Early End to Substance Use Linked to Better Outcome in First-Episode Psychosis

Patients experiencing a first-episode psychosis who stop using drugs or alcohol within two years of diagnosis have outcomes similar to those who have never used substances, with fewer symptoms than patients who continued using substances.

That’s the finding from a long-term longitudinal study of first-episode patients published last month in Schizophrenia Bulletin. Substance use has been associated with poorer outcomes, including more severe psychopathology, higher relapse rates, and lower life expectancy. While previous studies have suggested discontinuing substance use early in the course of illness can improve symptoms and function, most of these were short-term trials.

The new study tracked the relationship between substance use, early abstinence, and psychosis longitudinally over 10 years and suggests the detrimental effects of substance use on mental health may be all but entirely reversed if the person quits early.

“The fact that harm can be substantially minimized with early discontinuation gives a hopeful message for patients who struggle with addiction and psychosis,” wrote a global team of researchers, led by a group in Norway. “Addressing substance use as early as possible is critical, as early substance use termination predicts better long-term outcome.”

The study was a naturalistic, longitudinal follow-up of a large, clinical epidemiological sample collected consecutively from four Scandinavian health care sectors, with a combined estimated population of 665,000 inhabitants.

Inclusion criteria included being 15 to 65 years old; living in one of the participating sites; and having first-episode schizophrenia, schizophreniform disorder or schizoaffective disorder, delusional disorder, mood disorder with mood-incongruent psychotic features, brief psychotic disorder, or psychosis not otherwise specified.

Three hundred and one patients were included between 1997 and 2001 and followed up at three months and at 1, 2, 5, and 10 years. Symptom remission was defined as having no score of 4 or higher for the past six months on any of the following items on the Positive and Negative Syndrome Scale (PANSS): delusions, disorganized thought, hallucinatory behavior, affective flattening, passive social withdrawal, lack of spontaneity, bizarre posture, or unusual thought content.

Recovery was defined as a combination of symptom remission and adequate social functioning according to the Strauss-Carpenter Level of Functioning score. This includes at least 12 months of work or study full time, living independently, seeing friends at least once a week, and not having been hospitalized.

Of the 301 patients, 266 could be classified into one of four groups based on their patterns of substance use in the first two years after diagnosis: persistent users (n=43), episodic users (n=48), stop-users (stopped substance use within two years after diagnosis, n=34), and nonusers (n=141). There were 35 patients about whom substance use data were incomplete and who could not be designated into any of the four categories.

After 10 years, stop-users had similar symptom profiles as nonusers, and both groups had fewer symptoms than episodic or persistent users. In fact, while persistent users had PANSS negative scores that increased over the 10-year period, the negative scores of stop-users decreased over time.

“Our results, showing improvement in negative symptoms with cessation of substance use are of interest as these are symptoms that are difficult to treat with antipsychotics. In addition, these symptoms are closely linked to daily and social functioning and quality of life,” the authors concluded. ■