Claire E. Ramsay

Pre-illness cannabis use and the early course of nonaffective psychotic disorders: associations with premorbid functioning, the prodrome, and mode of onset of psychosis.

INTRODUCTION Limited research indicates that pre-illness cannabis use may result in an earlier age at onset of psychosis, though little is known about the influence of prior cannabis use on the premorbid and prodromal phases. This study examined the effects of prior or concurrent cannabis (as well as nicotine and alcohol) use on: (1) early adolescent (12-15 years) premorbid functioning, (2) late adolescent (16-18 years) premorbid functioning, (3) two features of the prodrome, and (4) mode of onset of psychosis. METHODS Participants included 109 well-characterized first-episode patients hospitalized in public-sector settings. Assessments included ages at initiation of first, weekly, and daily use of substances, the Premorbid Adjustment Scale, the Symptom Onset in Schizophrenia inventory, and a consensus-based best estimate of mode of onset. RESULTS Participants having used cannabis at ≤15 years had better early adolescence social functioning than those who had not used cannabis (p=0.02). Conversely, those who had used cannabis at ≤18 years had poorer late adolescence academic functioning (p<0.001). Participants having used cannabis before onset of psychotic symptoms did not differ from those who had not in terms of having had an identifiable prodrome or the number of prodromal symptoms experienced. Whereas 42% of those having used cannabis daily had an acute mode of onset of psychosis, only 20% of those without prior daily cannabis use had an acute onset (p=0.04). CONCLUSIONS Findings suggest that cannabis use is associated with premorbid social and academic functioning and mode of onset. Further research is warranted to elucidate the complex associations between cannabis use and diverse early-course features.

Clinical correlates of maltreatment and traumatic experiences in childhood and adolescence among predominantly African American, socially disadvantaged, hospitalized, first-episode psychosis patients

Associations among maltreatment and traumatic experiences in childhood and adolescence, later substance use, and subsequent mental health outcomes for individuals with schizophrenia-spectrum disorders have been initially explored in previous studies; however, research on these factors in socially disadvantaged patients with first-episode psychosis is unavailable. This exploratory, correlational analysis examined associations between maltreatment and trauma-related variables (e.g., traumatic experiences, parental harsh discipline, violence exposure) and: social variables (years of education attained and extent of Axis IV psychosocial problems at initial hospitalization), substance abuse (age at initiation of alcohol and cannabis use, as well as estimates of lifetime intake of both), and positive and negative symptom severity. Rates of childhood abuse and traumatic events were remarkably high in the sample. Years of educational attainment and number of Axis IV psychosocial problems were substantially correlated with several domains of childhood abuse/traumatic events. Age at initiation of alcohol and cannabis use, and lifetime alcohol and cannabis intake, were correlated with a number of trauma domains. Whereas positive symptom severity was correlated with four of the trauma variables, negative symptom severity was correlated only with prior emotional neglect. These results provide insights into the relations among childhood traumatic events, substance use, and clinical features of first-episode psychosis, creating hypotheses for future research.

Overview and initial validation of two detailed, multidimensional, retrospective measures of substance use: the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments.

Research on comorbidities between substance use disorders and serious mental illnesses would be facilitated by new methods for collecting comprehensive data on substance use, including data on onset, progression, frequency, amounts, and consequential behaviors. Given substantial limitations of available instruments, and a nearly complete absence of methodologies that allow derivation of continuous measures that estimate dose or cumulative exposure, this report describes the development and initial validation of two interviewer-administered, multidimensional measures of substance use, the Lifetime Substance Use Recall (LSUR) and Longitudinal Substance Use Recall for 12 Weeks (LSUR-12) Instruments. Participants (n=60) in an ongoing study of first-episode psychosis were evaluated with the LSUR, LSUR-12, and a number of other concurrent measures pertaining to substance use, substance use disorder diagnoses, select demographic features, and two personality traits. Specific a priori hypothesis tests were selected to demonstrate validity, relying on effect sizes to estimate strengths of association, considering small-to-medium correlations (e.g., ρ) as |.20-.50| and medium-to-large effect sizes as >|.50|. Numerous associations were observed between key nicotine-, alcohol-, and cannabis-related variables from the LSUR and LSUR-12 and scores from other concurrently administered measures. These findings provide a thorough initial validation of scores obtained with the new multidimensional instruments. Although validity of the two new measures of lifetime and past 12-week substance use was demonstrated, empirical data on inter-rater and test-retest reliability are needed. Careful development, and demonstration of psychometric properties, of these and related instruments may advance the fields of addiction and comorbidity research.

An exploration of perceptions of possible depression prevention services for caregivers of elderly or chronically ill adults in rural Georgia.

Caregiving for elderly or chronically ill adults can be stressful, contributing to a high rate of depression in caregivers. Rural caregivers are at particularly high risk due to reduced access to mental health care services. This study explored the acceptability among rural caregivers of introducing a program to prevent or alleviate depression. Focus groups with caregivers and community members were conducted in four rural counties of Georgia. Caregivers reported high levels of stress and depression and recommended the following interventions: support groups, respite care, a centralized source of information, training for caregivers and other community members, financial support, and a telephone hotline. There were more commonalities than differences across the locations, but some programmatic preferences and acceptability varied.

The Interface of Cannabis Misuse and Schizophrenia-Spectrum Disorders

This chapter provides an overview of the complex ways in which cannabis misuse intersects with schizophrenia-spectrum disorders. The centrally active constituents of Cannabis sativa are discussed, and the central endocannabinoid system is briefly reviewed. Information on cannabis use and misuse in the general population is provided, including the prevalence of use in general population samples and consequences of such use. Findings pertaining to cannabis misuse among individuals with schizophrenia-spectrum disorders are presented, along with an overview of the adverse effects of cannabis use in terms of symptoms, neurocognition, age at onset, and various aspects of the long-term course and outcomes. A discussion of the literature that suggests that cannabis use is a component cause of, or independent risk factor for, psychosis is given. Other potential mechanisms for the association are considered, including psychosis causing cannabis use or the existence of a shared diathesis that underlies both. To evaluate the literature suggesting that cannabis use, especially in early adolescence, is a component cause of schizophrenia-spectrum disorders, nine criteria for establishing causality are summarized. The chapter concludes with a brief discussion of treatment implications for clinicians and program developers, as well as prevention implications for researchers, public health officials, and policy-makers.

Predictors of the discharge dosage of an atypical antipsychotic agent among hospitalized, treatment-naive, first-episode psychosis patients in naturalistic, public-sector settings.

Objective: Little is known about determinants of second-generation antipsychotic dosages during initial hospitalization of first-episode psychosis. This study examined potential predictors of dosage of an atypical antipsychotic agent, risperidone, at hospital discharge after initial evaluation and treatment of first-episode nonaffective psychosis in 3 naturalistic, public-sector treatment settings. Methods: The number of psychotropic agents prescribed and discharge antipsychotic dosage were abstracted from the medical record. Demographic and extensive clinical characteristics were assessed through a clinical research study conducted at the 3 sites. One-way analyses of variance, trend tests using specific linear combinations of estimates, and &khgr;2 tests assessed for associations between atypical antipsychotic dosage and 5 hypothesized predictors, as well as 12 exploratory variables. Results: Among 155 hospitalized first-episode patients, 121 (78.1%) were discharged on risperidone, and subsequent analyses focused on that subset. The mean risperidone dosage among those 121 patients was 4.26 mg; 31 received 1 to 2 mg, 45 received 3 to 4 mg, 37 received 5 to 6 mg, and 8 received more than 6 mg. Analyses suggested that older age at hospitalization, the number of psychotropic agents prescribed, excited symptoms, and premorbid social functioning may be predictors of the discharge dosage. Conclusions: Although several factors emerged, in general, predictors of discharge dosages of second-generation agents, here exemplified by risperidone, in real-world practice settings remain to be clarified. Given the importance of antipsychotic initiation during first hospitalization, future research should test an even broader array of potential predictors.