A STUDY OF THE PREVALENCE OF CANNABIS ABUSE AND
ASSOCIATED PSYCHIATRIC MORBIDITY AMONG AUTOMOBILE
APPRENTICES IN SOKOTO METROPOLIS
A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE
MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE
COLLEGE IN THE FACULTY OF PSYCHIATRY
DR EGBEOLA, ADEYEMI ADEKUNLE M.B.Ch.B (O.A.U, IFE. 2OOO) DECLARATION
This is to certify that this work has not been presented to any other body for any award, and is original in all respects except where indicated.
………………………………….
Dr Egbeola A.A
2 CERTIFICATION This is to certify that this work was done by Dr. Egbeola Adeyemi Adekunle for his dissertation to the National Postgraduate Medical College with the title ‘A Study of the Prevalence of Cannabis Abuse and Associated Psychiatric Morbidity among
Automobile Apprentices in Sokoto Metropolis’ under our supervision.
Dr Nnaji F C Dr Owoidoho Udofia
3
TABLE OF CONTENTS DECLARATION ...... 2 This is to certify that this work has not been presented to any other body for any award, and is original in all respects except where indicated...... 2 …………………………………...... 2 Dr Egbeola A.ACERTIFICATION ...... 2 TABLE OF CONTENTS ...... 4 LIST OF TABLES ...... 6 TABLE OF APPENDICES ...... 7 DEDICATION ...... 8 ACKNOWLEDGEMENT ...... 9 ABSTRACT ...... 10 Cannabis is an illegal substance that has generated much debate in history. It is widely grown, cheap, readily available and widely abused. Cannabis abuse has been observed in a significant proportion of patients treated for psychosis. Various explanations have been proffered for the observed association between cannabis as a psychoactive substance and mental illnesses generally and psychosis specifically. The role of cannabis in precipitating psychosis in predisposed individuals is well known. However, there are arguments as to whether any association will be observed in individuals who abuse cannabis without familial vulnerability to developing mental illnesses. This study attempted to screen for possible general psychiatric morbidity as well as psychotic symptoms and determine any association these may have with cannabis abuse in a non-clinical population of young automobile apprentices, who have no familial predisposition to developing mental illnesses in Sokoto town, North-Western Nigeria...... 10 This is a cross-sectional study of 200 young, male, automobile apprentices without familial predisposition to development of mental illnesses in Sokoto metropolis. They were categorised on the basis of their abuse or otherwise of cannabis...... 11 The Instruments used were ...... 11 The Self administered General Health Questionnaire (GHQ-28), which screened for possible general psychiatric morbidity and ...... 11 The Psychosis Screening and Substance Use sections of the interviewer administered World Mental Health version of Composite International Diagnostic Interview (CIDI). The psychosis screening section screened for psychotic symptoms, types of symptom, onset and treatment. Substance use section assessed use and abuse of psychoactive substances, including cannabis, the substance of interest of this research...... 11 The lifetime and current prevalence rates of cannabis abuse among respondents were 26% and 21.5% respectively, rates that were higher than the national average of 10.8%. Apprentices who abused cannabis were likely to engage in chronic use, with a mean duration of 6.5± 3.4 years and with onset in the teen years in most (73%). Cannabis abuse was significantly associated with age (X2=13.49, df=1, p=0.001) and family history of substance use (X2=21.62, df=1, p<=0.05). The prevalence rates of both general morbidity and psychotic symptoms among those who reported lifetime abuse of cannabis were 44% and 39% respectively, which were higher than the rates for the rest of the respondents. Abuse of cannabis was found to be significantly associated with probable general psychiatric morbidity (X2=6.78, df=1, p=0.009) as well as psychotic symptoms (X2=6.79, df=1, p=0.009)...... 11 In conclusion, the prevalence of cannabis abuse in this group of youths was high and most commenced cannabis use in their teens. Cannabis abuse was significantly associated with psychiatric
4 morbidities, both probable general morbidity and psychotic symptoms, despite absence of familial predisposition to developing mental illness. Cannabis therefore, may not be as ‘harmless’ as some may have thought and there are probably other vulnerability factors besides familial predisposition to developing mental illnesses with which its abuse interacts...... 12 Chapter One ...... 13 1. INTRODUCTION ...... 13 Chapter Two ...... 17 1. LITERATURE REVIEW ...... 17 2.1 OVERVIEW ...... 17 2.2 CANNABIS ISSUES IN AFRICA ...... 20 2.3 CANNABIS USE/ABUSE IN NIGERIA ...... 21 2.4 CANNABIS AND PSYCHOLOGICAL SYNDROMES IN MAN ...... 24 Chapter Three ...... 38 AIMS AND OBJECTIVES ...... 38 HYPOTHESIS ...... 38 Chapter Four ...... 39 4. METHODOLOGY ...... 39 4.1 STUDY SETTING ...... 39 4.2 STUDY POPULATION...... 39 4.3 INCLUSION CRITERIA ...... 40 4.4 EXCLUSION CRITERIA ...... 40 4.5 ASSESSMENT INSTRUMENTS ...... 41 4.6 SAMPLE & SIZE ...... 42 4.7 SAMPLING ...... 43 4.8 PROCUDURE ...... 44 4.9 ETHICAL CONSIDERATIONS ...... 45 4.10 DATA ANALYSIS ...... 45 Chapter Five ...... 46 RESULTS ...... 46 Chapter Six ...... 66 6. DISCUSSION ...... 66 Chapter Seven ...... 72 7. LIMITATIONS OF THE STUDY ...... 72 Chapter Eight ...... 73 8. CONCLUSIONS AND RECOMMENDATIONS ...... 73 8.1 Conclusion ...... 73 8.2 Recommendation ...... 74 In view of the finding of a high prevalence of cannabis abuse among the young apprentices and its significant associations with psychiatric morbidities, it is important that public enlightenment programmes on the dangers of cannabis abuse be vigorously pursued, especially among the young people. This effort should not be limited to those in schools, but such should also be extended to other risk groups, such as these apprentices. It is also better to go beyond screening for these morbidities as was done in this study. A two-stage study design that allows for definitive assessment of morbidities is recommended. A longitudinal study with larger sample will help in establishing the direction of associations found between cannabis abuse and these morbidities. Furthermore, this is desirable in view of the finding of a previous study that reported later diagnosis of schizophrenia among those who previously reported psychotic symptoms...... 74 REFERENCE ...... 75 APPENDICES ...... 87
5 LIST OF TABLES
TABLE TITLE PAGE 1 Socio-demographic characteristics of respondents 46 2 Lifetime and current use of substances among respondents 48 3 Pattern of cannabis use among respondents 50 4 Prevalence of psychiatric morbidities among the respondents 52 5 Socio-demographic and clinical characteristics of respondents with 54 lifetime cannabis abuse and those without cannabis abuse 6 Distribution of psychiatric morbidity among respondents admitting 56 to lifetime abuse of cannabis and non-cannabis abuse respondents 7 Comparison of socio-demographic characteristics of psychotic 58 cannabis abusing and psychotic non-cannabis abusing respondents 8 Relationship between socio-demographic/pattern of cannabis abuse 60 and psychotic symptom experience among respondents with lifetime cannabis abuse 9 Relationship between socio-demographic/pattern of cannabis use 62 and general morbidity among respondents with lifetime cannabis abuse 10 Relationship between frequency of cannabis abuse and psychotic 64 symptom among respondents with current cannabis abuse 11 Relationship between frequency of cannabis abuse and general 66 psychiatric morbidity among respondents with current cannabis abuse
6 TABLE OF APPENDICES
APPENDIX Page
I General Health Questionnaire-28 (English) 86
II General Health Questionnaire-28 (Hausa) 88
III Composite International Diagnostic Interview- Psychosis Screening 90
IV Composite International Diagnostic Interview- Substance Use 97
V Ethical Approval Letter 122
7 DEDICATION
This work is dedicated to the glory of God and to the benefit of mankind.
8 ACKNOWLEDGEMENT I wish to acknowledge the grace of God in my life and for sparing me through troubled times, enabling me to achieve my dream. I acknowledge the contribution, support, prayers and encouragement of my darling wife, in-laws and beautiful daughter, Omotola. I appreciate my parents and siblings for their prayers, patience and love since I started my life journey. I am happy to be a part of you and pray that God spares your life for me, Amen. I cannot overemphasise the role played by my Chief, Dr Udofia O, who came into my life when I was at a cross-road. He related with me not as a student he was to supervise, but as a son and despite tight schedules, was always available. It is a big ‘Thank you’ to my Oga, Dr FC Nnaji, who first saw the potential for success in this field of endeavour in me. His patience, understanding and support right from my entry into residency programme through to completion deserve mention and commendation. I also wish to thank Dr Abdullahi Ibrahim, my consultant, for being there for me. Similarly, I appreciate all who have in one way or the other contributed to my learning since I entered my training. I say ‘Thank you’ to you all. I remain eternally grateful. I thank the management of Federal Neuro-psychiatric Hospital, Kware under the leadership of Dr Z.G Habib, for your interest, support and for the opportunity to complete my programme. I will not forget friends, colleagues and well-wishers too numerous to mention, in this great institution. My prayer is that God will bless and support you in all your endeavours. To my loving and spiritual instructor, Pastor Tayo Fatinikun, his family and brethren at Christian Worship Chapel, I say a big ‘Thank you’. My joy would not have been complete without your support, prayers and love. I remain eternally grateful. My profound gratitude also goes to all the chairmen of National Automobile Technicians Association and the apprentices who participated in this study. Finally, to my Lord and Redeemer, Jesus Christ, be honour, praise and adoration.
9 ABSTRACT
Cannabis is an illegal substance that has generated much debate in history. It is widely grown, cheap, readily available and widely abused. Cannabis abuse has been observed in a significant proportion of patients treated for psychosis. Various explanations have been proffered for the observed association between cannabis as a psychoactive substance and mental illnesses generally and psychosis specifically. The role of cannabis in precipitating psychosis in predisposed individuals is well known.
However, there are arguments as to whether any association will be observed in individuals who abuse cannabis without familial vulnerability to developing mental illnesses. This study attempted to screen for possible general psychiatric morbidity as well as psychotic symptoms and determine any association these may have with cannabis abuse in a non-clinical population of young automobile apprentices, who have no familial predisposition to developing mental illnesses in Sokoto town, North-
Western Nigeria.
The objectives of the study were
To determine the prevalence of psychiatric morbidities among young
persons who abuse cannabis
To determine any association between cannabis abuse and psychotic
symptoms
10 This is a cross-sectional study of 200 young, male, automobile apprentices without familial predisposition to development of mental illnesses in Sokoto metropolis. They were categorised on the basis of their abuse or otherwise of cannabis.
The Instruments used were
The Self administered General Health Questionnaire (GHQ-28), which
screened for possible general psychiatric morbidity and
The Psychosis Screening and Substance Use sections of the interviewer
administered World Mental Health version of Composite International
Diagnostic Interview (CIDI). The psychosis screening section screened
for psychotic symptoms, types of symptom, onset and treatment.
Substance use section assessed use and abuse of psychoactive substances,
including cannabis, the substance of interest of this research.
The lifetime and current prevalence rates of cannabis abuse among respondents were 26% and 21.5% respectively, rates that were higher than the national average of
10.8%. Apprentices who abused cannabis were likely to engage in chronic use, with a mean duration of 6.5± 3.4 years and with onset in the teen years in most (73%).
Cannabis abuse was significantly associated with age (X2=13.49, df=1, p=0.001) and family history of substance use (X2=21.62, df=1, p<=0.05). The prevalence rates of both general morbidity and psychotic symptoms among those who reported lifetime abuse of cannabis were 44% and 39% respectively, which were higher than the rates 11 for the rest of the respondents. Abuse of cannabis was found to be significantly associated with probable general psychiatric morbidity (X2=6.78, df=1, p=0.009) as well as psychotic symptoms (X2=6.79, df=1, p=0.009).
In conclusion, the prevalence of cannabis abuse in this group of youths was high and most commenced cannabis use in their teens. Cannabis abuse was significantly associated with psychiatric morbidities, both probable general morbidity and psychotic symptoms, despite absence of familial predisposition to developing mental illness.
Cannabis therefore, may not be as ‘harmless’ as some may have thought and there are probably other vulnerability factors besides familial predisposition to developing mental illnesses with which its abuse interacts.
12 Chapter One
1. INTRODUCTION Drugs are substances which, when ingested, alter the structure and function of the body, usually in a beneficial way. Psychoactive substances as a class of drugs are believed to affect the psyche of man, altering mood, perception, consciousness and motivation, among others (Kaplan & Saddock, 2003). Due to these influences, these substances are sought after by man and because of the high potential for maladaptive patterns of use, there are measures to control their use. Abuse results when a legally prohibited psychoactive substance such as cannabis is used (Habib and Sake, 2003).
Cannabis abuse is widespread, cutting across all socioeconomic classes
(Odejide & Sanda, 1976), religions and creeds. It is abused mostly by young single males. A product of a plant called cannabis sativa, it contains close to 400 different chemicals, the most active of which is delta 9-tetrahydrocannabinol (Kaplan &
Saddock, 2003). It has been reported as the most abused illicit substance in most regions of the world (Kaplan and Sadock, 2003; Kontominas, 2007). A substantial use of cannabis has been reported among Nigerian secondary and university students
(Anumonye, 1980; Nnaji, 2000; Ihezue, 1988; Adelekan et al, 1993), general population (Odeleye, 2000) as well as psychiatric patients (Nnaji, 1996). Cannabis abuse constitutes a problem among youths, not just in developed economies of the world only, but particularly so in developing ones where they are a substantial drain on resources.
13 It was noted that social, physical and psychological problems may be sequel to cannabis abuse (Pela, 1989). Possible roles for it in causing lung cancers, reduced immunity and infertility among smokers, have been noted. Its association with crimes of all sorts (Ohaeri and Odejide, 1993; Agbahonwe et, 1998) and road traffic accidents are also known. It is therefore a paradox that there are clamours for its unrestricted use in view of the claims of its being beneficial in treating conditions such as spasticity in multiple sclerosis patients as well as nausea associated with cancer chemotherapy. It is interesting to note that much politics have attended the issue of cannabis, especially as regards what it does and does not do.
In Nigeria, hospital data have mostly found high rates of cannabis abuse among psychiatric patients (Nnaji, 1996). There is also a belief that cannabis is a cause of mental illnesses, a view reported by Gureje et al (2005) in a community-based study in
South-Western Nigeria. In fact, Morakinyo (1983) was of the opinion that psychiatrists hold a popular view that cannabis abuse is associated with mental illness.
Associations have been demonstrated for cannabis abuse and depression (Bovasso,
2001) as well as psychosis (Degenhardt et al, 2003; Hall and Degenhardt, 2008). A number of possibilities have been postulated for the associations observed, such as self medication of a primary disorder using cannabis; a common factor responsible for the conditions; cannabis abuse causing psychiatric illness de novo; cannabis abuse precipitating a latent illness; a chance association only and finally, that there is no association between cannabis abuse and psychiatric illness (Thornicroft, 1990).
14 It has been noted that cannabis abuse in the teen years increases the risk of psychosis due to the fact that the period is critical in the development of the brain
(Ashtari et al, 2009). Therefore, the fact that cannabis abuse is high among the young population should be a cause of concern. Compounding the problem are easy availability of the drug, ineffective policing and control, and lack of an adequate and up-to-date database of information on cannabis. It is contended that the legal prohibition and criminalization of cannabis are likely to make obtaining information about it very difficult.
Ohaeri and Odejide (1993), in their review of data from psychiatric hospitals across Nigeria two decades ago, found a higher prevalence of cannabis abuse in the
Northern part. However, Nnaji (2000) observed that most of the studies into problems of substance use in Nigeria, cannabis inclusive, despite their great number, have been mostly carried out in the Southern part. While students in both secondary and tertiary institutions have been focused on in previous studies of drug abuse, their peers that are not within a regimented school environment apparently seem not to arouse significant research interests. This is particularly surprising, given the fact that this group of youths are supposedly more likely to be exposed to street drugs like cannabis and would therefore be expected to be at a higher risk. Therefore, beaming the searchlight of scientific scrutiny on cannabis abuse and problems among this group of youths in the North will go some length in enriching knowledge. The construct of a continuum of psychiatric states is of the view that health stretches between the extremes of
‘normal health’ to a state of minimal symptoms but where the individual functions 15 well, to the ‘illness, clinical state’ characterized by more and severe symptoms interfering with normal day-to-day living (Joshanloo and Nosratabadi, 2009). Most of the investigations of the association between cannabis abuse and mental ill-health done in this country have been hospital-based. Samples in such studies are likely to represent the tip of the iceberg. It is expected that the association found in patients between cannabis abuse and mental ill-health, psychosis especially, should also hold true for non-clinical population if earlier symptoms that are sub-clinical are investigated. Therefore, this study of a young, physically healthy, non-clinical population of apprentices without familial predisposition to developing mental illnesses, who are abusing cannabis in the community will not only afford an opportunity to have a firsthand impression about the prevalence of states of psychological disturbances associated with cannabis abuse at this level, but also throw more light on the nature of the associations. It is hoped that the findings of the study will add to knowledge in the cannabis field.
16 Chapter Two
1. LITERATURE REVIEW
2.1 OVERVIEW Man through the years and by his ingenuity has devised means and methods of harnessing the naturally occurring substances in herbs, roots of plants, animals among others into what we call “drugs,” which are used for various purposes such as recreation, medicinal and instrumental (Obot, 1992).
There is, however, a special class of substances that exceptionally affects mood, motivation, perception and other psychological functions in man. These psychoactive substances, as they are called, abound in nature and produce a variety of effects in man
(Kaplan & Saddock, 2003). Because of these effects on the psyche, they are sought after by man and have high abuse potential. In the words of Aldous Husley, a great thinker of his time, ‘The urge to escape, the longing to transcend themselves, if only for a few minutes, is and always has been one of the principal appetites of the soul’
(Semple et al, 2005).
Cannabis is a psychoactive substance of abuse. Both local and international studies show that it as the most abused illicit substance (Ebie and Tongue, 1988;
NDLEA report, 1993; Gelder et al, 2000). Around 9% of those who try it end up not being able to stop its use (Kontominas, 2007). In Nigeria, Obot (1992) reported 2.4% prevalence in the general population but much higher use has been reported in hospital patients (Nnaji, 1996). It is recognized that species coming from different sources have different strengths or potencies. Its production is in 3 types: leaves and flowers 17 (Marijuana); resinous exudates from flowering plant (Hashish) and oil (Hashish oil). It may be smoked, eaten either alone or in combination with cigarettes (Joints) (FIDES
Service, 2007).
It has been observed that, though most youths try using cannabis at one time or the other (experimental use), for most, the use ends at this level and does not progress to abuse (Gelder et al, 2000). The International Classification of Diseases in its 10th revision (ICD 10) and 4th edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM IV), the two prominent classificatory systems in psychiatry, recognise and specify criteria for diagnosing various maladaptive patterns of use such as abuse, dependence and other drug-induced mental ill-health states that are encountered in clinical practice.
Peoples’ perceptions of cannabis have varied over the course of man’s intercourse with this substance. It has been loved and hated at various times. In India it is still used as a seasoning. The United Kingdom recently reclassified cannabis as a class ‘C’ drug with the implication of its being labelled a milder drug compared to a drug like cocaine of a higher class (Science Daily, 2005). However, certain views consider this a move in bad faith, citing studies that have implicated cannabis in mental ill-health, especially, psychosis (Stuttaford, 2006). Cannabis has been known to be associated with mental illness by psychiatrists and the general population
(Morakinyo, 1983; Gureje at al, 2005). According to the World Health Organization
Report (2001), problems associated with psychoactive substances account for 4% of the Global Burden of Disease (GBD). Pela (1989) noted that social, psychological and 18 physical problems are associated with the use of psychoactive substances such as cannabis. Its association with increase in crime, road traffic accidents with attendant death toll and loss of manpower, jobs, family disruptions, among others, have been a source of concern (Ohaeri et al 1993; Agbahonwe et al, 1998; Gelder et al, 2000).
There are a number of treaties which various countries of the world are signatory to. These are aimed at controlling the availability of psychoactive substances, cannabis inclusive, through restrictions on cultivation, possession and trafficking, among others. Various governments have instituted a number of ways to ensure compliance. The adverse effects of cannabis on the economy have served as impetus to comply. In Nigeria, for example, the government established the National
Drug Law Enforcement Agency (NDLEA) as well as the National Agency for Food,
Drugs Administration and Control (NAFDAC) to spearhead its resolve and fight against the scourge in the country. However, casual observation will show that much is still left to be done, going by the increase in crime, decreasing age of onset of use of cannabis and increasing trend in consumption which appears to follow a global trend
(NDLEA Report, 1993; UNDOC World Drug Report, 2006).
Understanding the drug culture in any country appears to be a sine qua non if the battle against the ills associated with cannabis is to be won. The essence of a holistic approach which targets the production, distribution, use and treatment of associated problems has been stressed and cannot be overemphasised in our effort to be on top (Sijuwola, 1993).
19 2.2 CANNABIS ISSUES IN AFRICA In most parts of Africa, cannabis is the most common illicit drug of abuse
(Asuni and Pela, 1986). While the continent remains only a transit zone or residual market for drugs such as cocaine and heroin, the principal local drug product is cannabis. Introduced to East Africa by Arab, Persian and Indian traders in the 12th century, it spread to South African countries in the 19th century. It only came to West
Africa after the Second World War when returning soldiers from Nigeria and Ghana who fought alongside the British in Burma brought it home. African production was limited until the 1980s, when it began to increase for trade. According to the World
Drug Report (2006), cannabis is cultivated illegally in 176 countries of the world, 27% coming from the African countries of Nigeria, Morocco and South Africa. There is also a corresponding increase in seizures in Africa due to enhanced police control in
Nigeria and South Africa (FIDES Service, 2007).
Cannabis has remained the most commonly used recreational drug of abuse in countries of North Africa such as Morocco and Egypt (D’Orbain, 1980). Smoking is the main method of use, with youths engaging in the habit within the peak ages of 16-
18 years while dysfunctional families and socioeconomic problems emerged as factors involved in the use (Souief, 1967; 1971). North Africa is the world’s third largest market for cannabis, coming mainly from Morocco (FIDES Service, 2007).
In East Africa, Tanner (1966) noted the primal place of cannabis as the most common substance of abuse, with a prevalence of 50% in the populace. Presently, acres of land that could have been used for food crops production are being used to
20 cultivate cannabis. This is because it is easy to cultivate, being able to grow in most climates of the world, and it is reputed to be more profitable than food crops production. This may perhaps be due to ready growing markets fuelled by pockets of regional conflicts in the region. Most farming families are said to live more comfortably on the proceeds from cannabis production than what they could possibly get from food crops (FIDES Service, 2007). As a result of the growing menace of cannabis use, especially towards the end of the last century, and the apparent problems in the formal control programmes of governments, Asuni (1990) stressed the need to engage the informal system of drug control operating through the family, religious houses, school, neighbourhood, work environment as well as healthy recreational activities sector which will be complementary.
2.3 CANNABIS USE/ABUSE IN NIGERIA The problem of cannabis abuse is a global one. Cannabis was introduced into
Nigeria by soldiers returning from the Second World War (WWII) and has been found to grow readily under various climatic conditions (Asuni, 1978). Anumonye (1980) also noted the contribution of those who smuggled it from foreign territories.
Epidemiological studies in Nigeria revealed cannabis as abused mostly by individuals who are mostly young males (Boroffka, 1966; Obembe, 1988; Obot, and Olaniyi,
1991; Ohaeri and Odejide, 1993). It has a reported prevalence of 2.4% in the population (Obot I.S, 1992). Odejide and Sanda, (1976) observed that its substance abuse was present in all cultures and social classes. However, more recent studies have
21 noted a greater prevalence in the lower socioeconomic class (Sijuwola, 1988; Ohaeri, and Odejide, 1993). Investigating the psychosocial correlates of alcohol, tobacco and cannabis use among 636 university of Ilorin undergraduates, Adelekan et al (1993) found significant correlations between cannabis abuse and peer influence, self- reported poor mental health, religiosity, parental /guardian supervision, perceived availability and harmfulness, study difficulty and polygamous family background.
These findings were similar to those of Ihezue (1988) among medical students in a
Nigerian University in Enugu.
The National Drug Law Enforcement Agency (NDLEA) report (1993) of studies carried out and using data from different sources indicated that people are introduced into psychoactive substance use early, just about 9 – 11 years of life in
Nigeria. The study further reported cannabis as the most abused drug in 66% of respondents, followed by alcohol (22%). Multiple drug use was observed, with the user abusing more than one particular drug at a time (Ohaeri and Odejide, 1993). This is in conformity to what is observed globally (World Health Report, 2001).
Multiple factors come into play to explain involvement with drugs and these vary from one person to the other. One temptation is to assume that it borders on ignorance of the dangers associated with the use of substances. However, Abiodun et al (1994) and Adelekan et al (1993) in their separate studies of post secondary and
University students respectively in Nigeria demonstrated that knowledge of the harmful effect of these substances among the population may not necessarily serve as deterrents to their use. 22 An increased trend in drug related cases had been observed in Nigeria. Borrofka
(1966), alerted by an increasing observation of cannabis use among patients admitted to Psychiatric hospital, Yaba collected data over four years. Increasing trend was observed and he found higher incidence among non-traditional vocation. Makanjuola
(1986) in his review of patients admitted to Aro Drug Addiction and Research Centre found cannabis as the most commonly abused illicit substance. Anumonye (1980), in his study of 300 patients admitted at Lagos University Teaching Hospital, found that the majority (78%) were using cannabis. Ahmed (1989), who reviewed cases seen at the University Department of Psychiatry in Kaduna between 1980 through 1986, showed that the number of cases increased from 11% in an earlier study to 12%.
Similarly Obot (1992) analyzed data from files of patient in four psychiatric hospitals.
The proportion of abuse was reported to have increased from 9.1% in 1984 to 15.1% in 1988.
Various means were and are still being used by drug dealers to beat security measures in their trafficking of cannabis and other psychoactive substances. These, according to Obot (1992), are developed almost at about the same speed as the government policies formulated to check this worrisome trend. As a result of the negative effect this brought on the corporate image of the country in the committee of nations (Ahire, 1990), the Nigerian Government adopted a number of measures over time to combat the scourge, one of which was the promulgation of Decree 20 of 1984 which prescribed the death penalty and various prison sentences for drug traffickers
(Obot, 1992). Furthermore, various agencies were established. One of such is the 23 National Drug Law Enforcement Agency (NDLEA) which was established with enabling decrees to serve as the arrowhead of the government in its resolve to win the war. Earlier, Asuni (1977) had observed that drug control was weak, with a tolerant social system.
Having realized the inadequacy of legal control measures as a sole panacea to drug problems in the country, addiction treatment programmes were established by the government. It is also against this background that other programmes that focus on demand and supply reduction have become essential in the fight against the menace of drugs, cannabis inclusive (Asuni, 1990).
2.4 CANNABIS AND PSYCHOLOGICAL SYNDROMES IN MAN For a long time, the mode of action of cannabis was not known. Cannabis was thought to act through neurotransmitter modulation, similar to opioids and their derivatives. It was not until recently that greater insight was gained into the probable mechanism of action in the brain. The influence of cannabis is now known to be mediated through endogenous cannabinoid receptors designated CB 1 receptors. Their distribution correlates in rat brain with the distribution of the D1 receptors. The receptors are found in the hippocampus, the basal ganglia, cerebellum, and related cortical areas. The rarity of death associated with cannabis even in intoxication is an attestation to the fact that the receptors are not located in the brainstem (Kaplan &
Saddock, 2003). While it has been suspected for long to have a very influential role on the metabolism of dopamine, a more recent view holds that Δ9 Tetrahydrocannabinol
24 (THC), the most active of about 400 chemicals in cannabis, binds to its cannabinoid
CB1 receptors on pre-synaptic nerve terminals in the brain and activates G-proteins that activate/ inhibit a number of signal transduction pathways (CNS forum, 2005).
The G-proteins directly inhibit N and P/Q-type voltage dependent calcium channels and sodium channels via the inhibition of adenylate cyclase. The G-proteins also activate the potassium channels and the Mitogen Activated Protein kinase signalling pathways, resulting in the euphoria associated with cannabis use. The discovery of these receptors has therefore been greeted by a lot of enthusiasm with the aim of developing treatment strategies that, rather than being dopamine receptor-based, will concentrate on the cannabinoid system as the primary target.
The two classificatory systems in use in psychiatry, ICD 10 and DSM IV both recognise syndromes associated with psychoactive substances use. Syndromes of intoxication, abuse/ harmful use, dependence, psychosis, affective disorder and amnesia have all been identified among cannabis users.
Intoxication is a transient abnormal state resulting from the recent use of a substance and it produces clinically significant physical and psychological impairment. It may result from use of a large amount of cannabis in a novice or larger than usual dose in a cannabis user. It is a state that could be characterised by agitation, restlessness, euphoria, disinhibition, suspiciousness or paranoid ideas, temporal slowing, impaired attention, judgement and reaction time and hallucinatory experiences (visual, auditory and tactile). It is associated with conjunctival injection,
25 dryness of the mouth, tachycardia and increased appetite. These effects resolve in hours with elimination of the substance from the body.
Substance abuse and dependence are perennial problems and call for attention, especially in developing economies like Nigeria. Drug abuse is a concept that has varied definitions. Ebie and Pela (1982) observed that there is lack of universal agreement on a definition of ‘drug abuse’. While it has been defined as ‘the use of a drug when it is not medically necessary, when it is used in the face of legal prohibition or when, for socially acceptable drugs, excessive quantity is used (Habib and Sake,
2003), use of psychoactive substances other than alcohol and tobacco without a doctor’s prescription is equally believed to constitute an abuse (Tawasu, 2005). The
Diagnostic and Statistical Manual of Mental Disorders–IV (1994) defines abuse as a maladaptive pattern of use the leads to significant impairment or distress and manifested by recurrent substance use resulting in failure to fulfil major roles, increased risks of physical harm, substance-related legal problems as well as continued use despite persistent or recurrent social or interpersonal problems. World
Health Organisation’s ICD-10 defines it as a pattern of use that is usually associated with impaired mental or physical health (ICD 10, 1992). The ICD-10 definition is believed to be more inclusive and likely to depend on the judgement of the clinician
(Gelder et al, 2000). Studies have shown cannabis is the most widely abused illicit substance. One probable reason likely to explain this pattern of use of cannabis is people’s perception of the substance as a ‘soft’, harmless drug of which little is known about what it does and does not do (Bovasso, 2001). 26 Dependence is a syndrome of physical or psychological phenomena induced by repeated use of a substance leading to clinically significant impairment of functioning characterized by desire for the substance, its preference over other sources of gratification, repeated failure at control of its use, tolerance and withdrawal (ICD 10,
1992). Tolerance describes a state whereby progressively larger amounts of the substance is needed to achieve its earlier effect whereby withdrawal is characterized by physical or psychological discomfort whenever the dose of the substance used is reduced or stopped (Gelder et al, 2000). While it is believed that intermittent use of small quantity of cannabis is not associated with either severe physical dependence or prominent withdrawal symptoms after abrupt termination (Gelder et al, 2000), some studies suggested marked psychological dependence from heavy use producing compulsive drug taking in users (Indian Hemp, 1893; Lambo, 1965). There are problems of attendant job losses and disruptions in family and other relationships.
Compared with abuse, it is not as common and evidence shows that the majority of those who use cannabis do not abuse or become dependent on it (Gelder et al, 2000).
Inability to stop the use of cannabis is reported to be observed in 9% of those who use cannabis (Kontominas, 2007).
Mood problems, especially depression have continued to be witnessed among cannabis smokers. A community-based study among the indigenous population in
Northern territory of Australia by Clough et al (2005) investigated adverse mental health problems in relation to cannabis use. One hundred and three persons who used cannabis participated in interviews and completed survey questionnaires which were 27 cluster analysed into ‘anxiety- dependency’ and ‘mood- vegetative’ symptoms. These were found to be significantly associated with the quantity of cannabis used per week even after controlling for age, sex and use of other substances. In another Australian study, the researchers interviewed 1,600 14 to 16 year old through survey questionnaires, which inquired of symptoms of depression and use of cannabis. The survey was repeated years later. It was revealed that weekly use of cannabis increased two-fold the risk of depression in adulthood and this risk was increased four times with daily use of cannabis. Daily use of cannabis in young women was associated with
5 times the risk of depression and anxiety compared to those who did not use cannabis. The study however found that those who had depressive symptoms at outset were not more likely to use cannabis later on in life than those without such symptoms
(Bovasso, 2001). There is a question, however, concerning whether cannabis use caused these illnesses or it just precipitated them in predisposed individuals. Some researchers were of the view that certain psychosocial outcomes of cannabis use, such as educational failure and unemployment, may have contributed to depression. Others are of the view, however, that cannabis use might have caused a lasting chemical change in the central nervous system and therefore, affect its functions such as emotion, cognition, movement and memory (Bovasso, 2001).
Jerry and Nancy (1995) defined psychosis as a state of impaired reality testing, which may manifest as hallucinations, delusions, disordered pattern of thought and speech. It has been observed that the symptomatic syndromes encountered in substance induced psychosis bear similarity to other functional psychosis and as such, 28 the arrays of presentations have been qualified as schizophrenia-like (F1x.50), predominantly delusional (F1x.51), predominantly hallucinatory (F1x.52), predominantly polymorphic (F1x.53), predominantly depressive symptoms (F1x.54), predominantly manic symptoms (F1x.55) and mixed (F1x.56) (ICD 10, 1992). The presentation could be acute (occurring within 48 hours of use) or late-onset (occurring more than two weeks of substance use) but complete resolution is expected to occur within six (6) months.
In none of the psychological syndromes has the causative role of cannabis been as controversial as in psychosis. This problem has lingered for this long time because of ethical restriction of experimental studies of cannabis in human (Hall, 1998). The few studies conducted in this direction have produced mixed results.
Concerns about cannabis emerged with the recognition of its abusive properties and a number of other issues. First, there is a reclassification which makes possession of cannabis illegal but all the same not an arrestable offence (Kaplan and Saddock,
2003). There has been an increased clamour for unrestricted access to cannabis because of its alleged medical benefits in reducing spasticity in sufferers of multiple sclerosis, treatment of pains and nausea associated with cancer chemotherapy
(Salvage, 2005). It is feared that these, among others, will probably lead to increased availability and use of cannabis (Stuttaford, 2006).
However, Hall and Solowij (1998) observed that the current state of unresolved debate about the effects of the use of cannabis leaves the medical profession with the 29 dilemma of what concrete information to give current and intending users, especially in the developed economies.
Studies into the relationship between cannabis and psychosis have produced mixed results. However, it is well known that established psychosis gets worsened with the use of cannabis. This is evident in increased symptom severity (Grech et al,
2005), longer duration of hospitalization (Dervaux et al, 2003) and reduced responsiveness to anti-psychotic medications (Green et al, 2004). Thornicroft (1990) postulated a possible number of assumptions to explain the observed relationships between cannabis use and psychosis.
The Self-medication theory supposes that cannabis use could be a form of self medication to counter the negative symptoms, depressed mood or side effects of treatment of schizophrenia. In a study of why psychotic patients use cannabis by
Green et al (2004), the respondents with psychosis compared to those without psychosis were more likely report positive mood alteration and coping with negative affect as the main reasons for their use of cannabis. Affect alteration especially was found to correlate with frequency of use.
The second possibility is that of cannabis use being an independent cause of psychosis de novo. Its role as a ‘component’, ‘necessary’ or ‘sufficient’ cause of psychosis in individuals without predisposition to developing psychotic illness has also been considered. What is popularly accepted is that cannabis use is more of a component in a myriad of interacting influences which lead to psychosis. 30 The shared-cause or ‘common vulnerability model’ as it is called, assumes that similar risk factor(s) are responsible for both psychosis and cannabis use in the same individual. The ‘risk factor’ could be possible genetic background or childhood history which, while making people prone to developing schizophrenia for example, also increases their likelihood to use cannabis (Erowid, 2005).
The fourth possibility is that the use of cannabis precipitates a latent illness an individuals who is predisposed to developing such an illness. This particular view has over the years gained much research support in practice of psychiatry. Thornicroft
(1990) also suggested the possibilities that cannabis use and psychosis may not be associated or that when such an association is observed, it may have occurred by chance. While these may be intellectually refreshing, it has been noted that the consistent associations between cannabis use and psychosis often observed in various studies show that the assumption of a chance-association is more unlikely (Hall and
Degenhardt, 2008). Gureje et al (2005) found that the cannabis use is believed to be an important risk factor for mental disorders both by lay people.
The need to differentiate psychosis from psychotic symptoms was stressed by
Erowid (2005), who opined that the two do not necessarily mean the same thing. Some authors see psychosis as a spectrum which extends from few symptoms to more serious syndromes which often require medical intervention. A number of studies of the relationship between cannabis and psychosis spectrum have not shown any difference of results (Os J vans et al, 2002). It is believed that the symptoms could be seen as a prelude to the development of established psychotic disorder. Transient 31 symptoms of intoxication or toxic psychosis are known and explainable in the context of recent cannabis use. However, a more lasting ‘functional psychosis’ which is differentiated from ‘toxic’ psychosis by absence of altered sensorium has also been reported (Jagadisha et al, 2006). While toxic psychosis can be attributed wholly to cannabis, it appears the same cannot be said of the functional one, which is thought to be mediated by yet poorly described vulnerability.
Psychotic symptoms are said to be more in cannabis users than in the general population (Degenhardt et al, 2003). A cross-sectional study by Verdoux et al (2003) explored associations between cannabis use and dimensions of psychosis in a non- clinical population of females. The frequency of the use of cannabis was found to be independently associated with the intensity of positive and negative psychotic experiences. Similarly, Thomas (1996) conducted a community survey of adverse effects of cannabis use in a non-clinical population of 1000 New Zealanders, aged between 18-35 years. The most common effects found were anxiety and panic attacks in 22% while psychotic symptoms were reported in 15% following cannabis use.
The risk of psychosis among individuals who ordinarily were not cannabis users became increased with ‘ever’ use of cannabis (Kontominas, 2007). Chopra and Smith
(1974) had earlier reported cases of 200 patients in Calcuta who developed psychosis after taking cannabis. A number of other studies have shown similar results (Semple et al, 2005; Henquet et al, 2005; Farat et al, cited in Science Daily, 2005). Andreason et al (1987) showed that individuals who were psychosis-free at baseline in a
32 longitudinal study had increased risk of psychotic outcome after lifetime use of cannabis.
One reason why there is interest in assessing associations between cannabis use and psychosis lies in the understanding of a possible causal relationship between the two. This is believed to be an important prerequisite in formulating an effective preventive policy. The limitations of cross-sectional studies in the examination of causal relationship between cannabis use and psychosis (psychotic symptoms) have been expressed by Macleod et al (2004), who expressed the view that longitudinal and interventional studies are better options.
Henquet et al (2005) analysed the results of a longitudinal study in Germany conducted between 1995 and 1999. After correcting for some known risk factors for psychosis, the study found that individuals predisposed to developing psychosis who used cannabis (23.8%) were more likely to report psychotic symptoms than those who have similar predisposition but did not use cannabis.
Psychotic symptoms presence among non-clinical population has equally been investigated by Os J van et al (2002). In this three year follow-up of 4045 Dutch people free of psychosis and 59 who had baseline diagnosis of psychotic disorder, it was discovered that baseline cannabis use predicted at follow-up presence of any level of psychotic symptoms (OR= 2.76), severe level (OR= 24.17) and psychosis needing clinical attention (OR= 12.01). It was concluded that cannabis use increased the risk of incidence of psychosis in people free of psychosis at baseline. Furthermore, Fergusson et al (2005) as part of a 25 years follow-up of 1265 New Zealand children in the 33 Christchurch Health and Development Survey, controlled for known risk factors for psychosis. The study found that the risk of psychotic symptoms rate was 1.6-1.8 times higher in those using cannabis within 12 month period at ages 18, 21 and 25 years.
Using complex statistical analysis, it was revealed that the direction of causality was from cannabis to psychosis and not vice-versa.
Ferdinand et al (2005) conducted a 14 year follow-up of 4-6 year olds in a
Dutch society, where the use of cannabis is liberalized. It was found that lifetime use of cannabis in people who had no prior psychotic symptoms predicted its occurrence in future (HR= 2.81; 95%CI= 1.79-4.43), while psychosis in people with no prior use of cannabis predicted its use later in life (HR= 1.70; 95%CI = 1.13-2.57).
Systematic review of pooled studies with defined characteristics is believed to have advantage of a larger sample size. This approach has equally been employed in trying to address the issue of a causal relationship between cannabis and psychosis.
One of such is Semple et al (2005) meta-analysis of 7 studies conducted between 1966 and 2004. The study found that early cannabis use was associated with increased risk of psychosis (OR=2.9, 95%CI= 2.4-3.6).
The role of cannabis use in schizophrenia, an extreme form of psychosis, has also received attention. Currently, the discovery of more cannabinoid 1 (CB1) receptors in the prefrontal cortex as well as anandamide, an endogenous cannabinoid in the cerebrospinal fluid of patients with schizophrenia, have brought a new complexity into the equation involving cannabis and schizophrenia. Devoux et al
(2003) compared socio-demographic characteristics and clinical features of patients 34 with schizophrenia using cannabis and those who were abstinent. Despite the observation that the groups were similar in their characteristics, those who were using cannabis had longer hospitalisation. This may not be unconnected with possible reduced response to anti-psychotics (Green et al, 2004; Isaac et al, 2005). Green et al
(2004) also found an earlier age of schizophrenia-like disorders in those who used cannabis.
The need to be cautious in interpreting the observed associations between cannabis use and psychosis has been expressed. Erowid (2005) noted that, although about half of patients with schizophrenia have co-morbid cannabis use, this in itself does not translate to causality. Secondly, the observation that cannabis use starts at just about the age of prodrome may be explained either as an attempt to self medicate or that both may perhaps due to a common vulnerability. Certain symptoms are believed to have more weight than others in the equation of cannabis use and psychotic symptoms. Consequently, in a critique of works by Fergusson et al (2005) and
Henquet et al (2005), Erowid (2005) was of the view that symptoms of paranoia and having thoughts and/or ideas that others do not share should be expected in settings where cannabis use is legally prohibited. By implications, symptoms like auditory and visual hallucinations would be particularly more indicative.
Investigating the role of cannabis as independent cause for schizophrenia,
Degenhardt et al (2003) modelled the effect of cannabis on schizophrenia in eight cohorts from 1940 to 1979. The findings reported were worsening of symptoms of psychosis with cannabis use and the fact that the incidence of cannabis use among 35 schizophrenia patients was more than in the general population. However, they found that despite the steep rise in the use of the drug, a corresponding increase was not found for the incidence of schizophrenia. Another important review of 5 longitudinal studies was carried out by Arseneault et al (2004), which showed that at individual level, cannabis increased the risk of developing schizophrenia two-fold but only 8% on the population level.
The concept of ‘cannabis psychosis’ is based on the assumption that it is a psychosis which ordinarily would not have occurred in the absence of the drug use
(DSM-IV, 1994). Its existence as a matter of fact has been controversial. Most studies have not supported such a diagnostic entity. Comparing 70 patients diagnosed as having cannabis-induced psychosis, with 163 cases of schizophrenia, Imade and Ebie
(1991) found no difference or specificity in their symptoms. The search for specific symptomatology of cannabis psychosis has not yielded any positive findings
(Sijuwola, 1986; Thornicroft et al, 1992; Hall, 1998). Furthermore, Poole and Bebbins
(1996) noted that the diagnostic criteria were poorly specified; especially the requirement to ascertain that the condition would not have occurred due to other reasons (DSM IV-TR, 1994). This comes on the heel of the fact that the level of development in technology has afforded very little knowledge about aetiology of most psychiatric disorders (Gelder et al, 2000). Hall (1998) opined that though the existence of this condition may not be totally ruled out, they however must be very rare.
There is a popular belief that psychotic symptoms which occur in the setting of cannabis use should resolve after the user stops the use. This assumption some believe, 36 has fuelled the tolerant attitude to cannabis which is regarded as harmless, especially in those without previous history of psychotic experiences. However, going by recent studies, a rethink is definitely needed. Arendt et al (2005) conducted a five year follow-up of 535 individuals who were psychosis-free at baseline. Of those who were diagnosed as cases of cannabis-induced psychosis, 50% subsequently received a diagnosis of schizophrenia within 12 months of their first psychotic episode. He observed that the favourable tag attached could have been due to lack of follow-up of these cases.
While it may be said that the use of cannabis is age-long, Salvage (2005) noted that the wealth of clinical research evidence into its effects, relationship to psychotic experience inclusive, is minimal. In the opinion of Jagadisha et al (2006), understanding the psychotogenic properties of cannabis may be useful in evaluating the risk of development of psychosis among its users. Because of the observed greater increase in violence, aggression and crime among persons with both drug abuse and psychotic symptoms, it is believed that knowledge gained regarding the frequency of psychotic symptoms among drug users and their vulnerabilities may be useful from forensic point of view.
37 Chapter Three
AIMS AND OBJECTIVES The overall purpose of this study is to determine the prevalence of psychiatric morbidity and the association it may have with cannabis abuse.
The specific objectives are:
1. To determine the prevalence and pattern of psychiatric morbidities among
young automobile apprentices.
2. To determine any association between psychiatric morbidity and abuse of
cannabis.
HYPOTHESIS There is significant difference in the prevalence of and type of psychiatric morbidities between young male persons who abuse cannabis and those who do not.
38 Chapter Four
4. METHODOLOGY
4.1 STUDY SETTING Sokoto State is one of the 36 States in the Federal Republic of Nigeria.
According to the provisional census results released in 2006 by the National
Population Commission, it has an estimated population of 3,696,999. Situated in the north western part of the country, it shares its borders to the north with the Republic of
Niger, to the east with Zamfara State and to the South with Kebbi State. It is an agrarian society; predominantly Hausa speaking, though other tribes are represented.
The people engage in other socioeconomic activities during the dry seasons such as trading. The seat of the caliphate is situated in the State capital, Sokoto, a town from which the state derives it name. It is a town made up of 2 of the 23 local governments in the state. Most people in the town engage in businesses of various sorts.
The youths in the town, like their peers in other parts of the country, attend western or Quranic schools. Those who either cannot enrol for or continue their western education usually end up learning a trade or vocation such as automobile works.
4.2 STUDY POPULATION. The target population for the study comprised of all apprentices in the automobile workshops in Sokoto town. There are 4 major mechanic villages in the state capital, so designated because of the concentrations of such workshops. These
39 are in Illela, Kwannawa, More and J- Allen areas of the town. The apprentices constitute a well defined group of young male adults as well as teenagers who are enrolled for training under masters for an average period of 4-5yrs. These are those who, due to one reason or the other, might not have been able to go beyond the elementary levels of western education. They are into auto-electronics, mechanical works, panel beating, painting, vulcanising and welding, among others. These youths represent the major ethnic groups of Hausa, Yoruba and Ibo. By the circumstance of their training, these individuals stay most days of the week outside direct supervision of their parents. Most often, their work is more manual than intellectual, with greater need for physical energy. Furthermore, the likelihood of social contact with the street is more among this group of youths than their age-mates in school, who most of the day, are in the formal and regimented environment of schools. All these might make for greater risk of exposure to drugs such as cannabis in this group.
4.3 INCLUSION CRITERIA 1) Being an apprentice in an automobile works
2) Being 18 years and above.
3) Willingness to participate in the study.
4.4 EXCLUSION CRITERIA 1) Having had a positive family history of mental-illness.
2) Having a positive history of psychiatric treatment.
40 4.5 ASSESSMENT INSTRUMENTS The assessment instruments for the study are the General Health Questionnaire
(GHQ 28-Item) and World Health Organisation Composite International Diagnostic
Interview (CIDI).
GHQ-28
The General Health Questionnaire was developed in 1972 by Goldberg as a rapid assessment technique. Since then, several versions have been produced, with four main ones in use. These are the 60, 30, 28 and 12-items questionnaires
(Oladimeji, 2005). The 28-item version yields scores on four scales: anxiety and insomnia; somatic symptoms; social dysfunction and severe depression. It takes about four minutes to complete. Morakinyo (1983) was reported to have found a sensitivity of 69.7% and specificity of 96% for the GHQ-60 (Oladimeji, 2005). As an assessment instrument, the General Health Questionnaire-28 is very popular and has been used extensively in Nigeria (Makanjuola, 1979; Aghanwa, 1992). The Hausa version of the
General Health Questionnaire-28 has been developed by back translation and was used by Rabebe (1996) to assess psychiatric morbidity among inmates of a Nigerian prison in Maiduguri.
World Mental Health-CIDI
World Health Organisation’s World Mental Health (WMH) Survey version of the Composite International Diagnostic Interview (CIDI; Kessler and Ustun, 2004) is a highly and fully structured diagnostic interview, quite complex in its decision rules but flexible enough to be administered by trained interviewers who are not necessarily
41 clinicians. It generates diagnoses according to both ICD-10 (World Health
Organisation, 1992) and DSM-IV criteria. It is intended for use in epidemiological and cross-cultural studies as well as for clinical and research purposes. The CIDI allows investigators to measure prevalence, severity and burden of mental disorders. It also allows assessment of service and medication use in treating these mental disorders as well as the determination of who is treated or not and the barriers to such treatments. It is modular and reputed to be the most widely used structured diagnostic interview worldwide. The various versions of the instrument in use in Nigeria were developed using standard protocols of iterative back translation conducted by panels of bilingual experts and were used in the Nigerian Survey of Mental Health and Well-Being
(Gureje et al, 2007).
4.6 SAMPLE & SIZE
The prevalence of cannabis abuse in the Nigerian population was 2.4% (Obot,
1992). However the prevalence of psychotic symptoms among cannabis smokers was given by Thomas (1996) as 15%.
N= (Z/E) 2 (P) (1-P)
Where
N= Sample Size
Z= A constant usually 1.96 at 95% CI
E= Degree of error permissible for the study and is put at 0.05%
42 P= Prevalence of psychotic symptoms among cannabis smokers which is 15%
(Thomas, 1996).
N= (1.96)2 / (0.05)2 x (0.15) (1-0.15)
= (3.84 x 0.15 x 0.85) / 0.0025
= 0.4896 / 0.0025
= 196.
Therefore, Ns= 196. However, assuming that 10% of respondents may not respond
New Sample size= Ns X 100/90 (Araoye 2003).
Ns= 196 X 1.11
=218.
4.7 SAMPLING The required number of subjects for the study was recruited from the apprentices in mechanic villages in Sokoto town, the state capital. The chairmen of the mechanic villages were first contacted as well as the state chairman of the National
Automobile Technicians Association (NATA) to enlist their support and that of their registered members.
Enumeration of the automobile workshops was done by visiting the four mechanic villages. In all, 783 workshops were counted. With the assumption of one apprentice per workshop, 218 workshops were randomly selected. These were visited and enumeration of the apprentices done. A total of 437 apprentices were enumerated out of which 24 have family or personal history of mental illness. Random balloting 43 was done to select the 218 respondents out of the remaining 413. The 218 was to make provision for non-responses.
4.8 PROCUDURE Training with the use of the World Mental Health Survey version of the
Composite International Diagnostic Interview (WMHCIDI) was obtained from a consultant psychiatrist, Dr Abdullahi, who himself was trained and had also previously used the instrument in his study. The study commenced after an inter-rater reliability of 0.8 between my trainer and I and test re-test reliability of 0.85 was achieved on a sample of 8 nursing students who were on clinical posting after an interval of five days.
Before the conduct of the actual research, a pilot study was done among 20 young apprentices in auto repair workshops. These were apprentices in workshops not included in the main study. This pilot study allowed field experience with the use of the instruments and assessment of how long it took to administer the instruments to subjects. The time on average to complete an assessment with the interviewer administered instrument was about 45 minutes.
The main research started with briefing of each respondent on the essence of the work and they were given opportunity to ask questions. Verbal informed consent was given by respondents after which they were given copies of the GHQ-28 in the language version indicated. Some filled and returned it immediately while quite a few took it home. Appointments were made for the interview part of the study whenever 44 this was not immediately possible and these were conducted in as much privacy as was possible. Socio-demographic data of the respondents such as age, level of education, religion, marital status, ethnicity and type of apprenticeship were obtained followed by assessment with the psychosis screening and finally the substance use sections of the instrument. This sequence was to avoid or minimize a source of bias which could arise from foreknowledge of substance use in the respondents.
Respondents were thanked for their participation at the end of each interview.
4.9 ETHICAL CONSIDERATIONS Informed consent of respondents as well as ethical approval from Federal
Neuro-psychiatric Hospital, Sokoto were obtained.
4.10 DATA ANALYSIS Data was analysed using EPI-Info version 3.2.2 (CDC, 2004). The subjects were categorised into those who abused cannabis and those who did not. Results were presented as simple cross-tabulations and proportions calculated for distributions in different groups. Cross-tabulation of variables of interest as well as tests of association between variables were done using students t-test for continuous and Chi-square for categorical variables. The level of significance was set at p<0.05.
45 Chapter Five
RESULTS Table 1 shows the socio-demographic characteristics of the respondents. Two hundred and eighteen eligible apprentices were contacted, out of which 200 completed the interview, giving a response rate of 91.7%. There were no differences between those who participated and those who did not in terms of age, education level, ethnic background and apprenticeship. Reasons for non participation included refusal, not completing the interview part of the assessment and sudden, unexpected travel.
The Table shows that most of the respondents were in the age group 21-25 years
(38.5%) and about 90% were less than 31yrs of age. One hundred and seventy-two
(86%) were never married and 56.5% had no or only primary education. One hundred and sixteen (58%) were apprentice mechanics, followed by apprentices of panel beating (21%), auto-electronics (9.0%), welding (2.5%), vulcanising (7.5%) and spare parts salesmanship (2.0%).
It also shows that most of the respondents were of Islamic faith (83%) while
17% were Christians. There was a preponderance of Hausas (50.5%) with other major ethnic identities of Yoruba, Ibo and Others represented as 33%, 5% and 11% respectively.
46 Table 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS (N= 200) n (%) Age groups (yrs) 18 to 20 54 (27%) 21-25 77 (38.5%) 26-30 51 (25.5%) 31+ 18 (9%) Range (yrs) 18-35 Mean (SD) 24.1 ±4.5 yrs Marital Status Never Married 172 (86) Married 28 (14) Education level completed Nil 26 (13.0) Primary 87 (43.5) Secondary 85 (42.5) Tertiary 2 (1.0) Apprenticeship Mechanic 116 (58.0) Panel beating 42 (21.0) Welding 5 (2.5) Vulcanising 15 (7.5) Auto-electronics 18 (9.0) Spare part salesmanship 4 (2.0) Religion Christianity 34 (17.0) Islam 166 (83.0) Ethnicity Hausa 101 (50.5) Ibo 10 (5.0) Yoruba 66 (33.0) Others 23 (11.5)
47 Lifetime and past year use or abuse of alcohol and other substances among the respondents are presented in Table 2. One hundred and twenty six (63%) respondents reported lifetime use of one substance or the other, while 114 (57%) reported use of these substances during the previous one year. Non-prescription analgesic use was most common, both in terms of lifetime and past year use (31.5% and 28% respectively). Next most common were marijuana and alcohol (lifetime: 26% and
16.5%; past year: 21.5% and 11% respectively). Inhalant and non-prescription sedative use were less common (lifetime: 8% and 2.5%; past year: 3.5% and 2.5% respectively). Lifetime and past year multiple substance uses were 15.5% and 13% respectively.
48 Table 2: LIFETIME AND CURRENT USE OF SUBSTANCES AMONG THE RESPONDENTS (N=200) Substance †Lifetime use ‡Current use Alcohol 33 (16.5) 22 (11.0%) Marijuana 52 (26.0) 43 (21.5%) Analgesic 63 (31.5) 56 (28.0) Solvents 16 (8.0) 7 (3.5%) Sedative/hypnotics 5 (2.5) 5 (2.5%) Use of only one drug 95 (47.5) 88 (44.0) Multiple drug use 31 (15.5) 26 (13.0) NB: Some individuals took more than one drug. †Lifetime use of any substance was reported by 126 respondents. ‡Current use of any substance was reported in 114 respondents.
49 Table 3 presents the pattern of cannabis abuse. Abuse of cannabis commenced as early as 13 years of age, with 38 (73.1%) in the age group 13-17 years. It also shows that the tendency to start abuse of cannabis became lower as respondent’s age increased. The mean age of onset of abuse was 16.5±2.4 yrs. The Table shows that
32(61.5%) of those who abused cannabis had used it between 5-8 years, with a mean duration of use of 6.5±3.4 yrs. Most of those who currently abused cannabis took it nearly every day (30.2%). The next common frequencies were 1-2 days/week (27.9%),
1-2 days/month (20.9%), 3-4 days/week (18.6%) and less than once/month (2.3%).
50 Table 3 PATTERN OF CANNABIS ABUSE AMONG RESPONDENTS (N=52) Variable N (%) Age of onset of cannabis abuse (yrs) 13-17 38 (73.1) 18-22 11 (21.2) 23+ 3 (5.8) Mean age of onset of abuse (SD) 16.5 ±2.4 Duration of cannabis abuse (yrs) 1- 4 13 (25.0) 5- 8 32 (61.5) 9- 12 5 (9.6) 13- 16 4 (7.7) Mean duration of abuse (yrs) 6.5 ±3.4 Use of other drugs in those with lifetime cannabis abuse Yes 22 (42.3) No 30 (57.7) Frequency of current abuse of cannabis (n=43) Nearly every day 13 (30.2) 3- 4 days/week 8 (18.6) 1- 2 days/week 12 (27.9) 1-3 days/month 9 (20.9) Less than once/month 1 (2.3)
51 Table 4 shows the prevalence of psychiatric morbidity among the respondents.
It shows that general psychiatric morbidity was highest among those with lifetime and past year abuse of cannabis (both 44%), while it was 25% among the abstinent respondents. The prevalence of psychotic symptoms was higher among those who abused cannabis (lifetime: 39% and past year: 37%) than in those who did not (20%).
52 Table 4
PREVALENCE OF PSYCHIATRIC MORBIDITY AMONG RESPONDENTS
General psychiatric morbidity Present Absent Total Freq % Freq % Freq % Abstinent respondents 37 25 111 75 148 100 Lifetime (cannabis abuse) 23 44 29 56 52 100 Past year (cannabis abuse) 19 44 24 56 43 100
Psychotic morbidity Present Absent Freq % Freq % Freq % Abstinent respondents 30 20 118 80 148 100 Lifetime (cannabis abuse) 20 39 32 61 52 100 Past year (cannabis abuse) 16 37 27 63 42 100
53 The socio-demographic and clinical characteristics of respondents who reported lifetime cannabis abuse and those who did not are shown in Table 5. The Table shows that there is a significant association between cannabis abuse and age of the respondents (X2=13.49, df=2, p=<0.05) with most of the those who abused cannabis in the age group 21-25 yrs (59.6%) while 31.1% of the respondents who did not abuse cannabis was within this age group. Those who abused cannabis were younger, as indicated by their mean ages (Cannabis abuse=23.0±3.3 years; Non-cannabis abuser=24.5±4.9 years).
Cannabis abuse was also significantly related with type of apprenticeship
(X2=6.81, df=2, p=0.03) and a positive family history of substance use disorder
(X2=21.62, df=1, p=<0.05). More of the cannabis abuse group (21.2%) had a positive family history of substance use disorder. An association was demonstrated between cannabis abuse and religion (X2=4.31, df=1, p=0.03).
There was no significant association between cannabis abuse and marital status
(X2=1.12, df=1, p=0.29), years of western education completed (X2=1.39, df=1, p=0.24), and ethnicity (X2=2.94, df=3, p=0.40).
54 Table 5 SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF RESPONDENTS WITH LIFETIME CANNABIS ABUSE AND THOSE WITHOUT CANNABIS ABUSE Variable Cannabis abuse status Abuse No abuse N=52 % N=148 % t X2 df P Age groups (yrs) 18-20 8 15.4 46 31.1 21-25 31 59.6 46 31.1 26+ 13 25 56 37.8 13.49 2 <0.05 Mean age (SD) yrs 23.0±3.3 24.5±4.9 2.05 198 0.04 Range 18-33 18-35 Marital status Never married 47 90.4 125 84.5 Married 5 9.6 23 15.5 1.12 1 0.29 Education (years) 0-6 33 63.5 80 54.1 7+ 19 36.5 68 45.9 1.39 1 0.24 Religion Islam 48 92.3 118 79.7 Christianity 4 7.7 30 20.3 4.31 1 0.03 Ethnicity Hausa 30 57.7 71 48.0 Yoruba 17 32.7 49 33.1 Ibo 1 1.9 9 6.1 Others 4 7.7 19 12.8 2.94 3 0.40 Apprenticeship Mechanic 38 73.1 78 52.7 Panel beating 6 11.5 36 24.3 Others 8 15.4 34 23.0 6.81 2 0.03 Family History of substance use Yes 11 21.2 3 2.0 No 41 78.8 145 98.0 21.62 1 <0.05
55 Table 6 shows the prevalence of probable psychiatric morbidity in individuals with lifetime cannabis abuse and respondents without such an abuse of cannabis.
Cannabis abuse was significantly associated with probable general psychiatric morbidity (X2=6.78, df=1, p=0.009), with a higher proportion of 23 (44.2%) in those who abused cannabis compared to 37 (25%) in those who did not.
Respondents who abused cannabis also reported more psychotic symptoms
(38.5%) than those not abusing cannabis (20.3%), and this difference was found to be statistically significant (X2=6.97, df=1, p=0.009).
56 Table 6 DISTRIBUTION OF PSYCHIATRIC MORBIDITY AMONG RESPONDENTS ADMITTING TO LIFETIME ABUSE OF CANNABIS AND NON-CANNABIS ABUSE RESPONDENTS Cannabis abuse status Morbidity Abuse No abuse X2 df P N= 52 % N= 148 % General: Present 23 44.2 37 25.0 Absent 29 55.8 111 75.0 6.78 1 0.009 Psychotic: Present 20 38.5 30 20.3 Absent 32 61.5 118 79.7 6.79 1 0.009
57 Table 7 shows the socio-demographic variables of psychotic respondents who abused cannabis and those of psychotic respondents who did not abuse cannabis. The two groups are similar in age group distribution (X2=2.10, df=1, p=0.14). The mean age of onset of psychotic symptoms was earlier in those who abused cannabis
(16.1±3.1 yrs) in contrast to those who did not abuse it (18.1±3.9 yrs). The onset of psychotic symptoms was within the age range 11-16 years in 55% of those who abused cannabis whereas most of the psychotic non-cannabis abusers reported the onset at later ages. However, the differences were negligible and non-significant
(t=1.92, df=48, p=0.06).
Sixteen (53.3%) of the respondents without cannabis abuse reported the use of other drugs whereas only one-third of those who abused cannabis did so. Furthermore, there was no difference between psychotic respondents who were abusing and those who were not in terms of marital status, education level, religion or family history of substance use disorder.
58 Table 7 COMPARISON OF SOCIODEMOGRAPHIC CHARACTERISTICS OF PSYCHOTIC CANNABIS ABUSING AND PSYCHOTIC NON-CANNABIS ABUSING RESPONDENTS Psychotic symptom Factor Cannabis abuse No cannabis abuse t X2 df P Age of respondents (years) N= 20 % N=30 % 18-20 3 15.0 10 33.3 21-25 17 85.0 20 66.7 2.10 1 0.14 Mean age of 23.8 ±4.2 23.7 ±4.1 0.08 48 0.93 respondents(SD)yrs Age of onset of psychosis 11-16 11 55.0 10 33.3 17+ 9 45.0 20 66.7 2.31 1 0.13 Mean age of onset (SD)yrs 16.1 ±3.1 18.1 ±3.9 1.92 48 0.06 Co-use of other drugs Yes 6 30.0 16 53.3 No 14 70.0 14 46.7 2.65 1 0.10 Family history (Substance Use) Yes 2 10.0 1 3.3 No 18 90.0 29 96.7 0.95 1 0.33 Education years completed 0-6 12 60.0 14 46.7 7+ 8 40.0 16 53.3 0.86 1 0.36 Marital status Never married 16 80.0 26 86.7 Married 4 20.0 4 13.3 0.40 1 0.53 Religion Islam 20 24 80.0 Christianity 0 0.0 6 20.0 2.48 1 0.07
59 Table 8 presents subgroups of respondents with lifetime abuse of cannabis that did and did not report psychotic symptoms with a view to exploring factors that may distinguish them. Mean ages of onset of cannabis abuse were 16.1±2.1 and 16.9±3.1 respectively. No significant statistically important difference was found (X2=0.44, df=1, p=0.80).
The Table shows that the duration of cannabis abuse was longer in those who reported psychotic symptoms (7.6±2.1 yrs) than those who did not (5.7±2.9 yrs) and there was statistically significant difference in their mean duration of cannabis abuse
(t=2.09, df=50, p=0.04).
However, the subgroups did not differ as regards history of use of other drugs
(X2=2.02, df=1, p=0.16) and positive family history of substance use (X2=2.42, df=1, p=0.12).
60 Table 8
RELATIONSHIP BETWEEN SOCIODEMOGRAPHIC/PATTERN OF CANNABIS ABUSE AND PSYCHOTIC SYMPTOM EXPERIENCE AMONG RESPONDENTS WITH LIFETIME CANNABIS ABUSE Psychotic symptom among those who abuse cannabis Present Absent t X2 df P Factors N=20 % N=32 % Age groups (years) 18-20 3 15.0 5 15.6 21-25 11 55.0 20 62.5 26+ 6 30.0 7 21.9 0.44 2 0.80 Mean age (sd) years 23.8±4.2 23.0±3.2 0.78 50 0.44 Age of onset of cannabis abuse (yrs) 13-17 15 75.0 23 72.0 18+ 5 25.0 9 28.0 0.06 1 0.81 Mean age( yrs) of onset of 16.1±2.1 16.9±3.1 1.02 50 0.31 abuse Duration of cannabis abuse (yrs) 1-4 3 15.0 10 31.3 5-8 12 60.0 20 62.5 9+ 5 25.0 2 6.3 4.53 2 0.10 Mean duration of cannabis 7.6±3.6 5.7±2.9 2.09 50 0.04 abuse (yrs) Use of other drugs Yes 6 30.0 16 50.0 No 14 70.0 16 50.0 2.02 1 0.16 Family history of substance use Yes 2 10.0 09 28.1 No 18 90.0 23 71.9 2.42 1 0.12
61 Table 9 presents respondents with lifetime history of cannabis abuse who had probable general psychiatric morbidity and those who did not. These subgroups were not different in terms of their age group distribution (X2=3.15, df=2, p=0.21), age of onset of cannabis abuse (X2=0.03, df=1, p=0.87), the duration of cannabis abuse
(X2=4.85, df=2, p=0.09) and history of use of other drugs (X2=3.58, df=1, p=0.06).
However, there was significant association between positive family history of substance use and probable general morbidity (X2=4.59, df=1, p=0.03). Positive family history of substance use was found in approximately one third of the respondents with lifetime cannabis abuse who have probable general morbidity whereas it was obtained in 13.3% of those without such morbidity. The difference was statistically significant
(X2=4.59, df=1, p=0.03)
62 Table 9
RELATIONSHIP BETWEEN SOCIODEMOGRAPHIC/PATTERN OF CANNABIS USE AND GENERAL PSYCHIATRIC MORBIDITY AMONG RESPONDENTS WITH LIFETIME CANNABIS ABUSE
General morbidity among those who abuse cannabis Present Absent Factors N=23 % N=29 % t X2 df P Age groups (years) 18-20 4 17.4 4 13.8 21-25 16 69.6 15 51.7 26+ 3 13.0 10 34.5 3.15 2 0.21 Mean age (sd) years 22.4±1.9 24.1±4.3 1.76 50 0.08 Age of onset of cannabis abuse (yrs) 13-17 17 73.9 22 75.9 18+ 6 26.0 7 24.1 0.03 1 0.87 Mean age( yrs) of onset of 16.3±2.7 16.8±2.8 0.65 50 0.52 abuse Duration of cannabis abuse (yrs) 1-4 6 26.1 6 20.7 5-8 16 69.6 15 51.7 9+ 1 4.3 8 27.6 4.85 2 0.09 Mean duration of abuse (yrs) 5.8±2.1 6.9±3.9 1.22 50 0.23 Use of other drugs Yes 9 39.1 13 44.8 No 14 60.9 16 55.2 3.58 1 0.06 Family history of substance use Yes 8 34.8 3 10.3 No 15 65.2 26 89.7 4.59 1 0.03
63 Tables 10 and 11 show the frequencies of cannabis abuse in respondents who have probable psychiatric morbidities and those who did not. Table 12 shows that the frequency of cannabis abuse is related to experience of psychotic symptoms. Increase in frequency of cannabis abuse was associated with increased likelihood of experiencing psychotic symptoms. However, the association was not statistically significant (X2=4.61, df=2, p=0.10).
Table 13 reveals that the likelihood of probable general morbidity was highest in those who abused cannabis most frequently (42.1%). Furthermore, among those who did not have general psychiatric morbidity, abuse of cannabis was less frequent in most (58.3%). However, this difference was not statistically significant (X2=4.53, df=2, p=0.10).
64 Table 10
RELATIONSHIP BETWEEN FREQUENCY OF CANNABIS ABUSE AND PSYCHOTIC SYMPTOM AMONG RESPONDENT WITH CURRENT CANNABIS ABUSE Psychotic symptom
Present Absent
Frequency of use Freq % freq % X2 df P
5-7 days/week 6 37.5 7 25.9
3-4 days/ week 5 31.3 3 11.1
<3 days/week 5 31.3 17 63.0 4.61 2 0.10
Total 16 100 27 100
Table 11
RELATIONSHIP BETWEEN FREQUENCY OF CANNABIS ABUSE AND GENERAL PSYCHIATRIC MORBIDITY AMONG RESPONDENTS WITH CURRENT CANNABIS ABUSE General morbidity
Present Absent
Frequency of use Freq % Freq % X2 df P
5-7 days/week 8 42.1 5 20.8
3-4 days/ week 3 15.8 5 20.8
<3 days/week 8 42.1 14 58.3 2.28 2 0.32
Total 19 100 24 100
65 Chapter Six
6. DISCUSSION Socio-demographic characteristics of the respondents
Most of the respondents were Muslims (83%). An earlier study showed this predominance of Islam and this is really not surprising as Islam is the predominant religion in the north (Tawasu, 2005). There is also preponderance of Hausa (51%).
The respondents were mostly single (86%) and young (Mean age, 24.1±4.5 years).
Almost nine in ten of the respondents (87%) had some form of education. The age range of respondents was 18- 35 years. This range corresponds to the age at which most of them would have been in the university given the 6-3-3-4 system of education.
More than half (63%) of the respondents had used one drug or the other in their lifetime, while most continued this use even within the past year (57%). This might perhaps mean that most of these respondents use drugs for years.
Abuse has been defined as use of any illegal substance such as cannabis in the face of prohibition (Habib and Sake, 2003). This study found lifetime and current cannabis abuse prevalence rates of 26% and 22% respectively among the respondents.
Cannabis emerged as the most abused illicit substance, similar to findings of other previous researches (Anumonye, 1980; NDLEA report, 1993; UNDCP, 2000). The lifetime prevalence rate was higher than the national lifetime average prevalence of
10.8% obtained from the Rapid Situation Assessment of Drug Use in Nigeria
(UNDCP, 2000). This could have been due to the fact that this study was done on a population of youths given the fact that previous studies have shown that cannabis 66 abuse is more common among young people. This prevalence is equally higher than
11% reported by Ihezue (1988) among medical students in Enugu. This could mean that these apprentices have more abuse of cannabis than their age-mates in schools.
Some factors may be responsible in this group of youths such as increased need for energy as revealed in the study by Odeleye (2000), the greater level of exposure to street drugs such as cannabis or perhaps it may be a reflection of possible higher prevalence of drug use in the northern part of Nigeria than the south as found in an earlier study (Ohaeri and Odejide, 1993).
The mean age of onset of cannabis abuse was 16.5±2.4 years. Cannabis abuse started as early as 13 years in some respondents. Seven in ten of these respondents who abuse cannabis started while within the 13-17 year age group. An important observation that the age of onset of drug use coincides with the age of puberty was made by Obiora and Awaritefe (1985). This trend has been observed in a previous report (NDLEA, 1993) where the age of onset of cannabis abuse was reported to be as early as 9- 11 years. Odejide & Morakinyo (2004) were of the opinion that certain characteristics of this period make them vulnerable: challenge of transition to adulthood, a time of conflict with authority especially parental, vulnerability to peer pressure, sense of invincibility, novelty seeking. This finding particularly calls for caution as certain studies observed that cannabis use earlier than the age 21 years carries greater risk of psychosis. This is because the developing brain and its neural connections are more susceptible to damage by cannabis use at such a time.
67 Similar to an earlier study (Nnaji, 1996), those who abuse cannabis in this study have history indicating chronic abuse (mean duration of cannabis abuse=6.5±3.4 yrs) where more than half of these have abused it for between 5 and 8 years. Furthermore, only 9 out of 52 of those with lifetime abuse stopped such abuse in the previous year.
Macleod (2004) had observed that the popular assumption that most of those who abuse cannabis will ‘grow out’ of it was without evidential basis. Furthermore, ethnicity did not show any significant relationship with cannabis abuse which is similar to findings of other studies from various parts of the country (Ebie & Pela,
1982; Odejide & Sanda, 1976; Anumonye, 1980).
Previous studies have found that those who abuse cannabis take other substances (Ihezue, 1988; Pela, 1989; Nnaji, 1996). This was found in fifth of the respondents with lifetime cannabis abuse. Cannabis is usually regarded as a ‘gateway’ to use of ‘harder’ drugs such as cocaine. However, this study found no history of abuse of cocaine. This may be due to the high cost of the drug, a reflection of the socioeconomic reality of the group.
Psychiatric Morbidities
General psychiatric morbidity:
There are reports of associations between anxiety and depression with cannabis
(Anumonye, 1980; Thomas (1996); Gelder et al, 2000; Clough et al, 2005; Bovasso,
2001). Thomas (1996) found that the most common mental problem in his study of adverse effects of cannabis in a non-clinical population in New Zealand was 68 anxiety/panic attacks in 22% of cannabis users. This study found a prevalence of
44.2% of probable psychological problem among those who abuse cannabis, a rate that is higher than that of those without such an abuse (25%). Cannabis abuse was significantly associated with probable general psychiatric morbidity. Furthermore, this study found that those who abuse cannabis had higher means on the subscales of
GHQ-28 relative to those without such abuse though there was no significant difference statistically. Interestingly, the question has always been asked as to what extent these symptoms are a cause or consequence of cannabis. This study is hampered in answering this question. However, an earlier longitudinal study found that cannabis abuse predicted development of anxiety and depression later and not vice versa (Patton et al, 2008).
Psychosis:
Association has been reported in a number of studies both in Nigeria and abroad between cannabis and psychosis (Nnaji, 1996; Imade and Ebie, 1991; Boroffka, 1966;
Asuni, 1964; Sijuwola, 1986; Ferdinand et al, 2005; Fergusson et al, 2005). It has been observed that quite a proportion of patients treated in hospital for psychosis reported cannabis abuse. The prevalence of psychotic symptoms in this study is 39%, which is higher than 15% reported by Thomas (1996). It is possible that, since the studies were done in different parts of the world, the strengths of cannabis used could have been different. There are reports of production of cannabis with different strengths across different countries of the world (Kontominas, 2007). 69 Significant association has been found between cannabis abuse and psychotic symptom in previous studies (Hall and Degenhardt, 2008). Although earlier studies have demonstrated that cannabis produces psychosis readily in vulnerable individuals and also worsens established psychosis (Nnaji, 1996; Arseneault et al, 2004; Hall et al,
2004; Henquet et al, 2005; Degenhardt et al, 2003), the significant association obtained in this study occurred in absence of familial predisposition to mental illness.
Cannabis abuse has been reported to precipitate psychosis which may even become chronic in people who have no family and personal history of psychiatric illness
(Andreason et al, 1987; Os vans J et al, 2002). There is the possibility that there are risk factor(s) other than familial vulnerability to psychosis with which cannabis interacts.
The mean age of onset of psychotic symptoms was earlier among the respondents who abused cannabis (16.1±3.1 years) than among those who did not but who reported similar symptoms (18.1±3.9 years). Though there was no significant difference, it is likely that cannabis abuse brought about these symptoms earlier by interacting with some other risk factors. Similar finding was reported by Nnaji (1996) among schizophrenia patients in Uselu.
This study did not find significant associations between lifetime cannabis abuse and individual psychotic symptoms of hallucinations and delusions. Erowid (2005) had suggested that symptoms such as visual and auditory hallucinations would be more indicative of psychosis due to cannabis. However, similar to findings of some
70 studies in the past (Imade and Ebie, 1991; Sijuwola, 1986), no symptom specificity for psychosis was found among those who abused cannabis.
The tendency to report psychotic symptoms and general psychiatric disturbance was found to increase with higher frequency of cannabis use in the study. This is similar to what has been demonstrated earlier (Henquet et al, (2005). This study however did not demonstrate significant association between frequency of cannabis abuse and psychiatric morbidities despite this observation. There is the possibility that frequency of use of a drug may not be a true reflection quantity consumed. The limitation of use of frequency of use of a drug as a yardstick to measure dose has been expressed (Tawasu, 2005) and this is especially so in the case of cannabis which is not sold by any precise weight (Kontominas, 2007). More quantity of cannabis could actually have been consumed though less frequently. Furthermore, the possibility also exists that those who experienced psychotic symptoms could have wanted a different reason for their experience and therefore under-report the quantity used. Although this study found that those who abuse cannabis and reported psychotic symptoms used it for longer duration of time, the difference was not significant. Similar to Henquet et al
(2005) finding, this study found that use of other drugs did not differentiate those who abuse cannabis with psychotic experiences and those who did not.
71 Chapter Seven
7. LIMITATIONS OF THE STUDY The findings of this study cannot be generalized to all youths as it is a study
among a set of youth. Regional differences could also exist which may be
evident if this study is carried out in other settings.
Limited resources such as finance and time constrained the scope and coverage
of this work. There could be greater level of certainty regarding cannabis abuse
if urine and other blood assays were performed, given the likelihood of
underreporting and denial of cannabis use commonly experienced in studies in
an environment such as ours where its possession and use is prohibited.
The information was retrospectively obtained and there is the possibility of
recall bias. Furthermore, report of psychotic symptoms could not be objectively
verified.
The factors explored in an attempt to differentiate outcomes of psychosis among
those who abuse cannabis were by no means exhaustive. Other factors could
exist which were not covered.
The cross-sectional nature of the research design made it impracticable to be
unequivocal about causation. The observed associations between cannabis abuse
and types of psychiatric morbidity do not translate to causality. Cohort studies
or case control studies are better alternatives in this regard.
72 Chapter Eight
8. CONCLUSIONS AND RECOMMENDATIONS
8.1 Conclusion This study has attempted to investigate psychiatric morbidities and any association it may have with cannabis abuse among an identified group of young automobile apprentices. The assumption that this group of youths was highly exposed to cannabis and any associated deleterious effects, held true, evidenced by high prevalence of its abuse among the respondents. Those who abused cannabis were significantly younger and they have family history of substance use. Higher prevalence rates for both the probable general psychiatric morbidity as well as psychotic symptoms were found among those who abused cannabis, despite an apparent lack of genetic predisposition. They were found to be significantly different from those who did not abuse cannabis in terms of the prevalence of psychiatric morbidities, which was not affected by the use of other drugs. This calls for caution because there is indication that cannabis may not be as ‘harmless’ as some might think. There is the possibility that cannabis abuse might be precipitating psychotic symptoms in some people, by interacting with risk factors other than genetic predisposition, in ways that are probably still poorly understood.
73 8.2 Recommendation
In view of the finding of a high prevalence of cannabis abuse among the young apprentices and its significant associations with psychiatric morbidities, it is important that public enlightenment programmes on the dangers of cannabis abuse be vigorously pursued, especially among the young people. This effort should not be limited to those in schools, but such should also be extended to other risk groups, such as these apprentices. It is also better to go beyond screening for these morbidities as was done in this study. A two-stage study design that allows for definitive assessment of morbidities is recommended. A longitudinal study with larger sample will help in establishing the direction of associations found between cannabis abuse and these morbidities. Furthermore, this is desirable in view of the finding of a previous study that reported later diagnosis of schizophrenia among those who previously reported psychotic symptoms.
Government should encourage researches into health problems associated with cannabis abuse by providing funds. This is important in view of the high cost implications of undertaking such studies in a meaningful way which may be beyond what an individual may be able to afford. Furthermore, programmes targeting demand and supply of psychoactive drugs generally and cannabis in particular, should be made an important component of any preventive programme at all levels of governance.
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86 APPENDICES APPENDIX I
GENERAL HEALTH QUESTIONNAIRE GHQ-28
Please read the following carefully. We should like to know if you have any medical complaints and how your health has been over the past few weeks. Please answer ALL the questions on the following pages by simply underlining the answer you think nearly applies to you. Remember that we want to know present and resent complaints, not those that you had in the past. It is important that you try to answer ALL THE QUESTIONS
Have you recently A1- Been feeling perfectly well and in Better than Same as Worse than usual Much worse than good health? usual usual usual A2- Been feeling in need of a good Not at all No more than Rather more than Much more than tonic? usual usual usual A3- Been feeling tired and unable to Not at all No more than Rather more than Much more than cope with living (run down and out usual usual usual of sorts)? A4- feel that you are ill? Not at all No more than Rather more than Much more than usual usual usual A5- Been getting a feel of tightness or Not at all No more than Rather more than Much more than pressure in your head? usual usual usual A6- Been getting any pains in your Not at all No more than Rather more than Much more than head? usual usual usual A7- Been having hot or cold spells? Not at all No more than Rather more than Much more than usual usual usual B1- lost much sleep over worry? Not at all No more than Rather more than Much more than usual usual usual B2- Have difficulty staying asleep once Not at all No more than Rather more than Much more than you are off? usual usual usual B3- felt constantly under strain? Not at all No more than Rather more than Much more than usual usual usual B4- Been getting edgy and bad Not at all No more than Rather more than Much more than tempered? usual usual usual B5- Been getting scared or panicky for Not at all No more than Rather more than Much more than no good reasons? usual usual usual B6- found everything getting on top of Not at all No more than Rather more than Much more than you? usual usual usual B7- Been feeling nervous and strung-up Not at all No more than Rather more than Much more than all the time? usual usual usual
87 C1- Been managing to keep yourself More so than Same as Rather less than Much less than busy or occupied? usual usual usual usual C2- Been taking longer over the things Quicker than Same as Longer than usual Much longer than you do? usual usual usual C3- felt on the whole you were doing Better than About the Less well than Much less well things well? usual same usual C4- Been satisfied with the way you’ve More satisfied About same Less satisfied than Much less carried out your task? as usual usual satisfied C5- felt that you are playing useful part More so than Same as Less useful than Much less useful in things? usual usual usual C6- felt capable of making decisions More so than Same as Less so than usual Much less about things? usual usual capable C7- Been able to enjoy your normal day- More so than Same as Less so than usual Much less than to-day activities? usual usual usual D1- Been thinking of yourself as a Not at all No more than Rather more than Much more than worthless person? usual usual usual D2- felt that life is entirely hopeless? Not at all No more than Rather more than Much more than usual usual usual D3- felt that life is not worth living? Not at all No more than Rather more than Much more than usual usual usual D4- thought of the possibility that you Definitely not I don’t think Has crossed my Definitely might make away with yourself? so mind D5- felt at times you could not do Not at all No more than Rather more than Much more than anything because your nerves were usual usual usual too bad? D6- found yourself wishing you were Not at all No more than Rather more than Much more than dead and away from it all? usual usual usual D7- found that the idea of taking your Definitely not I don’t think Has crossed my Definitely own life kept coming into your so mind mind? Thank you.
88 JERIN TAMBOYOYI KAN SHA’ANIN LAFIYA – 28 Karanta wannan sakon a tsanaki: Za mu so sanin ko ka/kin taba kokawa lafiyar ka/ki. Yaya kuma lafiyar ka/ki take, a’ yan makwannin baya. Don Allah amsa dukan tamboyoyin ta hanyar zabar amsar da kake gani ta shafe ka. Sai dai mun fi sha’awar sanin matsayin lafiyarka na yanzu da na ‘yan kwanakin da suka gabata, amma bana wanda ya jima ba. Yana da kyau a amsa dukkan tamboyoyi. Mun gode da wannan hadin kai. Cikin kwanakin nan kakan ji: 1. Lafiyar jiki warai? Kwarai da gaske kwarai Ba kamar da ba Ba kamar da ba matuka 2. Bukatar Karin lafiya da kuzari? A’a sam Kamar da fiye da da kwarai fiye da da 3. Rashin dadi da katabus? A’a sam kamar da fiye da da kwarai fiye da da 4. kamar baka da lafiya? A’a sam kamar da fiye da da kwarai fiye da da 5. Ciwon a cikin kanka? A’a sam kamar da fiye da da kwarai fiye da da 6. Alamar matsi ko daurewar kai? A’a sam kamar da fiye da da kwarai fiye da da 7. Zafi ko sanyi a locaci locaci? A’a sam kamar da fiye da da kwarai fiye da da 8. Rasa barci saboda damuwa? A’a sam kamar da fiye da da kwarai fiye da da. 9. Kasa komawa barci bayan farkawa? A’a sam kamar da fiye da da kwarai fiye da da 10. Rashin walwalar jiki kodayaushe? A’a sam kamar da fiye da da kwarai fiye da da 11. Ji bacin rai da saurin hushi? A’a sam kamar da fiye da da kwarai fiye da da 12. Firgita ko gigita bada wani dalili ba? A’a sam kamar da fiye da da kwarai fiye da da 13. Komai ya dagule? A’a sam kamar da fiye da da kwarai fiye da da 89 14. Rika jin tsoro da takura kodayaushe? A’a sam kamar da fiye da da kwarai fiye da da 15. ka/ki kan shagaltu da wasu ayuyuka? fiye da da kamar da ba kamar da ba ba kamar da ba matuka 16. Ka/Ki kan dauki lokaci mai tsawo wajen yin abubuwa? Ina sauri fiye da da kamar da ba na sauri kamar da ba na sauri 17. Ka/ Ki kan ji cewa abubuwan da ka/ki ke yi daidai ne? Fiye da da kamar da ba kamar da ba ba kamar da ba matuka 18. Ka/Ki kan ji dadin yadda ka/ki ke gudanar da harkokin ki/ka? Akwai jin dadi kwarai jin dadi kamar da jin dadin ba so sai ba ba jin dadin 19. Ka/ki kan ji cewa rawar da ka/ki ke takawa a al’amura daidai ne? fiye da da kamar da ba kamar da ba ba kamar da ba matuka 20. Ka/ki kan iya yanke hukunci a kan abubuwa? fiye da kullum kamar kullum ba kullum ba lokaci lokaci 21. ka/ki kan ji dadin ayyukan yau da kullum? fiye da kamar da ba kamar da ba ba kamar da ba matuka 22. Ka/ki kan ji kamar ba ka/ki da wata daraja ko amfani? A’a sam kamar da ba kamar da ba ba kamar da da matuka 23. ka/ki kan ji kamar ba bu sa’a a rayuwa? A’a sam kamar da ba kamar da ba ba kamar da ba matuka 24. Ka/ki kan ji kamar ci gaban rayuwarka ba amfani? A’a sam kamar da ba kamar da ba ba kamar da ba matuka 25. ka/ki kan ji kamar ka/ ki halaka kan ka/ki? Hakika A’a Ba na zaton haka Na taba tununin haka hakika haka 26. Ka/ki kan ji wani zubin ba ka/ki iya komai saboda jin tsoro ko kunya? A’a sam kamar da kwarai kwarai kuwa 27. ka/ki kan yi fatar gara ma mutuwa baki daya ka huta? A’a sam A’a kwarai kwarai kuwa 28. Tunanin ka kashe kan ka/ki yakan zo ma ka/ki kullum? Hakika ba na ji ba na jin haka Na taba tunanin haka hakika na taba tunanin haka Na gode 90