Cannabis and Mental Health: an Environmental Scan and Scoping Review April 26, 2019 1 This report is authored by: Fiona Clement, PhD 1,2,3 Caroline Corbett, PhD1 Brenlea Farkas, MSc 1 Mark Hofmeister, MSc1 Ruth Diaz, MSc 1 John Taplin, BA 1 Matthew Hill, PhD 4,5,6,7 Scott Patten, MD, PhD 2,3,4,5,7 Rebecca Haines-Saah, PhD 2,3,5,7 1Health technology Assessment Unit, Cumming School of Medicine, University of Calgary 2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary 3O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary 4Department of Psychiatry, Cumming School of Medicine, University of Calgary 5 Mathison Centre for Mental Health Education & Research, Cumming School of Medicine, University of Calgary 6Department of Cell Biology and Anatomy, Cumming School of Medicine, University of Calgary 7Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary Cite as: Clement FM, Corbett C, Farkas B, Hofmeister M, Diaz R, Taplin J, Hill M, Patten SB, Haines-Saah RJ. Cannabis and Mental Health: An Environmental Scan and Scoping Review. Produced for the Mental Health Commission of Canada. April 2019. 2 Table of Contents Executive Summary ........................................................................................................................ 7 1. Introduction ............................................................................................................................. 9 2. Non-Medical Cannabis Legislations in Canada .................................................................... 10 3. Data Assets in Canada ........................................................................................................... 18 3.1. Trends in Cannabis Use ..................................................................................................... 23 3.1.1. Data used ..................................................................................................................... 23 3.1.2. Past-year Cannabis Use ............................................................................................... 23 3.1.3. Frequency of Cannabis Use ......................................................................................... 25 3.1.4. Age of First Time Cannabis Use ................................................................................. 28 3.1.5. Self-Reported Mental Health by Cannabis Use in Canada 2013-2017 ....................... 29 3.3 Prevalence of Mental Disorders in Canada by Cannabis use .............................................. 30 3.3.1.2. Mental Health Disorders by Cannabis Use ............................................................... 31 3.3.1.3. Prevalence of Cannabis Use Disorder Past- 12 Month ............................................. 32 4. Data assets of other legalized jurisdictions ............................................................................ 34 4.1 Models of Legalization................................................................................................... 35 4.2 Data Assets ..................................................................................................................... 38 4.3 Trends in Cannabis Use Pre- and Post-legalization ...................................................... 40 4.3.1 Data used ...................................................................................................................... 40 4.3.2 Past-Year Prevalence of Cannabis Use Pre-Post Legalization- Overall ....................... 41 4.3.3 Past-Year Prevalence of Cannabis Use Pre-Post Legalization- by Sex ........................ 42 4.3.4 Past-Year Prevalence of Cannabis Use Pre-Post Legalization- by Age C ................... 44 4.3.5 Past-Year Prevalence of Cannabis Use Pre-Post Legalization- by Age and Sex ........ 46 5. Scoping Review ..................................................................................................................... 49 5.1 Methods overview .......................................................................................................... 49 5.2 Overview of included studies ......................................................................................... 50 5.3 Preclinical Research ....................................................................................................... 54 5.3.1 Preclinical Animal Studies ........................................................................................... 54 5.3.2 Preclinical Human Studies: Brain outcomes in Humans ........................................ 57 5.4 Mental Health Outcome studies .................................................................................... 61 5.4.1 Mental Health in Community Populations ............................................................. 61 5.4.2 Clinical Population Outcomes ................................................................................ 69 5.5 Qualitative studies within this Literature ....................................................................... 76 5.6 Sex and Gender within this Literature........................................................................... 78 5.7 Indigenous Peoples within this Literature ...................................................................... 79 5.8 Knowledge strengths and gaps ....................................................................................... 81 5.8.1 Preclinical Animal Studies ...................................................................................... 81 5.8.2 Human Studies ........................................................................................................ 82 6. Moving Forward .................................................................................................................... 84 3 Appendix 1. Summary of Surveys Available for Analysis ........................................................... 87 Appendix 2. Cannabis Regulations in Other Jurisdictions ........................................................... 96 Appendix 3. Additional Pre-Post Legalization Figures .............................................................. 108 Appendix 4. Search Strategy for Scoping Review ...................................................................... 109 Appendix 5. PRISMA-ScR Checklist108 ..................................................................................... 113 Appendix 6. Inclusion/Exclusion Criteria for Scoping Review .................................................. 114 Appendix 7. References of Included Studies in Scoping Review .............................................. 116 Appendix 8: Published Literature on Indigenous Peoples .......................................................... 125 References ................................................................................................................................... 131 4 List of Figures Figure 3.1. Prevalence of Cannabis Use Past 12 Months in Canada 2013-2017 23 Figure 3.2. Prevalence of Past-Year Cannabis Use in Canada 2013-2017 by Age 24 Figure 3.2. Prevalence of Past-Year Cannabis Use in Canada 2013-2017 by Age 26 Figure 3.4. Frequency of Cannabis Use in Past Three Months among those who 27 Used Cannabis in the Past 12 Months in Canada 2013-2017 by Age Group Figure 3.5. Mean Age First Time Cannabis Use in Canada 2013 – 2017 28 Figure 3.6. Self-Reported Mental Health by Cannabis Use in Canada 2013 – 2017 29 Figure 3.7. Prevalence of Cannabis Use Disorder Past 12 Months in the Canadian 32 Household Population Figure 3.8. Prevalence of Cannabis Use Disorder Past 12 Months in Canada in 2012 32 by Age and Sex Figure 4.1. Year of non-medical cannabis legalization in US jurisdictions 34 Figure 4.2. Prevalence of past year cannabis use pre-post legalization in 7 41 jurisdictions Figure 4.3. Prevalence of past-year cannabis use pre-post legalization for males 43 Figure 4.4. Prevalence of past-year cannabis use pre-post legalization for females 43 Figure 4.5. Prevalence of past-year cannabis use pre-post legalization by age: US 44 12-17; Uruguay 13-17 years old Figure 4.6. Prevalence of past-year cannabis use pre-post legalization by age: 50 45 years or older Figure 4.7. Prevalence of past-year cannabis use pre-post legalization for males 47 under 18 years of age. US: 12-17 years old; Uruguay: 13-17 years old Figure 4.8. Prevalence of past-year cannabis use pre-post legalization for females 47 under 18 years of age. US: 12-17 years old; Uruguay: 13-17 years old Figure 4.9. Prevalence of past-year cannabis use pre-post legalization, males 18-25 48 years old Figure 4.10. Prevalence of past-year cannabis use pre-post legalization, females 18- 48 25 years old Figure 5.1. Flowchart of included studies in scoping review 51 Figure 5.2. Number of Studies in Each Research Category 52 Figure 5.3. Number of Studies per Country (research institute or study population), 53 by Research Category Figure 5.4. Number of Studies Conducted by Publication Year and Research Area 53 Category Figure 5.5. Type of Cannabis Extract Administered to Wild-type Animals 54 Figure 5.6. Number of Wild-type Animal Studies by Type and Number of Animal 54 Subjects Figure 5.7. Number of Animal Models of Human Disease Studies by Type and 55 Number of Animal Subjects Figure 5.8. Type of Human Disease Model Used in Animals 55 Figure 5.9. Type of Cannabis Extract Administered within Animal Models of 55 Human Disease Figure 5.10. Populations studied in human brain studies 57 5 Figure 5.11. Mode of Administration