Canadian Psychiatric Association
Brief Communication
Psychosocial Interventions in Reducing Cannabis Use in Early Phase Psychosis: A Canadian Survey of Treatments Offered
Association des psychiatres du Canada
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(6) 367-372 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716639931 TheCJP.ca | LaRCP.ca
Interventions psychosociales pour re´duire l’utilisation du cannabis en phase pre´coce de psychose : une enqueˆte canadienne sur les traitements offerts
Cristina Aydin, MD, FRCPC1, Philip G. Tibbo, MD, FRCPC2,3, and Zenovia Ursuliak, MD, PhD, FRCPC2,3
Abstract Objective: Cannabis use in people with early phase psychosis (EPP) can have a significant impact on long-term outcomes. The purpose of this investigation was to describe current cannabis use treatment practices in English-speaking early intervention services (EISs) in Canada and determine if their services are informed by available evidence. Method: Thirty-five Canadian English-speaking EISs for psychosis were approached to complete a survey through email, facsimile, or online in order to collect information regarding their current cannabis use treatment practices. Results: Data were acquired from 27 of the 35 (78%) programs approached. Only 12% of EISs offered formal services that targeted cannabis use, whereas the majority (63%) of EISs offered informal services for all substance use, not specifically cannabis. In programs with informal services, individual patient psychoeducation (86%) was slightly more common than individual motivational interviewing (MI) (76%) followed by group patient psychoeducation (52%) and information handouts (52%). Thirty-seven percent of EISs offered formal services for substance use, and compared to programs with informal services, more MI, cognitive-behavioural therapy, and family services were offered, with individual treatment modalities more common than groups. No EISs used contingency management, even though it has some preliminary evidence in chronic populations. Evidence-based service implementation barriers included appropriate training and administrative support. Conclusions: While most English-speaking Canadian EIS programs offer individual MI and psychoeducation, which is in line with the available literature, there is room for improvement in cannabis treatment services based on current evidence for both people with EPP and their families. Abre´ge´ Objectif : L’utilisation du cannabis chez les personnes en phase pre´coce de psychose (PPP) peut avoir un effet significatif sur les re´sultats a` long terme. Le but de cette recherche e´tait de de´crire les pratiques actuelles de traitement de l’utilisation du cannabis dans les services d’intervention pre´coce (SIP) anglophones du Canada et de de´terminer si leurs services sont e´claire´s par les donne´es probantes disponibles.
1 2 3
St. Paul’s Hospital, BC Women’s Hospital, Vancouver, British Columbia Dalhousie University, Halifax, Nova Scotia Nova Scotia Early Psychosis Program, Nova Scotia Health Authority, Halifax, Nova Scotia
Corresponding Author: Zenovia Ursuliak, MD, PhD, FRCPC, Nova Scotia Early Psychosis Program, 3rd Floor, Abbie J. Lane Building, 5909 Veteran’s Memorial Lane, Halifax, NS B0J 1T0, Canada. Email: [email protected]
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Me´thode : Trente-cinq SIP canadiens anglophones pour la psychose ont e´te´ approche´s pour remplir un sondage par courriel, te´le´copieur, ou en ligne afin de recueillir de l’information au sujet de leurs pratiques actuelles de traitement de l’utilisation du cannabis. Re´sultats : Les donne´es ont e´te´ obtenues de 27/35 (78 %) des programmes approche´s. Seulement 12 % des SIP offraient des services officiels qui ciblaient l’utilisation du cannabis, alors que la majorite´ (63 %) des SIP offrait des services informels pour toute utilisation de substances, pas spe´cifiquement du cannabis. Dans les programmes aux services informels, la psychoe´ducation individuelle des patients (86 %) e´tait le´ge`rement plus commune que l’entrevue motivationnelle (EM) individuelle (76 %), suivie de la psychoe´ducation de groupe (52 %) et des documents d’information (52 %). Trente-sept pour cent des SIP offraient des services officiels pour l’utilisation de substances, et comparativement aux programmes aux services informels, ils offraient plus de EM, de the´rapie cognitivo-comportementale (TCC), et de services familiaux, et plus de modes de traitement individuels qu’en groupe. Aucun SIP n’utilisait d’organisation des contingences, meˆme s’il y a des donne´es probantes pre´liminaires a` ce sujet dans les populations chroniques. Les obstacles a` la mise en œuvre de services fonde´s sur des donne´es probantes e´taient notamment la formation approprie´e et le soutien administratif. Conclusions : Meˆme si la plupart des programmes des SIP canadiens anglophones offrent l’EM et la psychoe´ducation individuelles, ce qui est conforme a` la litte´rature existante, il y a place a` l’ame´lioration des services de traitement du cannabis d’apre`s les donne´es probantes actuelles, tant pour les personnes souffrant de PPP que leurs familles. Keywords cannabis use, comorbidity, early phase psychosis, early intervention service, motivational Interviewing, psychosocial intervention, Canadian, survey
Clinical Implications Motivational interviewing (MI), for patients and families, shows promise for reducing cannabis use in people with early phase psychosis (EPP), and contingency management has preliminary support in people with chronic schizophrenia. MI, but not contingency management, is available for people with EPP in most English-speaking early intervention services (EISs) across Canada. Family members of people with EPP and cannabis use disorders have limited access to services in Englishspeaking EISs across Canada.
Limitations Very few RCTs evaluate psychosocial interventions to reduce cannabis use in people with EPP, and results are mixed. Our survey did not report on French-speaking EISs for psychosis in Canada. Within the early phase psychosis (EPP) population, cannabis is the most commonly used illicit substance, with 86% of EPP patients reporting lifetime experience with it.1,2 Ongoing cannabis use results in more negative outcomes compared to those EPP patients who do not use, and thus they do not maximally benefit from early intervention services (EISs).3 Cannabis use in EPP is associated with increases in aggression among males,4 higher risk of relapse5 and severity of symptoms,6 reductions in compliance to psychiatric medications,7 and global functioning deficits8 compared to EPP nonusers.
International guidelines for care in EPP recommend not excluding youth and young adults from EISs for psychosis care if they have a comorbid addictions diagnosis. 9,10 Given the detrimental effects of cannabis on outcomes in EPP, identifying and reducing cannabis use should be a key target for EISs for psychosis. Early intervention services are well positioned to affect negative long-term outcomes due to cannabis use, before use leads to more serious impairment.11 At present, there is limited research in effective psychosocial interventions to reduce cannabis use in the early psychosis population. Based on our literature review (see Supplemental Tables S1 and S2),12-33 motivational interviewing (MI) (individual and family) has preliminary support for reducing cannabis use in EPP, with the results for cognitive-behavioural therapy (CBT) being mixed. Psychoeducation, often part of standard care, may improve cannabis use in many people with EPP, making it difficult for an active intervention to demonstrate superiority. CBT and MI had some positive results in chronic populations when cannabis was grouped with other substances, especially when interventions were longer, but gains were not sustained over follow-up periods. Longer interventions for cannabis use in both early and chronic populations were found to be more efficacious in a recent meta-analysis.34 Contingency management has preliminary evidence in reducing cannabis use in people with severe mental illness35,36 but has not been studied in EPP. In this brief report, we describe the results of a national survey of English-speaking EISs for psychosis to assess current cannabis treatment practices available in the Canadian setting and suggest recommendations to address cannabis use in the EIS for psychosis setting.
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Figure 1. Treatment modalities in programs with formal addiction services. CBT, cognitive-behavioural therapy; MI, motivational interviewing.
Methods A cross-sectional survey was developed to collect information regarding current cannabis use treatment practices among Canadian English-speaking EISs for psychosis. The survey collected information on the specific treatment modalities (e.g., MI, CBT), formats (individual vs. group), service users (patients vs. families), and substances targeted. The survey also collected information on factors perceived to facilitate service delivery. Survey questions were dichotomous, contingency based, nominal, ordinal (Likert scale), and short answer. The survey questions were reviewed by the Capital District Health Authority research ethics board and were determined not to require ethics approval. Surveys were distributed to 35 English-speaking Canadian EISs for psychosis from major urban centres in each province across Canada. Response rates were maximized by 1) sending an introductory email to ask potential respondents to identify the most appropriate clinician for the survey, 2) using collaborators’ names and contact information on all communications to personalize survey implementation, and 3) following up with a telephone call and email if no response was received after 3 months. Based on the clinician’s preference, surveys were emailed, faxed, or administered with an online version of the survey via Dalhousie University Opinio (Opinio version 6.6.2; ObjectPlanet, Inc; Oslo, Norway).
Results Twenty-seven of 35 (78%) English-speaking EPP clinics across Canada responded to the survey with all provinces with EISs represented. Thirty-seven percent of EISs had
formal addiction services and 63% had informal services only, with 15% offering both. Cannabis was targeted specifically in 12% of EISs (those with formal services only). Formal treatment service was defined to be a specific intervention targeting substance use. Figure 1 illustrates frequencies of treatment modalities used in EISs with formal services, and Figure 2 depicts modality frequencies in programs with informal services. Individual rather than group therapies were offered more in programs with formal services, with MI, patient and family psychoeducation, and CBT being the most common. Addictions counselors delivered most of the formal addictions services (50%), followed by social workers (40%) and registered nurses (40%), occupational therapists (10%), psychologists (10%), and psychiatrists (10%). Seventy percent of programs with formal treatment services measured outcomes, including stages of change, problems associated with use, quality of life, and symptom scales. Eighty percent of programs with formal services used a screening method to determine treatment eligibility (e.g., clinician assessment, case discussion, or the Alcohol, Smoking, and Substance Involvement Screening Test tool37). Most of the programs, however, only offered informal services to address cannabis use. While the 4 most common therapies in programs with formal services were offered at rates of 80% to 100%, there was less consistency with informal programs. Individual psychoeducation was the most common (86%), followed by individual MI (76%), group psychoeducation (52%), and informal handouts (52%). Limitations of formal substance use treatment services generally fell under 3 areas: 1) client-related issues included challenges with engagement and stage of change, 2) staffrelated issues included low clinician numbers trained in both
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86%
76% 52%
52% 19%
24% 10%
5%
Figure 2. Treatment modalities in programs with informal addiction services. *Other ¼ timeline follow back assessment, multifamily group therapy, concurrent disorders consultation with staff/clients, family support group, recovery group not specific to addictions, and harm reduction.
substance use and EIS treatment modalities and philosophical differences between addictions and EIS staff (i.e., harm reduction vs. abstinence), and 3) systemic issues involved transportation difficulties for clients and staff, clinic hours, age restrictions, limited access to concurrent disorder services, and lack of crisis management services. For the majority of programs, the most important factor in the implementation of evidence-based services was training in substance use interventions, followed by having clinicians aware of current evidence-based treatments. Programs with formal services identified that strategies to engage patients were essential to establish their services, while programs without formal services thought administrative support was vital to establish formal services.
Discussion Informal individual psychoeducation was the most common intervention offered to reduce substance use in Canadian English-speaking EISs, despite preliminary literature that supports the use of MI, with only 12% of programs reporting formal interventions targeting cannabis. There may be regional/program-specific reasons for variations from the evidence-based therapies, including the perception of a lack of consistent or strong signal of effect from long-term studies. However, most EISs identified that training in substance use interventions was the most important factor for implementing services, as well as administrative support, indicating an acknowledgment of lack of training and support in this area rather than concerns of the literature. Of note, contingency management was not used by any respondents, despite some preliminary evidence supporting its use in a chronic population.32,35,36 Only a minority of EIS programs offered formal therapies specific to cannabis use, perhaps
reflecting the practicality of treating cannabis separate from other substances. The EPP population may also have low intrinsic motivation to change cannabis use because they perceive that cannabis is a nonharmful, ‘‘natural’’ substance. The Canadian Centre on Substance Abuse reports that Canadian youth considered marijuana to be much healthier and safer than tobacco and less addictive than stimulants and opiates.38 This suggests the importance of psychoeducation and public health campaigns. Preliminary studies support family interventions, not only in reducing substance use in patients but also in reducing distress and improving mental health functioning in the family members.15,31 However, only a low proportion of surveyed EIS programs use family-based therapies. EISs with formal addiction services report more groupbased interventions than programs with informal services. In a systematic review of psychosocial interventions for people with substance use disorders and severe mental illness, group therapies show a positive impact on substance use outcomes as well as outcomes such as hospitalization, quality of life, and independent living skills.39 The American Psychiatric Association’s 2006 substance use disorder guidelines support the use of group therapy as they allow efficient use of therapist time and group members who are further along in their recovery to act as positive role models.40 A major strength of this study was our response rate (almost 80%) from every province across Canada with an EIS. To our knowledge, this study is the first to describe substance use treatment services offered in Englishspeaking Canadian EISs. Some limitations of our study should be noted. First, the term formal treatment services in our survey was not operationalized. However, respondents seemed to easily be able
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to self-identify whether they had formal or informal services. Second, despite having a high response rate, we did not contact every EIS across Canada, particularly Frenchspeaking programs, and therefore our results may be less generalizable to French-speaking clinics. We make the following recommendations for EISs across Canada:
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4. 5.
6.
1.
Establish a national task force on addictions treatment in people with EPP with the goals of a) establishing treatment standards that stage treatment based on severity of cannabis abuse, b) establishing standard measures of treatment outcomes and factors predicting treatment response so data can be pooled across Canada, and c) developing training resources for clinicians in the MI, CBT, group, and family interventions that can be shared across Canada. 2. Offer MI (+ CBT) to patients who do not benefit from psychoeducation. Pilot contingency management interventions (+ MI/CBT) for patients who did not respond to previous interventions. 3. Engage families in psychoeducation programs and skill-based interventions such as MI. Acknowledgments We thank all the EISs across Canada who took time to fill out the survey. We also thank David Gardner for his suggestions in developing the survey questions and Sarah Henneberry for her help formatting the figures.
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8.
9.
10.
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12.
Author Note This article was presented in part as a poster presentation at the Canadian Psychiatric Association Meeting, Montreal, QC, 2012 September 27–29.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
13.
14.
15.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material
16.
The supplemental tables are available at http://cpa.sagepub.com/ supplemental
References 1. Van Mastrigt S, Addington J, Addington D. Substance misuse at presentation to an early psychosis program. Soc Psychiatry Psychiatr Epidemiol. 2004;39:69-72. 2. Sembhi S, Lee JWY. Cannabis use in psychotic patients. Aust N Z J Psychiatry. 1999;33:529-532. 3. Rosenbaum B, Valbak K, Harder S, et al. The Danish National Schizophrenia Project: prospective comparative longitudinal
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19. Peterson L, Jeooesen P, Thorup A, et al. Substance abuse and first-episode schizophrenia spectrum disorders. The Danish OPUS trial. Early Intervention Psychiatry. 2007;1:88-96. 20. Baker A, Bucci S, Lewin TJ, et al. Cognitive-behavioral therapy for substance use disorders in people with psychotic disorders. Br J Psychiatry. 2006;188:439-448. 21. Craig TKJ, Johnson S, McCrone P, et al. Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months. Psychiatr Serv. 2008;59:276-282. 22. Martino S, Carroll KM, Nich C, et al. A randomized controlled pilot study of motivational interviewing for patients with psychotic and drug use disorders. Addiction. 2006;101:1479-1492. 23. Baker A, Lewin T, Reichler H, et al. Evaluation of a motivational interview for substance use within psychiatric in-patient services. Addiction. 2002;97:1329-1337. 24. James W, Preston NJ, Koh G, et al. A group intervention which assists patients with dual diagnosis reduce their drug use: a randomized controlled trial. Psychol Med. 2004;34:983-990. 25. Graeber DA, Moyers TB, Griffith G, et al. A pilot study comparing motivational interviewing and an educational intervention in patients with schizophrenia and alcohol use disorders. Community Ment Health J. 2003;39:189-202. 26. Barrowclough C, Haddock G, Tarrier N, et al. Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Am J Psychiatry. 2001;158:1706-1713. 27. Barrowclough C, Haddock G, Wykes T, et al. Integrated motivational interviewing and cognitive behavioral therapy for people with psychosis and comorbid substance misuse: randomized controlled trial. BMJ. 2010;341:c6325. 28. Naeem F, Kingdon D, Turkington D. Cognitive behavior therapy for schizophrenia in patients with mild to moderate substance misuse problems. Cogn Behav Ther. 2005;34:207-215. 29. Bellack AS, Bennett ME, Gearon JS, et al. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness. Arch Gen Psychiatry. 2006;63:426-432.
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30. Ries RK, Dyck DG, Short R, et al. Outcomes of managing disability benefits among patients with substance dependence and severe mental illness. Psych Serv. 2004;55:445-447. 31. Mueser KT, Glynn SM, Cather C, et al. A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders. Schizophr Bull. 2013;9:658-672. 32. McDonell MG, Srebnik D, Angelo F, et al. Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness. Am J Psychiatry. 2013;170:94-101. 33. Burnam AM, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. J Addict Dis. 1995;14: 111-134. 34. Hjorthoj CR, Baker A, Fohlmann A, et al. Intervention efficacy in trials targeting cannabis use disorders in patients with comorbid psychosis systematic review and meta-analysis. Curr Pharm Des. 2014;20:2205-2211. 35. Sigmon SC, Steingard S, Badger GJ, et al. Contingent reinforcement of marijuana abstinence among individuals with serious mental illness: a feasibility study. Exp Clin Psychopharmacol. 2000;8:509-517. 36. Sigmon SC, Higgins ST. Voucher-based contingent reinforcement of marijuana abstinence among individuals with serious mental illness. J Subst Abuse Treat. 2006;30:291-295. 37. Humeniuk R, Ali R, Babor TF, et al. Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. 2008;103:1039-1047. 38. Porath-Waller AJ, Brown JA, Frigon AP, et al. What Canadian youth think about cannabis. Technical report. Ottawa, Ontario: Canadian Centre on Subtance Abuse; 2013. 39. Drake RE, O’Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat. 2008;34:123-138. 40. American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders. 2nd ed. Washington (DC): American Psychiatric Association; 2006.
Brief Communication
Psychosocial Interventions in Reducing Cannabis Use in Early Phase Psychosis: A Canadian Survey of Treatments Offered
Association des psychiatres du Canada
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(6) 367-372 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716639931 TheCJP.ca | LaRCP.ca
Interventions psychosociales pour re´duire l’utilisation du cannabis en phase pre´coce de psychose : une enqueˆte canadienne sur les traitements offerts
Cristina Aydin, MD, FRCPC1, Philip G. Tibbo, MD, FRCPC2,3, and Zenovia Ursuliak, MD, PhD, FRCPC2,3
Abstract Objective: Cannabis use in people with early phase psychosis (EPP) can have a significant impact on long-term outcomes. The purpose of this investigation was to describe current cannabis use treatment practices in English-speaking early intervention services (EISs) in Canada and determine if their services are informed by available evidence. Method: Thirty-five Canadian English-speaking EISs for psychosis were approached to complete a survey through email, facsimile, or online in order to collect information regarding their current cannabis use treatment practices. Results: Data were acquired from 27 of the 35 (78%) programs approached. Only 12% of EISs offered formal services that targeted cannabis use, whereas the majority (63%) of EISs offered informal services for all substance use, not specifically cannabis. In programs with informal services, individual patient psychoeducation (86%) was slightly more common than individual motivational interviewing (MI) (76%) followed by group patient psychoeducation (52%) and information handouts (52%). Thirty-seven percent of EISs offered formal services for substance use, and compared to programs with informal services, more MI, cognitive-behavioural therapy, and family services were offered, with individual treatment modalities more common than groups. No EISs used contingency management, even though it has some preliminary evidence in chronic populations. Evidence-based service implementation barriers included appropriate training and administrative support. Conclusions: While most English-speaking Canadian EIS programs offer individual MI and psychoeducation, which is in line with the available literature, there is room for improvement in cannabis treatment services based on current evidence for both people with EPP and their families. Abre´ge´ Objectif : L’utilisation du cannabis chez les personnes en phase pre´coce de psychose (PPP) peut avoir un effet significatif sur les re´sultats a` long terme. Le but de cette recherche e´tait de de´crire les pratiques actuelles de traitement de l’utilisation du cannabis dans les services d’intervention pre´coce (SIP) anglophones du Canada et de de´terminer si leurs services sont e´claire´s par les donne´es probantes disponibles.
1 2 3
St. Paul’s Hospital, BC Women’s Hospital, Vancouver, British Columbia Dalhousie University, Halifax, Nova Scotia Nova Scotia Early Psychosis Program, Nova Scotia Health Authority, Halifax, Nova Scotia
Corresponding Author: Zenovia Ursuliak, MD, PhD, FRCPC, Nova Scotia Early Psychosis Program, 3rd Floor, Abbie J. Lane Building, 5909 Veteran’s Memorial Lane, Halifax, NS B0J 1T0, Canada. Email: [email protected]
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Me´thode : Trente-cinq SIP canadiens anglophones pour la psychose ont e´te´ approche´s pour remplir un sondage par courriel, te´le´copieur, ou en ligne afin de recueillir de l’information au sujet de leurs pratiques actuelles de traitement de l’utilisation du cannabis. Re´sultats : Les donne´es ont e´te´ obtenues de 27/35 (78 %) des programmes approche´s. Seulement 12 % des SIP offraient des services officiels qui ciblaient l’utilisation du cannabis, alors que la majorite´ (63 %) des SIP offrait des services informels pour toute utilisation de substances, pas spe´cifiquement du cannabis. Dans les programmes aux services informels, la psychoe´ducation individuelle des patients (86 %) e´tait le´ge`rement plus commune que l’entrevue motivationnelle (EM) individuelle (76 %), suivie de la psychoe´ducation de groupe (52 %) et des documents d’information (52 %). Trente-sept pour cent des SIP offraient des services officiels pour l’utilisation de substances, et comparativement aux programmes aux services informels, ils offraient plus de EM, de the´rapie cognitivo-comportementale (TCC), et de services familiaux, et plus de modes de traitement individuels qu’en groupe. Aucun SIP n’utilisait d’organisation des contingences, meˆme s’il y a des donne´es probantes pre´liminaires a` ce sujet dans les populations chroniques. Les obstacles a` la mise en œuvre de services fonde´s sur des donne´es probantes e´taient notamment la formation approprie´e et le soutien administratif. Conclusions : Meˆme si la plupart des programmes des SIP canadiens anglophones offrent l’EM et la psychoe´ducation individuelles, ce qui est conforme a` la litte´rature existante, il y a place a` l’ame´lioration des services de traitement du cannabis d’apre`s les donne´es probantes actuelles, tant pour les personnes souffrant de PPP que leurs familles. Keywords cannabis use, comorbidity, early phase psychosis, early intervention service, motivational Interviewing, psychosocial intervention, Canadian, survey
Clinical Implications Motivational interviewing (MI), for patients and families, shows promise for reducing cannabis use in people with early phase psychosis (EPP), and contingency management has preliminary support in people with chronic schizophrenia. MI, but not contingency management, is available for people with EPP in most English-speaking early intervention services (EISs) across Canada. Family members of people with EPP and cannabis use disorders have limited access to services in Englishspeaking EISs across Canada.
Limitations Very few RCTs evaluate psychosocial interventions to reduce cannabis use in people with EPP, and results are mixed. Our survey did not report on French-speaking EISs for psychosis in Canada. Within the early phase psychosis (EPP) population, cannabis is the most commonly used illicit substance, with 86% of EPP patients reporting lifetime experience with it.1,2 Ongoing cannabis use results in more negative outcomes compared to those EPP patients who do not use, and thus they do not maximally benefit from early intervention services (EISs).3 Cannabis use in EPP is associated with increases in aggression among males,4 higher risk of relapse5 and severity of symptoms,6 reductions in compliance to psychiatric medications,7 and global functioning deficits8 compared to EPP nonusers.
International guidelines for care in EPP recommend not excluding youth and young adults from EISs for psychosis care if they have a comorbid addictions diagnosis. 9,10 Given the detrimental effects of cannabis on outcomes in EPP, identifying and reducing cannabis use should be a key target for EISs for psychosis. Early intervention services are well positioned to affect negative long-term outcomes due to cannabis use, before use leads to more serious impairment.11 At present, there is limited research in effective psychosocial interventions to reduce cannabis use in the early psychosis population. Based on our literature review (see Supplemental Tables S1 and S2),12-33 motivational interviewing (MI) (individual and family) has preliminary support for reducing cannabis use in EPP, with the results for cognitive-behavioural therapy (CBT) being mixed. Psychoeducation, often part of standard care, may improve cannabis use in many people with EPP, making it difficult for an active intervention to demonstrate superiority. CBT and MI had some positive results in chronic populations when cannabis was grouped with other substances, especially when interventions were longer, but gains were not sustained over follow-up periods. Longer interventions for cannabis use in both early and chronic populations were found to be more efficacious in a recent meta-analysis.34 Contingency management has preliminary evidence in reducing cannabis use in people with severe mental illness35,36 but has not been studied in EPP. In this brief report, we describe the results of a national survey of English-speaking EISs for psychosis to assess current cannabis treatment practices available in the Canadian setting and suggest recommendations to address cannabis use in the EIS for psychosis setting.
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Figure 1. Treatment modalities in programs with formal addiction services. CBT, cognitive-behavioural therapy; MI, motivational interviewing.
Methods A cross-sectional survey was developed to collect information regarding current cannabis use treatment practices among Canadian English-speaking EISs for psychosis. The survey collected information on the specific treatment modalities (e.g., MI, CBT), formats (individual vs. group), service users (patients vs. families), and substances targeted. The survey also collected information on factors perceived to facilitate service delivery. Survey questions were dichotomous, contingency based, nominal, ordinal (Likert scale), and short answer. The survey questions were reviewed by the Capital District Health Authority research ethics board and were determined not to require ethics approval. Surveys were distributed to 35 English-speaking Canadian EISs for psychosis from major urban centres in each province across Canada. Response rates were maximized by 1) sending an introductory email to ask potential respondents to identify the most appropriate clinician for the survey, 2) using collaborators’ names and contact information on all communications to personalize survey implementation, and 3) following up with a telephone call and email if no response was received after 3 months. Based on the clinician’s preference, surveys were emailed, faxed, or administered with an online version of the survey via Dalhousie University Opinio (Opinio version 6.6.2; ObjectPlanet, Inc; Oslo, Norway).
Results Twenty-seven of 35 (78%) English-speaking EPP clinics across Canada responded to the survey with all provinces with EISs represented. Thirty-seven percent of EISs had
formal addiction services and 63% had informal services only, with 15% offering both. Cannabis was targeted specifically in 12% of EISs (those with formal services only). Formal treatment service was defined to be a specific intervention targeting substance use. Figure 1 illustrates frequencies of treatment modalities used in EISs with formal services, and Figure 2 depicts modality frequencies in programs with informal services. Individual rather than group therapies were offered more in programs with formal services, with MI, patient and family psychoeducation, and CBT being the most common. Addictions counselors delivered most of the formal addictions services (50%), followed by social workers (40%) and registered nurses (40%), occupational therapists (10%), psychologists (10%), and psychiatrists (10%). Seventy percent of programs with formal treatment services measured outcomes, including stages of change, problems associated with use, quality of life, and symptom scales. Eighty percent of programs with formal services used a screening method to determine treatment eligibility (e.g., clinician assessment, case discussion, or the Alcohol, Smoking, and Substance Involvement Screening Test tool37). Most of the programs, however, only offered informal services to address cannabis use. While the 4 most common therapies in programs with formal services were offered at rates of 80% to 100%, there was less consistency with informal programs. Individual psychoeducation was the most common (86%), followed by individual MI (76%), group psychoeducation (52%), and informal handouts (52%). Limitations of formal substance use treatment services generally fell under 3 areas: 1) client-related issues included challenges with engagement and stage of change, 2) staffrelated issues included low clinician numbers trained in both
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86%
76% 52%
52% 19%
24% 10%
5%
Figure 2. Treatment modalities in programs with informal addiction services. *Other ¼ timeline follow back assessment, multifamily group therapy, concurrent disorders consultation with staff/clients, family support group, recovery group not specific to addictions, and harm reduction.
substance use and EIS treatment modalities and philosophical differences between addictions and EIS staff (i.e., harm reduction vs. abstinence), and 3) systemic issues involved transportation difficulties for clients and staff, clinic hours, age restrictions, limited access to concurrent disorder services, and lack of crisis management services. For the majority of programs, the most important factor in the implementation of evidence-based services was training in substance use interventions, followed by having clinicians aware of current evidence-based treatments. Programs with formal services identified that strategies to engage patients were essential to establish their services, while programs without formal services thought administrative support was vital to establish formal services.
Discussion Informal individual psychoeducation was the most common intervention offered to reduce substance use in Canadian English-speaking EISs, despite preliminary literature that supports the use of MI, with only 12% of programs reporting formal interventions targeting cannabis. There may be regional/program-specific reasons for variations from the evidence-based therapies, including the perception of a lack of consistent or strong signal of effect from long-term studies. However, most EISs identified that training in substance use interventions was the most important factor for implementing services, as well as administrative support, indicating an acknowledgment of lack of training and support in this area rather than concerns of the literature. Of note, contingency management was not used by any respondents, despite some preliminary evidence supporting its use in a chronic population.32,35,36 Only a minority of EIS programs offered formal therapies specific to cannabis use, perhaps
reflecting the practicality of treating cannabis separate from other substances. The EPP population may also have low intrinsic motivation to change cannabis use because they perceive that cannabis is a nonharmful, ‘‘natural’’ substance. The Canadian Centre on Substance Abuse reports that Canadian youth considered marijuana to be much healthier and safer than tobacco and less addictive than stimulants and opiates.38 This suggests the importance of psychoeducation and public health campaigns. Preliminary studies support family interventions, not only in reducing substance use in patients but also in reducing distress and improving mental health functioning in the family members.15,31 However, only a low proportion of surveyed EIS programs use family-based therapies. EISs with formal addiction services report more groupbased interventions than programs with informal services. In a systematic review of psychosocial interventions for people with substance use disorders and severe mental illness, group therapies show a positive impact on substance use outcomes as well as outcomes such as hospitalization, quality of life, and independent living skills.39 The American Psychiatric Association’s 2006 substance use disorder guidelines support the use of group therapy as they allow efficient use of therapist time and group members who are further along in their recovery to act as positive role models.40 A major strength of this study was our response rate (almost 80%) from every province across Canada with an EIS. To our knowledge, this study is the first to describe substance use treatment services offered in Englishspeaking Canadian EISs. Some limitations of our study should be noted. First, the term formal treatment services in our survey was not operationalized. However, respondents seemed to easily be able
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to self-identify whether they had formal or informal services. Second, despite having a high response rate, we did not contact every EIS across Canada, particularly Frenchspeaking programs, and therefore our results may be less generalizable to French-speaking clinics. We make the following recommendations for EISs across Canada:
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Establish a national task force on addictions treatment in people with EPP with the goals of a) establishing treatment standards that stage treatment based on severity of cannabis abuse, b) establishing standard measures of treatment outcomes and factors predicting treatment response so data can be pooled across Canada, and c) developing training resources for clinicians in the MI, CBT, group, and family interventions that can be shared across Canada. 2. Offer MI (+ CBT) to patients who do not benefit from psychoeducation. Pilot contingency management interventions (+ MI/CBT) for patients who did not respond to previous interventions. 3. Engage families in psychoeducation programs and skill-based interventions such as MI. Acknowledgments We thank all the EISs across Canada who took time to fill out the survey. We also thank David Gardner for his suggestions in developing the survey questions and Sarah Henneberry for her help formatting the figures.
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Author Note This article was presented in part as a poster presentation at the Canadian Psychiatric Association Meeting, Montreal, QC, 2012 September 27–29.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
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The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material
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The supplemental tables are available at http://cpa.sagepub.com/ supplemental
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