Dear Editor,

We are writing in response to the recent discussion regarding the diagnostic stability of cannabis-induced psychosis (CIP) in the article titled “Cannabis and psychopathology: 2024 Snapshot of a meandering journey”.[1] Drawing from both existing studies and their extensive clinical experience, the authors questioned the diagnostic stability of the CIP category, recommending that it be maintained as a provisional diagnosis, particularly noting that a significant proportion of cases eventually transitioned to independent psychosis.[1] While the exploration of the transition from CIP to independent psychosis is valuable, we are concerned that the current discourse presents an incomplete picture of this complex condition. Specifically, it overlooks the critical concept of CIP as a spectrum disorder, encompassing both intoxication and withdrawal states.[2]

Emerging evidence, including two recent case series, highlights that psychosis can manifest not only during active cannabis use but also during periods of withdrawal.[34] This distinction is vital as the clinical presentation, underlying mechanisms, and optimal management strategies may vary significantly depending on whether the psychosis is related to intoxication or withdrawal. In their article ‘Cannabis and Psychosis Through the Lens of DSM-5,’ Pearson and Berry[5] highlighted the complexities surrounding cannabis-related psychotic disorder, emphasizing the significant gaps in scientific literature.

Furthermore, we wish to draw attention to the clinical observation that CIP, when promptly recognized and appropriately treated, often demonstrates a favorable response to low-dose antipsychotics and a generally positive trajectory toward recovery. In contrast, the authors seem to imply that CIP generally progresses to a chronic psychotic disorder. Recent publications on CIP with onset during withdrawal further supports the idea that CIP exists on a spectrum and can have varying outcomes.[67]

To develop a more comprehensive and clinically relevant understanding of CIP, it is crucial to recognize its manifestation during both cannabis intoxication and withdrawal periods, acknowledge its treatment potential, and avoid promoting stigmatizing or overly pessimistic perspectives about the condition. Additional research is necessary to clarify the causal relationship between cannabis and psychosis as well as to establish the validity of CIP as a distinct clinical diagnostic category.