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Medical Marijuana Psychosis - Risk vs Benefit

Medical Marijuana Psychosis - Risk vs Benefit

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Published by PRMurphy
To the Editor: Over the past 15 years, it has become increasingly evident that cannabis use carries an increased risk for the development of psychosis (1, 2). At the same time, medicinal cannabis (medical marijuana) has been legalized in many states, with minimal restrictions on prescribing indications. The present case illustrates the evolution of a psychotic disorder, in the setting of medicinal cannabis use, in a young man at high risk for psychosis.
To the Editor: Over the past 15 years, it has become increasingly evident that cannabis use carries an increased risk for the development of psychosis (1, 2). At the same time, medicinal cannabis (medical marijuana) has been legalized in many states, with minimal restrictions on prescribing indications. The present case illustrates the evolution of a psychotic disorder, in the setting of medicinal cannabis use, in a young man at high risk for psychosis.

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Published by: PRMurphy on Feb 09, 2011
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02/09/2011

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Letters to the Editor
598
ajp.psychiatryonline.org Am J Psychiatry 167:5, May 2010
ceutical Industries; and he has received honoraria rom the  American Academy o Addiction Psychiatry, the Medical Uni-versity o South Carolina, and the University o New Mexico. Dr.Devous has received research support rom Alseres and AVID Radiopharmaceuticals, and he has served on the scientifc ad-visory board o AVID Radiopharmaceuticals.This letter (doi: 10.1176/appi.ajp.2010.10020157) was accepted  or publication in March 2010.
Psychosis Associated With Medical Marijuana:Risk vs. Benefts o Medicinal Cannabis Use
To the Editor
: Over the past 15 years, it has become in-creasingly evident that cannabis use carries an increased risk or the development o psychosis (1, 2). At the same time, me-dicinal cannabis (medical marijuana) has been legalized inmany states, with minimal restrictions on prescribing indica-tions. The present case illustrates the evolution o a psychoticdisorder, in the setting o medicinal cannabis use, in a young man at high risk or psychosis.
“Mr. Z” was a 24-year-old man who was frst hospital-ized or insomnia, irritability, and aggressiveness 2 yearsater military service. On admission, he displayed height-ened religiosity and mild suspiciousness. Urine toxicologyscreening revealed cannabinoids, supporting the patient’sendorsed semi-daily cannabis use via water pipe or thepast 18 months, without other substance abuse. He wasstarted on quetiapine (100 mg/day), with rapid resolutiono symptoms, and discharged ater 10 days.The patient subsequently discontinued quetiapineand was lost to ollow-up. Four months later, he presentedto a marijuana clinic complaining o chronic pain, insom-nia, and anxiety and was given a diagnosis o posttraumat-ic stress disorder (PTSD) and pain, along with a medicalrecommendation or cannabis. No psychotic symptomswere elicited. He later explained that he switched rom“street” marijuana to medical marijuana in order to ob-tain a more potent product as well as to avoid illegal ac-tivity and getting “ripped o” by drug dealers. He also in-creased the requency o his daily use rom approximatelyonce to twice daily.Six months later, Mr. Z was rehospitalized with new-onset auditory hallucinations (multiple voices speakingto each other and urging violence) and delusions (believ-ing that people were tampering with his windows andeavesdropping on his conversations and that he was JesusChrist). Aripiprazole (15 mg/day) was prescribed, with grad-ual symptomatic improvement, and then tapered to a low-er dose (7.5 mg/day) due to tremor. The patient reportedthat he believed smoking cannabis helped his chronic painbut that it worsened his psychotic symptoms, such thathe wanted help to stop smoking the drug. Ater 4 weeks,he was discharged to residential substance abuse treat-ment with only mild, residual psychotic symptoms and adischarge diagnosis o psychotic disorder not otherwisespecifed, PTSD, and cannabis dependence. At a 3-monthollow-up evaluation, while still taking aripiprazole, Mr. Zremained o cannabis and ree o psychotic symptoms.
 Although cannabis may have some health benefts, it alsohas a variety o adverse eects, including psychosis, especial-ly among those at high risk (1–3). The patient in the presentcase was at high risk or psychosis based on attenuated symp-
Scientifcally Unounded Claims in Diagnosingand Treating Patients
To the Editor
: We greatly appreciated the thoughtul book review by Andrew F. Leuchter, M.D. (1), published in the May 2009 issue o the
 Journal,
on Daniel Amen’s
Healing the Hard-ware o the Soul: Enhance Your Brain to Improve Your Work,Love, and Spiritual Lie 
(2). Dr. Amen claims that numerouspsychiatric illnesses can be diagnosed and treatments pre-scribed based on resting single photon emission comput-erized tomography (SPECT) images. Dr. Leuchter correctly points out the absence o empirical data to support the claimso Dr. Amen. Several years ago, ollowing conversations withDr. Amen on how to address such concerns, the Brain Imag-ing Council o the Society o Nuclear Medicine oered Dr. Amen the opportunity to submit his analyses o a blindedset o SPECT scans (to have been prepared by the Brain Im-aging Council) to determine how eective his technique is atcorrectly diagnosing subjects. Although this proposed study could have provided support or his approach, the oer wasdeclined. Nevertheless, or more than two decades, Dr. Amenhas persisted in using scientifcally unounded claims to diag-nose and treat patients (over 45,000 by his own count).There are several dangers to patients that can accrue romthis approach: 1) patients (including children) are adminis-tered a radioactive isotope without sound clinical rationale;2) patients pursue treatments contingent upon an interpre-tation o a SPECT image that lacks empirical support; and 3)based on a presumed diagnosis provided by Dr. Amen’s clin-ics, patients are guided toward treatment that may detractthem rom clinically sound treatments.Just as serious is the danger to our feld. It is likely that, within the next decade, Dr. Amen’s claims will be realized inthat psychiatrists will enjoy the ability to diagnose and pre-scribe treatments based, in part, upon neuroimaging fnd-ings. Unortunately, i previously led astray by unsupportedclaims, patients and their doctors may be less inclined to uti-lize scientifcally proven approaches once these are shown inthe peer-reviewed literature to be eective.It is thereore incumbent upon all o us to monitor andregulate our feld. We encourage physicians to remain vigilanto unproven approaches practiced by our peers and to imme-diately report these trespasses to their state medical boards.
Reerences
1. Leuchter AF: Healing the hardware o the soul: enhance yourbrain to improve your work, love, and spiritual lie, by DanielAmen (book review). Am J Psychiatry 2009; 166:6252. Amen D: Healing the Hardware o the Soul: Enhance YourBrain to Improve Your Work, Love, and Spiritual Lie. New York,Simon and Schuster, 2008
BRYON ADINOFF, M.D.MICHAEL DEVOUS, P
h
.D.
Dallas, Tex.
Dr. Adino has received grant/research support rom the De-partment o Veterans Aairs, the National Institute on Alcohol  Abuse and Alcoholism, and the National Institute on Drug  Abuse; he has served as a consultant to GlaxoSmithKline, the Hershewe Law Firm, Phillips Lytle (or GlaxoSmithKline),Shook, Hardy and Bacon, Simon Pissante, and Teva Pharma-

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