71
Drugand Alcohol Dependence, 1 (1975/76) 71 - 81 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
PSYCHOSOCIAL EFFECTS OF LONGTERM CANNABIS INDIA A STIJDY OF FIFTY HEAVY USERS AND CONTROLS S. S. MEHNDIRATTA Postgraduate (Received
Institute June
30,
USE IN
and N. N. WIG of Medical
Education
and Research,
Chandigarh-160011
*(India)
1975)
Summary Fifty cases of heavy cannabis users in India (25 smokers of charas and 25 drinkers of bhang) were studied for their physical and mental health and compared with 25 non-user controls. The average duration of cannabis use was more than 10 years with an estimated average consumption of about 150 mg of THC daily. Physical health and nutrition were relatively poor in users and there were more respiratory complaints. No case of definite psychosis related to the use of cannabis was found in this series, though minor neurotic complaints were present in all groups. In the social sphere cannabis users gave more often a history of poor work record, family maladjustment and episodes of violent behaviour.
Introduction The traditional use of cannabis and its preparation in India are well known and have been extensively reviewed in earlier literature [ 1 ]. With the recent widespread use of cannabis in Europe and America, particularly among young people, there has been a resurgence of interest about its use in India. There is currently a serious debate going on in Western countries about the possible harmful effects of this drug. Factual knowledge about its longterm effects is thus of crucial importance to decide about the future legislation and control in the countries where its widespread use did not exist before. However, in Western countries the use of this drug is only of recent origin and it is difficult to find a large number of cases with the history of prolonged heavy use. Moreover in these countries it is very uncommon to find isolated use of cannabis, because most of the cannabis users take a number of additional drugs. As a result of this it becomes difficult to separate the longterm effect of cannabis from that of other drugs. On the other hand, the Eastern countries like India, where the use of cannabis has been ritualized and traditionally accepted for centuries, offer a good opportunity to study such a phenomenon. It can be studied not only in isolation from other drugs and with all grades of heavy intake, but also in
12
relation to different nutritional and socio-economic conditions, and in environments of varying social acceptance. The present paper deals with a brief study of psychosocial correlates of heavy and longterm cannabis users, to elucidate in particular the effects of the drug on the physical, psychological and social health of the individual. In North India cannabis is commonly used both in the form of smoking ganja (dried flowering tops) or charas (hashish), or drinking bhang (a concoction made with cannabis leaves). The varieties of cannabis preparations in India and modes of consumption have been extensively reviewed by Chopra and Chopra [l] . The groups of longterm charas smokers and bhang drinkers were both considered for this study. Material and methods Sample
Fifty cases who were taking cannabis for more than 4 years regularly with an average frequency of at least 20 times a month and whose average estimated daily consumption was more than 50 mg of active THC were taken up for the present study. These cases were selected from the city of Amritsar in Punjab. The religious places like temples and common meeting places of cannabis drinkers and smokers were visited. Those persons who were taking cannabis regularly were approached either by personal visits or through a paid motivator. They were requested to tell the investigator about their cannabis intake in detail, about their social, personal and family life, and to take a battery of psychological tests. Each case was assured about the confidentiality of the information thus gathered from him. For his co-operation he was paid 5 - 10 rupees (about one dollar) in addition to any bus or rickshaw fare he had spent in coming to the place of investigation. None of the persons investigated belonged to any particular religious sect. Method
The cases thus selected were interviewed individually in a separate room. To make sure that none of them was coming just for the sake of money, every one was asked a few searching questions. Each person was asked separately about the company in which he took cannabis and was then shown samples of bhang, ganja and charas to identify the preparations. He was then questioned about the various places where it was illegally sold and taken. If there was any doubt that the informant was not a longterm heavy user, the case was excluded from the study group. Each case was then interviewed with the help of a semi-structured interview schedule especially prepared for the purpose of this study. For determination of the socio-economic status, Kuppuswamy’s Urban scale [2] was used. Each subject was then asked in detail about the type of preparation of cannabis he took, the daily dose, the duration of intake, the daily frequency and the mode of consumption of the drug. As most of the users were illiterate, it was difficult to get a good estimate of the amount daily
used. To overcome this difficulty, measured quantities of cannabis preparations were used to approximate his daily consumption. He was also asked abort other drugs he had taken earlier or was using at present and the frequency of their use. Interviews included his relations with family members, job adjustment, work record and sexual and marital life, physical and psychiatric illness, etc. A detailed physical and mental examination and a set of psychological tests were given to each case (the results of the psychological tests are reported elsewhere). The control sample consisted of 25 persons, who had never taken cannabis in their life. These people were selected from poor socio-economic groups such as unskilled workers, hospital attendants, and sweepers, carefully matched with the study group on the parameters of age, sex and socio-economic status and were interviewed on the same lines as those taken for the study group. Observations The total number of cases studied was 75 (25 bhang drinkers, 25 charas smokers and 25 controls). All the cases in the study as well as in the control group were males, coming from urban areas in Punjab. All belonged to the group-IV and group-V of socio-economic status. The mean age in the bhang drinkers was 33 years (range 21 - 51 years), in the charas smokers 27 years (range 16 : 47 years) and in the control group 32 years (range 16 45 years). Fourteen cases among charas smokers were unmarried as compared with only 6 in bhang drinkers and 2 in the control group. All the cases in the present study were predominantly from Hindu and Sikh religions. Only one was Christian in the group of bhang drinkers. The majority (80%) were illiterate or educated only up to primary school level. The mean duration of use of cannabis in bhang drinkers was 13.44 years and in charas smokers 10.48 years.
TABLE Duration
1 of use of cannabis
4-lOyears ll- 20years 21 years and over
Charas smokers N-25
Bhang drinkers N-25
15 9 1
8 12 5
Twenty-one of the charas smokers and 13 of the bhang drinkers started using cannabis below 20 years of age.
74
TABLE
2
Age at start
of cannabis Charas N-25
Below 20 years 21 - 30 years 31 - 40 years
Bhang N-25
smokers
21 4 -
drinkers
13 11 1
The majority of bhang drinkers and charas smokers were using cannabis at least 2 or more times per day. The average daily consumption of bhang and charas was 14.0 grams (leaves) and 5.0 grams respectively. TABLE Amount
3 of drug
used
daily
Charas N-25 Average amount Range *Probable amount of THC in average daily intake *Considering
the
Bhang N-25
smokers
5g 2-16g
150 bhang
drinkers
14 g 5 - 40 g
mg
having
140 1% and
the
ganjalcharas
mg having
3% THC
[ 31
Drugs used other than cannabis Almost all individuals in the 3 groups had taken alcohol occasionally (once a month or so) but only 4 char-as smokers, 5 bhang drinkers and one control case were using it more than once a week. Not one was a regular daily user. All cases in the charas group were smoking tobacco, as compared with 15 in the bhang group and 21 in the control group. Three of the bhang drinkers and one of the charas smokers were in the habit of chewing tobacco also. Opium had been occasionally (once a month or so) used by 12 bhang drinkers, 10 charas smokers and one control case, but none was using it at the moment. In the history, there was occasional mention of other drugs hke barbiturates, cocaine, methylated spirit, arsenic, amphetamines, dhatura (stramonium) and chloral hydrate, but their use was infrequent and none of them was being used concurrently. Medical history Weight loss, cough, dyspnoea and poor sleep were complained significantly more often by cannabis users compared with controls in Table 4.
of as shown
75
TABLE
4
Physical
complaints Charas N-25
smokers
17 8 7 3 3 1 2 -
23 17 5 2 1 -
Weight loss Cough and early dyspnoea Insomnia Dysentery Pain in legs Giddiness Piles Varicose veins
Bhang drinkers N-25
Control N-25
1 1 1 1
1
Physical examination Physical examination did not reveal any gross pathology in any of the cases. In general, cannabis users appeared in poor nutritional state as compared with the control group and were more often found to be anaemic. Nonspecific chest signs like generalised bronchitis and crepitations were encountered more often in charas smokers than in bhang drinkers or control group. Eye examination showed that 12 of the bhang drinkers and 17 of the charas smokers had conjunctival congestion, as compared with none in the control group (significant at 0.01 level). Only one of the charas smokers had transverse ciliary congestion. Family history of mental diseases There was a history of neurosis in the families of 2 bhang drinkers and one charas smoker as compared with none in the control group. In the families of 2 bhang drinkers and 2 charas smokers, a history of psychosis was reported as compared with one in the control group. TABLE
5
Mental illness in the families
of cannabis
Charas N-25 Neurosis Psychosis
1 2
users
smokers
Bhang N-25 2 2
drinkers
Control N-25 1
Psychiatric history and examination On psychiatric history and mental examination none of the users ( OEcontrols) showed any evidence of hallucinations, delusions or any other psychotic phenomenon except one case who gave a history of acute intoxication following a heavy dose and lasting only for a few hours. However, one
76
case seemed borderline and was considered as schizoid personality. There were vague anxiety, depressive and somatic symptoms present in nearly one-third of users in both groups (8 out of 25 each) compared with only 3 of controls. However, in only 2 bhang drinkers, 3 charas smokers and one control the symptoms seemed of sufficient clinical severity to be regarded as depressive neurosis. The findings are shown in Tables 6 and 7. TABLE
6
Past history
of mental
illness Charas smokers N-25
Bhang drinkers N-25
Psychosis Transient psychosis (acute intoxication)
1
-
Neurosis Anxiety and depressive neurosis Hysterical neurosis
2 1
3 -
Charas smokers N-25
Bhang N-25
-
-
2
3 1
TABLE
Control N-25
1 1
7
Psychiatric
examination
Psychosis Neurotic depression Schizoid personality
drinkers
Control N-25
1 -
Family relations
Family disturbances were more often reported in cannabis users. Six of the charas smokers and 3 of the bhang drinkers had uncordial relations with parents as compared with none in control (significant at 0.01, and approaching 0.05, respectively). Ten of the charas smokers and 9 bhang drinkers reported poor social relation with their brothers and sisters as compared with only 4 in the control (approaching 0.05 and N.S. respectively). Marital and sexual
life
General adjustment with wife and children was poor in 4 out of 11 married cases in the charas group and 4 out of 19 married in the bhang group. In the control group 3 out of a group of 23 married were poorly adjusted.
77 TABLE Marital
8 and sexual
adjustment
Marital adjustment Average Poor *Chi square
Charas smokers
Bhang drinkers
Control
Significance Charas
Bhang
Charas
N-11
N-19
N-23
VS.
us.
VS.
control
control
bhang
NS NS
NS NS
NS NS
7 4
15 4
20 3
of difference*
test.
Sexual history Sexual promiscuity was more frequent control group, as shown in Table 9.
TABLE Sexual
in cannabis
users than in the
9 history Charas
Bhang
Charas
VS.
vs.
vs.
N-25
control
control
bhang
2
-
0.05*
N.S.
N.S.
15
5
4
0.01
N.S.
0.01
3
6
2
N.S.
N.S.
N.S.
2
2
-
N.S.
N.S.
N.S.
Bhang drinkers N-25
Control
5
Charas smokers N-25 Homosexual experience Premarital sexual relations Extramarital sexual relations History of venereal disease *Chi
square
test.
Work record Significantly more cases in the cannabis groups had a poor work record. Nine of the charas smokers and 4 of the bhang drinkers, but only 2 in the control group, changed to 3 or more jobs in the last 10 years. Two in the charas group and one in the bhang group were not holding any job at present. Adjustment to the job was poor in 8 of the charas smokers, 7 of the bhang drinkers and only 2 of the control group cases.
78 TABLE
10
Persons’
own assessment
of job satisfaction Charas smokers N-25
Without
job
Poor job satisfaction
Average
job satisfaction
*Chi square
Antisocial
Levels of significance
Control N-25
Bhang drinkers N-25
2
1
8
7
2
15
17
23
*
Charas vs. control 0.05 Bhang vs. control Approach 0.05 Charas vs. Bhang N.S.
test.
behaviour
during drug use
Eleven in the charas group, 5 in the bhang group and 3 in the control group reported serious quarrels involving violence at one time or another. Seven out of these 11 charas smokers, and 4 out of 5 bhang drinkers, were under the influence of cannabis at the time of the quarrel. Three charas smokers, one bhang drinker and one control case quarrelled when they had taken alcohol. One of the charas smokers also served a prison sentence. TABLE
11
Antisocial
behaviour
Involved in violent quarrel Quarrel under effect of cannabis Quarrel under effect of alcohol Quarrel under effect of no drug *Chi square
Charas smokers N-25
Bhang drinkers N-25
Control
11
5
7
4
3
1
1
1
-
2
Charas
Bhang
Charas
VS.
vs.
VS.
N-25
control
control
bhang
3
0.05*
N.S.
App. 0.05
test.
Discussion In the state of Punjab where this study was conducted all forms of cannabis are now legally banned. However, since the wild grown plant is so easily available, there are a number of people who regularly take it. There are also certain social groups where its use is traditional. However, owing to
79
the legal prohibition, it is often difficult to obtain full cooperation of the users. Furthermore, a majority of those using the drug live in isolated groups outside the main stream of society. They are suspicious of the approach of any stranger and hesitant to disclose the information regarding their use of the drug. These factors impose limitations on any scientific study of this subject. The control group presents also a difficult problem. To find a group of individuals who are similar in all other respects but do not take cannabis and are also willing to give detailed personal information, is an exceedingly difficult proposition. Our first effort was to find the relatives of users, but most of the users were living alone in the city and their relatives were often socio-economically better off. We ultimately settled on having a control group which matched in age, sex and socio-economic status. In spite of these shortcomings certain interesting features of heavy cannabis use as it exists in India have emerged. A relatively large proportion of cannabis users complained of poor health as evidenced by reported loss of weight, cough, dyspnoea and poor sleep. Unfortunately X-ray and laboratory investigations could not be included in this study. Anaemia, weight loss, etc. would probably be related to poor nutritional status rather than to the cannabis itself. Similarly, the presence of cough, dyspnoea and chest findings suggests a respiratory pathology ascribable as well to tobacco smoking which was invariably practised by cannabis users. The presence of insomnia in onethird of users is an interesting finding and needs further confirmation. Effects of cannabis on mental health have been hotly debated for over a century now. At one time’during the last century cannabis was regarded as the largest single cause of insanity in lunatic asylums in India and nearly one-third to one-half of the cases of insanity were attributed to this habit. The Indian Hemp Commission in 1893, however, on critical assessment estimated that cannabis was a factor in not more than 7 - 13% of admissions to the asylums [4]. Over the years this controversy is not fully resolved. Dhunjibhoy (1930) working in Ranchi in Eastern India reported ganja psychosis as a fairly common diagnosis [5] _ From the same hospital, as recently as 1972, Varma has reported 1248 cases in a span of ten years, i.e., 3.2% of all admissions [ 61. Similarly Chopra and Smith (1974) from an addiction clinic in Calcutta have reported 200 cases of “psychotic reactions” [ 71. Unfortunately the methodology of these authors leaves much to be desired and one is never very sure if apart from transitory acute intoxications due to excessive dosage, these authors are dealing with a genuine cannabis psychosis or only with victims of other functional psychosis who, in addition, were using cannabis. As has been pointed out by Harding and Knight (1973), patients with functional psychosis who are previously using cannabis often increase their intake during the psychotic phase which causes confusion in symptomatology [ 81. Thacore’s (1972) cases of “Bhang psychosis” from Lucknow, India,
80
seem to be better documented and suggest that a short lasting psychosis with marked anxiety, panic, paranoid ideation and vivid hallucination in a clear state of consciousness may occasionally follow heavy cannabis use [9] . Epidemiological studies on the effect of cannabis use in the general population in India are very few in number. The present study is significant in the sense that in 50 long-term very heavy users of cannabis we did not come across any history of prolonged psychosis except in one case who had transient confusional reaction lasting only a few hours after ingestion of a heavy dose of cannabis. On present state mental examination also we did not find any sign of psychosis except in one case who seemed to be having a schizoid personality. Recently Aggarwal, Sethi and Gupta (1975) from Lucknow, India, have reported no case of cannabis psychosis in a study of 40 heavy users [lo]. However, such retrospective studies do not rule out the existence of such psychosis. Some of the cases who developed psychosis may have left the drug and may not now be available, but even on close questioning we did not come across any case who was known to informants and who had developed psychosis while using cannabis. However, mild mental symptoms like anxiety and depression seemed relatively more common in users. The findings of the present study suggest that cannabis users have a relatively poor record in social adjustment; they had more strained relations with parents and siblings, more frequent job changes and poor work satisfaction. Another unusual finding in this study is the history .of violent acts relatively more frequent in cannabis users. However, there is need for caution in interpreting results. In the absence of a well controlled prospective study it is very difficult to be sure whether cannabis per se produces social disturbances or previously disturbed personalities opt more often for this drug. Acknowledgement We are grateful to Mr. S. K. Verma, Clinical Psychologist, Department of Psychiatry P.G.I. Chandigarh for his advice on statistical analysis. References I. C. Chopra and R. N. Chopra, The use of cannabis drugs in India, U.N. Bull. on Narcotics, 9 (1957) 4. B. Kuppuswamy, Manual: Socio-economic Status Scale (Urban), Mansayan, Delhi, 1962. World Health Organisation, The use of cannabis, Tech. Rept. Series No. 478, Scientific Group, Geneva, 1971. Marihuana, Indian Hemp Drugs Commission, Rept. 1893 - 1894. Introduction by J. Kaplan, Silver Spring, Maryland, Jefferson Puhl. Co., 1969. J. E. Dhunjibhoy, A brief resume of the types of insanity met in India, with a full description of Indian hemp insanity peculiar to the country. Mental Sci., 76 (1930) 254. L. P. Varma, Cannabis psychosis, Indian J. Psychiat., 14 (1972) 241.
81 7 G. S. Chopra and J. W. Smith, Psychotic reactions following cannabis use in East India, Arch. Gen. Psychiat., 30 (1974) 24. 8 T. Harding and F. Knight, Marihuana-modified mania, Arch. Gen. Psychiat., 29 (1973) 635. 9 V. R. Thacore, Bhang psychosis, Brit. J. Psychiat., 123 (1973) 225. 10 A. K. Aggarwal, B. B. Sethi and S. C. Gupta, Physical and cognitive effects; of chronic bhang (cannabis) intake, Indian J. Psychiat., 17 (1975) 1.
Drugand Alcohol Dependence, 1 (1975/76) 71 - 81 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
PSYCHOSOCIAL EFFECTS OF LONGTERM CANNABIS INDIA A STIJDY OF FIFTY HEAVY USERS AND CONTROLS S. S. MEHNDIRATTA Postgraduate (Received
Institute June
30,
USE IN
and N. N. WIG of Medical
Education
and Research,
Chandigarh-160011
*(India)
1975)
Summary Fifty cases of heavy cannabis users in India (25 smokers of charas and 25 drinkers of bhang) were studied for their physical and mental health and compared with 25 non-user controls. The average duration of cannabis use was more than 10 years with an estimated average consumption of about 150 mg of THC daily. Physical health and nutrition were relatively poor in users and there were more respiratory complaints. No case of definite psychosis related to the use of cannabis was found in this series, though minor neurotic complaints were present in all groups. In the social sphere cannabis users gave more often a history of poor work record, family maladjustment and episodes of violent behaviour.
Introduction The traditional use of cannabis and its preparation in India are well known and have been extensively reviewed in earlier literature [ 1 ]. With the recent widespread use of cannabis in Europe and America, particularly among young people, there has been a resurgence of interest about its use in India. There is currently a serious debate going on in Western countries about the possible harmful effects of this drug. Factual knowledge about its longterm effects is thus of crucial importance to decide about the future legislation and control in the countries where its widespread use did not exist before. However, in Western countries the use of this drug is only of recent origin and it is difficult to find a large number of cases with the history of prolonged heavy use. Moreover in these countries it is very uncommon to find isolated use of cannabis, because most of the cannabis users take a number of additional drugs. As a result of this it becomes difficult to separate the longterm effect of cannabis from that of other drugs. On the other hand, the Eastern countries like India, where the use of cannabis has been ritualized and traditionally accepted for centuries, offer a good opportunity to study such a phenomenon. It can be studied not only in isolation from other drugs and with all grades of heavy intake, but also in
12
relation to different nutritional and socio-economic conditions, and in environments of varying social acceptance. The present paper deals with a brief study of psychosocial correlates of heavy and longterm cannabis users, to elucidate in particular the effects of the drug on the physical, psychological and social health of the individual. In North India cannabis is commonly used both in the form of smoking ganja (dried flowering tops) or charas (hashish), or drinking bhang (a concoction made with cannabis leaves). The varieties of cannabis preparations in India and modes of consumption have been extensively reviewed by Chopra and Chopra [l] . The groups of longterm charas smokers and bhang drinkers were both considered for this study. Material and methods Sample
Fifty cases who were taking cannabis for more than 4 years regularly with an average frequency of at least 20 times a month and whose average estimated daily consumption was more than 50 mg of active THC were taken up for the present study. These cases were selected from the city of Amritsar in Punjab. The religious places like temples and common meeting places of cannabis drinkers and smokers were visited. Those persons who were taking cannabis regularly were approached either by personal visits or through a paid motivator. They were requested to tell the investigator about their cannabis intake in detail, about their social, personal and family life, and to take a battery of psychological tests. Each case was assured about the confidentiality of the information thus gathered from him. For his co-operation he was paid 5 - 10 rupees (about one dollar) in addition to any bus or rickshaw fare he had spent in coming to the place of investigation. None of the persons investigated belonged to any particular religious sect. Method
The cases thus selected were interviewed individually in a separate room. To make sure that none of them was coming just for the sake of money, every one was asked a few searching questions. Each person was asked separately about the company in which he took cannabis and was then shown samples of bhang, ganja and charas to identify the preparations. He was then questioned about the various places where it was illegally sold and taken. If there was any doubt that the informant was not a longterm heavy user, the case was excluded from the study group. Each case was then interviewed with the help of a semi-structured interview schedule especially prepared for the purpose of this study. For determination of the socio-economic status, Kuppuswamy’s Urban scale [2] was used. Each subject was then asked in detail about the type of preparation of cannabis he took, the daily dose, the duration of intake, the daily frequency and the mode of consumption of the drug. As most of the users were illiterate, it was difficult to get a good estimate of the amount daily
used. To overcome this difficulty, measured quantities of cannabis preparations were used to approximate his daily consumption. He was also asked abort other drugs he had taken earlier or was using at present and the frequency of their use. Interviews included his relations with family members, job adjustment, work record and sexual and marital life, physical and psychiatric illness, etc. A detailed physical and mental examination and a set of psychological tests were given to each case (the results of the psychological tests are reported elsewhere). The control sample consisted of 25 persons, who had never taken cannabis in their life. These people were selected from poor socio-economic groups such as unskilled workers, hospital attendants, and sweepers, carefully matched with the study group on the parameters of age, sex and socio-economic status and were interviewed on the same lines as those taken for the study group. Observations The total number of cases studied was 75 (25 bhang drinkers, 25 charas smokers and 25 controls). All the cases in the study as well as in the control group were males, coming from urban areas in Punjab. All belonged to the group-IV and group-V of socio-economic status. The mean age in the bhang drinkers was 33 years (range 21 - 51 years), in the charas smokers 27 years (range 16 : 47 years) and in the control group 32 years (range 16 45 years). Fourteen cases among charas smokers were unmarried as compared with only 6 in bhang drinkers and 2 in the control group. All the cases in the present study were predominantly from Hindu and Sikh religions. Only one was Christian in the group of bhang drinkers. The majority (80%) were illiterate or educated only up to primary school level. The mean duration of use of cannabis in bhang drinkers was 13.44 years and in charas smokers 10.48 years.
TABLE Duration
1 of use of cannabis
4-lOyears ll- 20years 21 years and over
Charas smokers N-25
Bhang drinkers N-25
15 9 1
8 12 5
Twenty-one of the charas smokers and 13 of the bhang drinkers started using cannabis below 20 years of age.
74
TABLE
2
Age at start
of cannabis Charas N-25
Below 20 years 21 - 30 years 31 - 40 years
Bhang N-25
smokers
21 4 -
drinkers
13 11 1
The majority of bhang drinkers and charas smokers were using cannabis at least 2 or more times per day. The average daily consumption of bhang and charas was 14.0 grams (leaves) and 5.0 grams respectively. TABLE Amount
3 of drug
used
daily
Charas N-25 Average amount Range *Probable amount of THC in average daily intake *Considering
the
Bhang N-25
smokers
5g 2-16g
150 bhang
drinkers
14 g 5 - 40 g
mg
having
140 1% and
the
ganjalcharas
mg having
3% THC
[ 31
Drugs used other than cannabis Almost all individuals in the 3 groups had taken alcohol occasionally (once a month or so) but only 4 char-as smokers, 5 bhang drinkers and one control case were using it more than once a week. Not one was a regular daily user. All cases in the charas group were smoking tobacco, as compared with 15 in the bhang group and 21 in the control group. Three of the bhang drinkers and one of the charas smokers were in the habit of chewing tobacco also. Opium had been occasionally (once a month or so) used by 12 bhang drinkers, 10 charas smokers and one control case, but none was using it at the moment. In the history, there was occasional mention of other drugs hke barbiturates, cocaine, methylated spirit, arsenic, amphetamines, dhatura (stramonium) and chloral hydrate, but their use was infrequent and none of them was being used concurrently. Medical history Weight loss, cough, dyspnoea and poor sleep were complained significantly more often by cannabis users compared with controls in Table 4.
of as shown
75
TABLE
4
Physical
complaints Charas N-25
smokers
17 8 7 3 3 1 2 -
23 17 5 2 1 -
Weight loss Cough and early dyspnoea Insomnia Dysentery Pain in legs Giddiness Piles Varicose veins
Bhang drinkers N-25
Control N-25
1 1 1 1
1
Physical examination Physical examination did not reveal any gross pathology in any of the cases. In general, cannabis users appeared in poor nutritional state as compared with the control group and were more often found to be anaemic. Nonspecific chest signs like generalised bronchitis and crepitations were encountered more often in charas smokers than in bhang drinkers or control group. Eye examination showed that 12 of the bhang drinkers and 17 of the charas smokers had conjunctival congestion, as compared with none in the control group (significant at 0.01 level). Only one of the charas smokers had transverse ciliary congestion. Family history of mental diseases There was a history of neurosis in the families of 2 bhang drinkers and one charas smoker as compared with none in the control group. In the families of 2 bhang drinkers and 2 charas smokers, a history of psychosis was reported as compared with one in the control group. TABLE
5
Mental illness in the families
of cannabis
Charas N-25 Neurosis Psychosis
1 2
users
smokers
Bhang N-25 2 2
drinkers
Control N-25 1
Psychiatric history and examination On psychiatric history and mental examination none of the users ( OEcontrols) showed any evidence of hallucinations, delusions or any other psychotic phenomenon except one case who gave a history of acute intoxication following a heavy dose and lasting only for a few hours. However, one
76
case seemed borderline and was considered as schizoid personality. There were vague anxiety, depressive and somatic symptoms present in nearly one-third of users in both groups (8 out of 25 each) compared with only 3 of controls. However, in only 2 bhang drinkers, 3 charas smokers and one control the symptoms seemed of sufficient clinical severity to be regarded as depressive neurosis. The findings are shown in Tables 6 and 7. TABLE
6
Past history
of mental
illness Charas smokers N-25
Bhang drinkers N-25
Psychosis Transient psychosis (acute intoxication)
1
-
Neurosis Anxiety and depressive neurosis Hysterical neurosis
2 1
3 -
Charas smokers N-25
Bhang N-25
-
-
2
3 1
TABLE
Control N-25
1 1
7
Psychiatric
examination
Psychosis Neurotic depression Schizoid personality
drinkers
Control N-25
1 -
Family relations
Family disturbances were more often reported in cannabis users. Six of the charas smokers and 3 of the bhang drinkers had uncordial relations with parents as compared with none in control (significant at 0.01, and approaching 0.05, respectively). Ten of the charas smokers and 9 bhang drinkers reported poor social relation with their brothers and sisters as compared with only 4 in the control (approaching 0.05 and N.S. respectively). Marital and sexual
life
General adjustment with wife and children was poor in 4 out of 11 married cases in the charas group and 4 out of 19 married in the bhang group. In the control group 3 out of a group of 23 married were poorly adjusted.
77 TABLE Marital
8 and sexual
adjustment
Marital adjustment Average Poor *Chi square
Charas smokers
Bhang drinkers
Control
Significance Charas
Bhang
Charas
N-11
N-19
N-23
VS.
us.
VS.
control
control
bhang
NS NS
NS NS
NS NS
7 4
15 4
20 3
of difference*
test.
Sexual history Sexual promiscuity was more frequent control group, as shown in Table 9.
TABLE Sexual
in cannabis
users than in the
9 history Charas
Bhang
Charas
VS.
vs.
vs.
N-25
control
control
bhang
2
-
0.05*
N.S.
N.S.
15
5
4
0.01
N.S.
0.01
3
6
2
N.S.
N.S.
N.S.
2
2
-
N.S.
N.S.
N.S.
Bhang drinkers N-25
Control
5
Charas smokers N-25 Homosexual experience Premarital sexual relations Extramarital sexual relations History of venereal disease *Chi
square
test.
Work record Significantly more cases in the cannabis groups had a poor work record. Nine of the charas smokers and 4 of the bhang drinkers, but only 2 in the control group, changed to 3 or more jobs in the last 10 years. Two in the charas group and one in the bhang group were not holding any job at present. Adjustment to the job was poor in 8 of the charas smokers, 7 of the bhang drinkers and only 2 of the control group cases.
78 TABLE
10
Persons’
own assessment
of job satisfaction Charas smokers N-25
Without
job
Poor job satisfaction
Average
job satisfaction
*Chi square
Antisocial
Levels of significance
Control N-25
Bhang drinkers N-25
2
1
8
7
2
15
17
23
*
Charas vs. control 0.05 Bhang vs. control Approach 0.05 Charas vs. Bhang N.S.
test.
behaviour
during drug use
Eleven in the charas group, 5 in the bhang group and 3 in the control group reported serious quarrels involving violence at one time or another. Seven out of these 11 charas smokers, and 4 out of 5 bhang drinkers, were under the influence of cannabis at the time of the quarrel. Three charas smokers, one bhang drinker and one control case quarrelled when they had taken alcohol. One of the charas smokers also served a prison sentence. TABLE
11
Antisocial
behaviour
Involved in violent quarrel Quarrel under effect of cannabis Quarrel under effect of alcohol Quarrel under effect of no drug *Chi square
Charas smokers N-25
Bhang drinkers N-25
Control
11
5
7
4
3
1
1
1
-
2
Charas
Bhang
Charas
VS.
vs.
VS.
N-25
control
control
bhang
3
0.05*
N.S.
App. 0.05
test.
Discussion In the state of Punjab where this study was conducted all forms of cannabis are now legally banned. However, since the wild grown plant is so easily available, there are a number of people who regularly take it. There are also certain social groups where its use is traditional. However, owing to
79
the legal prohibition, it is often difficult to obtain full cooperation of the users. Furthermore, a majority of those using the drug live in isolated groups outside the main stream of society. They are suspicious of the approach of any stranger and hesitant to disclose the information regarding their use of the drug. These factors impose limitations on any scientific study of this subject. The control group presents also a difficult problem. To find a group of individuals who are similar in all other respects but do not take cannabis and are also willing to give detailed personal information, is an exceedingly difficult proposition. Our first effort was to find the relatives of users, but most of the users were living alone in the city and their relatives were often socio-economically better off. We ultimately settled on having a control group which matched in age, sex and socio-economic status. In spite of these shortcomings certain interesting features of heavy cannabis use as it exists in India have emerged. A relatively large proportion of cannabis users complained of poor health as evidenced by reported loss of weight, cough, dyspnoea and poor sleep. Unfortunately X-ray and laboratory investigations could not be included in this study. Anaemia, weight loss, etc. would probably be related to poor nutritional status rather than to the cannabis itself. Similarly, the presence of cough, dyspnoea and chest findings suggests a respiratory pathology ascribable as well to tobacco smoking which was invariably practised by cannabis users. The presence of insomnia in onethird of users is an interesting finding and needs further confirmation. Effects of cannabis on mental health have been hotly debated for over a century now. At one time’during the last century cannabis was regarded as the largest single cause of insanity in lunatic asylums in India and nearly one-third to one-half of the cases of insanity were attributed to this habit. The Indian Hemp Commission in 1893, however, on critical assessment estimated that cannabis was a factor in not more than 7 - 13% of admissions to the asylums [4]. Over the years this controversy is not fully resolved. Dhunjibhoy (1930) working in Ranchi in Eastern India reported ganja psychosis as a fairly common diagnosis [5] _ From the same hospital, as recently as 1972, Varma has reported 1248 cases in a span of ten years, i.e., 3.2% of all admissions [ 61. Similarly Chopra and Smith (1974) from an addiction clinic in Calcutta have reported 200 cases of “psychotic reactions” [ 71. Unfortunately the methodology of these authors leaves much to be desired and one is never very sure if apart from transitory acute intoxications due to excessive dosage, these authors are dealing with a genuine cannabis psychosis or only with victims of other functional psychosis who, in addition, were using cannabis. As has been pointed out by Harding and Knight (1973), patients with functional psychosis who are previously using cannabis often increase their intake during the psychotic phase which causes confusion in symptomatology [ 81. Thacore’s (1972) cases of “Bhang psychosis” from Lucknow, India,
80
seem to be better documented and suggest that a short lasting psychosis with marked anxiety, panic, paranoid ideation and vivid hallucination in a clear state of consciousness may occasionally follow heavy cannabis use [9] . Epidemiological studies on the effect of cannabis use in the general population in India are very few in number. The present study is significant in the sense that in 50 long-term very heavy users of cannabis we did not come across any history of prolonged psychosis except in one case who had transient confusional reaction lasting only a few hours after ingestion of a heavy dose of cannabis. On present state mental examination also we did not find any sign of psychosis except in one case who seemed to be having a schizoid personality. Recently Aggarwal, Sethi and Gupta (1975) from Lucknow, India, have reported no case of cannabis psychosis in a study of 40 heavy users [lo]. However, such retrospective studies do not rule out the existence of such psychosis. Some of the cases who developed psychosis may have left the drug and may not now be available, but even on close questioning we did not come across any case who was known to informants and who had developed psychosis while using cannabis. However, mild mental symptoms like anxiety and depression seemed relatively more common in users. The findings of the present study suggest that cannabis users have a relatively poor record in social adjustment; they had more strained relations with parents and siblings, more frequent job changes and poor work satisfaction. Another unusual finding in this study is the history .of violent acts relatively more frequent in cannabis users. However, there is need for caution in interpreting results. In the absence of a well controlled prospective study it is very difficult to be sure whether cannabis per se produces social disturbances or previously disturbed personalities opt more often for this drug. Acknowledgement We are grateful to Mr. S. K. Verma, Clinical Psychologist, Department of Psychiatry P.G.I. Chandigarh for his advice on statistical analysis. References I. C. Chopra and R. N. Chopra, The use of cannabis drugs in India, U.N. Bull. on Narcotics, 9 (1957) 4. B. Kuppuswamy, Manual: Socio-economic Status Scale (Urban), Mansayan, Delhi, 1962. World Health Organisation, The use of cannabis, Tech. Rept. Series No. 478, Scientific Group, Geneva, 1971. Marihuana, Indian Hemp Drugs Commission, Rept. 1893 - 1894. Introduction by J. Kaplan, Silver Spring, Maryland, Jefferson Puhl. Co., 1969. J. E. Dhunjibhoy, A brief resume of the types of insanity met in India, with a full description of Indian hemp insanity peculiar to the country. Mental Sci., 76 (1930) 254. L. P. Varma, Cannabis psychosis, Indian J. Psychiat., 14 (1972) 241.
81 7 G. S. Chopra and J. W. Smith, Psychotic reactions following cannabis use in East India, Arch. Gen. Psychiat., 30 (1974) 24. 8 T. Harding and F. Knight, Marihuana-modified mania, Arch. Gen. Psychiat., 29 (1973) 635. 9 V. R. Thacore, Bhang psychosis, Brit. J. Psychiat., 123 (1973) 225. 10 A. K. Aggarwal, B. B. Sethi and S. C. Gupta, Physical and cognitive effects; of chronic bhang (cannabis) intake, Indian J. Psychiat., 17 (1975) 1.
