Cross-Sectional study of
differences in phenomenology of acute psychosis with or without cannabis
Pal V. S1, Rastogi P2,
Chauhan A3, Niranjan V4
1Dr. V. S. Pal, Associate Professor, 2Dr. Pali Rastogi, Assistant
Professor, 3Dr. Amrita Chauhan, Post Graduate Resident, 4Dr. Vijay
Niranjan, Assistant Professor, All authors are affiliated with
Department of Psychiatry M. G. M Medical College Indore, MP, India.
Address Correspondence: Dr.
Pali Rastogi, Assistant Professor, Department of Psychiatry, Mahatma
Gandhi Memorial Medical College, A. B. Road, Indore, India. E-mail-
dr.palirastogi73@gmail.com
Abstract
Background:
Therehas been plethora of research regarding cannabis use disorder but
very few studiesreporteddemographicand phenomenological differences of
acute psychosis with cannabis use to those of acute psychosis without
cannabis use. This study attempted to evaluate the demographic and
phenomenology differences between two groups of patients presenting
with acute psychosis with cannabis use and acute psychosis without
cannabis use. Material
& Method: Two group of patients recruited for
study were ‘Cases with Cannabis’ and
‘control without Cannabis’ presenting with acute
psychosis with preceding cannabis use and second one presenting with
acute psychosis without preceding cannabis use in out-patient
department of psychiatry, M. Yhospital, Indore Assessment done using
rating scales. Results:
Acute psychosis with cannabis wascharacterizedby primarily polymorphic
clinical picture with predominance of positive and mood symptoms both
in clear and disturbed sensorium.Acute psychosis without cannabis was
characterized by mixed positive and negative symptoms in clear
sensorium. In ‘Cases with cannabis’ group 96.7% were
males and 3.3% were females, mean age was higher (33.7%) than control
(27.7%) group. Conclusion:
Acute psychosis with cannabis is characterized by primarily polymorphic
clinical picture with predominance of positive and mood symptoms both
in clear and disturbed sensorium. Acute psychosis without cannabis is
characterized by mixed positive and negative symptoms. General symptoms
of psychosis were also more in acute psychosis without cannabis.
Key words:
Cannabis, Acute Psychosis, Cannabis Psychosis, Phenomenology
Manuscript received: 4th
October 2017, Reviewed:
14th October 2017
Author Corrected:
20th October 2017,
Accepted for Publication: 26th October 2017
Introduction
The use of cannabis has been known to mankind for the time immemorial
and has been deeply ingrained in Indian Culture exemplified by its
heavy use on occasion “Mahashivaratri”. The United
Nations Office on Drugs and Crime (UNODC) reports that 3.9% of the
global adult population uses cannabis. Data from the National Household
Survey in India demonstrated a prevalence figure of 4% and 3.3% for
lifetime and current cannabis users [1]. However, cannabis use has been
widely reported to induce acute psychotic experiences, to affect the
severity of psychotic symptoms, and previous meta-analyses have reported
a 2-fold increase in the risk to develop a psychotic disorder in
cannabis users compared to nonusers [2]. The principal psychoactive
compound in cannabis is delta-9-tetra hydrocannabinol, content of which
varies in different preparation of cannabis [3]. Adverse mental health
effects generally seen with more potent form of cannabis. THC and other
cannabinoid agonist produce their effect by interacting with an
endogenous cannabinnoid signaling system. There are two types of
cannabinoid receptors. CB1 receptors found primarily in brainand
mediate the psychological and behavioral effects of THC [4]. Cannabis
is one of the environmental factor that has received attention in
recent literature as possibly contributing to risk for psychotic
disorder. Mostresearchers conclude to few type of psychosis associated
with cannabis use: Acute toxic or organic psychosis,acute functional
psychosis, chronic psychosis which persist after
abstinence, amotivational syndrome and schizophreniaS [5]. The study of
cannabis effects on clinical course and outcome remains an interesting
area both from academic and clinical point of view [6].
Material
& Method
Study Place- Study
was conducted in department of psychiatry, MGM Medical College after
clearance obtained from institutional ethic committee of MGMMC Indore.
Study design-
The study was carried out with a Cross-sectionaldesign.
Sampling Method- 30
patients were selected in each group with purposive sampling (Acute
psychosis with cannabis use and acute psychosis without cannabis use)
after satisfying inclusion criteria and taking informed consent.
Inclusion criteria
1. Patient or legally accepted relative
giving written informed consent
2. Patients fulfilling criteria of acute
psychosis with or without cannabis(As per ICD-10)
3. Patient aged 18-60 yrs
4. Patient taking alcohol not in
dependence pattern
Exclusion criteria
Persons were excluded from participation in the study if they met any
of the following:
1. Patient taking other substance
excluding tobacco.
2. Patient with mental retardation
3. Patient having organic brain disorder
4. Patient having life threatening
medical condition
5. Patient having history of mental
illness prior to onset of cannabis use in first group
We relied on self-reported data of cannabis use regarding pattern,
type, duration, and amount of use which was further confirmed by
keyrelatives.Data regarding cannabis use was collected using drug abuse
screening test (DAST-20). Diagnosis in both groups made with
ICD-10-DCR[7]. Patients were recruited from OPD, IPD and emergency
department with purposive samplingandassessed with scales for
comparison of phenomenologyusing PANSS (positive and negative syndrome
scale), OAS (overt aggression scale) and YMRS (Young mania rating
scale). Two group were assessed for socio-demographic variables with
Semi structured data entry Performa.In two major groups these similar
diagnosis matched for any differences crosssectionally.
Statistical Method-
Data analysis done with spsssoftware. Data gathered was of non-normal
distribution so we applied non-parametric test i.e., Mann-Whitney test
to test the significance. Pvalue less than 0.05 was considered as
statistically significant.
Results
In ‘Cases with cannabis’ group 96.7% were malesand
3.3% female was there in sample. While in ‘Control without
cannabis group’ 63.3% males and 36% females were there
(Table-1). 36.7% of ‘cases with cannabis’ while
56.3% of ‘controls without cannabis’ belong to
21-30 years age group. These figures shows that psychosis is more
common in 21-30 year of age group (Table-1). Mean age of
‘cases with cannabis’came out to be 33.7 years
while in ‘control without cannabis’ group it is
27.7 years. P value is 0.016 (Table-1). So there is significant
difference between proportion of cases and control in different age
group. 56.7% of subjects from ‘cases with cannabis’
group reside in urban area and 40% in rural area rest in semi
urbanarea. While in ‘control without cannabis’
group 30% subjects reside in both rural and urban area rest in semi
urban area. In both groups more than 50% of subjects belongs to nuclear
family type. In ‘Cases with cannabis’ group 70% of
patient were educated up to 10th standard while ‘Control
withoutcannabis’ group 50% of patient educated up to 10th
standard and 13.3% were illiterate.In ‘Cases with
cannabis’ group 30% of patient engaged in skilled and
semiskilled occupation while 26.7% in same occupation
in‘Control without cannabis’ group.
Baseline mean positive score (at 0 day)in ‘case with
cannabis’ group was 29.7 and of ‘control without
cannabis’ group was 23 (Table-2). Significant difference in
baseline mean positive scores between two groups with p value of 0.000
suggestive of prominence of positive symptom characterized by high
score on excitement, grandiosity, suspiciousness and hostility on PANSS
in ‘cases with cannabis’ groupas compared to
‘control without cannabis’ group. Baseline mean
negative score in ‘case with cannabis’ group is
16.2, in ‘control without cannabis’ group is 20.6
(Table-3). So there was significant difference in mean negative score
between two groups with P value of 0.011 indicative of prominence of
negative symptomin ‘control without cannabis’ group
as compared to ‘cases with cannabis’group.
Table-1: Sex &age
distribution &mean age distribution of case and control
|
Gender
|
Cases(N=30)
|
Control(N=30)
|
|
N
|
%
|
N
|
%
|
|
Male
|
29
|
96.7
|
19
|
63.3
|
|
Female
|
1
|
3
|
11
|
36
|
|
Age
|
|
|
|
|
|
16-20
|
3
|
10.0
|
4
|
13.3
|
|
21-30
|
11
|
36.7
|
17
|
56.7
|
|
31-40
|
8
|
26.7
|
7
|
23.3
|
|
41-50
|
5
|
16.7
|
2
|
6.7
|
|
51-60
|
3
|
10.0
|
0
|
0.0
|
|
Groups
|
Mean
|
Min
|
Max
|
‘p’
value
|
|
Cases
|
33.7
|
19.0
|
55.0
|
0.016
|
|
Control
|
27.7
|
15.0
|
45.0
|
Table-2: Comparative PANSS
Positive subscale scores between cases andcontrol
|
Groups
|
Mean
|
Min
|
Max
|
±SD
|
P
value
|
|
Cases
|
29.7
|
14.0
|
47.0
|
7.4
|
0.000
|
|
Control
|
23.0
|
13.0
|
37.0
|
6.0
|
|
Table- 3: Comparative
PANSS Negative subscale scores between cases and control
|
Groups
|
Mean
|
Min
|
Max
|
±SD
|
‘p’
value
|
|
Cases
|
16.2
|
8.0
|
36.0
|
7.9
|
0.011
|
|
Control
|
20.6
|
7.0
|
36.0
|
7.6
|
|
Table- 4: Comparative
PANSS General subscale score between cases and control
|
Groups
|
Mean
|
Min
|
Max
|
±SD
|
‘p’value
|
|
Cases
|
35.4
|
20.0
|
59.0
|
9.2
|
0.005
|
|
Control
|
43.4
|
23.0
|
61.0
|
8.5
|
|
Table- 5: Comparative
Overt Aggression scale scores between cases and control
|
Groups
|
Mean
|
Min
|
Max
|
±SD
|
‘p’value
|
|
Cases
|
19.3
|
0.0
|
67.0
|
15.8
|
0.001
|
|
Control
|
9.6
|
0.0
|
44.0
|
9.4
|
|
Table-6: Comparative YMRS
scale mean scores between cases and control
|
Groups
|
Mean
|
Min
|
Max
|
±SD
|
‘p’value
|
|
Cases
|
30.9
|
0.0
|
52.0
|
12.3
|
0.000 HS
|
|
Control
|
13.0
|
6.0
|
36.0
|
8.3
|
|
Baseline mean general score in ‘case with cannabis’
group was 35.4 and in ‘control without cannabis’
group was 43.4 (Table-4). Difference of score between two groups was
significant. This indicate that general symptom of psychosis were more
in ‘control without cannabis’ group as compared to
‘cases with cannabis’ group. Predominant symptom in
general psychopathology scale were anxiety, guiltfeelings, depression,
tension, active social avoidance in ‘control without
cannabis’ group while disorientation, poor, judgement,
attention, unusual thought content, uncooperativeness, poor impulse
control were common among ‘cases with
cannabis’group. Baseline mean Aggression score in
‘case with cannabis’ group was 19.3 which is more
than mean 9.6 of‘control without cannabis’ group. P
value is 0.01, so this difference between two group wassignificant.
This indicate aggression was more in ‘cases with
cannabis’ using group as compared to ‘control
without cannabis’ group (Table-5). Baseline Mean YMRS score
in ‘case with cannabis’ group was 30.9 which is
more than mean 13 of control group. P value is 0.000, so this
difference between two groups is highly significant. This indicate mood
symptoms were more common in ‘cases with cannabis’
group as compared to control group (Table-6).
Discussion
Among ‘cases with cannabis’ group, 29 cases (96.7%)
were male and one case (3.3%), was female. This could be attributed to
low prevalence of substance abuse among females in general population
in India and cannabis in particular. This finding was consistent with
previous studies like Varma et al concluded in his study that
prevalence for cannabis abuse in female is very less [8].
36.7% of ‘cases with cannabis’ while 56.7% of
‘controls without cannabis’ belong to 21-30 years
age group. These figures shows that psychosis is more prevalent among
21-30 year of age group population. Mean age of psychosis in
‘cases with cannabis’ group was 33.7 years while in
‘control without cannabis’ group it was 27.7 years.
There was significant difference between proportion of cases and
control in different age group and which is also consistent with
finding of previous studies. Varma concludedin his study of cannabis
psychosis that mean age of patients of cannabis psychosis is 35.81
years which is higher than average mean of 32 years for other mental
patient [8].
Baseline mean positive scorein ‘cases with
cannabis’ group was 29.7 and of ‘control without
cannabis’ group was 23. Significant difference in baseline
mean positive scores between two groups is suggestive of prominence of
positive symptom in ‘cases with cannabis’ group as
compared to ‘control without cannabis’ group.
Higher mean positive score in ‘cases with cannabis’
group was consistent with results from study by R Patel et al [9].
Baseline mean negative score in ‘case with
cannabis’ group was 16.2, in ‘control without
cannabis’ group was 20.6. There was significant difference in
mean negative score between two groups indicative of prominence of
negative symptom in ‘control without cannabis’
group. Carol. M et al study results also onbserved higher negative
symptom score (14.16 vs 11.67) of PANSS sub scale on comparing primary
psychosis with substance induced psychosis [9].
Baseline mean general score in ‘case with cannabis’
group was 35.4 and in ‘control without cannabis’
group was 43.4. Difference of score between two groups was significant.
This indicate that general symptom of psychosis were more in
‘control without cannabis’ group as compared to
‘cases with cannabis’ group. Similar results were
reported by Carol. M et al [10].
Baseline mean Aggression score in ‘case with
cannabis’ group was 19.3 which is more than mean 9.6 of
‘control without cannabis’ group. This difference
between two groups was significant. This indicate aggression was more
in ‘cases with cannabis’ using group as compared to
‘control without cannabis’ group. This finding was
consistent with other studies [9].
Baseline Mean YMRS score in ‘case with cannabis’
group was 30.9 which is more than mean 13 of control group. This
difference between two groupswas highly significant. This indicate mood
symptoms were more common in‘cases with cannabis’
group as compared to control group. Similar results were reported by
Debasish Basu et al from India [11].
Conclusion
This prospective case control study concludes that Acute psychosis with
cannabis is characterized by primarily polymorphic clinical picture
with predominance of positive and mood symptoms both in clear and
disturbed sensorium. Acute psychosis without cannabis is characterized
by mixed positive and negative symptoms. General symptoms of psychosis
were also more in acute psychosis without cannabis. The important
limitations of the study were of small sample size, cross sectional
assesement, purposive sampling and institutional setting. Further
research is warranted regarding phenomenology, course and outcome of
psychosis associated with Cannabis use.
What study adds to Existing knowledge-Very few studies reported from
India that differentiate the clinical feature of cannabis psychosis
from other acute psychosis which may have an important implication in
diagnosis and treatment part of illness. Our study gave a clear insight
in to the phenomenology of psychosis associated with cannabis use and
that would be helpful in elucidating role of Cannabis in modifying
psychosis, which has been a challenging task for specialist in field.
Recommendations
• There is dearth of research regarding phenomenology
of psychosis associated with cannabis use,particularly from India,
warranting further research to find out role of cannabis in psychosis.
• Government should implement strict rules
towards illicit drug trafficking, particularly of Cannabis.
• Awareness should be raised at community
level by social workers using mass media programmes regarding adverse
mental health effects of cannabis use.
Author contribution-
This study conducted under guidance of DrV.S Pal (Associate Professor)
with valuable contribution from Dr. Pali Rastogi (Assistant Professor)
in timely evaluation of study.Patient interviewing and data collection
done by Dr Amrita chauhan (PG Resident) in collaboration with Dr Vijay
Niranjan (Assistant Professor) doing data analysis and manuscript
preparation.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Pal V. S, Rastogi P, Chauhan A, Niranjan V. Cross-Sectional study of
differences in phenomenology of acute psychosis with or without
cannabis. Int J Med Res Rev 2017;5(10):883-887.doi:10.17511/ijmrr.
2017.i10.02.