America’s ongoing marijuana-legalization experiment will have many consequences. That goes especially for the seriously mentally ill, a sliver of the adult population but overrepresented among the ranks of compulsive pot users. Treating schizophrenia and bipolar disorder is never easy; even when treatment is available, the seriously mentally ill often fail to comply. A schizophrenic who spends most of his days in a dark room smoking weed is not a clinically promising case.
Modern mental-health systems are community-based and thus shaped by community norms. Decades ago, clouds of pot smoke were not often encountered on city streets. Now that they’re ubiquitous, a seriously mentally ill individual may be inclined to wonder what’s so objectionable about an activity that normal Americans do daily, in public and even during working hours.
The issue is only partly whether pot causes mental illness. A large body of research studies, involving tens of thousands of people, has suggested, with impressive replicability, that heavy cannabis use increases the risk of developing mental illness. Legalization proponents reject this, contending that, while the rate of marijuana consumption has soared over recent decades, the rate of serious mental illness seems to have stayed flat.
But this debate has eclipsed interest in the effect of continued cannabis use on those already mentally ill. What can be done about that? For scores of clinicians and families of the mentally ill across the nation, it’s the more pressing question.
In recent years, countless family memoirs and nonfiction accounts of mental illness have extensively chronicled the descent into madness. This literature often highlights marijuana more than any other intoxicating substance. Pot plays a notable role in several recent book-length treatments of mental illness, including Randye Kaye’s Ben Behind His Voices (2011), Patrick and Henry Cockburn’s Henry’s Demons (2011), Paul Gionfriddo’s Losing Tim (2014), Mindy Greiling’s Fix What You Can (2020), Miriam Feldman’s He Came in With It (2020), Meg Kissinger’s While You Were Out (2023), and Jonathan Rosen’s The Best Minds (2023).
Mentally ill Jordan Neely, who died on a New York subway train in 2023, after he menaced passengers and Daniel Penny subdued him with a chokehold, had a troubled upbringing, including the loss of his mother in a brutal murder. But what appeared to trigger his schizophrenia—and his shift from genial Michael Jackson impersonator to one of New York’s most troubled subway vagrants—was his use of K2, a synthetic cannabinoid. As Neely’s street-performer mentor explained to New York, “He always smoked a little weed, a little regular weed. . . . But someone gave him that K2 stuff—that’s what fucked him.” (The drug was found in Neely’s system after his death.)
Various theories exist about the relation between cannabis use and mental illness. No one disputes that marijuana can trigger psychotic episodes. It is not the only substance that can do this—other examples include steroids, Adderall, and cocaine. But researchers have found that the conversion rate from an acute psychotic episode to chronic schizophrenia is higher for users of cannabis than for any other substance. Old-school legalization proponents, like poet Allen Ginsberg, theorized that bad weed trips were not caused by the drug itself so much as fear of arrest; it was merely a question of the social setting in which the usage transpired. Legalization has put paid to that theory. Communities that have legalized have seen an increase in cannabis-related hospitalizations. Still, legalizers emphasize that, broadly speaking, acute psychosis is different from chronic psychosis and that for most problem users, marijuana’s mentally destabilizing effects will be self-limiting. A more rational adult, after he experiences a pot-induced psychotic episode so intense that he winds up hospitalized, will avoid ever doing that again. But risk/reward processing doesn’t happen so smoothly for people with disorganized minds.
Some argue that the relation boils down to correlation: serious mental illness develops around the same time that people are apt to use pot compulsively. Another standard theory maintains that cannabis triggers serious mental illness in someone genetically predisposed to it earlier than it would have otherwise developed. If true, that’s bad news: the earlier the onset of serious mental illness, the worse the prognosis. Still another hypothesis holds that the historically potent cannabis strains now on the market are more capable of causing mental illness—and induce a different kind of mental illness—than those varieties that develop more organically. The course of schizophrenia and its treatment-responsiveness varies tremendously among patients.
“The mentally ill often take cannabis for familiar reasons: social appeal, pleasure, and to enhance a life deficient in meaningful engagement.”
These questions might never be settled. But one uncontestable point is that, for hundreds of thousands of seriously mentally ill Americans, problem pot use often continues long after their first psychotic break. The federal government estimates that nearly half of all adults with serious mental illness use marijuana, a rate almost three times that of the non-mentally ill population. The seriously mentally ill’s rate of marijuana-use disorder (a clinical definition derived from the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is more than five times that of the non-mentally ill population.
Drug addiction is one of the many “bad outcomes” of serious mental illness. Just as they are overrepresented among the incarcerated and homeless populations, the seriously mentally ill make up a disproportionate share of America’s problem drug users. Of the 3.6 million seriously mentally ill Americans with a marijuana-use disorder, 980,000 meet the DSM standard of a “severe” disorder—a number exceeding the U.S. homeless population (770,000) and more than twice the sum of kids in foster care (370,000).
A psychiatric diagnosis is a cluster of symptoms, some reported directly by the individual experiencing them, and others observed by his or her clinician. We can speak of how an underlying condition “presents” with psychotic behavior, but we have no direct access to the biological substratum of genes and brain circuitry in which that condition is believed to be rooted. Symptoms are the locus of treatment. We apply psychiatric medications not to cure someone’s schizophrenia but to make him less “symptomatic.”
Clinicians tasked with treating co-occurring serious mental illness and cannabis-use disorder face a catch-22: you can’t treat the addiction without first treating the serious mental illness; but you can’t treat the serious mental illness without getting the addiction under control. We have no medication-assisted treatment (like methadone for heroin) for marijuana addiction. Yes, therapy can certainly benefit the seriously mentally ill. But, for therapy to take, medication typically must come first—to tamp down the symptoms and ensure a basic level of awareness of one’s mental illness. In her 1992 memoir, A Brilliant Madness, actress Patty Duke, who was bipolar, wrote: “Before taking lithium, trying to participate in therapy was like trying to fly a jet without ever having been on a plane.” Mentally ill adults who regularly use pot (and other drugs) tend to be less compliant with their psychiatric medicine, and more likely to relapse—and to do so more severely, thus requiring longer hospitalizations than nonusers.
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“Self-medication”—turning to pot to alleviate symptoms of psychological distress, without medical advice—is commonly invoked to explain why the seriously mentally ill use cannabis and other substances at such high rates. This theory is overrated. In the academic literature on violence, scholars take pains to distinguish violent crimes committed by the mentally ill from violent crimes motivated by mental illness. Such distinctions are less commonly encountered in the substance-abuse research, in which scholars presume that someone with a mental disorder who is addicted to or just using intoxicating substances does so as a substitute for psychiatric treatment.
This assumption presumes that mentally ill drug users, like other sick people, want treatment but face tragic obstacles and therefore rely on intoxicants as jerry-rigged antipsychotics. In reality, many people with mental illness don’t accept their diagnosis and aren’t pursuing treatment. The mentally ill often take cannabis, and other drugs, for the same reasons that people without mental illness take them: the social appeal, the pleasure of getting high, and to enhance a life otherwise deficient in meaningful engagement. As Leo Tolstoy argued in an 1890 essay, men “stupefy themselves” with intoxicants so as to “stifle the voice of conscience.”
Some of the seriously mentally ill may smoke pot to bury themselves in oblivion, like the depressive alcoholic on a bender. Such sad cases could be said to be self-medicating, though not necessarily self-medicating their psychoses. Many people with schizophrenia or bipolar disorder also have co-occurring mental-health conditions and may turn to drugs to ease a general sense of distress. In these situations, the goal should be to find healthier alternatives that don’t interfere with the treatment of psychosis, as marijuana does.
Cannabis use increases the seriously mentally ill’s risk of violence. The academic literature on the subject is somewhat disorienting, as mental-health advocates play up drugs’ role in causing violence to minimize the “stigma” associated with mental illness, whereas drug advocates play up mental illness’s role to minimize the “stigma” associated with using drugs. Both groups of advocates are half-right: mentally ill marijuana consumers are more violent than both non-mentally ill users and mentally ill individuals who don’t use.
In 1936, antidrug advocates produced Reefer Madness, a film that, in exaggerated fashion, suggests a seamless link between marijuana, psychosis, and violence. Contrary to filmmakers’ expectations, Reefer Madness contributed to widespread belief in pot’s harmlessness; viewing parties were long a staple ritual of stoner culture. When the film was released, the seriously mentally ill were mostly confined to asylums. Today’s community-oriented mental-health systems benefit the more functional Americans with mental disorders, for whom long-term confinement would be overkill. But the seriously mentally ill face risks in the community that they did not confront in state hospitals. One is cannabis use. Whether the dream of community mental health can become reality will depend in part on whether we can dissuade seriously mentally ill Americans from using the drug.
Proponents of the community-based system want the lives of the seriously mentally ill to approximate the lives of normal adults as closely as possible. Hallmarks of a normal adult life include a consistent routine, the management of daily living tasks, steady work, and nontoxic relationships with family and community members. Long ago, state mental-health agencies devoted virtually their entire budgets to mental institutions. Nowadays, most of that funding goes to outpatient services. Examples of community mental-health programs include supportive housing, assertive community treatment, supported employment, clinics, diversion services for the hundreds of thousands of the mentally ill entangled in the criminal-justice system, and first-episode-psychosis interventions. The goal of treatment is to control symptoms, and the goal of community mental-health policy is to reduce barriers to care. Those goals too often go unmet. The federal government estimates that close to one-third of seriously mentally ill adults get no treatment.
Legalization normalizes pot use, creating barriers to treatment for mentally ill users whose symptoms worsen with cannabis. Some analyses have linked legalization to chronic homelessness, though typical West Coast encampments are more often dominated by hard drugs like fentanyl and meth than pot. The more important effect of legalization, as a social phenomenon, is on middle-class norms. Normalization is economically essential for the nascent legal industry, whose marketing efforts work to “reduce the stigma around cannabis.” Insight—acceptance that you have a problem—is often considered the first and most essential step to take in overcoming an addiction or a serious mental illness. Thus, with the “dually diagnosed,” clinicians and family members face twice the challenge, often contending with double the denial. Convincing people that they have a drug problem becomes even harder when their addictive habit looks like the behavior of middle-class adults with stable jobs.
Rules should not be made from exceptions. Drug legalization is a broad policy question that affects the whole population, not just the seriously mentally ill. But the impact of legalization on the seriously mentally ill has not received the attention from policymakers that it merits. When everyone was prohibited from using cannabis, we didn’t have to worry about creating custom-tailored rules for the mentally ill. Targeted prohibition is made still harder to execute because of the imperative to treat mental illness in a community-based setting.
The easiest way to craft special rules for the mentally ill in the community is through court-ordered supervision, such as assisted outpatient treatment, mental-health-court programs, or conservatorship. The number of those currently participating in these programs, however, is small relative to the size of the mentally ill population. Expanding these initiatives would let policymakers exert greater control over the pot–mental illness nexus. Special legal arrangements are often seen as a temporary reaction to a crisis, not a long-term remedy. But psychosis and drug abuse are chronic conditions. Relapse is always a concern, and taking a “prevention” approach to it means maintaining legal restrictions, even in noncrisis circumstances.
“Convincing people that they have a drug problem becomes harder when their habit looks like the behavior of middle-class adults with stable jobs.”
Perhaps taxation could play a role here, too: in recent decades, it has helped bring down rates of tobacco consumption among the seriously mentally ill, though their rates remain much higher than those of the general population. We could try pricing legal cannabis out of the seriously mentally ill’s reach (they are generally poor), but cannabis retailers already believe that the industry is too regulated and that those rules, driving up the cost of legal pot, help a still-thriving black market retain market share. The same dilemma applies with potency restrictions, which could also theoretically benefit the seriously mentally ill. Some legalizers perform a rhetorical two-step in this context, first claiming that we need to legalize, so that government can control the product and market, only to claim, post-legalization, that government control is counterproductive. Legalization has thus far presented the worst of both worlds: normalization and a robust illegal market.
Full legalization may stall. We may never reach a point where public consumption is as common at Alabama church barbecues as it is across Manhattan. But while the question remains live, public education is vital. A key message should be that having a serious mental illness is like having a peanut allergy for pot. Anyone from a family with a known history of mental illness should be encouraged to avoid pot until at least their late twenties, after the typical onset period for serious mental illness has passed.
The messenger matters, too. Clinicians working with the seriously mentally ill have credibility on this issue and understand the difficulty of stabilizing a mentally ill person who uses drugs regularly. If a clinician feels disheartened when a pot dispensary opens near his office, he should speak up. Many don’t; mental-health professionals move in left-wing circles, where prohibitionist sentiments are verboten. Such peer pressure is also at work in mental-health advocacy organizations, which—if they prioritize serious mental illness at all (most don’t)—aren’t seriously concerned about marijuana’s harm to their purported constituents; they’re too worried about what their progressive friends will think about them.
Public mental-health agencies have been missing in action. Strategic plans to address the “mental-health crisis” are no more likely to mention reducing pot use today than would an asylum-management guidebook from the 1930s. No mental-health policy plan should be considered complete without some provision about trying to keep schizophrenics and bipolar people off weed. Again, mental-health policymakers have one job: clearing barriers to treatment. Mental-health agencies that are not working to reduce pot use—a treatment barrier faced by half the seriously mentally ill population—aren’t taking their responsibilities seriously.
Top Photo: Studies reveal that pot use worsens the symptoms of serious mental illness. (David Carson/St. Louis Post-Dispatch/AP Photo)
Mental-health policy should include efforts to keep the mentally ill off weed. Read More
