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Chapter 22 - The Acute Effects of Cannabinoids in Patients with Psychotic Illness

from Part VII - Cannabinoids and Schizophrenia: Aetiopathology and Treatment Implications

Published online by Cambridge University Press:  12 May 2023

By
Suhas Ganesh ,
Cécile Henquet ,
R. Andrew Sewell ,
Rebecca Kuepper ,
Mohini Ranganathan  and
Deepak Cyril D’Souza
Edited by
Deepak Cyril D'Souza ,
David Castle  and
Sir Robin Murray
Deepak Cyril D'Souza
Affiliation:
Staff Psychiatrist, VA Connecticut Healthcare System; Professor of Psychiatry, Yale University School of Medicine
David Castle
Affiliation:
University of Tasmania, Australia
Sir Robin Murray
Affiliation:
Honorary Consultant Psychiatrist, Psychosis Service at the South London and Maudsley NHS Trust; Professor of Psychiatric Research at the Institute of Psychiatry
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Summary

People with psychosis and those at clinical high risk (CHR) for this syndrome have significantly higher prevalence of cannabis use compared to the general population. Furthermore, cannabis use can negatively impact the course and treatment outcomes in psychosis. Understanding the acute subjective and cognitive effects of cannabis and cannabinoids in this population is necessary if we are to disentangle the reasons for the increased prevalence of use; and also to help design interventions. There is little evidence to support the ’self-medication’ hypothesis, in its original form. Among principal phyto-cannabinoids, while THC exacerbates positive and cognitive symptoms of psychosis, cannabidiol lacks these effects and may even improve these symptoms. With the liberalization of cannabis laws in many countries, cannabis and cannabis-based products will be more accessible to both individuals with psychotic disorders and those at risk for psychosis. This chapter summarizes the literature regarding acute effects of cannabis and cannabinoids in people at CHR and with established psychosis.

Keywords

cannabisacute effectspsychosisself-medicationTHCCBD
Type
Chapter
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Marijuana and Madness , pp. 225 - 239
Publisher: Cambridge University Press
Print publication year: 2023

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References

Addington, J., and Duchak, V. (1997). Reasons for substance use in schizophrenia. Acta Psychiatr Scand, 96, 329–333.Google Scholar
Allebeck, P., Adamsson, C., Engstrom, A. et al. (1993). Cannabis and schizophrenia: A longitudinal study of cases treated in Stockholm County. Acta Psychiatr Scand, 88, 21–24.Google Scholar
Arndt, S., Tyrrell, G., Flaum, M., et al. (1992). Comorbidity of substance abuse and schizophrenia: The role of pre-morbid adjustment. Psychol Med, 22, 379–388.Google Scholar
Baigent, M., Holme, G., and Hafner, R. J. (1995). Self reports of the interaction between substance abuse and schizophrenia. Aust NZ J Psychiatry, 29, 69–74.Google Scholar
Baker, A., Lewin, T., Reichler, H., et al. (2002). Motivational interviewing among psychiatric in-patients with substance use disorders. Acta Psychiatr Scand, 106, 233–240.Google Scholar
Barkus, E., and Lewis, S. (2008). Schizotypy and psychosis-like experiences from recreational cannabis in a non-clinical sample. Psychol Med, 38, 1267–1276.Google Scholar
Barkus, E., Stirling, J. Hopkins, R., et al. (2006). Cannabis-induced psychosis-like experiences are associated with high schizotypy. Psychopathology, 39, 175–178.CrossRefGoogle ScholarPubMed
Bhattacharyya, S., Wilson, R., Appiah-Kusi, E., et al. (2018). Effect of cannabidiol on medial temporal, midbrain, and striatal dysfunction in people at clinical high risk of psychosis: A randomized clinical trial. JAMA Psychiatry, 75, 1107–1117.Google Scholar
Brandt, J. (1991). The Hopkins verbal learning test: Development of a new memory test with six equivalent forms. Clin Neuropsychologist, 5, 125–142.CrossRefGoogle Scholar
Buhler, B., Hambrecht, M., Loffler, W., et al. (2002). Precipitation and determination of the onset and course of schizophrenia by substance abuse: A retrospective and prospective study of 232 population-based first illness episodes. Schizophr Res, 54, 243–251.Google Scholar
Cantor-Graae, E., Nordstrom, L., and McNeil, T. (2001). Substance abuse in schizophrenia: A review of the literature and a study of correlates in Sweden. Schizophr Res, 48, 69–82.Google Scholar
Carney, R., Cotter, J., Firth, J., et al. (2017). Cannabis use and symptom severity in individuals at ultra high risk for psychosis: A meta-analysis. Acta Psychiatr Scand, 136, 5–15.Google Scholar
Celofiga, A., Koprivsek, J., and Klavz, J. (2014). Use of synthetic cannabinoids in patients with psychotic disorders: case series. J Dual Diagn, 10, 168–173.CrossRefGoogle ScholarPubMed
Compton, M. T., Kelley, M. E., Ramsay, C. E., et al. (2009). Association of pre-onset cannabis, alcohol, and tobacco use with age at onset of prodrome and age at onset of psychosis in first-episode patients. Am J Psychiatry, 166, 1251–1257.CrossRefGoogle ScholarPubMed
Compton, W. M., Han, B., Jones, C. M., et al. (2019). Cannabis use disorders among adults in the United States during a time of increasing use of cannabis. Drug Alcohol Depend, 204, 107468.Google Scholar
Corkin, S., Milner, B., and Rasmussen, T. (1964). Effects of different cortical excisions on sensory thresholds in man. Trans Am Neurol Assoc, 89, 112–116.Google Scholar
D’Souza, D. C., Abi-Saab, W. M., Madonick, S., et al. (2005). Delta-9-tetrahydrocannabinol effects in schizophrenia: Implications for cognition, psychosis, and addiction. Biol Psychiatry, 57, 594–608.CrossRefGoogle ScholarPubMed
D’Souza, D. C., Ranganathan, M., Braley, G., et al. (2008). Blunted psychotomimetic and amnestic effects of delta-9-tetrahydrocannabinol in frequent users of cannabis. Neuropsychopharmacology, 33, 2505–2516.Google Scholar
Davies, C., Wilson, R., Appiah-Kusi, E., et al. (2020). A single dose of cannabidiol modulates medial temporal and striatal function during fear processing in people at clinical high risk for psychosis. Transl Psychiatry, 10, 311.Google Scholar
Dekker, N., Linszen, D., and De Haan, L. (2009). Reasons for cannabis use and effects of cannabis use as reported by patients with psychotic disorders. Psychopathology, 42, 350–360.Google Scholar
Di Forti, M., Morgan, C., Dazzan, P., et al. (2009). High-potency cannabis and the risk of psychosis. Br J Psychiatry, 195, 488–491.Google Scholar
Dixon, L., Haas, G., Weiden, P., et al. (1990). Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients’ self-reports. Schizophr Bull, 16, 69–79.Google Scholar
Dixon, L., Haas, G., Weiden, P. J., et al. (1991). Drug abuse in schizophrenic patients: Clinical correlates and reasons for use. Am J Psychiatry, 148, 224–230.Google Scholar
Elsohly, M. A., and Slade, D. (2005). Chemical constituents of marijuana: The complex mixture of natural cannabinoids. Life Sci, 78, 539–548.CrossRefGoogle ScholarPubMed
Fazio, R., and Zanna, M. (1981). Direct experience and attitude–behavior consistency. In Berkowitz, L. (ed.) Advances in Experimental Social Psychology (pp. 161–186). Chicago: University of Chicago Press.Google Scholar
Ferdinand, R. F., Sondeijker, F., van der Ende, J., et al. (2005). Cannabis use predicts future psychotic symptoms, and vice versa. Addiction, 100, 612–618.Google Scholar
Fishbein, M. (1980). A theory of reasoned action: Some applications and implications. Nebr Symp Motiv, 27, 65–116.Google Scholar
Fowler, I., Carr, V., Carter, N., et al. (1998). Patterns of current and lifetime substance use in schizophrenia. Schizophr Bull, 24, 443–455.Google Scholar
Gearon, J. S., Bellack, A. S., Rachbeisel, J., et al. (2001). Drug-use behavior and correlates in people with schizophrenia. Addict Behav, 26, 51–61.CrossRefGoogle ScholarPubMed
Gordon, M. (1986). Microprocessor-based assessment of attention deficit disorders (ADD). Psychopharmacol Bull, 22, 288–290.Google Scholar
Goswami, S., Mattoo, S. K., Basu, D., et al. (2004). Substance-abusing schizophrenics: Do they self-medicate? Am J Addict, 13, 139–150.Google Scholar
Grech, A., Van Os, J., Jones, P. B., et al. (2005). Cannabis use and outcome of recent onset psychosis. Eur Psychiatry, 20, 349–353.Google Scholar
Green, A. I., Tohen, M. F., Hamer, R. M., et al. (2004). First episode schizophrenia-related psychosis and substance use disorders: Acute response to olanzapine and haloperidol. Schizophr Res, 66, 125–135.Google Scholar
Green, B., Kavanagh, D. J., and Young, R. M. (2004). Reasons for cannabis use in men with and without psychosis. Drug Alcohol Rev, 23, 445–453.Google Scholar
Green, B., Young, R., and Kavanagh, D. (2005). Cannabis use and misuse prevalence among people with psychosis. Br J Psychiatry, 187, 306–313.Google Scholar
Gregg, L., Barrowclough, C., and Haddock, G. (2009). Development and validation of a scale for assessing reasons for substance use in schizophrenia: The ReSUS scale. Addict Behav, 34, 830–837.Google Scholar
Hambrecht, M., and Hafner, H. (1996). Substance abuse and the onset of schizophrenia. Biol Psychiatry, 40, 1155–1163.Google Scholar
Hasin, D. S. (2018). U.S. epidemiology of cannabis use and associated problems. Neuropsychopharmacology, 43, 195–212.CrossRefGoogle ScholarPubMed
Hekimian, L. J., and Gershon, S. (1968). Characteristics of drug abusers admitted to a psychiatric hospital. JAMA, 205, 125–130.Google Scholar
Henquet, C., Krabbendam, L., Spauwen, J., et al. (2005). Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people. BMJ, 330, 11.CrossRefGoogle ScholarPubMed
Henquet, C., van Os, J., Kuepper, R., et al. (2010). Psychosis reactivity to cannabis use in daily life: An experience sampling study. Br J Psychiatry, 196, 447–453.Google Scholar
Henquet, C., Rosa, A., Krabbendam, L., et al. (2006). An experimental study of catechol-o-methyltransferase Val158Met moderation of delta-9-tetrahydrocannabinol-induced effects on psychosis and cognition. Neuropsychopharmacology, 31, 2748–2757.Google Scholar
Hides, L., Baker, A., Norberg, M., et al. (2020). A web-based program for cannabis use and psychotic experiences in young people (keep it real): Protocol for a randomized controlled trial. JMIR Res Protoc, 9, e15803.Google Scholar
Hindocha, C., Quattrone, D., Freeman, T. P., et al. (2020). Do AKT1, COMT and FAAH influence reports of acute cannabis intoxication experiences in patients with first episode psychosis, controls and young adult cannabis users? Transl Psychiatry, 10, 143.Google Scholar
Kapur, S., Mizrahi, R., and Li, M. (2005). From dopamine to salience to psychosis: Linking biology, pharmacology and phenomenology of psychosis. Schizophr Res, 79, 59–68.Google Scholar
Kay, S. R., Opler, L. A., and Fiszbein, A. (1986). Significance of positive and negative syndromes in chronic schizophrenia. Br J Psychiatry, 149, 439–448.Google Scholar
Kessler, R. C., Chiu, W. T., Demler, O., et al. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62, 617–627.Google Scholar
Khokhar, J. Y., Dwiel, L. L., Henricks, A. M., et al. (2018). The link between schizophrenia and substance use disorder: A unifying hypothesis. Schizophr Res, 194, 78–85.CrossRefGoogle ScholarPubMed
Knudsen, P., and Vilmar, T. (1984). Cannabis and neuroleptic agents in schizophrenia. Acta Psychiatr Scand, 69, 162–174.Google Scholar
Kolliakou, A., Castle, D., Sallis, H., et al. (2015). Reasons for cannabis use in first-episode psychosis: Does strength of endorsement change over 12 months? Eur Psychiatry, 30, 152–159.Google Scholar
Konings, M., and Maharajh, H. D. (2006). Cannabis use and mood disorders: Patterns of clinical presentations among adolescents in a developing country. Int J Adolesc Med Health, 18, 221–233.Google Scholar
Koskinen, J., Lohonen, J., Koponen, H., et al. (2010). Rates of cannabis use disorders in clinical samples of patients with schizophrenia: A meta-analysis. Schizophr Bull, 36, 1115–1124.Google Scholar
Kraan, T., Velthorst, E., Koenders, L., et al. (2016). Cannabis use and transition to psychosis in individuals at ultra-high risk: Review and meta-analysis. Psychol Med, 46, 673–681.Google Scholar
Leweke, F., Koethe, D., and Gerth, C. (2005). Cannabidiol as an antipsychotic: A double-blind, controlled clinical trial of cannabidiol versus amisulpiride in acute schizophrenia. 15th Annual Symposium on Cannabinoids. Clearwater Beach, FL, Cannabinoid Research Society.Google Scholar
Leweke, F. M., Piomelli, D., Pahlisch, F., et al. (2012). Cannabidiol enhances anandamide signaling and alleviates psychotic symptoms of schizophrenia. Transl Psychiatry, 2, e94.Google Scholar
Linszen, D., and van Amelsvoort, T. (2007). Cannabis and psychosis: An update on course and biological plausible mechanisms. Curr Opin Psychiatry, 20, 116–120.Google Scholar
Linszen, D. H., Dingemans, P. M., and Lenior, M. E. (1994). Cannabis abuse and the course of recent-onset schizophrenic disorders. Arch Gen Psychiatry, 51, 273–279.Google Scholar
Lowe, D. J. E., Sasiadek, J. D., Coles, A. S., et al. (2019). Cannabis and mental illness: A review. Eur Arch Psychiat Clin Neurosci, 269, 107–120.Google Scholar
Mane, A., Fernandez-Exposito, M., Berge, D., et al. (2015). Relationship between cannabis and psychosis: Reasons for use and associated clinical variables. Psychiatry Res, 229, 70–74.CrossRefGoogle ScholarPubMed
Mason, O., Morgan, C. J., Dhiman, S. K., et al. (2009). Acute cannabis use causes increased psychotomimetic experiences in individuals prone to psychosis. Psychol Med, 39, 951–956.Google Scholar
Mauri, M., Volonteri, L., De Gaspari, I., et al. (2006). Substance abuse in first-episode schizophrenic patients: A retrospective study. Clin Pract Epidemiol Mental Health 2, 1–8.Google Scholar
McCreadie, R. G. (2002). Use of drugs, alcohol and tobacco by people with schizophrenia: Case-control study. Br J Psychiatry, 181, 321–325.Google Scholar
McHugh, M. J., McGorry, P. D. Yung, A. R., et al. (2017). Cannabis-induced attenuated psychotic symptoms: Implications for prognosis in young people at ultra-high risk for psychosis. Psychol Med, 47, 616–626.Google Scholar
Missouri Department of Health and Senior Services. (2010). Health Advisory: K2 Synthetic Marijuana Use among Teenagers and Young Adults in Missouri. Jefferson City, MO: Missouri Department of Health and Senior Services.Google Scholar
Morgan, C. J., and Curran, H. V. (2008). Effects of cannabidiol on schizophrenia-like symptoms in people who use cannabis. Br J Psychiatry, 192, 306–307.Google Scholar
Muller, H., Sperling, W., Kohrmann, M., et al. (2010). The synthetic cannabinoid Spice as a trigger for an acute exacerbation of cannabis induced recurrent psychotic episodes. Schizophr Res, 118, 309–310.CrossRefGoogle ScholarPubMed
Myin-Germeys, I., Krabbendam, L., Jolles, J., et al. (2002). Are cognitive impairments associated with sensitivity to stress in schizophrenia? An experience sampling study. Am J Psychiatry, 159, 443–449.Google Scholar
Myin-Germeys, I., van Os, J., Schwartz, J., et al. (2001). Emotional reactivity to daily life stress in psychosis. Arch Gen Psychiatry, 58, 1137–1144.Google Scholar
Myles, H., Myles, N., and Large, M. (2016). Cannabis use in first episode psychosis: Meta-analysis of prevalence, and the time course of initiation and continued use. Aust NZ J Psychiatry, 50, 208–219.Google Scholar
Negrete, J. C., Knapp, W. P., Douglas, D. E., et al. (1986). Cannabis affects the severity of schizophrenic symptoms: Results of a clinical survey. Psychol Med, 16, 515–520.Google Scholar
van Os, J., Bak, M., Hanssen, M., et al. (2002). Cannabis use and psychosis: A longitudinal population-based study. Am J Epidemiol, 156, 319–327.Google Scholar
Peralta, V., and Cuesta, M. J. (1992). Influence of cannabis abuse on schizophrenic psychopathology. Acta Psychiatr Scand, 85, 127–130.Google Scholar
Peters, B., de Koning, P., Dingemans, P., et al. (2009). Subjective effects of cannabis before the first psychotic episode. Aust NZ J Psychiatry, 43, 1155–1162.Google Scholar
Rabin, R. A., and George, T. P. (2017). Understanding the link between cannabinoids and psychosis. Clin Pharmacol Ther, 101, 197–199.CrossRefGoogle ScholarPubMed
Rabinowitz, J., Bromet, E. J. Lavelle, J., et al. (1998). Prevalence and severity of substance use disorders and onset of psychosis in first-admission psychotic patients. Psychol Med, 28, 1411–1419.Google Scholar
Raine, A. (1991). The SPQ: A scale for the assessment of schizotypal personality based on DSM-III-R criteria. Schizophr Bull, 17, 555–564.Google Scholar
Ramaekers, J. G., Kauert, G., Theunissen, E. L., et al. (2009). Neurocognitive performance during acute THC intoxication in heavy and occasional cannabis users. J Psychopharmacol, 23, 266–277.Google Scholar
Regier, D., Farmer, M., Rae, D., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study [comment]. JAMA, 264, 2511–2518.Google Scholar
Ringen, P., Lagerberg, T., Birkenaes, A., et al. (2008). Differences in prevalence and patterns of substance use in schizophrenia and bipolar disorder. Psychol Med, 38, 1241–1249.Google Scholar
Rottanburg, D., Robins, A. H., Ben-Arie, O., et al. (1982). Cannabis-associated psychosis with hypomanic features. Lancet, 2, 1364–1366.Google Scholar
Santesteban Echarri, O., Kim, G., Haffey, P., et al. (2021). LooseLeaf, a mobile-based application to monitor cannabis use and cannabis-related experiences for youth at clinical high-risk for psychosis: Development and user acceptance testing. Int J Hum–Comp Interact, 37, 501–511.Google Scholar
Schofield, D., Tennant, C., Nash, L., et al. (2006). Reasons for cannabis use in psychosis. Aust NZ J Psychiatry, 40, 570–574.Google Scholar
Schwarcz, G., Karajgi, B., and McCarthy, R. (2009). Synthetic delta-9-tetrahydrocannabinol (dronabinol) can improve the symptoms of schizophrenia. J Clin Psychopharmacol, 29, 255–258.CrossRefGoogle ScholarPubMed
Silver, H., and Abboud, E. (1994). Drug abuse in schizophrenia: Comparison of patients who began drug abuse before their first admission with those who began abusing drugs after their first admission. Schizophr Res, 13, 57–63.Google Scholar
Solomons, K., Neppe, V. M., and Kuyl, J. M. (1990). Toxic cannabis psychosis is a valid entity. S Afr Med J, 78, 476–481.Google Scholar
Spencer, C., Castle, D., and Michie, P. T. (2002). Motivations that maintain substance use among individuals with psychotic disorders. Schizophr Bull, 28, 233–247.CrossRefGoogle ScholarPubMed
Stefanis, N. C., Delespaul, P., Henquet, C., et al. (2004). Early adolescent cannabis exposure and positive and negative dimensions of psychosis. Addiction, 99, 1333–1341.Google Scholar
Stirling, J., Barkus, E. J., Nabosi, L., et al. (2008). Cannabis-induced psychotic-like experiences are predicted by high schizotypy. Confirmation of preliminary results in a large cohort. Psychopathology, 41, 371–378.Google Scholar
Swartz, M., Wagner, H., Swanson, J., et al. (2006). Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study. J Nerv Ment Dis, 194, 164–172.Google Scholar
Test, M. A., Wallisch, L. S., Allness, D. J., et al. (1989). Substance use in young adults with schizophrenic disorders. Schizophr Bull, 15, 465–476.Google Scholar
Thomas, B. F., and Elsohly, M. A. (2016). The botany of cannabis sativa L. In Thomas, B. F., and Elsohly, M. A. (eds.) The Analytical Chemistry of Cannabis (pp. 1–26). Amsterdam: Elsevier.Google Scholar
Treffert, D. A. (1978). Marijuana use in schizophrenia: A clear hazard. Am J Psychiatry, 135, 1213–1215.Google Scholar
Vadhan, N. P., Corcoran, C. M., Bedi, G., et al. (2017). Acute effects of smoked marijuana in marijuana smokers at clinical high-risk for psychosis: A preliminary study. Psychiatry Res, 257, 372–374.CrossRefGoogle ScholarPubMed
Vearrier, D., and Osterhoudt, K. C. (2010). A teenager with agitation: Higher than she should have climbed. Pediatr Emerg Care, 26, 462–465.Google Scholar
Veen, N. D., Selten, J. P., van der Tweel, I., et al. (2004). Cannabis use and age at onset of schizophrenia. Am J Psychiatry, 161, 501–506.Google Scholar
Wainberg, M., Jacobs, G. R., di Forti, M., et al. (2021). Cannabis, schizophrenia genetic risk, and psychotic experiences: A cross-sectional study of 109,308 participants from the UK Biobank. Transl Psychiatry, 11, 211.Google Scholar
Warner, R., Taylor, D., Wright, J., et al. (1994). Substance use among the mentally ill: Prevalence, reasons for use, and effects on illness. Am J Orthopsychiatry, 64, 30–39.Google Scholar
Weil, A. T. (1970). Adverse reactions to marihuana. Classification and suggested treatment. N Engl J Med, 282, 997–1000.Google Scholar
Wilson, R., Bossong, M. G., Appiah-Kusi, E., et al. (2019). Cannabidiol attenuates insular dysfunction during motivational salience processing in subjects at clinical high risk for psychosis. Transl Psychiatry, 9, 203.Google Scholar
Zuardi, A., Crippa, J. A., Hallak, J., et al. (2009). Cannabidiol for the treatment of psychosis in Parkinson’s disease. J Psychopharmacol, 23, 979–983.CrossRefGoogle ScholarPubMed
Zuardi, A. W., Hallak, J. E. Dursun, S. M., et al. (2006). Cannabidiol monotherapy for treatment-resistant schizophrenia. J Psychopharmacol, 20, 683–686.Google Scholar
Zuardi, A. W., Morais, S. L. Guimaraes, F. S., et al. (1995). Antipsychotic effect of cannabidiol. J Clin Psychiatry, 56, 485–486.Google Scholar

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