Suicide attempt and paranoia persisting for 28 days following heavy delta‐9‐tetrahydrocannabinolic acid and tetrahydrocannabinol use: A case report

Abstract

Background

Cannabis contains various cannabinoids, with Δ9‐tetrahydrocannabinol (Δ9‐THC) being the primary psychoactive compound. A non‐psychoactive precursor called Δ9‐tetrahydrocannabinolic acid (THC‐A) is converted to Δ9‐THC slowly over time or rapidly when heated. Cannabis use is linked to psychotic outcomes, with increased risk associated with heavier or earlier use. Additionally, Δ9‐THC's lipophilic nature leads to prolonged detection following heavy use. These factors highlight the need for a better understanding of cannabis formulations, dosing, and their psychiatric and pharmacokinetic implications.

Case Presentation

This case report describes a patient who attempted suicide after developing paranoia induced by cannabis use. The patient experienced paranoid thoughts following daily consumption of 15–30 mg Δ9‐THC gummies and THC‐A in dried plant form. He reported being unfamiliar with the dosing and effects of THC‐A, which contributed to his excessive and prolonged use.

Conclusion

This case highlights the potential risks of consumers being unaware of the differences in cannabinoids and dosing, which can result in adverse outcomes. THC‐A, often labeled as non‐psychoactive, becomes psychoactive when heated, which can confuse users. Improved product labeling is essential to help prevent poor patient outcomes.

BACKGROUND

Cannabis contains a variety of cannabinoids, with Δ9‐tetrahydrocannabinol (Δ9‐THC) recognized as the primary psychoactive compound. A cannabinoid produces psychoactive effects by stimulating cannabinoid receptor Type 1 (CB1), though some cannabinoids have minimal effects on CB1 and are not considered psychoactive. ¹ One such cannabinoid with limited effects on CB1 in the central nervous system is called Δ9‐tetrahydrocannabinolic acid (THC‐A). There is an important structural relationship between acidic cannabinoids with a carboxylic group and their conversion to a neutral cannabinoid. For example, THC‐A is the acidic cannabinoid pair to Δ9‐THC. ² While not psychoactive on its own, THC‐A is converted slowly over time to Δ9‐THC through decarboxylation or rapidly when exposed to heat. This includes heat through baking for edible consumption, vaporizing, or smoking. ³ THC‐A is not considered psychoactive due to limited binding affinity at CB1 and CB2 receptors. In fact, Δ9‐THC showed 62‐fold increased binding affinity at CB1 receptors and 125‐fold increased binding affinity at CB2 receptors as compared to THC‐A. ⁴

The Centers for Disease Control and Prevention warns that labeling of cannabis products is inconsistent, with some products listing the amount of Δ9‐THC as well as the potential Δ9‐THC from the THC‐A content, while other products solely list the Δ9‐THC content. Despite increasing legalization and use, knowledge regarding cannabis formulations, dosing, and pharmacokinetics remains limited. ⁵

Cannabis use is associated with psychotic outcomes. Systematic reviews and meta‐analyses indicate a significant link between cannabis exposure and the development of psychotic disorders, including schizophrenia spectrum disorders. ⁶ The risk is dose‐dependent, with earlier onset and heavier use correlating with a greater likelihood of psychosis. ⁷ The Centers for Disease Control and Prevention also notes that cannabis use can precipitate transient psychotic symptoms such as paranoia, disorientation, and hallucinations, as well as longer term psychiatric effects. ⁵ Identifying cannabis‐induced psychosis is essential in clinical assessments, as it can resemble primary psychotic disorders but carries important differences for prognosis, treatment, and patient counseling.

Another consideration is the duration of action of Δ9‐THC. Δ9‐THC is highly lipophilic, accumulating in adipose tissue and slowly redistributing into the bloodstream. As a result, Δ9‐THC and its metabolites can stay detectable in biological samples for prolonged periods, with reports indicating positive drug screens up to a month after the last exposure. ⁸ This prolonged half‐life has important implications for clinical assessment, especially in the context of Δ9‐THC induced psychopathology, as the symptoms may persist for an extended period of time even after cessation of use.

CASE PRESENTATION

A man in his 60s was brought into the emergency department (ED) via medevac after being found unresponsive with bilateral lacerations to the arms and a suicide note present. The patient's medical history included coronary artery disease with a history of myocardial infarction, hypertension, hyperlipidemia, diabetes mellitus, obstructive sleep apnea, and depression. The patient's hospital course details regarding medical stabilization can be found in Supplement S1.

On Day 24 of admission, the patient was transferred to the inpatient psychiatric unit with a diagnosis of cannabis‐induced psychotic disorder. He was exhibiting paranoid ideation and other psychiatric symptoms despite abstinence from cannabis use for the 24 days of hospitalization. At this time, he was guarded towards the staff and only provided limited information. Olanzapine 5 mg nightly was initiated for the management of psychotic symptoms. Olanzapine was chosen for its lower propensity to prolong Corrected QT Interval (QTc) in the context of the patient's significant cardiac history and older age. Trazodone 100 mg nightly was added as the patient noted having trouble sleeping.

The following day, the patient appeared disorganized but was able to provide a more detailed account of his condition before admission. He reported using cannabis to help him sleep and had recently begun to take higher amounts. Specifically, he was consuming a 30 mg Δ9‐THC edible in gummy form, typically taking half of the gummy but occasionally the entire dose. In the weeks leading up to admission, he also had purchased THC‐A in flower form and began to smoke this in addition to taking the gummy. He denies previous use of THC‐A. Family was able to provide images of the products' packaging, which confirm the 30 mg THC gummy and two THC‐A products. The first THC‐A product was labeled as a 50/50 indica‐sativa hybrid with 19.44% THC, and the other as a 55/45 indica‐sativa hybrid containing 22.28% THC. The patient noted unfamiliarity with the dosing and potency of the THC‐A products. The amount of THC‐A could not be accurately quantified because the product was provided in whole‐flower form, with the listed weight representing the total contents of the package. The patient did not consume the entire package per dose and was unable to estimate the portion consumed. The patient noted feeling increasingly paranoid before admission. He began to think that he was placed on a sexual offender list and that the list was about to become public. These fears are what led him to attempt suicide.

On Day 27 of admission, the olanzapine dose was increased to 7.5 mg at night due to the patient still expressing fears of being placed on a sexual offender list. Due to the continued paranoia, an order for urine toxicology was placed, and the patient was found to still be positive for THC.

On Day 28, the patient was noted to be less preoccupied with the sexual offenders list, and trazodone was discontinued due to an elevated QTc reading. The patient agreed to stop using THC products upon discharge.

On Day 29, the patient was noted to be much improved. He was eating and sleeping well. Suicidal ideations were resolved, and he no longer believed he was going to be placed on a sexual offender list. He was motivated to participate in follow‐up care, was remorseful about the suicide attempt, and was discharged home.

DISCUSSION

Patients may find it difficult to understand cannabis dosing due to the variety of products, differing cannabinoid compositions, and inconsistent or incorrect product labeling. Many states with recreational use set limits on the dosage of cannabis products. Some states limit a package to 100 mg of Δ9‐THC, and other states limit a dose to 10 mg of Δ9‐THC, though an estimated 4.2% of products exceed the 100 mg limit, with some products being sold with as much as 7000 mg of Δ9‐THC. ⁹ Another study sampled 107 Δ9‐THC products to compare labeling claims against the actual Δ9‐THC content. Only 32 of the 107 samples had a Δ9‐THC content within ±20% of the labeled content, again highlighting problems in labeling. ¹⁰ A case report of a different cannabinoid highlighted a similar problem due to a lack of product knowledge. In this case, a patient was unfamiliar with the appropriate dosing of delta‐9‐tetrahydrocannabiphorol (Δ9‐THCP) and therefore unknowingly consumed a large amount. The patient then experienced intense psychotic symptoms including depersonalization and a belief that they were already dead, which led to a suicide attempt. ¹¹ These previous examples show similarity to the current case. The patient in this case reported using 15–30 mg of edible Δ9‐THC along with smoking an unknown amount of THC‐A and unfamiliarity with THC‐A. He stated the amount of THC‐A was difficult to quantify because it was in dried plant form.

In addition to dosing inconsistencies, many patients feel that cannabis use is safe. A survey of 9003 participants found that 81% of US adults believe that cannabis has at least one benefit. Additionally, the survey found that 36.9% of respondents believe that edibles prevent health issues, and 29.2% of respondents believe that smoking or vaping cannabis prevents health problems. Although 91% of respondents believed that cannabis has at least one risk, the most common risk cited was legal problems at 51.8%. ¹² The website of the THC‐A product used by the patient highlights that THC‐A is a cannabinoid that does not produce psychoactive effects and is legal. The website also says that heating THC‐A makes it more potent and converts it to Δ9‐THC, though patients may not understand these details. The limited information provided may make it difficult for consumers to make educated decisions about the products they are using. Cannabis users are often uninformed about the products they are taking. A survey in Canada and the United States found that cannabis consumers were unable to accurately report the Δ9‐THC or cannabidiol (CBD) levels of the products that they used. This was especially seen in dried herb users with only 10% being able to report on the THC content of the products that they used. ¹³ The patient's unfamiliarity with cannabinoids and dosing along with his heavy and prolonged use also contributed to his paranoid and psychotic presentation.

Another noteworthy part of the case was that the patient's urine toxicology was positive for THC 27 days into the admission. Δ9‐THC is metabolized extensively in the liver by cytochrome (CYP) P450 isozymes including CYP2C9, CYP2C19, and CYP3A4. ¹⁴ Hepatic elimination is slower in older adults partly because liver size decreases by up to 40% with age and liver blood flow declines by up to 30%. Additionally, CYP‐dependent Phase I reactions are less efficient. ¹⁵ Also, Δ9‐THC is highly lipophilic and is readily absorbed and stored in fat tissues. ¹⁶ The body composition of older adults is characterized by an increase in body fat, and a decrease in lean mass and bone density. ¹⁷ This case highlights that older adults may eliminate cannabinoids more slowly, and any potential adverse effects may last for extended periods of time.

CONCLUSION

This case highlights the need for educating consumers about the various cannabinoids and proper dosing. Older adults, in particular, may metabolize cannabinoids more slowly, leading to prolonged adverse effects. Even individuals with little or no psychiatric history could be at risk when using high doses of cannabinoid products, emphasizing the potential dangers associated with these substances. Clearer labeling of cannabinoid products, including concentration, formulation, and recommended use, is especially important for older adults as they may be more susceptible to adverse effects and dosing errors.

AUTHOR CONTRIBUTIONS

Daniel Greer conceptualized the idea for this case report. All authors provided a critical review and revision of the manuscript. All authors provided care for the case study patient and drafted the initial case report manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS APPROVAL STATEMENT

Informed consent was obtained from the patient, and the institution agreed to the publication.

PATIENT CONSENT STATEMENT

The patient provided written informed consent for publication.

CLINICAL TRIAL REGISTRATION

N/A.

Supporting information

Supporting Information.

Greer D, Dey P, Kulig CE. Suicide attempt and paranoia persisting for 28 days following heavy delta‐9‐tetrahydrocannabinolic acid and tetrahydrocannabinol use: A case report. Psychiatry Clin Neurosci Rep. 2026;5:e70290. 10.1002/pcn5.70290

DATA AVAILABILITY STATEMENT

No additional public data are available due to the nature of this being a case report.