Community-initiated research: a study of psychiatrists' conceptualisations of 'cannabis psychosis'

Concern among black and ethnic minorities with current research in 'transcultural psychiatry' entails future work taking into account their collaboration to minimise the possibility that it is prejudicial to their interests. An instance is given of a project initiated by black community groups which looks at psychiatric conceptualisations of a diagnosis commonly used locally in inner-city Birmingham: cannabis psychosis. Responsibility remains with the researcher.


Community-initiated research: a study of psychiatrists' conceptualisations of 'cannabis psychosis'
ROLANDLITTLEWOOD, Senior Lecturer in Psychiatry and Anthropology, University College London (formerly Senior Lecturer, Birmingham University) Concern among black and ethnic minorities with current research in 'transcultural psychiatry' entails future work taking into account their collaboration to minimise the possibility that it is prejudicial to their interests. An instance is given of a project initiated by black community groups which looks at psychiatric conceptualisations of a diagnosis commonly used locally in inner-city Birmingham: cannabis psychosis. Responsibility remains with the researcher.

The study
Black and ethnic minority groups in Britain have provided the opportunity for much psychiatric research in the area of what has become generally known as 'transcultural psychiatry'. Over 80 papers and four books have been published which have focused largely on epidemiology and on differences in the psychiatric phenomenology of patients from these groups as contrasted with the white Britishborn population. Little attention has been paid to service provision, or to minority patients' percep tions of mental illness and the available facilities. The theoretical perspectives chosen have usually ignored social context whilst placing particular emphasis on 'race' or 'culture' as the independent variable requiring further (but unspecified) elucidation.1 Over the last few years, a number of minority groups have called attention to this focus on differen tial pathology and to the lack of interest in those cultural factors which might contribute to lower rates of illness, such as the relative infrequency of alcohol related admissions among the Afro-Caribbean population. It has been suggested that the medical categories used in this area are less free of political context than elsewhere.2-3 Similar points have been made in the United States where, unlike Britain, they have long been accepted as an appropri ate area for research.4 Some writers have called for a moratorium on all psychiatric research focused on minority groups, or at least for an assurance that it should involve their participation, and that it should be aimed at improving services rather than attempting to answer questions of purely academic interest. Thus, a policy document prepared by a Birmingham-based group which links mental health workers including psychiatrists, with lay members of local black and other minority groups, emphasises that research should involve such groups who might wish to initiate projects of their own: academics could either advise, offer technical assistance or carry out the project.5 The focus of minority groups in the area of research is likely to be very different from the conventional themes of transcultural psychiatry. In 1986 I discussed possible research needs with the Birmingham Community Relations Council, mem bers of the Wolverhampton Rastafarian Progressive Association, a number of West Indian churches and voluntary groups, and with colleagues in the For ward Planning Group. A matter of considerable con cern was the relationship between cannabis (ganja) use and psychiatric admission in the Afro-Caribbean community. Whilst some in the community did feel that cannabis use was likely to precipitate a psychi atric illness (a common belief in the Caribbean itself6), others suggested that the diagnosis of'canna bis psychosis' was used to admit under the Mental Health Act a considerable number of young black men who had various situational crises. An epide miolÃ³gica!study at the time found that 27% of local male Afro-Caribbean psychiatric patients were diag nosed as having 'cannabis psychosis'.7 a diagnosis given to only 1.4 of white males (a 95-fold difference in terms of rates). Ten years previously, however, the diagnosis was seldom used locally for any group.8 Some community members suggested that this rela tive prevalence did not reflect the actual differential use of cannabis in the two groups as it was extensively smoked by the local white working class.9 Increased prominence was given to the issue by evidence offered to the Silverman inquiry into the Handsworth riots by a local psychiatrist, who impli cated cannabis ingestion as a causative factor. This view was extensively (and critically) reported in the local black press. Concern was expressed that, what ever the psychiatric consequences of cannabis might be, 'cannabis psychosis' was a particularly broad term which was being employed in situations where psychiatrists had not taken enough time to under stand the social antecedents of personal crises. Because of the popular association of cannabis use with the black community, the use of the diagnosis had, in addition, the effect of 'pathologising' it: if West Indians used cannabis, and cannabis caused psychological difficulties, then the stresses black people in Britain experienced could be said to be, in part, a function of their own chosen way of life.
It was suggested that two questions could usefully be addressed: What were the actual psychiatric consequences of cannabis use? What was the current medical understanding of 'cannabis psychosis' and, given the serious implications, was there an accepted consensus? It was emphasised that the findings should be made accessible to the community itself. The first question is the subject of a proposal in pro gress, and has been addressed intermittently in the psychiatric literature without any agreement as to whether cannabis is necessary and sufficient to pro duce a specific reaction or whether it may serve as a non-specific Stressor in those already vulnerable.10 The psychiatric conceptualisation of 'cannabis psychosis', the second question, was examined with a questionnaire sent to the 132consultant psychiatrists and senior registrars in the Region, enclosed with a stamped addressed envelope for return.

The findings
One hundred and sixteen questionnaires were returned, 12 of which were not completed on the grounds of lack of experience. The remaining 104 responses are reported here question by question: (1) Do you find cannabis psychosis a useful diag nosis?

Comments
While any attempt to explain clinical procedures to our patients and their community is surely to be wel comed, in the case of a controversial diagnostic entity which has little academic standing, it is difficult to present the findings in a helpful way. To an extent this is the consequence of the short questionnaire: it is unlikely that any psychopathological consequences of cannabis ingestion will be neatly related to a specific syndrome as necessary and sufficient. What conclusions can be drawn from this project and use fully shared with the Afro-Caribbean community? Firstly, most local psychiatists do not, in general, regard cannabis as a 'significant' agent of psychopathology, nor do they use the term 'cannabis psychosis' (Questions 10, 1,2). On the general under standing of the term as used, they suggest it implies a precipitation of a non-specific illness (Question 3), and thus presumably presents no more of a characteristic phenomenological pattern than, say 'unemployment-precipitated depressive illness' or 'amphetamine-precipitated schizophrenia'. As to which reaction it is most likely to precipitate, there is an equal division of opinion between two functional psychoses (schizophrenia and paranoid psychosis) and a toxic confusional state (Question 4a). Mania was not implicated, although the only controlled prospective study conducted emphasises the 'hypomanic features'.10 Those who favour a discrete and unitary syndrome of 'cannabis psychosis' offer a variety of clusters of symptoms from the list offered (taken from the PSE Syndrome Check List as those most frequently described locally as constituting the reaction). Of these, only five were accepted by more than half: poor concentration, delusions of per secution, auditory hallucinations, clouded conscious ness and agitation. Only one, poor concentration, was accepted by more than 60%. Of interest is the salience of persecution previously reported as a common experience among black psychiatric patients. ' ' What does perhaps seem a little difficult to understand is the readiness to treat 'cannabis psychosis' with major tranquillisers given its perception as a self-limiting condition (Question 6, 7). The local black perception that the diagnosis is more frequently used for the Afro-Caribbean community agrees with the medical perception (Question 8); the reason given is that Afro-Caribbcans smoke more cannabis, although a minority of respondents (which included all those who felt there was a specific reaction) considered that West Indians were more vulnerable (Question 9). Whilst the possibility of ethnic stereotypes entering into the construction of the reaction was not asked, space was provided for additional comments but only one respondent suggested this.
It may be argued that to present these results back to the black consumer will not reflect particularly favourably on the practice of psychiatry. Clearly, there is no simple pattern of responses which would suggest a generally shared set of clinical knowledge and practice. Nevertheless, the diverse response may not be uncharacteristic of other, more generally accepted, categories such as personality disorder or even schizophrenia.4 The results are being shared with the local CRC and other groups as part of a continuing discussion on the feasibility and ethics of Psychiatric Bulletin a prospective study on the effects of cannabis on mental health. The immediate response has been, correctly I believe, of surprise that such an inchoate category is used so frequently. A major concern is that the diagnosis is one that is used overwhelmingly for a particular minority community, already disadvantagcd in numerous areas of social and medical provision, and that it implicates as pathogenic a pat tern of deviant social behaviour identified, correctly or otherwise, with that community.
It should be emphasised that whilst professionals should work closely with minority groups in such areas, the ultimate ethical and political responsibility for the projects and the dissemination of results remains with the researcher. It is not acceptable for the older type of studies to continue with account ability simply transferred onto "the community".