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The Cannabis & Psychosis (CAP) Project:
Implications for further Research and Clinical
Practice
Jane Edwards
Mark Hinton
Kathryn Elkins
Pat McGorry
Olympia Athanasopoulos
Kerry Pittman
Susie Harrigan
Michelle Downing
Department of Psychiatry, University of Melbourne &
Early Psychosis Prevention & Intervention Centre.
CAP is funded as a cannabis & psychosis initiative as part of the
“Turning the Tide Strategy” by the State Government of Victoria, Australia.
Background
•
Substance abuse is the most common comorbid
problem First Episode Psychosis
•
Alcohol and cannabis most prevalent substances
•
Cannabis use is associated with earlier onset,
delays in recovery, relapse (Gleeson et al., 1998; Kovasznay et al., 1997;
Linszen et al., 1994; Hides, 2001)
•
Regular use, even at relatively low levels, can
have a negative impact on illness course
Rates of cannabis use in FEP
U.K.
•
•
•
•
–
–
–
King et al., 1994
Cantwell et al., 1999
Gould et al., 2002
15% weekly use
18% current
40.5% current
German
–
Hambrecht et al., 1996
13% lifetime
Canadian
–
–
Addington et al., 1998
Addington et al., 2001
15% current
25% substance abuse DSM IV
US
–
–
Strakowski et al., 1998
Rabinowitz et al., 1998
34% lifetime dependence
30% lifetime
Aus
–
Lambert et al., 2005
44% current
Background
“…treatment strategies have to be
developed to discourage cannabis
abuse by patients with schizophrenia.
Further studies should include
cannabis abuse intervention
programs…”
(Linszen et al., 1994)
Delivery of Effective Interventions Complicated by:
(1)
Split between substance misuse and mental health services
(2)
Cannabis misuse given low priority within substance misuse
services – reduced threat associated with intoxication &
withdrawal, reduced association with crime and violence
(3)
Lack of research into Cannabis interventions
(4)
Pervasive social sense that cannabis is harmless
(5)
Delivery of interventions problematic due to:
(a) Clients using cannabis heavily are constantly in crisis
(b) More difficult to engage than normal difficult-to-engage
client
Aim
Develop and evaluate a brief
intervention for individuals with
first-episode psychosis and
“problematic”cannabis use.
Sample
Inclusion Criteria
• 15-29 years of age
• living in the western region of Melbourne
• first episode of psychosis
Exclusion Criteria
• Organic psychosis
• Learning disability
• Inadequate command of English
Timepoint representation of the Cannabis and Psychosis Project
Design
Time 1
Time 2
Time 3
Time 4
(6-8 weeks/Pre-Intervention)
(Post Intervention)
(6 months)
All Patients
N=193
(Converts - Those former non-users who commence use after admission to EPPIC)
Lifetime
Non-Users
(Converts - Those former users who commence use after admission to EPPIC)
Lifetime
Users
Non-Users
Users
*Control
*Intervention
*Randomized
Treatment Influences
Dual Diagnosis Intervention
Trends
•
•
•
•
•
• Cognitive-behavioral format
• Brief intervention
• Focus on commitment to change
(i.e., motivation)
• Psychoeducation
Long standing condition
Multiple substances
US
Older People
Heavily influenced by literature
on alcohol
Cannabis Use Interventions
• rarely available
• one off sessions
• assisting help seekers
Project Consultants
Areas of expertise
Australia
1st episode psychosis
Dual dx
Cannabis
Young people
• Wayne Hall & Co, NDARC, NSW
• David Kavanagh, Queensland
• Stephen Allsop, SA
International
• Jean Addington, Calgary, Canada
• Martin Hambrecht, Cologne,
Germany
• Roger Roffman, Seatle, USA
• Kim Mueser, New Hampshire, USA
Local
• Turning Point Alcohol & Drug Centre
Inc
• Western Hospital Drug & Alcohol
Services Council
• Australian Drug Foundation
The Intervention
• 10 Sessions of 1:1 therapy undertaken by clinical
psychologists
• 6 structured sessions and 4 semi-structured session of
45-50 minutes
• The explicit goal of intervention was non-problematic
cannabis use
Features of The Intervention
1.
Harm minimisation – Not interested in how much, how
often the individual uses cannabis. Focus on harm or
‘potential’ harm of any use
2. Develop a rationale for change via Psychoeducation –
cannabis use is likely to alter the course of psychotic
illness
3. Motivational Interviewing using ‘Motivational
Enhancement therapy’ approach
4. Goal Setting determines sessions 6-10 (e.g., harm
minimisation/MI approaches for ‘precontemplators’ and
CBT approaches for ‘actioners’)
“Manualised”
Sessions
(1)
Introduction, Assessment and engagement
(2)
Motivational interviewing
(3)
Feedback from MI and development of a statement of
intent
(4-6)
Goal setting, development of a goal achievement
strategy & addressing barriers to success
(7-10)
Considering Lifestyle change & Assessment of
Relapse ‘threats’
* 3-month follow up booster contact
Intervention
EPPIC Context: Outpatient Program
• Care Co-ordination Service
• Onsite crisis team
• Specialist programs
•
•
•
•
•
benefit & accommodation workers
family/carer interventions
focus on treatment resistance (CBT)
group & education program
vocational assessment, placement & support
Control Treatment
• Psycho-education
Hypotheses
(1) Cannabis intervention group will
demonstrate report significantly less cannabis
use than the control condition
As less cannabis associated with better
outcomes
(2) Cannabis group will demonstrate
significantly lower scores on measures of
functioning and psychopathology than the
control condition
Characteristics of Sample (N=193)
Age in years
(mean, S.D.)
Gender
Male
Educational level Tertiary
High School only
Marital status
Single
Diagnostic group
– DSM IV
criteria
Schizophrenia
Schizophreniform
Affective
Schizoaffective
Psychosis NOS
Delusional disorder
Brief Psychotic episode
Country of Birth = Australia
Accommodation Living with family
status
Employment
Student
status
Unemployed
21.7 ( 3.5)
67.4%
25%
75%
89.6%
31.0%
36.5%
19.0%
3.2%
3.2%
2.4%
2.4%
80.8%
63.7%
17%
56%
Cannabis Use at Admission
50
40
30
% of users
20
10
0
nil
<once
week
3-6
week
>once
day
Frequency of Cannabis Use
57% using
in month
prior to
service
entry
Other drugs used at Admission
100
78.6
50
more than
weekly
35.9
25
3.6
1
3.7
3.1
ha
d
ee
sp
pil
ls
oti
ne
roi
n
he
nic
llu
c
ino
oh
ge
n
ol
0
alc
% of users
75
drug consumed
Results
50
THC % days used
40
30
CAP means
20
Psychoed means
10
CAP medians (n=23)
Psychoed medians (n=24)
0
Time A
Time B
Time C
Percentage of days used THC (LOCF): medians and means of CAP and
Psychoed groups at time A, time B and time C
Results
70
Median % days used THC
60
Frequent users: CAP (n=14)
50
40
30
Frequent users: Psychoed (n=13)
20
10
Occasional users:
CAP (n=9)
0
Psychoed (n=11)
-10
Time A
Time B
Time C
CAP and Psychoed stratified by frequency of use at time A: Median % time used THC (LOCF) at
times A, B and C
Results
Psychopathology
End-of-treatment
Preintervention
BPRSa
BPRS-PS
SANS
BDIa
CAP
PE
CAP
PE
Mean
Mean
Mean
Mean
F
(sd)
(Med)
(sd)
(Med)
(sd)
(Med)
(sd)
(Med)
(df)
49.9
48.8
44.1
47.7
0.62
(1,44)
(16.3)
(17.0)
(13.8)
(18.2)
(49.0)
(42.5)
(40.0)
(40.0)
10.3
10.8
8.9
9.5
0.08
(5.4)
(5.2)
(4.8)
(5.4)
(1,44)
28.0
24.7
21.8
23.5
0.70
(16.0)
(13.6)
(14.9)
(14.0)
(1,44)
10.4
8.8
6.2
7.8
1.37
(6.6)
(8.1)
(5.9)
(8.1)
(1,40)
(11.0)
(6.0)
(5.5)
(4.0)
Follow Up
p
0.44
0.79
0.41
0.25
CAP
PE
Mean
Mean
F
(sd)
(Med)
(sd)
(Med)
(df)
45.6
44.8
0.01
(13.5)
(15.4)
(1,44)
(44.0)
(39.0)
9.4
8.8
0.38
(4.6)
(4.8)
(1.44)
23.7
19.4
0.34
(17.2)
(13.5)
(1,44)
7.5
6.3
0.08
(6.3)
(7.2)
(1,40)
(6.5)
(3.0)
p
0.91
0.54
0.57
0.78
Results
Social Functioning
Preintervention
CAP
PE
CAP
PE
Mean
Mean
Mean
Mean
(sd)
SoFAS
Out
Patient
Appts.
End-of-treatment
(sd)
(sd)
(sd)
(Med)
(Med)
(Med)
(Med)
48.7
49.8
50.5
51.3
(17.2)
(14.8)
(17.0)
(14.9)
9.7
9.0
13.4
11.8
(6.4)
(5.4)
(8.8)
(6.8)
[9.0]
[9.0]
[12.0]
[10.0]
F
Follow Up
p
(1,44
.02
.21
.96
.65
CAP
PE
Mean
Mean
(sd)
(sd)
(Med)
(Med)
51.7
56.4
(18.3)
(15.9)
11.6
9.3
(11.4)
(9.9)
[8.0]
[7.0]
F
p
(1,44)
.91
.35
.69
.41
Problems with the study
• Small numbers
• Randomisation problematic
• Psychoeducation – too ‘active’ as control
• Relative expertise of the clinicians in the
intervention versus psychoeducation
• Eppic environment ‘too rich’
Hypotheses regarding results
• Retention in treatment will assist cannabis
reduction
• With symptom reduction, the drive to use cannabis
decreases (self-medication model) (Lambert et al., 2005)
• Brief interventions will have little measurable
impact over the short term on cannabis use
• Psychoeducation is an important component of a
cannabis reduction intervention
Clinical Implications
1. Engagement – remains major issue in DD and FEP
2. Importance of Psycho-education & working within
the Client’s Explanatory Model.
3. Cognitive demands of some therapies necessitated
action to support cognitive deficits
4. Entertainment – Creative Therapy
5. Beware of Therapy Room Acquiescence
Clinical Implications
6. Influence of the Social Environment
7. Importance of Positive Lifestyle Change
8. Specialist Sub-Groups
9. Skill deficits
10.Termination & Booster Sessions
Future Research
• Replication outside enriched EPPIC environment
• Replication with change including:
– stratifying on the basis of level of use at randomisation
– change control group possibly against TAU
– increasing sessions (frequency?)
– increasing length of follow up
– Consider eligibility criteria & target recruitment (e.g.,
identify those willing to participate rather than
consecutive admissions)