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ScienceDirect Comprehensive Psychiatry xx (2013) xxx – xxx www.elsevier.com/locate/comppsych
Substance use disorders among treatment naïve first-episode psychosis patients Prabhat Chand⁎, Jagadisha Thirthalli, Pratima Murthy Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
Abstract Objectives: To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India. Methods: The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients. Results: Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen. Conclusion: The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Substance use among patients with psychotic disorders is reportedly higher than in the general population. Studies done in North America, Canada and UK have reported substance misuse in 20–50% first episode psychotic disorders [1–5]. Cannabis, LSD, alcohol, amphetamine, cocaine etc. can induce psychotic symptoms. Cannabis and alcohol misuse have been found to be consistently higher among patients with first episode psychosis. High prevalence of smoking has also been reported [5]. In view of such a common association between substance use and psychosis, it is recommended that all first episode psychosis patients undergo thorough medical as well as neurological investigations and urine toxicological testing for drugs of abuse [6]. Standard guideline and text books recommend
⁎ Corresponding author. Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Tel.: +91 80 26995298. E-mail address: [email protected] (P. Chand). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.07.075
routine medical history of substance use along with urine toxicology screen as a part of initial assessment [7–9]. The outcome of schizophrenia is reported to be better in developing country like India. Such a relatively better prognosis is attributed to a host of socio-cultural factors like lower expressed emotions, good social support as well as low prevalence of comorbid substance use disorder [10–12]. Whether this holds true for psychosis in general or not, is a matter of debate. There is a marked variation in the use of substances across different parts of India. A large scale epidemiological study had reported alcohol as the most common substance of use followed by cannabis (3%) and opioids (0.7%). This study also reported about one third of alcohol users fulfilled the ICD 10 criteria for dependence [13]. A study specific to this area i.e. Karnataka has reported higher prevalence of alcohol use i.e. among men was 23% in rural areas and 41% in urban areas [14]. Thirty five percent of adults in India use some form of tobacco. Among them 21% adults use only smokeless tobacco, 9% only smoke and 5% smoke as well as use smokeless tobacco. Smokeless tobacco use is more common than smoking both in male and females [15]. In
2
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
recent time, there is an increase in abuse of pharmaceuticals i.e. opioids, benzodiazepine in India as well as Southeast Asia [16]. Although India is reported to be one of the major exporters of amphetamine type stimulants (ATS), the reported use in the general population as well as clinical settings is very low. Presently, there are no data available on the prevalence of substance use among patients with first episode psychosis in clinical settings in India. Hence the current study was planned to look at prevalence of substance use among first episode, treatment naïve patients presenting with psychosis. To strengthen the study finding as well as to find the utility, we have included urine toxicological screen [17] for substance along with the routine assessment.
2. Methods The study was conducted over a six month period (January 2010 to June 2010) at an outpatient clinic of a neuropsychiatry hospital in South India after taking approval from institute ethics committee. We followed a two-stage diagnosis method. In the first stage, a psychiatrist examined the patient and made a clinical diagnosis of a psychotic disorder as per the International Classification of Diseases, 10th revision. After obtaining written informed consent, a trained researcher then applied the Mini International Neuropsychiatric Interview (MINI) [18] and re-confirmed the diagnosis. All subjects who fulfilled the criteria for acute psychosis (F23.xx), schizophrenia (F20.xx), schizoaffective disorder (F25.xx), other specified psychoses (F28), unspecified non-organic psychosis (F29) and affective psychosis according to ICD-10 DCR criteria and who had not received any prior psychiatric treatment were included for further evaluation. Patients diagnosed as having a psychosis due to substance withdrawal or intoxication were excluded from the study. Patients having substance induced psychosis were included in the study. One hundred forty-five eligible drug naïve first episode psychosis patients were screened. Six were excluded i.e. two of them were in catatonia and the other four patients were uncooperative, and consent could not be obtained. There were no patients in the sample with a diagnosis of psychosis due to substance withdrawal or intoxication. The remaining 139 patients were interviewed regarding the use of any substance during their life time. In each case, the history was corroborated by an accompanying family member. Parents, spouse or children had accompanied 70% of the patients and all the remaining were either accompanied by close relatives or friends. To facilitate proper reporting, the locally available names of the substances were used. Further details regarding substance use for the last 12 months were collected by applying the substance use section of MINI [18]. This section is in two parts and allows the diagnosis of alcohol abuse or dependence and non-alcohol substance abuse or
dependence. The non-alcohol section deals with stimulants, cocaine, narcotics, hallucinogens, phencyclidine, inhalants, cannabis, tranquilizers and miscellaneous. The MINI questions are based on ICD 10 criteria for dependence. The severity of smoking was measured by Fagerstrom Test for nicotine dependence (FTND) [19]. Breath analyzer (Alco-Sensor IV, Intoximeter, Inc., St Louis, Missouri) was used in all patients to detect recent ingestion of alcohol. The severity of psychosis was assessed on the Positive and Negative Symptom scale (PANSS) [20]. Drugs of abuse can be detected in saliva, urine, sweat, nail, semen and hair depending on time and duration of use. Hair can be positive for drugs from a few months to years depending on length of the hair [21]. The disadvantages of hair analysis to validate drug use include irregular growth, labor-intensive sample preparation, chemical dying/bleaching and excessive cost [22,23]. Urine testing for the various drugs of abuse has been standardized, easy to perform and highly sensitive and specific [23]. For the current study, urine testing was carried out by immunoassay based cassette method for six common substances, namely cannabis, benzodiazepine, morphine, amphetamine, barbiturates and cocaine. Immunoassay drug testing is based on the principle of competitive binding and uses antibodies to detect the presence of a particular drug or metabolite in a urine sample. It helps in detecting the drug as either present or absent depending on a predetermined cut off score. The cut off score for the sample to be positive for the drug under study was for cannabis 50 ng/ml, benzodiazepine 300 ng/ml, morphine (opiate metabolite) 2000 ng/ml, amphetamine 1000 ng/ml, barbiturate 200 ng/ml and cocaine 300 ng/ml [24]. Detailed history of any recent intake of medication was obtained to check for cross reactivity resulting in a false positive result in immunoassay method [23]. High performance thin layer chromatography (HPTLC) was performed in 20% of the random urine samples to minimize false positivity. 3. Results There were 54% males and the mean age of the patients was 35.09 (SD 13.6) years. The mean duration of symptoms before presentation to the clinic was 72.95 (SD 56.9) days. None of the patients were on any treatment at the time of evaluation. One patient was 20 weeks pregnant. 3.1. Psychiatric diagnosis The breakdown of the psychiatric disorder subtype is provided in Table 1. Acute and transient psychosis was the most common diagnosis (n = 59; 42.4%) followed by unspecified non-organic psychosis (n = 35; 25.2%) There were six patients who received a provisional diagnosis of substance induced psychosis. The mean scores on Positive, Negative and General psychopathology were 20.00 (SD 5.12), 17.59 (SD7.27) and 27.52 (SD6.63) respectively. The
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx Table 1 Diagnoses break up of treatment naïve first episode psychosis. Diagnosis (ICD 10)
N = 139
Percentage
Mean duration days (SD)
Acute and transient psychosis Substance induced psychosis Schizophrenia Delusional disorder Unspecified non-organic psychosis Mood disorder with psychotic symptoms
59
42.4
40.5 (45.8)
6
4.3
49.66 (33.3)
23 2 35
16.5 1.4 25.2
98.64 (48.17) 72.95 (00) 106.31 (62.5)
14
10.1
61.23 (55.4)
total PANSS score was 64.57 (SD 12.03). The total as well as domain PANSS scores among patients with and without substance dependence were comparable (t: 1.11, p = 0.26). The mean duration of illness was longest for patients with unspecified non-organic psychosis. 3.2. Substance abuse and dependence Overall prevalence of current alcohol and other substance dependence is shown in Table 2. Life time alcohol use was reported by 30 patients (21.58%). Twenty four patients (17.3%) fulfilled clinical diagnosis of current alcohol dependence syndrome. Cannabis use (life time) was selfreported in 6 patients (4.31%) and four patients (3.6%) fulfilled diagnostic criteria for current cannabis dependence. One patient reported current inhalant abuse. There was no other drug use or abuse reported apart from nicotine. Breath analyzer for alcohol was negative in all the patients (not tested in two uncooperative patients). Among females with first episode psychosis, none reported alcohol or other substance use, apart from tobacco (23.1%). Urine drug screen was positive in five patients for cannabis (3.6%), one for morphine and one for barbiturates. Urine benzodiazepine was positive in twenty five (17.9%) patients. The concordance between self-report interview and urine toxicology was high for cannabis (Kappa: 0.82, p b 0.001). For the other substances, Kappa could not be calculated as there is neither self-report nor toxicology positive urine sample for the same patient. Patients with substance dependence were older (p = 0.89), had a greater duration of illness (p = 0.60) than those who had no substance use history, but the difference was not statistically significant. A significantly greater proportion of substance dependent patients were likely to be male (χ 2 30.79, p b 0.001). Nicotine use was present in 37.4% of patients, with 20.1% reporting smoking and 13.7% reporting smokeless use. The mean Fagerstrom score for smokers was 3.58 (SD 2.59) suggesting minimal physical dependence to nicotine in this population [19]. Ten patients (7.2%) reported and their informants corroborated that they had either been prescribed some medications
3
by the local doctor/health care provider i.e. pharmacist or procured the medicine over the counter (which they described as “sleeping tablets”). There were no valid prescriptions. 4. Discussion The current study conducted among treatment naïve first episode patients with psychosis suggested a low prevalence of illicit drug use among those who came for the treatment. The mean age at presentation of this group is towards midthirties, which is in contrast to the similar studies from the west [25]. Studies from India in schizophrenia patients reported fairly later peak in age of onset in the early thirties followed by a steep decline through the older age ranges [26,27]. The previous authors have argued that poor perinatal care in India might have preferentially decreased the number at risk for lower age of onset for schizophrenia. Another important factor could be the lower rate of illicit substance use in this population which has prevented early onset of psychosis. It is known that abuse of illicit substances is associated with earlier age at onset [5,28,29]. Overall prevalence of current substance dependence (excluding nicotine) is 20% (95% CI 14.3–27.5), substantially less compared to the other studies from developed countries [3,4]. A study from UK reported 37% of patients having first episode psychosis having alcohol and other drug use or misuse [4]. Prevalence of any substance misuse was reported to be 51.5% among first episode psychosis study from Australia [30]. Another early intervention multi centre study (EIS) for psychosis from England reported that 38% patients had substance abuse or dependence at the time of presentation [31]. In contrast to the current study, a study done among a subsample of psychiatry in-patients in 2001 from this centre using Alcohol Use Disorder Identification Test (AUDIT) had showed about 8% having hazardous drinking (scored more than the cut off on the AUDIT) [12]. The reason for a twofold increase in alcohol use disorder in our study (17.3% vs 8%) can be explained by the nature of the sample (previous study being inpatient versus current study outpatient), diagnosis (all psychiatric disorders versus first episode psychosis). In fact, the prevalence of alcohol use among patients with first episode psychosis in this study is lower than the community prevalence of alcohol use among adults (21%–NHSDA) [13]. However, there is a higher prevalence of alcohol dependence in this population as compared to the general population [13]. One possibility is that patients with psychiatric disorder who use alcohol may become dependent more easily than those without any psychiatric disorder. The relative higher prevalence of alcohol dependence in first episode psychosis points to possible psychotogenic effects of alcohol in the onset of psychosis. Development of psychosis in the context of heavy drinking has not been well studied. A study done in a Malaysian hospital indicated that alcohol related psychotic disorders were more common in persons of Indian origin and those from the lower economic
4
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Table 2 Substance use disorder diagnosis. Current substance use/abuse/dependence (current use = last 1 year)
Interview (patient/relative report by MINI) (%)
Positive urine toxicology immunoassay
Diagnosis breakup: N (%)
No substance
109 (78.4)
Benzodiazepine : 21 Morphine: 1
Alcohol dependence Alcohol abuse Alcohol use
24 (17.3) 3 (2.15) 3 (2.15)
Cannabis: 1 Benzodiazepine: 4 Barbiturate: 1
Cannabis dependence Cannabis abuse Solvent abuse
4 (3.6) 2 (1.8) 1 (0.7)
Cannabis: 3 Cannabis: 2 Not tested
Acute and transient psychosis: 51 (46.78%) Schizophrenia: 17 (15.59%) Unspecified non-organic psychosis: 26 (23.85%) Substance induced psychosis: 0 Delusional disorder: 2 (1.83%) Affective disorder with psychotic symptoms: 9 (8.25%) Acute and transient psychosis: 8 (26.66%) Schizophrenia: 6 (20%) Unspecified non-organic psychosis: 7 (23.33%) Substance induced psychosis: 6 (20%) Delusional disorder: 0 Affective disorder with psychotic symptoms: 3 (10%) Unspecified non-organic psychosis: 1 (16.66%) Mood disorder with psychotic symptoms: 2 (33.33%) Unspecified non-organic psychosis: 1
No patients reported use/abuse of cocaine, opioids, benzodiazepine or amphetamine (type stimulants).
status [32]. One needs to carefully look at the association of increase or decrease alcohol in a newly presenting patient with psychosis. The prevalence of cannabis abuse/dependence is substantially lower in the current study, compared to similar studies on first episode psychosis across the world, which record high rates of up to 65% [3,30,33]. Our findings of low rates of cannabis dependence may reflect the generally lower prevalence of cannabis use in the community (3%) [13]. The prevalence of nicotine use is similar to that in the general population as well as among psychiatric in-patients from the same center [15,34]. The smokeless tobacco i.e. khaini tobacco mixed with areca nut use was more common among women which is in accordance with other studies. 4.1. Is there a need to have urine drug screen in all patients with first episode psychosis? Standard treatment guidelines have proposed routine urine drug screen especially for cannabis, cocaine and amphetamine in first episode psychosis [8]. In this study, we found very high concordance between self/informant report of drug use and urine screen (kappa: 0.82, p b 0.001). Although urine benzodiazepine was found positive in 25 patients, most of these patients (22) reported ingestion of “sleeping tablets” having procured these either from over the counter, or from a pharmacist etc, without any valid prescription. Although there is no systematic study in this area, it is known that poor monitoring in developing countries results in indiscriminate dispensing of benzodiazepines [35,36].
reserved for selected cases of acute psychosis. However, with changing general population trends and changes in the availability and misuse of substances, the need for routine urine screening among patients with first episode psychosis will have to be revisited in the future. Also future studies need to substantiate our findings of lower substance use in this population especially in a larger cohort of schizophrenia. This was a cross sectional study. Hence the proportion of patients with “psychosis” who would have received diagnosis of schizophrenia during the course of their treatment is not available. 4.3. Limitations The primary aim of the study was to look at prevalence of drug use among drug naïve first episode psychosis. The study did not examine the etiological role of substances in the evaluation of psychosis as well as substance use among patients presenting to the emergency services. Urine toxicology screen is usually positive if the person has used the substances in the prior three days and does not reflect more remote use. Another limitation is that the study was conducted in the hospital and there is the inherent problem of being generalizable to the community. A longitudinal follow up would have been ideal to establish any diagnosis shift and its association with substance use. Such limitations notwithstanding, this study conducted in a developing country has demonstrated the lower prevalence of substance use among patients with first episode psychosis.
4.2. Clinical implications
Acknowledgment
These findings suggest that patient self-report, with corroboration by a reliable informant is presently adequate in our clinical setting and toxicology urine screening can be
Funding provided by an academic research grant from Centre for Addiction Medicine, NIMHANS, Bangalore. There is no other declaration by any other authors.
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Substance use disorders among treatment naïve first-episode psychosis patients Prabhat Chand⁎, Jagadisha Thirthalli, Pratima Murthy Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
Abstract Objectives: To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India. Methods: The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients. Results: Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen. Conclusion: The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Substance use among patients with psychotic disorders is reportedly higher than in the general population. Studies done in North America, Canada and UK have reported substance misuse in 20–50% first episode psychotic disorders [1–5]. Cannabis, LSD, alcohol, amphetamine, cocaine etc. can induce psychotic symptoms. Cannabis and alcohol misuse have been found to be consistently higher among patients with first episode psychosis. High prevalence of smoking has also been reported [5]. In view of such a common association between substance use and psychosis, it is recommended that all first episode psychosis patients undergo thorough medical as well as neurological investigations and urine toxicological testing for drugs of abuse [6]. Standard guideline and text books recommend
⁎ Corresponding author. Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Tel.: +91 80 26995298. E-mail address: [email protected] (P. Chand). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.07.075
routine medical history of substance use along with urine toxicology screen as a part of initial assessment [7–9]. The outcome of schizophrenia is reported to be better in developing country like India. Such a relatively better prognosis is attributed to a host of socio-cultural factors like lower expressed emotions, good social support as well as low prevalence of comorbid substance use disorder [10–12]. Whether this holds true for psychosis in general or not, is a matter of debate. There is a marked variation in the use of substances across different parts of India. A large scale epidemiological study had reported alcohol as the most common substance of use followed by cannabis (3%) and opioids (0.7%). This study also reported about one third of alcohol users fulfilled the ICD 10 criteria for dependence [13]. A study specific to this area i.e. Karnataka has reported higher prevalence of alcohol use i.e. among men was 23% in rural areas and 41% in urban areas [14]. Thirty five percent of adults in India use some form of tobacco. Among them 21% adults use only smokeless tobacco, 9% only smoke and 5% smoke as well as use smokeless tobacco. Smokeless tobacco use is more common than smoking both in male and females [15]. In
2
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
recent time, there is an increase in abuse of pharmaceuticals i.e. opioids, benzodiazepine in India as well as Southeast Asia [16]. Although India is reported to be one of the major exporters of amphetamine type stimulants (ATS), the reported use in the general population as well as clinical settings is very low. Presently, there are no data available on the prevalence of substance use among patients with first episode psychosis in clinical settings in India. Hence the current study was planned to look at prevalence of substance use among first episode, treatment naïve patients presenting with psychosis. To strengthen the study finding as well as to find the utility, we have included urine toxicological screen [17] for substance along with the routine assessment.
2. Methods The study was conducted over a six month period (January 2010 to June 2010) at an outpatient clinic of a neuropsychiatry hospital in South India after taking approval from institute ethics committee. We followed a two-stage diagnosis method. In the first stage, a psychiatrist examined the patient and made a clinical diagnosis of a psychotic disorder as per the International Classification of Diseases, 10th revision. After obtaining written informed consent, a trained researcher then applied the Mini International Neuropsychiatric Interview (MINI) [18] and re-confirmed the diagnosis. All subjects who fulfilled the criteria for acute psychosis (F23.xx), schizophrenia (F20.xx), schizoaffective disorder (F25.xx), other specified psychoses (F28), unspecified non-organic psychosis (F29) and affective psychosis according to ICD-10 DCR criteria and who had not received any prior psychiatric treatment were included for further evaluation. Patients diagnosed as having a psychosis due to substance withdrawal or intoxication were excluded from the study. Patients having substance induced psychosis were included in the study. One hundred forty-five eligible drug naïve first episode psychosis patients were screened. Six were excluded i.e. two of them were in catatonia and the other four patients were uncooperative, and consent could not be obtained. There were no patients in the sample with a diagnosis of psychosis due to substance withdrawal or intoxication. The remaining 139 patients were interviewed regarding the use of any substance during their life time. In each case, the history was corroborated by an accompanying family member. Parents, spouse or children had accompanied 70% of the patients and all the remaining were either accompanied by close relatives or friends. To facilitate proper reporting, the locally available names of the substances were used. Further details regarding substance use for the last 12 months were collected by applying the substance use section of MINI [18]. This section is in two parts and allows the diagnosis of alcohol abuse or dependence and non-alcohol substance abuse or
dependence. The non-alcohol section deals with stimulants, cocaine, narcotics, hallucinogens, phencyclidine, inhalants, cannabis, tranquilizers and miscellaneous. The MINI questions are based on ICD 10 criteria for dependence. The severity of smoking was measured by Fagerstrom Test for nicotine dependence (FTND) [19]. Breath analyzer (Alco-Sensor IV, Intoximeter, Inc., St Louis, Missouri) was used in all patients to detect recent ingestion of alcohol. The severity of psychosis was assessed on the Positive and Negative Symptom scale (PANSS) [20]. Drugs of abuse can be detected in saliva, urine, sweat, nail, semen and hair depending on time and duration of use. Hair can be positive for drugs from a few months to years depending on length of the hair [21]. The disadvantages of hair analysis to validate drug use include irregular growth, labor-intensive sample preparation, chemical dying/bleaching and excessive cost [22,23]. Urine testing for the various drugs of abuse has been standardized, easy to perform and highly sensitive and specific [23]. For the current study, urine testing was carried out by immunoassay based cassette method for six common substances, namely cannabis, benzodiazepine, morphine, amphetamine, barbiturates and cocaine. Immunoassay drug testing is based on the principle of competitive binding and uses antibodies to detect the presence of a particular drug or metabolite in a urine sample. It helps in detecting the drug as either present or absent depending on a predetermined cut off score. The cut off score for the sample to be positive for the drug under study was for cannabis 50 ng/ml, benzodiazepine 300 ng/ml, morphine (opiate metabolite) 2000 ng/ml, amphetamine 1000 ng/ml, barbiturate 200 ng/ml and cocaine 300 ng/ml [24]. Detailed history of any recent intake of medication was obtained to check for cross reactivity resulting in a false positive result in immunoassay method [23]. High performance thin layer chromatography (HPTLC) was performed in 20% of the random urine samples to minimize false positivity. 3. Results There were 54% males and the mean age of the patients was 35.09 (SD 13.6) years. The mean duration of symptoms before presentation to the clinic was 72.95 (SD 56.9) days. None of the patients were on any treatment at the time of evaluation. One patient was 20 weeks pregnant. 3.1. Psychiatric diagnosis The breakdown of the psychiatric disorder subtype is provided in Table 1. Acute and transient psychosis was the most common diagnosis (n = 59; 42.4%) followed by unspecified non-organic psychosis (n = 35; 25.2%) There were six patients who received a provisional diagnosis of substance induced psychosis. The mean scores on Positive, Negative and General psychopathology were 20.00 (SD 5.12), 17.59 (SD7.27) and 27.52 (SD6.63) respectively. The
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx Table 1 Diagnoses break up of treatment naïve first episode psychosis. Diagnosis (ICD 10)
N = 139
Percentage
Mean duration days (SD)
Acute and transient psychosis Substance induced psychosis Schizophrenia Delusional disorder Unspecified non-organic psychosis Mood disorder with psychotic symptoms
59
42.4
40.5 (45.8)
6
4.3
49.66 (33.3)
23 2 35
16.5 1.4 25.2
98.64 (48.17) 72.95 (00) 106.31 (62.5)
14
10.1
61.23 (55.4)
total PANSS score was 64.57 (SD 12.03). The total as well as domain PANSS scores among patients with and without substance dependence were comparable (t: 1.11, p = 0.26). The mean duration of illness was longest for patients with unspecified non-organic psychosis. 3.2. Substance abuse and dependence Overall prevalence of current alcohol and other substance dependence is shown in Table 2. Life time alcohol use was reported by 30 patients (21.58%). Twenty four patients (17.3%) fulfilled clinical diagnosis of current alcohol dependence syndrome. Cannabis use (life time) was selfreported in 6 patients (4.31%) and four patients (3.6%) fulfilled diagnostic criteria for current cannabis dependence. One patient reported current inhalant abuse. There was no other drug use or abuse reported apart from nicotine. Breath analyzer for alcohol was negative in all the patients (not tested in two uncooperative patients). Among females with first episode psychosis, none reported alcohol or other substance use, apart from tobacco (23.1%). Urine drug screen was positive in five patients for cannabis (3.6%), one for morphine and one for barbiturates. Urine benzodiazepine was positive in twenty five (17.9%) patients. The concordance between self-report interview and urine toxicology was high for cannabis (Kappa: 0.82, p b 0.001). For the other substances, Kappa could not be calculated as there is neither self-report nor toxicology positive urine sample for the same patient. Patients with substance dependence were older (p = 0.89), had a greater duration of illness (p = 0.60) than those who had no substance use history, but the difference was not statistically significant. A significantly greater proportion of substance dependent patients were likely to be male (χ 2 30.79, p b 0.001). Nicotine use was present in 37.4% of patients, with 20.1% reporting smoking and 13.7% reporting smokeless use. The mean Fagerstrom score for smokers was 3.58 (SD 2.59) suggesting minimal physical dependence to nicotine in this population [19]. Ten patients (7.2%) reported and their informants corroborated that they had either been prescribed some medications
3
by the local doctor/health care provider i.e. pharmacist or procured the medicine over the counter (which they described as “sleeping tablets”). There were no valid prescriptions. 4. Discussion The current study conducted among treatment naïve first episode patients with psychosis suggested a low prevalence of illicit drug use among those who came for the treatment. The mean age at presentation of this group is towards midthirties, which is in contrast to the similar studies from the west [25]. Studies from India in schizophrenia patients reported fairly later peak in age of onset in the early thirties followed by a steep decline through the older age ranges [26,27]. The previous authors have argued that poor perinatal care in India might have preferentially decreased the number at risk for lower age of onset for schizophrenia. Another important factor could be the lower rate of illicit substance use in this population which has prevented early onset of psychosis. It is known that abuse of illicit substances is associated with earlier age at onset [5,28,29]. Overall prevalence of current substance dependence (excluding nicotine) is 20% (95% CI 14.3–27.5), substantially less compared to the other studies from developed countries [3,4]. A study from UK reported 37% of patients having first episode psychosis having alcohol and other drug use or misuse [4]. Prevalence of any substance misuse was reported to be 51.5% among first episode psychosis study from Australia [30]. Another early intervention multi centre study (EIS) for psychosis from England reported that 38% patients had substance abuse or dependence at the time of presentation [31]. In contrast to the current study, a study done among a subsample of psychiatry in-patients in 2001 from this centre using Alcohol Use Disorder Identification Test (AUDIT) had showed about 8% having hazardous drinking (scored more than the cut off on the AUDIT) [12]. The reason for a twofold increase in alcohol use disorder in our study (17.3% vs 8%) can be explained by the nature of the sample (previous study being inpatient versus current study outpatient), diagnosis (all psychiatric disorders versus first episode psychosis). In fact, the prevalence of alcohol use among patients with first episode psychosis in this study is lower than the community prevalence of alcohol use among adults (21%–NHSDA) [13]. However, there is a higher prevalence of alcohol dependence in this population as compared to the general population [13]. One possibility is that patients with psychiatric disorder who use alcohol may become dependent more easily than those without any psychiatric disorder. The relative higher prevalence of alcohol dependence in first episode psychosis points to possible psychotogenic effects of alcohol in the onset of psychosis. Development of psychosis in the context of heavy drinking has not been well studied. A study done in a Malaysian hospital indicated that alcohol related psychotic disorders were more common in persons of Indian origin and those from the lower economic
4
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
Table 2 Substance use disorder diagnosis. Current substance use/abuse/dependence (current use = last 1 year)
Interview (patient/relative report by MINI) (%)
Positive urine toxicology immunoassay
Diagnosis breakup: N (%)
No substance
109 (78.4)
Benzodiazepine : 21 Morphine: 1
Alcohol dependence Alcohol abuse Alcohol use
24 (17.3) 3 (2.15) 3 (2.15)
Cannabis: 1 Benzodiazepine: 4 Barbiturate: 1
Cannabis dependence Cannabis abuse Solvent abuse
4 (3.6) 2 (1.8) 1 (0.7)
Cannabis: 3 Cannabis: 2 Not tested
Acute and transient psychosis: 51 (46.78%) Schizophrenia: 17 (15.59%) Unspecified non-organic psychosis: 26 (23.85%) Substance induced psychosis: 0 Delusional disorder: 2 (1.83%) Affective disorder with psychotic symptoms: 9 (8.25%) Acute and transient psychosis: 8 (26.66%) Schizophrenia: 6 (20%) Unspecified non-organic psychosis: 7 (23.33%) Substance induced psychosis: 6 (20%) Delusional disorder: 0 Affective disorder with psychotic symptoms: 3 (10%) Unspecified non-organic psychosis: 1 (16.66%) Mood disorder with psychotic symptoms: 2 (33.33%) Unspecified non-organic psychosis: 1
No patients reported use/abuse of cocaine, opioids, benzodiazepine or amphetamine (type stimulants).
status [32]. One needs to carefully look at the association of increase or decrease alcohol in a newly presenting patient with psychosis. The prevalence of cannabis abuse/dependence is substantially lower in the current study, compared to similar studies on first episode psychosis across the world, which record high rates of up to 65% [3,30,33]. Our findings of low rates of cannabis dependence may reflect the generally lower prevalence of cannabis use in the community (3%) [13]. The prevalence of nicotine use is similar to that in the general population as well as among psychiatric in-patients from the same center [15,34]. The smokeless tobacco i.e. khaini tobacco mixed with areca nut use was more common among women which is in accordance with other studies. 4.1. Is there a need to have urine drug screen in all patients with first episode psychosis? Standard treatment guidelines have proposed routine urine drug screen especially for cannabis, cocaine and amphetamine in first episode psychosis [8]. In this study, we found very high concordance between self/informant report of drug use and urine screen (kappa: 0.82, p b 0.001). Although urine benzodiazepine was found positive in 25 patients, most of these patients (22) reported ingestion of “sleeping tablets” having procured these either from over the counter, or from a pharmacist etc, without any valid prescription. Although there is no systematic study in this area, it is known that poor monitoring in developing countries results in indiscriminate dispensing of benzodiazepines [35,36].
reserved for selected cases of acute psychosis. However, with changing general population trends and changes in the availability and misuse of substances, the need for routine urine screening among patients with first episode psychosis will have to be revisited in the future. Also future studies need to substantiate our findings of lower substance use in this population especially in a larger cohort of schizophrenia. This was a cross sectional study. Hence the proportion of patients with “psychosis” who would have received diagnosis of schizophrenia during the course of their treatment is not available. 4.3. Limitations The primary aim of the study was to look at prevalence of drug use among drug naïve first episode psychosis. The study did not examine the etiological role of substances in the evaluation of psychosis as well as substance use among patients presenting to the emergency services. Urine toxicology screen is usually positive if the person has used the substances in the prior three days and does not reflect more remote use. Another limitation is that the study was conducted in the hospital and there is the inherent problem of being generalizable to the community. A longitudinal follow up would have been ideal to establish any diagnosis shift and its association with substance use. Such limitations notwithstanding, this study conducted in a developing country has demonstrated the lower prevalence of substance use among patients with first episode psychosis.
4.2. Clinical implications
Acknowledgment
These findings suggest that patient self-report, with corroboration by a reliable informant is presently adequate in our clinical setting and toxicology urine screening can be
Funding provided by an academic research grant from Centre for Addiction Medicine, NIMHANS, Bangalore. There is no other declaration by any other authors.
P. Chand et al. / Comprehensive Psychiatry xx (2013) xxx–xxx
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