The darker side of smoking pot
Growing body of evidence that marijuana can trigger psychosis among those already at risk
VANCOUVER— It took years for doctors to figure out why she was hearing voices in her head. It started innocently at first. The voices were distant. Sometimes they came from her television. In this alternate reality, she was the belle of Hollywood’s A-list, sought after by the directors and actors of Beverly Hills.
Before age 25, Anita Smith had never touched marijuana. She had an otherwise unremarkable, sheltered upbringing with no family history of mental illnesses. Following high school, she spent three years in the Canadian Forces before deciding to enrol in film school. Her group of friends in college introduced her to pot.
That was back in the mid ’90s, when the psychoactive component in cannabis, THC, was mild compared to today’s standards. For more than two years, Smith was a daily user. So was everyone else in her peer group. But only she heard the voices.
As Canada is poised to legalize recreational marijuana in October this year, with federal legislation making the drug legal to possess in limited amounts for anyone 12 or older, experts are attempting to figure out how best to educate Canadians on the mental health risks for using the drug.
In particular, research in Denmark has discovered heavy cannabis users are substantially associated with the development of schizophrenia and bipolarism. In fact, of those who were hospitalized with a pot-related mental condition, almost 50 per cent were diagnosed with schizophrenia or bipolarism later on in life. The risks increase the younger a person starts using.
Experts have not yet determined whether cannabis causes schizophrenia or bi-polar disorder, or whether it simply triggers a first psychotic episode.
“I had my own world inside my head and it was a great world at first ... Conan O’Brien wanted to marry me, this rock star thought I was the greatest thing. It fed my ego so much,” Smith said.
But then she started believing what her mind was telling her. She was going to live in a van, move to the U.S., meet the lover of her dreams. The first time she went to hospital, she called 911 on herself. Smith, who was diagnosed with schizophrenia, is hardly the only example in British Columbia.
For the past seven years, emergency departments in the province have been tracking hospital admissions of those who were diagnosed with mental or behavioural issues due to cannabis consumption, and overdoses related to the drug. Each year, the numbers of people so mentally ill from marijuana that they had to go to the emergency room has increased consistently.
Data obtained from St. Paul’s Hospital, Vancouver General Hospital, Surrey Memorial Hospital and Kelowna General Hospital show 567 people in total in these categories were admitted to these emergency departments last year. In 2012, that figure was 168. The difference in the number of admissions for mental health issues due to marijuana at the four hospitals reveal an approximately 30-per-cent average year-over-year increase in these types of hospital visits.
In Denmark, the records examined by researchers displayed remarkably similar circumstances as the count from B.C. Each of the1,492 people examined in the country had been admitted to hospital for cannabis-related psychosis, defined under the same International Classification of Diseases metric as the figures presented by B.C. hospitals. Just under half were diagnosed with schizophrenia or bipolarism later on in life, often within the next two to three years after their first hospital visit.
“It was very surprising,” said Dr. Marie Starzer, lead author of the Danish study, in an interview. “(These) were cases so severe you would need hospitalization or at least a visit to the psychiatric emergency room ... there’s probably a lot more cases of people who get some sort of psychotic symptoms when they smoke cannabis but they pass after a couple of hours.”
Dr. Phil Tibbo, chair of the Schizophrenia Society of Canada Foundation, said there’s a misconception among the public that because marijuana is “natural,” that it’s completely safe for consumption.
“When you talk to youth, that’s what they hear. ‘There’s no issue. It’s harmless. It’s a natural product. How can it do me any harm?’ That’s the perception of cannabis,” Tibbo said.
Particularly, the concern for youth is how cannabis consumption disrupts the endocannabinoid system responsible for passing information in the brain during adolescent brain development, Tibbo said. It’s the disruption of that system that could result in psychosis. Or put another way, adolescent cannabis usage could potentially undermine the ability of the brain to properly pass along information.
To date, much of the prevailing theory is that marijuana doesn’t cause mental illness so much as act as a “trigger” for those already at risk, said Dr. Tim Stockwell, director of the Canadian Institute for Substance Use Research in B.C.
“That’s the summary of the established position. Personally, I think it may be a little more of a problem than that,” Stockwell said. “I’ve encountered people who it appears from family reports had no other symptoms until they got heavily into using cannabis.”
“It’s controversial and people argue fiercely on both sides.”
Dr. Bonnie Henry, B.C. health officer, said the increase in numbers may be due to how doctors are becoming ever more aware of marijuana-related symptoms, in addition to the presence of more users overall, thanks to the proliferation of recreational marijuana in recent years.
But Henry said the issue is how THC levels are not currently measured, and the provincial government is looking to Ottawa to enforce labelling requirements on the quantity of THC within recreational cannabis products. Henry said one option B.C. has at its disposal would be to set pricing based on the quantity of THC in each product.
“We know products that contain really high THC levels are ones more likely to trigger psychosis or other ill health effects,” Henry said in an interview. “If you’re somebody who has a family history of mental health issues of psychosis or anxiety, then you’re somebody who should not be using cannabis.”
Health officials also don’t know how much THC would be considered high enough to exacerbate risks due to lack of knowledge. In lieu of recommended daily dosage guidelines, the message of currently endorsed guidelines to prevent mental illness risk is simply: use less, use lower levels of THC or abstain.
None of the B.C. hospitals provided a subject matter expert, or anyone from their emergency departments, for an interview. Interior Health, which saw 81 cases at its Kelowna General Hospital in 2017, provided a statement from Andrew Hughes, the hospital’s health service administrator.
“The number of patients admitted with cannabis use disorders or overdoses has remained very small over the last eight years when taken in the context of the overall patients we see at Kelowna General Hospital,” Hughes said.
Fraser Health’s Surrey Memorial Hospital saw the largest proportion of cases, with 270 cases last year. Spokesperson Jacqueline Blackwell said the treatment for the typical patient with a cannabisrelated emergency would involve determining whether there is an ongoing mental health or substance use concern.
Janice Jacinto started using marijuana when she was 13. As a survivor of childhood trauma, she had always understood the anguish of mental pain. She dabbled with drugs, not just marijuana, simply due to the people she would hang out with at the time.
Jacinto’s problem is that when she uses marijuana, dark memories of years past come flooding back with the intensity of a current event taking place.
“It’s not always the memory. It’s a sensation in the body that remembers the stress. I was remembering things in from sixth grade I don’t normally think about ... when you’re moving in that sped up kind of dial, the noise gets louder,” the 33-year-old said. Her first true manic episode was in 2007. Since then, Jacinto’s been in and out of hospital for psychiatric treatment more than a dozen times, almost always due to psychosis following marijuana consumption.
For years, she was on and off antipsychotic medications that often leave her without energy or creativity. But despite her continuing occasional consumption of marijuana, in part to offset the effects of anti-psychotic medications, she’s been able to gain a measure of control. The last time she was hospitalized was around 2014.
The Vancouver Police Department, meanwhile, attributed the emergency room cases to an increase in mentalillness-related violence in the city. In its 2016 mental health strategy, the department described how its officers struggle to be the front-line of a mental health crisis in the city, with the number of contacts between police and the mentally ill increasing every year.
“It is only a small subset of this population who demonstrate a propensity toward violent behaviour, generally those with psychosis, often caused by schizophrenia or a related illness,” reads the mental health strategy. “The drivers of this increase include ... a 300-per-cent increase in marijuana-induced psychosis over the last five years.” The police attributed this increase to “an increase in the toxicity of marijuana in recent years.”
The data-set used by the Vancouver police is identical to the one obtained by StarMetro. Vancouver police did not provide an interview to clarify its interpretation of the information.
Henry said she believes the incidents referred to by Vancouver police are associated with “manufactured highly concentrated THC products like shatter,” which she believes should be illegal.
“While I agree with their stats and concerns, 300-per-cent increase is still quite small in the actual numbers,” Henry said.
As one positive sign, Henry referred to 2013 figures collected from 30,000 B.C. youths from Grades 7 to 12 that showed only about one-in-four teens had used marijuana in their lifetimes, down about 5 per cent from the previous survey done in 2008. Younger users under the age of 25 have an increased risk in developing mental illness due to marijuana use, she said.
“That age group from 19 to 25 is actually the highest using age group right now of cannabis, and prohibiting it in that group is not going to help,” Henry said.
“We know products that contain really high THC levels are ones more likely to trigger psychosis or other ill health effects.” DR. BONNIE HENRY B.C. PROVINCIAL HEALTH OFFICER