Research in Translation
Should Burden of Disease Estimates Include CannabisUse as a Risk Factor for Psychosis?
, Wayne D. Hall
, Michael Lynskey
, John McGrath
, Jennifer McLaren
, Harvey Whiteford
, Theo Vos
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia,
School of Population Health, University of Queensland, Herston,Australia,
Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, United States,
Queensland Brain Institute, University of Queensland,St. Lucia, Australia,
Queensland Centre for Mental Health Research, University of Queensland, St. Lucia, Australia
Evidence has accumulated suggesting that regular cannabis use is associated withpsychotic symptoms and disorders in thegeneral population [1,2] and elevatedamong incident cases of psychosis [3,4].In this paper, we present the arguments for,and implications of, considering cannabisuse as a risk factor for psychosis in the 2005Global Burden of Disease (GBD) project.
Examining Risk Factors forDisease Burden
Governments, policymakers, and fundersneed information on the comparative pop-ulation health impact of different diseasesand risk factors when making decisionsabout where to focus policy, services, andresearch. This field was revolutionised whenthe World Bank provided estimates using the disability-adjusted life year (DALY) .This measure combined measures of prema-ture mortality (years of life lost [YLL]) andmorbidity (years lived with disability [YLD])in order to estimate GBD. Estimates of burden attributable to various risk factors— ‘‘comparative risk assessment’’ (CRA) exer-cises—are particularlyimportantbecausethey quantify and allow comparison of theextent to which reduction or removal of exposure to risk factors would reduce diseaseburden by using a measure of estimatedPopulation Attributable Risks (PAR). TheGBD uses fairly standard criteria to evaluate‘‘risk factors’’, in line with Bradford Hill’s oft-quoted criteria (Box 1).
In the previous global CRA, cannabisuse was not included as a risk factor forany disease because of concerns aboutthe quality of the evidence . In theintervening years there has been a steadyincrease in the number and quality of research studies that have been conductedexploring the links between cannabis useand psychosis. Overall, these studiesindicate that chance is an unlikely expla-nation of their association [9–11]. Recentreviews of prospective general populationstudies of associations between cannabisuse and later psychosis (Table 1) [10,11]concluded that although control for con-founding reduced the size of the associa-tion, there was an increased risk of psychotic outcomes in individuals whoused cannabis, with the greatest risk among those who used cannabis mostfrequently.It is useful to distinguish two primaryways in which cannabis use could be a‘‘cause’’ of psychosis . The strongestform of causal link is that heavy cannabisuse causes a psychosis that would nototherwise have occurred. A second hy-pothesis is that cannabis use is a contrib-utory cause: it might precipitate psychosisin vulnerable individuals—that it is onefactor among many (including geneticpredisposition and other unknown causes)
Research in Translation discusses health interven-tions in the context of translation from basic toclinical research, or from clinical evidence topractice.
Degenhardt L, Hall WD, Lynskey M, McGrath J, McLaren J, et al. (2009) Should Burden of DiseaseEstimates Include Cannabis Use as a Risk Factor for Psychosis? PLoS Med 6(9): e1000133. doi:10.1371/ journal.pmed.1000133
September 29, 2009
2009 Degenhardt et al. This is an open-access article distributed under the terms of theCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in anymedium, provided the original author and source are credited.
This work was given funding support from the Australian Government Department of Health andAgeing. LD is the recipient of an Australian National Health and Medical Research Council (NHMRC) SeniorResearch Fellowship. The funders had no role in study design, data collection and analysis, decision to publish,or preparation of the manuscript.
The authors have declared that no competing interests exist.* E-mail: firstname.lastname@example.org
Not commissioned; externally peer reviewed.
Comparative risk assessments estimate the proportion of a disease that can beattributed to a particular risk exposure and are important guides for healthplanning.
In observational studies, there has been consistent evidence that cannabis useis associated with an increased risk of schizophrenia and more generally,psychosis.
There is debate about whether such observational evidence is sufficient to inferthat cannabis use is a contributory cause of psychosis.
Given the controversy, should the comparative risk assessment in the currentrevision of the Global Burden of Disease (GBD) include an attribution of psychosis to cannabis use?
We argue that the risk assessment should be included because the evidence isas good as that for many other risk factors included in the GBD, psychoticdisorders are associated with substantial unavertable disability, and cannabisuse is a potentially preventable exposure.
PLoS Medicine | www.plosmedicine.org 1 September 2009 | Volume 6 | Issue 9 | e1000133