Increase in Cases Greater in Those with Bipolar, Psychotic Disorders
Click to Enlarge: Trends in Cannabis Use Disorder Among Veterans with and without Mental Health Disorders
NEW YORK — Veterans with psychiatric disorders, especially those with serious mental health issues, are especially vulnerable to cannabis-use disorder, according to a new study warning of an increase in the condition.
The research published in the American Journal of Psychiatry found that cannabis-use disorder more than doubled among all VHA patients from 2005-2019, with a greater increase in cannabis-use disorder diagnoses among in veterans with psychiatric disorders compared to those without. Rates were considerably higher in patients with bipolar and psychotic-spectrum disorders, according to researchers from Columbia University / New York State Psychiatric Institute.1
Researchers from the Seattle Center of Innovation for Veteran-Centered and Value-Driven Care and Center the of Excellence in Substance Addiction Treatment and Education at the VA Puget Sound Health Care System in Seattle and the San Francisco VAMC also participated in the study.
“Cannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders,” the authors wrote. “Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder.”
The study team used VHA electronic health records from 2005-2019 ((N range, 4,332,165-5,657,277) to examine whether trends in cannabis-use disorder prevalence among veterans differed by whether they have psychiatric disorders. The focus was on overall and age-group-specific (<35, 35-64 and ≥65 years) trends in prevalence of cannabis-use disorder diagnoses among patients with depressive, anxiety, post-traumatic stress, bipolar or psychotic spectrum disorders. The patients with mental health diagnoses were compared to veterans without any of those disorders.
Because of transitions in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM).
Results indicated that increases in prevalence of cannabis-use disorder diagnoses were greater among patients with psychiatric disorders compared to those without (difference in prevalence change, 2005-2014: 1.91%, 95% CI=1.87-1.96; 2016-2019: 0.34%, 95% CI=0.29-0.38).
65 and Older at Risk
“Disproportionate increases in cannabis use disorder prevalence among patients with psychiatric disorders were greatest among those under age 35 between 2005 and 2014, and among those age 65 or older between 2016 and 2019,” the authors pointed out. “Among patients with psychiatric disorders, the greatest increases in cannabis use disorder prevalence were observed among those with bipolar and psychotic spectrum disorders.”
The findings put a spotlight on the disproportionately increasing disparities in risk of cannabis-use disorder among VHA patients with common psychiatric disorders, according to the report. “Greater public health and clinical efforts are needed to monitor, prevent, and treat cannabis use disorder in this population,” the researchers concluded.
The report cited a 2020 survey finding that nearly half of U.S. adults believed cannabis use is beneficial for stress, anxiety or depression.2
The survey authors, including representatives from the San Francisco VAMC, suggested that beliefs about marijuana use and prevalence of use appears to be associated with the legalization status of the state of residence. The study team examined differences in views and rates of use of marijuana among 16,280 residents in recreationally legal, medically legal and nonlegal states.
With a response rate of 56.3%, the authors found that residents in recreationally legal states were more likely to believe marijuana could be beneficial for pain management (73% in recreationally legal states, 67% in medically legal states, 63% in nonlegal states; P value: <0.0001), provide relief from stress, anxiety or depression (52% in recreationally legal states, 47% in medically legal states, 46% in nonlegal states; P value: 0.01), and improve appetite (39% in recreationally legal states, 36% in medically legal states, 33% in nonlegal states; P value: <0.009).
“In addition, residents in recreational states were significantly more likely to believe that smoking one marijuana joint a day is somewhat or much safer than smoking one cigarette a day (40.8% in recreationally legal states, 39.1% in medically legal states, and 36.1% in nonlegal states; P value: <0.0001),” according to the report in the Journal of Addiction Medicine. “Residents of recreationally and medically legal states were more likely to believe second-hand marijuana smoke was somewhat or much safer than second-hand tobacco smoke (38.3% in recreationally legal states, 38.3% in medically legal states, and 35.7% in nonlegal states; P value: 0.003).”
The results also indicated that past-year marijuana use in any form (20% in recreational, 14.1% in medical, 12% in nonlegal) and past-year marijuana use of multiple forms (11.1% in recreational, 6.1% in medical, 4.9% in nonlegal) were highest among residents of recreationally legal states. “Overall, prevalence of past-year use of any form of marijuana use was more common among residents of recreationally legal states compared with other states (20.3%, confidence interval [CI] 19.5, 21.1 in recreationally legal states; 15.4%, CI 14.7, 16.2 in medically legal states; 11.9%, CI 11.2, 12.6 in nonlegal states),” the researchers advised.
They warned that the common usage, as well as the view that marijuana has benefits and that marijuana smoke is safer than tobacco smoke is cause for concern, given the tide of commercialization, growing number of high-potency cannabis products, and favorable media coverage promoting use for health problems.
Based on that information, the authors of the more-recent study pointed out that, with greater availability, “patients with bipolar or psychotic-spectrum disorders may be using cannabis in an attempt to self-medicate, even though evidence suggests that this is inadvisable,” adding that those patients are at increased risk of functional impairments and other harms. The authors conclude that the study highlights the need to systematically monitor risky cannabis use among vulnerable populations, such as those with psychiatric disorders, and to develop preventive and harm reduction strategies.
- Livne O, Malte CA, Olfson M, Wall MM, et. Al. Trends in Prevalence of Cannabis Use Disorder Among U.S. Veterans With and Without Psychiatric Disorders Between 2005 and 2019. Am J Psychiatry. 2023 Nov 29:appiajp20230168. doi: 10.1176/appi.ajp.20230168. Epub ahead of print. PMID: 38018141.
- Steigerwald S, Cohen BE, Vali M, Hasin D, Cerda M, Keyhani S. Differences in Opinions About Marijuana Use and Prevalence of Use by State Legalization Status. J Addict Med. 2020 Jul/Aug;14(4):337-344. doi: 10.1097/ADM.0000000000000593. PMID: 31821192; PMCID: PMC7269858.