Schizophrenic Male Patients Who Misuse Cannabis - Essay Example

? SCHIZOPHRENIC MALE PATIENTS WHO MISUSE CANNABIS Fundamentally the issue of substance misuse amongst male adults with mental health problems is listed as co-morbidity. Substance misuse is a broad topic and hence for the purpose of this assignment the author will focus on the "schizophrenic male patients who misuse cannabis". Co-morbidity is not new, it has been going on for a number of years, however, the treatment interventions for tackling the problem are still developing only. And there has been “an over representation of men among” co-morbid patients (Weinberger and Harrison, 2011, p.124). The Royal College of Psychiatrists has acknowledged the problem and is working collaboratively to bring integrated treatment systems for individuals with co-morbidity problems (Hussein, 2002). Schizophrenia and cannabis abuse. Substance abuse is very prevalent among schizophrenia patients and it has been found that “the most often misused substances are alcohol and cannabis” (Weinberger and Harrison, 2011, p.123). The first study to find a connection between cannabis use and schizophrenia was done by Andreasson, Allbeck and Rydberg (1987), and this study concluded that there is some incontrovertible association. One estimate is that “roughly one quarter of patients with schizophrenia spectrum disorders currently use or misuse cannabis” (Weinberger and Harrison, 2011, p.123-124). In an Australian study also, it was found that 40.9% of the 852 schizophrenic patients were having lifelong use of cannabis (Weinberger and Harrison, 2011, p.201). Other research findings have also indicated that “patients with schizophrenia are more likely to use cannabis than other psychiatric patients or normal” persons (Hall and Pacula, 2003, p.90). A comprehensive study that examined about 4000 studies from around the world has also warned youngsters that using cannabis will make them more vulnerable to schizophrenia (Moore et al., 2007). While exploring this curious connection, researchers have found out that “cannabis use (induced) psychotic symptoms in adulthood” and resulted in an “earlier age at onset” (Weinberger and Harrison, 2011, p.124). In many schizophrenic individuals, the “first social/occupational dysfunction, first negative symptom, (or) first psychotic episode” occurred after the use of cannabis (Weinberger and Harrison, 2011, p.124). Another projection made by a UK study was that “by 2010, …approximately 10% of schizophrenia cases” would be attributable to cannabis misuse (Weinberger and Harrison, 2011, p.201). As almost all the studies on the connection between cannabis use and schizophrenia have been done taking adult male samples only, all these findings are mostly applicable only to adult males. But it has also been noted that the rate of occurrence of schizophrenia has not increased in proportion with the rate of use of cannabis among young males (Degenhardt, Hall and Lynskey, 2001, pp.32). Opposers of this view, on the other hand have argued that “in Australia — where marijuana use is heavy among teens — it’s not uncommon for 20 to 30 per cent of new episodes of schizophrenia to be among patients who use marijuana daily or almost daily” (Turning Point Detox, 2011). Why individuals who suffer from schizophrenia misuse cannabis. The question that arises from the above discussion and which is relevant to this study is why individuals suffering from schizophrenia often misuse cannabis. One answer could be that “schizophrenic brains may be more sensitive to toxic influences” (Aronson, 2008, p.480). The impact of cannabis on risk taking behavior is another aspect that needs to be considered as schizophrenic patients most often will be in an abnormal mental state and it will be easy for them to get used to the risk involved in substance abuse. Generally, there has been a controversy raging on whether cannabis use leads schizophrenia or whether schizophrenia prompts an individual to use cannabis. A third possibility including both is also there. One assumption has been that “prodromal symptoms of schizophrenia lead to an increased use of marijuana (cannabis)” (Ross, 2008, p.81). It is suggested that “a contributory causal relation is biologically plausible because psychotic disorders involve disturbances in the dopamine neurotransmitter systems with which the cannabinoid system interacts, as demonstrated by animal studies and one human provocation study” (as cited by International Mental Health Research Organization, 2006). Here, it has also to be kept in mind that though substance abuse has a proven connection with schizophrenia, cannabis specifically being used more, could be a result of its greater availability as compared to other drugs. This is a possibility in the context that the most popular drug in America has been cannabis for decades (Dautrich et al., 2009, p.85). But there have also been some studies, which have specifically tried to find out what is the bio-chemical reaction that happens in the brain of a schizophrenic when he/she uses cannabis (Hubbard and Martin, 2001, p.87). One hypothesis has been that cannabinoid interacts with the DA system of the brain (Hubbard and Martin, 2001, p.87). This preliminary finding is in need of further in depth studies as is the “interactions between the cannabinoid and various other neurotransmitter systems” (Hubbard and Martin, 2001, p.87). The patients themselves have reported that they used cannabis and other such drugs to have an experience of ‘high’, to get out of depression and for total relaxation (Dixon et al., 1991). Raby (2009) has also summarized this aspect of the discussion in the following words: In a study of the Dunedin cohort, Caspi and colleagues reported that individuals with a functional polymorphism in the catechol-O-methyltransferase (COMT) gene were at increased risk of schizophreniform disorder after use of marijuana during adolescence as compared with those who did not carry this polymorphism. Similar evidence is being found for polymorphisms at the cannabinoid receptor (CB1).These genetic factors may influence future risk of schizophrenia by interacting with other potential risk factors. For example, accumulating evidence points to dysregulation of the endogenous cannabinoid anandamide in patients with schizophrenia, with elevation of anandamide levels in blood and cerebrospinal fluid during acute exacerbations of psychosis and resolution after treatment (Figure). Hence, exogenous cannabinoids may worsen preexisting states that could make some individuals more at risk to develop schizophrenia from consuming marijuana. Yet another research effort has proven that there is a “shared genetic risk between” major depression, alcohol dependence and marijuana dependence and this can be scientifically “explained by genetic effects on ASPD (antisocial personality disorder), which in turn was associated with increased risk of each of the other disorders” (Qiang Fu et al., 2002). Though this result does not directly find a genetic link between cannabis abuse and schizophrenia, it indeed finds a link between psychotic disorders and cannabis abuse. It is also suggested that “a dysregulated mesocorticolimbic "brain reward circuit" (BRC) in patients with SCZ (schizophrenia) underpins their substance use, and that cannabis or other substance use ameliorates this dysregulated circuitry” (Dartmouth- Hitchcock Medical Center, Ongoing study). The impact of substance misuse (cannabis class B drug) on the individual, family, society and services. Generally, substance misuse has been found to have many social risks like “divorce, unemployment and crime” (Weinberger and Harrison, 2011, p.124). It is a proven fact that in schizophrenic patients, cannabis abuse has a tendency to enhance the “risk for relapse and hospital readmission” (Weinberger and Harrison, 2011, p.124). The severity of the disease is also increased as a result of cannabis abuse (Weinberger and Harrison, 2011, p.124; Aronson, 2008, p.483). But there has been a contradiction arising from the studies on cannabis use among schizophrenic patients- “cannabis use was associated with an increase in positive and negative symptoms” (Weinberger and Harrison, 2011, p.124). Though earlier studies had suggested no decrease in cognitive functioning caused by cannabis use among adult male schizophrenia patients, more recent studies have proven the opposite (Weinberger and Harrison, 2011, p.124). But another important study proved that “first-episode schizophrenia patients with continued use of cannabis showed increased loss of cerebral grey matter volume and larger increases in lateral and third ventricle volumes than […] patients who did not use cannabis during the follow-up” Ritsner, 2011, p.327). Another impact of cannabis on the user is found to be the “reduced serum FSH and LH concentrations” and “reduced serum testosterone, oligospermia, reduced sperm motility, and gynecomastia” (Aronson, 2008, p.480). But this has not been found to cause loss of male fertility (Aronson, 2008, p.480). Cannabis can also alter the effects of medicines used in treating schizophrenia in an unpredictable way (Aronson, 2008, p.483). Another problem with cannabis use among schizophrenia patients is that it can result in compromising the treatment, “prolonging the duration of […] illness and jeopardizing a successful outcome” (Emmett and Nice, 2009, p.56). Inayath Ur Rehman (n.d.) has revealed that schizophrenic patients using cannabis had more relapses and more number of getting involved with law and order institutions and hospitals/mental health professionals. Raby (2009) has opined that “in established schizophrenia, marijuana or other drug abuse leads to decreased adherence to treatment as well as increases recurrence of symptoms, episodes of violence, victimization (such as being used as drug “mules” to carry drugs), hospitalizations, and suicide.” The family of the schizophrenic patient using cannabis is seen to suffer much more than a schizophrenic patient having no co-morbidity (Hubbard and Martin, 2001, p.86). It is also observed that there is “significantly greater familial morbid risk of schizophrenia in patients with acute psychosis abusing cannabis compared to nonabusing patients” (Hubbard and Martin, 2001, p.86). Studies have also shown that there is “increased morbid risks for cannabis abuse in the first-degree relatives of schizophrenics compared to controls” (Hubbard and Martin, 2001, p.86). When the family and the individual gets affected, the impact is also projected to the society as a whole. The prevalence of cannabis use will potentially increase when an individual is surrounded by current users in a given society or community. As indicated by the discussion above, the youngsters who have been using cannabis become more prone to have schizophrenia and this phenomenon is evidently disastrous for the society as a whole. Critically analyse the interventions used in the treatment of individuals who suffer from schizophrenia who misuse cannabis. Schaub et al. (2008) have discussed the possibility that the symptoms exhibited by schizophrenic patients using cannabis are different from the symptoms shown by schizophrenic patients who are not using cannabis. They (Schuab et al., 2008) after studying this aspect, inferred that the symptoms differed only when the patients were treated with typical neuroleptics. Even then, this contradictory reports warn mental health practitioners that they might have to use different set of drugs in treating cannabis-using and abstaining schizophrenia patients. Typical medicines like antipsychotics are found to have only “limited value” in reduction of cannabis use among schizophrenia patients (Green at al., 2003, p.81). The use of the drug, Clozapine has been suggested for treating schizophrenia patients with co-morbidity of cannabis abuse (Brooks, March 4, 2011). This is based on the assumption that “Clozapine may reduce cannabis use among patients with schizophrenia and co-occurring cannabis use disorder” as is indicated by the “results of a randomized controlled study presented […] at the 13th International Congress on Schizophrenia Research in Colorado Springs, Colorado” (as cited by Brooks, March 4, 2011). A new antipsychotic named Risperidone is also found to be an effective medicine for cannabis-abusing schizophrenia patients (Green et al., 2003, p.81). But Risperidone is found to be less effective than Clozapine (Green et al., 2003, p.81). Another promising factor has been that “the cannabinoid receptor antagonist rimonabant is showing promise in primate trials to alter marijuana-seeking behavior” (Raby, 2009). The use of “low dose naltrexone (12 mg)” is recommended “to reduce the effects of marijuana” (Raby, 2009). Raby (2009) has also reported that “Nefazodone, buspirone, and dronabinol show some promise as well in attenuating the manifestations of marijuana withdrawal.” Critically analyse the treatment models, social policy and health promotion methods in responding to substance misuse problem. It has been discussed whether a separate treatment strategy need to be adopted for schizophrenia patients who have cannabis co-morbidity. Any intervention strategy in this regard will have to address two aspects of the problem. One is the approach to be adopted in treating schizophrenia patients with cannabis co-morbidity and the other has to be on preventing the “emerging psychosis” in people “dependent on Marijuana” (Raby, 2009, p.29). Raby (2009) has also suggested that “before moving on to potential medication treatments, […] programs that integrate counseling for substance abuse, psychosocial support for mental illness” have to be carried out. It is also suggested that medication has to be given only to “provide the continuity and comprehensiveness that is more likely to make such treatment a success” (Raby, 2009). Another successful strategy that has been delineated is “the inclusion of cognitive-behavioral and motivational interviewing approaches” (Raby, 2009). One criticism regarding government policy in this matter is that “many clinics are not equipped to provide […] comprehensive services, and much remains to be overcome to disseminate such services throughout the current mental health network” (Raby, 2009). The government has been taking a punitive rather than supportive strategy regarding Cannabis and other drug abuse for the last 40 years as part of its “war against drugs” (Drug Policy Alliance, 2011). The repressive measures of the government have back-lashed resulting in an increased percentage of the population supporting the legalization of Cannabis use (Meno, 2010). Conclusion Given the lack of solid evidence still to prove the causal connection between cannabis and schizophrenia and also the contradictory research findings, it can only be concluded that cannabis use can increase the possibility of becoming a schizophrenic among those who are already physically, mentally and socially disposed to develop psychotic disorders. Regarding the effect of cannabis abuse on schizophrenic patients also, further studies are the need of the hour. But as far as the treatment of schizophrenic patients having a cannabis abuse history, certain medicines discussed above could prove useful though it is not clear why they are so. In view of this fact, a reverse conclusion can also be partially made in favor of the connection between cannabis abuse and schizophrenia. Also, it is important to be aware that, majority of these studies were carried out by using adult male samples alone. Hence the application of their findings is also limited to that category alone. The danger inherent in the whole issue can be seen as “an environmental exposure that may have a deleterious impact on multiple neurotransmitter systems that are already disturbed in schizophrenia and consequently may contribute to worsening of cognitive functioning in the illness” (Swerdlow, 2010, p.495). One major thing that has to be investigated is the options for a policy change regarding Marijuana use and thereby imparting more support to cannabis abusing schizophrenic patients. This will avoid their incarceration, which will keep them available for treatment in a more humane atmosphere. Educating vulnerable groups on the consequences of cannabis abuse is also an important step to be taken as among schizophrenic patients and other psychotic patients, a tendency has been seen to take cannabis as self-medication (Sedvall, Terenius and Terenius, 2000, p.134). This practice has emerged because, cannabis intake can temporarily give relaxation to the patient and also help to “counteract the dysphoric side-effects of anti-psychotics” (Sedvall, Terenius and Terenius, 2000, p.134). Thus cannabis abuse and schizophrenia can turn into a vicious circle for the patient preventing all treatment to become ineffective. It is in this context that public awareness creation, especially among the young male population (who are the most vulnerable group) becomes an urgent necessity. References Andreasson, S., Allbeck, P., Engstrom, A. and Rydberg, U. 1987. ‘Cannabis and schizophrenia: a longitudinal study of Swedish conscripts’, The Lancet, 330, pp.1483-5. Aronson, J.K. 2008. ‘Meyler's side effects of psychiatric drugs’, Elsevier, Amsterdam. Brooks, M. March 4, 2011. ‘Clozapine may curb cannabis use in schizophrenia patients’, viewed 14 May 2011, http://www.medscape.com/viewarticle/740345 Dautrich et al., 2009. ‘American government: historical, popular, and global perspectives - Texas edition’, Cengage Learning, Connecticut. Dartmouth- Hitchcock Medical Center, Ongoing study, Cannabis and schizophrenia: self-medication and agonist treatment’, viewed 16 May, 2011, http://clinicaltrials.gov/ct2/show/NCT00946348?term=cognitive&rcv_d=14 Degenhardt, L., Hall, W. and Lynskey, M. 2001. ‘Comorbidity between cannabis use and psychosis: modeling some possible relationships’, NDARC Technical Report No.121, viewed 15 May, 2011, http://www.med.unsw.edu.au/ndarcweb.nsf/resources/TR_18/$file/TR.121.PDF Dixon et al., 1991. ‘Drug abuse in schizophrenic patients: clinical correlates and reasons for use’, Am J Psychiatry, 148, pp.224-230. Drug Policy Alliance, 2011. ‘Forty years of failure’, viewed 15 May, 2011, http://www.drugpolicy.org/facts/new-solutions-drug-policy/forty-years-failure Emmett, D. and Nice, G. 2009. ‘What you need to know about cannabis: understanding the facts’, Jessica Kingsley Publishers, London. Green et al., 2003. ‘Alcohol and cannabis use in schizophrenia: effects of Clozapine vs. Risperidone’, Schizophrenia Research, 60, pp.81-85. Hall, W. and Pacula, L. 2003. ‘Cannabis use and dependence: public health and public policy’, Cambridge University Press, Cambridge. Hubbard, J.R. and Martin, P.R. 2001. ‘Substance abuse in the mentally and physically disabled’, CRC Press, London. Inayath Ur Rehman, Saeed Farooq, n.d. ‘Schizophrenia and Comorbid self reported Cannabis Abuse: impact on course, functioning and services use’, Journal of Pakistan Medical Association, viewed 14 May, 2011, http://www.jpma.org.pk/full_article_text.php?article_id=1008 International Mental Health Research Organization, 2006. ‘Marijuana and schizophrenia: public policy implications’, Schizophrenia.com, viewed 14 May, 2011, http://schizophrenia.com/sznews/archives/003851.html Meno, M. 2010. ‘Gallup: record 46% of Americans support legal marijuana’, viewed 14 May, 2011, http://blog.mpp.org/tax-and-regulate/gallup-record-46-of-americans-support-legal-marijuana/10292010/ Moore et al., 2007. ‘Cannabis use and the risk of psychotic or affective mental health outcomes: a systematic review’, The Lancet, 370, pp.319-28. Qiang Fu et al., 2002. ‘Shared genetic risk of major depression, alcohol dependence, and Marijuana dependence’, Arch Gen Psychiatry, 59, pp.1125-1132. Raby, W.N., 2009. ‘Comorbid cannabis misuse in psychotic disorders: treatment strategies’, Primary Psychiatry, 16(4), pp.29-34. Ritsner, M. 2011. ‘Handbook of Schizophrenia Spectrum Disorders, Volume III: Therapeutic Approaches, Comorbidity, and Outcomes’, Springer, Berlin. Ross, M. 2008. ‘Schizophrenia: medicine's mystery - society's shame’, Bridgeross Communications, Ontario. Schaub et al. December, 2008. ‘Cannabis using schizophrenia patients treated with atypical neuroleptics: do their symptoms differ from those of cannabis abstainers?’, Substance Use Misuse, 43(14), pp.2045-52. Sedvall, G., Terenius, L.Y. and Terenius, L. 2000. ‘Schizophrenia: pathophysiological mechanisms : proceedings of the Nobel Symposium 111 on schizophrenia, held in Stockholm, Sweden on October 1-3, 1998’, Elsevier Health Sciences, Amsterdam. Swerdlow, N.R. 2010. ‘Behavioral neurobiology of schizophrenia and its treatment’, Springer, Berlin. Turning Point Detox, 2011. ‘Marijuana/Hash: Cannabis and schizophrenia’, viewed 15 May 2011, http://www.drug-detox-center.com/news/?p=242 Weinberger, D. R. and Harrison, P. 2011. ‘Schizophrenia’, John Wiley & Sons, New Jersey. Read More