Clairélaine Ouellet-Plamondon

Pharmacotherapy challenges in patients with first-episode psychosis

The first episode of a psychotic disorder typically occurs in late adolescence or young adulthood, a critical time of development with respect to personality, social role, education, and vocation. The first few years of psychosis appear to be a critical period during which intervention needs to be initiated before the consequences of psychosis become more severe. Early intervention is therefore crucial in maximizing outcomes. Although response rates to antipsychotic medication in first-episode psychosis (FEP) are good, there is a relatively high risk of relapse. The greatest challenges that physicians face in treating FEP and preventing relapse are engaging patients in treatment and preventing non-adherence to therapy. Overall rates of non-adherence to antipsychotic medications for FEP patients are estimated to be at or higher than 50% within the first year of treatment, suggesting that malleable factors linked to non-adherence need to be targeted in interventions provided. Factors influencing adherence can be categorized into four groups: (1) environment-related, (2) patient-related, (3) medication-related, and (4) illness-related. This paper will review the factors associated with adherence and discuss solutions to optimize engagement, adherence to medication, and treatment in order to prevent relapse. Factors like social and family support, therapeutic alliance, attitudes and beliefs toward illness and medication, insight, substance use disorders, medication efficacy, tolerability, and accessibility will be discussed. Solutions, such as early psychosis specialized services integrating psychosocial therapies and careful selection of appropriate antipsychotic medication, will be proposed.

Simulating the pattern of right-hemisphere-damaged patients for the processing of the alternative metaphorical meanings of words : Evidence in favor of a cognitive resources hypothesis

Lately, many studies have suggested that communication impairments in brain-damaged individuals might be explained--at least in part--in terms of cognitive resource allocation. Reproducing a clinical pattern in normal subjects by using a dual-task treatment might be a way of evaluating the role of cognitive resources in the right hemispheres contribution to verbal communication. This study suggests that the RHs presumed specific contribution to the processing of the alternative metaphorical meanings of words is, at least to some extent, the expression of the RHs complementary, and necessary, contribution to the pool of attentional resources needed for the most effortful processing.

Age-related changes in the processing of the metaphorical alternative meanings of words

Abstract The goal of this study was to contribute to a better understanding of the relative impacts of age and the occurrence of a right-hemisphere lesion on the processing of the non-literal alternative meanings of words. Eighty healthy individuals participated in this study. Participants were divided into two groups: the older group included participants between 50 and 65 years old whereas the younger group included participants between 20 and 30 years old. Participants performed a semantic pairing task involving metaphorical and non-metaphorical alternative meanings of words and a countdown task. There were two different task presentation conditions: (1) non-interfering context task in which participants completed the main task (word-triad task) without any interference, and (2) interfering-context task in which the word-triad task and the countdown task were executed simultaneously. The main results indicated an age-related change in the processing of the non-literal alternative meanings of words. The most interesting result was that the resource-limiting condition had an impact only on the young adult group.

Symptomatic and functional outcomes of substance use disorder persistence 2 years after admission to a first-episode psychosis program.

Substance use disorders (SUD) in first-episode psychosis (FEP) are highly prevalent and linked with poor outcomes. However, most longitudinal studies investigating their impacts in FEP have not reported proportions of patients who ceased SUD. Our aim was to examine the influence of SUD course on functional and symptomatic outcomes as well as service use in FEP. We performed a 2-year longitudinal study of 212 FEP patients, aged between 18 and 30 years, admitted to 2 early psychosis services in Montréal, Québec, Canada. We observed that cannabis was the first substance abused (42.9% at baseline), followed by alcohol (19.3%). The SUD rate decreased by approximately 30% during the first year. Patients with persistent SUD had worse functional outcomes (Quality of Life Scale, Social and Occupational Functioning Assessment Scale, employment), more symptoms (Positive and Negative Symptoms Scale) and heavier service use (emergency and hospitalization). SUD persistence was associated with illness severity, homelessness and cluster-B personality. Those living with their parents and financially supported by them were more likely to cease SUD. Our results indicate that SUD course was more significant than having SUD at admission; persistent SUD was associated with worse outcomes. SUD decreased during a general early psychosis intervention program (with no specialized SUD treatment). An integrated, specialized approach targeting FEP patients with predictive factors of SUD persistence during the first years of treatment might increase SUD cessation and possibly improve outcomes.

Engaging Immigrants in Early Psychosis Treatment: A Clinical Challenge.

OBJECTIVE The study compared engagement in treatment and medication adherence of immigrants and nonimmigrants in early intervention services for persons with first-episode psychosis. METHODS This two-year longitudinal prospective cohort study recruited patients with first-episode psychosis who were entering early intervention services in Montreal, Canada (N=223). Data on sociodemographic characteristics, symptoms, and social functioning were collected annually. RESULTS At two years, immigrants had more than three times the odds of attrition than nonimmigrants after the analysis controlled for potential confounding factors (first-generation immigrants: odds ratio [OR]=3.11, 95% confidence interval [CI]=1.01-9.57, p=.049); second-generation immigrants: OR=3.65, CI=1.07-12.50, p=.039). Medication adherence was similar among those who remained in the programs. CONCLUSIONS During the two years after entering a program for first-episode psychosis, immigrants were more likely than nonimmigrants to disengage from treatment. Further research is warranted to understand this phenomenon and to improve the ability of services to engage immigrants with first-episode psychosis.

Specific impact of stimulant, alcohol and cannabis use disorders on first-episode psychosis: 2-year functional and symptomatic outcomes

BACKGROUND Many studies have concluded that cannabis use disorder (CUD) negatively influences outcomes in first-episode psychosis (FEP). However, few have taken into account the impact of concurrent misuse of other substances. METHODS This 2-year, prospective, longitudinal study of FEP patients, aged between 18 and 30 years, admitted to early intervention programs in Montreal, Quebec, Canada, examined the specific influence of different substance use disorders (SUD) (alcohol, cannabis, cocaine, amphetamines) on service utilization, symptomatic and functional outcomes in FEP. RESULTS Drugs and alcohol were associated with lower functioning, but drugs had a greater negative impact on most measures at 2-year follow-up. Half of CUD patients and more than 65% of cocaine or amphetamine abusers presented polysubstance use disorder (poly-SUD). The only group that deteriorated from years 1 to 2 (symptoms and functioning) were patients with persistent CUD alone. Outcome was worse in CUD than in the no-SUD group at 2 years. Cocaine, amphetamines and poly-SUD were associated with worse symptomatic and functional outcomes from the 1st year of treatment, persisting over time with higher service utilization (hospitalization). CONCLUSION The negative impact attributed to CUD in previous studies could be partly attributed to methodological flaws, like including polysubstance abusers among cannabis misusers. However, our investigation confirmed the negative effect of CUD on outcome. Attention should be paid to persistent cannabis misusers, since their condition seems to worsen over time, and to cocaine and amphetamine misusers, in view of their poorer outcome early during follow-up and high service utilization.

Le craving comme symptôme central de la toxicomanie : de ses fondements neurobiologiques à sa pertinence clinique

OBJECTIVE Observed by physicians and often reported by patients, craving is a core symptom of addiction, although not well defined nor understood completely. In the last several years, functional imaging as well as the measurement of different biological substrates of addiction have greatly evolved, allowing for a better understanding of the underlying neurobiological pathways of craving. Furthermore, with the development of the DSM-V and its inclusion as a diagnostic criterion for substance use disorders, craving has gained a whole new level of interest. Hence, the general objective of this article is to examine findings of studies that have led to a better understanding of craving and its implications. First, we address the definition of craving and its epidemiology in individuals with substance use disorders. We then summarize the results of the research conducted on the neurobiological substrates of craving. Finally, we present the role of craving in the cycle of addiction and its potential as a therapeutic target for pharmacological and non-pharmacological interventions. METHODS Narrative review of the literature. RESULTS The definition of craving has greatly evolved throughout the years, and it is commonly described as an abnormal desire or need to take a drug. While its conscious aspect is well known, whereas it is expressed subjectively, it is growingly also defined as an unconscious phenomenon illustrated by a physiologic activation that is not perfectly correlated with subjective measures. Available data on craving have also demonstrated the presence of this symptom in all three phases of the addiction cycle, including early and prolonged abstinence, long after the acute physical withdrawal syndrome. Three factors have been identified as potent craving inducers: the drug itself, drug related cues and stress. PET scan studies and fMRI studies confirmed the implication of dopaminergic pathways in craving, and have more recently shed light on the contribution of other neurotransmission systems, such as GABA, norepinephrine as well as the endocannabinoid and opioid systems, but their roles are not yet fully understood. Furthermore, craving-related activations of specific areas of the brain involved in learned habits and behavior as well as memory have been demonstrated by various studies; in contrast, regions associated with regulation and control of emotion have been demonstrated to be hypoactive during craving episodes. Finally, several studies have demonstrated that craving is a valid predictive indicator of relapse, making it an interesting target for pharmacological and non-pharmacological treatment. Several anti-craving medications have been shown to decrease craving, including varenicline for tobacco and naltrexone for alcohol dependence. Studies examining the efficacy of other anti-craving medications for other substances are growing in numbers. CONCLUSIONS Available data on craving support its role as a core symptom of addiction and allow for a better understanding of the underlying neurobiological substrates. Studies tend to show that it is a valid indicator of relapse during early and prolonged abstinence. Further research is needed to truly understand the complexity of the neurobiological substrates involved in craving as well as to develop new anti-craving interventions to facilitate long-term abstinence in individuals with substance use disorders.