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báo cáo khoa học: " Do patients think cannabis causes schizophrenia? A qualitative study on the causal beliefs of cannabis using patients with schizophrenia"

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  1. Buadze et al. Harm Reduction Journal 2010, 7:22 http://www.harmreductionjournal.com/content/7/1/22 RESEARCH Open Access Do patients think cannabis causes schizophrenia? - A qualitative study on the causal beliefs of cannabis using patients with schizophrenia Anna Buadze1, Rudolf Stohler1, Beate Schulze2, Michael Schaub3, Michael Liebrenz1* Abstract Background: There has been a considerable amount of debate among the research community whether cannabis use may cause schizophrenia and whether cannabis use of patients with schizophrenia is associated with earlier and more frequent relapses. Considering that studies exploring patients’ view on controversial topics have contributed to our understanding of important clinical issues, it is surprising how little these views have been explored to add to our understanding of the link between cannabis and psychosis. The present study was designed to elucidate whether patients with schizophrenia who use cannabis believe that its use has caused their schizophrenia and to explore these patients other beliefs and perceptions about the effects of the drug. Methods: We recruited ten consecutive patients fulfilling criteria for paranoid schizophrenia and for a harmful use of/dependence from cannabis (ICD-10 F20.0 + F12.1 or F12.2) from the in- and outpatient clinic of the Psychiatric University Hospital Zurich. They were interviewed using qualitative methodology. Furthermore, information on amount, frequency, and effects of use was obtained. A grounded theory approach to data analysis was taken to evaluate findings. Results: None of the patients described a causal link between the use of cannabis and their schizophrenia. Disease models included upbringing under difficult circumstances (5) or use of substances other than cannabis (e. g. hallucinogens, 3). Two patients gave other reasons. Four patients considered cannabis a therapeutic aid and reported that positive effects (reduction of anxiety and tension) prevailed over its possible disadvantages (exacerbation of positive symptoms). Conclusions: Patients with schizophrenia did not establish a causal link between schizophrenia and the use of cannabis. We suggest that clinicians consider our findings in their work with patients suffering from these co-occurring disorders. Withholding treatment or excluding patients from certain treatment settings like day-care facilities or in patient care because of their use of cannabis, may cause additional harm to this already heavily burdened patient group. [6]. Considering that studies exploring patients’ view on Background There still is a debate among the research community a controversial topic have contributed to our knowledge of important clinical issues [7], such as patients’ reasons whether cannabis use may cause schizophrenia [1,2] and whether cannabis use of pati ents with schizophrenia for following or refusing medical recommendations might lead to a more untoward outcome like earlier and [8,9], and patients needs and wishes at the end of life more frequent relapses [3]. [10], it is surprising how little these views have been Arguments in this debate primarily stem from cohort explored to add to our understanding of the link studies [4], systematic reviews [5], and meta analyses between cannabis and psychosis. Even though patients’ beliefs on the role of cannabis in the pathogenesis of schizophrenia have - to our * Correspondence: Michael.Liebrenz@puk.zh.ch 1 Psychiatric University Hospital, Research Group on Substance Use Disorders, knowledge - not been studied so far, some studies have Selnaustrasse 9, 8001 Zurich, Switzerland explored reasons for cannabis and/or other substance Full list of author information is available at the end of the article © 2010 Buadze et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
  2. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 2 of 8 http://www.harmreductionjournal.com/content/7/1/22 use in psychosis, mainly by means of questionnaires (e.g. Care was taken to shape a conversation in which the the Reasons for Cannabis Use Questionnaire, the patient felt free to present his or her own view [20]. Psychosis and Drug Abuse Scale (PADAS) and the Can- All interviews were conducted by the same researcher in nabis Use Effects Survey [11-13]). the outpatient clinic. Patients received a compensation of Generally, it was found that the most frequent reasons 20 Swiss Francs for participation. In addition to the inter- for cannabis use among individuals with psychotic disor- views, information on prescribed medication and exact ders were similar to those of healthy subjects (e. g. a diagnosis (ICD-10) was obtained from clinical records. wish to relax, to be high, to reduce boredom, social A grounded theory approach to data analysis was motives [e. g. “to go along with the group"], improving taken to evaluate findings. This meant allowing the data to “speak for themselves” rather than approaching the sleep, anxiety, and agitation). However, some of these studies also found that an important part of patients data within existing theoretical frameworks [21]. All (11-40%) reported to use cannabis to reduce hallucina- interviews were tape recorded and then transcribed in tions [12,14,15]. full. Transcripts were compared with tapes by the These rather unexpected statements stand in contra- research team and validated with patients, if necessary. diction to the widely held belief of most clinicians that Validation of transcripts with patients was necessary in cannabis use is specifically unhealthy for patients with three cases. This was due to technical difficulty (e.g. dis- schizophrenia and underline the importance of integrat- tracting side noise on tape). ing patients’ views into treatment, since they may influ- Materials were coded using an inductive qualitative ence adherence to medical treatment and therefore have procedure [22]. Categories obtained were discussed in an impact on the overall outcome [8,16]. the research team to validate ratings and achieve con- The present exploratory study uses a grounded theory sensus. AB applied the final code, with confirmation of approach, conducting narrative interviews [17] to consistency through blind dual coding of two transcripts explore - to our knowledge for the first time - disease with ML. Authorization by the local ethics committee models of patients with schizophrenia who use cannabis was obtained before the study was conducted. All and to clarify whether patients believe in a causal link patients were assured complete confidentiality and pro- between cannabis use and schizophrenia. vided their written informed consent to the study, speci- fically to the tape-recorded interviews. Method Ten consecutive patients fulfilling criteria for schizo- Topic Guide phrenia (ICD-10 F20.0) and for a current harmful use « How would you describe the condition you are suffer- of/dependence from cannabis (ICD-10 F12.1 or F12.2) ing from? » were recruited from the in- and outpatient clinic of the « What is/are the cause/s of your illness? » Psychiatric University Hospital Zurich. Further inclusion « You might have heard that there might be a rela- criteria included being 18 years of age or older and will- tionship between the consumption of cannabis and the ingness to give written informed consent. Exclusion cri- likelihood of developing a mental disorder at a later teria were insufficient language skills, acute psychosis or time. How do you feel about that? » intoxication and a diagnosis of personality disorder. For « What are the effects if you consume cannabis? » each patient the full patient’s chart from the clinic with « Do these effects vary over time or condition you are a complete biographical and psychiatric history was in when smoking? » available, including diagnosis according to ICD-10. In order to identify patients’ personal perceptions and Results Patients’ characteristics, diagnosis and consumption pat- motivations we used single, unstructured, in depth inter- views [18] lasting for about 1.5 hours. Our topic guide terns are described in table 1. (vide infra) provided a flexible interview framework. A Patients’ explanatory models about the origin of their definitive version of it had emerged after the 4th narra- tive. Interviews started with a narrative opening question mental illness concerning patient’s subjective disease models. Probes Nine of the interviewed patients regarded themselves as were used to explore the role of cannabis in case it was suffering from a mental disorder. While seven patients not covered spontaneously in patients’ initial narrative. identified themselves as suffering from schizophrenia, In addition, we allowed themes and motives identified one viewed himself as being depressed and one in earlier interviews to be explored in those following, described himself as emotionally unstable. One patient combining the principles of maximum variation and did not regard himself as suffering from a mental disor- complexity reduction to simultaneously widen the scope der at all, but stated to only have some mental health of results and examining previous assumptions [19]. problems.
  3. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 3 of 8 http://www.harmreductionjournal.com/content/7/1/22 Table 1 Patients’ characteristics, cannabis use, and medication subject age sex Initials use of cannabis prescribed drugs diagnosis occupation at time of (ICD-10) interview** starting years of max. way of frequency age consumption quanity in consumption of use joints/d VP1 26 m P.O. 12 14 10 smoking 2-3/w none F20.0 F12.24 disability F20.0, pension commercial clerk, VP2 27 m P.A. 16 11 7 smoking 2/w C, AD, B F11.22, disability F12.25, pension F14.26, medical school F13.20 VP3 42 m M.B. 14/15 27 12 smoking daily N F20.0 F.12.25 drop out commercial clerk, VP4 27 m K.C. 12 15 20 smoking 2/w M, B, N F20.0, disability F11.22, pension F12.24 commercial clerk, VP5 36 m S.F. 16 20 3 smoking daily N, AD F20.0, 50% workload F12.25, F33.0 lumberjack, VP6 43 m H.G 20 23 15 smoking 1-2/w N, AD F11.22, disability F12.24, F20.0 pension high school drop VP7 34 m Z.A. 17 17 15 smoking sporadic N, MS, M F20.03, out, disability F12.20 pension VP8 51 m R.S. 17 34 10 smoking sporadic N, MS, AD F20.0, F43.1, mason, F14.2, F12.24 disability pension VP9 44 f N.A. 20 24 5 smoking sporadic N F41.3, social worker, F20.0,12.24 100% workload VP10 53 f B.L. 16 37 4 smoking sporadic N, B F20.01, waitress, 100% F11.22, workload F12.2, F50.1 **AD = antidepressants; N = neuroleptics; R = Ritalin®; C = Concerta®; B = benzodiazepines; M = modafinil; MS = mood stabilizers I n our sample all patients had developed thorough anxiety. It is still enough if someone raises the voice explanatory models about the origin of their mental to me. It will scare me. Both my parents, my father condition. Although each individual etiological concept and my mother, beat me physically...» was unique in its own way, it was possible to identify S.F. 36y. male, cannabis use since age 16 common major themes and shared features. It has to be «...It all started when I was around 12 - 13 years old. noted, however, that some overlapping between themes My parents were constantly quarrelling, so I began occurred. Three of the ten patients identified more than daydreaming: Everything what happened was just a one contributing cause and had adopted a multi-factor- theatrical play with me becoming merely a facade. ial explanatory model. Because of that I had no chance to relax. The lack We identified five major themes on perceived causa- of relaxation is the reason, why I suffer from schizo- tion, which we characterize below, starting with the phrenia today...» most commonly expressed perception. M.B. 40y. male, cannabis use since age 14 «...Discrimination. My mother completely denied me Family induced Most frequently patients attributed the development of when she got a new partner. I got my voices because their mental disorder to their upbringing under difficult of the denial. The entire story with my psychosis circumstances, comprising parental neglect, parental started because of discrimination...» overprotection, and physical or psychological abuse: N.A. 44y. female, cannabis use since age 20 Drug induced «... I suffer from paranoia. That is because I was bea- Repeatedly patients described an alteration of their men- ten at home and I was neglected. What is left over is tal state, after a moderate or excessive use of one or
  4. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 4 of 8 http://www.harmreductionjournal.com/content/7/1/22 more legal or illegal substances. They thought that this «...On the other hand I am burdened by a family his- alteration had led to a permanent damage of their men- tory with schizophrenia and that has practically to tal health. Our patients attributed the capability of indu- do with it as well. My grandfather had this cing such changes solely to hallucinogens and non- disposition...» hallucinogenic amphetamines. Interestingly, cannabis Z.A. 34y. male, cannabis use since age 17 was rarely mentioned in this context. «...All three girls have problems. One of my sisters is in psychiatric treatment as well. One person was «...To put it simply: Excessive labor of the brain, contagious, like spreading influenza... this person because of to much methamphetamine. That was was my mother» difficult. I went to a friend of mine, banged against N.A. 44y. female, cannabis use since age 20 her door and told her that she should be watching Esoteric models out for me... It went on for an entire night, it just Magical explanatory models were adopted by two of our was too much. I think the reason (for my illness) is patients. It has to be noted that both patients had an an overwork of my brain...» immigrant background. K.C. 27y. male, cannabis use since age 12 «...I once took too much ecstasy. They took me to «...Having fever is being sick. Having cancer is being the Klinik Hard (regional hospital in the Zurich sick. Vomiting is being sick. Having a headache is area) and after this event it was a gradual process being sick. What I have... I always have the feeling until I got schizophrenia...» that I do not have everything under control. But it is not really an illness. It is power, and god gives this P.O. 26y. male, cannabis use since age 12 «...I had used other stuff before, LSD, so I had heard power to me. I can hear my mother and my father voices at the age of 17-18 years. Also alcohol played and also other dead people. I have been off to war a major role in developing this illness...» and I have killed people. People came to me. And now I am scared of those people. I can see through H.G. 43y. male, cannabis use since age 20 «...At a party I was finally offered a drug cocktail people. One glimpse is enough. This is a gift by containing stimulants and LSD and that is when my god...» illness really got rolling...» R.S. 51y. male, cannabis use since age 17 «...Back then I was very interested in occultism and Z.A. 34y. male, cannabis use since age 17 that is why I later got into trouble. I started to hear Socially induced Some explanatory models given by patients focused on voices and I was followed by demons...» social factors as the main reason for developing schizo- P.A. 27y. male, cannabis use since age 16 phrenia. Factors like loneliness, conflicts in partnership, Patients’ view of a causal relationship between cannabis and problems at work or school were mentioned, but were not seen as causally related. The main motive use and schizophrenia identified was “social pressure” as exemplified below: As seen above, one of the explanatory models was con- nected to the use of substances, mainly focusing on the «...My family put a lot of social pressure on me and I role of hallucinogens and amphetamines. However, none began to feel stressed. My siblings are all very suc- of the participants made a direct link between cannabis cessful and have prestigious jobs. My sister is an consumption and the onset of psychotic symptoms in attorney, my older brother is a doctor, and the other their initial narrative statements. This was surprising to is a philologist. During my first years of attending us since a potential causal relationship between cannabis school, I was successful as well. But then I started to use and schizophrenia is currently widely discussed in feel a lot of pressure and a lot of stress. I am sure the Swiss public. Upon further exploration concerning that my illness was to some extent induced by that the effects of their cannabis consumption, patients stress...» expressed very differentiated views on that topic. First, patients presupposed a clear temporal order Z.A. 34y. male, cannabis use since age 17 “Biological” or genetic models between consuming cannabis and the occurrence of psy- Two patients put forward biological explanations for chotic symptoms for assigning a causal role to their sub- why they were suffering from schizophrenia. Interest- stance use: ingly though, biological explanations were only given as part of a multi-factorial approach, when patients «...I have tried to answer this question myself. I described more than one contributing cause for their really tried to put both things into connection after I had a “ mega"-psychosis. But I can assure you, it illness.
  5. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 5 of 8 http://www.harmreductionjournal.com/content/7/1/22 came not because of cannabis, this is not the origin comparisons with sufferers experiencing more severe of it. I mean I believe that it can make some things psychotic symptoms than themselves by considering the latter to be “more vulnerable” and thus feel somewhat more apparent. Not must, but can. Really, it cannot be the origin of it all, because I had these feelings, protected themselves: long before I started with it...» M.B. «...Cannabis might have played a minor role. I just believe that cannabis is different in every person. In this context, cannabis use was clearly framed as a You cannot really generalize it. ...» consequence of psychotic symptoms rather than their K.C. origin: Finally, some study participants denied a causal con- «...The scenario is this: You first go crazy and then nection between cannabis use and their illness alto- you start to smoke. It’s not the origin... it is rather gether . This may be motivated by the fact that they that you try to medicate yourself. ...» clearly distinguish between the causation of their illness Z.A. and an exacerbation of individual symptoms. As the fol- lowing statements suggest: Further, those questioned reasoned that possible nega- tive effects of cannabis are related to the quality of the «...It did not cause the voices...(but) it disturbs my cannabis preparation. Differentiating between “good” memory when I use it a lot...» and “ bad ” cannabis, they associated “ good ” cannabis H.G. with positive effects, while the use of “bad” cannabis was «...No. I do not see a connection between my mental seen as resulting in negative experiences. In other problems and cannabis...» words, they feel on the safe side as long as they assure N.A. using high quality preparations: «...There is no causal relationship. Some slight influ- Effects of cannabis use, its advantages and disadvantages ence: It depends on the quality of it. Sometimes it’s Our study patients regarded the use of cannabis as an worse, sometimes it’s better, but most often you feel important way of self-regulation and self-medication. better...» While most patients had a rather positive view of can- S.F. nabis and used it (specifically) to reduce tension, to attenuate symptoms of depression or (simply) for relaxa- In addition, patients stated that, in their view, adverse tion purposes, some raised concerns especially because of its worsening psychotic symptoms and anxiety. Other reactions to cannabis are dose-related: drawbacks of using cannabis included its causing of «...I am mentally unstable, not very stable. It can increasing feelings of indifference and its acute aggravat- really put me into it (psychosis) if I smoke every ing of cognitive deficits. day...once, or twice per week that is fine, at the max- Frequently it was a shared belief among all patients imum three times. You know, one glass of red wine that positive aspects prevailed over possible disadvan- per day is fine too... as long as it does not become tages of cannabis use. three bottles. It all depends on the amount. For me Most frequently, those questioned described that can- cannabis is a medical plant. You really can grow old nabis served them to reduce anxiety and tension Patients’ statements may point to the fact they patients with it. Not like with hard drugs...» P.O. perceive cannabis particularly helpful in reducing posi- «...No. I would say if you consume it within a nor- tive psychotic symptoms: mal range it could have positive results. If you overdo it then results will follow. If you take it «...When I smoke it I am better, I am less scared and I don’t have bad dreams anymore. I can “regenerate together with cocaine symptoms just intensify. I got my feelings” with it. Cannabis is an aid. It takes the really anxious and then I started hearing voices...» P.A. speed out of my thoughts, I can see my own thoughts and I can arrange them properly...» Study participants moreover believed that the effects P.O. of cannabis are varying between different individuals. «...I can calm down using it. It has something of a In these contexts, patients might use downward social ritual too, when I come home after work at night. It
  6. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 6 of 8 http://www.harmreductionjournal.com/content/7/1/22 can reduce my anxiety. However, if it is bad stuff, it cannabis I can also bear my crazy thoughts...discon- can aggravate anxiety too. I just can lead a better life nect. ...» with cannabis. It makes my problems bearable...» «...I use cannabis as an antidepressant medication...» S.F. M.B. «...The voices (with my schizophrenia it is like this - I only hear words, not sentences but words) go Some participants expressed a differentiated view on away. It calms me down. It also reduces my chronic the effects of cannabis. In their view, effects of con- pain and it loosens me up...» sumption differ between phases of the illness and their N.A. personal state, also implying negative outcomes if using cannabis in the “wrong circumstances": «... In the beginning I was fascinated by it, because I could relax so easily. It helped me to put all other «...In 90% of the times I don’t have adverse effects. things aside...» P.A. In 10% of the times I get flashbacks. That is a price I am willing to pay... Cannabis enhances my feelings One patient even envisages a role of cannabis in sui- either way. If I have a bad day I will become more cide prevention, assuming that stopping to use it may depressed, on a good day I become more joyful...» exacerbate symptoms to such an extent that suicidal P.O. behavior might ensue: «... When I first started using it and I was really ner- vous and I smoked marijuana I was panicking... » «...During psychosis it was different. I felt that some- R.S. thing was going on and I thought that cannabis might have different effects altogether. So I stopped Discussion using it during this time. I had not used it for days when I jumped...» (The patient had committed a sui- In this present exploratory study we examined disease cide attempt, by jumping out of the window) models expressed by cannabis using patients with schi- zophrenia and clarified whether this patient group sus- M.B pected a causal link between cannabis use and their Patients further identified benefits of cannabis in alle- illness. viating blunted affect, social withdrawal and lack of We identified five major motives in the disease models motivation. Here, participants ascribed energizing and of schizophrenia patients with a co-occurring abuse of mood-lifting effects to their cannabis use: cannabis: Mental illness was attributed towards upbring- ing under difficult familial circumstances, to social pres- «...I see clear advantages. I am more of a “lonesome sure, and to the use of legal and illegal substances. wolf”. When my spirits are low, it is even worse. I Additionally, genetic and esoteric explanations were don’t want to see anybody. A joint can reverse this. given. Before I go to work I need to smoke in order to These motives do not fundamentally differ from expla- reduce my inner tension somewhat. It disturbs my natory models that have been elucidated in a study on memory when I use it a lot. schizophrenia patients without a co-occurring substance use disorder. Using a semi-structured interview, Anger- Sometimes when I go shopping and I return, I have meyer et al. (1988) identified recent psychosocial factors, forgotten something that I knew I wanted to get personality, family, biology, and esoteric reasons as before...» explanations put forward by patients suffering from schizophrenia, schizo-affective disorders, and “affective psychosis” [23]. H.G. «...You cannot even imagine how tired I was. With it Three patients favored a multi-modal explanation, I was more awake and I could think clearly. My identifying more than one reason as causes for their tiredness was attenuated and I felt more composed. disorder. Again, this finding is in line with the results In the beginning it even improved my concentration of previous quantitative [23] and semi-quantitative stu- and my memory. Disadvantages: If it is of bad qual- dies [24]. Their causal explanations further reflect the ity it makes me feel indifferent...» stress-vulnerability model underlying recent studies on Z.A. the etiology of psychosis in a framework of gene-envir- «...I have more fantasy and I am more creative. In onment interaction [25]. However, patients tended to school it really helped. I could write better essays. I prefer psychological and social causes over genetic could read more and I was more active. With explanations for their condition regardless of whether
  7. Buadze et al. Harm Reduction Journal 2010, 7:22 Page 7 of 8 http://www.harmreductionjournal.com/content/7/1/22 they thought they suffered from schizophrenia or from negated a causal link between schizophrenia and canna- other disturbances. bis. Thus, we suggest that clinicians consider these find- Interestingly, in this sample patients made a direct con- ings in their work with patients suffering from such nection between the use of hallucinogens and ampheta- co-occurring disorders. Frequently, cannabis use of mines and the development of a mental illness at a later patients with schizophrenia has only been seen as a mis- time. With regard to cannabis such a relationship was behavior leading to an untoward treatment outcome. not made. One the contrary, apart from some adverse Therefore, it often resulted and still results in withhold- effects, (e.g. induction of flashbacks and perturbance of ing treatment or excluding such patients from certain memory) patients had a rather positive view of cannabis treatment settings like day-care facilities or fulltime hos- and stated to use it to reduce tension, to attenuate symp- pitals (RS, personal communication). In view of the toms of depression, to blunt the disturbing effects of beliefs surrounding cannabis use described above the acoustic hallucinations, or for relaxation purposes. majority of this patient group may not understand such Furthermore, patients repeatedly described that they an intervention. Rather patients may construe this thera- had experienced mental health problems well before peutic strategy as social rejection on the part of their they had started using cannabis, thus negating a causal therapists, which has been shown to significantly contri- relationship between the use of cannabis and the onset bute to experiences of stigma and discrimination [29,30]. of schizophrenia all together. Stigma, then, has been found to act as an environmental Previous studies had found that reasons for cannabis risk factor for the onset and course of schizophrenia [31]. use among individuals with psychotic disorders mainly Further, treatment approaches which do not take account of patients ’ subjective illness models are not likely to comprised boredom, social motives, the wish to improve sleep, anxiety and agitation, control of negative and enhance early help-seeking for psychosis and treatment positive psychotic symptoms, increased energy levels, collaboration [32]. Moreover, given the missing scientific and improved cognitive function [12,13]. evidence of deleterious effects of cannabis use on the A recent review, categorized reasons for cannabis use course of schizophrenia [3], we think that such confron- in 4 main groups: enhancement of positive feelings, tational approaches cause additional harm to this already heavily burdened patient group. In conclusion patients’ relief of dysphoria, social reasons, and reasons related to the illness and side effects of medication. It was found causal attributions and individual recovery strategies that patients most commonly describe enhancement of should be routinely explored in the context of the doc- positive affect, relief from dysphoria and social enhance- tor-patient-relationship. ment. Fewer patients reported reasons related to relief of psychotic symptoms or relief of side effects of medi- Acknowledgements cation. Patients sometimes stated that cannabis nega- We acknowledge the work of Kaethi Muster, Bignetta Caprez, and Kurt tively affected positive symptoms [26]. Braegger in transcribing the tape-recorded interviews and their contribution to the preparation of the manuscript. Our results are in accordance with these findings. The differentiation between “good” and “bad” cannabis Author details might relate to the findings of variable potency of can- 1 Psychiatric University Hospital, Research Group on Substance Use Disorders, Selnaustrasse 9, 8001 Zurich, Switzerland. 2University of Zurich, Center for nabis extracts and its different ratios of Δ9-THC, CBD, Disaster and Military Psychiatry, Zurich, Switzerland and University of Leipzig, and other pharmacological active ingredients [27]. How- Department of Social Medicine, Leipzig, Germany. 3Research Institute for ever, it has also been known for a long time that the Public Health and Addiction, Zurich, Switzerland. effects of cannabis are socially “constructed” and may Authors’ contributions vary across different situations and expectations [28]. AB, ML, RS, BS contributed to the design and the coordination of the study. Our study has some important limitations. First, this is All authors helped to draft the manuscript. All authors read and approved the final version of the manuscript. an exploratory study aiming at an in-depth understand- ing of patients’ views, thus using a small sample. Second, Competing interests all study patients were recruited from the same treat- The authors declare that they have no competing interests. ment facility. Thus, it is unclear to what extent the pre- Received: 7 April 2010 Accepted: 28 September 2010 sent findings can be generalized. 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