The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study

Marta Di Forti*, Diego Quattrone, Tom P. Freeman, Giada Tripoli, Charlotte Gayer-Anderson, Harriet Quigley, Victoria Rodriguez, Hannah E. Jongsma, Laura Ferraro, Caterina La Cascia, Daniele La Barbera, Ilaria Tarricone, Domenico Berardi, Andrei Szoke, Celso Arango, Andrea Tortelli, Eva Velthorst, Miguel Bernardo, Cristina Marta Del-Ben, Paulo Rossi MenezesJean-Paul Selten, Peter B. Jones, James B. Kirkbride, Bart P. F. Rutten, Lieuwe de Haan, Pak C. Sham, Jim van Os, Cathryn M. Lewis, Michael Lynskey, Craig Morgan, Robin M. Murray, EU-GEI WP2 Group

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background Cannabis use is associated with increased risk of later psychotic disorder but whether it affects incidence of the disorder remains unclear. We aimed to identify patterns of cannabis use with the strongest effect on odds of psychotic disorder across Europe and explore whether differences in such patterns contribute to variations in the incidence rates of psychotic disorder.

Methods We included patients aged 18-64 years who presented to psychiatric services in 11 sites across Europe and Brazil with first-episode psychosis and recruited controls representative of the local populations. We applied adjusted logistic regression models to the data to estimate which patterns of cannabis use carried the highest odds for psychotic disorder. Using Europe-wide and national data on the expected concentration of Delta(9)-tetrahydrocannabinol (THC) in the different types of cannabis available across the sites, we divided the types of cannabis used by participants into two categories: low potency (THC = 10%). Assuming causality, we calculated the population attributable fractions (PAFs) for the patterns of cannabis use associated with the highest odds of psychosis and the correlation between such patterns and the incidence rates for psychotic disorder across the study sites.

Findings Between May 1, 2010, and April 1, 2015, we obtained data from 901 patients with first-episode psychosis across 11 sites and 1237 population controls from those same sites. Daily cannabis use was associated with increased odds of psychotic disorder compared with never users (adjusted odds ratio [OR] 3.2, 95% CI 2.2-4.1), increasing to nearly five-times increased odds for daily use of high-potency types of cannabis (4.8, 2.5-6.3). The PAFs calculated indicated that if high-potency cannabis were no longer available, 12.2% (95% CI 3.0-16.1) of cases of first-episode psychosis could be prevented across the 11 sites, rising to 30.3% (15.2-40.0) in London and 50.3% (27.4-66.0) in Amsterdam. The adjusted incident rates for psychotic disorder were positively correlated with the prevalence in controls across the 11 sites of use of high-potency cannabis (r=0.7; p=0.0286) and daily use (r=0.8; p=0.0109).

Interpretation Differences in frequency of daily cannabis use and in use of high-potency cannabis contributed to the striking variation in the incidence of psychotic disorder across the 11 studied sites. Given the increasing availability of high-potency cannabis, this has important implications for public health. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.

Original languageEnglish
Pages (from-to)427-436
Number of pages10
JournalLancet Psychiatry
Issue number5
Publication statusPublished - May 2019


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