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Cannabis use severely affects the outcome of people with psychotic disorders, yet there is a lack of treatments. To address this, in 2019 the National Health Service (NHS) Cannabis Clinic for Psychosis (CCP) was developed to support adults suffering from psychosis to reduce and/or stop their cannabis use.
Aims
Examine outcome data from the first 46 individuals to complete the CCP's intervention.
Method
The sample (N = 46) consisted of adults (aged ≥ 18) with psychosis under the care of the South London and Maudsley NHS Foundation Trust, referred to the CCP between January 2020 and February 2023, who completed their intervention by September 2023. Clinical and functional measures were collected before (T0) and after (T1) the CCP intervention (one-to-one sessions and peer group attendance). Primary outcomes were changes in the Cannabis Use Disorders Identification Test-Revised (CUDIT-R) score and pattern of cannabis use. Secondary outcomes included T0–T1 changes in measures of delusions, paranoia, depression, anxiety and functioning.
Results
A reduction in the mean CUDIT-R score was observed between T0 (mean difference = 17.10, 95% CI = 15.54–18.67) and T1, with 73.91% of participants achieving abstinence and 26.09% reducing the frequency and potency of their use. Significant improvements in all clinical and functional outcomes were observed, with 90.70% being in work or education at T1 compared with 8.70% at T0. The variance in CUDIT-R scores explained between 34 and 64% of the variance in our secondary measures.
Conclusions
The CCP intervention is a feasible strategy to support cannabis use cessation/reduction and improve clinical and functional outcomes of people with psychotic disorders.
Edited by
Deepak Cyril D'Souza, Staff Psychiatrist, VA Connecticut Healthcare System; Professor of Psychiatry, Yale University School of Medicine,David Castle, University of Tasmania, Australia,Sir Robin Murray, Honorary Consultant Psychiatrist, Psychosis Service at the South London and Maudsley NHS Trust; Professor of Psychiatric Research at the Institute of Psychiatry
Abrupt cessation of chronic and frequent cannabis use is associated with cannabis withdrawal. Cannabis withdrawal syndrome is a clinically significant diagnosis and a criterion of cannabis use disorder (CUD) marked by mood and sleep disturbance symptoms, appetite and/or weight loss and restlessness, and physical symptoms such as abdominal pain, shakiness/tremors, sweating, fever, chills and headaches. The goal of this chapter is to fully characterize the clinical significance, time course, neurological mechanisms and treatment of cannabis withdrawal. The chapter synthesizes studies examining individual difference factors (demographics, cannabis use patterns, genetics and heritability and psychiatric comorbidity) that place some people at disproportionally higher risk for cannabis withdrawal or greater severity of symptoms. The cyclical nature of resuming use due to the inability to cope with the distress of cannabis withdrawal is negatively reinforcing and presents major challenges to individuals trying to abstain from problematic cannabis use. Implications for evidence-based strategies that can help mitigate the psychological and physiological symptoms of cannabis withdrawal are discussed.
How do states create agreements with one another, and how do they ensure they are followed? The first half of this chapter details the process by which states make, maintain, and rescind treaties. We elaborate on the treaty process set forth in the Vienna Convention on the Law of Treaties, and explain different treaty types (e.g., bilateral vs. multilateral, self-executing vs. non-self-executing). Reservations—portions of a treaty a state does not wish to join—are also discussed, as well as their ramifications. The second half of the chapter establishes the centrality of diplomats to the creation and execution of much of international law, including treaties. We elaborate on diplomatic and consular functions as well as diplomatic immunity and asylum. Diplomats are noted as change agents in the international system, but the potential for abuse of that immunity is always present.
This chapter recalls the distinction between responsibility and liability as it emerged in the work of the International Law Commission and its inherent difficulties, before turning to its relevance in relation to the interplay between the obligation to prevent harm and the prohibition to cause harm, the question of cessation and the procedural treatment at the International Court of Justice of the issues of injury, causality and reparation owed. The chapter questions the received wisdom according to which ‘responsibility’ and ‘liability’ would be two different legal genres and argues that the dichotomy between them is porous.
Tobacco smoking is one of the leading causes of preventable morbidity and mortality worldwide (WHO, 2020). Smoking cessation campaigns have been effective at reducing smoking in the general population, but not in individuals with mental illness (Lê Cook et al., 2014). A downward trend in smoking has been noted in EU countries but smoking rates have remained stable in Malta (Country Health Profile, 2019).
Objectives
This audit aims to assess smoking status, provision of smoking cessation advice and psychotropic dose adjustment depending on smoking status by the Bormla Mental Health Team.
Methods
Patient health records were reviewed for patient demographics, psychiatric diagnosis, medical co-morbidities, smoking status and cessation advice and changes in psychiatric medication according to smoking status.
Results
Of the 171 patients studied, 35% (n=61) were smokers, 33% (n=58) were non-smokers while in 30% (n=52) the smoking status was undocumented. Smokers had a mean age of 50 years with an almost equal gender distribution (49% (n=30) male and 51% (n=31) female). The most common documented psychiatric diagnoses were depression (52.5% (n=32)) and anxiety (34.5% (n=21)), while 59% (n=36) had documented medical co-morbidities. Only 14% (n=9) where given smoking cessation advice and one patient was referred to the smoking cessation clinic. One third of smokers (n=20) were prescribed psychotropic medications which are affected by smoking status but only two patients had their doses adjusted.
Conclusions
Improved smoking cessation advice, referral to services, consideration of smoking cessation while prescribing and documentation are need to better patient care.
Chapter 11 accounts for the redress required by Article 13. The chapter demonstrates that in early case law the Court mostly limited itself to a statement that redress had to be provided, without any further specification. However, increasingly, in some specific contexts, the Court has laid down the form and specific measures required. But the Court's reasoning is very case specific. This makes it hard to deduce general and principled starting-points which can be applied to new cases. For example, the Court has not in a general manner required that the remedy needs to be able to put an end to continuing violations, with possible proportional exceptions, or set out any principled starting-points as to when compensation and/or restitution is necessary. Further, the the case law concerning effective investigations is particularly unclear. Indeed, even though the Court requires effective investigations under Article 13, it is highly unclear how this requirement relates to similar requirements under substantive Articles and to what extent effective investigations is percieved as a form of redress, as such.
The analysis in this chapter proceeds from the assumption that shared responsibility for a breach of a shared obligation has been established and focuses on the content of that responsibility. In the case that secondary obligations of reparation or cessation arise, what can be claimed from which responsible actor, and to what extent is this influenced by the fact that the underlying primary obligation is shared? And if injured parties wish to effectuate these secondary obligations through international adjudication, are there any obstacles to the claiming of cessation and reparation? It will ultimately be argued that conceiving of the content of shared responsibility as consisting of shared obligations incumbent on all responsible actors can help untangle which of the responsible states or international organizations is bound to do what in terms of cessation and reparation. In this context, the distinction between divisible and indivisible shared obligations has an important role to play. After all, determining whether responsible actors are each bound only to their own share of cessation or reparation or whether, alternatively, all of them become bound to achieve a common result has direct implications for what can be claimed from whom.
There are various situations in which multiple states or international organizations are bound to an international obligation in the context of cooperative activities and the pursuit of common goals. This practical phenomenon of sharing international obligations raises questions regarding the performance of obligations (who is bound to do what) and international responsibility in case of a breach (who can be held responsible for what). This book puts forward a concept of shared obligations that captures this practical phenomenon and enables scholars and practitioners to tackle these questions. In doing so, it engages in positive law-based categorization and systematization, building on existing categorizations of obligations and putting forward new typologies of shared obligations. Ultimately, it is contended that the sharing of obligations has relevant legal implications: it can influence the content and performance of obligations as well as the responsibility relations that arise in case of a breach.
In Chapter 7, I analyse cases in which decision-makers have to determine whether a person can seek refuge in an internally displaced persons’ (IDP) camp. This occurs in what is known as an ‘internal protection alternative’ inquiry. In some cases, asylum seekers have pleaded that if they returned to their homeland and relocated, they would have no option but to live in an IDP camp. Initially, in such cases decision-makers set a broad scope for adequate refuge and approached decisions with an ethic of international cooperation. But subsequently, there has been a transition in which decision-makers produce rudimentary notions of refuge. They give it a narrow scope – limiting it to bare survival rights – and there is a shift from understanding that refuge involves a nation-state bestowing protection to positioning refuge as something an individual can forge themselves. The understanding that refuge is an act of international solidarity has dissipated from the jurisprudence. Protection from life in an IDP camp will only be granted if the asylum seeker can establish that they are exceptionally vulnerable. A feminist analysis highlights that decision-makers’ notional approaches to the interactions between gender and vulnerability have resulted in problematic outcomes for both male and female refugees.
The rules of state responsibility are set out in the International Law Commission’s (ILC) Articles on the Responsibility of States for Internationally Wrongful Acts. This chapter introduces the basic features of the ILC’s Articles on State Responsibility, beginning with an explanation of what constitutes an internationally wrongful act. The following section discusses the circumstances precluding wrongfulness that may be invoked by states seeking to avoid responsibility for an internationally wrongful act. The chapter then covers the aftermath of an internationally wrongful act, which can involve legal consequences, such as reparations, as well as countermeasures. This chapter focuses specifically on the responsibility of states, rather than the responsibility of international organizations or individuals.
The rules of state responsibility are set out in the International Law Commission’s (ILC) Articles on the Responsibility of States for Internationally Wrongful Acts. This chapter introduces the basic features of the ILC’s Articles on State Responsibility, beginning with an explanation of what constitutes an internationally wrongful act. The following section discusses the circumstances precluding wrongfulness that may be invoked by states seeking to avoid responsibility for an internationally wrongful act. The chapter then covers the aftermath of an internationally wrongful act, which can involve legal consequences, such as reparations, as well as countermeasures. This chapter focuses specifically on the responsibility of states, rather than the responsibility of international organizations or individuals.
Chapter 5 addresses the manner in which the International Court of Justice interprets and applies cessation and assurances and guarantees of non-repetition as remedies of international law. These remedies are treated in a single chapter because they are, to a certain degree, complementary. The definition and function of these remedies and their interaction with each other, and with other remedies of international law, such as specific performance or satisfaction, are issues that clarify their meaning. The manner in which cessation interacts with specific performance, and the relevance of the principle of pacta sunt servanda, clarifies the manner in which this remedy is applied before the International Court of Justice. Further, the distinction between assurances and guarantees of non-repetition and their related formality, as provided by states through their pleadings before the Court and by the judicial body, through its judgments, contribute to the clarification of their substance.
Chapter 2 addresses the competence of the International Court of Justice to grant the remedies of international law through its orders containing provisional measures. This issue is assessed, first, through the determination of the binding character of said orders, in accordance with the jurisprudence of the Court. Second, the jurisprudence of the Court related to the substance of its provisional measures is addressed, in order to determine if the judicial body has the competence to give remedies of international law, which would contribute to the preservation of the rights of states, pending the issuance of its judgments on merits. This chapter shows that the Court has jurisdiction to grant remedies of international law through its orders for provisional measures. However, presently, only a handful of remedies have the potential to preserve the rights of states, in accordance with the case-law of the Court. As such, it is for its future judgments to establish a framework of remedies, capable of being included within its orders for provisional measures.
Chapter 4 addresses the justifications for which specific performance is a remedy of international law before the Court. It focuses on the controversial issues regarding this remedy, which range from determining the power of the Court to order it, to analysing the effects of its relationship with other remedies, such as restitution in kind or declaratory judgments. The differences of opinion expressed by commentators regarding its availability before the International Court of Justice originate from a series of misunderstandings that gravitate around the effects of qualifying this remedy as a form of injunctive relief. A consequence of this conceptual confusion influences the relationship and interaction between specific performance, declaratory judgments, cessation and restitution in kind and the main features of this remedy. Further, the interpretation and application of specific performance is also influenced by differences in terminology between scholars and practitioners originating from different legal systems.
Individuals with schizophrenia are more likely to smoke and less likely to quit smoking than those without schizophrenia. Because task persistence is lower in smokers with than without schizophrenia, it is possible that lower levels of task persistence may contribute to greater difficulties in quitting smoking observed among smokers with schizophrenia.
Aims
To develop a feasible and acceptable intervention for smokers with schizophrenia.
Methods
Participants (N = 24) attended eight weekly individual cognitive behavioral therapy sessions for tobacco use disorder with a focus on increasing task persistence and received 10 weeks of nicotine patch.
Results
In total, 93.8% of participants rated the intervention as at least a 6 out of 7 regarding how ‘easy to understand’ it was and 81.3% rated the treatment as at least a 6 out of 7 regarding how helpful it was to them. A total of 62.5% attended at least six of the eight sessions and session attendance was positively related to nicotine dependence and age and negatively related to self-efficacy for quitting.
Discussion
This intervention was feasible and acceptable to smokers with schizophrenia. Future research will examine questions appropriate for later stages of therapy development such as initial efficacy of the intervention and task persistence as a mediator of treatment outcome.
A growing number of states have started pointing to the customary doctrine of countermeasures as the most feasible unilateral remedy in the case of a malicious cyber operation carried out by an adversarial actor. Thus, the legal requirements of successfully invoking a right to resort to countermeasures are analysed in depth. In particular, the chapter deals with state policies such as 'active cyber defences' and 'hacking back' as reactions to cybersecurity incidents, and their lawfulness as countermeasures. After examining the pervasive problem of attribution in cyberspace, the states' duty to prevent malicious cyber operations emanating from their territory and the standard of due diligence in this regard are investigated. The chapter concludes with considering the invocation of countermeasures for the purpose of guarantees of non-repetition and reparation in the aftermath of a cybersecurity incident.
The duration of incoming quitline calls may serve as a crude proxy for the potential amount of reactive counseling provided.
Aims
To explore whether call duration may be useful for monitoring quitline capacity and service delivery.
Methods
Using data on the duration of incoming quitline calls to 1-800-QUIT-NOW from 2012 through 2015, we examined national trends and state-level variation in average call duration. We estimated a regression model of average call duration as a function of total incoming calls, nationally and by state, controlling for confounders.
Results
From 2012 through 2015, average call duration was 11.4 min, nationally, and was 10 min or longer in 33 states. Average call duration was significantly correlated with quitline service provider. Higher incoming call volume was significantly associated with lower average call duration in 32 states and higher average call duration in five states (P-value <0.05). The relationship between call volume and call duration was not correlated with quitline service provider.
Conclusions
Variation in average call duration across states likely reflects different service delivery models. Average call duration was associated with call volume in many states. Significant changes in call duration may highlight potential quitline capacity issues that warrant further investigation.
The existence of secondary rules of responsibility stems from two cumulative elements: a breach of an international obligation and the attribution of this breach to a State. The present chapter analyses the obligations owed by the State responsible for a cyber operation against another State: firstly, if the cyber operation has a continuing character, the responsible State is under the obligation to cease the operation; secondly, the responsible State may have to offer assurances and guarantees of non-repetition if required by the circumstances of the case; and thirdly, the responsible State has to repair the injury resulting from the cyber operation. Finally, it is necessary to examine the question of shared responsibility, which is applicable when multiple States are involved in the cyber operation.
Cigarette smoking is highly prevalent among young people experiencing homelessness, and many of these smokers are motivated to quit. However, there is a lack of readily available cessation services for this population, which is highly mobile and can be challenging to engage in services.
Aims
We describe the development of a smoking cessation text messaging intervention (TMI) for homeless youth who are interested in quitting smoking.
Methods
Participants were 18–25 years old and recruited from drop-in centers serving homeless youth. Three focus groups (N = 18) were conducted with smokers to refine the TMI content, and a separate sample of smokers (N = 8) provided feedback on the TMI after using it for 1 week. Survey data assessed the TMI's acceptability and feasibility.
Results
Participants generally rated the TMI as helpful and relevant, and nearly all had cell phone plans that included unlimited texting and were able to view TMI content with few difficulties. Qualitative feedback on strengths/limitations of the TMI in terms of content, tone, and delivery parameters was used to finalize the TMI for a future evaluation.
Conclusions
Results suggest that a TMI is a feasible and acceptable option for young people experiencing homelessness who are interested in quitting smoking.
The US Navy utilizes numerous resources to encourage smoking cessation. Despite these efforts, cigarette smoking among service members remains high. Electronic cigarettes (EC) have provided an additional cessation resource. Little is known regarding the utilization efficacy of these cessation resources in the US Navy.
Aims
This study sought to explore the utilization and efficacy of ECs and other smoking cessation resources.
Methods
An anonymous cross-sectional survey was conducted at a military clinic from 2015 to 2016. Participants were active duty in the US Navy and reported demographics, smoking behaviors, and utilization of cessation resources.
Results
Of the 977 participants in the study, 14.9% were current and 39.4% were former smokers. Most current smokers (83.6%) previously attempted cessation, smoked an average of 2–5 cigarettes per day (34.7%), and smoked every day of the month (26.4%). The number of daily cigarettes smoked and number of days cigarettes were smoked per month was not significantly different between cigarette-only smokers and EC dual users (p = 0.92, p = 0.75, respectively). Resources used by current and former smokers include: ‘cold turkey’ (44.6%, 57.1%, respectively), ECs (22.3%, 24.7%), nicotine patch (8.3%, 1.3%), medicine (6.6%, 3.9%), nicotine gum (5.8%, 10.4%), and quit programs (2.5%, 2.6).
Conclusion
Current and former cigarette smokers utilized similar resources to quit smoking. Electronic cigarettes are being used for cessation but do not significantly reduce the number of cigarettes smoked on a daily or monthly basis. Future studies may benefit from exploring the use of cessation resources and ECs within the military as a whole.