The Cannabis & Psychosis (CAP) Project: Implications for further Research and Clinical Practice Jane Edwards Mark Hinton Kathryn Elkins Pat McGorry Olympia.

The Cannabis & Psychosis (CAP) Project:Implications for further Research and Clinical

Practice

Jane EdwardsMark Hinton

Kathryn ElkinsPat McGorry

Olympia AthanasopoulosKerry PittmanSusie 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.

• 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

Background

U.K.– King et al., 1994 15% weekly use – Cantwell et al., 1999 18% current – Gould et al., 2002 40.5% current

• German– Hambrecht et al., 1996 13% lifetime

• Canadian– Addington et al., 1998 15% current – Addington et al., 2001 25% substance abuse DSM IV

• US– Strakowski et al., 1998 34% lifetime dependence – Rabinowitz et al., 1998 30% lifetime

• Aus– Lambert et al., 2005 44% current

Rates of cannabis use in FEP

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)

(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

Delivery of Effective Interventions Complicated by:

Develop and evaluate a brief intervention for individuals with first-episode psychosis and “problematic”cannabis use.

Aim

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 PatientsN=193

(Converts - Those former non-users who commence use after admission to EPPIC)LifetimeNon-Users

(Converts - Those former users who commence use after admission to EPPIC)

Lifetime Non-Users Users

Users *Control

*Intervention

*Randomized

Treatment InfluencesDual Diagnosis Intervention

• 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

Trends

• Cognitive-behavioral format

• Brief intervention

• Focus on commitment to change (i.e., motivation)

• Psychoeducation

Project ConsultantsAreas of expertise

1st episode psychosis

Dual dx

Cannabis

Young people

International• Jean Addington, Calgary, Canada

• Martin Hambrecht, Cologne, Germany

• Roger Roffman, Seatle, USA

• Kim Mueser, New Hampshire, USA

Australia• Wayne Hall & Co, NDARC, NSW

• David Kavanagh, Queensland

• Stephen Allsop, SA

Local• Turning Point Alcohol & Drug Centre

Inc

• Western Hospital Drug & Alcohol Services Council

• Australian Drug Foundation

• 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

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’)

Features of The Intervention

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

“Manualised”

• 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

InterventionEPPIC Context: Outpatient Program

• Psycho-education

Control Treatment

(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

Hypotheses

Characteristics of Sample (N=193)

Age in years (mean, S.D.) 21.7 ( 3.5) Gender Male 67.4% Educational level Tertiary

High School only 25% 75%

Marital status Single 89.6%

Diagnostic group – DSM IV criteria

Schizophrenia Schizophreniform Affective Schizoaffective Psychosis NOS Delusional disorder Brief Psychotic episode

31.0% 36.5% 19.0% 3.2% 3.2% 2.4% 2.4%

Country of Birth = Australia 80.8%

Accommodation status

Living with family 63.7%

Employment status

Student Unemployed

17% 56%

Cannabis Use at Admission

0

10

20

30

40

50

nil <onceweek

3-6week

>onceday

Frequency of Cannabis Use

% of users

57% using in month prior to service entry

Other drugs used at Admission

35.9

1 3.6

78.6

3.7 3.1

0

25

50

75

100

drug consumed

% o

f u

se

rs

more thanweekly

Results

Percentage of days used THC (LOCF): medians and means of CAP and Psychoed groups at time A, time B and time C

0

10

20

30

40

50

Time A Time B Time C

TH

C %

day

s u

sed

CAP medians (n=23)Psychoed medians (n=24)

CAP means

Psychoed means

ResultsResults

-10

0

10

20

30

40

50

60

70

Time A Time B Time C

Med

ian

% d

ays

use

d T

HC

Frequent users: CAP (n=14)

Frequent users: Psychoed (n=13)

CAP (n=9)

Psychoed (n=11)

Occasional users:

CAP and Psychoed stratified by frequency of use at time A: Median % time used THC (LOCF) at times A, B and C

  Pre-intervention

End-of-treatment Follow Up

  CAP PE CAP PE     CAP PE    

  Mean(sd)

(Med)

Mean(sd)

(Med)

Mean(sd)

(Med)

Mean(sd)

(Med)

F(df)

p Mean(sd)

(Med)

Mean(sd)

(Med)

F(df)

p

BPRSa 49.9(16.3)

(49.0)

48.8(17.0)

(42.5)

44.1(13.8)

(40.0)

47.7(18.2)

(40.0)

0.62(1,44)

0.44 45.6(13.5)

(44.0)

44.8(15.4)

(39.0)

0.01(1,44)

0.91

BPRS-PS 10.3(5.4)

10.8(5.2)

8.9(4.8)

9.5(5.4)

0.08(1,44)

0.79 9.4(4.6)

8.8(4.8)

0.38(1.44)

0.54

SANS 

28.0(16.0)

24.7(13.6)

21.8(14.9)

23.5(14.0)

0.70(1,44)

0.41 23.7(17.2)

19.4(13.5)

0.34(1,44)

0.57

BDIa 10.4(6.6)

(11.0)

8.8(8.1)

(6.0)

6.2(5.9)

(5.5)

7.8(8.1)

(4.0)

1.37(1,40)

0.25 7.5(6.3)

(6.5)

6.3(7.2)

(3.0)

0.08(1,40)

0.78

ResultsPsychopathology

ResultsSocial Functioning

  Pre-interventio

n

End-of-treatment Follow Up

  CAP PE CAP PE     CAP PE    

  Mean

(sd)(Med)

Mean

(sd)(Med)

Mean

(sd)(Med)

Mean

(sd)(Med)

F(1,44

p Mean

(sd)(Med)

Mean

(sd)(Med)

F(1,44)

p

SoFAS

48.7

(17.2)49.8

(14.8)50.5 (17.0)

51.3(14.9) .02 .96

51.7 (18.3)

56.4

(15.9) .91 .35

OutPatien

tAppts.

9.7 (6.4)

[9.0]

9.0 (5.4)

[9.0]

13.4

(8.8) [12.0]

11.8

(6.8) [10.0]

.21 

.6511.6

(11.4) [8.0]

9.3 (9.9) [7.0]

.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)