From the Editor
First, there was decriminalization; then, legalization.
How have these major legal shifts influenced the presentation of our patients? In the first selection, we consider a new paper from The Canadian Journal of Psychiatry. Taylor McGuckin (of the University of Waterloo) and her co-authors look at cannabis use and inpatient care, drawing on databases. “This study identified a significant increase in the proportion of patients who used cannabis within 30 days of their first admission to inpatient psychiatry in Ontario, Canada, between 2009 and 2017, compared to 2007.”
How do our biases affect the care we provide? In a moving and personal essay, Karen Alexander (of Thomas Jefferson University) discusses the loss of her baby. She thinks about another time, when a patient of hers was in a similar situation, and she mulls her own views and biases. “The weeping woman was always much more than someone who was grieving, but I never really knew her as a person until I mourned the loss of my own child.”
Selection 1: “How High? Trends in Cannabis Use Prior to First Admission to Inpatient Psychiatry in Ontario, Canada, between 2007 and 2017”
Taylor McGuckin, Mark A. Ferro, David Hammond, et al.
The Canadian Journal of Psychiatry, 31 December 2021
Canada’s medical cannabis policy framework has evolved since 2001 and has coincided with a proliferation of illegal online and storefront dispensaries purporting to provide medical access to cannabis. Trends in cannabis use among the general population have varied by age between 2004 and 2014, with the only decrease being among those under 18 years. Among adults, trends in cannabis use among the general population in Canada remained stable between 2004 and 2010 and increased across all age groups between 2011 and 2017. Between 2007 and 2014, the health care costs for cannabis in Canada increased by 28%, where hospital stays for cannabis-use disorders increased by 40%. Similarly, hospitalizations in the United States associated with cannabis use disorders have increased with the emergence of medical and nonmedical cannabis policies. Furthermore, variations in medical cannabis policies across the United States are associated with variations in prevalence of severe mental illness. With evolving cannabis policies in Canada, there remains a need to understand broader patterns of cannabis use among persons with mental illness.
This study examines trends in cannabis use prior to first psychiatric hospital admissions in Ontario, Canada, between 2007 and 2017, the year prior to legalization of cannabis for nonmedical use. We also examine the characteristics associated with reports of cannabis use prior to admission.
So begins a paper by McGuckin et al.
Here’s what they did:
- They authors conducted a retrospective cross-sectional analysis for first-time admissions to inpatient psychiatric beds in Ontario, Canada.
- Admissions were between January 1, 2007, and December 31, 2017.
- They drew on databases, including the Ontario Mental Health Reporting System, which contains data from the Resident Assessment Instrument for Mental Health (the RAI-MH) – completed for all inpatient Ontario admissions at the times of admission and discharge. The database contains demographic information, as well as answers to questions around substance and substance use.
- The analysis considered various variables, including age and diagnoses.
Here’s what they found:
- “The proportion of patients who used cannabis increased from 16.7% to 25.9%.”
- “Cannabis use was more common among males and increased by 9.9% between 2007 and 2017 (compared to a 7.9% increase among females).”
- “In 2017, 47.9% of patients aged 18 to 24 and 39.2% of patients aged 25 to 34 had used cannabis within 30 days of admission, representing increases of 8.2% and 10.7%, respectively.”
- “While relatively few patients aged 55 to 64 used cannabis, the proportion reporting cannabis use more than doubled between 2007 and 2017…”
- “There was a 4.0% increase in the proportion of patients with schizophrenia or other psychotic disorders and a 10.4% increase in anxiety disorders.”
- “While the proportion of patients with a noncannabis substance use diagnosis decreased by 4.2%, the proportion with cannabis use disorders increased from 3.8% to 6.0% between 2007 and 2017.”
- Considering the logical regression: “Holding all other variables constant, the odds of cannabis use prior to admission decreased as patient age and/or cognitive impairment increased, and among those who were married and/or had a higher level of education”
- “The proportion of males with schizophrenia and other psychotic disorders who used cannabis was 12.1% higher than males without this diagnosis. There proportion of females with schizophrenia who used cannabis was 1.6% lower compared to the proportion of females without this diagnosis.” See figure below.
A few thoughts:
- This is a good study. And the title is catchy.
- The data is clear: there’s been a significant increase in the use of cannabis among those with first-time admission; for male patients with psychosis, more than one in three used in the month before admission. (!)
- The authors consider various explanations. “Are increases in cannabis use prior to first admission to inpatient psychiatry related to increases in the use of cannabis for self-medication of unmet mental health needs among the general population? Self-medication to cope with mental health challenges has become a prominent theory to explain use of cannabis…”
- Are we surprised? Cannabis is now promoted by a private industry that emphasizes the medicinal qualities of that drug. It’s also readily available; there are three cannabis stores across the street from my hospital building.
- How do we respond in terms of care? Mental health wards tend to focus on mental health services, and less on substance. Is that appropriate for the 21st realities of legalized cannabis?
- While the RAI-MH data is good, it’s not great. The survey is burdensome and populated by nurses who have other obligations. Is cannabis use underestimated?
- Thinking more practically, how can we up our game in terms of talking to patients about cannabis? Consider taking a look (or another look) at the podcast interview with Dr. Leslie Buckley, who serves as Chief of Addictions Division at CAMH. Featured in a past Reading, her comments on cannabis, edibles, and motivational interviewing can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-better-ptsd-symptom-control-less-diabetes-jama-psych-also-buckley-on-cannabis-quick-takes-and-the-life-of-kajender-globe/
The full CJP paper can be read here:
Selection 2: “Shared Grief”
JAMA, 26 January 2021
In the neonatal intensive care unit, acuity is high. As nurses, our shifts are typically 12 hours during which we generally care for only 2 or 3 patients. Nurses are the constants and stay at the bedside with those few infants the entire 12 hours, only leaving to take a quick lunch break or to use the bathroom. A shift can be a chaotic flurry of activities, sounds, and lights. Or it can be somber and quiet, dark, with just the glow of the digital monitors showing each child’s heartbeat and breathing, like a silent news feed passing the time.
Ten years ago, I gave birth to my oldest child, a daughter named Molly. She had a genetic condition that resulted in her death shortly after she was born. I knew the nurses in the delivery room, and they cried with me after the resuscitation. I’ll never forget the nurse who said, ‘I’m so sorry, my dear, we lost her.’ I see her above my head, covered in a gown, mask, and cap, still able to communicate love and sympathy. My obstetrician choked back tears as she stitched me up, taking her time to stitch me twice instead of using staples.
My grief was deeply physical. Each time I got out of bed, or even stretched in bed, I would remember the pain of losing Molly.
So begins an essay by Alexander.
She talks about the loss:
“I wished many times that I had been the one to die. I was sliced open in an effort to give her life. Instead, I was left empty. My arms were empty, my belly was empty. I wanted to run away from my body, which I felt bore death, reminded me of death, and reminded everyone else of death.”
Unable to hold her daughter, the author thinks back to a former patient who was a sex worker and had lost her child. “Her line of work and her drug use complicated things. Even though we often ask about drugs and sexual practices as health care professionals, when such behaviors present themselves, we tend to have a conscious or unconscious reaction. We may become noticeably tense, or distant, or lose a bit of friendliness. A darker shadow comes upon an already stressful event. For the mother, it made the tears that flooded her face, and her cries which pierced the room’s silence, different.”
“We would never say we don’t have empathy for the mother as a result of her past. Yet we don’t do some things because of it. We don’t stand as close, we don’t make as much eye contact, and we don’t identify or draw close.”
She wonders about this former patient:
“I think of the mother at the bedside of her son often. I wonder if she is still living. I wonder if she had anyone to cry with later that week, or month, or year. I wonder if her year in a pandemic had any moments of rest. I wonder if she is in prison, if she is in recovery, and if she has other children. I look for her on the subway and on my walk home from work.”
And she notes that this person was able to hold her dying child. “She who looked discarded, weak, and almost silly in her grief. She who was all alone, without a partner, without a stable job, and without sympathy. She had done the incredibly heroic thing of loving a baby who was about to die and held him close. What a strong woman, what a woman to admire, and what a woman to be like.”
A few thoughts:
- This essay is very raw.
- She also speaks openly of stigma and judgment, including the biases she holds. Wow.
- She notes the larger implications: “It has been argued that stigma in health care is a critical factor in population-level health disparities for marginalized populations. Our assumptions about a patient and the relational distance that we create between ourselves and a patient substantially affect the patient’s well-being. Once experienced, stigma may also keep someone from seeking or maintaining health care in the future.”
The JAMA paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.