Tag Archives: Tell Your Children

04/13/21

Telling the Truth About Marijuana and Psychosis

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In January of 2019 Alex Berenson’s book, Tell You Children: The Truth About Marijuana, Mental Illness and Violence, was published. He hoped it would at least make his readers skeptical of the pro-marijuana arguments that advocates have peddled for the last twenty-five years. He said, “I hope it will open your eyes to the mental illness and violence that marijuana causes in your community.” In his career as a reporter, he made some enemies and gave an example of when private detectives, who were hired by an angry executive, chased him down the Long Island Expressway. “Yet nothing in my career prepared me for the reaction to this book.”

The article in Wikipedia on Tell Your Children, seemed to capture the rancor Berenson stirred up. He was said to have made “harsh” claims that cannabis use causes psychosis and violence, claims that were denounced by members of the scientific and medical communities. Two scientists who wrote an opinion piece for The Guardian said his assertions were “misinformed and reckless.” A group of 75 scholars and medical professionals signed an open letter that disagreed with Berenson, accusing him of cherry-picking data, attributing cause to mere associations and selection bias. “His work is a polemic based on a deeply inaccurate misreading of science.”

In an Afterword Berenson wrote in October of 2019 for the e-book edition, he said it was crucial to understand that these critics did not claim his book presented false or incorrect data, or was in any other way was “factually inaccurate.” “They can’t, because it doesn’t and isn’t.” He added that “misinterpret” and “cherry-pick” were word critics used when they could not find actual factual errors. He found the anger against what he wrote almost bizarre. “One can be aware that cannabis can cause mental illness and still favor legalization. But the cannabis industry, academics, and journalist-advocates would rather try to shout down anyone who raises it.”

Despite the attacks, both pro- and anti-legalization forces have said the book has affected the public debate. Berenson said, “And the evidence about the serious health harms has only mounted since January [of 2019].” Let’s look at some of this new evidence about the serious health harms from marijuana. There were two studies published in JAMA Psychiatry that appeared to support Berenson’s understanding of the science. Follow the links and see if he has been misreading the science.

A study done in 2018 and published in March of 2019 in JAMA Psychiatry found that prenatal cannabis exposure may be associated with a small increase in the proneness for psychosis during middle childhood. Another study published in May of 2019 in the journal JAMA Psychiatry suggested that risks for cannabis use problems and anxiety disorders were higher among those using high-potency cannabis. There was a small increase in the likelihood of psychotic experiences, but this risk decreased with an adjustment for the frequency of cannabis use.

Dr. Marta Di Forti is one of the leading researchers in the world for cannabis and psychosis. In a previous meta-analysis Di Forti and other researchers showed there was a positive association between the extent of cannabis use and the risk of psychosis. They observed “a consistent increase in the risk of psychosis-related outcomes with higher levels of cannabis exposure” in all the studies included in the meta-analysis. “Although this meta-analysis shows a strong and consistent association between cannabis use and psychosis, a causal link cannot be unequivocally established.”

Di Forti and others also noted that epidemiological evidence demonstrates that cannabis use is associated with an increased risk of psychosis in “Traditional marijuana, high-potency cannabis and synthetic cannabinoids: Increasing risk of psychosis.” The researchers said concern that cannabis might induce psychosis is not new. In 1896 the Scottish psychiatrist T. Clouston visited the Cairo asylum and noted that 40 out of 253 people in the hospital had insanity attributed to the use of hashish. By the 1960s, this view was commonly ridiculed as ‘reefer madness.’ The implication was that those who believed marijuana could induce psychosis were mad, rather than those who consumed it. This seems to be the thrust of the approach from those scholars and medical professionals that signed the open letter disagreeing with Berenson.

However, there have been several longitudinal studies showing cannabis as a risk factor for psychosis. “Nine out of twelve found that cannabis use was associated with a significantly increased risk of psychotic symptoms or psychotic illness.” In a 2015 study for Lancet Psychiatry, Di Forti and others found that high-potency cannabis users in south London had three times the risk of having a psychotic disorder than those who never used cannabis.

The following link is to a talk Dr. Di Forti gave in December of 2019 before the American College of Pharmacology, where she presented data from her research in South London, at a clinic where she works. First, she asked, does the frequency and type of cannabis matter?

The charts below from her presentation showed that individuals who used hash did not have rates that were statistically different than the controls. However, she had already said that hash was found to have a combination of THC and CBD, where the “skunk” or high-potency cannabis had very little CBD. Notice in the first graph that the probability of an individual experiencing a psychotic disorder increased as the frequency and strength of cannabis increased to daily use of high-potency skunk. The second chart shows both the use of high-potency cannabis and daily use of high-potency cannabis increased the chance of having a first-episode psychosis by 53% and 25% respectively.

Di Forti then asked, why should potency matter? Why should the amount of THC in cannabis matter? The results of a 2016 study she contributed to, “The Effects of continuation, frequency, and type of cannabis use on relapse,” found that once someone had a psychotic episode, if they continued to use cannabis, especially high-potency skunk, they “are much more likely to have a bad clinical outcome.” There was an increased risk of relapse, there were more relapses, there were fewer months until a relapse occurred, AND more intense psychiatric care was needed after the onset of psychosis.

Adverse effects associated with continued use of cannabis after the onset of a first episode of psychosis depend on the specific patterns of use. Possible interventions could focus on persuading cannabis-using patients with psychosis to reduce use or shift to less potent forms of cannabis.

In May of 2019, Di Forti and others published this research in The Lancet. The strongest independent predictors of whether an individual would have a psychotic disorder or not were daily use of cannabis and the use of high-potency cannabis. Starting cannabis use by the age of 15 modestly increased the odds for a psychotic disorder, but not independent of the frequency of use or of the potency of the cannabis used. “The odds of psychotic disorder among daily cannabis users were 3.2 times higher than for never users, whereas the odds among users of high-potency cannabis were 1.6 times higher than for never users.” Compared with individuals who never used, individuals who used high-potency cannabis daily had four-times higher odds of psychosis. Their findings were consistent with previous evidence suggesting that using high-potency cannabis has more harmful effects on mental health than does the use of weaker forms.

Our findings confirm previous evidence of the harmful effect on mental health of daily use of cannabis, especially of high-potency types. Importantly, they indicate for the first time how cannabis use affects the incidence of psychotic disorder. Therefore, it is of public health importance to acknowledge alongside the potential medicinal properties of some cannabis constituents the potential adverse effects that are associated with daily cannabis use, especially of high-potency varieties.

Serendipitously, it seems Marta Di Forti reviewed Tell Your Children by Alex Berenson for Amazon on January 18, 2019. She titled her review “Outstanding and engaging narrative.” She said:

This book is a rare and compelling combination of journalistic rigor, elegant writing and engaging style. A unique appraisal of the sociological and scientific facts feeding the never-ending debate on the good and bad of the most popular recreational drug in the world. A “must” read for everyone that can read or listen.

In his Afterword, Berenson cited a review study of twenty-six meta-analyses and literature reviews on cannabis and psychosis, “Cannabis use and psychosis: a review of reviews” published on September 28, 2019 in the European Archives of Psychiatry and Clinical Neuroscience. He said its findings were no surprise. There was consistent support for cannabis use being a contributing cause of psychosis.

The scientific literature indicates that psychotic illness arises more frequently in cannabis users compared to non-users, cannabis use is associated with a dose-dependent risk of developing psychotic illness, and cannabis users have an earlier onset of psychotic illness compared to non-users. Cannabis use was also associated with increased relapse rates, more hospitalizations and pronounced positive symptoms in psychotic patients.

Although not research, in August of 2019 the U.S. Surgeon General published an advisory on Marijuana Use and the Developing Brain. He noted how the marijuana available today is much stronger than it was in the past. The THC concentration in marijuana plants has increased three-fold between 1995 and 2014, 4% to 12% respectively. Marijuana available in some state dispensaries has an average THC concentration between 17.7% and 23.2%. Concentrated products, known as dabs or wax, may contain between 23.2% and 75.9%.

The risks of physical dependence, addiction, and other negative consequences increase with exposure to high concentrations of THC and the younger the age of initiation. Higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis.

The ad hominem arguments against Alex Berenson and Tell Your Children just do not hold up. Attempting to misdirect the debate over the significance of what Berenson elegantly documents and say he should contend with the failures of marijuana prohibition, illustrates how his critics argue past him. The open letter noted above is an example of this: “Weighed against the harms of prohibition, including the criminalization of millions of people, overwhelmingly black and brown, and the devastating collateral consequences of criminal justice system involvement, legalization is the less harmful approach.” The Guardian noted that Berenson was open to that position, although he disagreed with it.

“You can believe that cannabis is a real risk for psychosis and violence and still believe it should be legal,” he said. “That’s a totally reasonable position to take. Just tell the truth.”

For more on marijuana and psychosis, see: “Cannabis and Psychosis: More Reality than Satire.”

03/31/20

Cannabis and Psychosis: More Reality Than Satire

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On December 19, 2014, in Cairns Australia Raina Thaiday stabbed eight children to death. She was related to all the children. “Seven of the kids were hers. The eighth was her niece.” On April 6, 2017, a Justice of the Supreme Court of Queensland heard testimony from Thaiday’s psychiatrists and later determined she couldn’t control her actions and had broken from reality when she killed her children. “In medical terms, she suffered from psychosis and the devastating mental illness schizophrenia, which can cause hallucinations, delusions, and paranoia.” Justice Dalton ruled that marijuana had caused her mental illness.

“Thaiday gave a history of the use of cannabis since she was in grade 9,” Dalton wrote. “All the psychiatrists thought that it is likely that it is this long-term use of cannabis that caused the mental illness schizophrenia to emerge.” With those words, Dalton made one of the first judicial findings anywhere linking marijuana, schizophrenia, and violence—a connection that cannabis advocates are desperate to hide.

The above anecdotal story was described in Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence, by Alex Berenson. He noted the association of cannabis and violence dated back to around 100 AD. A Chinese pharmacopeia called the Pen-ts’ao Ching, warned how cannabis “stimulate(d) uncontrollable violence and criminal inclinations.” More recently, in 2017 the National Academy of Medicine issued a research report titled, “The Health Effects of Cannabis and Cannabinoids.” The report concluded there was substantial evidence of an association between cannabis use and the development of schizophrenia or other psychoses. And the highest risk was among the most frequent users.

The association between cannabis use and the development of a psychotic disorder is supported by data synthesized in several good-quality systematic reviews. The magnitude of this association is moderate to large and appears to be dose-dependent, and it may be moderated by genetic factors. Factors contributing to the strength of the evidence derived from the cited systematic reviews include large sample sizes, the relative homogeneity of the findings, the presence of relationships between the dose/exposure and the risk, the studies having been controlled for confounders, and the systematic reviews having assessed for publication bias. The primary literature reviewed by the committee confirms the conclusions of the systematic reviews, including the association between cannabis use and psychotic outcome and the dose-dependency of the effects, further bolstering the overall strength of evidence for our conclusions.

Cascading social changes, with state-after-state legalizing medical and then recreational marijuana has broadened its use beyond the subculture of jazz musicians who smoked it in the 1920s and 1930s. Berensen noted the number of emergency room visitors diagnosed primarily with psychosis and secondarily with marijuana-related problems tripled between 2006 and 2014 from 30,000 to 90,000. “By 2014, 11 percent of Americans who showed up in emergency rooms with a psychotic disorder also had a secondary diagnosis of marijuana misuse.” Studies from Denmark and Finland have shown recent increases in schizophrenia diagnoses coming after rising cannabis use. The authors of the Denmark study said: “The increase in cannabis-induced psychosis follows both the increase in the level of THC in cannabis, and the increase in cannabis use.”

Marijuana is an intoxicant that can disinhibit users, too. And though it sends many people into a relaxed haze, it also frequently causes paranoia and psychosis. Sometimes those are short-term episodes in healthy people. Sometimes they are months-long spirals in people with schizophrenia or bipolar disorder.

There is also a correlation between marijuana and violence, despite the denial of marijuana proselytizers. All four states that legalized marijuana in 2014 and 2015—Alaska, Colorado, Oregon and Washington—have seen sharp increases in murders and aggravated assaults. The four states combined have an increase in murders of 25% and an increase in assaults of 35% between 2013 and 2017. That compares nationally to an increase in murders of 20% and in aggravated assaults of 10%. There is only an association here; it is correlative, not causative. “Knowing exactly how many of these crimes are related to marijuana is impossible without researching each of them in detail, but police reports and arrest warrants show a clear connection in many cases.”

There is also a genre of scholarly studies linking marijuana and psychosis. Jim van Os, a Dutch psychiatrist and epidemiologist was the lead author of a 2002 study, “Cannabis use and psychosis: A longitudinal population-based study,” that found a history of cannabis use increased the risk of a follow-up psychosis outcome for subjects with no history of psychosis. “A baseline lifetime history of cannabis use was a stronger predictor of psychosis outcome than was use over the follow-up period and use of other drugs.” There was an additive interaction between cannabis use and the risk of psychosis. “The difference in risk of psychosis at follow-up between those who did and did not use cannabis was much stronger for those with an established vulnerability as baseline than for those without one.” Berensen said Os’s survey of Dutch adults indicated adult users of marijuana were far more likely to develop psychosis than nonusers.

Benjamin Murrie and others did a study of the proportion of people with substance-induced psychoses who transition to schizophrenia. They found that the rate of transition to schizophrenia was higher after cannabis-induced psychosis (34%) than other substance-induced psychoses, including amphetamines (22%) and hallucinogens (24%). Their study found that substance-induced psychoses (especially cannabis-, hallucinogen- and amphetamine-induced psychoses) are associated with a significant risk of a later diagnosis of schizophrenia. And that risk is “only slightly less than that observed for some other brief psychotic episodes.”

Commenting on the study for Psychiatric Times, Brian Miller said the study’s findings have important implications for mental health services. Substance-induced psychoses are common reasons for individuals to seek help. Additionally, they are associated with a substantial risk of transition to schizophrenia. He said a key implication of the findings is that treating cannabis-, amphetamine-, and hallucinogen-induced psychoses should be considered in the same framework of intervention as other brief psychotic disorders, and may help decrease the rates of transition to schizophrenia.

Sir Robin MacGregor Murray and Marta Di Forti, leading experts on cannabis and psychosis, were part of a team of researchers in a study of first-episode psychosis attributable to the use of high potency cannabis, or “skunk.” Compared to those who never used cannabis, individuals who used skunk were nearly twice as likely to be diagnosed with a psychotic disorder if they used less than once per week, almost three times as likely if they used skunk weekends, and more than five times as likely if they were daily users. In a Reuters article on the study, Murray said: “Fifteen years ago, nobody thought that cannabis increased the risk of psychosis… But now the evidence is pretty clear.”

The results of our study support our previous conclusions from analysis of part of the sample; use of high-potency cannabis (skunk) confers an increased risk of psychosis compared with traditional low-potency cannabis (hash). Additionally, because of the increased sample size in the present study, we were able to combine information on frequency of use and type of cannabis used into a single measure. This combined measure suggested that the strongest predictor of case-control status (ie, predictor of whether a random individual would be case or control) was daily-skunk use.

Even the founder of NORML, Keith Stroup, knew that when marijuana was potent enough to get him high, it could make him paranoid. In his 1981 book, High in America, Patrick Anderson related how onetime Stroup “rocked so obsessively in a rocking chair that the chair broke.” Then he became convinced someone was about to murder his new daughter and raced home to save her. Another time after smoking pot, he became convinced that a friend who had come for dinner was going to kill them.

Case reports connecting marijuana and psychosis began appearing in the 1970s, as cannabis use surged. There was “Psychotic symptoms due to cannabis abuse,” in the National Library of Medicine, 1970; “Forty-six cases of psychosis in cannabis abusers,” in International Journal of the Addictions, 1972; “Psychotic reactions following cannabis use in East Indians,” in Archives of General Psychiatry, 1974. “Cannabis-associated psychosis with hypomanic features” appeared in Lancet in 1982. But these were only case reports.

Sven Andréasson was able to demonstrate a statistical link between marijuana and schizophrenia for the first time in, “Cannabis and schizophrenia: A longitudinal study of Swedish conscripts,” Lancet, 1987. Andréasson did a follow up study to examine if people who developed schizophrenia after smoking marijuana were different than schizophrenic patients who had never smoked, “Schizophrenia in users and nonusers of cannabis,” Acta Psychiatrica Scandinavica, 1989. Berenson reported Andréasson found that marijuana smokers tended to be relatively high-functioning before their illness, while nonsmokers had a more classic history representative of schizophrenia—they were troubled from a much younger age.

Based on his data and later findings, Andréasson says he believes that cannabis is responsible for between 10 percent and 15 percent of schizophrenia cases. Few people develop schizophrenia solely because of smoking, he thinks. But many who would not have become sick do so because marijuana pushes their vulnerable brains over the edge.

Then there was a longitudinal study of individuals from Dunedin, New Zealand: “Cannabis use in adolescence and risk for adult psychosis,” in the British Medical Journal, 2002. The authors found cannabis use in adolescence increased the likelihood of experiencing symptoms of schizophrenia in adulthood. Individuals who used cannabis by the age of 15 were 4 times as likely to have a diagnosis of schizophreniform (a psychotic illness with schizophrenia-like symptoms lasting less 6 months). Their findings agreed with the Andréasson study, and added three new pieces of evidence.

Firstly, cannabis use is associated with an increased risk of experiencing schizophrenia symptoms, even after psychotic symptoms preceding the onset of cannabis use are controlled for, indicating that cannabis use is not secondary to a pre-existing psychosis. Secondly, early cannabis use (by age 15) confers greater risk for schizophrenia outcomes than later cannabis use (by age 18). The youngest cannabis users may be most at risk because their cannabis use becomes longstanding. Thirdly, risk was specific to cannabis use, as opposed to use of other drugs, and early cannabis use did not predict later depression.

Along with the van Os study, described above, the Andréasson study and the Dunedin study provide significant and powerful evidence linking cannabis and mental illnesses, such as schizophrenia and depression. They all reached the same conclusion, came at the question of marijuana and psychosis from three different directions and were from three different countries. An editorial in the BMJ, “Cannabis and mental health,” discussing these three studies said:

Although the number of studies is small, these findings strengthen the argument that use of cannabis increases the risk of schizophrenia and depression, and they provide little support for the belief that the association between marijuana use and mental health problems is largely due to self-medication.

The connection between marijuana and madness harkens back to an education-exploitation film called Reefer Madness or Tell Your Children. Reefer Madness is a melodramatic, 1936 film that attempted to show the dangers of marijuana use. It became a satirical favorite among advocates for marijuana reform in the 1970s when it was used in an attempt to raise support for the California Marijuana Initiative in 1972. Keith Stroup found a copy in the Library of Congress archives and bought a print for $297. Robert Shaye of New Line Cinema saw the film, realized it was in the public domain, and began distributing the film nationally.

In the film, Ralph, who is a dealer, becomes paranoid from his use of marijuana (and he also accidentally killed a teenaged girl). The Boss eventually sends someone to kill Ralph, who struggles with the hitman and beats the assassin to death with a stick. Ralph is then arrested and sent to an asylum for the criminally insane, “for the rest of his natural life.” The connection between marijuana and madness seems to becoming less campy satire and more reality. For more on the film, see “Remembering Reefer Madness.”