Oeqri4l Qo'Oulato*substance use among the patients with First Episode psychosis

*Ahsan Msr, Mutrick MS2, Begum K3, Arafat sM4, shah MAs, podder BR6, Roy J?

Substance Use Disorder is a frequent problem in Bangladesh and rnany of these patients developpsychosis' Substance use can cause psychosis and it-can modify it"'"oo.r" of psychosis. Thiscross-sectional study was done to see the proportion of substrance use in patients with -FirsrEpisode

Psltusis (FEP) in t-w9..1er1iar1 care-hospitals in Dliaka, n-giJo"rt menrioned here asBagabandhu Sheikh Mujib ,Medical univeisity and Dhad Medical College Hospital; llomNovember 2oo7 March 2009. Fifty consecutive FEr pme*s were taken as subjJcts and50 healthyattendants were recruited as control. Mean age of tie patlents was 2i.il, male (62vo) are morehaving first-episode psychosis than female ts8zO. N{qioi,ity,of the patients were unmarrie d (64vo).Regarding occupation students were 34vo, followed-by-unemployed Z|vo and servicelgTo. Incontrol group's occupation; service 34vo, housewlfe ?ivo. Lifi time substance use was founddouble in patients with.first-episode psychosis than corurol. can uuir was rouno to be the mostcommon substance causing psychosis. Among the lifetime substance users in fist-episode psychosispatients 77.78vo were male where as, in control group l007o patients were male. However, theresearcher did not find any of the first-episode psychoiis patienis taking current use of substance(abuse and /or dependence). The small size or tte pr"sent study was oily 50. Future prospectivestudy is required having large sample size to see the outcoine of substance use in first-episodepsychosis.

tMymensingh Med J 2018 Apr;27 (2):313_320)

Key words: First episode psychosis, Substance abuse, Cannabis

Introduction

fflhe rerm psychosis historically received a

t number of different definitions, none ofr which has achieved universal acceptance.The narrowest detinition of psychosis is restricted.to the symptoms of delusions and/or prominenthallucinations, with the hallucinations octurring inthe absence of insight into their pathologicalnature. Broader definition that also includes otherpositive symptoms of Schizophrenia (i.e.,disorganized speech, grossly disorganized behavioretc.). The term substance use disorder is a clusterof cognitive, 'behavioral and physiologicalsymptoms indicating that the individual continuesusing the substance despite substance-relatedproblemsr. According to DSM-IV TR, substancerefers to a drug of abuse, a medication, or a toxin.The substances can be classified according toDSM-IV TR into 11 classes: alcohol, amphetamineor other sympathomimetics; caffeine; cannabis;cocaine; hallucinogens; inhalants; nicotine;opioids; phencyclidine(PCp) or similarly actingaryl cyclohexylamines; and sedatives, hypnotics, or

Mymensingh Med J 2018 Apr;27 (Z)

l. *Dr Mohammad Shamsul Ahsan, AssistantProfessor, Department of psychiatry,Bangabandhu Sheikh Mujib Medical University(BSMMU), 'Dhaka, Bangladesh; E-,tnail:.

2. Professor Dr Mohammad SI Mullick, professor,.Department of Psychiatry BSMMU,

'Ohoko,

Bangladesh3. Dr Khaleda Begum, Assistant professor.,

Department of Psychiatry, Dhaka MedicalCollege, Dhaka, Bangladesh :

a. lr SM Yasir Arafat, Resident, Department ofPsychiatry, BSMM U, Dhaka, Banglatlesh

5. Dr Md Mohsin Ali Shah, Associate professor,Department of, Psychiatry, BSMMU, Dhaka,Bangladesh

6. Dr Bidhan 'Ranjan Roy podder, AssociateProfessor, ' Department of psychiatry,Mymensingh Medical College, Mymensingh,Bangladesh

7. Dr Jotirmoy Roy, Associate professor,Department of Psychiatry, Rangpur MedicalCollege, Rangpur, Bangladesh

*for correspondence

313

OdrdralThe relationship of substance use and psychosis iscomplex. Many a time's substa.r"" ur"lritiutes theonset of psychosis. Other way round psychoticpatients have more chances oi using substance.Misuse of substances like cannabis, nJoin, alcoholand other elicit drugs is gommon among peo.plewith psychotic illnesses3.a. There is -gqw1-ng

number of researches showed ttre possfr{i.pausallinks between cannabis and psyc-hosiss:1,.,kr anepidemiological representalive itudy in U&,.highprevalence of substance use was reporfed fupcaptewithf irstepisodepsychosis.t*,tirnepr*,*e:..(not

-using currently but at some point of time-they

satisfied the criteria of substance use disorder) ofsubstance use among the First-Fpisoae psyptrosis(FEP) was 55.3Vo where as in general popirtition ofsubstance use was L3Vo in UK. In thi same studycurrent substance use (defined as substance use iirlast 30 days) was detected 29Vo in first episodepsychosis ,as compared to l3Eo of the generalpopulation/. Among Dutch population, researchshowej that cannabis use causes much earlier onsetof schizophrenia8. In Bangladesh, a communitybased prevalence study was done on awareness andattitude towards mentally ill patients, conducted byNationai Institute of Mental Health in year 2OO3_2005. This study showed that substancedependence was 0.6Vo and psychosis was l.l?oe.Emphasis has. been given on the use of substanceuse and earty orrcet of psychosis. In Bangladesh,the issue ofsubstance use in first episode psychosiswaS :not: addrdssed adequately.The objective of the present study was to seewhether the proportion of current and life timesr$stano'e use were more among the patients withfirsGepisode psychosis than controli. types ofsubstances used were also seen.

This was a cross-sectional study. patients, wererecruited from the department of psychiatry ofBangabandhu Sheikh Mujib Medicil University(BSMMU)'& Dhaka Medicat College Hospitil(DMCH) from both in-patients & out-patients.andthis study was carried out from November. 2007March 2009. These patient socio-demographic ddtawere obtained from the patient or their,reliableinformant. They were assesseil in more than,oiiesession to reach diagnosip, Structured interviewwere carried out by psychiatrists in the study places

Mymensingh Med J 2018 Apr;27 (2)

by applying structured clinical InterviewDSM criteria-Clinical Version/patient \(SCID-CV). Diagnoses of thesJ patients

substance use was ascertained by the aboveSimilarly Structured Clinical Interview usingcriteria- Non parient version (SCID_NP|applied- to- control group who were assignedrartdomly from the attendants of patients in thabove mentioned hospitals.(BSMMU & DMCII).The participants were clearly informed about tbfiatafe.6T:the,stu*y "&I{d {+s,.scope and .tirnitctim"Written, thumb impression or verbal consent w6obtained from the patients. If the patient was not itra position to give a valid consent (e.g., psychoticpatienl with no insight or Catatonic Sitrlioptrenitetc.), informed consent were obtained from thlegal guardian. Another written signature or thumbimpression was taken from a witness whwitnessed while giving consent. Fifty consecutirrecases attending the above mentioned institutes in

assigned according to DSM-IV_fif. Life

or negative symptom, and affective psychoses werGincluded. Patients having first continuous episodc

the specified time were taken as sample. Age andsex matched control group consists of 50 hialthyvolunteers, who did not suffer from any physical amental illness were also randomly selected fromthe attendants in these hospitals. All adult patientsage 18 and above were included in the studyirrespective of sex, ethnicity or religion. AIIpatients reporting for the first time having positive

for long time {not more than six monthi; brnremained untreated were also included. psychoticpatients who were intellectually disablej wercexcluded. Substance induced psychosis patienBwere also excluded. Purposive sampling techniquewas used._ The case registrar (in the study places)were used as a sampling frame, the diagnoses offirst episode psychosis were confirmed initially bya qualifi ed psychiatrist.This questionnaire consists of socio-demographicvariables and other questions relevant for this studylike name of psychoactive drugs used, age at firstintake, frequency of the drug of abuse oi ur", ug.at first ever psychotic symptoms, duration ofuntreated illness etc. This questionnaire was pre_tested among IOTo of the sample. Little necessarycorrection was done. Then corrected questionnaircwas applied to the patients.

Psychiatric interview was done by using SCID bythe consultant psychiatrist and diagnoses wereassigned by using DSM-MR. Substance Use,Dependence and Abuse disorders were identifiedsimilarly the researchers using SCID-CV & SCID-NP.

For the statistical analysis, Microsoft windowsbased software products will be used (SPSS 13,SPSS incorporation, Chicago, IL, USA). Statisticalanalysis will be done and presented as frequencyand percentage" and qignificance of data wjll bedetermined by appropriate statistical tests such as,chi square and student't' test.

ResultsThe main objective of the current study was to see

the lifetime substance use among the patients andcontrol groups. In order to get 50 patients we hadto approach 63 patients. Nine patients had positivesymptoms (delusions and hallucination) andcurrent substance use; were excluded from thestudy as they were found as substance relatedpsychosis on subsequent sessions. Two patientswere having cognitive dysfunction and lack ofreliable informants therefore excluded from thestudy. The remaining two patient's socio-demographic data sheet was obtained on first dayand they did not attend in subsequent session$.Participation rate was found 7 9.367o.

In present study we failed to get any of the first-episode psychosis patients having currentsubstance (within last 30 days) abuse ordependence. All of the patients (9) having currentsubstance use or dependence were subsequentlyexcluded from the study for their diagnosissubstance induced psychosis. Among the controlpopulation one patient was found to have currentsubstance (phensedyl) intake but not abuse.Therefore, comparison of current substance useamong FEP patients and control group was n6tpossible.

The mean age of patients (27.24t9.671) years waslower than that of healthy control (32.71=9:Ml)-

Table I shows among the FEP patient's majoritywere male both in patients (62Vo) and controls(72Vo). Regarding education; among the patients 20patients (407o) studied up-to SSC level; 15 patients

Mymensingh Med J 2018 Apr;27 (2)

O,,r*al eodurcdrr',(307o) completed primary level. Among the controlgroup 20 (407o) patients completed up to SSClevel, 17 (34Vo) patients complEted gqaduation leveland above and 9(l8Vo) patients completed primarylevel. Bpgarding occupation of the patients,studenrs 17(34%) topped the list, followed byunemployed l2(24vo), service O9(I8Vo), house wifeA7Q4Vo). Regarding, occupation of control group,service was highest l7(347o), followed by house

wifs lL(Z2Vo), business 9(l8Eo). The patients camegqually qane froqr urban and rural areas. (507o

from each place) where as TOVo of the control came,from urban areas. Majorities were Muslim in boththe patients (947o) and control gtoup (9OVo).

Among the patients 32(64Vo) were foundunmarried and only l5(3OVo) were married. Whereas, among control 3l(627o) iratients were marriedand only l9(387o) were found unmarried.Regarding Socio-economic status of the patients28(56Vo) patients belong to middle class andl9(387o) patients belong to lower class and onlyO3(67o) patients belong to upper class. One (l)where as, O9(187o) patients belong to upper class,27(54Vo) belong to middle class and l4(28Eo)patients belong to lower class.

Table II shows that among 50 first-episodepsychosis (FEP) patients, 17 (347o) had mooddisorders, 28 (56Vo) had schizophrenia and otherpsychotic disorders and 5 (107o) had psychoticillness not other wise specified (NOS).

Table III shows that among the mood disorderpatients (n=17), bipolar affective disorder currentlymanic with psychotic feature was 13(76.57o) where&S, major depressive disorder with psychoticfeature was found 0aQ3.5Vo). i

In Table IV among the 50 patients with FEP, 28.

patients had schizophrenia and other psychoticdisorders (except psyphotic disorder not other wisespecified). Of them, 16(57.l%o) patients werediagnosed as schizophreniform disorder, 5(l7.9Vo)patients were diagnosed as briefpsychotic disorderuad 2(7.1?o) patients were. diagnosed as

schizophrenia. Three (IO.7Vo) patients . haddelusional disorder and2(7.17o) were diagnosed as

Psychotic disorder due to General MedicalCondition (psychotic disorder due to GMC).

ll

O,*4r&lTable I: Distribution of socio-demographic variables

Characteristics Case ControlVoNo.%No.

SexMaleFemaleEducational statusIlliteratePrimaryUp to secondaryDegree or aboveUp to Higher SecondaryOccupationUnemployedStudentHousewifeFarmerBusinessServiceOtherS oc i o - ec onomic c ond i t io nUpperMiddleLowerHabitatUrbanRuJal, '

ReligionIslamHinduismOthersMarital statusUnmarriedMarriedSeparatedDivorcedWidowed

31 62.0t9 t:,=' 38.0

'r i i!.:ri':0l :ivrs*.92.6

ls eH#tO.OZA r,iiffqtp.O13.,siUS.,26.60l ,'i in&t 92.6

''.iqr-r*{i '

12 "i.surtiS. 24.917 ii=fiiE:,i 34-0O7' '";': :'1 14.003 : ": 06.0@ : "' '',-" 04.009 r8.000 I oo.o

06.056.038.0

50.050.0

94.004.002.0

64.030.002.002.002.o

3515

450302@

t931

000000

04.018.040.034.004.0

08.014.022.002.018.034.002.o

18.054.O

28.0

70.030.0

90.0'06.004.0

38,062.000.000.000.0

0.288

0.006**

0.151

0.041*

0.749

0.018*

72.028.0

36l4

6z0920t702

040711

010917

01

0927I4

o328t9

2525

470201

3215

01

010l

I

xp<0.05 & ** p<0.01; Chi-square test applied for test of significance

Table II: Major psychiatric disorder in FEP

Psychiatric Diqorder Number of patient (n) Percentage (7o)

Myarensingh Med J 2018 Apr;27 (2)

,, 50

Mood disorder

$chizophrenia and other psychotic disorderPsychotic disorder NOSTOtal . r:".i !. : , :'

L7

2805

34.056.010.0

100.0

O,u?aral QooAtaa'oTable III: Types of mood disorder among FEp

of mood disorder Number of nts (n)Bipolar disorder (manic with psychotic featureMDD* with psychotic featureTotal

13

0417

MDD-Major Depressive Disorder*

Table fV: Schizophrenia and other psychotic

SchizophreniaSchizophreniform disorderBrief psychotic disorderPsychotic disorder due to GMC*Delusional DisorderTotal

efuu1605020328

ients ( Percent01.157.t17.907.tt0.1

100.0

GMC* -General Medical Condition :

Table V: Lifetime substance use in FEp and conffol

Lifetime substance use FEP Control P valueNo. 7oNo.Vo

PresentAbsent

0941

18

3236.064.0

18.0

"82.O

0.043*

xp<0.05; Chi-square test applied for test of significance

The above table shows that life time substance use was found among 18 patients of first-episode psychosis,whereas the rate was present in 9 subjects in conffol group.

Table VI: Life time substance use disorder in FEp & control

ControlSubstance related disorderOpoid dependance

Benzo dependance

Cannabis dependence

Yaaba dependence*x

Alcohol abuse

Cannabis abuse

Phensidyl abuse

(n=18)x

II9

1

2

4

I

Vo

05.6

05.6

50.0

05.6

11.1

22.2

05.6

(n=09)*

0

0

0

0

1

J

2

7o

00.0

00.0

00.0

00.0

63.6

27.3

18.2

x*Yaaba is amphetamine containing substance; xmultiple response

Table VI shows that most of the cannabis use disorder is more among the patients and Alcohol use disorderis more among the controls. Among the FEP patients cannabis use is-most prominent. . Nine (502o) patientswith FEP had life time cannabis dependence and 4(22vo) patients have cannabis abuse disorder. About7(63.66Eo) of the controls with life time substance use disordlr had alcohol use problems.

Codeine containi

Mymensingh Med J 2018 Apr;27 (2) 317

7T

OaqtalQodddr"'aAmong the patients with first-episode psychotic patients (18), 14 were male and 4 were female. Among the

control group all the 9 patients were male; no female patients had lifetime substance use history.

@ Case I Gontrol

oE,,IE

640ooo-

PhensidylYaaba AlcoholBenzo Cannabis

Figure l: Substance use (both abuse & dependence) percentage of case (FEP; n:1 8) and control (n:09)

Figure 1 shows that among the case (first-episode psychosis patitjnts) 72.22% had cannabis use (both abuse

& dependence) where as,33.33Yo ofthe control had cannabis use (both abuse and dependence). However,

p.oportio, wise alcohol use was found more among the conhol (77.78%) group than FEP patients

1tt-.tt[1. Among the FEP patients each of opoid users (heroin and buprinorphine), benzodiazepite, yaaba

& phensidyl had 5.5% substance use; whereas, no control had opoid, benzo or yaaba use disorder.

mean age of the co-ntrolwas32.7l+9.441.The age

of FEP patient group is significantly lower thancontrol group. The control group was taken fromdifferent wards randomly. The reason of thisdifference may be multi factorial. It may be due tothe reason psychosis starts in early twenties orshort sample size of the both case and control. Itmay simply be a fault of recruiting relatively agedpopulation among the controls.Regarding occupation ofthe patient and control; inpresent study unemployed were 24o/o in FEPpatients where as, only 8% among controls.Besides, 34o/o of patients of FEP were students and

odry l4%o in control. However, highest respondents

among control group were service holder (34%)and that in patients were l8ol0. There is statisticallysignificant difference in patient and control. The

DiscussionThis cross-sectional study was done to see the lifetime substance use among the patients with first-episode psychosis and healthy hospital affendants

in the study places. The expected study period was

initially November 2007 lp to July 2008. Only the

persons having age 18 and above were includedwho ever developed psychosis for the fust time.Control's age was similarly 18 and above.

Among the patients with first-episode psychosismajority were male (31 out of 50; 62%). However,36(72%) healthy control were male and l4(28%o

were female). Presence of male patients indicates

their willing ness to take treatment or it may be due

to the fact that these facilities were more accessible

to male patients than female patients. The age ofthe patients with FEP was 27 -24+9'671 where as

Mymensingh Med J 2018 APr; 27 (2) 318

reason of unemployment more in patients may bedue the disease process causing incapacity. Amongthe patients with FEP, patients came equally fromurban & rural areas. Where as, TOVo of theattendants were from urban and 3OVo from ruralareas; which is statistically significant. Regardingreligion both the patients (947o) and conttol (90Va)

showed Muslim majority. About 647o of thepatients with FEP were unmarried in comparison to38% of control who were unmarried. Thisdifference is statistically significant. It may be dueto the fact that the premorbid personality, lack ofsocial engagement, oddity of behavior can be theunderlying reasons.In the present study 18 (367o) first-episodepsychosis patients had life time history ofsubstance use (both abuse and dependencedisorder); where as only 9(187o) persons in thecontrol group had life time history of substance useThe overall life time proportion of substance use inpeople with first-episode psychosis was founddouble than that in the control. This difference isstatistically significant (p<0.05). In one UK basedstudy the overall substance misuse was found to be37Vo among first-episode psychosis patients whichis almost equal to what we get in present studyl0. Inanother UK based epidemiological study, 66.38Voof the first-episode psychosis patients had lifetimesubstance abuse/dependence'. So, our finding ofmore lifetime substance use among patients withfirst-episode psychosis than control group; isconsistent with western studies.Among the patients with FEP life time cannabisuse disorder was found to be 72.22Eo among allclass of drugs abused (13 out of 18 patients).Lifetime cannabis use was tbund around 33Vo (3out of 9 controls) in control group. In UK basedepidemiological study cannabis use anytime in lifewas found to be around 807o second to alcoholabuse disorder. However, cannabis dependence orabuse was only 50.87o. Life time alcohol abuseand/or dependence were found to be ll.ll%o inFEP where as; in control group it was 77.78Vo (7out of 9 patients). This proportion is higher inconffol group than patients; the reason is not clear.Small sample size may be a reason. In westernstudies alcohol abuse and/or dependence was foundhighest in patients with FEP. Alcohol intake is partof their social norms. This may be the reason whyin a country with Islamic background alcohol abuse

Mymensingh Med J 2018 Apr;27 (2)

is not seen to be highest abusing substance. Therate of patients taking opoid, benzodiazepine,yaaba, phensidyl was 5.5Vo (1 in 18 patients) eachin FEP. However, the researcher failed to get anyofthe controls getting opoid drugs, benzodiazepineand Yabba (a class of illicit drug containingcaffeine and amphetamine) in their life time. It maybe due to small sample size. In UK based study,mote than half (n=68, 55Vo) had used Class A&ugs like ecstasy, heroin, crack or cocaine,methadone etc. We know.substance like Yaaba,eoeaine and heroin are expensive drugs. In presentstUdy the 387o patients with FEP had income lessttrmn 5000/month and 56Vo patients had income5000-1000 BDT/month. So, these drugs were notused by the patients with FEP.In this study cannabis abuse and dependence wasfound to be the highest which is consistent withstudies done abroad6' 8.

In present study, among the 50 FEP patients,17(347o) had affective psychosis (mood disorderwith psychotic feature), 28(56Vo) patients had non-affective psychosis like schizophrenia and otherpsychotic disorder and only S(lOVo) had psychoticdisorder NOS. Among the patients with affectivepsychosis, 13 patients had Bipolar I disorder(single manic episode) with psychotic featurewhere as, 4 patients had major depressive disorder(MDD) with psychotic feature. Among the non-affective psychosis patients we foundschizophrenia 2, schizophreniform disorder 16,

brief psychotic disorder 3, delusional disorder 3 ,

psychotic disorder due to general medicalcondition (GMC) 2 patients.In a longitudinhl naturalistic out come study inCanada, out of 151 patients with FEP; affectivepsychosis was found in24 patients (L6Vo) where as,

schizophrenia-spectrum disorder was found in11O(737o) patients and psychotic disorder NOSwas found among l7(ll7o) patientsll. In anotherUK based epidemiologically representativetreatment sample schizophrenia andschizophreniform psychoses was found in35(32.7IVo) patients, mood disorders in37(34.57Vo) patients and psychotic disorder nototherwise specified h 37(34.577o) patients. Herepsychotic disorder NOS included cases where itwas unclear whether the psychosis was druginduced6. Another UK based prevalence study ofsubstance misuse in FEP found schizophrenia-

3t9

T

Odto,al eodd&bospectrum disorder 63.57o (schizophrenia 33.lVo,delusional disorder 8.4Vo, acute psychosis IB.gVo,schizo-affective disorder 3.2Vo), mood disorderwith psychotic feature 24.27o (manic psychosis13.6%, depressive psychosis LO.4Vo). However,this study included Substance related psychosiswhich was found to be 8.47o. In present sttrdysubstance induced psychosis was excluded. Weltidnot get any schizo-affective disorder in our studp

Limitations of the study " "1.,

Sample size was small and study was co@.fuonly at two tertiary level hospitals in Dhal<a @y.Separate substance dependence clinic/ward areabsent in above mentioned hospitals, EWlyIntervention clinic is not present during the tirme ofstudy in above mentioned study places. So,generalization of the study findings is not possible.Another potential limitation of present study is thatbelow 18 years were excluded from both thepatients and control groups. Therefore, substantialproportions of individuals who have onset ofpsychosis prior to 18 years of age and/or startingtaking substance(s) below that age; were excluded.As a result these factors consequently shift thecontents of intervention away from youth issues.Diagnosis of current and lifetime substance usedisorder were done after information gathered frompatient or their reliable informant, investigationfinding (urine assay for substance etc.,) were notdone on the patients; Ieading to possibleunderreporting. In a country like Bangladesh wheremajority are Muslim, people might be reluctant totalk about their substance use pattern.

ConclusionThis study showed that lifetime alcohol andsubstance abuse/ dependence disorder is double inpatients with first-episode psychosis than age andsex matched healthy control group. However,present study failed to compare the currentsubstance use pattern in patients with FEp andcontrols due to small sample size. Among thepatients with First Episode Psychosis, Cannabiswas found to be the most commonly usedsubstance followed by alcohol and phensidyl.Substance use was found more among malepatients than female patients. This study will

provide baseline data of substance use inpatients for fi.rther studies.

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Mymensingh Med J 2018 Apr;27 (2)

services for first-episode psychosis and