Faculty Bibliography

BACKGROUND: Increasing reports of synthetic cannabinoid (SC)-related adverse events have largely comprised case reports and analyses of calls to poison control centers. Existing studies have also mostly involved white male populations. OBJECTIVES: The purpose of this study is to systematically describe clinical characteristics of SC use in a relatively large, diverse, urban sample presenting to a psychiatric emergency setting. METHODS: SC users (n = 110) were identified by reviewing charts (n = 948) from the psychiatric emergency service of a large, urban public hospital in the United States for November 2014, which was randomly selected from the 12 months of that year. Sociodemographic data were collected from administrative databases and clinical data were collected from the electronic medical record. RESULTS: SC users were mostly non-white (90.0%) males (95.5%), who were likely to be police-involved (34.5%) and homeless (84.5%). SC users also had significant and often pre-existing psychiatric and substance use comorbidity, including acute psychotic symptoms (70.0%), more than one comorbid psychiatric diagnosis (31.8%) and primary psychotic disorder diagnosis (40.0%), past psychiatric visits to the hospital (70.9%), comorbid substance use (62.7%), agitation requiring intervention (22.7%), and the need for extended psychiatric observation (15.5%) and inpatient admission (34.5%). Relatively limited medical complications were identified. Conclusions/Importance: In this sample, SC use affected a sociodemographically disadvantaged and mentally ill population, likely exacerbating existing psychiatric problems. This is one of the only studies to systematically examine the clinical effects of SC use in a significant clinical sample, and the first study in an urban, racial/ethnic minority, and vulnerable sample.

BACKGROUND: Growing evidence of adverse outcomes following synthetic cannabinoid use has engendered interest into populations at risk. The existing literature reports that synthetic cannabinoid use is predominant among young, white males. However, reports from local Departments of Health have found contrary evidence, showing that synthetic cannabinoid use is prevalent in populations other than those of young, white men. OBJECTIVES: This study sought to examine sociodemographic characteristics associated with self-reported synthetic cannabinoid use among a clinical psychiatric population within a public hospital in New York City. METHODS: A cross-sectional medical record review was conducted on synthetic cannabinoid users and non-users in an emergency psychiatric setting. A total of 948 patients who presented at the emergency psychiatric setting in 2014 were included in this sample, 110 (11.6%) of whom were synthetic cannabinoid users. Logistic regressions were used to determine the sociodemographic correlates of synthetic cannabinoid use. RESULTS: The most prominent correlate of synthetic cannabinoid use was homelessness/residing in a shelter during time of treatment (AOR = 17.77, 95% CI = 9.74-32.5). Male (AOR = 5.37, 95% CI = 2.04-14.1), non-white (AOR = 2.74, 95% CI = 1.36-5.54), and younger age (AOR = .961, 95% CI = .940-.980) were also significant correlates of synthetic cannabinoid use. CONCLUSION: Synthetic cannabinoid use among the homeless and mentally ill is a growing public health concern, representing a population with unique clinical and social needs. Areas and populations with high rates of homelessness should be targeted for synthetic cannabinoid prevention and treatment efforts, particularly in urban and racial/ethnic minority communities.

Substance use disorders are prevalent co-occurring problems among people with schizophrenia, with lifetime rates approaching 80% in this population when tobacco use is taken into account. Substance use disorders are associated with significant adverse effects among people with schizophrenia, including worse psychiatric symptoms, lower functioning, and increased medical morbidity and mortality compared with schizophrenia patients without co-occurring substance use. The etiology of this relationship is multifactorial, involving neurobiological, genetic, and environmental factors. The substances most commonly used by people with schizophrenia are tobacco, alcohol, cannabis, and cocaine. Screening, diagnosis, and treatment of substance use disorders are important and can have significant effects on clinical outcomes. Treatments for comorbid disorders include psychopharmacological, psychotherapeutic, and multidisciplinary interventions. Several medications have been approved by the U.S. Food and Drug Administration for the treatment of substance use disorders, which also appear to be helpful for patients with schizophrenia, although few controlled trials have been conducted specifically in this population. Psychosocial and psychological interventions have been adapted for use among patients with schizophrenia as well. Treatment of both psychotic illness and substance use disorders in an integrated way improves functional and clinical outcomes.

A convergence of evidence shows that use of Cannabis sativa is associated with increased risk of developing psychotic disorders, including schizophrenia, and earlier age at which psychotic symptoms first manifest. Cannabis exposure during adolescence is most strongly associated with the onset of psychosis amongst those who are particularly vulnerable, such as those who have been exposed to child abuse and those with family histories of schizophrenia. Schizophrenia that develops after cannabis use may have a unique clinical phenotype, and several genetic polymorphisms may modulate the relationship between cannabis use and psychosis. The endocannabinoid system has been implicated in psychosis both related and unrelated to cannabis exposure, and studying this system holds potential to increase understanding of the pathophysiology of schizophrenia. Anandamide signaling in the central nervous system may be particularly important. Delta9-Tetrahydrocannabinol in cannabis can cause symptoms of schizophrenia when acutely administered, and cannabidiol (CBD), another compound in cannabis, can counter many of these effects. CBD may have therapeutic potential for the treatment of psychosis following cannabis use, as well as schizophrenia, possibly with better tolerability than current antipsychotic treatments. CBD may also have anti-inflammatory and neuroprotective properties. Establishing the role of CBD and other CBD-based compounds in treating psychotic disorders will require further human research.

OBJECTIVE: The purpose of this study was to examine racial-ethnic differences in use of mental health treatment for a comprehensive range of specific disorders over time. METHODS: Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were used to examine adult outpatient mental health visits to U.S. physicians from 1993 to 2008 (N=754,497). Annual visit prevalence for three racial-ethnic groups was estimated as the number of visits divided by the group's U.S. population size. Visit prevalence ratios (VPRs) were calculated as the minority group's prevalence divided by the non-Hispanic white prevalence. Analyses were stratified by diagnosis, physician type, patient characteristics, and year. RESULTS: VPRs for any disorder were .60 (95% confidence interval [CI]=.52-.68) for non-Hispanic blacks and .58 (CI=.50-.67) for Hispanics. Non-Hispanic blacks were treated markedly less frequently than whites for obsessive-compulsive, generalized anxiety, attention-deficit hyperactivity, personality, panic, and nicotine use disorders but more frequently for psychotic disorders. Hispanics were treated far less frequently than whites for bipolar I, impulse control, autism spectrum, personality, obsessive-compulsive, and nicotine use disorders but more frequently for drug use disorders. Racial-ethnic differences in visits to psychiatrists were generally greater than for visits to nonpsychiatrists. Differences declined with increasing patient age and appear to have widened over time. CONCLUSIONS: Racial-ethnic differences in receipt of outpatient mental health treatment from U.S. physicians varied substantially by disorder, provider type, and patient age. Most differences were large and did not show improvement over time.