America’s ongoing marijuana-legalization experiment will have many consequences. That goes especially for the seriously mentally ill, a sliver of the adult population but overrepresented among the ranks of compulsive pot users. Treating schizophrenia and bipolar disorder is never easy; even when treatment is available, the seriously mentally ill often fail to comply. A schizophrenic who spends most of his days in a dark room smoking weed is not a clinically promising case.
Modern mental-health systems are community-based and thus shaped by community norms. Decades ago, clouds of pot smoke were not often encountered on city streets. Now that they’re ubiquitous, a seriously mentally ill individual may be inclined to wonder what’s so objectionable about an activity that normal Americans do daily, in public and even during working hours.
The issue is only partly whether pot causes mental illness. A large body of research studies, involving tens of thousands of people, has suggested, with impressive replicability, that heavy cannabis use increases the risk of developing mental illness. Legalization proponents reject this, contending that, while the rate of marijuana consumption has soared over recent decades, the rate of serious mental illness seems to have stayed flat.
But this debate has eclipsed interest in the effect of continued cannabis use on those already mentally ill. What can be done about that? For scores of clinicians and families of the mentally ill across the nation, it’s the more pressing question.
In recent years, countless family memoirs and nonfiction accounts of mental illness have extensively chronicled the descent into madness. This literature often highlights marijuana more than any other intoxicating substance. Pot plays a notable role in several recent book-length treatments of mental illness, including Randye Kaye’s Ben Behind His Voices (2011), Patrick and Henry Cockburn’s Henry’s Demons (2011), Paul Gionfriddo’s Losing Tim (2014), Mindy Greiling’s Fix What You Can (2020), Miriam Feldman’s He Came in With It (2020), Meg Kissinger’s While You Were Out (2023), and Jonathan Rosen’s The Best Minds (2023).
Mentally ill Jordan Neely, who died on a New York subway train in 2023, after he menaced passengers and Daniel Penny subdued him with a chokehold, had a troubled upbringing, including the loss of his mother in a brutal murder. But what appeared to trigger his schizophrenia—and his shift from genial Michael Jackson impersonator to one of New York’s most troubled subway vagrants—was his use of K2, a synthetic cannabinoid. As Neely’s street-performer mentor explained to New York, “He always smoked a little weed, a little regular weed. . . . But someone gave him that K2 stuff—that’s what fucked him.” (The drug was found in Neely’s system after his death.)
Various theories exist about the relation between cannabis use and mental illness. No one disputes that marijuana can trigger psychotic episodes. It is not the only substance that can do this—other examples include steroids, Adderall, and cocaine. But researchers have found that the conversion rate from an acute psychotic episode to chronic schizophrenia is higher for users of cannabis than for any other substance. Old-school legalization proponents, like poet Allen Ginsberg, theorized that bad weed trips were not caused by the drug itself so much as fear of arrest; it was merely a question of the social setting in which the usage transpired. Legalization has put paid to that theory. Communities that have legalized have seen an increase in cannabis-related hospitalizations. Still, legalizers emphasize that, broadly speaking, acute psychosis is different from chronic psychosis and that for most problem users, marijuana’s mentally destabilizing effects will be self-limiting. A more rational adult, after he experiences a pot-induced psychotic episode so intense that he winds up hospitalized, will avoid ever doing that again. But risk/reward processing doesn’t happen so smoothly for people with disorganized minds.
Some argue that the relation boils down to correlation: serious mental illness develops around the same time that people are apt to use pot compulsively. Another standard theory maintains that cannabis triggers serious mental illness in someone genetically predisposed to it earlier than it would have otherwise developed. If true, that’s bad news: the earlier the onset of serious mental illness, the worse the prognosis. Still another hypothesis holds that the historically potent cannabis strains now on the market are more capable of causing mental illness—and induce a different kind of mental illness—than those varieties that develop more organically. The course of schizophrenia and its treatment-responsiveness varies tremendously among patients.
These questions might never be settled. But one uncontestable point is that, for hundreds of thousands of seriously mentally ill Americans, problem pot use often continues long after their first psychotic break. The federal government estimates that nearly half of all adults with serious mental illness use marijuana, a rate almost three times that of the non-mentally ill population. The seriously mentally ill’s rate of marijuana-use disorder (a clinical definition derived from the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is more than five times that of the non-mentally ill population.
Drug addiction is one of the many “bad outcomes” of serious mental illness. Just as they are overrepresented among the incarcerated and homeless populations, the seriously mentally ill make up a disproportionate share of America’s problem drug users. Of the 3.6 million seriously mentally ill Americans with a marijuana-use disorder, 980,000 meet the DSM standard of a “severe” disorder—a number exceeding the U.S. homeless population (770,000) and more than twice the sum of kids in foster care (370,000).
A psychiatric diagnosis is a cluster of symptoms, some reported directly by the individual experiencing them, and others observed by his or her clinician. We can speak of how an underlying condition “presents” with psychotic behavior, but we have no direct access to the biological substratum of genes and brain circuitry in which that condition is believed to be rooted. Symptoms are the locus of treatment. We apply psychiatric medications not to cure someone’s schizophrenia but to make him less “symptomatic.”
Clinicians tasked with treating co-occurring serious mental illness and cannabis-use disorder face a catch-22: you can’t treat the addiction without first treating the serious mental illness; but you can’t treat the serious mental illness without getting the addiction under control. We have no medication-assisted treatment (like methadone for heroin) for marijuana addiction. Yes, therapy can certainly benefit the seriously mentally ill. But, for therapy to take, medication typically must come first—to tamp down the symptoms and ensure a basic level of awareness of one’s mental illness. In her 1992 memoir, A Brilliant Madness, actress Patty Duke, who was bipolar, wrote: “Before taking lithium, trying to participate in therapy was like trying to fly a jet without ever having been on a plane.” Mentally ill adults who regularly use pot (and other drugs) tend to be less compliant with their psychiatric medicine, and more likely to relapse—and to do so more severely, thus requiring longer hospitalizations than nonusers.
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