Cocaine-induced psychotic symptoms in clinical setting

Psychiatry Research 217 (2014) 115–120

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Cocaine-induced psychotic symptoms in clinical setting Esperanza Vergara-Moragues a,b,n,1, Pedro Araos Gómez c,1, Francisco González-Saiz d, Fernando Rodríguez-Fonseca c a

Department of Education, International University of La Rioja (UNIR), Spain Neuropsychology Research Group and Clinical Psychoneuroimmunology (CTS-581), University of Granada, Granada, Spain c FIMABIS, Mental Health Clinical Management Unit, Hospital Carlos Haya (Málaga), Spain d Community Mental Health Unit, Villamartín, UGC-SM Hospital de Jerez, Andaluz Health Service (Cádiz), Spain b

art ic l e i nf o

a b s t r a c t

Article history: Received 2 April 2013 Received in revised form 3 February 2014 Accepted 9 February 2014 Available online 22 February 2014

Cocaine use is significantly associated with psychiatric co-morbidities of which psychotic symptoms are the most typical. The primary goal of this study is to estimate the life-time prevalence of cocaine-induced psychotic symptoms (CIPS) in a sample of patients without a history of primary psychosis, who attended specific out-patient drug-dependence treatment centres (ODDTCs). This is an observational, crosssectional design and a consecutive sampling technique. The Scale for Assessment of Positive SymptomsCocaine Induced Psychosis (SAPS-CIP) was used to interview 114 patients who request treatment at specific ODDTCs for problems related to cocaine use. Most patients, 89.5% (95% CIs: 83.8–95.2%) had dependence of cocaine and 84.2% (95% CIs: 77.5–90.9%) showed at least one CIPS. Patients with CIPS had used cocaine more times throughout their lives and had a more frequency of use during the period of higher abuse severity in the last year, had higher severity of dependence score and had fewer abstinence periods greater than 30 days compared with those without CIPS. Cocaine dependency severity scale scores were significantly greater in patients with CIPS compared with those without CIPS. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Cocaine Psychosis Evaluation Treatment Diagnosis

1. Introduction In its most recent report, the European Monitoring Centre for Drugs and Drug Addiction noted that 4.1% of people between 15 and 64 years of age have used cocaine at least one time during their lives, and 1.3% used cocaine over the last two months. Furthermore, Spain had the highest use rates of all the countries in the European Union (European Monitoring Centre for Drugs and Drug Addiction, 2010). Acute and chronic exposure to cocaine is associated with significant psychiatric co-morbidities of which psychotic symptoms are one of the most typical (Roncero et al., 2001). The symptoms seen most frequently are paranoid ideation and the auditory and visual hallucinations (Fiorentini et al., 2011). The cocaine-induced psychotic symptoms (CIPS) are aggressive serious adverse effects and may lead to psychomotor agitation and behaviours potentially lifethreatening (Vorspan et al., 2001). The correspondence between CIPS and DSM-IV diagnostic criteria are complex. In cocaine intoxication we can typically find n Corresponding author at: Departament of Education, International University of La Rioja (UNIR), Paseo de la Castellana, 163. 8a Planta 28046, Madrid, Spain. Tel.: þ 34 91 567 43 91. E-mail address: [email protected] (E. Vergara-Moragues). 1 These authors contributed equally to this work.

http://dx.doi.org/10.1016/j.psychres.2014.02.024 0165-1781 & 2014 Elsevier Ireland Ltd. All rights reserved.

perceptual phenomena that disappear with abstinence and with intact reality testing. In psychotic disorder induced by cocaine, psychotic symptoms are more severe and lasting than in cocaine intoxication and usually with altered reality testing (American Psychiatric Association (APA), 1994). Finally, cocaine users diagnosed with a primary psychotic disorder such as schizophrenia may also experience acute psychotic symptoms induced by cocaine, but it is difficult to distinguish their primary symptoms. CIPS prevalence is not exactly known, although is undoubtedly high, there is a lot of variation in the estimation of CIPS prevalence ranging between 43% and 88%. This variation depends on the methodological aspects such as design, criteria selection, applied diagnostic procedures, and sample biases (Brady et al., 1991; Kalayasiri et al., 2006; Roncero et al., 2013; Satel et al., 1991). For these methodological aspects the diagnostic tool used to assess the CIPS effectively is of utmost importance because it could standardise their measurement and improve the comparability of results between studies. Cubells et al. (2005) designed the Scale for the Assessment of Positive Symptoms of Cocaine-Induced Psychosis (SAPS-CIP) for this purpose. However, studies that have used this semi-structured clinical interview estimate rates that vary depending on both the number of symptoms included in the analysis and the psychopathological profile sample (i.e. the decisions as to whether to exclude patients with primary psychotic disorders). For this purpose, Cubells et al. (2005) conducted

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a study in a sample of cocaine users using single subscales of SAPSCIP delusions and hallucinations, excluding the primary psychotic disorders, observing a CIPS prevalence of 75%. In another similar study, the same research group just used the “cocaine-related behaviour” subscale and observed prevalence for the different behaviour ranging from 44.9% to 79% (Tang et al., 2009). Only one study has employed the SAPS-CIP full version, finding that 86.5% of the subjects described at least one psychotic symptom induced by cocaine (Vorspan et al., 2012). However subjects with primary psychotic disorders were not excluded and the risk of not being able to distinguish primary and secondary symptomatology is possible. The primary goal of this paper is to estimate the prevalence of cocaine-induced psychotic symptoms at any moment of their lifetime in a sample of cocaine users without primary psychotic disorders who attended specific outpatient drug-dependence treatment centres (ODDTCs) using the full SAPS-CIP version. The secondary goal is to explore the relationships between CIPS and the lifetime cocaine use pattern. 2. Methods 2.1. Participants The sample was composed of 114 patients who used cocaine and sought treatment for this addiction at ODDTCs located in Málaga. The inclusion criteria were (a) cocaine use that was considered problematic by the patient, accompanied by a request for treatment for this addiction (independently of whether other substances were being used); (b) 18 years of age or older; and (c) ability and willingness to sign the informed consent form. The exclusion criteria were (a) a current or lifetime diagnosis of primary psychosis (schizophrenia, schizophreniform disorder, schizoaffective disorder, or delusional disorder) evaluated by the Psychiatric Research Interview for Substance and Mental Disorders (PRISM); (b) a manic episode at the time of the interview; or (c) intoxication or serious organic disease at the time of the interview. The Ethics Committee of Clinical Research of the Hospital Carlos Haya de Málaga approved this study. A cross-sectional, observational design was implemented, and a consecutive sampling technique was used that recruited individuals seeking care at ODDTCs. This study was part of a broader project that explores the proteomic factors associated with cocaine dependence. 2.2. Procedures When the patient attended a scheduled appointment in the ODDTCs, his or her therapist evaluated the selection criteria. When the patient met the criteria, the therapist discussed the goals of the study and ensured the patient's anonymity and voluntary participation. After the patient agreed to participant, he or she scheduled an appointment for a study interview. The same clinical psychologist (P.A.G.) conducted all the interviews and administered the measurement tools after collecting the informed consent forms. 2.3. Assessments 2.3.1. Measurement of sample characteristics Code variables relating to socio-demographics and prior treatments and DSMIV diagnoses of substance use and dependence were collected and assessed via a checklist of symptoms. 2.3.2. Assessment of cocaine-induced psychotic symptoms (CIPS) 2.3.2.1. SAPS-CIP (Cubells et al., 2005). The SAPS-CIP is a semi-structured clinical interview used to evaluate the presence CIPS at any moment of the subject's lifetime history of cocaine use. This tool was adapted from the more general Scale for Assessment of Positive Symptoms (SAPS) by Nancy C. Andreasen (1984). The original SAPS evaluated positive psychotic symptoms as a complement to the author's Scale for the Assessment of Negative Symptoms (SANS; Andreasen and Grove, 1986). The SAPS-CIP is composed of 17 items grouped under three sections. The first section, hallucinations (HAL), includes four items that evaluate the presence and severity of auditory, visual, somatic/tactile, and olfactory hallucinations. The delusions (DEL) section uses nine items to identify feelings of persecution, jealousy, guilt, grandiosity, and religiosity; physical complaints and self-reference; and delusions of control, mindreading, broadcasting, insertion, and thought stealing. The last section, cocaine related behaviour (CRB) includes four items that evaluate behaviour prior to use that were either agitated or aggressive, repetitive or stereotyped, socially or sexually inappropriate, and/or criminal. Each interview item is followed by one or more follow-up question that allows the patient to describe the contents of their symptoms. All 17 questions are coded using a 6-degree Guttman

ordinal scale. The severity scoring criteria reflect several simultaneous dimensions: (a) the presence of symptoms during cocaine intoxication; (b) the degree of certainty regarding the symptoms; (c) the degree of extension or invasion of the symptom; and (d) the degree of potential danger of the patient's behaviour with regard to them self and others. Thus, a score of zero (“none”) was assigned when the individual was certain that the evaluated symptom did not occur during CI; a value of one (“doubtful”) was assigned when the patient admits that the symptom may have been present during cocaine intoxication but they are uncertain; an answer is classified as two (“mild”) when the patient admits that the symptom was clearly present at some point during cocaine intoxication; a score of three (“moderate”) was assigned when the symptom was clearly present during cocaine intoxication and generated a coherent behavioural response; a value of four (“marked”) is indicated when the symptom is clearly present during cocaine intoxication, generating a coherent behavioural response with a high degree of extension/invasion; lastly, a score of five (“serious”) occurs when the criteria for four are met and the patient displays verified behavioural response that is clearly dangerous to themselves and others. Cubells et al. (2005) apply a concurrent validity analysis using the HAL and DEL sections of the SAPS-CIP with respect to the Cocaine Experience Questionnaire (CEQ) (Satel et al., 1991) that measures “cocaine-induced paranoia”. This analysis found that “persecution” delusions best explain the item measured by this questionnaire. It should be especially noted that the objective of the SAPS-CIP is to evaluate and measure the presence and severity of cocaine-induced psychotic symptoms throughout life and that this was designed as a measure of the symptomatic endophenotype of psychosis in studies of genetic vulnerability, therefore it should not be regarded as an interview to diagnose the nosological category of “cocaineinduced psychotic disorder” DSM criteria. Given the importance of the clinical judgments applied when conducting this semi-structured interview, a degree and experience in psychopathology is required for its correct administration. Before our study began, a Spanish version of the SAPS-CIP did not exist. Based on recommendations by Gaite et al. (1997), a fivephase procedure was followed. First, two clinicians conducted independent conceptual translations into Spanish. Second, a single and provisional Spanish version was agreed upon to ensure technical, semantic and conceptual equivalency with the original version. Third, a specialist in English philology (F. Vigier) supervised the translation to ensure grammatical correctness. Fourth, a native translator (D. Fuldauer) conducted a retro translation into English. In the last phase of the procedure, the author himself (F. Cubells) compared the conceptual equivalency of the retro-translated English version with the original English version. A concurrent validity analysis was conducted using the SAPS-CIP hallucinations and delusions sections with respect to the Cocaine Experience Questionnaire (CEQ) by Satel et al. (1991). The CEQ measures “cocaine-induced paranoia” and asserts that “persecution” delusion best explains the item measured by this questionnaire (Vorspan et al., 2012). Following the same criteria used in previous SAPS-CIP studies, we first considered any diagnosis that presented at least one of the 17 CIPS symptoms. A “symptom was present” when an equivalent score had a value equal to or greater than two. The Spanish version of the SAP-CIP is available and may be requested from the first author. 2.3.3. Assessment of frequency and duration of cocaine use 2.3.3.1. Lifetime Severity Index for Cocaine Use Disorder (LSI-Cocaine; Hser et al., 1999). The LSI-Cocaine is a structured clinical interview that provides a profile of CIPS severity. A Spanish version of this scale exists (Morales-Manrique et al., 2007). LSI-Cocaine is composed of 28 items and evaluates four dimensions: “Consumption throughout life”, “Attempts to stop”, and “Psychological dependence”. Items 1–10 correspond to the first three dimensions and this study explored their interrelationship with cocaine-induced psychotic symptoms. The “Psychological dependence” dimension assesses the presence of DSM-III-R diagnostic criteria and its factorial score is interpreted as a measure of cocaine dependency severity.

2.4. Data analyses The descriptive data are presented as means and percentages with their corresponding dispersion estimates. We describe the proportion of patients using scores Z2 for each symptom and dimension with SAPS-CIP. A comparison study between the two groups was conducted to explore the association between different explanatory variables and CIPS symptoms. Thus, the following statistical tests were used: t-test for continuous variables and χ2 with Fisher's exact test for categorical variables. The results were analysed using SPSS Version 18.0 (SPSS Inc., Chicago, IL).

3. Results 3.1. Sample description As shown in Table 1, the sample of 114 patients was composed of 99 males (86.8%). The mean age of the group was 36 years and

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Table 1 Baseline sociodemographic variable and lifetime substance use disorders. N (%)

Total 114(100)

No CIPS þ group 18(15.8)

CIPS group 96(84.2)

p

Age [mean (S.D.)]

36(8.8)

35(8.5)

37(8.9)

0.484

Gender Men Women

99(86.8) 15(13.2)

17(94.4) 1(5.6)

82(85.4) 14(14.6)

0.298

Current marital status Never married Married/cohabiting Divorced/separated/widowed

45(39.5) 45(39.5) 24(21.1)

6(33.3) 8(44.4) 4(22.2)

39(40.6) 37(38.5) 20(20.8)

0.839

Educational level No education Primary level Secondary level

2(1.8) 72(63.2) 40(35.1)

– 11(61.1) 7(38.9)

2(2.1) 61(63.5) 33(34.4)

0.788

Work Employed Unemployed Retired/disabled

42(36.8) 67(58.8) 5(5.2)

9(50) 9(50) –

33(34.4) 58(60.4) 5(5.2)

0.329

53(46.5)

7(38.9)

46(47.9)

0.481

59(51.8)

12(66.7)

47(49)

0.168

38(33.3)

3(16.7)

35(36.4)

0.244

102(89.5) 12(10.5) 72(63.2) 26(22.8) 10(8.8) 5(4.4) 4(3.5) 8(7)

10(55.6) 2(11.1) 7(38.9) 5(27.8) – – 1(5.6) –

92(95.8) 10(10.4) 65(67.7) 21(21.9) 10(10.4) 5(5.2) 3(3.1) 8(8.3)

0.000n 0.93 0.020n 0.584 0.152 0.322 0.607 0.204

Prison admissions Treatment(ever) drug use Treatment(ever) psychological or psychiatric Lifetime substance use disorder(abuse or dependence) Cocaine Heroin Alcohol Cannabis Benzodiazepines Hallucinogens Other stimulants Polydrugs (three or more substance use disorders)

Note: values are means and standard deviations for quantitative variables and percentages for qualitative variables. CIPSþ : cocaine-induced psychotic symptoms. n

po 0.005.

50 45 40 35 30 25 20 15 10 5 0

Fig. 1. Proportion of subjects with CIPS. *Mindreading, transmission, insertion or extraction delusions. (We change the figure and we attach another one because instead to write MTIE delusions (* mindreading, transmission, insertion or extraction delusions.) It is MBIW delusions (* Mind reading broadcasting, insertion, withdrawal delusions) like we can read on the paper.)

the subjects were mainly divorced or single. About half the subjects (n ¼59, 51.5%) had previously been treated for an addiction disorder and almost one third (n ¼38, 33.3%) of the total

sample had no history of treatment at a mental health centre. Most patients interviewed (n ¼102, 89.5%) met the DSM-IV criteria for cocaine substance disorders. The administration route of

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cocaine for all patients was intranasal/sniffed. As shown in the table, alcohol abuse/dependence was the second most frequent addiction disorder after cocaine. 3.2. Cocaine-induced psychotic symptoms Almost all of the patients (84.2%, 95% CIs: 77.5–90.9%) described at least one psychotic symptom induced by cocaine at any point in their life history of cocaine use (HAL or DEL or CRB Z2). The proportion of patients showing CIPS described by the HAL section included the following: auditory (36%), visual (38%), somatic/tactile (29%) and olfactory (10%). The DEL section showing delusions of persecution (43%), jealousy (20%), sin/guilt (20%), grandiosity (10%), religious (3%), somatic (12%), reference (25%), being controlled (2%), and delusions of mind reading, broadcasting, insertion, withdrawal (3%). The CRB section showing aggressive/agitated behaviour (25%), stereotyped behaviour (46%), unusual social/sexual behaviour (41%), and preparatory behaviour (37%) (Fig. 1). 3.3. Variables associated with CIPS 3.3.1. Sociodemographics, previous treatments and substance use disorders As shown in Table 1, patients with CIPS were significantly more likely than those without CIPS to be single, have a prior history of addiction treatment, and meet the DSM-IV criteria for cocaine abuse/dependence. We did not observe significant between-group differences with regard to age, gender, or level of education. 3.3.2. Cocaine consumption pattern The pattern of cocaine consumption is shown in Table 2. Patients with CIPS had used cocaine more frequently throughout their lives and during the last year, used cocaine more frequently during their peak-use times, and had fewer periods of abstinence of more than 30 days compared with those without CIPS. Furthermore, the majority of patients with CIPS used cocaine over the last year regularly. In addition, the majority of these patients had achieved abstinence at some point in a treatment programme. No significant between-group differences were observed for the other descriptive variables of use. Moreover, no differences were observed with respect to the onset age of cocaine use. 3.3.3. Severity of cocaine dependence The mean “severity of cocaine dependence” subscale score was 13.8 (S.D. ¼3.8) among patients with CIPS and 4.4 (S.D. ¼6.1) among those without CIPS. This was a significant difference (p o0.0001). 4. Discussion In the present study, we observed that the prevalence of cocaineinduced psychotic symptoms at any moment of their lives was high and similar to the rate previously found by other authors on which primary psychotic patient were included. The 84.2% prevalence of CIPS that we observed is significantly higher but similar to the 86.5% found in another study (Vorspan et al., 2012). However, although these authors used the full SAPS-CIP and they did not exclude patients with primary psychosis from their sample, the prevalence observed is not much greater than ours. One possible explanation for this similarity, although not unique, is that, contrary to our previous cautions, the SAPS-CIP could allow proper CIPS assessment in patients with primary psychotic disorders. In this regard, Swendsen et al. (2011) conducted an interesting study in patients diagnosed with schizophrenia by monitoring acute psychotic symptoms

induced after cocaine use as distinct from positive primary psychotic symptoms. Furthermore, 75% CIPS prevalence was described in the first study using SAPS-CIP (Cubells et al., 2005). Although these authors also excluded patients with primary psychosis from their sample, they did not analyse the Cocaine Related Behaviours subscale data. This fact might explain the differences in prevalences found between our study and those authors. Similarly, other authors (Roncero et al., 2013) who also excluded patients with functional psychosis, explored primary psychotic symptoms using a series of standardised questions and observed a CIPS prevalence of 53.8%. Thus, over all, the type of diagnostic tool to assess CIPS, the number of items to analyse, and whether to exclude cocaine-related behavioural, would influence the variability of the CIPS prevalence observed. Of the hallucinations reported, the most frequent were auditory and visual, followed by somatic/tactile. The most prevalent delusions were persecutory and reference, followed by somatic. Previous SAPS-CIP studies (Cubells et al., 2005; Vorspan et al., 2012) described this same pattern of frequency in different samples. Furthermore, these results are very similar to those of authors who used other types of CIPS measurements (Roncero et al., 2013). The presence of visual hallucinations is characteristic of CIPS and other psycho-organic disorders, which helps differentiate this diagnosis from functional psychosis (Mitchell and Vierkant, 1991). Like other authors, we observed a relatively low prevalence of somatic/tactile hallucinations and somatic delusions, although these symptoms are elements of the classic descriptions by Magnan-Saury and De Clérambault (Berrios, 1996; Siegel, 1978). In this sense, we agree with Berrios with regard to the difficulty of differentiating the nature of phenomena focused on the skin (either hallucinatory or delusional), primarily when microscopic visual hallucinations are also taken into account (Berrios, 1996). With respect to cocaine-related behaviours, the two most frequent are the repetitive/stereotyped movements and the unusual social/ sexual behaviour, followed by preparatory and aggressive/agitated behaviours. The two previous SAPS-CIP studies that have explored these behaviours (Tang et al., 2009; Vorspan et al., 2012) described this same frequency pattern, although their prevalence in our study is slightly lower, which we attribute to the characteristics of our sample. We observed that the presence of CIPS was significantly associated with greater frequency of cocaine use over the lifespan. Other authors have also reported this finding (Cubells et al., 2005; Kalayasiri et al., 2006; Floyd et al., 2006; Tang et al., 2009). Cubells et al. (2005) also reported a greater number of use episodes among patients with CIPS. However, we did not observe a significant association between onset age of cocaine use (i.e., the number of years of use) and the development of CIPS, whereas prior studies have found this relationship (Cubells et al., 2005; Kalayasiri et al., 2006; Floyd et al., 2006). We also observed that CIPS was significantly related to a greater severity of cocaine dependence. This finding is congruent with the more severe pattern of lifetime cocaine use that we observed in CIPS group. Our small sample size might be a limitation to this study. A larger sample might have allowed us to have sufficient power to detect significant between-group differences. We evaluated a group of patients who sought treatment for cocaine abuse; thus, our results cannot be generalised to other groups who use this substance. Our study employed a cross-sectional design, and the retrospective evaluation period spanned patients' entire consumption histories. This method might entail biases and memory errors, which makes the cause-and-effect relationship between consumption pattern and CIPS development difficult to determine. Another limitation of this study it is that the sample is made up of cocaine users who also consume other substances. That is why the assessment of symptoms can make for difficult delineation.

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Table 2 Relationship of lifetime cocaine consumption pattern and cocaine-induced psychotic symptoms (CIPS). LSI-Cocaine

Total 114 (100)

No CIPSþ group 18 (15.8)

CIPS group 96 (84.2)

p

0.000n

Number of times to consumption the cocaine a lifetime From three to four times From 11 to 49 times From 50 a 99 times From 100 to 199 times 200 Times or more

1(0.9) 5(4.4) 7(6.1) 6(5.3) 95(83.3)

1(5.6) 5(27.8) 1(5.6) 2(11.1) 9(50)

– – 6(6.3) 4(4.2) 86(89.6)

Frequency of cocaine use during the 12 months previous Without consumption Less than once per month From one to three times a month From one to two times a week From three to four times a week From five to six times a week Daily or almost daily From two to three times per day Four or more times a day

2(1.8) 7(6.1) 4(3.5) 14(12.3) 29(25.4) 12(10.5) 26(22.8) 7(6.1) 13(11.4)

2(11.1) 3(16.7) 2(11.1) 5(27.8) 3(16.7) – 2(11.1) 1(5.6) –

– 4(4.2) 2(2.1) 9(9.4) 26(27.1) 12(12.5) 24(25) 6(6.3) 13(13.5)

Frequency of cocaine use in the period of greatest consumptions Less than once per month From one to three times a month Fromone to two times a week From three to four times a week From five to six times a week Daily or almost daily From two to three times per day Four or more times a day

1(0.9) 7(6.1) 7(6.1) 24(21.1) 10(8.8) 27(23.7) 13(11.4) 25(21.9)

1(5.6) 6(33.3) 4(22.2) 3(16.7) – 2(11.1) – 2(11.1)

– 1(1) 3(3.1) 21(21.9) 10(10.4) 25(26) 13(13.5) 23(24)

Age of onset for regular consumption (at least once a week)

23(7.1)

21(6.9)

24(7.1)

0.213

Withdrawal period longer Week Month Year

12(10.5) 43(37.7) 59(51.8)

3(16.7) 5(27.8) –

9(9.4) 38(39.6) 49(51)

0.658

4(6.3)

8(13.3)

3(3.5)

0.003n

Situation during periods of abstinence In a treatment programme In prison Without outside help Others

45(39.5) 9(7.9) 52(45.6) 8(7)

6(33.3) – 8(44.4) 4(22.2)

39(40.6) 9(9.4) 44(45.8) 4(4.2)

0.030n

Last regular consumption Last 12 months Over one year ago

77(67.5) 37(32.5)

10(55.6) 8(44.4)

67(69.8) 29(30.2)

Last use of cocaine During the previous months During the past 12 months Over a year ago

1(0.9) 86(75.4) 27(23.7)

1(5.6) 10(55.6) 7(38.9)

– 76(79.2) 20(20.8)

Regular consumption frequency in last period Less than once per month From one to three times a month From one to two times a week From three to four times a week From five to six times a week Daily or almost daily From two to three times per day Four or more times a day

18(15.8) 15(13.2) 23(20.2) 25(21.9) 8(7) 15(13.2) 3(2.6) 7(6.1)

4(22.2) 6(33.3) 5(27.8) 1(5.6) – 2(11.1) – –

14(14.6) 9(9.4) 18(18.8) 24(25) 8(8.3) 13(13.5) 3(3.1) 7(7.3)

4.4(6.1)

13.8(3.8)

0.000n

0.000n

Withdrawal period longer than 30 days

Severity of cocaine dependence [Mean (S.D.)]

0.237

12.3(5.4)

0.014n

0.054

0.000n

Note: values are means and standard deviations for quantitative variables and percentages for qualitative variables. CIPSþ : cocaine-induced psychotic symptoms. n

po 0.005.

However, on the one hand, in clinical practice it is very difficult to find a pure sample of people using cocaine and, secondly, the majority of the sample was cocaine dependence with severe cocaine consumption problems and their principal drug was cocaine and not any other substance. Certain characteristics of SAPS-CIP must be taken into account to interpret the results obtained properly. First, this tool was specifically designed for genetic linkage studies that explore an

individual's vulnerability to developing CIPS over the length of their cocaine use (which determines their evaluation period). However, this design makes evaluating the relationship between the pattern of cocaine use and CIPS development during a specific time period difficult unless the evaluation period is modified (as other studies have done; Vorspan et al., 2001) or lifetime scales of consumption are used (e.g., the LSI-Cocaine used in this study). This limitation, together with the specific design of the SAPS-CIP,

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makes adequate psychometric analyses difficult; otherwise, we would be able to provide evidence related to construct validity. In this sense, is necessary to consider each item of SAPS-CIP assessment if the symptom is present during cocaine intoxication, but not to assess the intact reality testing (insight), that is to say, whether or not the patient knows that the psychotic symptom is induced by cocaine but does not represent external reality. We believe that this work will open a future line of research related to the transitional psychotic episodes induced by cocaine. On the one hand, we believe that modifications should be made to the SAPS-CIP, especially with regard to the retrospective evaluation period. Another interesting modification would introduce a specification for each item to assess it for reality testing, which would explore a possible correspondence with the diagnostic categories of DSM-5 (stimulant intoxication and stimulantinduced psychotic disorder). Inter-examiner and test–retest reliability analyses are still needed, and the role of behavioural alterations in the symptomatic CIPS definitions should continue to be explored. On the other hand, we believe that the use of this tool will improve the psychopathological evaluation of these patients so that adequate treatment plans can be established. Funding This study contributes data from research projects funded by the National Drug Plan (PND 049/2009), the Carlos Tercero Health Institute, Network of Addictive Disorders (RD06/0001/0000), and the Ministry of Economy and Competitiveness. Acknowledgements We thank all of the patients who participated in this study from the different drug dependence treatment centres of Málaga, Spain: the Provincial Centre for Drug Dependence, Mijas; the Centre of Alternative Addictions 2, Fuengirola; the Provincial Centre for Drug Dependence, Cadiz Highway; and the Provincial Centre for Drug Dependence-Vélez-Málaga. We also thank all of the professionals from these centres who recruited the study's sample: Maribel Soria (clinical psychologist) and Drs. Rafael Campos, Pilar Gardeta, Juan Jesús Ruiz, and José Torroba. References American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. American Psychiatric Association, Washington DC Andreasen, N.C., Grove, W.M., 1986. Evaluation of positive and negative symptoms in schizophrenia. Psychiatry and Psychobiology 1, 108–121. Andreasen, N.C., 1984. Scale for the Assessment of Positive Symptoms (SAPS). University of Iowa, Iowa City

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