Many people with the serious mental illness schizophrenia smoke cannabis but it is not known why people do so or the effects of smoking cannabis. It is unclear what the best methods are that help people to reduce or stop smoking cannabis. Cannabis is the most consumed illicit drug in the world – amounting to 120 to 224 million users. Cannabis, which is usually smoked or eaten, gives a feeling of well-being, but in high doses it may also cause mental illness or psychosis. Clinical evidence suggests people who have schizophrenia have a worse overall outcome from using cannabis, however, there are some people with schizophrenia who claim that using cannabis helps their symptoms and reduces the side effects of antipsychotic medication. This review aims to look at the effects of cannabis, both its use and withdrawal, in people who have schizophrenia. A search for trials was conducted in 2013, eight randomised trials, involving 530 participants were included. Five trials investigated the effects of using a specific psychotherapy aimed at reducing cannabis intake, two investigated the effects of antipsychotic medication for cannabis reduction and one investigated the use of cannbidiol (a compound found in cannabis) as a treatment for the symptoms of schizophrenia.
The results of the review are limited as trial sizes were small and data were poorly reported.
Overall, there is currently no evidence for any intervention, whether it is psychological therapy or medication, being better than standard treatment or each other in reducing or stopping the use of cannabis. More research is needed to explore the benefits of medication or psychological therapy for those with schizophrenia who use cannabis. It is unclear if cannabidiol has an antipsychotic effect.
Ben Gray, Service User Expert, Rethink Mental Illness.
Results are limited and inconclusive due to the small number and size of randomised controlled trials available and quality of data reporting within these trials. More research is needed to a) explore the effects of adjunct psychological therapy that is specifically about cannabis and psychosis as currently there is no evidence for any novel intervention being better than standard treatment,for those that use cannabis and have schizophrenia b) decide the most effective drug treatment in treating those that use cannabis and have schizophrenia, and c) assess the effectiveness of cannabidiol in treating schizophrenia. Currently evidence is insufficient to show cannabidiol has an antipsychotic effect.
Schizophrenia is a mental illness causing disordered beliefs, ideas and sensations. Many people with schizophrenia smoke cannabis, and it is unclear why a large proportion do so and if the effects are harmful or beneficial. It is also unclear what the best method is to allow people with schizophrenia to alter their cannabis intake.
To assess the effects of specific psychological treatments for cannabis reduction in people with schizophrenia.
To assess the effects of antipsychotics for cannabis reduction in people with schizophrenia.
To assess the effects of cannabinoids (cannabis related chemical compounds derived from cannabis or manufactured) for symptom reduction in people with schizophrenia.
We searched the Cochrane Schizophrenia Group Trials Register, 12 August 2013, which is based on regular searches of BIOSIS, CINAHL, EMBASE, MEDLINE, PUBMED and PsycINFO.
We searched all references of articles selected for inclusion for further relevant trials. We contacted the first author of included studies for unpublished trials or data.
We included all randomised controlled trials involving cannabinoids and schizophrenia/schizophrenia-like illnesses, which assessed:
1) treatments to reduce cannabis use in people with schizophrenia;
2) the effects of cannabinoids on people with schizophrenia.
We independently inspected citations, selected papers and then re-inspected the studies if there were discrepancies, and extracted data. For dichotomous data we calculated risk ratios (RR) and for continuous data, we calculated mean differences (MD), both with 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. We excluded data if loss to follow-up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence.
We identified eight randomised trials, involving 530 participants, which met our selection criteria.
For the cannabis reduction studies no one treatment showed superiority for reduction in cannabis use. Overall, data were poorly reported for many outcomes of interest. Our main outcomes of interest were medium-term data for cannabis use, global state, mental state, global functioning, adverse events, leaving the study early and satisfaction with treatment.
1. Reduction in cannabis use: adjunct psychological therapies (specifically about cannabis and psychosis) versus treatment as usual
Results from one small study showed people receiving adjunct psychological therapies specifically about cannabis and psychosis were no more likely to reduce their intake than those receiving treatment as usual (n = 54, 1 RCT, MD -0.10, 95% CI -2.44 to 2.24, moderate quality evidence). Results for other main outcomes at medium term were also equivocal. No difference in mental state measured on the PANSS positive were observed between groups (n = 62, 1 RCT, MD -0.30 95% CI -2.55 to 1.95, moderate quality evidence). Nor for the outcome of general functioning measured using the World Health Organization Quality of Life BREF (n = 49, 1 RCT, MD 0.90 95% CI -1.15 to 2.95, moderate quality evidence). No data were reported for the other main outcomes of interest
2. Reduction in cannabis use: adjunct psychological therapy (specifically about cannabis and psychosis) versus adjunct non-specific psychoeducation
One study compared specific psychological therapy aimed at cannabis reduction with general psychological therapy. At three-month follow-up, the use of cannabis in the previous four weeks was similar between treatment groups (n = 47, 1 RCT, RR 1.04 95% CI 0.62 to 1.74, moderate quality evidence). Again, at a medium-term follow-up, the average mental state scores from the Brief Pscychiatric Rating Scale-Expanded were similar between groups (n = 47, 1 RCT, MD 3.60 95% CI - 5.61 to 12.81, moderate quality evidence). No data were reported for the other main outcomes of interest: global state, general functioning, adverse events, leaving the study early and satisfaction with treatment.
3. Reduction in cannabis use: antipsychotic versus antipsychotic
In a small trial comparing effectiveness of olanzapine versus risperidone for cannabis reduction, there was no difference between groups at medium-term follow-up (n = 16, 1 RCT, RR 1.80 95% CI 0.52 to 6.22, moderate quality evidence). The number of participants leaving the study early at medium term was also similar (n = 28, 1 RCT, RR 0.50 95% CI 0.19 to 1.29, moderate quality evidence). Mental state data were reported, however they were reported within the short term and no difference was observed. No data were reported for global state, general functioning, and satisfaction with treatment.
With regards to adverse effects data, no study reported medium-term data. Short-term data were presented but overall, no real differences between treatment groups were observed for adverse effects.
4. Cannabinoid as treatment: cannabidiol versus amisulpride
Again, no data were reported for any of the main outcomes of interest at medium term. There were short-term data reported for mental state using the BPRS and PANSS, no overall differences in mental state were observed between treatment groups.