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Cannabis and young peoples mental health: a guide for those working with young people

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This leaflet summarises what is known about the links between regular cannabis use and mental health problems/disorders in children and young people and is designed for those working with that age group.1 The information and advice given here is based on the most relevant and up-to-date research and has been considered by a range of experts in the field.

the researchers, for a variety of reasons, have not yet either identified or accounted for in their results. There is now general agreement that cannabis use, particularly if regular or heavy,2 (NB: see endnote for definitions of these terms) is associated with a number of mental health problems/mental disorders. However, the evidence for the strength of this association varies across different types of mental health problems/mental disorders. With certain types of problems, there may not be universal agreement about the nature of the link, but the fact that the experts do not agree fully on the interpretation of the research (there are differences of opinion about the role of confounding factors, for example) is not a reason to be unconcerned about the use of cannabis by young people.

INTERPRETING THE RESEARCH

It is vital when interpreting research not to assume causal conclusions of the kind that A (cannabis use) leads to B (for instance, psychosis or depression). Some young people have problematic lives; the causal roots of their problems may arise from a number of sources, including their genetic make-up, early childhood experiences, or more recent negative life events such as bereavement or psychological trauma. Such young people may be more prone to problematic use of cannabis but this may not be the primary cause of poorer subsequent outcomes. The research on which this leaflet is based takes factors such as these (called confounding factors) into account when coming to its conclusions. For an association between cannabis use and a particular mental health problem/mental disorder to remain, even after allowing for such confounding factors, strongly points to a causal link. This is not to rule out, however, the possibility that there may be further confounders, which

CANNABIS AND THE DEVELOPING BRAIN

Recent findings suggest that the human brain is not fixed from early childhood, as previously thought, but continues to develop during adolescence. Research is showing that there is a mismatch between emotional and cognitive regulatory modes in adolescence which leaves adolescents with powerful emotional responses to social stimuli that they cannot easily regulate or inhibit. This may explain some young adult behaviour, such as susceptibility to drug and alcohol abuse. The fact that the brain is still developing also means that the brain may be particularly susceptible to exposure to various illicit drugs, including cannabis. Although this area of research is still in its early stages, it is already suggesting potential neurobiological mechanisms through which cannabis may be exerting both its desired effects on brain functioning, as well as its potentially detrimental effects on the developing brain. There is growing consensus that it is the cumulative toxicity from repeated cannabis exposure which contributes to the observed negative outcomes, including both higher rates of mental disorders, particularly psychosis, and cognitive impairment.

1. Please note, different factors may affect adults. Those seeking information about adult cannabis use and mental health problems should consult other sources. For instance, see the leaflet Cannabis and your mental health. www.csip.org.uk/mentalhealthandcannabis 2. The amount or dose of cannabis used depends on several factors, including frequency, duration, method of use and potency of cannabis. The terms regular and heavy are often used, yet there is no consistent approach in the way these terms are defined by different researchers. This variation leads to difficulties when comparing or aggregating the findings across studies. However, those studies that have looked at the relationship between dose and clinical outcome have almost invariably found significant differences between occasional use of cannabis (which researchers variously define as anything from sporadic up to once a week) and regular use (which researchers again variously define as once a week or more). Likewise, the term heavy could refer to more than one joint at a time or differences of tetrahydrocannabinol absorption depending on whether the joint has been shared or not. It should be borne in mind that, unlike alcohol, there is no recommended sensible dose of the psychoactive ingredient present in cannabis tetrahydrocannabinol (THC) at which harm is considered unlikely to occur.

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This suggests a potential for greater problems for those starting younger.

CANNABIS AND PSYCHOSIS

Although it is well known that using cannabis can induce transient psychotic/hallucinatory symptoms or states of mind (which do not necessarily result in enduring problems), an accumulating body of evidence has highlighted that cannabis use in adolescence may be associated with enduring psychosis in some individuals. Several recent studies suggest that using cannabis regularly during adolescence is associated with a significantly increased risk of developing schizophrenia or other psychoses, often after a delay of several years. One recent study, which reviewed evidence from four other studies, has suggested that if young people use cannabis regularly or heavily they are at least twice as likely to develop a psychosis by young adulthood as those who dont use cannabis. Studies indicate that those already reporting psychotic symptoms or who have a family history of schizophrenia are at particular risk of developing schizophrenia or other psychoses. Furthermore, one recent study has suggested that cannabis exposure in some susceptible individuals may also hasten the first episode of their psychosis. An increasing number of studies are currently looking more specifically at whether or not regular cannabis use beginning in childhood or the early teens carries an even greater risk of psychosis than later use in the mid or late teens. However, a recent consensus statement has determined that the number of young users who have been the subject of relevant published studies is too small for reliable conclusions to be drawn about the additional risks in users aged 15 years old or younger. There have also been concerns that the more widespread use of higher potency forms of cannabis, such as skunk, may further increase the risks for developing schizophrenia. Skunk is a term used to

describe herbal cannabis usually grown from selected seeds by intensive methods which results on average in two or three times as much THC (tetrahydrocannabinol, the main psychoactive agent in cannabis) as traditional cannabis (see footnote 2). Although there is some anecdotal evidence that skunk may be contributing to recent increases in hospital admissions for acute drug-induced psychosis, a link specifically between skunk (as opposed to other forms of cannabis) and schizophrenia remains speculative. Even if scientists disagree about the level of risk associated with regular cannabis use in young people, there is consensus that using cannabis regularly when young increases the risk of developing a psychosis. It should be noted, however, that because the prevalence of psychosis is low, only a relatively small percentage of young people is at risk of developing psychosis, whether or not they use cannabis.

Cannabis and anti-psychotic medication

Young people may be prescribed anti-psychotic medication for a variety of reasons. Often it will be to help with psychotic symptoms. In light of the evidence already cited, it is highly inadvisable for those receiving such treatment to use cannabis. Research suggests that those with schizophrenia taking anti-psychotic medication who use cannabis at the same time are far more likely to experience a deterioration in their psychotic symptoms than those who desist from using cannabis.

CANNABIS AND OTHER MENTAL HEALTH PROBLEMS/MENTAL DISORDERS

An increasing number of studies have looked into possible links between cannabis use and other general mental health problems or diagnosable mental disorders (e.g. mood or conduct disorders), particularly in young people. Of those that have looked at this area,

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one study has shown that cannabis use in young girls increases the risk of depression and anxiety. Another study found that weekly cannabis users between the ages of 14 and 21 were almost twice as likely to suffer from depression as non-users. Suicidal ideation and suicide attempts were 7 and 13 times higher respectively for 14-15 year old cannabis users than 14-15 year old non-users (but that these rates dropped significantly with age). Another study found that those who used cannabis heavily were four times as likely to develop depressive symptoms than those who did not. In contrast to these studies, a recent survey of 12-16 year olds found cannabis use was linked more strongly with aggression and delinquency, rather than depressive or anxiety problems. As with psychosis, without further more powerful studies there remains the possibility that the association between cannabis use and poor mental health consequences is not causal and depends on other factors and mechanisms as yet unaccounted for. Given the strengthening of the evidence for an association, and a consensus that regular cannabis use exacerbates pre-existing mental health problems, it seems prudent to caution strongly against the use of cannabis, especially by those who already have mental health or behavioural problems. There are also often less direct, but long-lasting and profound mental health consequences of heavy cannabis use, such as missing a lot of school, a lessening of motivation to achieve and a withdrawal into a small circle of like-minded friends, thereby reducing the exploration of other worlds which is such an important part of adolescence. Furthermore, cannabis use (even after its reclassification to a Class C drug) remains illegal and carries with it the risk of criminalisation. Under-18s face arrest if caught with cannabis. The criminal and social consequences that can arise from young people being identified as cannabis users may indirectly have a negative impact on their mental health.

CANNABIS AND COGNITIVE IMPAIRMENT

In the short term, cannabis users are all too aware of the powerful subjective effects of cannabis on their mental functioning. However, surprisingly few studies have looked at objective measurable effects on cognitive function and those that have, report subtle or inconsistent findings. Similarly, in the longer term, the few studies that have investigated the direct effects of regular cannabis use on later cognitive functioning have been largely inconclusive. Where cognitive impairments have been identified in regular users, for instance in the case of the amotivational syndrome, they have been equally or better explained by other factors such as leaving school early or associated mental health problems, rather than as a direct effect of cannabis exposure. Nevertheless, virtually all the research on both short and longer-term cognitive effects has been undertaken with adults and extrapolation to children and young people might be considered premature and perhaps unwise, particularly given valid concerns that young developing brains could be more vulnerable to such effects. Until relevant age-specific studies have been conducted, it is important for professionals working with young people to be aware of the potential for both short and long-term detrimental effects of cannabis on cognitive performance and development. In addition to any potential direct effects of cannabis use on cognitive function, it is worth reiterating that there are many other factors associated with cannabis use in young people, including those referred to in the previous section, which, less directly but collectively and cumulatively, are associated with significant impairments in learning, academic performance and educational attainment.

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WHAT ARE THE PRACTICAL IMPLICATIONS OF THE RESEARCH?

The major implication from the emerging research on cannabis and young people is that the adolescent brain has no unique protection from those adverse effects of cannabis which have already been identified and replicated in adult populations. On the contrary, some research is pointing to an increased vulnerability of the developing brain and the possibility that earlier and heavy exposure to cannabis, i.e. in young people, is even more likely to have negative and possibly enduring consequences than later exposure. However, at this stage, the evidence for a causal association between cannabis use and mental health problems is more robust for some groups of young people than for others. For young people who have already been diagnosed with, or suffered from, any form of psychosis, particularly schizophrenia, the evidence confirms that cannabis exposure carries very high risks and is best avoided altogether, as even minimal re-exposure may be harmful and cause a major relapse, with potentially dire consequences. For young people with a family history of psychosis, particularly a schizophrenic illness in a close relative, the evidence indicates that repeated exposure to cannabis may trigger or bring forward the onset of a psychotic disorder, particularly if they are genetically predisposed. However, in the absence of genetic screening to quantify this risk, the best advice for these young people would be to minimise and, if possible, avoid exposure to cannabis altogether. For young people with other mental health problems/mental disorders, the evidence suggests that cannabis is unlikely to be helpful in managing their situation, even in the short term. On the contrary, the effects of cannabis are likely to worsen their symptoms and complicate their treatment, particularly if they are already taking psychoactive medications. The best advice here would be to minimise cannabis exposure

and, where this proves difficult, to watch closely for its negative effects, including the onset of psychosis or the possible relapse of problems that were otherwise improving. For the vast majority of young people, many of whom are at risk at different times and in different ways of developing both mental health problems or of using cannabis, the evidence on the impact of cannabis use is still emerging. Given what we know thus far, this should lead to a very cautious approach to those people who engage in cannabis use at a young age or who are becoming regular and/or heavy users. Finally, it is important to stress that the dangers of tobacco, usually smoked with cannabis, are well evidenced. Young people need to be reminded of these in this context.

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GLOSSARY
Amotivational syndrome This refers to a pattern of symptoms, including apathy, social withdrawal and impairment of memory, concentration and judgement which has been described in long-term cannabis users. Cognitive impairment This term refers to a reduction in the ability to use higher-level mental faculties, such as concentration, idea-formulation, problem-solving, reasoning, memory and motivation. Mental health problems/mental disorders Mental health problems refer to a broad range of emotional and behavioural difficulties, covering stress, anxiety, depression etc. These vary in the level of distress they cause and the extent to which they interfere with everyday living. It is estimated that around 20% of children and young people have a mild-to-moderate mental health problem. Often these problems can be contained with help and support within the family, school or community before they become overwhelming. The term mental disorders refers to conditions that are diagnosable and may require treatment. They are usually more severe and distressing than isolated mental health problems, often resulting in significant interference with everyday life for weeks, months and even years. Just over 10% of children and young people between the ages of 5 and 15 have a mental disorder. Psychoactive medication This refers to a wide range of prescribed medications that have effects on the brain and on thinking and feeling, some of which are used in the treatment of mental health problems and disorders. They include anti-psychotic drugs. Most drugs of abuse, such as cannabis, also have substantial psychoactive effects. Psychosis This is a general description for an acute or chronic abnormal state of mind that can be characterized by a number of psychotic symptoms and signs, such as rigidly-held false beliefs (delusions), sensing things that are not really there (hallucinations), disorganised thinking patterns and behaviour, and in which the individual appears to have lost contact with reality in some way. There are many possible causes of psychosis, including genetically determined conditions, prescribed and illicit drugs, severe infections and, in some

predisposed young people, excessive psychological stress. As well as the acute or short-lived psychoses, certain clinically recognised mental disorders particularly schizophrenia and bipolar (or manic-depressive) disorder - are characterised by severe and persistent symptoms, hence these are also known as psychotic disorders. However, many research studies use the term psychotic disorder more imprecisely to refer only to disorders with schizophrenia-like features. In this text we have used the term explicitly and in its widest sense. Psychotic symptoms These are the specific abnormalities of mood, thought and experience, such as hallucinations or delusional beliefs that may occur in isolation (for example as an acute effect of cannabis or other drug use) or with other psychotic symptoms and signs in a range of different psychotic and non-psychotic disorders in young people. An individual may be very troubled by one particular symptom (e.g. paranoia whilst using cannabis or cocaine) but may otherwise maintain quite good contact with reality generally. Schizophrenia This refers to a specific type of psychosis which is particularly important because of its severity or its persistence in many of those affected (with a generally accepted lifetime prevalence of 1%). Schizophrenia usually begins in early adulthood and commonly requires lifelong treatment. Although it is understood that genetic predisposition plays an important role, environmental factors have also been shown to influence both the onset and severity of its course. Much of the research that has looked at early cannabis use and risk for later development of psychosis has measured either risk of psychotic symptoms, risk of schizophrenia-like states or risk of developing schizophrenia itself, which has made reaching confident conclusions more difficult. Tetrahydrocannabinol (THC) This is the main psychoactive ingredient in cannabis.

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BIBLIOGRAPHY
Advisory Council on the Misuse of Drugs (ACMD) (2006). Further consideration of the classification of cannabis under the Misuse of Drugs Act 1971. London: Home Office. See: http://www.drugs.gov.uk/ publication-search/acmd/cannabis-reclass-2005 Arendt, M., Rosenberg, R., Foldager, L., et al. (2005). Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: follow-up study of 535 incident cases. British Journal of Psychiatry, 187, pp. 510515. Arseneault, L., Cannon, M., Poulton, R., et al. (2002). Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. British Medical Journal, 325, pp. 1212-1213. Arseneault, L., Cannon, M., Witton, J., et al. (2004). Causal association between cannabis and psychosis: examination of the evidence. British Journal of Psychiatry, 184, pp. 110-117. Bovasso, G. B. (2001). Cannabis abuse as a risk factor for depressive symptoms. American Journal of Psychiatry, 158 (12), pp. 2033-2037. Fergusson, D. M., Horwood, L. J. & Swain-Campbell, N. (2002). Cannabis use and psychosocial adjustment in adolescence and young adulthood. Addiction, 97 (9), pp. 1123-1135. Fergusson, D. M., Horwood, L. J. & Ridder, E. M. (2005). Tests of causal linkages between cannabis use and psychotic symptoms. Addiction, 100 (3), pp. 354-366. Henquet, C., Krabbendam, L., Spauwen, J., et al. (2005). Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people. British Medical Journal, 330 (7481), pp. 11-14. Jenkins, R. (2006). Cannabis and young people: reviewing the evidence. London: Jessica Kingsley. Macleod, J., Oakes, R., Copello, A., et al. (2004). Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studies. The Lancet, 363 (9421), pp. 1579-1588. Monshouwer, K., Van Dorsselaer, S., Verdurmen, J., et al. (2006). Cannabis use and mental health in secondary school children: Findings from a Dutch survey. British Journal of Psychiatry, 188 (2), pp. 148-153. Negrete, J. C., Knapp, W. P., Douglas, D. E., et al. (1986). Cannabis affects the severity of schizophrenic symptoms: results of a clinical survey. Psychological medicine, 16 (3), pp. 515-520. Patton, G. C., Coffey, C., Carlin, J. B., et al. (2002). Cannabis use and mental health in young people: cohort study. British Medical Journal, 325, pp. 1195-1198. Schneider, M. & Koch, M. (2003). Chronic pubertal, but not adult chronic cannabinoid treatment impairs sensorimotor gating, recognition memory and the performance in a progressive ratio task in adult rats. Neuropsychopharmacology, 28 (10), pp. 1760-1769. YoungMinds (2006). A work in progress: the adolescent and young adult brain: a briefing paper. London: YoungMinds. See: http://www.youngminds.org.uk/sos/SOS_YM_AdolescentBrain.pdf

USEFUL RESOURCES AND ORGANISATIONS Publications

Cannabis what does it really do to you?
This is a useful booklet for young people about cannabis and young peoples mental health. It is also useful for parents. Visit www.youngminds.org.uk/cannabis to download a copy. Up to five free copies can be obtained by calling the YoungMinds Parents Information Service on 0800 018 2138; bulk copies can be ordered from the YoungMinds Order Line on 0870 870 1721.

Cannabis and your mental health

This leaflet is designed for 18 year-olds and above and tells them about how using cannabis if they have a mental health problem can stand in the way of getting on with their life. www.csip.org.uk/mentalhealthandcannabis

Websites
www.drugs.gov.uk
Visit the government drugs strategy website for more information on the latest research, the reclassification of cannabis and information for professionals and others interested in this area. Website contains resources that professionals can download or order for users.

Advice for parents about talking to their children about drugs

www.talktofrank.com/worriedaboutsomeone/parent s/1to4.aspx

www.knowcannabis.org.uk
This website can help young people assess their cannabis use, its impact on their life and how to make changes and cut down if they want to.

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Useful organisations
Addaction
Tel: 020 7251 5860 (Mon-Fri 9am-5pm) Email: info@addaction.org.uk Website: www.addaction.org.uk Provides a range of drug and alcohol services for adults and young people.

Rethink
Rethink general enquiries: 0845 456 0455 Email: advice@rethink.org or info@rethink.org Website: www.rethink.org Website includes information and discussion boards about cannabis and mental health. Rethink provides services for people with severe mental illness and their families and carers.

DrugScope
Call 0870 774 3682 for further information on drugs and their effects Email: info@drugscope.org.uk Website: www.drugscope.org.uk Provides a full range of information and other resources on drug issues.

Youth Access
Signposting Service: 020 8772 9900 (Mon-Fri 9am-1pm and 2-5pm) Email: admin@youthaccess.org.uk Website: www.youthaccess.org.uk (directory of services now available online) A national membership organisation for youth information, advice and counselling agencies. Provides information on youth agencies to children aged 11-25, their carers and professionals who work with them, but does not provide direct advice.

FRANK
Freephone: 0800 77 66 00 (24-hour service. If you call from a landline the call is free and wont show up on your phone bill. Also provides language interpreting service for non-English speakers.) Textphone: 0800 917 8765 (24 hours) Email: frank@talktofrank.com Website: www.talktofrank.com Friendly, confidential advice about drugs.

Mind
MindInfoLine: 0845 766 0163 (Mon-Fri 9.15am-5.15pm. Also provides a language translation service.) Textphone: 0845 766 0163 (if you are using BT Textdirect, add the prefix 18001) Email: info@mind.org.uk Website: www.mind.org.uk Offers information about mental health.

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YoungMinds PO BOX 52735 LONDON EC1P 1YY Parents Information Service: 0800 018 2138
(Monday and Friday 10am-1pm,Tuesday and Thursday 1-4pm, Wednesday 1-4pm and 6-8pm) Office telephone: 020 7336 8445 YoungMinds Order Line: 0870 870 1721 Fax: 020 7336 8446 Email: enquiries@youngminds.org.uk Website: www.youngminds.org.uk YoungMinds is the leading charity committed to improving the mental health of all children and young people. YoungMinds Parents Information Service is a free confidential telephone service providing information, advice and details of other national/local services to any adult with concerns about the mental health of a child or young person.

This leaflet can be downloaded from: www.youngminds.org.uk/cannabis To obtain up to five further copies of this leaflet (ref L15), please call the YoungMinds Parents Information Service on 0800 018 2138. Alternatively, bulk copies can be purchased by calling the YoungMinds Order Line on 0870 870 1721.
This leaflet was produced by YoungMinds. YoungMinds 2006. This publication was up to date at the time of going to print. YoungMinds Parents Information Service is supported by the Department for Education and Skills. Freephone supplied by Verizon Business. YoungMinds wishes to thank those people who commented on drafts of this publication. YoungMinds is a registered charity no. 1016968.