Patterns of the drug habit in hospitalized psychiatric patients

Sections

Introduction
Method
Observations
Distribution by age
Distribution by religion and caste
Educational level
Occupation
Residence
Income
Diagnosis
Duration, frequency and quantity
Discussion and conclusions

Details

Author: K. C. DUBE, S. C. JAIN, A. K. BASU, N. KUMAR
Pages: 1 to 10
Creation Date: 1975/01/01

Patterns of the drug habit in hospitalized psychiatric patients

M.B.B.S., D.P.M., F.R.C. Psych., F.A.P.A., F.A.M.S. K. C. DUBE Professor of Psychiatry, S.N. Medical College, and retired Senior Medical Superintendent, Mental Hospital, Agra, India
M.B.B.S. S. C. JAIN Medical Officer, Mental Hospital, Agra, India
M.Sc., D.N. and S.P. A. K. BASU Assistant Research Officer, ICMR Enquiry, Clinical Psychologist, Mental Hospital, Agra
M. Sc. N. KUMAR Statistician, I.P.S. project, Field Research Centre, Mental Hospital, Agra, India

Introduction

Indulgence in cannabis has become a universal phenomenon. While effects of acute cannabis intoxication are known, evidence regarding effects attributable to long-term use is less well established. The drug is commonly used in northern India, where doctors working in mental hospitals are aware that a history of cannabis consumption is frequently obtained from patients. In order to explore a possible causal connexion between cannabis use and psychiatric illness, all 566 males admitted for the first time to Agra Mental Hospital between 1 April 1971 and 31 March 1972, were submitted to an inquiry. There were no female cannabis users.

Method

Information regarding frequency, quantity, duration, types of cannabis preparation used, mode of intake, etc. was obtained from patients and any other available source. According to these data, ganja 1 and bhang 2 were the most frequently used drugs, while the use of charas 3 was negligible. Use of other intoxicating substances was a further point covered in the study. Psychiatric diagnosis was reached by consensus at case conferences, generally without much difficulty. But in a few cases final diagnostic evaluation could be made only after a certain period of observation had elapsed or even after an assessment of the patient's response to treatment.

Ganja dried flowering tops of the female cannabis plant (marihuana used in western countries contains both, flowering tops and leaves of the upper half of the female plant) which are smoked.

Bhang dried leaves of the cannabis plant ground to a fine paste, which is either rolled into a pill and eaten or consumed as a beverage.

Charas resin exuded from the leaves and flowering tops of the plant which is smoked.

Observations

Among the 566 male adults admitted, 134 persons were identified as users; 4 the remaining 432 persons were considered to be non-users (table 1). The latter category included 56 'one-time users'.

TABLE 1

Distribution of psychiatric patients by cannabis users and non-users

Non-users

Drug users

Total admissions

432 (76.33%)
134 (23.67%)
566 (100%)

Twenty-nine patients used bhang only, 24 others ganja only and 42 persons used both; 39 persons used cannabis together with alcohol. Altogether 95 persons used only cannabis; 106 consumed bhang in one form or another, of whom 35 also took alcohol; 93 persons smoked ganja, 27 of them in combination with alcohol (table 2).

TABLE 2

Distribution of cannabis users by substance

 

Total number of users

Percentage

Bhang alone
29 21.64
Ganja alone
24 17.91
Both bhang and ganja
42 31.34
Bhang with alcohol (12)
   
Ganja with alcohol (4)
   
Bhang and ganja with
39 29.10
alcohol (23)
   
TOTAL
134  

Distribution by age

All the cannabis users were below 54 years of age; the highest number of users was found in the age group 25-34 years.

Most persons had started using cannabis early, i.e. between 15 and 24 years of age; they were followed by the age bracket 25 - 34. Ten had started using cannabis before they reached 15, and 19 after their 34th year of age.

4 A "user" for the purpose of this study is a person who used cannabis frequently, occasionally or more than once, immediately prior to the onset of mental illness and preceding admission to the hospital.

TABLE 3

Distribution of psychiatric patients by age

 

Cannabis users

Non-users

 
 

Age on hospitalization

No.

Percentage

No.

Percentage

Total

1.
15-24 years
37 19.78 150 80.22 187
2.
25-34 years
56 28.57 140 71.43 196
3.
35-44 years
25 24.51 77 75.49 102
4.
45-54 years
16 25.00 48 75.00 64
5.
55-64 years
0 0.00 12 100.00 12
6.
65 and above
0 0.00 5 100.00 5
 
TOTAL
134   432   566

TABLE 3A

Distribution of cannabis users by substance and age at which use was started

Age at first intake

Bhang a

Ganja a

Total

less than 15 years
9 3 10
15-24 years
50 38 60
25-34 years
33 38 45
35-44 years
9 10 13
45-54 years
5 4 6
TOTAL
106 93 134

a Bhang and ganja either separately, or together or in combination with alcohol.

Distribution by religion and caste

There were only two users of Moslem faith and one Christian amongst the non-users (table 4). The ratio between Moslems and Hindus in the general population of gravitational area of the hospital at Agra (Uttar Pradesh) is 1:75 ( [ 1] ; see also foot-note a to ables 5, 6, 7, 8). The total population studied was 29,468.

Among the Hindu caste itself no particular difference was noted between users and non-users (table 5), except that there were more bhang users among Brahmins and Vaishs and more ganja users among Thakurs.

The caste system originates from the "Aryans" and was based on occupational pursuits. The original classification of caste system has undergone changes since the "Aryan civilization" during 3,600 years of history. New castes and subdivisions have sprung up. The hierachical system does not exist in the original form now. The following main categories of castes have been mentioned in this study.

TABLE 4

Distribution of psychiatric patients by religion

 

Cannabis users

Non-users

 

Religion

No.

Percentage

No.

Percentage

Total

Hindu
132 25.78 380 74.22 512
Moslem
2 3.77 51 96.23 53
Christian
0 0.00 1 100.00 1
TOTAL
134   432   566

TABLE 5

Distribution of psychiatric patients by caste

 

Cannabis users

Non-users

 

Caste

No.

Percentage

No.

Percentage

Total

Brahmin
29 23.97 92 76.03 121
Thakurs
44 30.56 100 69.44 144
Kayasth
6 20.69 23 79.31 29
Vaish
18 27.69 47 72.31 65
Jatav
10 27.78 26 72.22 36
Khatri
2 11.11 16 88.89 18
Others
23 23.23 76 76.77 99
TOTAL
132   380   512

a The distribution of castes in the general population of the gravitational area of the hospital (in percentages) is as follows: Brahmin 13.9; Thakurs 18.0; Kayasth 1.9; Vaish 7.3; Jatav 21.1; Khatri 12.9; Others 24.9.

  1. Brahmin: This is the highest caste. Priests come from this class.

  2. Kshatriya: (Thakurs) Warriors come from this caste. They are mostly residents of Rajasthan, but are also found abundantly in rural and urban parts of Uttar Pradesh.

  3. Vaish: Businessmen and tradesmen belong to this caste.

  4. Kayasth: In the times of Moghuls, persons of this caste, mostly employed in office work, were prominent.

  5. Khatri: Probably a variation of the Kshatriya, this caste seems to have lost its importance as a warrior class. Khatri are found mostly in Punjab and in Northern Uttar Pradesh. In Agra there is a large concentration in the urban but almost none in the rural area.

  6. Jatav: A lower caste in the hierarchy. Their main occupation is now shoe making.

  7. For the purpose of this study "others" include other sub-castes, e.g. barbers, sweepers, carpenters, etc. [ 1] .

Educational level

There was no significant difference in the level of education between users and non-users (table 6); by contrast there was a marked preference for a given substance according to educational level; "illiterates" 5 used ganja more frequently; "educated persons" 6 prefered bhang to ganja (p < 0.01). This tallies with the general impression that the less educated rural population prefers smoking ganja.

TABLE 6

Distribution of psychiatric patients by educational level a

 

Cannabis users

Non-users

 

Level of education

No.

Percentage

No.

Percentage

Total

Illiterate
35 22.73 119 77.27 154
Primary school standard
15 23.08 50 76.92 65
Middle school standard
40 32.26 84 67.74 124
Secondary school standard
33 21.02 124 78.98 157
Above secondary school standard
11 18.64 48 81.36 59
Not known
0
-
7 100.00 7
TOTAL
134   432   566

a The distribution of cannabis users by literacy in the general (adult) male population in the gravitational area of the hospital (in per cent) is as follows: illiterate 1.8; primary or middle school standard 3.4; secondary school standard 1.2; above secondary school standard 0.9.

Occupation

The highest rate of cannabis use was found among labourers, followed by agriculturalists (table 7). Ganja is their first choice, while students and unemployed persons, who have the lowest incidence of drug use, take bhang in some form or another.

5 Illiterate - person without education or educated up to primary school level.

6 Educated person - person with level of education beyond primary school.

TABLE 7

Distribution of psychiatric patients by occupational groups a

 

Cannabis users

Non-users

 

Occupation

No.

Percentage

No.

Percentage

Total

Unemployed and students
20 17.39 95 82.61 115
Labourers
38 33.93 74 66.07 112
Agriculturalists
39 23.08 130 76.92 169
Service
25 21.93 89 78.07 114
Business
12 21.43 44 78.57 56
TOTAL
134   432   566

a The distribution by occupation of the general (adult) male population in the gravitational area of the hospital (in per cent) is as follows: unemployed and students 17; labourers 24; agriculturalists 42; service 7.6; business 9.4.

Residence

65. 7 per cent of cannabis users came from a rural area but only 55.09 per cent of non-users came from the same setting (table 8). Rural residence is significantly related to cannabis use (p < 0.01). The preference for ganja among rural residents was significant (p. < 0.05) (table 8A).

TABLE 8

Distribution of psychiatric patients by residence a

 

Cannabis users

Non-users

 

Residence

No.

Percentage

No.

Percentage

Total

Rural
88 28.53 238 71.47 333
Semi-rural
11 11.11 32 88.80 36
Urban
35 17.77 162 82.23 197
TOTAL
134   432   566

a The distribution by residence of cannabis users in the general (adult) male population in the gravitational area of the hospital (in per cent) is: rural 2.4; semi-rural 3.5; urban 1.2.

TABLE 8A

Distribution of users by substance and residence

Residence

Bhang alone

Ganja alone

Bhang and ganja

Cannabis and alcohol

Total

Rural
16 21 29 22 88
Semi-rural
1 1 4 5 11
Urban
12 2 9 12 35
TOTAL
29 24 42 39 134

Income

The analysis of data undertaken showed no association between the level of income and cannabis consumption.

Diagnosis

The proportion of cannabis users amongst manic depressive psychotics and schizophrenics is nearly the same, the only difference being that most cases of toxic psychosis diagnosed were due to cannabis. The specific percentage for each category is given in table 9. No conclusion can however be drawn because of the small sample studied.

TABLE 9

Distribution of cases by psychiatric diagnosis

 

Cannabis users

Non-users

 

Diagnosis

No.

Percentage

No.

Percentage

Total

Schizophrenia and schizoaffective psychosis
79 19.79 312 80.21 391
Manic depressive psychosis
27 22.5 93 77.5 120
Toxic psychosis
26 96.29 1 3.71 27
Organic psychosis
0 0.00 14 100.00 14
Epilepsy
0 0.00 5 100.00 5
Alcoholics
0 0.00 4 100.00 4
Psychopathic personality
2 66.66 1 33.74 3
Diagnosis (?)
0 0.00 2 100.00 2
TOTAL
134   432   566

TABLE 9A

Distribution of users by psychiatric diagnosis and substance

Diagnosis

Bhang only

Ganja only

Bhang and ganja

Cannabis with alcohol

Total

Schizophrenia and schizoaffective psychosis
22 12 23 22 79
Manic depressive psychosis
5 2 8 12 27
Toxic psychosis
1 9 11 5 26
Psychopathic personality
1 1 0 0 2
TOTAL
29 24 42 39 134

Duration, frequency and quantity

Irrespective of multiple drug use by some of the 106 consumers of bhang, 6.61 per cent used bhang for less than one year; 9.43 per cent for one to two years and 83.96 per cent for two years or more. The corresponding figures for ganja users were 20.43, 9.67 and 69.90 per cent (table 10). As can be seen from the table, there is a high proportion of long-term users among consumers of both bhang and ganja, though the number of short-term users is higher amongst consumers of ganja.

TABLE 10

Distribution of users by duration of cannabis use

 

Bhang users

Ganja users

 

Duration

No.

Percentage

No.

Percentage

Total

Less than 1 year
7 6.61 19 20.43 26
1 to 2 years
10 9.43 9 9.67 19
2 years or over
89 83.96 65 69.90 154
TOTAL
106   93   199

Of all ganja users more than one third took the substance at least once a day while only one ninth of all bhang users consumed bhang daily (p. < 0.01) (table 11). There were more chronic bhang users than chronic ganja users (table 10); amongst the latter the frequency of use was however significantly higher (table 11).

TABLE 11

Distribution of users by frequency of drug use

 

Bhang users

Ganja users

 

Duration

No.

Percentage

No.

Percentage

Total

At least once a day
12 11.32 34 36.56 46
Twice a week
35 33.02 14 15.05 49
Once or less a week
59 55.66 45 48.39 104
TOTAL
106   93   199

Distribution by quantity of the substance used is given in tables 12 and 12A. In view of the approximate nature of these indications no further comments are offered.

TABLE 12

Distribution of bhang users by quantity consumed

Quantity taken at a time

Daily

Weekly

Monthly

Total

Less than 24 g
7 27 23 57
24 to 60 g
2 12 3 17
over 60 g
3 24 5 32
TOTAL
12 63 31 106

TABLE 12A

Distribution of ganja users by quantity smoked

Quantity in chilams smoked each time

Daily

Weekly

Monthly

Total

Less than 2 chilams
21 27 17 65
2 to 5 chilams
5 7 2 14
more than 5 chilams
8 6 0 14
TOTAL
34 40 19 93

a Chilam-earthenware pipe, containing approx. 5 g of ganja.

Discussion and conclusions

Of the 566 consecutive admissions 23.67 per cent were regular cannabis users (table 1). 21.6 per cent used bhang only, 17.9 per cent used ganja only and 60.5 per cent more than one drug (table 2). These findings indicate a much higher prevalence of drug use than previously found in a large-scale study in a general (adult) male population (4.2 per cent drug users and 1.4 per cent cannabis users only [ 2] ). These two findings are not strictly comparable, since the two studies were undertaken at different times and for different purposes. Apart from the fact that mental patients seeking hospital treatment are of a highly selective type, the drug habit in a population may have changed in the interval between the two studies. In a general population a variety of mental cases can be found ranging from mild to severe psychotics, neurotics and others, whereas among hospitalized patients most of the cases are psychotics who have reached an advanced stage and who are problematic patients.

In the present study, users in the age bracket 25-34 represented a significant proportion. A selective nature of admission policy would influence a number of variables. In a hospital where old-age patients were either not brought or not encouraged to be admitted and in a culture where younger age groups were under strict parental control denying them access to narcotics, it would only be natural that most patients would fall into the middle age group. Although some of these factors may have been present, our findings show that none of the 17 cases above the age of 55 used cannabis. There is thus strong evidence that users are mostly younger in age (table 3) and started drug in early life mostly between 15 and 34 years of age (table 3A).

A comparison by caste between users of bhang and ganja revealed that Brahmins, Kayasthas and Vaishs, with a generally higher educational standard, preferred bhang, while Thakurs, Jatavs and others were found to be rather smoking ganja. Similarly, in an earlier study [ 2] educational level was found to influence choice of substance. The same holds true of occupational categories. Labourers and agriculturalists tend to smoke ganja; ganja is prevalent in rural areas where one finds a higher number of agriculturalists, labourers and uneducated persons.

References

001

K. C. Dube, A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh/India. Acta psychiatrica scandinavica, 46, pp. 327-359, 1970.

002

K. C. Dube, Drug abuse in northern India. Observations concerning the Delhi and Agra regions , Bulletin on Narcotics, XXIV, 1, pp. 49-53, 1972.