Helena Vorma

Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases.

BACKGROUND Despite the clinical importance of substance-induced psychosis (SIP), few studies have examined the course of this condition after its acute manifestation. OBJECTIVE To investigate the rate of SIP conversion to a schizophrenia spectrum disorder and the length of follow-up needed to catch the majority of these patients whose diagnoses change. In addition to the conversion rate and pattern, we wanted to look for possible related factors. METHOD Using the nationwide Finnish Hospital Discharge Register, we followed all patients (N = 18,478) since their first inpatient hospital admission with a diagnosis of SIP (codes 2921 and 2928 in DSM-III-R and codes F10-F19 in ICD-10 with a third digit of 4, 5, or 7) between January 1987 and December 2003 in Finland. Patients (mean age = 43.7 years, standard deviation = 13.5 years) were followed until first occurrence of schizophrenia spectrum disorder, death, or the end of December 2003, whichever took place first. Conversions of discharge diagnoses into schizophrenia spectrum disorders (codes 2951-2959 and 2971 in DSM-III-R and codes F20, F22, and F23 in ICD-10) were recorded at follow-up. RESULTS Eight-year cumulative risk to receive a schizophrenia spectrum diagnosis was 46% (95% CI, 35%-57%) for persons with a diagnosis of cannabis-induced psychosis and 30% (95% CI, 14%-46%) for those with an amphetamine-induced psychosis. Although alcohol-induced psychosis was the most common type of SIP, 8-year cumulative risk for subsequent schizophrenia spectrum diagnosis was only 5.0% (95% CI, 4.6%-5.5%). No differences were detected with regard to gender, except for amphetamine-induced psychosis, which converted into a schizophrenia spectrum disorder significantly more often in men (P = .04). The majority of conversions to a schizophrenia spectrum diagnosis occurred during the first 3 years following the index treatment period, especially for cannabis-induced psychosis. CONCLUSION Substance-induced psychotic disorders predict schizophrenia spectrum disorders to a greater extent than previously thought. The intensity of clinical attention focused on substance-induced psychotic disorders should be increased.

Extended-release methylphenidate for treatment of amphetamine/methamphetamine dependence: a randomized, double-blind, placebo-controlled trial

AIMS To assess the efficacy of methylphenidate as a substitution therapy for amphetamine/methamphetamine dependence in Finland and New Zealand. DESIGN Parallel-group, double-blind, randomized placebo-controlled trial. SETTING Out-patient care. PARTICIPANTS Amphetamine-/methamphetamine-dependent, aged 16-65 years. MEASUREMENTS The primary outcome measure was presence/absence of amphetamine/methamphetamine in urine samples collected twice weekly. Secondary measures included treatment adherence, alterations in craving scores and self-reported use. Primary analysis was by intention-to-treat (ITT). The study drug, methylphenidate (as Concerta(®) ), was up-titrated over 2 weeks to a maximum dose of 54 mg daily and continued for a further 20 weeks. Doses were given under daily supervision at the clinics. FINDINGS Seventy-nine participants were randomized (40 methylphenidate; 39 placebo); 76 received allocated treatment and 27 completed the trial. ITT analysis (n = 78) showed no statistically significant difference in the percentage of positive urines between the methylphenidate and placebo arms (odds ratio: 0.95, 95% confidence interval: 0.83-1.08). However, there was a significant difference (P < 0.05) between the active and placebo arms in retention, the placebo arm displaying a significantly lower retention from 6 weeks that persisted until the end of the trial. CONCLUSIONS The trial failed to replicate earlier findings suggesting that methylphenidate was superior to placebo. The low retention rate confounded the ability to draw firm conclusions about efficacy. The higher retention rate was observed in the methylphenidate arm. Any replication of this work would need to consider alternatives to the rigid clinic attendance criteria, and consider an increased dose.

Long-term outcome after benzodiazepine withdrawal treatment in subjects with complicated dependence

BACKGROUND The study aimed to monitor subjects with benzodiazepine (BZ) dependence after withdrawal treatment in order to evaluate long-term outcome and predictors of remaining BZ-free. Subjects with high-dose dependence or co-occurring alcohol problems were not excluded. METHOD Seventy-six participants in an earlier, randomized, controlled trial of outpatient BZ discontinuation were interviewed, and documents from their treatment settings obtained, along with urine and serum samples for BZ use. Long-term outcomes for a cognitive-behavioral treatment group and a treatment-as-usual group were measured. RESULTS BZ discontinuation treatment outcomes were maintained in both treatment groups. No between-group differences were found. At the end of the study 25% of the subjects were BZ-free, and the median dose decrease from pre-treatment levels was 16.1 mg in diazepam equivalents. Subjects with pre-treatment doses exceeding 40 mg were able to maintain their doses at therapeutic levels through the follow-up. Pre-treatment low BZ dose, no previous withdrawal attempts, and high life satisfaction predicted success in staying BZ-free. CONCLUSIONS In subjects with complicated BZ dependence, the benefits of BZ discontinuation treatment may persist, but more studies are needed.

Predictors of Benzodiazepine Discontinuation in Subjects Manifesting Complicated Dependence

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age ±SD of subjects was 40.0±9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg /day (range 2.5–180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8–360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with “dropping out” of treatment. Alcohol use–related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.

Participation in opioid substitution treatment reduces the rate of criminal convictions: Evidence from a community study

OBJECTIVE Positive outcomes associated with opioid substitution treatment include reduced illicit opioid use and lower risk of HIV and other blood-borne infections. The effect on the reduction of criminal activity remains unclear. Our aim was to investigate the impact of treatment on criminal activity using conviction register data. METHOD This observational retrospective study included all new patients (N=169) enrolled in an opioid substitution treatment program in the Helsinki University Central Hospital Clinic for Addiction Psychiatry between 2000 and 2005. Psychiatric and psychosocial services were provided as part of the program. Patient treatments were followed up for 18 months. Data on criminal convictions were collected for approximately 3 years before and after the start of treatment. RESULTS Mean rates of convictions decreased significantly during treatment. The effects were similar for total convictions, drug convictions, and property crime convictions. Although the numbers of violence and drunk driving convictions were too small to be analysed separately, on a bivariate level there was no indication of reduction in these crime types. Patients with amphetamine co-dependence fared best. Sex, age, other co-dependences or psychiatric diagnoses, negative urine analyses during the treatment, and dropping out from treatment had little impact on the outcomes. CONCLUSIONS Opioid substitution treatment seems to reduce criminal activity effectively. However, more information is needed to determine how treatment influences different types of criminality and which types of patients benefit most.