Substance use in individuals at clinical high risk of psychosis.

BACKGROUND: A series of research reports has indicated that the use of substances such as cannabis, alcohol and tobacco are higher in youth at clinical high risk (CHR) of developing psychosis than in controls. Little is known about the longitudinal trajectory of substance use, and findings on the relationship between substance use and later transition to psychosis in CHR individuals are mixed. METHOD: At baseline and 6- and 12-month follow-ups, 735 CHR and 278 control participants completed the Alcohol and Drug Use Scale and a cannabis use questionnaire. The longitudinal trajectory of substance use was evaluated with linear mixed models. RESULTS: CHR participants endorsed significantly higher cannabis and tobacco use severity, and lower alcohol use severity, at baseline and over a 1-year period compared with controls. CHR youth had higher lifetime prevalence and frequency of cannabis, and were significantly younger upon first use, and were more likely to use alone and during the day. Baseline substance use did not differentiate participants who later transitioned to psychosis (n = 90) from those who did not transition (n = 272). Controls had lower tobacco use than CHR participants with a prodromal progression clinical outcome and lower cannabis use than those with a psychotic clinical outcome at the 2-year assessment. CONCLUSIONS: In CHR individuals cannabis and tobacco use is higher than in controls and this pattern persists across 1 year. Evaluation of clinical outcome may provide additional information on the longitudinal impact of substance use that cannot be detected through evaluation of transition/non-transition to psychosis alone.

Informed Consent in Early Psychosis Research: National Institute of Mental Health workshop, November 15, 2000.

Recent research on the early detection and treatment of schizophrenia has generated significant scientific interest along with considerable controversy and debate. Because our ability to alleviate fully the symptoms and deficits of established schizophrenia is limited, the prospect of interrupting disease progression early is compelling. At the same time, in the absence of an infallible marker of disease risk, there are serious questions about the safety, feasibility, and ethics of intervention research on "at-risk" or putatively prodromal individuals. A workshop, Informed Consent in Early Psychosis Research, was convened by the National Institute of Mental Health (NIMH) on November 15, 2000, to review the results of recent research on early detection and intervention in schizophrenia. Beginning with the assumptions that (1) treatment of asymptomatic individuals with antipsychotic medication is not appropriate in research or clinical care, and (2) neither data nor clinical consensus defines optimal intervention for symptomatic at-risk individuals, workshop participants-including clinical researchers, mental health consumers and family members, bioethicists, community health care providers, and NIMH staff-systematically reviewed available data on the potential risks and benefits of alternate approaches to the management of prodromal states. Ethical issues involved in early detection and intervention studies were discussed. Workshop participants summarized information presented during the meeting into informed consent "bullets" that must be communicated to, and understood and appreciated by, potential research participants.

Psychosocial skills training for schizophrenia: lessons from the laboratory.

A large body of research supports the efficacy of psychosocial treatments for schizophrenia, particularly learning-based therapies. The Schizophrenia Patient Outcomes Research Team recommended that cognitive-behavioral therapies be used in schizophrenia, and skills training was included in the practice guideline for treating patients with schizophrenia published by the American Psychiatric Association. This article provides an updated review of empirical studies of psychosocial skills training, showing its value in treating patients with schizophrenia as well as its broader clinical effectiveness. Data supporting the efficacy of psychosocial skills training continue to accumulate. Such programs should continue to be included in best practices guidelines and treatment recommendations for schizophrenia. Future clinical service research could be directed toward integration of skills training with other psychosocial treatment methods.

Determinants of medication compliance in schizophrenia: empirical and clinical findings.

Advances in psychopharmacology have produced medications with substantial efficacy in the treatment of positive and negative symptoms of schizophrenia and the prevention of relapse or symptom exacerbation after an acute episode. In the clinical setting, the individual patient's acceptance or rejection of prescribed pharmacological regimens is often the single greatest determinant of these treatments' effectiveness. For this reason, an understanding of factors that impede and promote patient collaboration with prescribed acute and maintenance treatment should inform both pharmacological and psychosocial treatment planning. We review the substantive literature on medication adherence in schizophrenia and describe a modified health belief model within which empirical findings can be understood. In addition to factors intrinsic to schizophrenia psychopathology, medication-related factors, available social support, substance abuse comorbidity, and the quality of the therapeutic alliance each affect adherence and offer potential points of intervention to improve the likelihood of collaboration. Because noncompliance as a clinical problem is multidetermined, an individualized approach to assessment and treatment, which is often best developed in the context of an ongoing physician-patient relationship, is optimal. The differential diagnosis of noncompliance should lead to interventions that target specific causal factors thought to be operative in the individual patient.

Client as colleague. Therapeutic contracting with the seriously mentally ill.

This article introduces the therapeutic contracting program as a comprehensive treatment system for persons with serious mental illness. Therapeutic contracting offers a promising framework for integrating medical, psychological, and social therapies in a manner that fosters clients' active involvement in treatment. This article outlines a multistage therapy program that mobilizes clients' adaptational resources through experimental interventions, structured goal-setting exercises, and skills-building experiences. Data illustrate the effectiveness of therapeutic contracting for (a) securing clients' treatment compliance, (b) promoting positive clinical outcomes, (c) reducing overall treatment costs. The therapeutic contracting model is discussed as a potential vehicle for expanding the professional role of psychologists in psychiatric settings, particularly in areas of clinical and administrative decision making.

Predicting hospital adjustment by adolescent inpatients.

Data about 145 adolescent inpatients were used to examine the relationship between past patterns of aggressive behavior and behavior during the initial period of psychiatric hospitalization. During their first month in the hospital, adolescents with a history of externally directed aggression were more likely to present management problems, compared with adolescents without this history. Adolescents with a history of internally directed aggression were more likely to be self-destructive. However, no association was found between adolescents' preadmission patterns of aggression and the likelihood that they would experience depressive symptoms in the hospital. Associations were found between adolescents' patterns of aggression and diagnoses. The authors suggest strategies to enhance treatment of adolescents with various patterns of aggression during the initial phase of hospitalization.

Grandparent deaths and severe maternal reaction in the etiology of adolescent psychopathology.

Relationships between the extent of psychopathology and the occurrence of 21 major life events during five developmental periods (prebirth, infancy, childhood, latency, and adolescence) were examined with multiple regression and X2 analyses for 114 hospitalized male and female adolescents. Psychopathology was assessed with the Global Assessment Scale (GAS) at admission to long-term residential treatment in a private psychiatric hospital. Data on deaths, physical illnesses, psychological disturbances, and socioenvironmental events experienced by patients before admission were gleaned from interviews and institutional records. Life events and GAS were scored independently. Only deaths and socioenvironmental events were significantly associated with psychopathology. Specifically, deaths of grandparents during infancy corresponded to lower functioning at admission. Additional analyses showed that severe reactions of patients' mothers to grandparent deaths had been more common among those adolescents who were most disturbed at the time they were admitted to the hospital. These findings were largely serendipitous, however, and need replication.

Narcissistic, antisocial, and noncomorbid subgroups of borderline disorder. Are they distinct entities by long-term clinical profile?

This study evaluates the influence of narcissistic and antisocial features on the long-term functioning of individuals with borderline personality disorder. Borderline patients discharged from Chestnut Lodge Hospital, an inpatient residential treatment facility, were followed up an average of 15 years later to assess longitudinal clinical profile. Despite differences in baseline psychopathology, members of Narcissistic, Antisocial, and Noncomorbid Borderline subgroups turned out to be roughly equivalent on almost all long-term course and outcome dimensions. The implications of these results for the nosology and treatment of personality disorders are discussed.

Psychosis, aggression, and self-destructive behavior in hospitalized adolescents.

The authors studied the history of aggressive and self-destructive behaviors in psychotic and nonpsychotic hospitalized adolescents (N = 137). A multidimensional measure of self- and other-directed aggression was retrospectively applied to each patient's social and developmental history. Nonsignificant gender and diagnostic differences were obtained on ratings of violence and suicide. Broader definitions of internal and external aggression yielded nonsignificant diagnostic differences, but gender differences were observed on both internal and external aggression measures. Females displayed greater internal aggression, and males reported higher external aggression scores. These results, compared to those of other investigators, suggest the importance of social and cultural variables in understanding adolescent psychosis and aggression.

A comparison of DSM-III and DSM-III-R schizophrenia.

The authors compared DSM-III and DSM-III-R definitions of schizophrenia among 532 inpatients treated in a long-term residential setting and reevaluated an average of 15 years later. Largely by excluding those with nonbizarre delusions (somatic, grandiose, or religious) without hallucinations, DSM-III-R reduced the number of patients diagnosed with schizophrenia by 10%. With the exception of the sign and symptom variables used to define them, the DSM-III schizophrenic patients included (N = 164) and excluded (N = 18) by DSM-III-R did not differ with respect to demographic, premorbid, or long-term outcome characteristics. The authors argue that frequent changes in diagnostic schemes in the absence of evidence of improved validity are likely to impede progress in research.

Predicting hospital discharge status for patients with schizophrenia, schizoaffective disorder, borderline personality disorder, and unipolar affective disorder.

The empiric literature reports few distinctive features among patients discharged against medical advice (AMA) or absent without leave and regularly discharged inpatients. Interactive relationships between predictors of discharge status and diagnosis have not been studied, however. This study used discriminant function analyses to test for predictors of discharge with medical advice, AMA, and by transfer for inpatients with schizophrenia (N = 132), schizoaffective disorder (N = 61), borderline personality disorder (N = 69), and unipolar affective disorder (N = 42) from a follow-up study. Results showed that indexes of chronic psychosis predicted transfer for all diagnoses. Angry, impulsive behavior and unstable relationships predicted AMA discharge in all but the unipolar patients. For the latter, being married was most powerfully associated with AMA status.

Hospital discharge status and long-term outcome for patients with schizophrenia, schizoaffective disorder, borderline personality disorder, and unipolar affective disorder.

The prognosis of self-discharged inpatients has seldom been studied, especially by diagnosis, and is frequently assumed to be poor. This study evaluated the long-term (15-year average) outcome of inpatients discharged with medical advice (WMA), against medical advice (AMA), or by transfer for patients with schizophrenia (N = 113), schizoaffective disorder (N = 46), borderline personality disorder (N = 63), and unipolar affective disorder (N = 33) from a follow-up study. Results showed that outcome among discharge cohorts varied considerably depending on diagnostic category. Within each diagnostic cohort, outcome of transferred patients was poorest. The outcome of AMA-discharged patients was poorer than the outcome of patients discharged with medical advice only in the unipolar cohort, except that AMA discharge in schizoaffective patients correlated significantly with suicide.