Differences between early-phase primary psychotic disorders with concurrrent substance use and substance-induced psychoses

Context: The distinction between a substance-induced psychosis and a primary psychotic disorder that co-occurs with the use of alcohol or other drugs is critical for understanding illness course and planning appropriate treatment, yet there has been little study and evaluation of the differences between these 2 diagnostic groups. Objective: To identify key demographic, family, and clinical differences in substance-induced psychosis and primary psychotic disorders diagnosed according to DSM-IV criteria using a research diagnostic instrument for psychiatric and substance use comorbidity. Design: Data on demographic, family, and clinical factors were gathered at baseline as part of a 3-year longitudinal study of early-phase psychosis and substance use comorbidity in New York, NY. Setting: Psychiatric emergency department admissions. Participants: The study is based on a referred sample of 400 subjects interviewed at baseline. Participants had at least 1 psychotic symptom assessed during administration of the research protocol, had used alcohol and/or other drugs within the past 30 days, and had no psychiatric inpatient history before the past 6 months. Subject race included 43.5% black, 42.0% Hispanic, and 14.5% white or other. Main Outcome Measure: Psychotic disorders defined by the DSM-IV. Results: Overall, 169 (44%) were diagnosed as having substance-induced psychosis and 217 (56%), as having primary psychosis. Significant differences were observed in all 3 domains. Multivariate analysis using logistic regression identified the following 3 key predictors as being greater in the substance-induced group: parental substance abuse (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.00-2.85), a diagnosis of dependence on any drug (OR, 9.41; 95% CI, 5.26-16.85), and visual hallucinations (OR, 2.13; 95% CI, 1.10-4.13). The key predictor of total positive and negative symptom score was greater in the primary psychosis group (OR, 0.96; 95% CI, 0.94-0.97). Conclusions: Differences in demographic, family, and clinical domains confirm substance-induced and primary psychotic disorders as distinct entities. Key predictors could help emergency clinicians to correctly classify early-phase psychotic disorders that co-occur with substance use.