Cannabis and psychosis

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Moira G Sim, MBBS CWA), FRACGP, FACbAM, is Senior Medical Officer, the Drug and Alcohol Office of Westem. Australia, Adjunct senior Clinical Lecturer, ...
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Cannabis and psychosis Moira G Sim, MBBS CWA), FRACGP, FACbAM, is Senior Medical Officer, the Drug and Alcohol Office of Westem Australia, Adjunct senior Clinical Lecturer, School of Psychiatry and Clinical Neurosciences, the University of Western Australia, Associate Professor, Edith Cowan University, and a general practitioner, Yokine, Western Australia. Eric Khong, MBBS CWA), GradDipPHC, I'RACGP, is Medical Officer, Drug and Alcohol Office, Adjunct Clinical Lecturer, School of Psychiatry and Clinical Neurosciences, the University of Western Australia, and a general practitioner, Edgewater and Duncraig, Western Australia. Gary Hulse. BBSc, PhD, is Associate Professor and Head, Unit for Research and Education in Drugs and Alcohol, School of Psychiatry and Clinical Neurosciences, the University of Western Australia.

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Confidentiality This is the first article in :1 series of casc files from general pr~lctice exploring treatmenl i~~lIe~ around suhslance use commonJy encountered gcncr~ll pr:telice prescntations.

Case history - Dan

General practitioners need to balance the competing needs of confidentiality and keeping the family on-side. At some point, it is important to see Dan by himself, but you will need to make a clinical decision as to whether this needs to happen at the first appointment or later. At the first consultation it is essential to set up some ground rules about your interaction with the family, This will help manage your dual responsibility without gelling caught in any family conflict. Dan is your patient and you have a relationship with him that is separate from that with his parents. As the family GP, you will almost certainly have to manage the parents' con-

Dan. 20 ~Tars of age, Was rlTl'ntly disCh:lrgl.'lI following" month in (he local ho,"pi!:J1 psydli;urk waft! afler prtsl'nt· ing to lhe

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BACKGROUND Cannabis use is commonly identified in people who present with psychosis. OBJECTIVE This case study aims to provide a practical approach for general practitioners seeing patients with comorbid cannabis and mental health concerns. DISCUSSION Cannabis related comorbidity is commonly seen in general practice. General practitioners can manage most presentations and help to reduce the likely occurrence of cannabis induced psychosis through the use of psychosocial support. brief interventions and harm minimisation.

D;m sl11ukl's :l paCKl'l of !o\)an:o a \\'cl'k. Sll1okl' Glllnahb ;IS it hdps relax. I il" drinks alcohol only on wl't:kl'mb. His parcnts :lrc awarl' of his sllhst:ll1n: lISl' and li:ar Ill" may mo\"l' 011 10 ·ht::l\"kr drugs' such :I:'> lwroin. Dan·s hcalth has always beell good apart from mild asthma. lll' has jll:'>! mO\Td out of IJolllt· ami startt:u an apprellticeship in

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cerns and any requests for information. However, Dan's agreement needs to be sought before any information is discussed with his parents. The initial ground rules will help manage these requests.

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What is achievable at the frrst appointment?

Addressing Dan's concerns

The most important outcome of the first appointment is to undertake a risk assessment of Dan and to have the patient - and his parents - leave the consultation feeling you have listened to their immediate concerns and that you have a plan for dealing with the problem.

Ask Dan what has happened from his point of view and elicit his concerns. For Dan, the concern is likely to be the recurrence of the 'psychotic' episode. Assess his level of distress and risk of suicide, self harm and harm to others. Arranging a follow up appointment will give you time to seek information about his psychiatric admission. Remember, that

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Australian Family Physician vo!. 33, No. 4, April 2004 • 229

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CUnlcal practice, Cannabis and psychosis

even specialist agencies with more resources

cause a toxic psychosis ('cannabis psy-

often require several appointments to fully

chosis') and that cannabis use can

assess the situation.

exacerbate existing psychosis....' Before addressing Dan's question you provide him with this factual information. Then, in addressing his question, you need to consider the common differential diagnoses that might account for his psychotic episode. These are: • 'cannabis psychosis' • psychosis/schizophrenia • other drug use, and • other psychiatric and physical disorders. You already know some details about Dan such as his age, but you also need to know about his: • premorbid personality, ego social relationships, mood, school performance • history of drug use, ego amphetamines, solvents • HEADSS (Table 11 • presence of current and past symptoms, and • family psychiatric and medical history.

Addressing the parents' concerns A major concem for Dan's parents is likely to be their son's psychiatric prognosis and his use of illicit drugs. Common emotions experienced by parents include distress, stigma, shame and guilt,' and these need to be acknowledged.

Dan

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Cannabis is the most commonly used illicit psychoactive drug in Australia' (Figure 11. There is good evidence to show that both acute and chronic use are related to physical and psychiatric harm.' Although a clear causal link has not been established, there is consensus that high doses of cannabis can

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