Double whammy: When early psychosis and substance use go hand in hand

CrossCurrents

By Anne Ptasznik

In July 2006, Paul Humphreys left his Toronto home and walked to a subway station an hour away. He boarded a train, but fearing that some passengers were going to attack him, he jumped off, crossed the platform and dove onto the tracks, breaking his glasses and cutting his head open. Fortunately, no trains were coming. The police took Paul to a local hospital he had visited several times previously. The 23-year-old also used drugs – primarily cocaine, but also marijuana, alcohol and ecstasy.

Paul’s experience with substances is not unusual among individuals experiencing a first episode of psychosis. According to the Canadian Mental Health Association, first-episode psychosis (FEP) – with a lifetime prevalence of about three per cent – typically occurs in a person’s late teens or early 20s – a time when many young people use alcohol and other drugs.

Research has shown that early intervention for psychosis reduces psychotic symptoms and hospital readmissions; however, the complex issues involved in co-occurring substance use and psychosis can make detection, diagnosis and, ultimately, treatment and recovery particularly challenging.

Indeed, clinical research has found that substance use during psychosis increases negative outcomes, including treatment non-adherence, relapse, rehospitalization, poorer social functioning and higher treatment costs. Alcohol can interact with antipsychotic medication, compounding the medication’s sedating effects and exacerbating depression.

Given these risks, it makes sense that identifying and reducing substance use and abuse should be a key target for early psychosis intervention services.

Cannabis and alcohol are the most commonly used substances among young people with FEP. A 2007 study in Acta Psychiatrica Scandinavica found that 33 per cent of its sample, with an average age of 25, met DSM-IV criteria for cannabis abuse or dependence and 35 per cent met criteria for alcohol abuse or dependence. Some first episode programs report that more than 80 per cent of clients use substances.

Various hypotheses have been developed to explain these high rates of substance use. One theory suggests that substances are used to self-medicate early symptoms of psychosis. Another theory posits that substances trigger psychosis in individuals with an underlying vulnerability. According to a third theory, some common variable underlies both substance use and psychosis.

Although causality is still debated, a growing body of evidence, such as that summarized in a 2007 issue of Current Psychiatry Reviews, shows that substance use, in the review’s case, cannabis, in combination with genetic or environmental factors exerts a causal influence on the onset of psychosis in individuals at risk. “There is now consistent evidence that cannabis use, particularly heavy use in early adolescence, increases risk of psychosis by as much as 40 per cent,” says Dr. Heather Milliken, until recently director of the Nova Scotia Early Psychosis Program in Halifax.

But detecting the signs that something is wrong can be difficult. Milliken says that changes in behaviour that signal early psychosis are often attributed to the ups and downs of adolescence or to drug use and may not be recognized as indications of a psychotic disorder.

Other experts agree: “Many times families think in the early stages of psychosis that their kids are stoned when their behaviour mimics what look like negative symptoms,” says Sabrina Baker, a family worker with the Centre for Addiction and Mental Health’s (CAMH) First Episode Learning Employment Advocacy Recreation Network (LEARN) program in Toronto, which provides social, educational and vocational support for individuals with FEP. Negative symptoms include social and emotional withdrawal, flat affect and low energy. Positive symptoms include hallucinations, delusions and thought disorders.

Some drugs, such as amphetamines and cocaine, can cause a condition known as drug-induced psychosis. This psychosis can last up to a few days and is often characterized by hallucinations, delusion, memory loss and confusion. It usually results from prolonged or heavy use and responds well to treatment.

Experts advise that young people who experience changes in functioning, such as difficulties at school or becoming increasingly isolated, and who exhibit persistent and worsening odd behaviours or preoccupations with bizarre ideas should be referred for assessment.

 

Paul: I’d go to work, get paid and then go and do drugs. When I ran out I’d go back to work again … I think my dad might have known a bit. I stayed in my room, played a lot of computer games, tried to hide it.

 

Because psychosis is a phased illness, it is sometimes only in retrospect that families recognize the early signs. Corrine, Paul’s 32-year-old sister, says the entire family was affected by their mother’s death in 1985, leaving their father with four young children to raise; but while the other siblings were social and active, Paul was different. He kept to himself, had school difficulties and did not get involved in sports or other activities. He began smoking cigarettes, progressed to marijuana and then other drugs.

 

Paul: I went to see my sister one day. I didn’t have any shoes on. I believe I was in bare feet. I was just kind of not thinking straight.

 

A few days after Paul’s subway jump, Corrine drove Paul to the emergency department at CAMH, where he was admitted and later transferred to the inpatient Early Psychosis Unit, where he remained for about two months. More recently, he entered the outpatient First Episode Psychosis Clinic.

Dr. Donald Addington, head of psychiatry for the Calgary Health Region in Alberta, says the key to treatment is to address psychosis and substance use issues simultaneously. Most FEP programs assess for substance abuse and then integrate treatment into individual and group counselling, family intervention, cognitive-behavioural therapy, psychoeducation and wellness or recovery groups. Clients who do not respond to integrated treatment are usually referred to substance use programs in the community.

Taking a psychoeducational harm reduction approach is critical. Milliken says that if staff come on too strong, about drinking, for example, it makes building the therapeutic alliance more difficult. It also means that when clients start feeling better and resume socializing, they may stop taking their medication or may not be honest about using substances.

Baker uses expressive arts to help clients explore positive activities. “Often people’s lives have broken down and it’s important to have something to wake up for,” she says. “The arts can inspire a freedom of self-expression that can be healing and transformative.”

 

Corrine: When Paul was in the hospital, we put everything on hold – school, work, our social lives. It was all for Paul, but we needed to do it for ourselves, too, to try to start a family healthy from the start.

 

Family intervention is another evidence-based best practice for FEP. A study published in a 2005 issue of Schizophrenia Research looked at family members participating in family counselling and a short-term family group at the Calgary Early Psychosis Treatment Service. Clients showed significant reductions in moderate levels of stress in the first year; those with more severe stress showed improvement in the second year.

Paul’s father and two siblings attended LEARN’s family psychoeducational group, which Baker facilitates. Families learn about psychosis, including medications, side-effects, symptoms, treatment and relapse. They learn how substances, stress and other factors can trigger psychosis in a person with an underlying vulnerability, and how important it is to take care of themselves.

Families and clients indeed face big challenges, given the double stigma of mental illness and substance use or addiction. Baker says that some families may have a harder time accepting that their loved one has psychosis than a substance use problem, while for others, it’s the reverse. Some families are referred for additional help because they may have their own mental health issues or may be self-medicating to cope with stress. Because alcohol is socially sanctioned and some parents smoke marijuana themselves, clients and their families may not understand why substance use can be problematic. In such cases, Baker explains that for those at risk for psychosis, drugs can exacerbate symptoms and interfere with recovery.

Sometimes families end up feeling like the police and ask for a “hermetically sealed” program where there is no access to drugs, in the hope that once medication begins working, their relative will make better choices. Baker helps families understand that although families can positively impact their relative’s recovery, ultimately, their relative needs to become an active participant in recovery.

 

Paul: I’m just trying to find a job that I can like and work at for a while. Alcohol is a bit of a temptation; my new doctor doesn’t want me to drink. Personally, I know that if I have a beer or two a week, it’s not going to make me go back to using hard drugs.

 

If clients adhere to treatment, 80 to 85 per cent will have a remission of psychotic symptoms, says Milliken. But what about substance use? Few studies have actually examined whether early intervention programs decrease substance use. Existing studies have shown that concurrent treatment does reduce use. The prevalence of substance abuse at the Calgary program dropped in one year from 52 to 33 per cent and continued to decline. In a multi-site study at four Ontario early intervention services, published in a 2007 issue of Schizophrenia Bulletin, substance abuse and use rates were significantly lower after 12 months of treatment.

However, even with treatment, many clients continue to use drugs. A 15-month follow-up study of 103 FEP clients in Melbourne, Australia, showed that only one in five clients ceased substance misuse. However, the study, published in a 2006 issue of Schizophrenia Research, found that among the more than 50 per cent who continued using substances, severity and frequency were reduced. These individuals also tended to be younger, single males who had not completed secondary school and who had more severe cannabis use before entering the program.

The challenge is intensified for clients who use crack cocaine or the stimulant methamphetamine, which has been a significant problem on the West Coast. Approximately 10 to 20 per cent of people who abuse crystal methamphetamine, a form of the drug, develop psychosis, according to Dr. Bill MacEwan, clinical director of the Fraser South Early Psychosis Intervention Program in British Columbia. A one-time high of 50 per cent of MacEwan’s clients taking methamphetamine has now decreased to about 10 per cent, due in part, he suspects, to a major public health campaign. The problem is particularly challenging because stimulants affect parts of the brain involved in cognition, which makes cognitive-behavioural therapy, the basis of most FEP programs, difficult.

MacEwan believes that for young people to stop using drugs, take medication, come to groups and see a doctor regularly requires a “big, big change,” particularly for clients who have no family support or who live in shelters or on the street, or who are involved with the sex trade. Even a client in MacEwan’s program who has family support and who has recently stopped using cannabis and is tapering off of alcohol took two years to engage in treatment.

 

Sabrina: I think Paul’s family has played a large role in believing in him and having hope in Paul’s future, even when things seemed really futile.

 

Recently, Paul started a new job assisting a pastry chef. But the family has also just discovered that Paul has started using drugs again. Corrine understands that relapse is part of recovery and remains committed to supporting Paul. For these families, sometimes what looks like the end of the road to recovery is just the beginning.

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