Screening first-episode psychotic patients with a 6-minute assessment tool provides a more reliable indication of a patient’s risk of readmission than urinalysis, according to a new study in Schizophrenia Research.
Patients scoring in the "at-risk" range of the cannabis/cocaine subscale of the Dartmouth Assessment of Lifestyle Inventory (DALI) were at 4.5 times greater risk of readmission, with a better sensitivity rate than urinalysis after adjusting for confounders. "The optimum cutoff point for DALI cannabis/cocaine subscale to predict readmission was above minus one," Dr. Albert Batalla of the University of Barcelona and his associates reported (Schizophr. Res. 2013;146:125-31).
Dr. Albert Batalla
The DALI is an 18-item screening tool in which the 15 scored items are divided into the alcohol subscale and the cannabis/cocaine subscale. It takes an average of 6 minutes to administer.
The team’s analysis of 58 patients’ readmissions found no association between readmission risk and self-reported alcohol use or the alcohol subscale of the DALI. Although a positive urinalysis for cannabis was associated with readmission in the bivariate analysis, only the DALI cannabis/cocaine subscale remained significantly associated with readmission after controlling for sex, age, duration of psychosis, and the positive subscale of the Positive and Negative Syndrome Scale (PANSS).
The 58 nonaffective first-episode psychotic patients were consecutively recruited from the Hospital Clinic in Barcelona from Jan. 1, 2004 to Oct. 31, 2010, with a study end date of April 30, 2011. Using DSM-IV diagnoses, 40 patients (69%) had schizophrenia, 5 (8.6%) had brief psychotic disorder, 4 (6.9%) had schizophreniform disorder, and 9 (15.5%) had psychosis not otherwise specified.
The patients underwent blood and urine sampling (at least one of which was within 48 hours of admission) and were interviewed with the PANSS and the DALI. Patients were drug naive, with no history of diabetes or any other condition associated with glucose intolerance or insulin resistance, and were taking no medications related to insulin resistance.
Urine was screened for benzodiazepines, cannabis, cocaine, amphetamines, opiates, methadone, and LSD. Blood samples were analyzed for alcohol. Among the 25 patients (43.1%; 95% confidence interval, 31.2%-55.9%) whose blood/urine screened positive for psychoactive substances, four patients (6.9%) screened positive for alcohol and 22 (37.9%) for cannabis.
During interviews, patients also were asked whether they had used alcohol, tobacco, cannabis, cocaine, amphetamines, LSD, or ecstasy within the previous 3 months. A total of 38 patients (65.5%) reported using at least one substance of abuse, excluding tobacco, including 31 (53.4%) reporting using cannabis (29 patients, 50%) and/or cocaine (14 patients, 24.1%). Meanwhile, the DALI cannabis/cocaine subscale identified 20 patients (50%) as high risk for cannabis and/or cocaine-use disorders, 80% of whom had reported recent cannabis and/or cocaine use during interviews.
Over a median follow-up of 888 days (348-1,556), 16 patients (27.6%) were readmitted, three of whom (18.8%) were false negatives on the DALI cannabis/cocaine subscale. With the cutoff of above minus one on the DALI subscale, sensitivity was 0.81 (95% CI, 0.57-0.93) and specificity was 0.62 (0.47-0.75), compared with a sensitivity of 0.56 (95% CI, 0.33-0.77) and a specificity of 0.69 (95% CI, 0.54-0.81) for the urine test.
The baseline DALI cannabis/cocaine subscale score yielded a hazard ratio of 4.5 (95% CI, 1.1-18.7; P = .036) in the multivariate analysis, while the urinalysis’ hazard ratio of 2.0 was not statistically significant (P = .2) when confounders were factored in. Factors significantly associated with readmission in the bivariate analysis included younger age, male gender, and high PANSS positive subscale scores. Neither a positive alcohol blood test (P = .773) nor the alcohol subscale of the DALI (P = .330) was associated with readmission.
The study was limited by the population’s sample size and exclusivity of nonaffective psychosis, as well as the fact that the DALI does not quantify amount or severity of drug use. The researchers only assessed substance use at baseline and did not assess medication adherence.
The study was funded by several sources, including the government of Catalonia and the Esther Koplowitz Center. The authors declared no conflicts of interest.