Abstract
Objective
Mental health conditions and race/ethnicity are independently associated with cannabis use. However, the current prevalence of and trends in cannabis use at the intersection of serious psychological distress (SPD) and race/ethnicity are unknown.
Methods
This study assessed past 30-day cannabis use using data from the 2008–2019 National Survey on Drug Use and Health (n=484,732). Joinpoint regression examined trends over time, stratified by SPD and race/ethnicity.
Results
The prevalence of past 30-day cannabis use in the US increased significantly between 2008–2019 regardless of racial/ethnic group identification and past-month SPD status. The prevalence of cannabis use in 2019 was significantly greater for individuals with (27.9%) versus without SPD (10.7%) overall (p<0.001) and within each race/ethnicity.
Conclusions
Because cannabis use prolongs and exacerbates psychiatric symptoms, the disproportionately high and increasing prevalence of cannabis use among people with SPD emphasizes the importance of continued surveillance of cannabis use in this group. This is especially true among intersectional priority populations where particularly large disparities in the prevalence of cannabis use are observed (e.g., Hispanic with SPD versus Hispanic without SPD). Additionally, trends highlight the need to screen all patients for cannabis use, especially patients with SPD and related conditions.
Introduction
Mental health conditions and cannabis use are frequently comorbid. For instance, recent research indicates that approximately 30% of college students (1) and adults (2) with serious psychological distress (SPD) also used cannabis . In the context of epidemiological surveys, mental health conditions can be approximated by the construct of serious psychological distress (SPD), which is a binary indicator of intense psychiatric symptoms derived from the Kessler Psychological Distress Scale (K6), a validated screening tool for symptoms of serious mental illness (3–5). Moreover, the likelihood of cannabis use disorder (CUD) is greater among persons with a mental health condition, and vice versa (6,7) (8–10). Results from the National Survey on Drug Use and Health (NSDUH) showed that the prevalence of daily cannabis use increased significantly between 2008–2016 among people with and without SPD, but was persistently higher among people with SPD (11). By 2016, the prevalence of daily cannabis use among people with SPD was more than three times that of people without SPD (8.07% versus 2.66%).
While the short- and long-term harms of cannabis use are not yet fully understood, available evidence indicates that cannabis use is associated with adverse mental health outcomes. Not only is cannabis use associated with risk of developing psychosis in a dose-dependent manner (12–14), but also continued (versus discontinued) cannabis use after the onset of psychosis is associated with longer hospital admissions and more severe positive psychotic symptoms (15). Cannabis use may also increase the risk of developing major depressive disorder and promote the progression of depressive symptoms (16,17). Beyond the implications for mental health, other potential adverse effects of cannabis use include—but are not limited to—respiratory and cardiovascular disorders, cognitive alterations, sleep disturbances, and addiction (18–20).
Race/ethnicity is another factor that has been associated with cannabis use. For instance, analyses utilizing data from the NSDUH found that in 2005–2013 and 2015–2019, the prevalence of monthly cannabis use, daily cannabis use, and past-year CUD were higher among non-Hispanic Black adults and adults reporting more than one race compared to non-Hispanic White adults, but lower among Hispanic and non-Hispanic Asian-American adults (21,22). Moreover, among adults who used cannabis, CUD was more prevalent among racial/ethnic minoritized groups versus non-Hispanic White adults (21).
Research increasingly demonstrates the importance of investigating substance use at the intersection of multiple priority populations, such as racial/ethnic minoritized groups (22,23). At the intersection of race/ethnicity and SPD, an analysis of 2008–2016 NSDUH data indicated that the association between SPD and daily cannabis use was significantly stronger for non-Hispanic White as compared to non-Hispanic Black respondents (11). However, this analysis did not examine whether trends in cannabis use over time differed by race/ethnicity and SPD. Given the high risk of cannabis use and related negative consequences among individuals with SPD and among individuals reporting minoritized racial/ethnic identities, results of this study may inform future assessment and treatment for individuals at the intersection of both groups. In particular, understanding these trends will be essential to best tailor cessation and public health approaches for individuals from diverse, intersecting groups. The present analysis used data from the 2008–2019 NSDUH to examine and compare trends in past-month cannabis use, stratified by race/ethnicity and past-month SPD, as well as to report and compare recent estimates of cannabis use among intersecting race/ethnicity and SPD groups.
Methods
Data Source and Study Population
Data came from adult (i.e., ages ≥18) respondents from the 2008–2019 (n=484,732) NSDUH public use data files. NSDUH is a nationally representative, annual, cross-sectional survey assessing tobacco, alcohol, and drug use, as well as mental health and other health-related issues in the US among those ages ≥12. NSDUH is sponsored by the Substance Use Mental Health Services Administration (SAMHSA). Due to changes in data collection methodologies between 2008–2019 and 2020/2021, survey years 2020 and 2021 could not be combined or included in trend analyses. Additional information regarding changes made to the NSDUH in 2020 (24) and 2021 (25), and detailed descriptions of the sampling methods and survey techniques for the 2008–2019 NSDUH (24), are available elsewhere. This study was exempt from IRB review as NSDUH data are deidentified and publicly available.
Measures
Sociodemographic characteristics:
Sociodemographic variables included race/ethnicity (non-Hispanic White; non-Hispanic Black; Hispanic; non-Hispanic Other), sex (male/female), age (18–25; 26–34; 35–49; 50+), and total family income (<$20,000; $20,0000-$74,999; $75,000+.
Cannabis use.
Prior to answering questions regarding cannabis use, respondents were presented with the following information: “The next questions are about marijuana and hashish. Marijuana is also called pot or grass. Marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. It is sometimes cooked in food. Hashish is a form of marijuana that is also called “hash.” It is usually smoked in a pipe. Another form of hashish is hash oil.” Respondents who reported ever using marijuana were then asked how long it had been since they last used marijuana. The primary outcome measure for this analysis was self-reported cannabis use within the past 30 days (yes/no).
Serious psychological distress (SPD).
Past-month SPD was assessed using the Kessler Psychological Distress Scale (K6) screening instrument (4,5), which is a 6-item scale that assesses the frequency of feeling nervous; hopeless; restless or fidgety; sad or depressed; that everything is an effort; or feeling down on oneself, no good, or worthless. Items were measured on a 5-point Likert scale (0 = “none of the time”; 4 = “all of the time”); responses were summed across the six items (range=0–24). As in prior research (26,27), scores of ≥13 were classified as indicating the presence of SPD. SPD was assessed among respondents ages ≥18 only.
Statistical Analysis
Data were weighted to reflect the complex design of the NSDUH sample and analyzed with STATA SE version 18.0 (28) and RStudio (29). We used Taylor series estimation methods (i.e., STATA ‘svy’ commands) to obtain proper standard error estimates for cross-tabulations. We examined the prevalence of past 30-day cannabis use from 2008–2019, first by SPD status, then by race/ethnicity, and lastly, by SPD status and race/ethnicity together.
Joinpoint (Joinpoint version 5.0.2.0, Surveillance Research Program, US National Cancer Institute) regression characterized trends for all estimates and calculated trend joinpoints (i.e. inflection points) and annual percent change (APC) in each identified segment. The number of potential joinpoints is determined by the number of data points (i.e., years); for 12 years of data, the recommended maximum number of joinpoints is two (30). The segments (i.e., the lines between joinpoints) are determined by taking the trend data and fitting the simplest regression model that the data allow. The Joinpoint Regression Program tests whether apparent changes in the slope of the line (i.e., segments before and after a joinpoint) are statistically significantly different from one another using a Monte Carlo Permutation method (31). We compared trends in cannabis use among pairs of two groups (e.g., SPD versus no SPD; non-Hispanic Black versus non-Hispanic White) using pairwise comparisons by examining whether two trends were parallel, allowing for different intercepts (i.e., tests of parallelism) (32,33). A Bonferroni-corrected p-value of <0.002 for each test was indicative of trends being significantly different from one another. We also analyzed the prevalence estimates of past 30-day cannabis use in the 2019 NSDUH data and used chi-square tests to assess whether the current prevalence differed between each of the groups we compared.
Results
Among 42,739 respondents in 2019, 6,775 (11.9%) respondents reported past 30-day cannabis use and 4,148 (6.7%) reported past-month SPD. A total of 25,226 (63.0%) reported non-Hispanic White race/ethnicity, 5,475 (11.9%) reported non-Hispanic Black race/ethnicity, 7,662 (16.5%) reported Hispanic race/ethnicity, and 4,376 (8.5%) reported non-Hispanic Other race/ethnicity. Other sociodemographic characteristics, stratified by SPD status, can be found in Table 1.
Table 1.
Weighted prevalence of descriptive characteristics by serious psychological distress — National Survey on Drug Use and Health, United States, 2019 (n = 42,739)
| With Serious Psychological Distress (n = 4,148) |
Without Serious Psychological Distress (n = 38,591) |
Overall (n = 42,739) |
|
|---|---|---|---|
| wt% (95% CI) | wt% (95% CI) | wt% (95% CI) | |
| Sex | |||
| Male | 39.8 (37.4, 42.3) | 48.9 (48.2, 49.6) | 48.3 (47.6, 49.0) |
| Female | 60.2 (57.7, 62.6) | 51.1 (50.4, 51.8) | 51.7 (51.0, 52.4) |
| Age | |||
| 18 to 25 | 31.6 (29.7, 33.5) | 12.2 (11.8, 12.5) | 13.5 (13.2, 13.8) |
| 26 to 34 | 23.3 (21.6, 25.1) | 15.6 (15.1, 16.1) | 16.1 (15.6, 16.6) |
| 35 to 49 | 21.5 (19.9, 23.1) | 24.5 (24.0, 25.1) | 24.3 (23.8, 24.9) |
| 50 and over | 23.6 (21.6, 25.8) | 47.7 (46.7, 48.7) | 46.1 (45.2, 47.0) |
| Race/ethnicity | |||
| Non-Hispanic White | 61.3 (59.1, 63.6) | 63.2 (62.1, 64.2) | 63.0 (62.0, 64.0) |
| Non-Hispanic Black | 13.3 (11.5, 15.2) | 11.8 (11.1, 12.6) | 11.9 (11.2, 12.7) |
| Hispanic | 18.0 (15.9, 20.2) | 16.4 (15.6, 17.2) | 16.5 (15.7, 17.3) |
| Non-Hispanic Other | 7.4 (6.2, 8.9) | 8.6 (8.1, 9.2) | 8.5 (8.0, 9.0) |
| Education | |||
| High School/GED or Less | 44.1 (41.2, 47.0) | 35.8 (34.9, 36.6) | 36.3 (35.5, 37.1) |
| Some College or More | 55.9 (53.0, 58.8) | 64.2 (63.4, 65.1) | 63.7 (62.9, 64.5) |
| Income | |||
| <$20,000 | 27.7 (25.6, 30.0) | 13.8 (13.3, 14.4) | 14.8 (14.3, 15.3) |
| $20,000–75,000 | 47.8 (45.6, 50.1) | 44.2 (43.3, 45.0) | 44.4 (43.6, 45.2) |
| $75,000+ | 24.4 (22.1, 26.8) | 42.0 (41.0, 43.0) | 40.8 (39.9, 41.8) |
95% CI = 95% confidence interval
Cannabis use trends by SPD status
Past 30-day cannabis use was stagnant among individuals with SPD (14.1% to 13.8%) from 2008–2010 (see Figure 1, Table 2, and Supplemental Table 1) and increased significantly between 2010–2019 (13.8% to 27.9%). Among individuals without SPD, cannabis use increased significantly from 2008–2019 (5.7% to 10.7%). A pairwise parallel test was non-significant, indicating parallel trends. The 2019 prevalence of past 30-day cannabis use was significantly greater among individuals with versus without SPD (27.9% vs. 10.7%, p < 0.001).
Figure 1. Trends in past 30-day cannabis use by serious psychological distress — National Survey on Drug Use and Health, United States, 2008–2019 (n = 484,732).
Table 2.
Trends in prevalence of past 30-day cannabis use by serious psychological distress and race/ethnicity — National Survey on Drug Use and Health, United States, 2008–2019 (n = 484,732)
| Year | APC (95% CI) | Year | APC (95% CI) | Year | APC (95% CI) | |
|---|---|---|---|---|---|---|
| Serious Psychological Distress (SPD) status | ||||||
| With SPD | 2008–2010 | −2.0 (−18.3, 17.4) | 2010–2019 | 7.7 (6.3, 9.1)* | - | - |
| Without SPD | 2008–2019 | 5.3 (4.5, 6.2)* | - | - | - | - |
| Race/ethnicity | ||||||
| White | 2008–2017 | 4.8 (0.0, 7.4)* | 2017–2019 | 11.3 (5.3, 16.2)* | - | - |
| Black | 2008–2019 | 5.7 (4.3, 7.6)* | - | - | - | - |
| Hispanic | 2008–2010 | 15.1 (9.5, 22.8)* | 2010–2014 | 3.2 (0.0, 5.0)* | 2014–2019 | 8.4 (7.0, 12.8)* |
| Other | 2008–2019 | 7.4 (5.6, 9.7)* | - | - | - | - |
Joinpoint regression is used to identify statistically significant trend change points and the APC in each trend segment using a Monte Carlo permutation method allowing for a maximum of 2 joinpoints.
indicates statistically significant findings at the P < .05 level
APC = Annual Percentage Change
95% CI = 95% confidence interval
Cannabis use trends by race/ethnicity
From 2008–2019, past 30-day cannabis use increased significantly among all four race/ethnicity groups: non-Hispanic White (6.1% to 12.3%), non-Hispanic Black (8.5% to 14.5%), non-Hispanic Other race/ethnicity (4.8% to 8.9%), and Hispanic (4.2% to 9.8%; see Figure 2, Table 2, and Supplemental Table 1). All parallel tests were non-significant, indicating parallel trends. The 2019 prevalence of past 30-day cannabis use significantly differed between the four race/ethnicity groups (p < 0.001).
Figure 2. Trends in past 30-day cannabis use by race/ethnicity — National Survey on Drug Use and Health, United States, 2008–2019 (n = 484,732).
Cannabis use trends by race/ethnicity and SPD
With SPD
Among respondents with past-month SPD, from 2008–2019, past 30-day cannabis use increased significantly among individuals with SPD from the following racial/ethnic groups: non-Hispanic White (15.0% to 29.4%), Hispanic (7.6% to 27.0%), non-Hispanic Other race/ethnicity (4.7% to 23.9%; see Figure 3, Table 3, and Supplemental Table 2). Among non-Hispanic Black adults with SPD, cannabis use decreased significantly from 2008–2012 (20.7% to 13.5%), increased significantly from 2012–2017 (13.5% to 26.9%), and was stagnant from 2017–2019 (26.9% to 24.8%). All pairs of trends were parallel. There were no significant differences in the 2019 prevalence of past 30-day cannabis use by race/ethnicity among individuals with SPD.
Figure 3. Trends in past 30-day cannabis use among those with (n = 35,325) and without serious psychological distress (n = 449,407) by race/ethnicity— National Survey on Drug Use and Health, United States, 2008–2019.
Table 3.
Trends in prevalence of past 30-day cannabis use by race/ethnicity, within serious psychological distress categories — National Survey on Drug Use and Health, United States, 2008–2019 (n = 484,732)
| Year | APC (95% CI) | Year | APC (95% CI) | Year | APC (95% CI) | |
|---|---|---|---|---|---|---|
| With Serious Psychological Distress | ||||||
| White | 2008–2019 | 5.9 (4.1, 7.7)* | - | - | - | - |
| Black | 2008–2012 | −9.9 (−15.7, −3.8)* | 2012–2017 | 15.0 (7.6, 23.0)* | 2017–2019 | −4.1 (−18.1, 12.4) |
| Hispanic | 2008–2019 | 11.6 (9.3, 13.9)* | - | - | - | - |
| Other | 2008–2019 | 14.6 (9.6, 19.8)* | - | - | - | - |
| Without Serious Psychological Distress | ||||||
| White | 2008–2019 | 5.3 (4.3, 6.3)* | - | - | - | - |
| Black | 2008–2019 | 5.5 (4.4, 6.7)* | - | - | - | - |
| Hispanic | 2008–2019 | 5.6 (4.4, 6.8)* | - | - | - | - |
| Other | 2008–2011 | −2.2 (−20.5, 20.1) | 2011–2019 | 8.0 (5.3, 10.8)* | - | - |
Joinpoint regression is used to identify statistically significant trend change points and the APC in each trend segment using a Monte Carlo permutation method allowing for a maximum of 2 joinpoints.
indicates statistically significant findings at the P < .05 level
APC = Annual Percentage Change
95% CI = 95% confidence interval
Without SPD
Among respondents without past-month SPD, from 2008–2019, past 30-day cannabis use increased significantly among individuals without SPD from the following racial/ethnic groups: non-Hispanic White (5.7% to 11.1%), non-Hispanic Black (7.8% to 13.6%), and Hispanic (4.0% to 8.5%). Among adults without SPD reporting non-Hispanic Other race/ethnicity, cannabis use was stagnant from 2008–2011 (4.8% to 4.4%) and increased significantly from 2011–2019 (4.4% to 8.0%). All pairwise parallel tests were non-significant, indicating parallel trends (p’s<0.001). Among adults without SPD, the 2019 prevalence of past 30-day cannabis use significantly differed between the four race/ethnicity groups (p < 0.001).
With versus without SPD
All pairwise parallel tests were not significant (p’s >0.002). Within all four race/ethnicity groups, individuals with versus without SPD had a significantly higher prevalence of past 30-day cannabis use in 2019 (all p’s<0.001): non-Hispanic White (29.4% vs. 11.1%), non-Hispanic Black (24.8% vs. 13.6%), Hispanic (27.0% vs. 8.5%), non-Hispanic Other race/ethnicity (23.9% vs. 8.0%).
Discussion
Overall, we observed significant increases in past 30-day cannabis use among individuals with and without SPD between 2008–2019, with prevalence in 2019 that was more than twice as high among individuals with SPD compared to those without SPD (27.9% versus 10.7%). This increase was observed in all four race/ethnicity groups queried, with the prevalence of past 30-day cannabis use in 2019 differing by race/ethnicity groups, and being greatest among non-Hispanic Black respondents. Cannabis use increased significantly between 2008–2019 among all strata when examining the intersection of SPD status and race/ethnicity, despite an initial period of decline (20.7% to 13.5%) among non-Hispanic Black adults with SPD from 2008–2012. When comparing the prevalence of cannabis use in 2019 between individuals with and without SPD within each race/ethnicity group, the prevalence was higher among individuals with SPD for all four groups. The prevalence for Hispanic individuals with SPD was over three times that of those without SPD (27.0% versus 8.5%) and was at least 1.8 times greater for all other race/ethnicity groups with versus without SPD.
The consistently higher past 30-day cannabis use prevalence among individuals with versus without SPD is consistent with trends reported for past month daily cannabis use in NSDUH from 2008–2016 (11). Additionally, the 2019 cannabis use prevalence of 27.0% among adults with SPD mirrors the high prevalence of cannabis vaping in adolescents with SPD (34) and of CUD in adults with schizophrenia (10). Nevertheless, directionality in the relationship between cannabis use and psychiatric symptoms is unclear, and other variables such as social determinants of health might contribute to increased risk of cannabis use and SPD. Multiple cohort studies indicate that cannabis use increases the odds of developing both psychotic (e.g., schizophrenia, bipolar disorder) and non-psychotic (e.g., depression, anxiety) mental health conditions (14,35–37). On the other hand, a Danish cohort study found that schizophrenia was associated with later developing cannabis abuse (38). Development of cannabis use during the prodromal phase of a mental health condition is also possible (37).
Our analyses concerning the prevalence of cannabis use by examination of intersectional race/ethnicity and SPD status build on prior findings. Trends in cannabis use among most groups are supported by the increasing prevalence of exclusive cannabis use and cannabis and tobacco co-use in the US general population (39), with the exception of a period of decreasing cannabis use among non-Hispanic Black adults with SPD from 2008–2012. The trends in cannabis use that we found in this analysis are very different from the trends found for cigarette smoking in the same racial/ethnic and SPD strata, where non-White groups with SPD were the only ones with stagnant versus decreasing smoking prevalence in all race/ethnicity groups without SPD and White adults with SPD (23). This indicates that, while there are large differences in recent cannabis use between SPD and non-SPD groups, cannabis use may be less variable across race/ethnicity than cigarette smoking.
Our findings indicate a need for more detailed surveillance of cannabis use, especially among intersectional priority populations. While findings regarding potential benefits of cannabis for pain relief and sleep are mixed (18,40,41), the drastic increases in cannabis use among people with SPD likely confer overall harm to this population since cannabis use may prolong and worsen both psychotic and depressive symptoms (15–17). Furthermore, this could lead to worsened racial/ethnic disparities in not only substance use and substance use disorders, but also mental health symptoms and conditions. Although the NSDUH does not assess route of cannabis administration, smoked cannabis may also cause respiratory disease (42).
The present study is not without limitations. While SPD serves as an approximation of serious mental illness, some respondents may score higher on the K6 due to situational stressors at the time of the survey, which may increase the heterogeneity of the SPD group, though if this introduced bias, it would be toward the null. In the NSDUH, race and ethnicity were assessed within the same question, and due to small cell sizes, many racial groups were combined to form the “Other” category. Both of these factors precluded our ability to conduct a finer-grained exploration of cannabis use by race/ethnicity (e.g., among respondents identifying as Hispanic Black, Asian, more than one race) in the context of SPD. We recommend oversampling for these and other minoritized priority populations in future data collection efforts. We were also unable to include state-level recreational cannabis status in our analyses; recent commercialization of legal cannabis markets may have impacted the observed trends in use. It is possible that state-level legislative changes regarding cannabis contributed to the observed different inflection points for the various race/ethnicity and SPD groups via regional demographic composition variability. Future work should continue to investigate reasons behind the disparate trends in cannabis use by race/ethnicity and SPD status, including any critical events or incidents that occurred during this timeframe to influence the observed inflection points. Additionally, at present, Joinpoint software does not allow users to include potential confounders in order to generate adjusted estimates. It will be important to revisit the question of potential confounding as new statistical approaches become available.
Our findings indicate that the prevalence of past 30-day cannabis use in the US has increased significantly between 2008–2019 regardless of respondent racial/ethnic group identification and the presence of past-month SPD. Despite uniformity in terms of general increases in prevalence, the overall prevalence of cannabis use in 2019 was significantly greater among respondents with versus without SPD; moreover, the prevalence of cannabis use was greater among all race/ethnicity groups with SPD than the corresponding races/ethnicities without SPD. If current trends continue, the prevalence of cannabis use will be more than three times greater among people with SPD than without SPD by the year 2030. Findings emphasize the importance of screening all patients for cannabis use, but particularly those who present for SPD and related conditions. Additionally, our findings help to support and drive a research agenda focused on understanding the differential prevalence of cannabis use in these groups (e.g., What are the mechanisms responsible for these differences?). This work can also help to inform the development of novel clinical and public health interventions specifically tailored to these race/ethnicity and SPD subpopulations.
Supplementary Material
Acknowledgments:
DR was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Award Number TL1 TR002555. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
The authors thank NSDUH respondents for their time and effort.
Footnotes
Disclosures: All authors report no financial relationships with commercial interests.
Previous presentation: Analyses from this study were presented at the American Academy of Addiction Psychiatry Annual Meeting in San Diego, CA, 12/6/23–12/9/23.
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