Academic journal article South African Journal of Psychiatry

A Retrospective Chart Review of the Clinical and Psychosocial Profile of Psychotic Adolescents with Co-Morbid Substance Use Disorders Presenting to Acute Adolescent Psychiatric Services at Tygerberg Hospital

Academic journal article South African Journal of Psychiatry

A Retrospective Chart Review of the Clinical and Psychosocial Profile of Psychotic Adolescents with Co-Morbid Substance Use Disorders Presenting to Acute Adolescent Psychiatric Services at Tygerberg Hospital

Article excerpt

Tygerberg Hospital serves as the Western Cape (WC)'s only tertiary-level acute inpatient facility for the assessment and management of adolescents (13-18 years) presenting with severe mental illness. A substantial number of these adolescents meet criteria for a dual diagnosis (defined as psychiatric disorder plus co-morbid substance use disorder (SUD)). The presence of these co-existing diagnoses prolongs initial treatment response and complicates subsequent intervention strategies. The current service model divides the care of such patients into a psychiatric inpatient treatment component and a separate post-discharge substance use intervention. One of the challenges the child and adolescent mental health (CAMH) service faces is the high rate of readmission of adolescents into psychiatric services before utilisation of community-based substance abuse services can even occur. Furthermore, existing adolescent substance abuse and rehabilitation programmes (offered by the Department of Social Services) do not address co-occurring mental illness. This situation has arisen not only due to a lack of evidence-based treatment guidelines for dual-diagnosis adolescents, but also because, to date, epidemiological as well as clinical data for this group have not been systematically documented in South Africa (SA).

There is evidence that co-morbid substance use in patients with psychotic disorders has important implications for patient management, in that co-morbid SUDs are often associated with a variety of adverse outcomes such as treatment non-compliance, high rates of relapse and rehospitalisation. (1) Psychosis and substance abuse occur together more frequently than can be explained by chance alone. Dixon (2) reported that a substantial proportion of substance abusers experience psychosis, and that a SUD is one of the greatest obstacles to the effective treatment of people with schizophrenia.

In 2008, in a large population-based study, Miettunen et al. (3) examined cannabis use and prodromal symptoms of psychosis in 6 330 Finnish adolescents. The study concluded that cannabis use was associated with prodromal symptoms in adolescents and that this effect was not secondary to any confounding effects of other drugs, emotional or behavioural problems or family background. Furthermore, an apparent shared underlying genetic vulnerability to both SUD and mental illness has been well documented. (4-6) Mental illness itself may also lead to an increase in drug-seeking behaviour to alleviate symptoms, while mental illness may be induced by substance abuse. (7) Caspi et al. (4) demonstrated that the presence of a functional polymorphism of the COMT gene is likely to moderate the influence of adolescent cannabis use on the development of psychosis in adulthood.

A significant increase in the abuse of methamphetamine in the WC, in addition to already high levels of alcohol and cannabis use, has resulted in the Tygerberg adolescent psychiatry unit seeing an increase in the number of patients with methamphetamine-related psychotic disorders presenting for admission. It has been established that abuse of amphetamines is associated with the development of schizophrenia-like symptoms (including hallucinations and paranoid delusions) and mood disturbances. Grelotti et al. (8) describe patients with prolonged methamphetamine abuse being at risk of persistent psychotic features and showing poor response to antipsychotic treatment, even after stopping methamphetamine use. The risks for development of amphetamine-related psychosis include young age of onset of substance abuse, high doses of amphetamine, and having a family member with an amphetamine-related psychotic disorder. (8)

Risk factors for the development of a psychotic illness in adolescent substance abusers described in the international literature include severity and duration of use, age at time of first substance use, genetic, familial or personality vulnerabilities to the development of psychosis, and the type of substance used. …

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