From the Editor
It’s legal. It’s also addictive.
As clinician, we worry about who may be at risk of heavier use of cannabis. In a new paper published in The Canadian Journal of Psychiatry, the University of Montreal’s Erika Nicole Dugas and her co-authors draw on data to try to identify early risk factors for daily use, drawing on 23 potential risk factors. Their findings are plausible – could the list be used for early interventions?
Also, this week, we consider my podcast interview with Harvard University’s Vikram Patel, who talks about mental health services in low-income nations. Dr. Patel is fresh off his win of the John Dirks Canada Gairdner Global Health Award, called the Canadian Nobel by some. (I do ask him what he plans to do with the prize money.)
And, in our third selection, singer Ladan Hussein discusses her psychosis – “I returned home to Toronto in January 2018, broken, dishevelled and deranged” – and her recovery.
Selection 1: “Early Risk Factors for Daily Cannabis Use in Young Adults”
Erika Nicole Dugas, Marie-Pierre Sylvestre, Esthelle Ewusi-Boisvert, Michael Chaiton, Annie Montreuil, Jennifer O’Loughlin
The Canadian Journal of Psychiatry, May 2019
Marijuana is commonly used. Who is at risk of cannabis use – and possible misuse?
Here’s what they did:
- “Data were drawn from the Nicotine Dependence in Teens (NDIT) study, a longitudinal investigation of grade 7 students recruited in a purposive sample of 10 secondary schools in Montreal, Canada, in 1999-2000.”
- “A total of 1294 of 2325 eligible students (56%) participated in the baseline data collection.”
- “Self-report questionnaires were administered at school every 3 months from grades 7 to 11, for a total of 20 cycles.”
- A multivariable logistic regression was done to estimate the association between the 23 potential risk factors and daily cannabis use.
Here’s what they found:
- At age 20, 44% of participants reported past-year cannabis use; 10% reported daily use.
- “Older age, male sex, higher family stress, higher levels of other stress, higher impulsivity and novelty seeking, lower self-esteem, alcohol use, cigarette use, other tobacco use, parent(s) smoke, sibling(s) smoke, friend(s) smoke, and higher BMI were associated with daily cannabis use.”
These results should be taken with a grain of salt, to use the old expression. The data is drawn from self reporting, and the dropout rate was high. Still, the findings are interesting, and they seem reasonable.
The authors are keen on the applicability of their work. “The finding that those at risk can be identified as early as grade 7 represents an important prevention opportunity; it provides the basis for early screening, informs development of programs and policy, lays the groundwork for developing prognostic clinical tools, and permits optimally matching individuals with appropriate intervention depending on their risk profile…” In a family of smokers, the authors wonder, should the children be targeted with an intervention?
The authors are ambitious – but shouldn’t we be? Prevention would be a worthwhile goal, regardless of whether recreational cannabis is legal or not. But does such a list lend itself to practical considerations? To go back to their example, there are many families with smokers, making an attempted intervention complicated given how many would need to be reached.
Selection 2: “What every physician should know about global psychiatry”
Vikram Patel and David Gratzer
Quick Takes Podcast, 22 May 2019
What to do when there are no psychiatrists? For my latest podcast, I sat down with one of the leading experts in global psychiatry, Dr. Vikram Patel of the Harvard School of Medicine, to discuss global psychiatry, and the lessons for us.
A few highlights –
On global inequity:
There are more psychiatrists of African origin in the US than in the whole of Africa. And I could actually say similar examples from the Philippines, or India, or many other countries. So, I think there is an enormous shortage of mental health resources, but it’s also important to highlight the inequitable distribution. So, for example, in India even though there might be four or five thousand psychiatrists, a minuscule number for a population of one point three billion, those four or five thousand are largely concentrated in the big cities of the country where only about 30 percent of the population live.
On trying to provide care in low-income countries:
I borrowed heavily from the innovations that other areas of global health have used in order to address these human resource shortages, and perhaps the single most important innovation is that of the community health worker. An innovation which I think has huge significance to high income countries as well. So, community health worker typically is a health provider who, by definition, works in the community but is typically also belonging to that community, lives in that community, speaks the same language, shares very similar social and cultural factors with the broader community which he or she serves. This is a person who doesn’t necessarily have to go through an elaborate medical training in order to become a health provider. The training is much shorter but most importantly its task based.
On the potential of technology:
I think digital technologies are incredibly exciting opportunity to leapfrog some of these enormous structural barriers… I’m most enthusiastic about young people. Why? They’re the ones who embrace digital technologies the quickest…
On the lessons for high-income nations:
Amongst the innovations that I do think are very relevant in the developed world, is the use of alternative providers. Not the mainstream mental health providers, but alternative providers, to extend mental health care into the community. And Daisy Singla’s work here in Toronto, which is seeking to use nurses to deliver behavioural activation for perinatal depression, is one example; the use of simpler forms of psychological treatments like behavioural activation as the first line of psychotherapy, is another kind of innovation; you don’t need to know the whole of CBT you can just take a very specific component of CBT…
These last few comments may be the most interesting, as Dr. Patel considers how the lessons of Goa may be relevant in Guelph or Gander – or just down the street.
The podcast can be found here, and is just over 25 minutes long:
Selection 3: “How I survived a psychotic break”
Toronto Life, 8 May 2019
Two years ago, my mind unravelled. I record music under the stage name Cold Specks, and in late 2017, I went on a three-month international tour to support my third album, Fool’s Paradise. The shows weren’t selling, and I was playing to empty rooms. I thought my career was finished. Over the next few months, I stopped sleeping, clocking only three or four hours every few nights. I also starved myself, subsisting on 400 calories a day.
I returned home to Toronto in January 2018, broken, dishevelled and deranged.
So begins a short, raw essay on illness and recovery by Ladan Hussein. The piece is short, and doesn’t require much of a summary here.
She talks about her illness:
I became convinced that several pop stars were members of the Illuminati, trying to recruit me through their music. I thought they had set up hidden cameras in my apartment and tapped my phone, and I’d talk for hours alone in my apartment, figuring they were listening. I’d see the giant video ads at the Eaton Centre outside my window and assume they were sending me hidden messages. I cut off contact with most of my friends, and feigned normalcy when I spoke to my family.
She talks about a challenging journey – at one point, she was taken to the hospital by friends, but she refused to go in; another time, she was admitted for 72 hours, then released.
Later, she does have a longer admission and slowly heals: “I was miserable: the windows in my room wouldn’t open, and I wasn’t allowed outside. But soon I was eating three meals a day and gaining weight. I stayed off the Internet and read books instead. And within a few weeks, I was writing again. At first, it was a collection of words. Then melodies. Then piano and guitar chords. I was reflecting on my delusions, and it was beautifully therapeutic.”
She is now out of hospital and working as a musician again.
The next time I record music, I’ll use my own name instead of Cold Specks. Because I finally feel like myself again.
It’s a great essay. For the record, I’m looking forward to hearing her new music.
The full essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.