Factors associated with readmission in South African adolescents discharged from two inpatient psychosocial rehabilitation units.

OBJECTIVE: This study aimed to describe the socio-demographic and clinical factors associated with readmission in an adolescent population discharged from two inpatient psychosocial rehabilitation (PSR) units in Cape Town, South Africa. METHOD: Data were obtained from 97 consecutive patients discharged from two adolescent psychiatric PSR units over a period of one year. Patients were followed up for readmission to hospitals offering specialised psychiatric care in the Western Cape Province over a period of 18 months. RESULTS: 35 patients (36%) were readmitted during the study period. Multivariable analysis showed that previous admission increased readmission rate (Incidence Rate Ratio (IRR): 8.01, p < 0.001). Adolescents who were still schooling (IRR: 0.29, p < 0.001) or had a higher level of education (IRR: 0.45, p = 0.001) were less likely to be readmitted. No association was seen with type of diagnosis and readmission, although 51 adolescents (53%) were diagnosed on the schizophrenia spectrum of disorders. CONCLUSION: Study findings highlight the need for increased collaboration between the Departments of Health and Education. Furthermore, the study illustrates the need for specific post-discharge community follow-up for adolescents. Prospective research in this particular population group is needed to contribute to the literature on factors associated with readmission in South African adolescent patients.

Ketamine users have high rates of psychosis and/or depression.

Ketamine has been linked to psychosis and used in the treatment of depression. However, no study has examined the prevalence of psychotic and depressive disorders in dependent ketamine users. This study aimed to examine the frequency of various psychopathologies among a series of patients seeking treatment for ketamine use in Hong Kong, China. The case records of 129 patients with a history of ketamine use receiving treatment at three substance use clinics between January 2008 and August 2012 were retrieved for data collection. Patients' demographic data, patterns of substance misuse, and comorbid psychiatric diagnoses were recorded and entered into analyses. The mean age of onset and length of ketamine use were 17.7 ± 4.4 and 8.7 ± 5.7 years, respectively. All patients were dependent on ketamine at the time of data collection. Multiple substance misuse was common. Eighty-four of the 129 (65.1%) patients were found to have comorbid psychiatric disorders, most commonly substance-induced psychotic disorder (31.8%) followed by depressive disorder (27.9%). Psychosis and/or depression were common in ketamine-dependent patients referred to a psychiatric substance use clinic. The findings provide evidence of an association between chronic ketamine use and the presence of psychosis and/or depression. The results raise the issue of safety when using ketamine in the long-term treatment of depression.

Clinical features of methamphetamine-induced paranoia and preliminary genetic association with DBH-1021C→T in a Thai treatment cohort.

AIMS: To explore the clinical features of methamphetamine-induced paranoia (MIP) and associations between MIP and a genetic polymorphism in dopamine ß-hydroxylase (DBH-1021C→T). DESIGN: Retrospective analysis of clinical presentation and genetic association by χ(2) test and logistic regression analysis. SETTING: A Thai substance abuse treatment center. PARTICIPANTS: A total of 727 methamphetamine-dependent (MD) individuals. MEASUREMENTS: Clinical: Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA) and the Methamphetamine Experience Questionnaire (MEQ). Genetic: DBH-1021C→T. FINDINGS: Forty per cent of individuals (289 of 727; 39.8%) with MD had MIP. Within-binge latency to MIP onset occurred more rapidly in the most recent compared with initial MIP episode (P = 0.02), despite unchanging intake (P = 0.89). Individuals with MIP were significantly less likely to carry lower (TT/CT) compared with higher (CC) activity genotypes (34.3 versus 43.3%; χ(2) 1 = 5, P = 0.03). DBH effects were confirmed [odds ratio (OR) = 0.7, P = 0.04] after controlling for associated clinical variables (MD severity, OR = 3.4, P < 0.001; antisocial personality disorder, OR = 2.2, P < 0.001; alcohol dependence, OR = 1.4, P = 0.05; and nicotine dependence, OR = 1.4, P = 0.06). TT/CT carriers were more likely to initiate cigarette smoking (OR = 3.9, P = 0.003) and probably less likely to be dependent on alcohol (OR = 0.6, P = 0.05). CONCLUSIONS: Among methamphetamine-dependent individuals, paranoia appears to occur increasingly rapidly in the course of a session of methamphetamine use. Severity of methamphetamine dependence and antisocial personality disorder predicts methamphetamine-induced paranoia. The genetic polymorphism in dopamine ß-hydroxylase is associated with methamphetamine-induced paranoia and influences smoking initiation.

A case of methamphetamine use disorder treated with the antibiotic drug minocycline.

Methamphetamine (METH) use is one of the major public health concerns worldwide. Long-term use of METH induces not only dependence but also psychosis which is associated with METH-induced brain damage, including neuroinflammation produced by activated microglia. We report the case of a female patient whose psychotic symptoms in METH use disorder were successfully improved by anti-inflammatory drug minocycline therapy. Although the precise mechanism(s) underlying the efficacy of minocycline in METH use disorder are currently unclear, minocycline appears to be a good candidate for future investigation clinical trials for medication development in METH using populations.

Raves, psychosis, and spirit healing.

This paper reflects the intersection of three cultures: the rave (all night dance party and use of the drug, Ecstasy) culture; the ward culture of an inpatient psychiatric program for First Episode Psychosis; the spirit healing culture of the Philippines. All three intersected in Toronto, Canada in the mid 1990s, as illustrated by the clinical case of a 19-year-old university student who was hospitalized with symptoms of drug-induced psychosis. Her initial treatment was not successful and presented dilemmas for the treating staff. Transfer to a second psychiatric facility that permitted attendance at a traditional Filipino healing ceremony resulted in a cure, with no recurrence 10 years later. According to James Dow's 1986 formulation, the components of the key spiritual healing session paralleled the very elements the young woman had sought by participating in raves, an activity that was problematic because it led to family displeasure. Whereas attendance at a rave triggered illness, the healing session, sanctioned by her family and taking place in their midst, resulted in healing.

Illicit substance use and its correlates in first episode psychosis.

OBJECTIVE: To determine if substance use (particularly cannabis) is more frequent among first episode psychosis patients and associated with a more problematic clinical presentation. METHOD: All first episode psychosis (FEP) patients presenting to secondary services were recruited from London and Nottingham, over 2 years, in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study broad framework. Clinical and sociodemographic variables were assessed using a set of standardized instruments. A schedule was created to retrospectively collate substance use data from patients, relatives and clinicians. RESULTS: Five hundred and eleven FEP were identified. They used three to five times more substances than general population. Substance use was associated with poorer social adjustment and a more acute mode of onset. Cannabis use did not affect social adjustment, but was associated with a more acute mode of onset. CONCLUSION: Cannabis has a different impact on FEP than other substances. Large epidemiological studies are needed to disentangle cannabis effect.

Occurrence of comorbid substance use disorders among acute psychiatric inpatients at Stikland Hospital in the Western Cape, South Africa.

OBJECTIVE: Little is known about the epidemiology of substance use disorders (SUD) among psychiatric inpatients in the Western Cape, South Africa. Therefore, this study was conducted to examine the prevalence of SUD among acute adult psychiatric inpatients at Stikland Hospital, one of three state acute psychiatric hospitals in the Western Cape. METHOD: A prospective descriptive prevalence survey was undertaken over a three-month period. During this period, data was collected on psychiatric patients (N=298) who were hospitalized in the acute psychiatric wards at Stikland. This included patient demography, psychiatric and substance use history. Urine was also collected and analyzed for substances commonly abused in the Western Cape. RESULTS: A co-morbid SUD (abuse or dependence) was diagnosed in 51% of patients. In addition, a diagnosis of a substance-induced psychiatric disorder was made in 8% of these patients, 1% of who was diagnosed with a substance-induced mood disorder, while 7% was diagnosed with a substance induced psychotic disorder. Patients diagnosed with a co-morbid SUD were younger than those without a SUD and more likely to have been involuntary admissions. These patients also displayed more violence prior to admission that contributed to their admission and were more likely to have used cannabis or methamphetamine as their preferred drug of abuse. Only a small group of patients had documented evidence of any prior interventions for their SUD. CONCLUSION: SUD are prevalent among psychiatric inpatients and contribute to their morbidity. This has implications for staff training and service development.

Familial predisposition for psychiatric disorder: comparison of subjects treated for cannabis-induced psychosis and schizophrenia.

CONTEXT: Cannabis-induced psychosis is considered a distinct clinical entity in the existing psychiatric diagnostic systems. However, the validity of the diagnosis is uncertain. OBJECTIVES: To establish rate ratios of developing cannabis-induced psychosis associated with predisposition to psychosis and other psychiatric disorders in a first-degree relative and to compare them with the corresponding rate ratios for developing schizophrenia spectrum disorders. DESIGN: A population-based cohort was retrieved from the Danish Psychiatric Central Register and linked with the Danish Civil Registration System. History of treatment of psychiatric disorder in family members was used as an indicator of predisposition to psychiatric disorder. Rate ratios of cannabis-induced psychosis and schizophrenia associated with predisposition to psychiatric disorders were compared using competing risk analyses. SETTING: Nationwide population-based sample of all individuals born in Denmark between January 1,1955, and July 1, 1990 (N = 2,276,309). Patients During the 21.9 million person-years of follow-up between 1994 and 2005, 609 individuals received treatment of a cannabis-induced psychosis and 6476 received treatment of a schizophrenia spectrum disorder. RESULTS: In general, the rate ratios of developing cannabis-induced psychosis and schizophrenia spectrum disorder associated with predisposition to schizophrenia spectrum disorder, other psychoses, and other psychiatric disorders in first-degree relatives were of similar magnitude. However, children with a mother with schizophrenia were at a 5-fold increased risk of developing schizophrenia and a 2.5-fold increased risk of developing cannabis-induced psychosis. The risk of a schizophrenia spectrum disorder following a cannabis-induced psychosis and the timing of onset were unrelated to familial predisposition. CONCLUSIONS: Predisposition to both psychiatric disorders in general and psychotic disorders specifically contributes equally to the risk of later treatment because of schizophrenia and cannabis-induced psychoses. Cannabis-induced psychosis could be an early sign of schizophrenia rather than a distinct clinical entity.

Profiles associated with treatment retention in Japanese patients with methamphetamine use disorder: preliminary survey.

AIMS: To identify profiles associated with treatment retention in Japanese patients with methamphetamine use disorder. METHODS: The study used a retrospective design based on clinical records. The subjects were 101 patients at the Kanagawa Psychiatric Center, Serigaya Hospital, who were diagnosed as having methamphetamine use disorder. They were divided in two groups, namely those who remained in treatment 3 months after the initial assessment, and those who did not. The primary analysis compared patient profiles between the two groups to detect discriminating variables, which were then submitted for secondary analysis using logistic regression to determine the most relevant predictor of retention. RESULTS: Primary analysis indicated that older age, having psychotic symptoms, receiving public assistance, and history of incarceration were associated with treatment retention after 3 months. Secondary analysis showed that positive history of incarceration was the most significant predictor of the outcome. CONCLUSIONS: History of incarceration had the most significant treatment-retention effect on Japanese patients with methamphetamine use disorder. The development and introduction of integrated programs that link methamphetamine-dependent offenders to drug treatment is recommended in outpatient treatment for Japanese patients with methamphetamine user disorder.

Dextromethorphan psychosis, dependence and physical withdrawal.

As part of a synthesis of evidence regarding the abuse and addiction liability of dextromethorphan (DM), an over-the-counter cough medicine available in over 140 preparations, an uncommonly published case of dextromethorphan dependence (addiction) is described, with specific, rarely published complications. The individual was interviewed and several medical databases were also reviewed (Medline, 1966-present; PubMed) for all content relating to the Keywords: dextromethorphan, abuse, dependence, cough medicine, addiction, withdrawal, psychosis. The patient evidenced history suggesting substance dependence, substance-induced psychosis and substance withdrawal in relation to DM. A literature review revealed that DM has specific serotonergic and sigma-1 opioidergic properties. Dextrorphan (DOR), the active metabolite of DM, has similar properties; however, DOR is a weaker sigma opioid receptor agonist, and a stronger NMDA receptor antagonist. DM and DOR display specific biological features of addiction, and are capable of inducing specific psychiatric sequelae. A specific, reproducible toxidrome with significant psychiatric effects occurred, when DM was abused at greater than indicated doses, with more profound and potentially life-threatening effects at even higher doses. DM withdrawal appears evident. DM's active metabolite, DOR, has pharmacodynamic properties and intoxication effects similar to dissociatives, and may be more responsible for the dissociative effect that this DM abuser sought. However, it is this same metabolite that may be fraught with the potentially life-threatening psychoses and dissociative-induced accidents, as well as addiction. While DM has been hypothesized as the most commonly abused dissociative, health-care providers seem largely unaware of its toxidrome and addiction liability.

Injecting and non-injecting cocaine use in Sydney, Australia: physical and psychological morbidity.

This study aimed to examine the physical and psychological harms of cocaine use and investigate the role of injecting versus non-injecting routes of administration in the severity of such harms. Two hundred and twelve cocaine users from inner-city and south-western Sydney were administered a structured interview containing sections on demographics, drug treatment history, drug use history, cocaine use patterns, cocaine dependence and physical and psychological problems associated with cocaine use. Serious physical and psychological symptoms were prevalent among both injecting and non-injecting cocaine users. The prevalence and extent of symptoms was greater among injecting cocaine users, however route of administration did not prove to be a significant independent predictor of harm when other factors, such as frequency of use and level of dependence, were taken into account. While the level of physical and psychological harm was greater among cocaine injectors, it would appear that factors engendered by injecting, such as more frequent use and higher levels of dependence, result in higher levels of harm, rather than the route of administration per se. Physical and psychological problems were also reported among infrequent users, suggesting that cocaine can cause harm irrespective of frequency or method of use. Harm reduction initiatives should be targeted towards all cocaine users, not just those who seek treatment for dependence or present with acute medical complications.

Psychotic symptoms in methamphetamine psychotic in-patients.

The present study was aimed at exploring the prevalence and factor structure of methamphetamine (MA) psychotic symptoms. The data were obtained from a cross-country evaluation of substance use, health, and treatment in MA psychotic in-patients. The prevalence rates of lifetime and current psychotic symptoms were determined by using Mini-International Neurospychiatric Interview-Plus, Module M. The Manchester scale was used to assess the severity of psychotic symptoms during the week prior to assessment. All eight items of the Manchester scale were subjected to principal-component analysis, eigenvalue one test, and varimax rotation. The data of 168 patients (127 male and 41 female) included in the analyses were obtained from Australia, Japan, the Philippines and Thailand. Persecutory delusion was the most common lifetime psychotic symptom found in 130 participants (77.4%), followed by auditory hallucinations, strange or unusual beliefs, and thought reading. Auditory hallucinations were the most common current symptom found in 75 participants (44.6%), followed by strange or unusual beliefs and visual hallucinations. Current negative symptoms were also found in 36 patients (21.4%). Apart from a factor of anxiety and depression, the results yielded a two-factor model of MA psychotic symptoms, which were negative and positive/disorganized syndromes. The negative syndrome comprised poverty of speech, psychomotor retardation, and flattened/incongruous affects. The positive syndrome consisted of delusions, hallucinations, and incoherent speech. Both positive/disorganized and negative syndromes should be taken into account in assessing MA psychotic symptoms. The clinical findings do not support the shortcomings of amphetamine-induced psychosis in modelling the negative symptoms of schizophrenia.

Ketamine associated psychedelic effects and dependence.

Ketamine, a dissociative anaesthetic in use since 1970, produces prominent psychoactive effects in humans. Its non-medical use has raised concerns in many countries, including Singapore. This paper narrates the psychedelic and psychotic effects of ketamine in two ketamine dependent patients who have presented to the psychiatric service. These effects were dose-related and comprised multimodal hallucinatory experiences, a sense of slowing, paranoid ideation and enhancement of sexual, musical and sensory enjoyment. In both ketamine users the psychotic symptoms resolved quickly with symptom-targeted treatment. However, breaking the ongoing addiction cycle seemed more difficult. The neuro-pharmacological mechanisms of these phenomena are largely due to its complex multi-receptors actions, notably through the excitatory amino acids through mainly the N-methy-D-aspartate (NMDA) receptors. The detection of ketamine abuse requires a high index of suspicion and needs to be considered when there is an acute presentation with multi-modal hallucinations and psychosis.

[Levodopa dependency in Parkinson's disease: case report and review]. / Levodopa-Abhängigkeit bei Parkinsonkrankheit Fallbericht und Literaturübersicht.

Only a few patients with Parkinson's disease and levodopa dependency or abuse have been reported. We present a 35-year-old patient with young-onset Parkinson's disease who developed motor complications, levodopa dependency, and drug-induced psychosis after primary treatment with levodopa. Diagnostic criteria and treatment guidelines for this neuropsychiatric disorder are presented as well as a tentative neurobiological answer to the question of why levodopa dependency is observed only in a minority of patients with Parkinson's disease.

[Psychotic disorders and drug abuse in adolescents]. / Psychotische Störungen und Drogenmissbrauch bei Jugendlichen.

OBJECTIVES: The relation between substance abuse and symptoms of psychosis as well as related disorders was evaluated among patients at the Hospital for Child and Adolescent Psychiatry and Psychotherapy of the University of Marburg. METHODS: Using a child and adolescent version of the IRAOS (Instrument of the Retrospective Assessment of the Onset of Schizophrenia, Häfner et al., 1990), all patients with a co-morbid substance abuse were assessed. Patients with a drug-induced psychosis (n = 8) were compared to psychotic patients with co-morbid substance abuse and to patients with other psychiatric disorders and substance abuse (n = 30). RESULTS: These three groups could be significantly distinguished on the basis of pre-morbid symptoms and pre-morbid functioning. CONCLUSIONS: The IRAOS shows some evidence that psychotic patients with co-morbid substance abuse can be distinguished from patients with a drug-induced psychosis according to the course of the initial psychopathology and pre-morbid functioning.

[Is there a temporal correlation between substance abuse and psychosis in adolescents?]. / Gibt es einen zeitlichen Zusammenhang von Substanzmissbrauch und Psychose bei Jugendlichen?

OBJECTIVES: The temporal relationship between substance abuse and symptoms of psychosis in adolescent patients was examined. METHODS: The hospital records of all adolescent inpatients admitted to the Central Institute of Mental Health in Mannheim during the period from 1976-1997 with a first-time diagnosis of psychosis were examined retrospectively for evidence of co-morbid substance abuse. RESULTS: In 18 of a total of 165 psychotic patients, co-morbid substance abuse was present, whose frequency rose after 1988, with a renewed increase since 1996. Two of the 18 adolescents began taking drugs only after the appearance of the first symptoms of psychosis, in 13 others the abuse was already well established, while for the final three patients the onset of psychotic symptoms and substance abuse was congruent, occurring within the same month. A close temporal correlation between symptoms of psychosis and substance abuse was established for amphetamines (including ecstasy), LSD and excessive abuse of cannabis. CONCLUSIONS: Substance abuse constitutes a risk factor for the development of psychoses without, however, necessarily being a direct trigger of psychosis.