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Cases of Cannabis-Induced Psychosis Rise. Lawmakers Want to Add Mental Health Warnings to Pot Products

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An older woman with white skin and white-blond hair cut in a pageboy sits at her dining room table. She's wearing a pink shirt and tortoise-shell glasses. The table is made of polished wood and has a flower arrangement of pink and white flowers on a table runner. Her chair has a high back of carved wood with pink upholstery.
Elizabeth Kirkaldie sits at the dining room table in her home in Napa on June 6, 2022. (Beth LaBerge/KQED)

Elizabeth Kirkaldie’s grandson was at the top of his class in high school and a talented jazz bassist when he started smoking pot. The more serious he got about music, the more serious he got about pot.

And the more serious he got about pot, the more he became paranoid, even psychotic. He started hearing voices.

“They were going to kill him and there were people coming to eat his brain. Weird, weird stuff,” Kirkaldie says. “I woke up one morning and no Kory anywhere. Well, it turns out, he'd been running down Villa Lane here totally naked.” 

Kory came to live with his grandmother for a couple years in Napa. She thought maybe she could help. Now, she says that was naïve. 

Kory was diagnosed with schizophrenia. Kirkaldie blames the pot.

“The drug use activated the psychosis, is what I really think,” she says.

Indeed, research confirms people who use cannabis are four times more likely to develop chronic psychosis, or schizophrenia, compared to people who don’t. For people who smoke every day or use higher potency products, the risk is up to six times higher. One study found eliminating marijuana use in adolescents would reduce global rates of schizophrenia by 10%.

Doctors and lawmakers in California want cannabis producers to warn consumers of this and other health risks on their package labels and in advertising, similar to requirements for cigarettes. They also want sellers to distribute health brochures to first-time customers outlining the risks cannabis poses to youth, drivers and those who are pregnant, especially for pot that has high concentrations of THC.

“Today's turbocharged products are turbocharging the harms associated with cannabis,” says Dr. Lynn Silver with the Public Health Institute, a nonprofit sponsoring the proposed labeling legislation, SB 1097, the Cannabis Right to Know Act. 

Californians voted to legalize pot in 2016. Three years later, emergency room visits for cannabis-induced psychosis went up 54% across the state, from 682 visits to 1,053, according to state hospital data. For people who already have a psychotic disorder, cannabis can make things worse: It leads to more ER visits, more hospitalizations, and more legal troubles, says Dr. Deepak Cyril D’Souza, a psychiatry professor at Yale University School of Medicine, who also serves on the physicians’ advisory board for Connecticut's medical marijuana program.

But D’Souza faces great difficulty convincing his patients of the dangers, especially as 19 states have legalized recreational marijuana.

“Both my patients with schizophrenia, and also adolescents, hear very conflicting messages that it's legal — [that] in fact, there may be medical uses for it,” he says. “If there are medical uses, how can we say there's anything wrong with it?”

A rectangular wooden frame holds three images of children. Two are blurred and the third shows Kory as a young boy in a denim shirt with a mop of dark hair, black eyes, and a happy smile.
Elizabeth Kirkaldie holds a photo of Kory as a child at her home in Napa on June 6, 2022. (Beth LaBerge/KQED)

Legalization is not the problem, he says, but rather the commercialization of cannabis — the heavy marketing, which can be geared toward attracting young people to become customers for life — and the increase in THC from 4% on average up to 20%-35% in today’s varieties.

Limiting the amount of THC in pot products and including health warnings on the labels could help reduce the health harms associated with cannabis use, D’Souza says, the same way they worked for cigarettes. He credits warning labels, education campaigns and marketing restrictions for the sharp drop in smoking rates among kids and teens in the last decade. 

“We know how to message them,” D’Souza says. “But I don’t think we have the will or the resources, as yet.”

Some states, including Colorado, Oregon and New York, have dabbled with cannabis warning label requirements. California’s proposed legislation suggests language for 10 distinct warnings, including:

Three suggested warning labels in black lettering on a bright yellow background read: WARNING: Cannabis use may contribute to mental health problems, including psychotic disorders such as schizophrenia. Risk is greatest for frequent users and when using products with high THC levels. WARNING: Not for Kids or Teens! Starting cannabis use young or using frequently may lead to problem use and, according to the U.S. Surgeon General, may harm the developing brain. WARNING: Do not use if pregnant or breastfeeding. Substances in cannabis are transferred from the mother to the child and may harm your baby’s health, including causing low birth weight.
California’s proposed rules are modeled after comprehensive protocols established in Canada: rotating health warnings would have to be set against a bright yellow background, use black 12-point font, and take up a third of the front of the package. (Image by Matthew Green/KQED)

Opponents of the proposed warning labels say the requirements are excessive and expensive, especially since marketing to children is already prohibited in California and people must be 21 to buy. 

“This bill is really duplicative and puts unnecessary burdens on the legal cannabis industry, as we already have incredibly restrictive packaging and advertising requirements,” says Lindsay Robinson, executive director of the California Cannabis Industry Association, which represents legal pot businesses.

The state should focus more on combatting the illicit pot market, rather than further regulating the legal one, she says. Legal dispensaries are already struggling to keep up with existing rules and taxes: The state’s 1,500 licensed pot retailers generated $1.3 billion in state tax revenue last year. Adding more requirements just makes it harder for them to compete with the illicit market, she says, and more likely to go out of business.

“The only real option if they fail out of the legal system is to shutter their businesses altogether or to operate underground. And I don't think the state of California, with the tax revenue, wants either of those to happen,” she says. “The heart of the issue is that there's a massive, unregulated market in the state.” 

Some people, even parents like Elizabeth Kirkaldie, are skeptical the labels will work. Her grandson, Kory, is stable now, living with his dad. But she’s not sure a yellow warning would’ve stopped him when he was a teen. 

“They’re just not going to pay attention,” she says. “But if it helps even one person? Great.”

Scientists still do not know what causes schizophrenia, but they believe multiple factors are at play, including genetics, family history, trauma and other influences in a person’s environment, like smoking pot. Some scientists believe having schizophrenia itself is what predisposes people to smoking pot. While it’s difficult to prove a direct causal link between cannabis use and schizophrenia, the associations are strong enough to warrant action, says D’Souza — and importantly, pot use is one of the only risk factors people can control.

“Not everyone who smoked cigarettes developed lung cancer, and not everyone who has lung cancer smoked cigarettes,” he says. “But I think we would all agree that one of the most preventable causes of lung cancer is cigarette smoking.”

Applying the same health education strategies to cannabis that were used for tobacco, he says, is long overdue.

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