The Cannabis Psychosis CAP Project Implications for

The Cannabis & Psychosis (CAP) Project: Implications for further Research and Clinical Practice Jane Edwards Mark Hinton Kathryn Elkins Pat Mc. Gorry 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 *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 1 st 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

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

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

Other drugs used at Admission

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 Preintervention End-of-treatment CAP PE Mean (sd) (Med) (df) 49. 9 48. 8 44. 1 47. 7 (16. 3) (17. 0) (13. 8) (18. 2) (49. 0) (42. 5) (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) BDIa 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 (sd) (Med) BPRSa BPRS-PS SANS (sd) (Med) CAP PE F p Mean (sd) (Med) (df) F p 0. 62 0. 44 45. 6 44. 8 0. 01 0. 91 (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) (1, 44) 0. 79 0. 41 0. 25 (sd) (Med) 0. 54 0. 57 0. 78

Results Social Functioning Preintervention CAP PE Mean (sd) End-of-treatment (sd) (Med) So. FA S Out Patient Appts. (Med) 48. 7 49. 8 50. 5 (14. 8) (17. 0) (14. 9) 9. 7 9. 0 13. 4 (5. 4) (8. 8) (6. 8) [9. 0] [12. 0] [10. 0] CAP PE F p Mean (1, 44 11. 8 (6. 4) 51. 3 (17. 2) Follow Up (sd) . 21 . 65 (18. 3) (15. 9) (9. 9) [8. 0] [7. 0] p (1, 44) 9. 3 (11. 4) F 56. 4 11. 6 . 96 (Med) 51. 7. 02 (Med) . 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)