Is Medical Cannabis Overly Promoted In Minnesota?

 

Karl Marx wrote his famous metaphor about religion being an opiate for the proletariat in 1843:

“Religious suffering is, at one and the same time, the expression of real suffering and a protest against real suffering. Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the people.”

He suggests in the next paragraph that the abolition of religion would rid people of the illusory happiness and it would be more consistent with the goal of real happiness for the people.  Marx’s formulation has not withstood the test of time. There is no more happiness now with widespread secularism than there was in Marx’s day.  Despite that fact - his metaphor survives and I thought about it quite a lot as I read through the Minnesota Medical Cannabis Program Report (MMCP) Anxiety Disorder Review.  The main difference of course is that cannabis is an equivalent metaphor only at the level of the idea of what medical cannabis can do.  When some writers suggest that religion can cause people to sleep and dream unrealistically, cannabis can physically do the same thing.  But it is promoted as doing many other things for many people – despite a profound lack of evidence.

The MMCP has been around for a number of years. I have taken the longstanding position that the medical cannabis concept is basically a way to legitimize cannabis and eventually get it legalized. I have also taken the position that physicians should not be involved in what is essentially a political maneuver.  The grandest aspect of that political maneuver has been the MMCP acting as a mini-FDA and coming up with their own indications for cannabis use. Initially, the idea was to use cannabis for the treatment of chronic pain and hospice care. I attended one of the early CME courses where most of the speakers were pain doctors and oncologists. Psychiatric input on these decisions has generally been minimal, despite the fact that psychiatric populations are at the highest risk from cannabis exposure and psychiatrists typically see most of the complications of cannabis.  The initiative to treat anxiety (in all forms) has not been approved by the MMCP and they state that was the reason for a more detailed look at the literature on cannabis as a treatment for anxiety and producing the report. 

Reading the report is an interesting exercise. It is not written very much from a scientific standpoint. They are very explicit about what they are considering as evidence.  For example they consider a literature search, a small panel of experts that does not really come to any consensus, and the experience of other states with medical cannabis and the indication of anxiety to be the basis for the report.  There are significant problems with all of those sources. 

 

The Research Matrix

At first the Research Matrix of papers included in the appendix looks impressive. There are 30 papers listing the reference, study type, total number of participants, dose and results.  Reading through the studies - some are single person case reports, some are reviews, and there are 15 studies listed as randomized controlled trials (RCTs). Looking at the RCTs there are probably one or two studies with an adequate number of participants to be adequately powered to show a statistical difference. Additional problems include the lack of an actual anxiety diagnosis.  In fact the diagnoses involved were frequently not anxiety related at all. Three observational studies at the end probably had the most merit and their results were equivocal. So the research studies really add nothing toward answering the question of whether medical cannabis should be used to treat anxiety and certainly nothing about the dose, delivery, or cannabis subtype.

Experience of Other States

Tables 1 summarizes the information about how other states have handled the question about medical cannabis and anxiety.  The states listed are Nevada, New Jersey, North Dakota and Pennsylvania.  In Nevada and North Dakota, the legislatures were petitioned to add anxiety (as DSM-5 Generalized Anxiety Disorder) to the medical cannabis formulary.  In New Jersey and Pennsylvania it was a commissioner decision. The Pennsylvania Secretary of Health was described as being “proactive” by suggesting that medical cannabis for anxiety was a “tool in the toolbox” and recommended duration of use, specific formulations, and avoidance in teenagers.  In all 4 states where cannabis was approved, anxiety quickly rose to the top or second most frequent indication for prescribing medical cannabis. None of the states collects any outcome data. 

What about other countries with more experience with cannabis like the Netherlands?  I contacted a colleague there who forwarded my questions to 2 other psychiatrists who were anxiety experts and doing active research in the area.  They responded that medical cannabis was not prescribed for anxiety and that there was a medical cannabis site for the Netherlands.  The site suggests that a CBD product is recommended. They had the same concerns about THC causing anxiety and psychosis.  A direct comparison of the indications for medical cannabis use comparing the Minnesota program to the Netherlands is included in the following table and linked directly to the respective web sites.

Medical Cannabis Qualifying Conditions

Minnesota   Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting Glaucoma HIV/AIDS Tourette syndrome Amyotrophic lateral sclerosis (ALS) Seizures, including those characteristic of epilepsy Severe and persistent muscle spasms, including those characteristic of multiple sclerosis Inflammatory bowel disease, including Crohn’s disease Terminal illness, with a probable life expectancy of less than one year* Intractable pain Post-traumatic stress disorder Autism spectrum disorder (must meet DSM-5) Obstructive sleep apnea Alzheimer's disease Chronic pain Sickle cell disease Chronic motor or vocal tic disorder

The Netherlands   Pain, muscle cramps and twitching in multiple sclerosis (MS) or spinal cord injury; nausea, loss of appetite, weight loss and weakness in cancer and AIDS; nausea and vomiting due to medication or radiation treatment for cancer, HIV infection and AIDS; long-lasting pain of a neurogenic nature (cause is in the nervous system) for example due to damage to a nerve pathway, phantom pain, facial pain or chronic pain that persists after shingles has healed; tics in Tourette's syndrome; treatment-resistant glaucoma

 Expert Consensus

In terms of the professional consensus, the participants were described as  3 psychiatrists, a pediatrician, a person in recovery, a primary care physician, and a marriage and family therapist. On a scale of recommendations, there was one vote for non-approval, one vote in favor of a limited pilot study and follow-up outcomes, one vote for neutral not opposed, three votes in favor of considering for generalized anxiety disorder, panic disorder, and agoraphobia. No consideration is given to the experience of the physicians or the asymmetry of expertise. It appears to be a political approach to neutralizing the opinion of the group of physicians (psychiatrists) who essentially are left treating the complications of cannabis use disorder.  Those complications include acute mania or psychosis, anxiety and panic, chronic depression and amotivational syndromes, and significant cognitive problems.  Cannabis obscures whether the patient has a true psychiatric diagnosis or not.  It also destabilizes psychiatric disorders. That is the common theme I noted above.  This is really not expert consensus – it is a man-on-the street poll.

Apart from the very weak lines of evidence, some of the conclusions in this document are even worse.  There are basically 6 common themes:

1:  Protect the brain: There are longstanding concerns about the new timetable for brain development extending into the mid to late 20s. This is a peak period for drug experimentation and heavy use of alcohol and most substances. There appears to be consensus on this theme and I would agree.

2:  Safer alternative to benzodiazepines: the rationale here is much rockier.  The authors in this case cite the increase in benzodiazepine overdose deaths in the state of Minnesota, but the quality of this data is not clear.  I took a look at the data and contacted the Minnesota Department of Health about it – specifically if opioids were excluded as a primary cause along with fentanyl being sold as benzodiazepines. I was informed by an epidemiologist that a T42.4 code was present and the coding is not mutually exclusive. In other words, more drugs may be involved and fentanyl may have been involved. The death certificates and toxicology confirmations are dependent on the county medical examiner. The accuracy of the data is therefore in question. There are clearly ways to safely prescribe benzodiazepines.  Benzodiazepines are research proven alternatives for severe anxiety when conventional treatments have failed as a tertiary medication and cannabis is not.

In terms of addiction risk, the risk with cannabis is 8-12% overall and 17% for people who start using cannabis in their teens (1-6).  That compares with an addiction liability of about 10% with benzodiazepines (7).  Benzodiazepines are used by people who are taking multiple addicting drugs to amplify the effect, treat withdrawal symptoms, and treat the anxiety and insomnia that accompanies chronic substance use or opioid agonist therapy.  This population is often acquiring benzodiazepines from non-medical sources. There is no real good evidence that medical cannabis will replace non-medical use of benzodiazepines in that setting, since benzodiazepines are easily acquired from non-medical sources.

3:  Therapy is the standard:  Therapy is not the standard. The standard is whatever works for a particular practice setting.  Psychiatrists see people who have already seen a therapist and quite probably a primary care physician where their anxiety was diagnosed with a rating scale. That means they will have failed therapy and at least one or two medication trials. Psychiatrists are not going to start treatment by repeating ineffective therapies. In many cases, substance use including cannabis use is the main reason for the anxiety disorder in the first place.

4: Health Equity:  This was perhaps the most unlikely reason for cannabis use. To emphasize how far this document goes off the rails I am going to quote this section directly:

 “Known disparities exist in the level of care available for anxiety disorder among historically disadvantaged communities. Medical cannabis may offer these individuals the option for an alternative to current medications, however this view was not shared by all participants.” (p.15)

Are the authors of this document really suggesting that disadvantaged communities should settle for a substance that has been inadequately studied, has known severe medical and psychiatric side effects, and is associated with higher rates of suicidal ideation and suicide attempts in these disadvantage communities (14) rather than providing them with standard care? That statement to me is quite unbelievable. It is the first time I have seen a recommendation to use a prescription substance to address a social problem.  It may happen by default – but if you really want to promote health equity equivalence evidence based treatments are the only acceptable standard.

When  "an alternative to current medications" is mentioned cost is not discussed as a factor. In my discussions with people who have received medical cannabis from the Minnesota dispensaries, high cost was often mentioned as a limiting factor. This current price list from one of the dispensing pharmacies shows that nearly all of their products are much more expensive than the generic antidepressants used to treat anxiety disorders.

5: Limited research:  Cannabis advocates point to the lack of research due to the fact that cannabis is a Schedule 1 compound. That means there is no known medical use and a high potential for abuse. Since certain compounds have been FDA approved for specific indications, I anticipate that these compounds will be rescheduled.  That is one of many hurdles in researching cannabis.  A few of the others would include the issue of subject selection (cannabis naïve or not), placebo controls, specific form (THC:CBD ratio), type of drug delivery, and a general methodology that would capture a good sample of persons with an anxiety disorder in adequate numbers for the trial.

6: Harm Reduction:  The authors suggest that medical cannabis could serve to limit exposure to other more harmful drugs obtained on the street to treat anxiety like benzodiazepines. There is no evidence that this would occur given the availability and preference for non-prescribed benzodiazepines.  The issue of polysubstance dependence is complex.  A significant number of opioid users also use benzodiazepines. Despite a black box warning about respiratory depression from using that combination, the FDA has been clear that the medications can be prescribed together. Further, a recent study suggests that retention in a methadone maintenance program was twice as likely if the patients received prescription benzodiazepines as opposed to non-prescription benzodiazepines (10).  No such data exists for cannabis.

In terms of substituting cannabis for benzodiazepines the only study I could find was a retrospective observational study of new patients in a cannabis clinic. Over the course of 2 months 30.1% were able to stop benzodiazepine use and at 6 months that number had increased to 45.2%.  These authors (11) conclude

“Without dependable safety data and evidence from randomized trials for this cohort, cannabis cannot be recommended as an alternative to benzodiazepine therapy.”

 The conclusion of this paper suggests the options of maintaining the status quo or no approval for anxiety, approve for a limited number of “subconditions” defined as specific anxiety disorders, or approve for anxiety disorders.  They list the pros and  cons associated with each approach but not much was added relative to the above discussion.  There are a few comments that merit further criticism. The risks of maintaining the status quo are seriously overstated.  From reviewing previous tabulated data from the MN Medical Cannabis program, it is unlikely that any meaningful real world data will be collected. It is not possible to collect non-randomized, uncontrolled data on a substance that is highly valued and reinforces its own use that has any meaning. The results will predictably be like the comments solicited by this program that are 96% favorable. There are similar speculative predictions of the direct consequences of not providing medical cannabis in terms of not seeking therapy if using cannabis off the street, suicides due to not tolerating SSRIs, and patient harm from “illicit use”. Similar speculation occurs throughout the remaining bullets points and there seems to be a strong pro-medical cannabis for anxiety disorders bias.

To summarize, I am not impressed with the Minnesota Medical Cannabis Program report on the use of medical cannabis for anxiety. It clashes with my 35 years of clinical experience where cannabis has been a major problem for the patients I treated in community mental health centers, clinics, substance use treatment centers, and hospitals. It suggests a great potential for a substance that has been around and used by man for over 7 millennia.  You would think with that history, man would have realized by now that it was a panacea for his most common mental health problem – anxiety. The report also ignores the commonest role of cannabis in American society and that is as an intoxicant and not a medication.  Physicians should not be prescribing intoxicants.  You don’t need a prescription to go to a liquor store and purchase alcoholic beverages. If the real goal is to get cannabis out to the masses, the option is legalization of cannabis not medical cannabis.

 

George Dawson, MD, DFAPA

 

References:

1:  Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-1297.2.3.244

2:  Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004

3:  Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treat:ment. Cambridge, UK: Cambridge University Press; 2006:58-105.

4: NIDA. 2021, April 13. Is marijuana addictive?. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive on 2021, September 13.

5:  Moss HB, Chen CM, Yi HY (2012). Measures of substance consumption among substance users, DSM-IV abusers, and those with DSM-IV dependence disorders in a nationally representative sample. J Stud Alcohol Drugs 73: 820–828

6:  Perkonigg A, Goodwin RD, Fiedler A, Behrendt S, Beesdo K, Lieb R et al (2008). The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 103: 439–449 discussion 450–451.

7: Becker WC, Fiellin DA, Desai RA. . Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug Alcohol Depend. 2007; 90 2-3: 280- 7. DOI: 10.1016/j.drugalcdep.2007.04.009 PubMed PMID: 17544227.

 

Harm Reduction:

8: Okusanya BO, Asaolu IO, Ehiri JE, Kimaru LJ, Okechukwu A, Rosales C. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. 2020 Jul 28;9(1):167. doi: 10.1186/s13643-020-01425-3. PMID: 32723354; PMCID: PMC7388229.

9: Shover CL, Davis CS, Gordon SC, Humphreys K. Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proc Natl Acad Sci U S A. 2019 Jun 25;116(26):12624-12626. doi: 10.1073/pnas.1903434116. Epub 2019 Jun 10. PMID: 31182592; PMCID: PMC6600903.

10: Eibl JK, Wilton AS, Franklyn AM, Kurdyak P, Marsh DC. Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study. J Addict Med. 2019 May/Jun;13(3):182-187. doi: 10.1097/ADM.0000000000000476. PMID: 30543543; PMCID: PMC6553513.

11: Purcell C, Davis A, Moolman N, Taylor SM. Reduction of Benzodiazepine Use in Patients Prescribed Medical Cannabis. Cannabis Cannabinoid Res. 2019 Sep 23;4(3):214-218. doi: 10.1089/can.2018.0020. PMID: 31559336; PMCID: PMC6757237.

 

Cannabis and Psychosis:

12: Kuepper R, van Os J, Lieb R, Wittchen H, Höfler M, Henquet C et al. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study BMJ 2011; 342 :d738 doi:10.1136/bmj.d738

13: Murray RM, Mondelli V, Stilo SA, Trotta A, Sideli L, Ajnakina O, Ferraro L, Vassos E, Iyegbe C, Schoeler T, Bhattacharyya S, Marques TR, Dazzan P, Lopez-Morinigo J, Colizzi M, O'Connor J, Falcone MA, Quattrone D, Rodriguez V, Tripoli G, La Barbera D, La Cascia C, Alameda L, Trotta G, Morgan C, Gaughran F, David A, Di Forti M. The influence of risk factors on the onset and outcome of psychosis: What we learned from the GAP study. Schizophr Res. 2020 Nov;225:63-68. doi: 10.1016/j.schres.2020.01.011. Epub 2020 Feb 6. PMID: 32037203.

 

Cannabis Use and Suicide:

14:  Kelly LM, Drazdowski TK, Livingston NR, Zajac K. Demographic risk factors for co-occurring suicidality and cannabis use disorders: Findings from a nationally representative United States sample. Addict Behav. 2021 Nov;122:107047. doi: 10.1016/j.addbeh.2021.107047. Epub 2021 Jul 12. PMID: 34284313; PMCID: PMC8351371.

 

Cannabis Use and Life-Threatening Medical Problems:

15:  Ladha KS, Mistry N, Wijeysundera DN, Clarke H, Verma S, Hare GMT, Mazer CD. Recent cannabis use and myocardial infarction in young adults: a cross-sectional study. CMAJ. 2021 Sep 7;193(35):E1377-E1384. doi: 10.1503/cmaj.202392. PMID: 34493564.

16:  Parekh T, Pemmasani S, Desai R. Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis. Stroke. 2020 Jan;51(1):308-310. doi: 10.1161/STROKEAHA.119.027828. Epub 2019 Nov 11. PMID: 31707926.

17:  Shah S, Patel S, Paulraj S, Chaudhuri D. Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults. Am J Med. 2021 May;134(5):614-620.e1. doi: 10.1016/j.amjmed.2020.10.019. Epub 2020 Nov 9. PMID: 33181103.

18:  Desai R, Fong HK, Shah K, Kaur VP, Savani S, Gangani K, Damarlapally N, Goyal H. Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse. Medicina (Kaunas). 2019 Aug 5;55(8):438. doi: 10.3390/medicina55080438. PMID: 31387198; PMCID: PMC6723728.

Pharmacokinetics and Adverse Effects of Cannabis:

19:  Schlienz NJ, Spindle TR, Cone EJ, Herrmann ES, Bigelow GE, Mitchell JM, Flegel R, LoDico C, Vandrey R. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug Alcohol Depend. 2020 Mar 21;211:107969. doi: 10.1016/j.drugalcdep.2020.107969. Epub ahead of print. PMID: 32298998; PMCID: PMC8221366.

20: Spindle TR, Cone EJ, Goffi E, Weerts EM, Mitchell JM, Winecker RE, Bigelow GE, Flegel RR, Vandrey R. Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug Alcohol Depend. 2020 Jun 1;211:107937. doi: 10.1016/j.drugalcdep.2020.107937. Epub 2020 Apr 1. PMID: 32247649; PMCID: PMC7414803.

21:  Spindle TR, Martin EL, Grabenauer M, Woodward T, Milburn MA, Vandrey R. Assessment of cognitive and psychomotor impairment, subjective effects, and blood THC concentrations following acute administration of oral and vaporized cannabis. J Psychopharmacol. 2021 Jul;35(7):786-803. doi: 10.1177/02698811211021583. Epub 2021 May 28. PMID: 34049452. 

22:  Spindle TR, Cone EJ, Schlienz NJ, Mitchell JM, Bigelow GE, Flegel R, Hayes E, Vandrey R. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw Open. 2018 Nov 2;1(7):e184841. doi: 10.1001/jamanetworkopen.2018.4841. Erratum in: JAMA Netw Open. 2018 Dec 7;1(8):e187241. PMID: 30646391; PMCID: PMC6324384.

Vaping and Pulmonary Toxicology:

23:  Meehan-Atrash J, Rahman I. Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology. Chem Res Toxicol. 2021 Oct 8. doi: 10.1021/acs.chemrestox.1c00290. Epub ahead of print. PMID: 34622654.

24:  Tehrani MW, Newmeyer MN, Rule AM, Prasse C. Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography-High-Resolution Mass Spectrometry. Chem Res Toxicol. 2021 Oct 5. doi: 10.1021/acs.chemrestox.1c00253. Epub ahead of print. PMID: 34610237.

25:  McDaniel C, Mallampati SR, Wise A. Metals in Cannabis Vaporizer Aerosols: Sources, Possible Mechanisms, and Exposure Profiles. Chem Res Toxicol. 2021 Oct 27. doi: 10.1021/acs.chemrestox.1c00230. Epub ahead of print. PMID: 34705462.

Epidemiology:

26: Lim CCW, Sun T, Leung J, et al. Prevalence of Adolescent Cannabis Vaping: A Systematic Review and Meta-analysis of US and Canadian Studies. JAMA Pediatr. Published online October 25, 2021. doi:10.1001/jamapediatrics.2021.4102

Prevalence of cannabis vaping by adolescents has recently increased for lifetime use, use in the past 30 days and use in the past year.

Maternal Cannabis Use and Anxiety in Offspring:

Rompala G, Nomura Y, Hurd YL. Maternal cannabis use is associated with suppression of immune gene networks in placenta and increased anxiety phenotypes in offspring. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2106115118. doi: 10.1073/pnas.2106115118. PMID: 34782458.

LaSalle JM. Placenta keeps the score of maternal cannabis use and child anxiety. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2118394118. doi: 10.1073/pnas.2118394118. PMID: 34789581.

Graphics Credit: The graphic at the top of this post is from Shutterstock per their standard user agreement.

 

 

Drapetomania - The Lack of Relevance To Psychiatry

 

I will address this issue one final time. I have written about it in the pages of this blog in past. Drapetomania was a pseudo diagnosis coined by Southern physician named Samuel A. Cartwright. He wrote the following in 1851:

“DRAPETOMANIA, OR THE DISEASE CAUSING NEGROES TO RUN AWAY.
It is unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers...
In noticing a disease not heretofore classed among the long list of maladies that man is subject to, it was necessary to have a new term to express it. The cause in the most of cases, that induces the negro to run away from service, is as much a disease of the mind as any other species of mental alienation, and much more curable, as a general rule. With the advantages of proper medical advice, strictly followed, this troublesome practice that many negroes have of running away, can be almost entirely prevented, although the slaves be located on the borders of a free state, within a stone's throw of the abolitionists.” 

Characterizing running away from slavery as a disease and physical punishment as a treatment was certainly a radical concept even in the Southern states before the American Civil War. In subsequent paragraphs Cartwright invokes divine providence to explain why white masters are destined to remain in a superior role to slaves.  He was concerned about “two classes of person who were apt to lose their negroes – the overly permissive defined as “treating them as equals” and the cruel owners who denied slaves the ordinary necessities of life.  His solution was to treat them well enough, but not allow many freedoms, and physically punish them into a submissive state “for their own good.”  Since Cartwright wrote these paragraphs the common interpretation is that his disease characterization of a rational act is a prototypical misapplication of the disease concept.

Not much has been written about criticism at the time. Writing in the Buffalo Medical Journal Samuel Hunt provided a satirical editorial on the original paper (2):

“Our purpose in this formal introduction, is to give due importance to an article recently published in its pages by Dr. Samuel Cartwright, of New Orleans. Characterized by the same cautious induction and logical accuracy whichever attended the literary efforts of that gentleman, it deserves careful consideration of the medical philosopher, the anatomical statesman, and the benighted Saratoga convention.

Those of our readers who are in the habit of referring to Cullen’s Nosology for the definition of diseases, will find no mention there of Drapetomania. The ignorance of the ancients was surprising, and we need but refer to Drapetomania as an evidence of this progressive spirit of the age in which we live.

Dr. Cartwright has conferred this name, Drapetomania, upon a disease peculiar to the south, and which is, we believe entirely confined to that section, and only manifested at the north in certain analogous if not identical forms, which we shall have occasion to mention when we have given our readers time for the perusal the following extract from Dr. Cartwright’s able article:”

After additional sarcasm following the extract, the author goes on to close his editorial by describing a disease he calls Effugium discipulorum or a tendency of school boys to leave school and spend time in the fields and orchards of rural districts. He suggests that the same solution – whipping “have been sanctioned by ages of experience in Effugium discipulorum; thus confirming the allied nature of the 2 diseases and the correctness of Dr. C’s hypothesis.” Hunt’s satirical editorial of 1855 and additional sources describing how the paper was mocked in the northern states is an indication of how serious this “diagnosis” was taken by some physicians at the time.

Historian Christopher D. E. Willoughby (3) described a much more nuanced environment and the multiple roles that Cartwright played. He was apparently widely published on a number of medical topics and there was widespread interest in the medical community about racial differences in medicine. Cartwright portrayed himself as an expert in this area, but due to his reputation he generally received deferential treatment – even when other physicians disagreed with him.  The medical emphasis at the time was on anatomy and in terms of disease theory there was a doctrine of specificity outlining the few factors relevant to how a disease could be treated. One of those factors was race. A physician could be regarded as a quack if one of these factors was disregarded – reinforcing the role of racial medicine. Despite Cartwright’s medical and political role, Willoughby describes his drapetomania as being so far outside of the medical norms at the time that drapetomania was not adopted as a diagnosis by many physicians and it was never a psychiatric diagnosis for the obvious reason that psychiatry and its diagnostic systems did not exist.

.The sampling of how often the term was used over the intervening decades both independently and relative to actual psychiatric diagnoses is indicated in the following Google NGRAMS.  To read about the graphing procedure consult this source (4). (Click to enlarge)

It seems fairly obvious that there was a flurry of references around the time of Cartwright’s article and then a very long flat period until Szasz resuscitated it in the 1970s (5) and it was picked up by the anti-psychiatry crowd subsequent to that.  Given the Google NGRAMS approach, relative to standard psychiatric diagnoses the interest in this pseudo diagnosis was practically nil.

A critical question is how a theory largely ignored at the time, now has more references than in the past?  A lot of that may have to do with a reinterpretation of his image. The description of him as a respected surgeon who trained with Benjamin Rush at Pennsylvania Hospital was apparently due to mistakes in an early biographical history (3) and persist today in Wikipedia and many other places.  Further reading suggests that he was in medical school as a teenager, dropped out to fight in the War of 1812 where he sustained injuries and then went back to complete his medical training. Looking at that timeline does it seem plausible? (click to enlarge)

Cartwright was born in 1793. In the years 1808-1813 he would have been 15-20 years old. Benjamin Rush died in April of 1813 and had been ill since the previous November. His biographer Stephen Fried (6) described Rush writing and active doing hospital rounds during this time period but for the first time starting to miss those rounds. It seems unlikely that even in the 19th century that anyone in their late teens would have been a military veteran and in medical school between the ages of 15-19. Willoughby (3) confirmed that there was no evidence that Cartwright matriculated at Penn or that he apprenticed with Rush. There are a multitude of sites on the Internet and in papers that state otherwise. Contrary to these many references there was no connection between Cartwright or Rush and the University of Pennsylvania Medical School. He did graduate from Transylvania Medical School (Lexington, KY) in 1823.

What about the purported connection between psychiatry and Cartwright and his invented diagnosis? Per the timeline above psychiatry had not yet been invented. There was an organization of asylum superintendents at the time but they had no formal diagnostic system.  The Association of Medical Superintendents of American Institutions for the Insane (AMSAII) was founded in 1844 and it had a total of 13 members - none of them were described as psychiatrists or alienists.  Despite the fact that racism and proslavery attitudes were widespread,  none of them used the term drapetomania or admitted asylum patients on that basis. In fact, only one asylum accepted slaves with mental illnesses at that time.  

The American Medico-Psychological Association was established in 1892 and at that time the number of alienists versus psychiatrists was not known.  In fact, it wasn’t until a meeting of the Alienists and Neurologists of America in 1917 (7) that anyone suggested specific training was necessary to treat asylum patients.  In those proceedings there are three times as many references to alienists than there are to psychiatrists, despite Reil’s first use of the term in 1816.  No mention at all of drapetomania but an interesting section on the importance of social diagnosis and social work.  The main diagnostic focus was on alcoholism, catatonia, epilepsy, syphilis, dementia praecox, various forms of chronic illness, and intellectual disability described as “feeble mindedness”.  None of the alienists or neurologists seem remotely concerned about drapetomania.  This is the only reference to race in that 228-page document:

“Preservation of self and of the race are directly dependent upon gratification of the appetites and this fact necessitates reaction of man to his environment and appropriation of those things which serve to fulfill his desires.”

It was included in a section on “Criteria of Defective Mental Development”.

On the timeline, the initial forms of psychiatric diagnostic manuals appeared in 1918 and 1952. Neither contained any reference to drapetomania and most of the diagnoses proposed are recognized as being similar or precursors to current diagnoses. One of the often-used tactics in criticizing psychiatry today has to do with the diagnostic manual and what it means.  Contrary to the rhetoric, alienists and psychiatrists involved in asylum care were often criticized for the lack of science in those settings most notably by the neurologist Weir-Mitchell (8):

“I shall frankly have to reproach many of those who still bear the absurd label of ‘medical superintendents'. Where are your annual reports of scientific study of the psychology and pathology of your patients? We commonly get as your contributions to science, odd little statements, reports of a case or two, a few useless pages of isolated post mortem records and these are sandwiched among incomprehensible and farm balance sheets”.  He went on to state that neurologists believed asylum care was care of “last resort”.

From the start psychiatric diagnostic manuals had the dual role of diagnostic description and data collection in asylums, specialty hospitals, specific populations, and for research purposes. Contrary to modern antipsychiatry philosophy there was no goal to increase diagnoses or the number of people with a diagnosis and no goal of social control through diagnosis.

I have established that Cartwright had no connection to Benjamin Rush of the University of Pennsylvania medical school. I have also established that drapetomania was certainly not accepted as a diagnosis and was probably widely derided in some areas.  It was essentially a product of the racist south, inadequate diagnostic theory and medical racism, had medical and political implications, and was written by a physician who owned 14 slaves and had a personal interest maintaining that practice.  I have also established that it has nothing to do with the field of psychiatry or its intellectual roots. It is only through massive misinformation that these false ideas persist. That misinformation landscape if so large at this point that it is not likely to ever be corrected. I certainly doubt that this blog will have much of an effect against what is now decades of drapetomania misinformation.  Many of the people spreading that misinformation are doing it in bad faith and by definition are not interested in correcting it.  There are also many (presumably) good faith errors such as recent statements from within organized psychiatry and in texts. A psychology colleague posted that every undergraduate Abnormal Psychology text uses drapetomania as an example of coercive psychiatry. Hopefully the good faith errors will correct themselves.  

The modest goal of this post is to hope that I can keep all of this misinformation out of the psychiatric literature.  That will be no small task. Szasz is already published despite the fact that he has been widely discredited. Even last month I was reading the American Journal of Psychiatry (9) and came across this statement:

“Over 60 years after the ratification of the US Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in psychiatry.  His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaethesia aethopica, a disease of ‘rascality’, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression.”

Based on everything I have established this is an inaccurate statement. Cartwright was not a psychiatrist or even an alienist. He was not trained in researching or diagnosis any mental health conditions and essentially made these up. His isolated racist ideology has nothing to do with the subsequent development of psychiatry or the way psychiatry is practiced today. Cartwright and drapetomania have become a convenient meme with the imitators using it as an indictment of psychiatry or the psychiatric diagnostic system – even though it is unrelated to both.  The latest application has been the use of this meme by psychiatrists to acknowledge systematic racism within the field as a basis for future correction. I have no problem with acknowledging that racism in psychiatry and society exists – but let’s make that acknowledgment on a realistic basis not an unconnected anecdote.

I expect a fair amount of opposition to this post. I base that on a reaction I got in a psychiatry listserv when I suggested that professional organizations should suggest the Rosenhan paper be retracted. Although I got several very supportive replies and replies from people who were shocked about the facts, there was also a very vocal contingent proclaiming they want social justice. Social justice cannot be predicated on a misinformation, even if that misinformation seems consistent with your overall message.  And there is a much better way.  That better way was in this weeks New England Journal of Medicine (10) in an article highlighting the work of W.E.B. Dubois and his colleagues who accomplished what can only be described as landmark work in the area of structural racism. In it DuBois and colleagues concluded that the excess mortality from tuberculosis in the black community was a product of racial disparities secondary to social forces. The report was published in 1899.  DuBois also successfully countered the theory of an insurance company actuary who suggested that black people were “ill adapted to freedom but also doomed to imminent extinction because of their biological differences from white people.” (note the parallels with drapetomania). Dubois successfully refuted these claims and showed that heredity could explain only a small part of differential mortality between groups and that social inequity accounted for most differences. The work of these social scientists and theorists is a solid place to start.

The solid scientific ground that we are on today is that we know race is a non-specific factor and that biologically all of mankind comes from the same place.  We are much more biologically similar than different. Discrimination and the resulting outcome disparities based on racism are the real problems to be addressed and there has been a scientific basis for that since 1899.    

 

George Dawson, MD, DFAPA

 

References:

1:  Cartwright SA.  Diseases and Peculiarities of the Negro Race.  De Bow's Review. Southern and Western States. Volume XI, New Orleans, 1851  Link

2:  S. B. Hunt (1855). "Dr. Cartwright on "Drapetomania"". Buffalo Medical Journal. 10: 438–442. (full text). https://books.google.com/books?id=coBYAAAAMAAJ&pg=PA438#v=onepage&q&f=false

3:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

4:  Younes N, Reips UD. Guideline for improving the reliability of Google Ngram studies: Evidence from religious terms. PLoS One. 2019 Mar 22;14(3):e0213554. doi: 10.1371/journal.pone.0213554. PMID: 30901329; PMCID: PMC6430395.

5: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

6:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018.

7:  Alienists and Neurologists of America: Proceedings of Sixth Annual Meeting.  Chicago, IL  July 10-12, 1917.

8:  Shorter E.  A History of Psychiatry: from the era of the asylum to the age of Prozac.  John Wiley & Sons, Inc. New York, 1997: p.68

Weir-Mitchell’s criticism was delivered in 1894.

9: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

10:  White A, Thornton RLJ, Greene JA.  Remembering Past Lessons about Structural Racism — Recentering Black Theorists of Health and Society.  New England Journal of Medicine August 26, 2021 385(9):850. doi: 10.1056/NEJMms2035550

11:  Callender JH.  History and Work of the Association of Medical Superintendents of American Institutions For The Insane - President's Address.  Am J Insanity. July 1883: p. 1-32.

In this reference, the Association President reviews the first 40 years of progress and points out that 13 members started in 1844 but by 1880 there were 115 members representing 130 public and private institutions in the US or Canada and a total of 41,000 patients.  In this same document the President refers to the distinguished members of the organization as alienists rather than psychiatrists. Gonaver (see below) refers to the physicians of the AMSII as "asylum doctors" or "psychopathists" but also points out that many had no specialized training at all in the treatment of the mentally ill.

Supplementary 1:

This reference was posted to me on Twitter.  In it the author points out that the term drapetomania was not a diagnosis in the only asylum that treated slaves during the time when there was peak interest in the term:

"Readers may be therefore surprised by the conspicuous absence of these so-called conditions in the only insane asylum in which  slaves were patients."

Gonaver W. The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880. University of North Carolina Press, 2019.

Supplementary 2:

The nosology text by Cullen referenced in the satirical critique of Cartwright's work is available online through the National Library of Medicine.  The only references to mental disorders were mania, melancholia, and bulimia.  

Cullen W (1710-1790).  Synopsis and nosology: being an arrangement and definition of diseases. Hartford : Printed by Nathaniel Patten, MDCCXCII [1792]: 80 pages.  Link to NLM

Supplementary 3:

 

I got this book in the mail today and read it.  It is a 1918 edition "prepared for the Committee on Statistics by the American Medico-Psychological Association" - see timeline. The text is 40 pages long, contains 21 diagnoses in the classification system and was designed to facilitate data collection for statistical analysis. There was a detailed section on race and ethnicity that would not be included in any modern analysis.  Drapetomania was not listed anywhere in this volume.

Supplementary 4:

Precursor organizations to the American Psychiatric Association published a journal - The American Journal of Insanity that encompassed the period of time when drapetomania was proposed. In order to see if there was any recognition of drapetomania in the line of journals that the APA considers related to psychiatry I went back and looked at one 1850s decade of the American Journal of Insanity and then did a search on the APA web site validated against terms like sitomania discovered in that decade of material.

On the APA web site, the time span of journals is indicated below:

American Journal of Insanity vol. 1 no 1 (July 1844) to vol. 99 no. 6 (May 1943)

American Journal of Psychiatry vol. 100 no. 1 (July 1943) to current time.

There were no references to drapetomania in the interval 1851-1859.

The search engine was validated to discover relevant diagnoses in the American Journal of Insanity.

The search of APA journals yielded 19 references dating back to 1971.  The first two references from that year were both written by Thomas Szasz.  The references in general have to do with racism in medicine including a recent number of references, some book reports including one about ADHD that for some reason contains the word drapetomania. 

The exercise in this supplemental information confirms that drapetomania was never considered a diagnosis in what are considered the early journals of psychiatry.  In my reading of the American Journal of Insanity I also found much to support Weir-Mitchell's 1894 criticism of the field (see above and reference 8).

Supplementary 5:

I received the following book in the mail today after a Twitter colleague referenced it.  The author Wendy Gonaver is a historian who had access to a significant volume of records from the only asylum that treated and accepted slaves and free black persons as patients and employed slaves as caregivers.  So far I have read the 18 page introduction and the writing and rationale are excellent.  She introduces a level of insight and objectivity that is rarely seen in the content that she is covering. On page 6 and 7 she debunks the importance of drapetomania that occurred right in the middle of the years she is covering for this book (1840-1880). In commenting on the complete absence of Cartwright's invented diagnoses:

"For good reason, Cartwright's work has become synonymous with all that was horribly wrong with both slavery and spurious science.... but Cartwright's posthumous notoriety does not appear to match his reputation during his lifetime.  His fabrications were, at least for Southern doctors who considered themselves serious practitioners, more rhetorical proslavery provocation than legitimate diagnoses." (p. 6-7).

She points out that Cartwright was not a "mental health specialist", never attended a meeting of The Association of Medical Superintendents of American Institutions for the Insane the only professional organization at the time, his work was never discussed at those meetings, and there were no records to suggest that slaves were admitted for running a way or that they were whipped.  There is also no mention of a connection to Benjamin Rush - another frequent error when Cartwright is discussed.

At the same time Gonaver points out that previous historical documents ignored race as a dimension for analysis and illustrates some of her insights in that area in the introduction.  I look forward to completing the book. 

A brief synopsis of the book follows:

After some consideration, I elected to post a synopsis of the book rather than each chapter due to the length of that document. The book is based on archives of the Eastern Lunatic Asylum (ELA) as reviewed by the author historian Wendy Gonaver. The descriptions of the state of the asylum, administration, staff including the enslaved staff, and the patient population role based on detailed notes by the asylum superintendent during the time interval of interest (1840-1880). Most of the material consisted of records written by John Galt, the superintendent. He was appointed age 22 and 1841 after studying at the University of Pennsylvania. He remained the superintendent until his death by suicide on May 18, 1862. Although the author refers to her book as a study of the “broader ideological underpinnings of early psychiatry” - the asylum doctors were clearly not psychiatrists. They are typically referred to as “asylum doctor” or “psychopathist”.  He was a member of the Association of Medical Superintendents of American Institutions for the Insane (AMAAII). This association was founded in 1844 and at that time it had 13 members. The only real connection to psychiatry is that the American Psychiatric Association uses this date to claim that psychiatry was the first medical specialty. That is a questionable claim on multiple levels.

The ELA itself was housed in an inadequate physical plant even in the pre-Civil War era. Sanitation was clearly a problem with inadequate drainage and sewerage systems. Potable water was also problem. There were a large number of fires on the campus for heating purposes until central heat could be installed. Nutrition was also a problem. Although the patients got about a pound of meat 5 days a week and fish 2 days a week several patients were diagnosed with scurvy. That led to an emphasis on expanded gardening of fruits and vegetables. Children of staff living on campus were not served regular meals but had to subsist on scraps.

One obvious conclusion is that there is much material in this book that could be used to blame psychiatry in much the same way that drapetomania has been used. But there are many qualifiers. Racism both overt and covert were clearly present in both the northern and southern states. Even though much of the events described in this book occurred 30 – 70 years after Benjamin Rush’s death there were no true abolitionists, not even reformer Dorthea Dix.  John Galt supported his enslaved staff in many cases humanistically but from a pragmatic rather than a moral perspective. He clearly believed that blacks were socially and intellectually inferior, but he realized that his institution could not run without enslaved blacks.  That led him to defend the quality of care provided by the enslaved staff at his institution. Racial stereotypes cut across the dimensions of religion, gender, and culture with African Americans receiving the harshest treatment and the greater work load. When John Galt died and the Civil War ended, the integrated ELA also ended and black patients were transferred to a segregated institution where their care was noticeably worse.  During a transition period, multiple military physicians with no training in asylum care were appointed to run the ELA.

Politics factored prominently in the workings of the ELA and whether Galt received any recognition for his work of ideas.  Shortly after his arrival, a conflict developed with the asylum board when they removed his hiring ability and blamed him for the resulting problems. He was also resented by AMAII colleagues over his advocacy for integrated asylums and eventually an outpatient community-based model. Despite praise for innovation at their meetings he was never credited for his ideas or his death mentioned in one of their meetings.

The author is a critical presence in this book. In places, she is clearly suggesting that stressors, abuse, domestic violence, war, and other forms of trauma may be the most important factors in why someone, but particularly white, black, and enslaved black women ended up in the ELA. She acknowledges that there may be a role for severe post-partum states. As I read though these case reports, I had questions about the degree of detail available as well as the primitive to non-existent diagnostic system. If all of the details of stressful events were there – could they really not be considered given the primitive state of medicine that was being used?  The only treatment being supplied was basically moral therapy and environmental containment to reduce the risk of aggression, suicide, and starvation.  There were no trauma or stress based therapies available in the mid-19^th century. If there were it would take a much larger professional staff to administer them.

All things considered, the logical conclusion is that the ELA, like most institutions was not able to rise above the prejudices of the population where it was located. The practices described in the book are common overt and implicit racist themes – even today. Covert segregation still exists even though school segregation ended in 1954. In keeping with the timeline of this book, the Civil Rights Act of 1875 was supposed to have ended racial discrimination but the Supreme Court overturned it in 1883 saying that individuals and private business could discriminate on the basis of race.  

The Peculiar Institution is a very scholarly work. It is well written and I encourage anyone with an interest in the history of this time or discrimination based on race or gender to read it.  My only other concern is with the extended title – The Making of Modern Psychiatry.  I would submit that it really contains very little to do with modern psychiatry – and like Cartwright’s drapetomania diagnosis is more the product of racism, politics, and an inadequate system of care. 

Supplementary 6:

The state of Virginia lists Eastern State Hospital as the first mental hospital in the United States dating back to October 12, 1773 and states that at one point it was called the Eastern Lunatic Asylum.  There is some history available on this Virginia State web site including commentary on Dr. Galt.

Supplementary 7:

The journal Alienist and Neurologist: a quarterly journal of scientific, clinical and forensic psychiatry and neurology was published between 1880 and 1920 when publication ceased.

Full text of this journal is available via the HathiTrust web site. 

Supplementary 8:

Drapetomania errors on the Internet - needless to say there are many.  I thought I would catalogue them but do not have the time. Unless the use is restricted to Cartwright and not applied to psychiatry it is probably safe to say it is being used rhetorically.