Treated incidence and baseline characteristics of substance induced psychosis in a Norwegian catchment area

Early and later remission from clinical high risk of psychosis. A latent class and predictor analysis

BACKGROUND

In high-risk for psychosis (CHR-P) much focus has been on the transition to psychosis. However, the desired outcome remains symptomatic remission and improved functioning as early as possible. This study aims to investigate predictors of sub-groups of remission and functional outcomes.

MATERIAL AND METHODS

A two-year prospective follow-up study of 104 CHR-P participants recruited in Norway using systematic early detection strategies. The Structural Interview for Prodromal Syndromes (SIPS) was used to assess CHR-P. Participants were classified as remitted or non-remitted based on their symptom scores. A latent class analysis was performed on the dichotomous data to identify latent classes regarding the timing of remission. t-tests and chi-squared tests were used to assess the association between class affiliations, predictors and outcomes.

RESULTS

The latent class analysis showed moderate fit and divided the participants into three remission classes: "poor chance of remission" (16.7 %), "later remission" (34.3 %), and "early remission" (49.0 %). The "early remission" class had the highest probability of fast and stable remission, and had better premorbid academic, and baseline and 2-year global functioning than the "later remission" class. Baseline predictors such as age, SIPS symptoms, drug use, years in school and gender were not significantly associated with remission class.

DISCUSSION

The study's main finding is the division of CHR-P remission into "early remission" and "later remission" and predictors of class affiliation. The monthly follow-up during the first six months allowed for the detection of this division. The findings suggest the importance of considering functioning in models of remission from CHR-P.

Annual incidence of substance-induced psychoses in Scandinavia from 2000 to 2016

BACKGROUND

Substance-induced psychosis (SIP) is a serious condition and may predispose for schizophrenia. We know too little about SIP incidence over time and across countries, including substance-specific SIPs. We estimated annual incidence rate of SIP in Denmark, Norway, and Sweden according to substance, age, gender, and socioeconomic background.

METHODS

Data were drawn from registries covering the whole adult population in the countries. Annual incidence rate per 100 000 persons of SIPs was estimated for Denmark and Sweden from 2000 to 2016 and for Norway from 2010 to 2015.

RESULTS

The annual incidence rate of any SIP fluctuated between 9.3 and 14.1. The most commonly occurring SIPs were those induced by alcohol, cannabis, amphetamines, and multiple substances. There was a steady decrease in the incidence rate of alcohol-induced psychosis from the first to the last year of the observation period in Denmark (from 4.9 to 1.5) and Sweden (from 4.5 to 2.2). The incidence rate of cannabis-induced psychosis increased in all countries, from 2.6 to 5.6 in Denmark, from 0.8 to 2.7 in Sweden, and from 1.8 to 3.0 in Norway. Median age of any SIP decreased in Denmark (from 36 to 29 years) and Sweden (from 41 to 31 years). Incidence rates were higher in men and in individuals on disability pension, and increased more among those with high parental education.

CONCLUSIONS

We found similar and stable incidence rates of any SIP in all Scandinavian countries through the observation period. The incidence of alcohol-induced psychosis decreased. The incidence of cannabis-induced psychosis increased.

Drogeninduzierte Psychosen

Substanzkonsumstörungen und Psychosen stehen häufig in einem kausalen Zusammenhang. Dieser kann uni- oder bidirektional sein – oder beide Störungen beruhen auf gemeinsamen ätiopathogenetischen Faktoren. Substanzen wie Cannabinoide, Stimulanzien oder Halluzinogene scheinen wichtige Ko-Faktoren für die Entwicklung einer (sekundären) Psychose darzustellen. Der Beitrag gibt einen Überblick über die Substanzgruppen, Diagnostik und Therapie.

Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis

Cannabis, a widely used psychoactive substance, can trigger acute cannabis-associated psychotic symptoms (CAPS) in people who use cannabis (PWUC). To assess rates and correlates of CAPS requiring emergency medical treatment, we analyzed data from an international sample of PWUC (n = 233,475). We found that 0.47% (95%CI 0.42; 0.52) PWUC reported lifetime occurrence of CAPS, defined as the occurrence of hallucinations and/or paranoia requiring emergency medical treatment following the use of cannabis. A range of factors correlated with risk of CAPS in the last year: higher rates were observed in young individuals [risk ratio (RR) 2.66, compared to older PWUC] and those residing in Denmark (RR 3.01, compared to PWUC from other countries). Furthermore, risk was elevated in those using predominantly high-potency resin (RR 2.11, compared to PWUC using herbal cannabis), those mixing cannabis with tobacco (RR 2.15, compared to PWUC not mixing with tobacco) and those with a diagnosis of psychosis (RR 14.01), bipolar (RR 4.30), anxiety (RR 2.92) and depression (RR 2.68), compared to individuals without a mental health diagnosis. Taken together, acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC's lifetime. Some individuals could be particularly sensitive to the adverse psychological effects of cannabis, such as young individuals or those with pre-existing mental health vulnerabilities. In light of the movements towards legalization of recreational cannabis, more research should focus on the potential harms related to cannabis use, to educate PWUC and the public about risks related to its use.

Associations between symptom and neurocognitive dimensions in clinical high risk for psychosis

Introduction

Clinical high risk for psychosis (CHR) is associated with mild cognitive impairments. Symptoms are clustered into positive, negative and disorganization symptoms. The association between specific symptom dimensions and cognitive functions remains unclear. The aim of this study was to investigate the associations between cognitive functions and positive, negative, and disorganization symptoms.

Method

53 CHR subjects fulfilling criteria for attenuated psychotic syndrome in the Structural Interview for Prodromal Syndromes (SIPS) were assessed for cognitive function. Five cognitive domain z-scores were defined by contrasting with observed scores of a group of healthy controls (n = 40). Principal Components Analyses were performed to construct general cognitive composite scores; one using all subtests and one using the cognitive domains. Associations between cognitive functions and symptoms are presented as Spearman's rank correlations and partial Spearman's rank correlations adjusted for age and gender.

Results

Positive symptoms were negatively associated with executive functions and verbal memory, and disorganization symptoms with poorer verbal fluency. Negative symptoms were associated with better executive functioning. There were no significant associations between the general cognitive composites and any of the symptom domains, except for a trend for positive symptoms.

Conclusion

In line with previous research, data indicated associations between positive symptoms and poorer executive functioning. Negative symptoms may not be related to executive functions in CHR the same way as in psychosis. Our results could indicate that attenuated positive symptoms are more related to cognitive deficits in CHR than positive symptoms in schizophrenia and FEP.

Exploring specific predictors of psychosis onset over a 2-year period: A decision-tree model

AIM

The fluctuating symptoms of clinical high risk for psychosis hamper conversion prediction models. Exploring specific symptoms using machine-learning has proven fruitful in accommodating this challenge. The aim of this study is to explore specific predictors and generate atheoretical hypotheses of onset using a close-monitoring, machine-learning approach.

METHODS

Study participants, N = 96, mean age 16.55 years, male to female ratio 46:54%, were recruited from the Prevention of Psychosis Study in Rogaland, Norway. Participants were assessed using the Structured Interview for Psychosis Risk Syndromes (SIPS) at 13 separate assessment time points across 2 years, yielding 247 specific scores. A machine-learning decision-tree analysis (i) examined potential SIPS predictors of psychosis conversion and (ii) hierarchically ranked predictors of psychosis conversion.

RESULTS

Four out of 247 specific SIPS symptom scores were significant: (i) reduced expression of emotion at baseline, (ii) experience of emotions and self at 5 months, (iii) perceptual abnormalities/hallucinations at 3 months and (iv) ideational richness at 6 months. No SIPS symptom scores obtained after 6 months of follow-up predicted psychosis.

CONCLUSIONS

Study findings suggest that early negative symptoms, particularly those observable by peers and arguably a risk factor for social exclusion, were predictive of psychosis. Self-expression and social behaviour might prove relevant entry points for early intervention in psychosis and psychosis risk. Testing study results in larger samples and at other sites is warranted.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

Reduced Expression of Emotion: A Red Flag Signalling Conversion to Psychosis in Clinical High Risk for Psychosis (CHR-P) Populations

Objective: In this hypothesis-testing study, which is based on findings from a previous atheoretical machine-learning study, we test the predictive power of baseline "reduced expression of emotion" for psychosis.Method: Study participants (N = 96, mean age 16.55 years) were recruited from the Prevention of Psychosis Study in Rogaland, Norway. The Structured Interview for Prodromal Syndromes (SIPS) was conducted 13 times over two years. Reduced expression of emotion was added to positive symptoms at baseline (P1-P5) as a predictor of psychosis onset over a two-year period using logistic regression.Results: Participants with a score above zero on expression of emotion had over eight times the odds of conversion (OR = 8.69, p < .001). Data indicated a significant dose-response association. A model including reduced expression of emotion at baseline together with the positive symptoms of the SIPS rendered the latter statistically insignificant.Conclusions: The study findings confirm findings from the previous machine-learning study, indicating that observing reduced expression of emotion may serve two purposes: first, it may add predictive value to psychosis conversion, and second, it is readily observable. This may facilitate detection of those most at risk within the clinical high risk of psychosis population, as well as those at clinical high risk. A next step could be including this symptom within current high-risk criteria. Future research should consolidate these findings.

Childhood interpersonal trauma and premorbid social adjustment as predictors of symptom remission in first episode psychosis

BACKGROUND

Childhood interpersonal trauma (CIT) and premorbid adjustment are both associated with poor outcome in psychosis. In this study we investigate the relative impact of CIT and premorbid adjustment on symptom remission in first episode psychosis (FEP) over two years.

METHOD

A total of 232 participants with FEP were recruited through the early detection program of the The early detection and Intervention in Psychosis (TIPS)-2 study and followed up after two years. Symptom remission was according to consensus criteria. CIT was assessed with the semi-structured interview Freyd Goldberg Brief Betrayal Trauma Survey, and premorbid adjustment with the Premorbid Adjustment Scale. Generalized estimating equations and multivariate models were used to analyze the associations between remission, symptom levels over time, CIT and premorbid adjustment; and a path analysis of mediation effects of CIT through premorbid adjustment on remission.

RESULTS

In this sample with 57% males and a mean age of 26.6 years (SD 10.2), a third of participants had experienced CIT. The participants with CIT had poorer premorbid adjustment compared to those without. Statistical analyses found independent effects of CIT and an interaction effect of CIT with premorbid adjustment on remission after two years, suggesting that CIT moderates the effect of premorbid adjustment. However contrary to expectations, premorbid adjustment did not mediate the effect of CIT.

CONCLUSION

Our findings indicate a complex interplay between effects of interpersonal trauma and premorbid social adjustment on remission in psychosis. CIT appeared to moderate the effect of premorbid adjustment such that individuals with CIT and who had poor social functioning in childhood are at greater risk of non-remission. Findings indicate that better premorbid social relations could provide a buffer for the effects of trauma on symptom course.

Early Detection of Ultra High Risk for Psychosis in a Norwegian Catchment Area: The Two Year Follow-Up of the Prevention of Psychosis Study

Objectives: Most individuals experience a relatively long period of sub-clinical psychotic like symptoms, known as the ultra high risk (UHR) or at risk mental states (ARMS), prior to a first episode of psychosis. Approximately 95% of individuals who will later develop psychosis are not referred to specialized clinical services and assessed during the UHR phase. The study aimed to investigate whether a systematic early detection program, modeled after the successful early detection of psychosis program TIPS, would improve the detection of help-seeking UHR individuals. The secondary aim was to examine the rates and predictors of conversion to psychosis after 2 years. Method: The overall study design was a prospective (2012-2018), follow- up study of individuals fulfilling UHR inclusion criteria as assessed by the structural interview for prodromal syndromes (SIPS). Help-seeking UHR individuals were recruited through systematic early detection strategies in a Norwegian catchment area and treated in the public mental health services. Results: In the study period 141 UHR help-seeking individuals were identified. This averages an incidence of 7 per 100,000 people per year. The baseline assessment was completed by 99 of these and the 2 year psychosis conversion rate was 20%. A linear mixed-model regression analysis found that the significant predictors of conversion were the course of positive (0.038) and negative symptoms (0.017). Age was also a significant predictor and showed an interaction with female gender (<0.000). Conclusion: We managed to detect a proportion of UHR individuals in the upper range of the expected prediction by the population statistics and further case enrichment would improve this rate. Negative symptoms were significant predictors. As a risk factor for adverse functional outcomes and social marginalization, this could offer opportunities for earlier psychosocial intervention.

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.

Preventing Suicide among Psychiatric Inpatients with Psychotic Depression

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Substance-Induced Psychosis in Youth

Youth experiencing psychosis also frequently misuse substances, making it clinically challenging to differentiate substance-induced psychosis (SIP) from a primary psychotic disorder (PPD), which has important implications for management and prognosis. This article presents practical considerations related to differentiating SIP from PPD, including information on substances associated with symptoms of psychosis. Recommendations for management of SIP are also reviewed, including screening for and treating comorbid substance use disorders and using evidence-based medication and psychosocial interventions.

Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs) and schizophrenia. This systematic review and meta-analysis estimated prevalence rates of SUDs in epidemiological and treatment-seeking patients diagnosed with schizophrenia or first episode psychosis.

METHODS

A literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2017 inclusive. Prevalence of co-morbid SUDs and schizophrenia were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Combining like studies was dictated how authors reported substance use.

RESULTS

There were 123 included articles with a total sample size of 165,811 subjects that yielded six epidemiological studies, 11 national or state case-registry studies, 20 large cohort studies and 86 clinical studies using in- or out-patient samples. The prevalence of any SUD was 41.7%, followed by illicit drugs (27.5%), cannabis (26.2%), alcohol (24.3%) and stimulant use (7.3%). Meta-analysis showed the pooled variance of any SUD in males was 48% which was significantly higher than that for females with schizophrenia (22.1%, OR 3.43, 95% CI 3.01, 3.92). Patients with SUD had an earlier age of onset of schizophrenia. Meta-regression showed prevalence increased over time for illicit drugs but not for other substances, including alcohol.

CONCLUSIONS

The meta-analysis revealed that SUDs in schizophrenia is highly prevalent and rates have not changed over time. This indicates SUD are difficult to treat in this patient population and there is an urgent need for more informative studies to help develop better prevention, detection and treatment of SUDs in persons with schizophrenia and co-morbid disorders.

Structural and functional alterations in the brain during working memory in medication-naïve patients at clinical high-risk for psychosis

Several previous studies suggest that clinical high risk for psychosis (CHR) is associated with prefrontal functional abnormalities and more widespread reduced grey matter in prefrontal, temporal and parietal areas. We investigated neural correlates to CHR in medication-naïve patients. 41 CHR patients and 37 healthy controls were examined with 1.5 Tesla MRI, yielding functional scans while performing an N-back task and structural T1-weighted brain images. Functional and structural data underwent automated preprocessing steps in SPM and Freesurfer, correspondingly. The groups were compared employing mass-univariate strategy within the generalized linear modelling framework. CHR demonstrated reduced suppression of the medial temporal lobe (MTL) regions during n-back task. We also found that, consistent with previous findings, CHR subjects demonstrated thinning in prefrontal, cingulate, insular and inferior temporal areas, as well as reduced hippocampal volumes. The present findings add to the growing evidence of specific structural and functional abnormalities in the brain as potential neuroimaging markers of psychosis vulnerability.

"With a little help from my friends" social predictors of clinical recovery in first-episode psychosis

Social functioning is a conglomerate of factors central to clinical recovery after a first-episode psychosis. There is a lack of studies investigating the relative impact of factors related to social interaction. Disentangling these could facilitate improvement of psychosocial interventions. This study aims to investigate the impact of social interactions on two-year clinical recovery in first-episode psychosis, by examining frequency and satisfaction of relationships with family and friends. A baseline sample of 178 first-episode psychosis individuals were followed up over two years regarding social functioning and clinical status. We longitudinally compared those who were to those who were not recovered using generalized estimating equations analyses. Our results showed that frequency of social interactions with friends was a significant positive predictor of clinical recovery over a two-year period. Perceived satisfaction with relationships, and frequency of family interaction did not show significant effects. We conclude that interaction with friends is a malleable factor that could be targeted for early intervention. This would facilitate protective factors through the preservation of existing social networks and thus reduce the risk of disability associated with long-term psychosis. Findings indicate that even individuals with an inclination towards social withdrawal and isolation could benefit from this type of intervention.

Psychotic Depression and Suicidal Behavior

OBJECTIVE

This study investigated how severely depressed individuals experienced the relationship between psychotic symptoms and suicidal ideation and behavior.

METHOD

Semi-structured qualitative interviews were conducted with a purposive sample of nine inpatients from a psychiatric university hospital between September 2012 and May 2013 fulfilling diagnostic criteria for a psychotic depressive episode as part of a unipolar or bipolar disorder. Analysis was conducted using systematic text condensation.

RESULTS

Participants experienced (1) being directed to perform impulsive potentially fatal actions, (2) feeling hounded to death, (3) becoming trapped in an inescapable darkness, and (4) being left bereft of mental control. They described how impulsivity directed by delusions and hallucinations resulted in unpredictable actions with only moments from decision to conduct. Suicide was seen as an escape not only from life problems but also from psychotic experiences and intense anxiety. Participants reported being in a chaotic state, unable to think rationally or anticipate the consequences of their actions. Their ability to identify and communicate psychotic symptoms and suicidal ideation and behavior was compromised, leaving them to struggle alone with these terrifying experiences.

CONCLUSIONS

Suicide risk assessments based on verbal reports from individuals with psychotic depression may not always be valid due to potential impulsivity and underreporting of suicidal ideation. It may be important for clinicians to explore the delusional content of such patients' experiences to assess the possibility of suicide as a result of shame, guilt, remorse, or altruistic intentions to save others from harm.

"Everyone Needs a Friend Sometimes" - Social Predictors of Long-Term Remission In First Episode Psychosis

Background: Predictors of long-term symptomatic remission are crucial to the successful tailoring of treatment in first episode psychosis. There is lack of studies distinguishing the predictive effects of different social factors. This prevents a valid evaluating of their independent effects.

Objectives: To test specific social baseline predictors of long-term remission. We hypothesized that first, satisfaction with social relations predicts remission; second, that frequency of social interaction predicts remission; and third, that the effect of friend relationship satisfaction and frequency will be greater than that of family relations satisfaction and frequency.

Material and Methods: A sample of first episode psychosis (n = 186) completed baseline measures of social functioning, as well as clinical assessments. We compared groups of remitted and non-remitted individuals using generalized estimating equations analyses.

Results: Frequency of social interaction with friends was a significant positive predictor of remission over a two-year period. Neither global perceived social satisfaction nor frequency of family interaction showed significant effects.

Conclusions: The study findings are of particular clinical importance since frequency of friendship interaction is a possibly malleable factor. Frequency of interaction could be affected through behavioral modification and therapy already from an early stage in the course, and thus increase remission rates.

Cannabis use is associated with 3years earlier onset of schizophrenia spectrum disorder in a naturalistic, multi-site sample (N=1119)

BACKGROUND

Patients with schizophrenia spectrum disorders and substance use may have an earlier onset of illness compared to those without substance use. Most previous studies have, however, too small samples to control for confounding variables and the effect of specific types of substances. The present study aimed to examine the relationship between substance use and age at onset, in addition to the influence of possible confounders and specific substances, in a large and heterogeneous multisite sample of patients with schizophrenia spectrum disorders.

METHODS

The patients (N=1119) were recruited from catchment areas in Oslo, Stavanger and Bergen, Norway, diagnosed according to DSM-IV and screened for substance use history. Linear regression analysis was used to examine the relationship between substance use and age at onset of illness.

RESULTS

Patients with substance use (n=627) had about 3years earlier age at onset (23.0years; SD 7.1) than the abstinent group (n=492; 25.9years; SD 9.7). Only cannabis use was statistically significantly related to earlier age at onset. Gender or family history of psychosis did not influence the results.

CONCLUSION

Cannabis use is associated with 3years earlier onset of psychosis.