Long-term outcomes in methamphetamine psychosis patients after first hospitalisation

Psychotic symptoms associated increased CpG methylation of metabotropic glutamate receptor 8 gene in Chinese Han males with schizophrenia and methamphetamine induced psychotic disorder: a longitudinal study

Methamphetamine use can produce psychotic symptoms almost indistinguishable from schizophrenia (SCZ). Variation in DNA methylation may be closely implicated in the etiology and longitudinal development of psychiatric disorders. However, the relationship between psychotic symptoms, functional disability, and DNA methylation is still unclear. This study consists of three periods: discovery, validation, and follow-up. In the discovery stage, we employed genome-wide DNA methylation profiling (Illumina 450K) in peripheral blood mononuclear cells to test whether DNA methylation associates with psychotic symptoms and function state in representative SCZ and methamphetamine-induced psychotic disorder (MIP) patients. Then, we found seven differentially methylated regions/genes (DMRs, in UBA6, APOL3, KIF17, MLLT3, GRM8, CSNK1E, SETDB1) overlapping with genetic variants reported in previous studies of psychosis. In the validation stage, we compared the above-mentioned seven genes by MethLight qPCR method in Chinese Han males (N = 109 SCZ patients, N = 99 methamphetamine use disorder with MIP patients, N = 150 methamphetamine use disorder without MIP patients, N = 282 normal controls, age range: 18-50 years). GRM8 showed robustly altered methylation, which has passed rigorous filtration in subsequent validation, suggesting a remarkable contribution to SCZ and MIP. In addition, hypermethylation of GRM8 showed a significant association with the total scores of the Positive Negative Syndrome Scale and WHO disability assessment schedule II in both baseline and follow-up periods. Our findings suggest that increased CpG methylation in the promoter of GRM8 is a potential candidate epigenetic biomarker of psychotic symptoms in transdiagnostic samples of SCZ and MIP.

Methamphetamine (MA) use and MA-induced psychosis are associated with increasing aberrations in the compensatory immunoregulatory system, interleukin-1α, and CCL5 levels

There are only a few studies reporting on the immunological profiles of methamphetamine (MA) use, MA dependency, or MA-induced psychosis (MAP). This study measured M1 macrophage, T helper (Th)-1, Th-2, growth factor, and chemokine profiles, as well as the immune inflammatory response system (IRS) and compensatory immunoregulatory system (CIRS) in peripheral blood samples from patients with MA use (n = 51), MA dependence (n = 47), and MAP (n = 43) in comparison with controls (n = 32). We discovered that persistent MA use had a robust immunosuppressive impact on all immunological profiles. The most reliable biomarker profile of MA use is the combination of substantial CIRS suppression and a rise in selected pro-inflammatory cytokines, namely CCL27 (CTACK), CCL11 (eotaxin), and interleukin (IL)-1α. In addition, MA dependency is associated with increased immunosuppression, as demonstrated by lower stem cell factor levels and higher IL-10 levels. MAP is related to a significant decrease in all immunological profiles, particularly CIRS, and an increase in CCL5 (RANTES), IL-1α, and IL-12p70 signaling. In conclusion, long-term MA use and dependency severely undermine immune homeostasis, whereas MAP may be the consequence of increased IL-1α - CCL5 signaling superimposed on strongly depleted CIRS and Th-1 functions. The widespread immunosuppression established in longstanding MA use may increase the likelihood of infectious and immune illness or exacerbate disorders such as hepatitis and AIDS. Furthermore, elevated levels of CCL5, CCL11, CCL27, IL-1α, and/or IL-12p70 may play a role in the peripheral (atherosclerosis, cutaneous inflammation, immune aberrations, hypospermatogenesis) and central (neuroinflammation, neurotoxic, neurodegenerative, depression, anxiety, and psychosis) side effects of MA use.

The transition to Schizophrenia spectrum disorder from a first psychotic episode that did or did not appear to be induced by substance use

The first years following a first-episode psychosis (FEP) are crucial. This retrospective cohort study investigates the evolution of first-episode psychosis (FEP), including substance-induced psychosis (SIP), and explores factors influencing the diagnostic conversion to Schizophrenia or Schizophrenia Spectrum Disorders (SSD). Diagnoses of patients discharged from Basurto University Hospital's inpatient psychiatry unit between January 2002 and December 2016 were reviewed. Sociodemographic, clinical, and substance use data, including cannabinoids, opioids, amphetamines, cocaine, and alcohol, were collected. The analysis utilized descriptive statistics, Kaplan-Meier survival curves, and Cox regression. Among 341 patients, 64.8% were male, with a mean age of 33.8 years. Psychiatric family history was present in 33.4% of cases, and cannabis was the most commonly used substance (78.9%). Of the patients, 52.8% received subsequent diagnoses of Schizophrenia or SSD, with 86.9% of these cases occurring within the first five years. No significant differences were observed between patients diagnosed with SIP and other diagnoses in terms of sociodemographic, clinical characteristics, or progression to Schizophrenia or SSD. However, use of cannabis (compared to use of another substance or polysubstance use) was associated with a higher risk to conversion (HR 1.96; p = 0.001). These findings underscore the importance of addressing substance use and treatment adherence in FEP.

Patients languishing in emergency departments: A descriptive analysis of mental health-related emergency department presentations in Australia between 2016-17 and 2020-21

OBJECTIVE

In the context of concerns regarding hospital access block, this paper provides a descriptive longitudinal analysis of mental health-related ED episodes in Australian public hospitals between 2016-17 and 2020-21.

METHOD

We descriptively analysed Australian Institute of Health and Welfare data for mental health-related ED presentations, outcomes and 5-year trends for Australian public hospitals.

RESULTS

There were more than 300,000 Australian mental health-related ED presentations in 2020-21. Presentations increased by an average annual rate of 2.8% between 2016-17 and 2020-21, commonly involving first responder (police, paramedic) attendance. From 2016-17 to 2020-21, the average annual rate of mental health-related ED presentations receiving a triage category of resuscitation increased by 13.7%, emergency by 9.4% and urgent by 4.7%. 90% of MH-related ED presentations were completed within 14 h, which was longer than the 90th percentile for all ED presentations (up to 8 h).

CONCLUSIONS

Current mental health policies have not stemmed the rising tide of ED presentations. Mental health-related ED presentations are increasing in number and severity, likely due to health systemic and societal factors. Psychiatry patients stay longer in EDs than other patients. Healthcare reforms should be targeted to provide the best outcome based on principles of equity of access.

Spurious Autobiographical Memory of Psychosis: A Mechanistic Hypothesis for the Resolution, Persistence, and Recurrence of Positive Symptoms in Psychotic Disorders

Psychotic disorders are complex disorders with multiple etiologies. While increased dopamine synthesis capacity has been proposed to underlie psychotic episodes, dopamine-independent processes are also involved (less responsive to dopamine receptor-blocking medications). The underlying mechanism(s) of the reduction in antipsychotic responsiveness over time, especially after repeated relapses, remain unclear. Despite the consistent evidence of dopamine overactivity and hippocampal volume loss in schizophrenia, few accounts have been provided based on the interactive effect of dopamine on hippocampal synapse plasticity mediating autobiographical memory processes. The present hypothesis builds upon previous works showing the potential effects of dopamine overactivity on hippocampal-mediated neuroplasticity underlying autobiographical memory, alongside known patterns of autobiographical memory dysfunction in psychosis. We propose that spurious autobiographical memory of psychosis (SAMP) produced during active psychosis may be a key mechanism mediating relapses and treatment non-responsiveness. In a hyperdopaminergic state, SAMP is expected to be generated at an increased rate during active psychosis. Similar to other memories, it will undergo assimilation, accommodation, and extinction processes. However, if SAMP fails to integrate with existing memory, a discontinuity in autobiographical memory may result. Inadequate exposure to normalizing experiences and hyposalience due to overmedication or negative symptoms may also impede the resolution of SAMP. Residual SAMP is hypothesized to increase the propensity for relapse and treatment non-responsiveness. Based on recent findings on the role of dopamine in facilitating hippocampal synapse plasticity and autobiographical memory formation, the SAMP hypothesis is consistent with clinical observations of DUP effects, including the repetition of contents in psychotic relapses as well as the emergence of treatment non-responsiveness after repeated relapses. Clinical implications of the hypothesis highlight the importance of minimizing active psychosis, integrating psychosis memory, avoiding over-medication, and fostering normalizing experiences.

Psychosis among individuals with methamphetamine use disorder is associated with elevated rates of hospitalizations and emergency department visits across an academic health care system

INTRODUCTION

Methamphetamine (MA) is increasingly available in the United States and manufactured with increasing potency. Although psychosis is a known harm related to MA use, we know little about the clinical outcomes and prognosis of individuals who use MA and experience psychosis. Some evidence exists that psychosis among people who use methamphetamine leads to a high utilization of emergency and acute inpatient services, but the extent of this use is unclear.

METHODS

Using an electronic health record (EHR) database, this study assessed acute care visits of individuals receiving diagnostic codes of the following disorders: methamphetamine use disorder with undifferentiated psychosis (MUDp), schizophrenia (MUDs) and no history of psychosis (MUD) in addition to individuals without MUD diagnosis but with diagnoses of either undifferentiated psychosis (Psy) or schizophrenia (Scz) from 2006 to 2019. The study explored potential clinical risk factors associated with rate of acute care visits.

RESULTS

Receiving diagnoses of psychotic disorders and MUD were both associated with high rates of acute care utilization. The incidence rate ratio (IRR) was highest in the MUDp group 6.30 (95 % CI: 5.73, 6.93) followed by the MUDs group 4.03 (95 % CI: 3.87, 4.20), the Psy group 3.77 (95 % CI: 3.45, 4.11), the Scz group 3.11 (95 % CI: 2.99, 3.23), and the MUD group 2.17 (95 % CI: 2.09, 2.25). Receiving another SUD diagnosis was identified as a risk factor for acute care visits in the MUDp group, and mood and anxiety disorder diagnoses were a risk factor in the MUDs group.

CONCLUSIONS

In a general health care system, individuals receiving diagnoses of MUD and co-occurring psychotic disorders were observed to have particularly high rates of acute care service utilization, suggesting a high degree of disease burden and the need for development of targeted treatment interventions with both MUD and psychosis.

Prevalence, demographics, and clinical correlates of antisocial personality disorder in Chinese methamphetamine patients

BACKGROUND AND OBJECTIVES

Antisocial personality disorder (ASPD) is very common among methamphetamine (MA) patients, but very few studies have been conducted in China. This study aimed to investigate the prevalence and clinical correlates of ASPD among Chinese MA patients.

METHODS

We recruited 627 MA patients and collected demographic and MA use data through one-on-one semi-structured interviews. ASPD was measured by the Mini International Neuropsychiatric Interview (M.I.N.I.). The Desires for Drug Questionnaire (DDQ) and visual analog scale (VAS) were used to assess drug cravings.

RESULTS

The prevalence rate of ASPD among MA patients was 27.59% (173/627). Patients with ASPD had greater age at the first onset, duration of MA use, length of abstinence, VAS, DDQ desire and intention, negative reinforcement, and total DDQ scores than patients without ASPD. Stepwise binary logistic regression analysis revealed that age, age at the first onset, length of abstinence, and DDQ-negative reinforcement were independently associated with ASPD in MA patients.

DISCUSSION AND CONCLUSIONS

Our findings suggest that the prevalence of ASPD is high among Chinese MA patients. Furthermore, some demographic and clinical variables are associated with ASPD in MA patients.

SCIENTIFIC SIGNIFICANCE

We focused our study on the clinical profile of ASPD and the reasons for its high prevalence in Chinese methamphetamine patients. We identified several demographic and clinical variables as correlates of the occurrence of ASPD in methamphetamine patients, which provides evidence for ASPD comorbidity in methamphetamine patients.

Cannabidiol but not cannabidiolic acid reduces behavioural sensitisation to methamphetamine in rats, at pharmacologically effective doses

RATIONALE

Cannabidiol (CBD) and cannabidiolic acid (CBDA) are non-psychoactive components of the cannabis plant. CBD has been well characterised to have anxiolytic and anticonvulsant activity, whereas the behavioural effects of CBDA are less clear. Preclinical and clinical data suggests that CBD has antipsychotic properties and reduces methamphetamine self-administration in rats. An animal model that is commonly used to mimic the neurochemical changes underlying psychosis and drug dependence is methamphetamine (METH) sensitisation, where repeated administration of the psychostimulant progressively increases the locomotor effects of METH.

OBJECTIVE

The aim of this study was to determine whether CBD or CBDA attenuate METH-induced sensitisation of locomotor hyperactivity in rats.

METHODS

Eighty-six male Sprague Dawley rats underwent METH sensitisation protocol where they were subjected to daily METH (1 mg/kg on days 2 and 8, 5 mg/kg on days 3-7; i.p.) injections for 7 days. After 21 days of withdrawal, rats were given a prior injection of CBD (0, 40 and 80 mg/kg; i.p.) or CBDA (0, 0.1, 10 and 1000 µg/kg; i.p.) and challenged with acute METH (1 mg/kg; i.p.). Locomotor activity was then measured for 60 min.

RESULTS

Rats displayed robust METH sensitisation as evidenced by increased locomotor activity to METH challenge in METH-pretreated versus SAL-pretreated rats. CBD (40 and 80 mg/kg) reduced METH-induced sensitisation. There was no effect of any CBDA doses on METH sensitisation or acute METH-induced hyperactivity.

CONCLUSION

These results demonstrate that CBD, but not CBDA, reduces METH sensitisation of locomotor activity in rats at pharmacologically effective doses, thus reinforcing evidence that CBD has anti-addiction and antipsychotic properties.

Increased medical utilization and psychiatric comorbidity following a new diagnosis of methamphetamine use disorder

BACKGROUND

Evidence of patterns of medical utilization and distribution of comorbidities among individuals using methamphetamine remains limited.

OBJECTIVE

This study aims to investigate changes in medical utilization and comorbidities before and after a diagnosis of methamphetamine use disorder.

METHODS

A total of 3321 cases (79% were male) of methamphetamine use disorder between January 1, 1996, and December 31, 2012, were identified from Psychiatric Inpatient Medical Claims database in Taiwan. Information was collected on demographics, diagnoses, and medical utilizations. The date of newly diagnosed with methamphetamine use disorder was defined as the baseline. Mirror-image study design was used to compare changes in medical utilization and comorbidities between the pre-baseline period (within 1 year before diagnosis) and the post-baseline period (within 1 year after diagnosis). Conditional logistic regression was used to estimate changes in medical utilization and comorbidities.

RESULTS

Most cases (77%) were first identified in a psychiatric department. There is a significant increase (P < .001) in psychiatric admission (odds ratio[OR] = 2.19), psychiatric emergency visits (OR = 1.31), and psychiatric outpatient visits (OR = 1.15) after diagnosis. Multivariable analysis revealed significantly increased risks (P < .001) of non-methamphetamine drug induced mental disorders (adjusted OR[aOR] = 29.47), schizophrenia (aOR = 2.62), bipolar disorder (aOR = 2.14), organic mental disorder (aOR = 1.82), and upper respiratory tract infection (aOR = 2.03) after diagnosis.

CONCLUSIONS

We found significant increases of medical utilization and psychiatric comorbidities after diagnosed with methamphetamine use disorder. These findings may reflect the problem of delayed diagnosis and treatment. Enhancement of early identification of methamphetamine use disorder in general practice is required for early intervention and decreased subsequent morbidities.

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.

Treatment Response Distinguishes Persistent Type of Methamphetamine Psychosis From Schizophrenia Spectrum Disorder Among Inmates at Japanese Medical Prison

Introduction: Persistent methamphetamine-associated psychosis (pMAP) is a disorder similar to schizophrenia, so much so that the differences in clinical symptoms and treatment response between the two remain unknown. In this study, we compared the features of pMAP with those of schizophrenia spectrum disorders (SSD). Materials and Methods: This was a retrospective quasi-experimental case-control study of inmates in a medical prison. The behavioral problems, clinical symptoms, and chlorpromazine (CP)-equivalent doses of 24 patients with pMAP and 27 with SSD were compared. Results: Patients in the pMAP group were hospitalized for fewer days than those in the SSD group (281.5 vs. 509.5; p = 0.012), but there were no other significant group differences in behavioral problems or clinical symptoms. The pMAP group received fewer antipsychotics in CP-equivalent doses than the SSD group at 4, 8, and 12 weeks after admission and at the time of discharge (p = 0.018, 0.001, 0.007, and 0.023, respectively). The number of CP-equivalent doses in the SSD group tended to increase after admission, but not in the pMAP group. Discussion: These findings suggest that differentiation between pMAP and SSD based on behavior and symptoms alone may be difficult, and that patients with pMAP may respond better to treatment with a lower dose of antipsychotic medication than those with SSD. Further confirmatory studies are warranted.

Prevalence of oral conditions among methamphetamine users: NHANES 2009-2014

OBJECTIVES

Methamphetamine (MA) is a widely used illicit drug and a nationwide public health concern. Although dental complications are consistently reported among MA users, yet limited nationally representative studies on the associations between MA use and oral health currently exist.

METHODS

Using the National Health and Nutrition Examination Survey 2009-2014, we analyzed 8,762 respondents aged 30-64 years who had completed a periodontal examination. MA use was self-reported; periodontitis, untreated caries, and missing teeth were assessed by calibrated dentists. Descriptive statistics as well as multivariable regression analyses were performed. Data were weighted to yield representative estimates of the US adult population.

RESULTS

Overall 7.8 percent of US adults aged ≥30 years had ever used MA. Ever-use prevalence was higher among males, whites, and individuals below the federal poverty level. Established MA users had a higher prevalence of untreated dental caries (36.6 percent), any periodontitis (54.8 percent), and severe periodontitis (12.2 percent) than those who had never used MA. The prevalence of any periodontitis was higher among current MA users (PR: 1.31; 95% CI: 1.05-1.62) than those who never used MA. Prevalence of untreated dental caries was higher among current MA users (PR: 1.53; 95% CI: 1.10-2.13) and established users (PR: 1.21; 95% CI: 1.02-1.48) than never users. Taking MA orally and/or through injection was associated with higher odds of severe periodontitis than orally only (AOR: 3.72; CI: 1.79-7.75).

CONCLUSIONS

MA users had a higher prevalence of periodontitis and dental caries. Continued research assessing the relationship between MA use and oral health can inform clinical interventions and management of dental diseases in MA users.

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.

Cognition and Related Neural Findings on Methamphetamine Use Disorder: Insights and Treatment Implications From Schizophrenia Research

Despite the prevalence of methamphetamine (meth) use disorder, research on meth is disproportionately scarce compared to research on other illicit drugs. Existing evidence highlights cognitive deficits as an impediment against daily function and treatment of chronic meth use. Similar deficits are also observed in schizophrenia, and this review therefore draws on schizophrenia research by examining similarities and differences between the two disorders on cognition and related neural findings. While meth use disorder and schizophrenia are two distinct disorders, they are highly co-morbid and share impairments in similar cognitive domains and altered brain structure/function. This narrative review specifically identifies overlapping features such as deficits in learning and memory, social cognition, working memory and inhibitory/impulse control. We report that while working memory deficits are a core feature of schizophrenia, such deficits are inconsistently observed following chronic meth use. Similar structural and functional abnormalities are also observed in cortical and limbic regions between the two disorders, except for cingulate activity where differences are observed. There is growing evidence that targeting cognitive symptoms may improve functional outcome in schizophrenia, with evidence of normalized abnormal brain activity in regions associated with cognition. Considering the overlap between meth use disorder and schizophrenia, targeting cognitive symptoms in people with meth use disorder may also improve treatment outcome and daily function.

Factors affecting the occurrence of psychotic symptoms in chronic methamphetamine users

Studies of risk for psychotic symptoms in methamphetamine users have focused primarily on drug use immediately before symptoms had appeared. Here we assessed factors reflecting characteristics of lifetime methamphetamine use before the appearance of psychotic symptoms. Four hundred ninety-five methamphetamine users (322 men, 173 women) were studied with consideration of the following features of methamphetamine use: age of initiation, maximum single dose, number of uses at or near the maximum dose, longest period of daily use, average dosage during that period, number of heavy use periods, and number of sustained abstinence periods (>1 month). Use of drugs other than methamphetamine and family history of schizophrenia were also considered. Retrospective self-reports of psychotic symptoms were obtained on the Brief Psychiatric Rating Scale. Factors associated with the occurrence of initial psychotic symptom(s) were identified using logistic regression. Later age of initiation, more uses at maximal or near maximal dosage, and more periods of prolonged abstinence were identified as protective factors. We conclude that early methamphetamine use can promote psychotic symptoms, possibly by altering neurodevelopment, whereas long abstinence periods may protect by allowing recovery. Negative associations of the appearance of psychotic symptom(s) with frequent high-dose administration suggest protection through tolerance.

Psychostimulant use and the brain

Psychostimulant users are typically young adults. We have conducted a narrative review of neuropsychiatric harms associated with the psychostimulants methamphetamine/amphetamine, cocaine and 3,4-methylenedioxymethamphetamine (MDMA), focusing on epidemiological factors, common clinical presentations, underlying causal mechanisms and treatment options. The major neuropsychiatric harms of psychostimulant use are stroke, neurocognitive impairment, Parkinson's disease, seizures and psychotic illness. These arise through a combination of acute monoamine release, longer-term neurotransmitter effects and indirect effects. These effects are moderated by factors in the individual and in the pattern of substance use. Neuropsychiatric harms associated with psychostimulant use can thus lead to severe long-term impairment.

Risks of psychosis in methamphetamine users: cross-sectional study in Thailand

OBJECTIVE

To determine factors related to recent methamphetamine-associated psychosis (MAP) among individuals recently using methamphetamine (MA).

DESIGN

Cross-sectional study carried out between July 2015 and June 2017.

SETTING

Four mental health hospitals and one substance abuse treatment centre in Thailand.

PARTICIPANTS

Individuals recruited onto the study included those aged 18 years or over, of both sexes, who reported MA use in the month prior to admission.

MEASURES

Any recent psychosis was confirmed using the Mini International Neuropsychiatric Interview-Plus psychotic module. The Timeline Follow Back was used to determine days of MA use. The severity of MA dependence was assessed using the Severity of Dependence Scale. Quantitative hair analysis was carried out to confirm recent use of MA and to measure the amount of MA use. We compared several characteristics between those who had recently experienced psychosis and those who had not.

RESULTS

This study included 120 participants without MAP and 113 participants with MAP. The mean age was 28 years and the mean abstinence was 17 days. The levels of MA concentration in hair were not significantly different between groups (p=0.115). Based on the final logistic regression model, the independent factors associated with MAP (OR and 95% CI) included being male (OR 4.03, 95% CI 1.59 to 10.20), ≥16 days of MA use in the past month (OR 2.35, 95% CI 1.22 to 4.52), MA dependence (OR 9.41, 95% CI 2.01 to 44.00) and hospitalisation history related to substance abuse (OR 3.85, 95% CI 2.03 to 7.28).

CONCLUSIONS

Health professionals should closely monitor the development of MAP in MA-dependent men who frequently use MA and have a history of hospitalisation for substance abuse. The measure of MA concentration levels in the hair may add no benefit for the prediction of the development of MAP.

Mortality among people with regular or problematic use of amphetamines: a systematic review and meta-analysis

BACKGROUND AND AIMS

Amphetamines are the second most commonly used class of illicit drugs. We aimed to produce pooled estimates of mortality risks among people with regular or dependent use of amphetamines, with a focus upon all-cause mortality as well as specific causes of death.

DESIGN

Systematic review and meta-analysis of cohorts of people with problematic use or dependence on amphetamines with data on all-cause or cause-specific mortality.

SETTING AND PARTICIPANTS

Of 4240 papers, 30 were eligible, reporting on 25 cohorts that measured all-cause mortality, drug poisoning, suicide, accidental injuries, homicide and cardiovascular mortality. Cohorts (n = 35-74 139) were in North America, several Nordic countries and Asia Pacific.

MEASUREMENT

Titles/abstracts were independently screened by one reviewer and excluded those reviewed by a second reviewer. Full-text screening was by two reviewers with discrepancies resolved via a third reviewer. We extracted data on crude mortality rates (CMR) per 100 person-years (py), standardized mortality ratios (SMRs). We imputed SMRs where possible if not reported by study authors. We also calculated mortality relative risks. Data were pooled using random-effects models; potential reasons for heterogeneity were explored using subgroup analyses and meta-regressions.

FINDINGS

Twenty-three cohorts contributed data for the pooled all-cause CMR: 1.14 per 100 py [95% confidence interval (CI) = 0.92-1.42]. Pooled cause-specific mortality rates were: drug poisoning, 0.14 per 100 py (95% CI = 0.06-0.34); cardiovascular disease, 0.13 per 100 py (95% CI = 0.06-0.29); suicide, 0.20 per 100 py (95% CI = 0.07-0.55); accidental injury, 0.20 per 100 py (95% CI = 0.08-0.47) and homicide, 0.03 per 100 py (95% CI = 0.02-0.06). There was substantial heterogeneity for all pooled CMR estimates except homicide. The pooled all-cause SMR was 6.83 (95% CI = 5.27-8.84). Pooled cause-specific SMRS were: poisoning, 24.70 (95% CI = 16.67, 36.58); homicide, 11.90 (95% CI = 7.82-18.12); suicide, 12.20 (95% CI = 4.89-30.47); cardiovascular disease, 5.12 (95% CI = 3.74-7.00) and accidental injury, 5.12 (95% CI = 2.88-9.08).

CONCLUSIONS

People with regular or dependent amphetamine use are at elevated risk of a range of causes of mortality compared with people without regular or dependent amphetamine use.

Prediction of Onset of Substance-Induced Psychotic Disorder and Its Progression to Schizophrenia in a Swedish National Sample

OBJECTIVE

The objective of this study was to clarify the etiology of substance-induced psychotic disorder and its progression to schizophrenia in a Swedish national sample.

METHODS

Individuals with a registration of substance-induced psychotic disorder between 1997 and 2015 in national medical registries (N=7,606) were followed up for a mean of 84 months. Data from medical, criminal, and pharmacy registries on first-degree through third-degree relatives were used to calculate familial risk scores for nonaffective psychosis, drug abuse, and alcohol use disorder.

RESULTS

Individuals with substance-induced psychotic disorder had large elevations in standardized familial risk scores for drug abuse (+1.09, 95% CI=1.02, 1.15) and alcohol use disorder (+0.98, 95% CI=0.93, 1.03) and modest elevations for nonaffective psychosis (+0.35, 95% CI=0.30, 0.41). The cumulative risk for progression to schizophrenia was 11.3%; it was lowest for alcohol-induced and highest for cannabis-induced psychotic disorder, and it was predicted by early age at diagnosis of substance-induced psychotic disorder, male sex, and further registrations for episodes of drug abuse, alcohol use disorder, and substance-induced psychotic disorder. A risk prediction model found that 47% of individuals who converted to schizophrenia were in the upper 20% of risk. Familial risk scores for drug abuse and alcohol use disorder did not significantly discriminate those who converted to schizophrenia from those who did not, while familial risk score for nonaffective psychosis did (0.67, 95% CI=0.40, 0.95, versus 0.33, 95% CI=0.28, 0.39). Familial risk scores for nonaffective psychosis were indistinguishable between individuals with schizophrenia with and without prior substance-induced psychosis. Assignment of early retirement by the Swedish Social Insurance Agency strongly discriminated between individuals with substance-induced psychotic disorder with and without later schizophrenia.

CONCLUSIONS

Substance-induced psychotic disorder appears to result from substantial drug exposure in individuals at high familial risk for substance abuse and moderately elevated familial risk for psychosis. Familial risk for psychosis, but not substance abuse, predicts progression from substance-induced psychosis to schizophrenia. Schizophrenia following substance-induced psychosis is likely a drug-precipitated disorder in highly vulnerable individuals, not a syndrome predominantly caused by drug exposure.

Meta-analysis of natural, unnatural and cause-specific mortality rates following discharge from in-patient psychiatric facilities

BACKGROUND

People discharged from in-patient psychiatric facilities have highly elevated rates of suicide, and there is increasing concern about natural mortality among the seriously mentally ill.

METHOD

A meta-analysis of English-language, peer-reviewed longitudinal studies of mortality among patients discharged from in-patient psychiatric facilities was conducted using papers published in MEDLINE, PsycINFO or EMBASE (from 1 January 1960 to 1 April 2018) located using the terms ((suicid*).ti AND (hospital OR discharg* OR inpatient OR in-patient OR admit*)).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* OR hospital* OR inpatient* OR in-patient* OR discharg*).ab. Pooled mortality rates for aggregated natural and unnatural causes, and the specific causes of suicide, accident, homicide, vascular, neoplastic, respiratory, gastrointestinal, infectious and metabolic death were calculated using a random-effects meta-analytic model. Between-study heterogeneity was investigated using subgroup analysis and metaregression.

RESULTS

The pooled natural death rate of 1128 per 100 000 person-years exceeded the pooled unnatural deaths of 479 per 100 000 person-year among studies with varying periods of follow-up. Natural deaths significantly exceeded unnatural deaths among studies with a mean follow-up of longer than 2 years, and vascular deaths exceeded suicide deaths among studies with mean period of follow-up of 5 years or longer.

CONCLUSION

Suicide may be the largest single cause of death in the short term after discharge from in-patient psychiatric facilities but vascular disease is the major cause of mortality in the medium- and long-term.

Prediction of psychiatric comorbidity on premature death in a cohort of patients with substance use disorders: a 42-year follow-up

BACKGROUND

We need to better understand how the use of different substances and psychiatric comorbidity influence premature death generally and cause-specific death by overdose, intoxication and somatic disorders in people with substance use disorders.

METHOD

A cohort of 1405 patients consecutively admitted to a Swedish detoxification unit for substance use disorders in 1970-1995 was followed-up for 42 years. Substances were identified by toxicological analyses. Mortality figures were obtained from a national registry. Causes of death were diagnosed by forensic autopsy in 594 patients deceased by 2012. Predictions were calculated by competing risks analysis.

RESULTS

Forty-two per cent of the cohort died during follow-up; more men than women (46.3% vs 30.4%). The standardised mortality ratio (SMR) was calculated as the ratio of observed deaths in males and females in specific age groups in the cohort versus expected deaths in corresponding groups in the general population. SMR was 5.68 for men (CI 95%; 5.04-6.11) and 4.98 (CI 95%; 4.08-5.88) for women. The crude mortality rate (number of deaths divided by number of person observation years) was 2.28% for men and 1.87% for women. Opiates predicted increased risk of premature death while amphetamine and cannabis predicted lower risk. Comorbid psychiatric disorders were identified in 378 cases and personality disorders in 763 cases. Primary psychoses or mood/depression and anxiety disorders predicted a higher risk of premature mortality. Death by overdose was predicted by male gender, younger age at admission to substance treatment, opiate use, and comorbid depression and anxiety syndromes. Cannabis and amphetamine use predicted a lower risk of overdose. Death by intoxication was predicted by male gender, use of sedatives/hypnotics or alcohol/mixed substances, primary psychoses and depression/anxiety syndromes. Premature death by somatic disorder was predicted by male gender and alcohol/mixed abuse.

CONCLUSION

Psychiatric comorbid disorders were important risk factors for premature drug-related death. Early identification of these factors may be life-saving in the treatment of patients with substance use disorders.

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.

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.

Relationship between the duration of methamphetamine use and psychotic symptoms: A two-year prospective cohort study

BACKGROUND

Psychosis is a key harm associated with methamphetamine (MA) use. This study examined the relationship between the duration of MA use and risk of psychotic symptoms.

METHODS

A cohort of 528 individuals with chronic MA use was followed for two years after leaving treatment center in Guangdong, China. Psychotic symptoms were assessed using the Positive and Negative Syndrome Scale at baseline and four follow-up visits (6, 12, 18 and 24 months after baseline). MA use during the past six months was investigated at each assessment. Generalized Estimating Equations for longitudinal panel data were developed to examine the risk of MA-associated psychotic symptoms among individuals with different durations of MA use. 340 MA users who completed at least one follow-up were included in the analysis.

RESULTS

During 6-month intervals, participants who reported MA use showed a two-fold increase in the risk of psychotic symptoms compared to those with no MA use (odds ratio [OR] = 2.15, 95% confidence interval [CI] = 1.33-3.49). A dose-response effect was found between the duration of MA use and the risk of psychotic symptoms (continued 12-month MA use vs. no use: OR = 2.84, 95% CI = 1.39-5.77; continued 18-month MA use vs. no use: OR = 9.93, 95% CI = 3.58-27.57). There was no assessment for 24-month intervals due to a small sample size of the continuous use group.

CONCLUSIONS

Longer periods of MA use predicted a higher risk of experiencing psychotic symptoms. Early prevention of MA use could help reduce the risk of psychosis in MA users.

Profile of psychiatric symptoms in methamphetamine users in China: Greater risk of psychiatric symptoms with a longer duration of use

Chronic methamphetamine (MA) use is associated with psychiatric symptoms. This study explored pattern of co-occurring psychiatric symptoms in MA users and their relationship to duration of MA use. A cross-sectional study was conducted among MA users at the Shenzhen Compulsory Drug Detoxification Center from April 2012 to October 2015. The Positive and Negative Syndrome Scale, Hamilton Anxiety Scale, and Beck Depression Inventory were used to assess psychiatric symptoms. Among 1277 MA users, 57.6% participants had any type of psychiatric symptoms including depressive, anxiety and psychotic symptoms. A dose-response relationship was found between duration of MA use and risk of psychiatric symptoms. The odds ratios (OR) of depressive symptoms increased with the duration of MA use (1-5 years vs. < 1 year: 1.74 [95% CI, 1.24-2.42]; ≥ 5 years vs. < 1 year: 2.07 [1.19-3.61]), so did the ORs of co-occurring anxiety and depressive symptoms (1-5 years: 1.74 [1.20-2.51]; ≥ 5 years: 3.09 [1.76-5.40]). Methamphetamine-dependent individuals were four-times more likely to experience any type of psychiatric symptoms than non-dependent users. The prevalence of psychiatric symptoms was high in chronic MA users and increased with MA use duration. Early prevention and treatment strategies targeting both MA use and associated psychiatric symptoms are needed.

A Research of Methamphetamine Induced Psychosis in 1,430 Individuals With Methamphetamine Use Disorder: Clinical Features and Possible Risk Factors

Background and Aims: Methamphetamine (MA) abuse is commonly associated with the development of psychotic symptoms. The predictors and related risk factors of MA induced psychosis (MIP) are poorly understood. We investigated the occurrence of MIP, and analyzed the clinical features and possible risk factors among individuals with MA use disorder Method: One thousand four hundred and thirty participants with MA use disorder were recruited from compulsory rehabilitation centers in Shanghai. A structured questionnaire including demographic characteristics, drug use history, visual analog scales, Beck Depression Inventory-13 (BDI-13), and Hamilton anxiety scale-14 (HAMA-14) were used to collect clinical related information. Fifty-six participants had accomplished the test of CogState Battery. Results: Among the 1430 individuals with MA use disorder, 37.1% were diagnosed as MIP according DSM-IV. There were significant differences in age, marital status, age of drug use onset, MA use years, Average MA use dose, interval of MA use, maximum dose, concurrent use of alcohol, and other drugs, VAS score, MA dependence, BDI-13 scores, HAMA-14 scores, verbal learning memory, and visual learning memory between the MIP group and the none MIP group (P < 0.05). The age of drug use onset (OR = 0.978, p = 0.011), average drug use dose (OR = 1.800, p = 0.015), craving score (OR = 1.069, p = 0.031), MA dependence (OR = 2.214, p < 0.001), and HAMA scores (OR = 1.028, p < 0.001) were associated to MIP. Conclusion: Individuals with MIP had more severe drug use problems, emotional symptoms and cognitive impairment. Earlier onset of drug use, higher quantity of drug use, higher craving, middle or severe drug use disorder and more anxiety symptoms may be related risk factors of MIP.

A Comparison of Methamphetamine-Induced Psychosis and Schizophrenia: A Review of Positive, Negative, and Cognitive Symptomatology

Methamphetamine is a potent psychostimulant that can induce psychosis among recreational and chronic users, with some users developing a persistent psychotic syndrome that shows similarities to schizophrenia. This review provides a comprehensive critique of research that has directly compared schizophrenia with acute and chronic METH psychosis, with particular focus on psychiatric and neurocognitive symptomatology. We conclude that while there is considerable overlap in the behavioral and cognitive symptoms between METH psychosis and schizophrenia, there appears to be some evidence that suggests there are divergent aspects to each condition, particularly with acute METH psychosis. Schizophrenia appears to be associated with pronounced thought disorder, negative symptoms more generally and cognitive deficits mediated by the parietal cortex, such as difficulties with selective visual attention, while visual and tactile hallucinations appear to be more prevalent in acute METH-induced psychosis. As such, acute METH psychosis may represent a distinct psychotic disorder to schizophrenia and could be clinically distinguished from a primary psychotic disorder based on the aforementioned behavioral and cognitive sequelae. Preliminary evidence, on the other hand, suggests that chronic METH psychosis may be clinically similar to that of primary psychotic disorders, particularly with respect to positive and cognitive symptomatology, although negative symptoms appear to be more pronounced in schizophrenia. Limitations of the literature and avenues for future research are also discussed.

A Review of Risk Factors for Methamphetamine-Related Psychiatric Symptoms

The illegal use of methamphetamine (MA) is a growing public health concern globally and results in a series of negative effects. The prominent detrimental effect of MA use is MA-related psychiatric symptoms (MAP) and is observed at a much higher incidence compared to the general population. MAP often includes multiple dimensions of cognitive impairment and induces adverse consequences such as, violence and suicide. However, the assessment methods for MAP are not standardized. Hence, it is necessary to investigate factors that affect the progression of psychiatric symptoms in individuals who use MA. A review of published studies was performed by searching the following databases: PubMed, EMBASE, and PsycINFO from inception to 31 May, 2018. The search strategy included methamphetamine, dependence, psychiatric symptoms, and risk factor terms. We reviewed the different features of MAP and the various types of assessment instruments and summarized MAP risk factors from MA use-related factors, socio-demographic characteristics, life events, and genetic factors. We found that MAP was consistently and causally associated with MA use, particularly as it relates to the frequency and amount of MA use. Other MAP-related risk factors like life events and genetics were relatively inconsistent in their association with MAP. Hence, causal and longitudinal studies that focus on multilateral comparisons are required. This review provides high quality evidence for MAP risk factors and would be helpful for developing early prevention and treatment strategies for MAP.

Epidemiological Characteristics and Risk Factors of Methamphetamine-Associated Psychotic Symptoms

Objective: To explore the epidemiological characteristics and the risk factors for methamphetamine (MA)-associated psychotic symptoms among MA users in China. Methods: A cross-sectional study was conducted between April, 2012 and October, 2015 among individuals for whom MA was the principal drug of use in a Compulsory Drug Detoxification Center in Beijing, Guangdong Province. Demographic, drug use and psychological characteristics were examined using a specifically-designed questionnaire, the Positive and Negative Syndrome Scale, Barratt Impulsive Scale, Hamilton Anxiety Scale and Beck Depression Inventory. Logistic regression was performed to explore the risk factors for MA-associated psychotic symptoms. Results: A total of 1685 participants were included. Participants were predominantly aged 30 or above, unemployed, and were unmarried Han Chinese men, with limited education. The duration of MA use was more than 3 months in 72.3%. 47.8% reported that the dose of MA use was ≥ 0.2 g per occasion of use. 11.5% had used two or more synthetic drugs. The prevalence of MA-associated psychotic symptoms was 17.0% among MA users during periods of abstinence. Multiple logistic regression analyses showed that a higher dose (≥0.2 g per time), a longer duration of MA use (>3 months) a history of heroin use and a history of tobacco use were associated with MA-associated psychotic symptoms, with adjusted odds ratios (ORs) of 1.96 (95% confidence interval [CI]: 1.40-2.76), 1.98 (95% CI: 1.33-2.96) and 2.45 (95% CI: 1.67-3.60), 1.78 (95% CI: 1.27-2.49) respectively. MA-associated psychotic symptoms were less common among married/cohabitating than unmarried (OR = 0.56; 95% CI: 0.39-0.81), and unemployed than employed (OR = 0.65; 95% CI: 0.47-0.92) individuals. MA users with anxiety and depression symptoms had significantly greater risk for MA-associated psychotic symptoms by 9.70 (6.92-13.59) and 1.90 (1.36-2.65) times respectively. Individuals with higher impulsivity were more likely to have MA-associated psychotic symptoms than those with lower (OR = 2.19; CI:1.50-3.20). Conclusion: MA-associated psychotic symptoms occurred frequently among MA users in China. The efforts that facilitate drug users' attempts to reduce MA use, abstain from poly-drug use, and control associated psychiatric symptoms and impulsivity should be supported because of their potential contribution to MA-associated psychotic symptoms in this population.

Risk of transition to schizophrenia following first admission with substance-induced psychotic disorder: a population-based longitudinal cohort study

BACKGROUND

The potential for drugs of abuse to induce acute psychotic symptoms is well recognised. However, the likelihood of transition from initial substance-induced psychotic disorder (SIPD) to chronic psychosis is much less well understood. This study investigated the rate of SIPD transition to schizophrenia (F20), the time to conversion and other possible related factors.

METHODS

Using data from the Scottish Morbidity Record, we examined all patients (n = 3486) since their first admission to psychiatric hospital with a diagnosis of SIPD [International Classification of Diseases, Tenth Revision (ICD-10) codes F10-F19, with third digit five] from January 1997 to July 2012. Patients were followed until first episode of schizophrenia (ICD-10 code F20, with any third digit) or July 2012. Any change in diagnosis was noted in the follow-up period, which ranged from 1 day to 15.5 years across the groups.

RESULTS

The 15.5-year cumulative hazard rate was 17.3% (s.e. = 0.007) for a diagnosis of schizophrenia. Cannabis, stimulant, opiate and multiple drug-induced psychotic disorder were all associated with similar hazard rates. The mean time to transition to a diagnosis of schizophrenia was around 13 years, although over 50% did so within 2 years and over 80% of cases presented within 5 years of SIPD diagnosis. Risk factors included male gender, younger age and longer first admission.

CONCLUSIONS

SIPD episodes requiring hospital admission for more than 2 weeks are more likely to be associated with later diagnosis of schizophrenia. Follow-up periods of more than 2 years are needed to detect the majority of those individuals who will ultimately develop schizophrenia.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis

Importance

High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.

Objectives

To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.

Data Sources

English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.

Study Selection

Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.

Data Extraction and Synthesis

The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.

Main Outcomes and Measures

The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.

Results

A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.

Conclusions and Relevance

The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

Comparison of demographic characteristics and psychiatric comorbidity among methamphetamine-, heroin- and methamphetamine-heroin co- dependent males in Hunan, China

BACKGROUND

There is little research of psychiatric comorbidity differences among people with different types of drug dependence in Chinese population. We explored demographic and comorbid psychiatric differences among methamphetamine- dependent males (MDs), heroin-dependent males (HDs) and methamphetamine and heroin co-dependent males (M/HDs) in Hunan province, China.

METHODS

A cross-sectional, structured and clinical interview method was used to examine differences in DSM-IV-TR Axis I Disorders among 346 MDs, 698 HDs and 247 M/HDs from three compulsory rehabilitation centers and two voluntary rehabilitation centers in Hunan.

RESULTS

MDs and M/HDs were younger, more likely to choose inhalation administration, less likely to have a family history of substance use, less likely to have undergone detoxification treatment, had higher incomes and shorter duration of drug use than HDs. Overall, methamphetamine-dependence related to higher rates of current and lifetime psychotic disorders, lifetime hallucinogen use disorders. Heroin-dependence related to higher rates of current and lifetime substance-induced mood disorders, sedative/hypnotic/anxiolytic and other drug use disorders and current alcohol use disorder. For M/HDs, they were more likely to have any other lifetime substance use disorders than MDs and HDs.

CONCLUSIONS

There were substantial differences in epidemiological characteristics and comorbidity among MD, HD and M/HD groups, which highlights the urgent need to develop treatment services and policies for drug-specific users in China.

Violent offences of methamphetamine users and dilemmas of forensic psychiatric assessment

Methamphetamine (MA), an extremely addictive synthetic stimulant, has quickly spread to become the most frequently used illicit drug in China. People with a history of chronic and heavy MA use have a high possibility of exhibiting schizophrenia-like psychotic symptoms, mainly delusions of reference, auditory hallucinations and cognitive deficits. These emerging findings suggest MA use increases aggression and violence and that there is a correlation between MA use and violence. However, it is unclear how to assess the capacity of criminal responsibility in "MA-induced" psychosis and how to set clear boundaries between schizophrenia and MA-induced psychosis when only limited and inconsistent evidence is available. Furthermore, a final persuasive differential diagnostic method based on improved understanding of schizophrenia and MA-induced psychotic disorders has yet to be developed. This paper will evaluate the epidemiology, social harm, and forensic psychiatric assessment of MA users, propose a future direction for the differential diagnosis between MA-induced psychotic disorders and schizophrenia, and put forward some practical solutions to assess the capacity of criminal responsibility of defendants with drug-induced psychotic disorder.

Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report

BACKGROUND

The high prevalence of comorbid illicit drug use in persons with chronic psychotic illness represents a strong determinant of psychotic relapse and rehospitalization. Epidemiological studies indicate changing patterns of illicit drug use in Australia, which are concerning because of increased use of crystal methamphetamine, also known as "ice." An important complication of habitual use of crystal methamphetamine is the development of a dose-dependent acute psychotic reaction. We report a case of an acute psychotic relapse in response to polydrug use most notable for multiple recent binges of crystal methamphetamine. Unlike previously described case reports, our patient's acute psychosis was refractory to ultra-high doses of multiple antipsychotic medications. This presented safety challenges due to the risk of serious side effects with high-dose antipsychotic medications.

CASE PRESENTATION

A 30-year-old white man with a past history of schizoaffective disorder was brought to our emergency department by the police in a state of extreme agitation, combativeness, and paranoia after use of cannabis and crystal methamphetamine. Despite existing compliance with zuclopenthixol decanoate depot medication, he required multiple emergency injections of zuclopenthixol acetate, and regular high-dose droperidol, chlorpromazine, and lorazepam. However, he remained severely agitated and psychotic with continuous threats of harm to others. A test of antipsychotic drug metabolism by cytochrome P450 enzymes did not reveal a pharmacogenetic cause for the poor therapeutic efficacy of antipsychotic medications. His psychosis did not appear to be modified by psychoactive medications but was instead self-limited to the presence of endogenous methamphetamine within his system. He fully recovered 96 to 120 hours post-presentation and was discharged home with out-patient clinic follow-up.

CONCLUSIONS

The current case highlights the challenging nature of a severe psychotic relapse precipitated by illicit substances that is resistant to medical management. High doses of multiple antipsychotic medications may be required to manage dangerous behaviors associated with these acute psychotic relapses. These patients require close monitoring for adverse effects with adjustment of dosing to ensure the optimal balance of risk versus benefit while the patient is acutely psychotic. The results are of relevance for the management of psychiatric emergencies in emergency departments and acute mental health settings.

GABAergic mRNA expression is differentially expressed across the prelimbic and orbitofrontal cortices of rats sensitized to methamphetamine: Relevance to psychosis

Psychotic disorders, such as schizophrenia, are characterized by prevalent and persistent executive deficits that are believed to be the result of dysfunctional inhibitory gamma-aminobutyric acid (GABA) processing of the prefrontal cortex (PFC). Methamphetamine (METH) is a commonly used psychostimulant that can induce psychotic and cognitive symptoms that are indistinguishable to schizophrenia, suggesting that METH-induced psychosis may have a similar GABAergic profile of the PFC. As the PFC consists of multiple subregions, the aim of the current study was to investigate changes to GABAergic mRNA expression in the prelimbic (PRL) and orbitofrontal (OFC) cortices of the PFC in rats sensitized to repeated METH administration. Male Sprague Dawley rats underwent daily METH or saline injections for 7 days. Following 14 days of withdrawal, rats were challenged with acute METH administration, RNA was isolated from the PRL and OFC and quantitative PCR was used to compare the relative expression of GABA enzymes, transporters, metabolites and receptor subunits. GAD₆₇, GAD₆₅, GAT₁, GAT₃, VGAT and GABA_T mRNA expression were upregulated in the PRL. Ionotropic GABAA receptor subunits α1, α3, α5 and β2 were specifically upregulated in the OFC. These findings suggest that alterations to GABAergic mRNA expression following sensitization to METH are biologically dissociated between the OFC and PRL, suggesting that GABAergic gene expression is significantly altered following chronic METH exposure in a brain-region and GABA-specific manner. These changes may lead to profound consequences on central inhibitory mechanisms of localized regions of the PFC and may underpin common behavioral phenotypes seen across psychotic disorders.

Altered social cognition in male BDNF heterozygous mice and following chronic methamphetamine exposure

Growing clinical evidence suggests that persistent psychosis which occurs in methamphetamine users is closely related to schizophrenia. However, preclinical studies in animal models have focussed on psychosis-related behaviours following methamphetamine, and less work has been done to assess endophenotypes relevant to other deficits observed in schizophrenia. Altered social behaviour is a feature of both the negative symptoms and cognitive deficits in schizophrenia, and significantly impacts patient functioning. We recently found that brain-derived neurotrophic factor (BDNF) heterozygous mice show disrupted sensitization to methamphetamine, supporting other work suggesting an important role of this neurotrophin in the pathophysiology of psychosis and the neuronal response to stimulant drugs. In the current study, we assessed social and cognitive behaviours in methamphetamine-treated BDNF heterozygous mice and wildtype littermate controls. Following chronic methamphetamine exposure male wildtype mice showed a 50% reduction in social novelty preference. Vehicle-treated male BDNF heterozygous mice showed a similar impairment in social novelty preference, with a trend for no further disruption by methamphetamine exposure. Female mice were unaffected in this task, and no groups showed any changes in sociability or short-term spatial memory. These findings suggest that chronic methamphetamine alters behaviour relevant to disruption of social cognition in schizophrenia, supporting other studies which demonstrate a close resemblance between persistent methamphetamine psychosis and schizophrenia. Together these findings suggest that dynamic regulation of BDNF signalling is necessary to mediate the effects of methamphetamine on behaviours relevant to schizophrenia.

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.

Long-term risk factors for substance-induced and primary psychosis after release from prison. A longitudinal study of substance users

PURPOSE

The purpose of this study was to determine long-term risk factors for substance-induced and primary psychosis after release from prison.

MATERIAL

We used a longitudinal register-based cohort study combining European version of Addiction Severity Index (Europ-ASI) interviews and the Swedish inpatient register. The study included 6217 individuals who were in the Swedish criminal justice system from 2001 to 2006.

MEASUREMENTS

The outcomes were substance-induced and primary psychosis as defined by the International Classification of Disease - 10th version. All variables for estimating baseline risk were drawn from the Europ-ASI interview, and included information on substance use, demographics and health. The interview database and the inpatient register were coupled, and groups were compared by using tests of significance and logistic regression.

RESULTS

Polydrug use was the strongest predictor for substance induced psychosis (OR=9.55, 95% CI 3.42-26.67), but all substances imposed an increased risk. Previous psychiatric hospitalization and non-drug related hallucinations were significant, but weaker, risk factors. The only substance variable that predicted primary psychosis was cannabis (OR=2.62, 95% CI 1.39-4.96), but previous psychiatric hospitalization (OR=3.22, 95% CI 2.27-4.54) and non-drug related hallucinations (OR=4.00, 95% CI 2.82-5.67) were even stronger predictors.

CONCLUSIONS

Cannabis use was a risk factor for primary psychosis, but other health related individual risk factors were even more important. Polydrug use was the strongest risk factor for substance-induced psychosis.

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

BACKGROUND AND OBJECTIVES

We investigated transition from amphetamine-induced psychosis (AIP) to schizophrenia.

METHODS

A sample of 28 individuals was identified while hospitalized for AIP. We reviewed their hospital records after six years.

RESULTS

During follow-up, seven individuals (25%) died and nine (32%) had moved from the area. Of the remaining 12, four individuals (25%) were diagnosed with schizophrenia. These individuals were, at baseline, characterized by fewer hallucinatory symptoms and more homelessness.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Hospitalization for AIP was a relatively specific risk factor for schizophrenia and the mortality rate in AIP was high.

The epidemiology and progression time from transient to permanent psychiatric disorders of substance-induced psychosis in Taiwan

INTRODUCTION

Substance-induced psychosis (SIP), including alcohol-induced psychotic disorder (AIPD) and substance-induced psychotic disorder (SIPD), is gradually increasing in importance in clinical practice. However, few studies have investigated the epidemiology and progression time from transient to permanent psychiatric disorders for AIPD and SIPD patients.

METHODS

We utilized the National Health Insurance Research Database (NHIRD) to investigate the incidence and prevalence of AIPD and SIPD in Taiwan and determined the timing of AIPD or SIPD followed by the development of persistent psychotic conditions.

RESULTS

The average incidence and prevalence were 1.97 and 2.94 per 100,000 person-years for AIPD, 3.09 and 5.67 per 100,000 person-years for SIPD in Taiwan. Moreover, 10.9% to 24.3% of subjects with either AIPD or SIPD had a change in diagnosis to either schizophrenia or affective disorder, and ~50% of patients had a psychotic or affective transformation in their first year after AIPD and SIPD diagnoses. The mean progression time of psychotic or affective transformation was 1.9 to 2.7 years.

CONCLUSIONS

SIP is a predictive factor for persistent psychotic and affective transformation, and a three-year follow-up may be an optimal clinical practice to prevent psychotic or affective transformation in 60% of patients.

Primary and substance-induced psychotic disorders in methamphetamine users

This study investigates the rates of primary psychotic disorders (PPD) and substance-induced psychotic disorders (SIPDs) in methamphetamine (MA) users accessing needle and syringe programs (NSPs). The aim was to determine if there are systematic differences in the characteristics of MA users with PPDs and SIPDs compared to those with no psychotic disorder. Participants were 198 MA users reporting use in the previous month. Diagnosis was determined using the Psychiatric Research Interview for DSM-IV Substance and Mental Disorders (PRISM-IV). Current psychiatric symptoms and substance use were also measured. Just over half (n=101) of participants met DSM-IV criteria for a lifetime psychotic disorder, including 81 (80%) with a SIPD and 20 (20%) with a PPD. Those with a younger age of onset of weekly MA use were at increased risk of a lifetime SIPD. A current psychotic disorder was found in 62 (39%), comprising 49 SIPDs (79%) and 13 PPDs (21%). MA users with a current PPD were more likely to have received psychiatric treatment in the past month than those with a current SIPD, despite a similar level of psychotic symptom severity. A high proportion of MA users accessing NSPs have psychotic disorders, the majority of which are substance-induced.

Neuropsychiatric Adverse Effects of Amphetamine and Methamphetamine

Administration of amphetamine and methamphetamine can elicit psychiatric adverse effects at acute administration, binge use, withdrawal, and chronic use. Most troublesome of these are psychotic states and aggressive behavior, but a large variety of undesirable changes in cognition and affect can be induced. Adverse effects occur more frequently with higher dosages and long-term use. They can subside over time but some persist long-term. Multiple alterations in the gray and white matter of the brain assessed as changes in tissue volume or metabolism, or at molecular level, have been associated with amphetamine and methamphetamine use and the psychiatric adverse effects, but further studies are required to clarify their causal role, specificity, and relationship with preceding states and traits and comorbidities. The latter include other substance use disorders, mood and anxiety disorders, attention deficit hyperactivity disorder, and antisocial personality disorder. Amphetamine- and methamphetamine-related psychosis is similar to schizophrenia in terms of symptomatology and pathogenesis, and these two disorders share predisposing genetic factors.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation

OBJECTIVE

Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates.

METHODS

PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression.

RESULTS

Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors.

CONCLUSIONS

Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.