the association between substance use and psychotic symptoms , however , is not simply due to substance - induced psychosis . the rate of substance abuse among people with severe mental illness far exceeds that in the general population , even at the first onset of psychosis . one of the challenges in diagnosing substance use disorders among psychiatric patients is to distinguish symptoms that are the result of a psychiatric illness from those resulting from substance abuse . some studies have reported this observation in nearly half of admissions in a psychiatric emergency set up . with greater awareness in the community and availability of effective treatment options , more and more people are being referred at an early stage of psychosis . moreover , diagnostic certainty in early phase psychosis is often difficult to attain and is further challenged when it occurs with the co - morbid use of alcohol and other drugs . . international classification of disease ( icd ) classificatory system gives a separate nosological status to substance - induced psychosis , and hence , a need to differentiate it from primary psychotic disorders in the absence of organic damage . a change in diagnosis from a substance - induced psychosis to a primary psychosis can reflect the progression of an illness or defective diagnostic assessments . psycho - active drugs may precipitate schizophrenia - like illness or may develop into a chronic psychotic disorder over time . in fact , diagnostic and statistical manual of mental disorders , fifth edition research agenda has included this substance abuse / psychosis co - morbidity as an important area for research . the distinction between a substance - induced psychosis and a primary psychotic disorder is an important because they require fundamentally different approaches to treatment . despite this , very little is known about longitudinal diagnostic stability and change in early phase psychosis co - occurring with psychoactive substance use . hence , the present study was planned to evaluate the diagnostic stability over a period of 1-year and to analyze the differences in key demographic , family , clinical , and laboratory parameters between the two groups . this study was carried out in a general hospital psychiatry unit of a large hospital at pune . all consecutive cases presenting with first episode psychosis ( fep ) and concurrent substance abuse admitted between january 1 , 2010 and june 30 , subjects were in the age range of 1845 years of age and were english or hindi speaking . inclusion criteria were the presence of at least one psychotic symptom during admission and use of alcohol or other psychoactive substance within preceding 30 days . the patients with a head injury and organic psychotic disorder were excluded . a specially designed semi - structured sociodemographic performa was used to obtain demographic , family , and clinical data . brief psychiatric rating scale ( bprs ) was used for evaluating psychiatric symptoms and alcohol use disorder identification test ( audit ) questionnaires was used to evaluate alcohol use at baseline , at 6 months , and at 1-year . laboratory evaluation of substance use and urine drug screen for opioids , amphetamines , cannabis , benzodiazepines , and cocaine was also done at these points . diagnostic stability was defined as having the same category ( primary or substance - induced psychosis ) at baseline and at follow - ups . the diagnostic change was defined as a change of diagnosis from the baseline substance - induced psychosis to the primary psychosis or from the primary psychosis to the substance - induced psychosis at either the 6 months or at 12 months follow - ups . subjects with primary psychosis were compared to those with substance - induced psychosis on the demographic , family , clinical , and social domains . the group differences were tested using either chi - square , two - tailed , unpaired t - tests , or others depending on the type of variable . of the 50 cases , during the study , 31 cases were diagnosed with primary psychosis and 19 cases were diagnosed with substance - induced psychosis . after initial management , all were placed on medications and followed monthly . primary psychosis group had 14 cases of schizophrenia , 9 cases of depression with psychosis , 4 cases of unspecified psychosis , 2 cases of persistent delusional , and 2 cases of mania with psychosis , whereas substance - induced psychosis group had 16 cases of alcohol - induced psychosis and 3 cases of cannabis - induced psychosis . the mean age , socioeconomic background , and family history in both primary and substance - induced psychotic disorder is as brought out in table 1 . the majority of cases ( 89% ) in substance - induced psychosis group had an education till higher secondary as compared to 64% in primary psychosis group . forty - two percent of cases in substance - induced psychosis group had poor family support as compared to 29% cases in primary psychosis group . the most common substance of abuse was alcohol in 80% cases and the rest had used cannabis . distribution of auditory and visual hallucination in both primary and substance - induced psychotic disorder is as brought out in table 2 . only 25% cases in primary psychosis group had suicidal ideations in comparison to 50% in the substance - induced group . distribution of demographic variables in primary psychotic and substance - induced psychotic disorder distribution of hallucinations at baseline in cases of primary psychosis , substance - induced psychosis , and change disorder the severity of psychopathology ( bprs ) and alcohol use ( audit ) in both primary and substance - induced psychotic disorder is as brought out in table 3 . distribution of bprs and audit score in primary and substance - induced disorder groups all 31 cases of primary psychosis at baseline retained their diagnostic status at 6 months and 12 months follow - ups . however , by the end of study follow - up , of the 19 cases of substance - induced psychotic disorders , 7 ( 36% ) required a change of diagnosis to primary psychosis , 5 at 6 months , and another 2 at the end of 1-year . the revised diagnosis was schizophrenia in 5 cases and persistent delusional disorder in 2 cases . the mean age of the cases in primary psychosis group was 31.52 years , whereas it was significantly higher in the substance - induced psychotic group at 37.47 years . caton et al . in their study of 2005 reported that the mean age of cases in primary psychosis was 25 years as compared to 29 years in substance - induced psychosis . the majority of cases ( 89% ) in substance - induced psychosis group had an education till higher secondary as compared to 64% in primary psychosis group . this finding suggests that the cases of primary psychosis group probably had problems even during the education leading to less years of formal education in this group . forty - two percent of cases in substance - induced psychosis group had poor family support as compared to 29% cases in primary psychosis group . this could be due to more severe psychopathology possibly related to the substance abuse in the former group leading to family problems . however , the study by caton et al . had found approximately equal distribution of poor family support among the two groups . about 20% cases in primary psychosis group had a family history of psychotic illness as compared to only 10% cases in the substance - induced group indicating the importance of family history in assessing the diagnosis at baseline . the most common substance of abuse was alcohol in 80% cases and the rest had used cannabis . alcohol use was prevalent in 77% of cases in primary psychosis group and 84% in substance - induced psychosis group . a systematic review by archie and gymrey in 2009 showed that at baseline , substance use disorder occurred in up to 53% of fep patients . all the cases of substance - induced psychosis had auditory hallucinations in comparison to 58% cases in the primary psychosis group and similar results were found when comparing the presence of visual hallucinations . caton had also reported visual hallucination to be more common in the substance - induced group ( 23.7% vs. 14.7% ) . considering the presence of suicidal ideations among the groups , only 25% cases in primary psychosis group had suicidal ideations in comparison to 50% in the substance - induced group . however , the primary psychosis group had more severe symptoms and the severity was more at all the points of assessment . similar finding has been reported by caton et al . comparing the audit scores to identify substance use / abuse , 68% cases in substance - induced psychosis group had alcohol use suggestive of abuse / or dependence as compared to 29% cases in the primary psychosis group . alcohol dependence was predictive of psychotic experience in a general adult population survey in great britain . it reported two - fold higher risk independent of other risk factors for psychotic symptoms , suggesting that alcohol dependence per se doubles the risk of psychotic symptoms . when they assessed 400 participants are presenting with first psychotic episode concurrent with substance use . the analysis identified three key predictors as being greater in participants of the substance - induced psychotic group : parental substance abuse , diagnosis of any drug dependence , and visual hallucinations . at 1-year follow - up , found the change of diagnosis to be 20% in their retrospective study on indian substance - induced psychotic disorder sample . johns et al . in their study found that 11% cases required a change in diagnosis . on comparison of the characteristics of the participants in the change disorder group with primary psychosis group , the change disorder group had lower scores on baseline psychopathology and more suicidal ideations . when the change group was compared to stable substance - induced psychotic disorder group parental mental illness reasons for a change from substance - induced psychotic disorder to a primary psychotic disorder over time might be due to few possibilities like first , there is no change in diagnostic status over time and cases diagnosed as substance - induced psychosis at baseline might have been primary psychotic disorder at baseline but due to cross - sectional assessment diagnosis might have been missed and a second possibility is that substance - induced psychotic disorder might be marker for an emerging psychosis that was not yet manifest at first admission . such individuals might be especially vulnerable to the psycho - mimetic properties of the substances . the third possibility is that the fep might be part of a process of moving toward an autonomous psychotic disorder in those chronically misusing drugs . however , this study with a longer follow - up is recommended to be conducted for robust evidence of understanding of the stability of fep with concurrent substance use . the present study is one of the few studies carried out especially in reference with diagnostic stability . it is pertinent to mention that differential diagnosis between a primary and a substance - induced psychotic disorder at baseline is important from the clinical , prognostic , and follow - up perspectives . our research found out a significant difference in clinic - psycho - social paradigm between the primary psychotic disorder group and substance - induced psychotic disorder group . the primary psychotic disorders group is relatively stable over time , but the diagnosis in substance - induced psychotic disorders group changed over time .
background : co - morbid substance use is common among individuals presenting with symptoms of psychosis . 
 there is a paucity of research in this area.aim:to study the longitudinal follow - up of patients over 1-year of first episode psychosis with concurrent substance use in terms of their diagnostic stability.materials and methods : fifty patients having at least one symptom of psychosis at first admission at a general hospital psychiatric unit along with concurrent substance abuse were included and followed up for 1-year . 
 international classification of disease-10 , diagnostic criteria were used for diagnosis . 
 semi - structured sociodemographic performa to assess the sociodemographic profile . 
 brief psychiatric rating scale and alcohol use disorder identification test as rating scales were used for the assessment at 6 and 12 months.results:of 50 patients , 31 patients who had a diagnosis of primary psychosis retained their diagnosis at follow - up . 
 the mean age of cases in substance - induced psychosis group was 37.47 years , which was significantly higher than in primary psychosis group at 31.52 years . however , 7 patients of the substance - induced psychosis group required a change in diagnosis to primary psychosis group . 
 the primary psychosis group patients were significantly younger , less educated , had less family support , had greater family mental illness , had more severe symptoms , and less hallucinations.conclusion:the present study is a forerunner in this area . 
 salient differences indicated in the study can help in differentiating the diagnosis and in the management of cases . 
 this is particularly relevant in the management setting and for long - term intervention purpose .