Is it now time to prepare psychiatry for a psychedelic future?

Australia has just rescheduled two drugs controlled under the United Nations Psychotropic Drug Conventions, psilocybin and MDMA, as treatments for treatment-resistant depression and post-traumatic stress disorder respectively. This feature explores the reasons for these developments, the opportunities and challenges they provide to psychiatry communities and how along with health systems these communities might respond to these developments.

Substance misuse in later life: challenges for primary care: a review of policy and evidence.

BACKGROUND: Substance misuse in older people represents a growing clinical and public health problem within primary care. AIM: The aim of article is to explore policy and research evidence for informing best practice in the assessment, treatment effectiveness, treatment implementation and approaches to recovery for older people with substance misuse in primary care. METHODS: Relevant search terms were used to examine the databases MEDLINE, EMBASE, CINAHL and PsychINFO up to January 2016. RESULTS: An age-sensitive approach is required to overcome barriers to assessment. Training is essential for developing relevant knowledge, skills and attitudes. Clinical audit be used to develop care pathways, particularly for older people with dual diagnosis. There is also a need to develop closer links between primary care and the secondary care specialties, as well as added value in working with carers and voluntary agencies. DISCUSSION: Further research is needed to inform more effective approaches to treatment. Adequate funding for workforce development and quality improvement in service development are also essential to improve health outcomes and quality of life in older people with substance misuse.

Alcohol and age.

Alcohol consumption constitutes a substantial burden of disease. Older people are being admitted to hospital for alcohol problems in increasing numbers. A recent systematic review reports cautious supportive evidence for primary prevention interventions in reducing excessive alcohol consumption in older drinkers, but does not focus on treatment of dependent drinkers. The evidence base for treatment interventions for dependent drinkers is comparatively limited, but it is growing. In addition to brief interventions, specialist outpatient treatment and inpatient treatment have been evaluated.The responses of older people to treatment are promising: they want to abstain, they have the capacity to change, they respond well to brief advice and motivational enhancement therapy, they achieve improvements at least as comparable to younger counterparts-and sometimes better-and they do have the prospect of long-term recovery.There is a need to develop services tailored to the needs of older substance misusers. Education of the workforce, including medical students and other health care professionals, is the key. Collaboration and coordination of services, training, research and policy are essential.There are very few designated services for older substance misusers in the UK and only 7% of older people who need treatment for alcohol problems access them. There is a massive gap in the whole gamut of research from basic to clinical research in this vulnerable patient population: this has to be developed if management is to be effective and up to date.

Substance Misuse Education for Physicians: Why Older People are Important.

This perspective article focuses on the need for training and education for undergraduate medical students on substance-related disorders, and describes initiatives undertaken in the United Kingdom (UK), Netherlands, United States (US), and Norway to develop the skills, knowledge, and attitudes needed by future doctors to treat patients adequately. In addition, we stress that in postgraduate training, further steps should be taken to develop Addiction Medicine as a specialized and transverse medical domain. Alcohol use disorder is a growing public health problem in the geriatric population, and one that is likely to continue to increase as the baby boomer generation ages. Prescription drug misuse is a major concern, and nicotine misuse remains problematic in a substantial minority. Thus, Addiction Medicine training should address the problems for this specific population. In recent years, several countries have started an Addiction Medicine specialty. Although addiction psychiatry has been a subspecialty in the UK and US for more than 20 years, in most countries it has been a more recent development. Additional courses on addiction should be integrated into the curriculum at both undergraduate and postgraduate levels, as well as form part of the continuous training of other medical specialists. It is recommended that further research and mapping of what is currently taught in medical programs be undertaken, so as to enhance medical education in addiction and improve treatment services.

Empowerment through education and science: three intersecting strands in the career of Griffith Edwards.

This paper describes three important strands in the career of Griffith Edwards that define him as a leader and an innovator. Believing that education and science were critical for the development of addiction as a profession and as a field of inquiry, his approach was multi-faceted: educating all doctors to appreciate the fundamental issues in addiction; training psychiatrists in the complexity of 'dual diagnosis' and specific specialist intervention; and teaching that addiction could be a chronic condition which required care management over the life course. These three inter-related areas are directly related to the need for a range of practitioners to have an understanding of addiction so that patients can be properly managed. The greater our understanding of the nature of addiction behaviour, the more likely the potential to optimize treatment and train practitioners from different professional disciplines.

Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study.

OBJECTIVE: To test the hypothesis that people taking anxiolytic and hypnotic drugs are at increased risk of premature mortality, using primary care prescription records and after adjusting for a wide range of potential confounders. DESIGN: Retrospective cohort study. SETTING: 273 UK primary care practices contributing data to the General Practice Research Database. PARTICIPANTS: 34,727 patients aged 16 years and older first prescribed anxiolytic or hypnotic drugs, or both, between 1998 and 2001, and 69,418 patients with no prescriptions for such drugs (controls) matched by age, sex, and practice. Patients were followed-up for a mean of 7.6 years (range 0.1-13.4 years). MAIN OUTCOME: All cause mortality ascertained from practice records. RESULTS: Physical and psychiatric comorbidities and prescribing of non-study drugs were significantly more prevalent among those prescribed study drugs than among controls. The age adjusted hazard ratio for mortality during the whole follow-up period for use of any study drug in the first year after recruitment was 3.46 (95% confidence interval 3.34 to 3.59) and 3.32 (3.19 to 3.45) after adjusting for other potential confounders. Dose-response associations were found for all three classes of study drugs (benzodiazepines, Z drugs (zaleplon, zolpidem, and zopiclone), and other drugs). After excluding deaths in the first year, there were approximately four excess deaths linked to drug use per 100 people followed for an average of 7.6 years after their first prescription. CONCLUSIONS: In this large cohort of patients attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.

Psychopharmacological treatment of young people with substance dependence: a survey of prescribing practices in England.

BACKROUND: Prescribing for substance-dependent youth requires expert knowledge of developmental and contextual issues and use of largely unlicensed medicines. This first national survey aimed to determine the nature of pharmacological treatments delivered in England including the extent of maintenance therapy, supervised consumption and specialties prescribing. METHOD: Data were gathered regarding opiate substitutes & other medications prescribed for opiate, alcohol & benzodiazepine dependence, drug & alcohol relapse prevention and comorbidities. Evidence of distinct approaches to younger compared with older adolescents was sought. RESULTS: The overall response rate was 73%. The majority treated were over 16 years. 85% treatments were opiate substitute therapies; many received longer term maintenance therapy. Prescribing for alcohol dependence & comorbidity was low; the largest prescribing group were General Practitioners. CONCLUSIONS: Questions remain about the scale of youth dependence, the use of substitute agents in maintenance treatment and the number of adolescent addiction specialists in the treatment cadre.

Substance misuse in the older person: setting higher standards.

The number of older substance misusers requiring treatment is likely to double over the next couple of decades. However, there are many misconceptions and myths about this often hidden population. Older people misuse alcohol, nicotine, prescription medication and illicit drugs. All indications are that this is increasing. This may be as a cause and/or the result of physical or mental illness, and the consequent morbidity and mortality are costly to the patient, their families and society. Patients present to a very wide variety of social and medical care settings, so screening and assessment for substance use are of paramount importance. This provides the opportunity to determine to what extent the substance problem is related to the presentation, which may be subtle and atypical in older people. Since evidence is accumulating of the benefit of treatment for substance problems in the older population, this group should not be marginalised and neglected by practitioners, researchers, educators and policy makers.

Incidence of psychoses among drug dependentpatients in primary care with no psychiatrichistory: A retrospective observationalmatched-cohort study

Background and Objectives: While several studies have indicated a link betweenillicit drug use and the development of psychosis, the confounding role of pre-existingpsychiatric illness is unclear. This study controls for this factor to a greater extentthan has hitherto been possible, using a retrospective observational matched-cohort designcontrolling for age, gender, socioeconomic status and prior psychiatric illness.Methods: 592 cases (diagnosed with drug misuse/dependence) and 592 controls (norecorded history of drug misuse/dependence) were drawn from all patients aged 16-44 in183 practices within the General Practice Research Database (UK). On study entry, casesand controls had never had a psychiatric diagnosis since registering with their practice.The average look-back period was 17.7 years. The main outcome measure was diagnosisof psychosis (including schizophrenia) from study entry onwards.Results: Patients with a drug misuse/dependence diagnosis are significantly more likelyto be diagnosed with psychosis than those with no drug misuse/dependence history (RR =2.10, 95% C.I. = 1.23-3.59) with the relative risk increasing as the definition of psychosisgets narrower (AU)

Engaging young people who misuse substances in treatment.

PURPOSE OF REVIEW: The focus of this review is to examine service utilization, treatment effectiveness, and future directions for adolescents who misuse substances. RECENT FINDINGS: Although the effectiveness of treatments has improved in the last two decades, young people's utilization of services has remained relatively stable. This is disconcerting because early intervention improves outcomes and deterioration is associated with physical, psychological, and social problems. The requirement for coordinated service provision across a wide range of treatment agencies cannot be emphasized enough, because young substance misusers come to services with a variety of symptoms and problems. It is encouraging that, to date, treatment studies indicate that adolescents in almost all types of treatment reduce their use of substances. The greatest reductions are shown for family therapy, followed by cognitive behavior therapy (CBT), motivational enhancement therapy (MET)/CBT, MET behavior therapy, and pharmacological treatment. Despite the developing treatment literature, important methodological limitations restrict comparability between studies. SUMMARY: The requirement for holistic, systematic assessments should include adolescents' social contexts, trauma, and psychiatric and physical illnesses because they are the cornerstones to understanding engagement and retention. Our review shows the importance of coordinating primary healthcare, mental health, and substance abuse treatment facilities, and highlights networking between other providers as integral to providing an optimal response to this unpredictable, often marginalized, group.

Alcohol use and alcohol-use disorders among older adults in India: a literature review.

OBJECTIVES: With changing attitudes to alcohol and an increasing life span in India, the prevalence of alcohol use and misuse in successive cohorts of older people is likely to increase. In this paper, we attempt to review the most recent evidence covering alcohol use and alcohol-use disorders in the Indian elderly. METHODS: PubMed, PsycINFO and Indmed databases were searched using relevant keywords. Papers meeting eligibility criteria were selected through a sequential process of screening title, abstract and full text. Data were extracted into Excel sheets. RESULTS: There was a dearth of pan-national studies. There were several methodological issues with many studies especially related to measurement. A substantial proportion of individuals above the age of 50 years are current consumers of alcohol and the prevalence is generally higher in urban compared to rural areas. Older women are generally likely to be alcohol abstainers. The general trend appears to be a reduction in current drinking among successive age cohorts over the age of 50. Alcohol consumption in the older adults is associated with educational status, health status, chronic morbidity, employment status, socioeconomic status, auditory/locomotor impairment and asthma. CONCLUSION: Alcohol use and misuse is a problem among the Indian older adults. With socio-demographic changes that will further increase longevity, this problem is likely to increase and policy-makers need to plan for it. Future research needs to improve validity and reliability in study methodology, as well as add to the current evidence base.

Cannabis psychosis: examining the evidence for a distinctive psychopathology in a systematic and narrative review.

BACKGROUND: The term "cannabis psychosis" has become ubiquitous in the psychiatric literature. Few authors have described the precise psychopathology of this potentially distinct subtype of psychosis. Specifically, little attention has been paid to exploring whether cannabis psychosis is characterized by a psychopathology which is different from that of other types of psychosis. OBJECTIVE: The purpose of this paper was to systematically review the literature for evidence of a specific constellation of symptoms which are consistently characteristic of cannabis psychosis within an inpatient psychiatric setting and to determine whether these combine to create a psychopathology which is distinct from that of other types of psychosis. METHOD: Systematic review using Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. RESULTS: 13 studies of the 439 identified met the inclusion criteria. Only eight studies had sufficient internal and external validity to allow comparison in a narrative format of the psychopathology present, compared with controls. Of these eight selected studies, seven reported at least one significant difference (p < .05) in the psychopathology of the cannabis group to the control group used as a comparator. DISCUSSION AND CONCLUSION: This study should be interpreted with great caution and conclusions should not be generalized. These findings do not suggest that "cannabis psychosis" does not exist, only that from a psychopathological perspective it may not be qualitatively any different from other forms of psychosis. Future research in this area needs to focus on clarifying the definition or description of "cannabis psychosis" and the use of standardized robust experimental and/or observational designs to eliminate heterogeneity that may lead to inconclusive results.

The epidemiology of addiction in Sub-Saharan Africa: a synthesis of reports, reviews, and original articles.

Use of alcohol and other psychoactive substances is associated with serious social and public health problems, but the extent of the problem in Sub-Saharan Africa is not well known. We set out to review epidemiological publications on alcohol and other psychoactive substances in Sub-Saharan Africa by performing a systematic search of electronic databases and paper records. Ten Sub-Saharan African countries are among the 22 in the world with the highest increase in per capita alcohol consumption. Cannabis, tobacco, and khat are widely used, and use of cocaine, stimulants, and heroin is increasing. More epidemiological research and implementation and evaluation of interventions is needed. Collaboration between African researchers and those in developed countries could help.

Triply troubled: criminal behaviour and mental health in a cohort of teenage pregnant substance misusers in treatment.

BACKGROUND: Teenage substance misuse and pregnancy are major public health problems in the UK, where the most recent figures on maternal deaths suggest that they have doubled among young substance misusers. In general, little is known about their pregnancy outcomes. AIMS: The aims of this study were to describe the characteristics of a sample of teenage pregnant drug users in the UK, to examine their psychosocial risk and complicating factors at presentation, to evaluate adherence to current national guidelines and to assess the adequacy of guidelines in relation to identified characteristics. METHODS: A six-year records survey of young people attending a specialist adolescent drug misuse service in the west midlands of the UK. RESULTS: Ten pregnant adolescents were identified from records. These girls have had unstable or abusive experiences through childhood, half having other substance misusers in the family. All were with substantially older partners, who were also substance misusers. All had required a mental health assessment and 90% had a history of self-harm. There were no maternal or neonatal deaths, and only one girl had a miscarriage, but in four cases, the child had to be fostered. CONCLUSIONS: To our knowledge, this is the first analysis of this kind in the UK. Available guidelines were followed, but our findings suggest that more detailed and comprehensive guidelines are required. Preventive measures through education are likely to be hampered by the early age at which these girls cease attending school.

Assessing the impact of cannabis use on trends in diagnosed schizophrenia in the United Kingdom from 1996 to 2005.

A recent systematic review concluded that cannabis use increases risk of psychotic outcomes independently of confounding and transient intoxication effects. Furthermore, a model of the association between cannabis use and schizophrenia indicated that the incidence and prevalence of schizophrenia would increase from 1990 onwards. The model is based on three factors: a) increased relative risk of psychotic outcomes for frequent cannabis users compared to those who have never used cannabis between 1.8 and 3.1, b) a substantial rise in UK cannabis use from the mid-1970s and c) elevated risk of 20 years from first use of cannabis. This paper investigates whether this has occurred in the UK by examining trends in the annual prevalence and incidence of schizophrenia and psychoses, as measured by diagnosed cases from 1996 to 2005. Retrospective analysis of the General Practice Research Database (GPRD) was conducted for 183 practices in England, Wales, Scotland and Northern Ireland. The study cohort comprised almost 600,000 patients each year, representing approximately 2.3% of the UK population aged 16 to 44. Between 1996 and 2005 the incidence and prevalence of schizophrenia and psychoses were either stable or declining. Explanations other than a genuine stability or decline were considered, but appeared less plausible. In conclusion, this study did not find any evidence of increasing schizophrenia or psychoses in the general population from 1996 to 2005.