Assignment 3.

3 1

Assignment 3.3 – Research Paper on Marijuana Use in Populations Experiencing Psychosis or

Diagnosed with Psychotic Disorders

Wake Forest University

Michelle White
Assignment 3.3 2

Rationale

Clinicians at Daymark Recovery Services, a chain of community-based organizations

across North Carolina, have recently noticed an emergence of cannabis usage in clients who are

seeking to receive or currently utilize our services for medication management to treat psychosis

or psychotic disorders. This trend is most notable in clients seeking medication management

services, but the behavior has also been noted amongst current clients. This is of particular

concern because, while marijuana isn’t considered as serious as some other drugs, it can

significantly impact the effects of medications and potentially place clients who experience

psychosis at risk of harm. The consultee clients tend to have a positive adjustment to their mental

health issues, as they are seeking treatment or maintaining treatment. However, this population

of clientele typically doesn’t believe that their cannabis usage is a problem. They will make

claims such as, “I can stop using any time,” but will then make contradictory reports of using

marijuana “all day, every day” or with similar frequencies. Their urine drug screens also indicate

cannabinoid usage after agreeing to maintain abstinence from all substances to continue to

receive services.

However, this phenomenon isn’t limited to Daymark Recovery Services or to North

Carolina. As the legal landscape of the United States changes to accommodate the legalization of

marijuana and the decriminalization of drugs, cannabis use has become increasingly popular

across all demographics in recent years. Among individuals with psychosis or psychotic

disorders, marijuana use continues to become more common. According to Hirschtritt, et. al., in

“a meta-analysis of 35 studies, among 6321 patients with first-episode psychosis, 33.7%

endorsed cannabis use (Hirschtritt et al., 2021).” The marijuana use rate among populations with

psychotic disorders, not just those experiencing first episode psychosis, is equally as staggering.
Assignment 3.3 3

Avery, et. al., reports that the population of those with severe psychotic disorders have an odds

ratio of 3.5 of heavily using marijuana when compared to the general population (Avery et al.,

2016).

Literature Review

For this particular topic, understanding the relationship between cannabis use and

psychosis makes up a considerable portion of the literature. According to an article by Gage,

Hickman, and Zammit, the authors assert that associations between cannabis use and psychotic

outcomes are consistently reported, but caution that establishing causality from observational

designs (as many other studies have done) can be incredibly problematic. Instead, Gage, et al.

review ten cohort studies investigating the association between cannabis use and schizophrenia,

psychotic disorders, or psychotic experiences to create a longitudinal study and come to a more

accurate conclusion. Overall, the article finds there is a strong body of epidemiologic evidence to

support the view that regular or heavy cannabis use increases the risk of developing psychotic

disorders (Gage et al., 2016). Based on their review, they report that “if the association between

cannabis and schizophrenia is causal and of the magnitude estimated across studies to date, this

would equate to a schizophrenia lifetime risk of approximately 2% in regular cannabis users”

with a greater risk for broader psychotic outcomes (Gage et al., 2016). The authors also share

that the risk could be much greater for populations that have a higher genetic risk or use strains

of marijuana with a higher potency (Gage et al., 2016).

Hirschtritt, et. al., focus on the effects of cannabis use among individuals who have

already developed and/or been diagnosed with a psychotic disorder. They assert that following

psychosis, initiation or continued cannabis use is associated with worse treatment outcomes. The

authors rely on and quote a recent meta-analysis of 24 studies encompassing 16,565 patients that
Assignment 3.3 4

compared clinical outcomes of patients who did and did not use cannabis over 6 months to 13

years. Utilizing this study, they point out three main points: One, patients who continued to use

cannabis, compared with those who never used cannabis or discontinued use, had more

psychosis relapses (Hirschtritt et al., 2021). Two, continued cannabis users had longer

hospitalizations when compared with non-marijuana users (Hirschtritt et al., 2021). And three,

among young adults with recent-onset psychosis, those with concurrent substance use, including

cannabis, were more likely to have recent legal involvement than those who did not use

substances (Hirschtritt et al., 2021). These effects are complicated by the fact that “despite the

common co-occurrence between psychotic spectrum disorders and substance use disorders, they

are often under-recognized and under-treated, leading to poor treatment outcomes (Avery et al.,

2016).”

Another large portion of the literature revolves around treatment of individuals

experiencing psychotic spectrum disorders and simultaneous substance use disorders. Arsalan, et

al., investigated the impact of self-reported cannabis use on treatment response in a cohort of

schizophrenia patients from Pakistan, a middle-income country. The data for this study and paper

was collected from a psychiatric hospital in Khyber Pakhtunkhwa province of Pakistan where

cannabis use is prevalent. The article reports that the authors received data from over 230

different patients, 90% of whom were men and 60% of whom were resistant to treatment (in this

study, treatment resistance is characterized as reduced effectiveness of antipsychotic drugs). The

study found that frequent and regular use of cannabis was associated with treatment resistance

(Arsalan Arsalan et al., 2019). schizophrenia. Avery, et. al. found that clinician and psychiatrist

attitudes towards diagnoses and clients can further hinder this population’s response to treatment.

They assert that “attitudes towards individuals with severe psychotic disorders and co-occuring
Assignment 3.3 5

substance use disorders may be more negative than towards individuals with other diagnoses,

and these attitudes worsen over time (Avery et al., 2016). Hirschtritt, et. al. also provides some

insight into treatment recommendations for clients experiencing a psychotic disorder and a

substance use disorder, providing reviews of studies that argue for a combination of behavioral

treatments to be most effective at treating this population (Hirschtritt et al., 2021).

Limitations of Available Research

Unfortunately, there are significant gaps in the research. According to Hirschtritt, et. al.,

“evidence specifically among individuals with psychosis and CUDs [cannabis use disorders] is

inconsistent (Hirschtritt et al., 2021).” The article shares that, “the most comprehensive review of

this topic to date reveals that the few randomized controlled trials of behavioral interventions in

this population either demonstrate no or mild and time-limited (ie, < 6 months) effect of any one

or any combination of modalities on cannabis use (Hirschtritt et al., 2021).” Gage, et. al., reports

that “there remains a need for stronger evidence to address questions regarding the magnitude of

causal effect on risk of psychotic disorders and the impact of different strains of cannabis and to

identify any groups at particularly high risk of developing psychosis following use of cannabis

(Gage et al., 2016).” Overall, the sources highlight the complexities of accounting for all of the

factors that may influence the emergence and perpetuation of psychotic disorders in populations

that utilize marijuana. As an example, much of the research fails to discuss socioeconomic status

in its discussion on the different strains of cannabis and its relationship to psychosis. While

studies have found that cannabis strains with higher THC to CBD ratios may result in greater risk

of psychotic outcomes and that CBD by itself might have antipsychotic properties, these same

studies fail to explore which of the strains or ratios are more commonly available to certain

socioeconomic classes or to specific cultural groups. There are certainly many other gaps.
Assignment 3.3 6

Implications

Gage, et. al. offers great insight into the association between psychotic disorders and

cannabis use, particularly just how many factors (like genetic components, cultural practices,

etc.) need to be considered when debating its role in causation and aggravating existing

conditions. The authors made a very helpful addition with their section exploring the THC to

CBD ratios of certain strains and how that could impact the effect of certain cannabis products

on individuals experiencing schizophrenia or other disorders with psychosis as a presenting

concern.

Hirschtritt, et. al. and Avery, et. al., emphasize the need for greater research into the

treatment methods for individuals with comorbid psychotic disorders and substance use disorders

– especially those that emphasize training of professionals and multidisciplinary approaches.

Further studies might also identify trainees and psychiatrists with particularly stigmatizing

attitudes towards these individuals, the various factors which contribute to these poor attitudes,

and which combination of multidisciplinary approaches (such as a combination of

pharmacological interventions, behavioral interventions, and community support interventions)

have been most successful for clients in this particular population.

Finally, some of the most pertinent information from the Arsalan, et. al. article comes

from its discussion of limitations. The authors note that the rate of female participation in the

study results from family members not wanting the female patients to be involved in the research

due to a strong stigma in this province. This article reminds clinicians and consultants to

constantly consider multicultural and sociological facets of client identities when examining

symptoms and deciding on diagnoses. Furthermore, this article emphasizes the need to consider
Assignment 3.3 7

the geographical region and how it may translate to other regions and areas of research being

done.
Assignment 3.3 8

References

Arsalan Arsalan, Zafar Iqbal, Muhammad Tariq, Oyedeji Ayonrinde, John B. Vincent, &

Muhammad Ayub. (2019). Association of smoked cannabis with treatment resistance in

schizophrenia. Psychiatry Research, 278, 242–247.

Avery, J., Zerbo, E., & Ross, S. (2016). Improving Psychiatrists’ Attitudes Towards Individuals

with Psychotic Disorders and Co-Occurring Substance Use Disorders. Academic

Psychiatry, 40(3), 520–522. https://doi.org/10.1007/s40596-015-0361-6

Gage, S. H., Hickman, M., & Zammit, S. (2016). Association Between Cannabis and Psychosis:

Epidemiologic Evidence. Biological Psychiatry, 79(7), 549–556.

https://doi.org/10.1016/j.biopsych.2015.08.001

Hirschtritt, M. E., Young-Wolff, K. C., Mathalon, D. H., & Satre, D. D. (2021). Cannabis Use

Among Patients With Psychotic Disorders. The Permanente Journal, 25, 20.179.

https://doi.org/10.7812/TPP/20.179