis that starts in the context of substance abuse but persists for days and weeks with no substance use. There is as yet little knowledge about the longitudinal course of this psychosis, which suggests that significant numbers go on to be diagnosed with a severe mental disorder (SMD). The objective of this study was to analyse the progression of SIP to SMD in our environment and the possible factors that may be involved in that conversion.

MATERIAL AND METHODS

We used a retrospective cohort follow-up design. We reviewed all diagnoses of patients discharged from the psychiatric hospitalisation unit of the University Hospital of Basurto from January 2002 to December 2015 inclusively. In addition to sociodemographic and clinical data, information was collected on the consumption of cannabinoids, opioids, amphetamines, cocaine and alcohol. The data were analysed using descriptive analysis, Kaplan-Meier survival curves and Cox regression.

RESULTS

Of the 116 patients, 78.4% were male, had an average age of 33.0 (SD: 8.9) years and 44.0% were single; 31.0% had a psychiatric family history; the most commonly used substance was cannabis (60.3%), followed by cocaine (40.5%). The cumulative risk of diagnostic conversion to an SMD in 16years was 41.6% (95%CI: 32.2-52.2) over a mean 36.43months.

CONCLUSIONS

In interventions in episodes of SIP we must bear in mind that a significant proportion will progress to an SMD in the first three years.

A Systematic Review of the Symptom Profile and Course of Methamphetamine-Associated PsychosisSubstance Use and Misuse

OBJECTIVES

The psychiatric symptom profile of methamphetamine-associated psychosis (MAP) has varied considerably across studies of different research designs. We performed a systematic review to examine the available evidence for specific psychotic symptoms associated with MAP, including the clinical course and longitudinal changes in this symptom profile.

METHODS

Five key electronic databases were searched to identify studies that examined the symptom profile or clinical course of MAP in individuals identified as having MAP. The reporting of specific psychiatric symptoms, and duration of symptoms where available, was recorded for each study.

RESULTS

Ninety-four articles were identified (n = 7387), including case-control (k = 29), cross-sectional (k = 20), experimental (k = 6), case report (k = 29), and longitudinal (k = 20) studies. Persecutory delusions, auditory and visual auditory hallucinations were by far the most commonly reported symptoms (reported in 65-84% of studies). Hostility, conceptual disorganization, and depression were reported in a large proportion of studies (31-53%). Negative symptoms were mostly absent (<20%). The median percentage of participants with persistent psychotic symptoms (>1 month duration) across studies was 25% (excluding case reports).

CONCLUSION

Persecutory delusions, auditory and visual hallucinations, hostility, depression and conceptual disorganization are central to MAP, whereas negative psychotic symptoms are typically absent. An overrepresentation of institutionalized or male participants may have overemphasized negative symptoms and underreported affective symptoms in past research. Symptoms of MAP may persist beyond one month after drug cessation in some individuals. Clinicians are encouraged to manage affective symptoms in MAP individuals, and monitor for the development of chronic psychotic symptoms.

Trajectories of depressive symptoms in the acute phase of psychosis: Implications for treatment

Depression is common in schizophrenia and associated with negative outcomes. Previous studies have identified heterogeneity in treatment response in schizophrenia. We aimed to investigate different trajectories of depression in patients suffering from psychosis and predictors of change in depressive symptoms during antipsychotic treatment. Two hundred and twenty-six patients >18 years acutely admitted due to psychosis were consecutively included and the follow-up was 27 weeks. The Calgary Depression Scale for Schizophrenia (CDSS) sum score was the primary outcome. Latent growth curve (LGCM) and Growth Mixture Models (GMM) were conducted. Predictors were the Positive sum score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Schizophrenia spectrum/non-spectrum psychoses, gender and being antipsychotic naive at inclusion. We found support for three depression-trajectories, including a high- (14.7%), a low depression-level (69.6%) class and a third depressed class quickly decreasing to a low level (15.7%). Change in CDSS was associated with change in PANSS positive score in all time intervals (4 weeks: b = 0.18, p < 0.001, 3 months: 0.21, p < 0.023, 6 months: 0.43, p < 0.001) and with a diagnosis within schizophrenia spectrum but not with antipsychotic naivety or gender. The schizophrenia-spectrum patients had less depressive symptoms at inclusion (-2.63, p < 0.001). In conclusion, an early responding and a treatment refractory group were identified. The treatment-refractory patients are candidates for enhanced anti-depressive treatment, for which current evidence is limited. The post-psychotic depression group was characterized by depressive symptoms in the acute phase as well. We could not identify differentiating characteristics of the depression trajectories.

Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment

Individuals with schizophrenia lead a poor quality of life, due to poor medical attention, homelessness, unemployment, financial constraints, lack of education, and poor social skills. Thus, a review of factors associated with the holistic management of schizophrenia is of paramount importance. The objective of this review is to improve the quality of life of individuals with schizophrenia, by addressing the factors related to the needs of the patients and present them in a unified manner. Although medications play a role, other factors that lead to a successful holistic management of schizophrenia include addressing the following: financial management, independent community living, independent living skill, relationship, friendship, entertainment, regular exercise for weight gained due to medication administration, co-morbid health issues, and day-care programmes for independent living. This review discusses the relationship between different symptoms and problems individuals with schizophrenia face (e.g., homelessness and unemployment), and how these can be managed using pharmacological and non-pharmacological methods. Thus, the target of this review is the carers of individuals with schizophrenia, public health managers, counselors, case workers, psychiatrists, and clinical psychologists aiming to enhance the quality of life of individuals with schizophrenia.

Can the symptoms of schizophrenia be reset?

This work basing on a study of medical records is a story of a young patient, repeatedly hospitalized with various diagnoses, in whom the psychiatric symptoms significantly decreased after waking from coma, resulting from an unfortunate accident.

There are presented subsequent stages of treatment and hospitalizations and the analysis of the problem if the restart is possible in terms of mental state, in a patient who for years had experienced omental-delusive experiences of high severity and anxiety, leading to several suicidal attempts with serious consequences.

The discussion also describes the issue of double diagnosis and the criteria for amphetamine-induced psychosis.

Can schizophrenia be cured and its symptoms reset ?

Cannabis and psychosis: the impact of polydrug use

Purpose

While research has consistently identified an association between cannabis use and psychosis, few studies have examined this relationship in a polydrug context (i.e. combining cannabis with other illicit substances). The paper aims to discuss this issue.

Design/methodology/approach

The present study sought to examine the association between recreational drug use (cannabis only vs polydrug) and psychotic disorders. Analysis was conducted on a large, representative survey of young Danish people aged 24 (n=4,718). Participants completed self-report measures of lifetime drug use and this information was linked to the Danish psychiatric registry system.

Findings

Multivariate binary logistic regression analysis was used to examine the association between drug use (no drug use, cannabis only, cannabis and other drug) and ICD-10 psychotic disorders, while controlling for gender and parental history of psychosis. Compared with no drug use, the use of cannabis only did not increase the risk of psychosis while the odds ratio for cannabis and other drug were statistically significant.

Research limitations/implications

Psychosis risk may be associated with the cumulative effect of polydrug use.

Practical implications

Cannabis use may be a proxy for other drug use in research studies.

Originality/value

This study is innovative as it uses linked self-report and administrative data for a large sample. Administrative data were used to as an objective mental health status indicator.

N-Methyl-d-aspartate Modulation of Nucleus Accumbens Dopamine Release by Metabotropic Glutamate Receptors: Fast Cyclic Voltammetry Studies in Rat Brain Slices in Vitro

The N-methyl-d-aspartate (NMDA) receptor antagonist, phencyclidine, induces behavioral changes in rodents mimicking symptoms of schizophrenia, possibly mediated through dysregulation of glutamatergic control of mesolimbic dopamine release. We tested the hypothesis that NMDA receptor activation modulates accumbens dopamine release, and that phencyclidine pretreatment altered this modulation. NMDA caused a receptor-specific, dose-dependent decrease in electrically stimulated dopamine release in nucleus accumbens brain slices. This decrease was unaffected by picrotoxin, making it unlikely to be mediated through GABAergic neurones, but was decreased by the metabotropic glutamate receptor antagonist, (RS)-α-methyl-4-sulfonophenylglycine, indicating that NMDA activates mechanisms controlled by these receptors to decrease stimulated dopamine release. The effect of NMDA was unchanged by in vivo pretreatment with phencyclidine (twice daily for 5 days), with a washout period of at least 7 days before experimentation, which supports the hypothesis that there is no enduring direct effect of PCP at NMDA receptors after this pretreatment procedure. We propose that NMDA depression of accumbal dopamine release is mediated by metabotropic glutamate receptors located pre- or perisynaptically, and suggest that NMDA evoked increased extrasynaptic spillover of glutamate is sufficient to activate these receptors that, in turn, inhibit dopamine release. Furthermore, we suggest that enduring functional changes brought about by subchronic phencyclidine pretreatment, modeling deficits in schizophrenia, are downstream effects consequent on chronic blockade of NMDA receptors, rather than direct effects on NMDA receptors themselves.

Psychosis induced by amphetamines

PURPOSE OF REVIEW

The study reviews publications on the use of methamphetamine and amphetamine in relation to psychotic symptoms, substance-induced psychosis, and primary psychosis published between July 2014 and December 2015. The databases MEDLINE, Embase, and PsycINFO were searched using the terms 'amphetamine psychosis' and 'methamphetamine psychosis' for the time period 1 July 2014 to 31 December 2015.

RECENT FINDINGS

There were 37 studies published on the subject during this time period. Risk factors for psychotic symptoms, substance-induced psychosis, and primary psychosis included patterns of drug use, but results also pointed to the importance of nondrug-related vulnerability. Cognitive impairment is associated with both amphetamine use and psychosis, and the impairment among those with amphetamine-induced psychosis resembles that of schizophrenia. At the neuronal level, GABAergic mechanisms may offer some understanding about the association between stimulant use and psychosis. Several different types of antipsychotic medication are effective for treating agitation and psychosis, but drugs with high DRD2 blockade should be used with caution. Some novel treatments are described, but are not sufficiently repeated to be recommended.

SUMMARY

During the past 18 months, studies have been published that cover risk factors, neuronal mechanisms, and treatment. These recent results do not differ from previous understandings, but the role of cognition and GABAergic dysfunction should be further investigated, and knowledge about resilience factors is still scarce. Also, a clearer evidence base for medical treatment of psychosis with concurrent amphetamine use is warranted. VIDEO ABSTRACT.

Clinical features, course and treatment of methamphetamine-induced psychosis in psychiatric inpatients

BACKGROUND

Over the past few years, methamphetamine-induced psychosis (MIP) has increased in Iran, accounting for a significant percentage of psychiatry hospital admissions. The present study was conducted with an aim to investigate clinical symptoms, and course and treatment methods of MIP inpatients in Shafa Psychiatry Hospital in northern Iran.

METHODS

Participants were 152 MIP inpatients. Brief Psychiatric Rating Scale (BPRS) subscales of suspiciousness, unusual thought content; hallucinations and hostility were used to measure psychiatric symptoms. Data regarding suicide and homicide and violence were also obtained through interviews with the inpatients and their family. Based on their lengths of recovery time, the inpatients were categorized into 3 clinical groups. These inpatients received their usual treatments and were monitored for their psychiatric symptoms and clinical course of illness. The data were analyzed by descriptive statistics.

RESULTS

The most frequent psychiatric symptoms were violence (75.6 %), intimate partner violence (61.2 %), delusions of persecution (85.5 %), delusions of reference (38.5 %), delusions of grandiosity (32.9 %), delusions of infidelity (30.2 %), auditory hallucinations (51.3 %), visual hallucinations (18.4 %), suicidal thoughts (14.5 %), homicidal thoughts (3.9 %), suicide attempts (10.5 %) and homicide attempts (0.7 %). Recovery from psychotic symptoms in 31.6 % of the inpatients took more than one month. 46.1% of the inpatients were treated with Risperidone and 37.5 % with Olanzapine. Persecutory delusion and auditory hallucination were the most frequent persistent psychotic symptoms. 20.8 % of the inpatients with duration of psychosis more than one month were treated with electroconvulsive therapy (ECT) along with antipsychotics.

CONCLUSION

All forms of violence are highly frequent in MIP inpatients. Our finding agrees with many other studies suggesting that recovery from MIP can take more than a month. Initial promising findings were found regarding the efficacy of Electroconvulsive therapy in MIP patients.