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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.

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


2 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.

3 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

4 U.K. – King et al., 199415% weekly use – Cantwell et al., 199918% current – Gould et al., 200240.5% current German – Hambrecht et al., 199613% lifetime Canadian – Addington et al., 199815% current – Addington et al., 200125% substance abuse DSM IV US – Strakowski et al., 199834% lifetime dependence – Rabinowitz et al., 199830% lifetime Aus – Lambert et al., 200544% current Rates of cannabis use in FEP

5 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)

6 (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:

7 Develop and evaluate a brief intervention for individuals with first-episode psychosis and problematiccannabis use. Aim

8 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

9 Timepoint representation of the Cannabis and Psychosis Project Design Time 1Time 2Time 3Time 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 Non-Users Users Users *Control *Intervention *Randomized

10 Treatment Influences Dual 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

11 Project Consultants Areas 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

12 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

13 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

14 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

15 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 Intervention EPPIC Context: Outpatient Program

16 Psycho-education Control Treatment

17 (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

18 394 Consecutive Admissions Participants 193 –Time 1 complete 193 –Time 2 complete 130 Trial: CAP 23 PE 24 –Time 3 complete 101 –Time 4 complete 75 Refusers 56 Excluded 27 Missed during trial suspension 118


20 Cannabis Use at Admission 57% using in month prior to service entry

21 Other drugs used at Admission

22 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 ATime BTime C THC % days used CAP medians (n=23) Psychoed medians (n=24) CAP means Psychoed means

23 Results -10 0 10 20 30 40 50 60 70 Time ATime BTime C Median % days used THC 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

24 Pre- intervention End-of-treatmentFollow Up CAPPECAPPE CAPPE Mean (sd) (Med) Mean (sd) (Med) Mean (sd) (Med) Mean (sd) (Med) F (df) pMean (sd) (Med) Mean (sd) (Med) F (df) p BPRS a 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) 0.4123.7 (17.2) 19.4 (13.5) 0.34 (1,44) 0.57 BDI a 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) 0.257.5 (6.3) (6.5) 6.3 (7.2) (3.0) 0.08 (1,40) 0.78 Results Psychopathology

25 Results Social Functioning Pre- intervention End-of-treatmentFollow Up CAPPECAPPE CAPPE 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 Out Patient Appts. 9.7 (6.4) [9.0] 9.0 (5.4) [9.0] 13.4 (8.8) [12.0] 11.8 (6.8) [10.0].21.65 11.6 (11.4) [8.0] 9.3 (9.9) [7.0].69.41

26 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

27 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

28 Clinical Implications 1. Engagement – remains major issue in DD and FEP 2. Importance of Psycho-education & working within the Clients Explanatory Model. 3. Cognitive demands of some therapies necessitated action to support cognitive deficits 4. Entertainment – Creative Therapy 5. Beware of Therapy Room Acquiescence

29 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

30 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)

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