"Dear Mr. Cowan -

Regarding the BMJ's author's "psychotic reaction" to "1" incident of trying cannabis; I am a "mental health professional". (After the laughter dies) (Ed. note: His comment, not mine.)

I work on the "front line" of a large, urban mental health center and everyday I am face to face with a kaleidoscope of mental illnesses and drug use. I get to know very well people with family histories of "psychotic illnesses not otherwise specified". Many of those folks experience psychotic episodes following their pot smoking. National figures (if accurately tracked) would show that a small percentage of people experience this as a response of their underlying illness to cannabis, and also that the bulk of cannabis use throughout the whole population, does not have this experience.

I figure you already know this. Thanks for the news!

M. Ed.

Atlanta Georgia USA"

Yes, and thanks for the letter.

It really should not be surprising that some people with mental problems would "experience psychotic episodes following their pot smoking." Cannabis is a "mind-altering" drug that changes perception. This is what makes it of value to many of its users. However, if a person has a tenuous grasp on reality or is emotionally unstable, this can be frightening and might very well trigger a "psychotic episode."

One of the problems with dealing with the real risks in marijuana use is that they often get lost in the reefer madness that so exaggerates the risks that it is difficult to get around to making a constructive contribution to understanding the effects of cannabis, good and/or bad.

We can never even know if the marijuana use was cause or effect of a given problem. It is obviously not ethically possible to explore the impact of cannabis on the mentally ill in a controlled, double blind test of the sort so beloved of "science." However, over the years I have been involved in this issue I have also had a number of people tell me how they used cannabis to deal with very serious mental and emotional illnesses. It is quite moving to have someone say, "I have not tried to kill myself since I started using marijuana."

Now, with the clear understanding that I am not saying that marijuana could be of benefit to everyone with mental or emotional problems, and it may in fact be harmful to some of them, I would like to briefly explore the matter.

The late Drs. Timothy Leary and Norman Zinburg developed the concept that "set and setting" – the state of mind and the environment – of the drug user greatly influence the drug experience. Marijuana would certainly be no exception to this. Also, consider that people who are mentally ill or emotionally unstable would be even more influenced by their "set and setting" than someone who is "stable."

Moreover, the "set and setting" for the mentally ill in America can be very frightening. People who are mentally ill are given pharmaceuticals, which often have very unpleasant side-effects, and then they are left to live in unpleasant environments. It is hardly surprising that under these circumstances that they would try to "self-medicate" with alcohol, tobacco and a variety of illicit drugs. Tobacco may actually help them, but most of the rest are counterproductive. But what about cannabis?

Taken in small doses, cannabis is a very safe sedative for most people, probably including some people with mental illness. But consider the "set and setting" of marijuana under marijuana prohibition. Obviously, it is difficult in California and impossible elsewhere in the world -- with the partial exception of Holland, another topic – for a doctor even to discuss the medical use of cannabis with anyone who is mentally ill. Patients may even be told that marijuana is a very dangerous drug. They will certainly be arrested and placed under even greater stress if caught using it. However, what if they use it, and find that it helps them? Is this good? Remember we are talking about someone who is mentally ill finding out that something that is anathematized actually helps them. That sort of thing could drive you crazy.

The point is that while some of the psychotic episodes associated with marijuana use may be caused by the marijuana and others may simply be correlated to failed self-medication, it is also worth considering that the set and setting of marijuana prohibition help create these conditions. This is not just a political argument against marijuana prohibition. I would be against marijuana prohibition, even if marijuana use is a genuine risk factor to this vulnerable segment of the population.

Rather, my point is that the prohibitionist propaganda that has become so much a part the practice of some segments of the mental health professions – and especially those involved in treating "drug abuse" – may be counterproductive. In short, some of the marijuana related psychotic episodes might actually be iatrogenic – caused by the medical profession. I would urge that mental health professionals not addicted to reefer madness consider this possibility. It might help them in counseling some of their patients, but it certainly won’t help their careers.