Drug use and first episode psychosis: Exploring associations with occupational expectations and achievements
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Background: Schizophrenia and other psychoses are reliably associated with high rates of unemployment at first presentation, although occupational expectations may remain undiminished. Whilst a causal relationship has not been established, unemployment in this population is linked to poor clinical course and compromised social functioning. Similarly, drug use has been independently linked to reduced employment rates, a relatively lower income and low academic attainment and aspirations. Given that substance misuse rates are elevated in individuals presenting with first episode psychosis, the question therefore remains as to whether the presence of both first episode psychosis and drug use has a cumulative effect upon individuals' occupational expectations and achievements. Methods: Secondary analysis was carried out on cross sectional data collected in Nottingham (UK) between 1997 and 2003 for the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study (AESOP). Data was drawn from control and case participants who provided information upon both drug use and occupational related variables (n = 163). Perceptions of current occupational achievement and prior occupational expectations were rated by participants on identical 10 point scales with point 10 representing the highest level of achievement. The outcome measure was derived by subtracting scores on achievement from those on expectations to provide a new variable representing the 'achievement-expectation gap'. This was dichotomised into the following groups: Those who had met or exceeded their expectations (scores 0 to 9) and those who had failed to attain them (scores -1 to -9). Illness status (cases versus controls) and drug use (drug use versus no drug use) were entered separately into a regression model to ascertain their independent contribution to the outcome variable. An interaction term was calculated to investigate the cumulative impact of both drug use and psychoses upon the achievement-expectation gap. Results: Pearson's Chi-Square analysis indicated that the four groups (cases with drug use, cases with non use, controls with drug use, controls with non use) differed significantly according to gender (x2 (3, n = 163) = 9.29, p = .026) and age (x2 (3, n = 163) = 35.56, p = .001). This finding was not replicated for either education or ethnicity. Binary logistic regression analysis revealed no significant effect of age or gender upon the outcome variable. Subsequently, the binary logistic regression analysis was rerun with these predictors excluded from the model. This analysis revealed a significant association between drug use and a relatively higher gap between occupational achievements and expectations (OR=3.62 95% CI = 1.292 - 10.130, p = .014). Specifically, individuals with self reported drug use were three times more likely to have not met, or exceeded, their employment expectations. Illness status (case or control) was not significantly associated with this outcome (OR=1.11; 95%CI = 0.311 - 3.923, p = .877). There was not a significant interaction between drug use and illness status with regard to prediction of the achievement-expectation gap (OR=0.55; 95% CI = 0.123 - 2.426, p = .426). A post hoc test of analysis of variance revealed that drug users had significantly higher occupational expectations relative to non drug users (F(1,159) = 6.45, p = .012). Discussion: There was no association between psychosis and a heightened gap between occupational expectations and achievements. Independent of illness status, drug users were three times more likely to report failing to attain, or exceed, their desired occupational status. This was attributable to the presence of significantly higher employment expectations in this population.