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Depression and anxiety symptom outcomes in adolescent users of smoked, vaporized, edible and blunt cannabis

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Depression and anxiety symptom outcomes in adolescent users of smoked, vaporized, edible and blunt cannabis

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Depression and Anxiety Symptom Outcomes in Adolescent Users of Smoked, Vaporized, Edible
and Blunt Cannabis

by

Esthelle Ewusi Boisvert

A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF LETTERS, ARTS AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTERS OF ARTS
(PSYCHOLOGY)

August 2020

Copyright 2020 Esthelle Ewusi Boisvert
ii
Table of Contents

List of Tables iii
List of Figures iv
Abstract v
Introduction 1
Methods 6
Participants and Procedures 6
Measures 7
Covariates 9
Statistical Analyses 10

Results 13
Participants 13
Primary Analyses 13
Supplementary Analyses 16

Discussion 17
Conclusions 22
References 23

iii
List of Tables
Table 1: Demographic Characteristics for Total Sample, and by RCADS Symptomatology at
Follow-up 36
Table 2: Binary Logistic Regression Model for the Association between Ever Cannabis Use
Status at Baseline and Any Internalizing Disorder Symptoms at Follow-up 38
Table 3: Binary Logistic Regression Model for the Association between Ever Cannabis Use
Status at Baseline and Clinical Symptoms for Specific Internalizing Disorders at Follow-up 40
Table 4: Multinomial Logistic Regression Model for the Association between Ever Cannabis
Use Status at Baseline and Clinical Symptoms for Any 1 Internalizing Disorder, or 2 or More
Internalizing Disorders at Follow-up 41
Supplemental Table 1: Binary Logistic Regression Model for the Association between Cannabis
Use Frequency at Baseline and Any Internalizing Disorder Symptoms at Follow-up 42
Supplemental Table 2: Binary Logistic Regression Model for the Association between Cannabis
Use Frequency at Baseline and Clinical Symptoms for Specific Internalizing Disorders at
Follow-up 43
Supplemental Table 3: Multinomial Logistic Regression Model for the Association between
Cannabis Use Frequency at Baseline and Internalizing Disorder Symptoms 44
Supplemental Table 4: Bivariate Linear Regression Model for the Association between Cannabis
Use Frequency at Baseline and Clinical Symptoms Score for Specific Internalizing Disorders at
Follow-up 46

iv
List of Figures
Figure 1: Flow chart of study participants 35

v
ABSTRACT

Background: Evidence indicates that cannabis use in adolescence puts individuals at risk for
developing mental health disorders in young adulthood. Whether cannabis use in adolescence
contributes to the occurrence of mental health disorders in later adolescence is unknown. Also,
with the increase in use of cannabis across different administration methods amongst
adolescents, it is unknown whether cannabis products have differential consequences on mental
health outcomes in youth. The current study explored the association between different methods
of cannabis administration and mental health outcomes in later adolescence.
Methods: Surveys were administered to students across 10 public schools in Los Angeles, CA,
USA. Students (N = 1666; M[SD] = 17.22 [.19] years) who reported lifetime use of combustible,
vaporized, edible or blunt cannabis, and who do not meet clinical threshold for internalizing
disorders symptoms (major depressive disorder, generalized anxiety disorder, panic disorder,
social phobia, obsessive-compulsive disorder) were included in the analyses. For each cannabis
product, binary logistic regression models were conducted to test the association between
cannabis use in grade 11, and the odds of meeting clinical threshold for internalizing disorder
symptoms at 12-month follow-up.
Results: Following adjustment for covariates, we found no significant association between
cannabis use or poly-use and later occurrence of clinical symptoms of major depression disorder,
generalized anxiety disorder, panic disorder and obsessive-compulsive disorder (odd ratios
range: 0.41-2.21). Lower likelihood of occurrence of social phobia symptoms over follow-up
was associated with baseline use of edible cannabis (ever vs. never users: 4.8% vs. 1.5%; OR:
0.24), and blunts (ever vs. never users: 4.8% vs. 1.6%; OR: 0.22).

vi
Conclusion: Findings suggest that adolescent users of edible and blunt cannabis are at lesser risk
of developing clinically significant symptoms of social phobia at 1-year follow-up. No
associations were found between use of any cannabis products and likelihood of occurrence of
major depressive disorder, generalized anxiety disorder, panic disorder, or obsessive-compulsive
disorder. Further investigations of the differential effects of cannabis products on later
occurrence of mental disorder symptoms is warranted to better inform prevention and
intervention programs for youths.
Keywords: adolescents, cannabis, anxiety, depression, combustible, vaporized, edible, blunt

1
Introduction

Adolescents are particularly vulnerable to suffering from mental health issues (Kessler et
al., 2007). Internalizing disorders, such as depression and anxiety disorders, are among the most
frequently reported mental illnesses in adolescents, affecting approximately 10% to 30% of
youth (Merikangas et al., 2010; Mojtabai, Olfson, & Han, 2016). Internalizing disorders are
associated with substantial impairment and disability, including increase in suicidal behavior,
social impairment, hospitalization and chronic stress.
Substance use is one of the risk factors most strongly associated with internalizing
disorders in adolescents (Marmorstein, 2009; Marmorstein, White, Loeber, & Stouthamer-
Loeber, 2010; O'Neil, Conner, & Kendall, 2011; Wolitzky-Taylor, Bobova, Zinbarg, Mineka, &
Craske, 2012). While to date researchers have focused on an array of substances as risk factors,
cannabis might be of particular relevance seen as it is the most widely consumed illicit substance
by adolescents (i.e., (Johnston et al., 2018). Cannabis exposure in adolescence has been
associated with having negative consequences on neurobehavioral development, including
disruptions to critical underlying structures that play a role in emotional processing, executive
functions and social cognition (Broyd, van Hell, Beale, Yuecel, & Solowij, 2016; Curran et al.,
2016; Renard, Krebs, Le Pen, & Jay, 2014; Renard et al., 2017). This in turn may have
implications for risk of meeting criteria for internalizing disorders.
There is strong evidence to suggest an association between cannabis exposure in
adolescents and subsequent internalizing disorder symptomatology (Kedzior & Laeber, 2014;
Rubino, Zamberletti, & Parolaro, 2012). Previous studies and systematic reviews have found
associations between cannabis use and the maintenance or occurrence of anxiety and depression
in youths (Duperrouzel et al., 2018; Lev-Ran et al., 2014). Despite these findings, most of the

2
evidence which highlights the association between cannabis use and later incidence of
internalizing disorder symptoms focuses on outcomes in young adulthood (Hayatbakhsh et al.,
2007; Patton et al., 2002; Rasic, Weerasinghe, Asbridge, & Langille, 2013; Van Laar, Van
Dorsselaer, Monshouwer, & De Graaf, 2007; Wittchen et al., 2007). Delineating the potential
risk of cannabis use on internalizing disorders outcomes during adolescence can help clarify
potential underlying mechanisms of internalizing symptom development, and provide evidence
on the sequential progression of internalizing disorders.
Considering the array of social and cognitive domains potentially affected by cannabis
exposure, there is reason to consider the association between cannabis use and multifinality in
adolescent internalizing disorders. Even though internalizing disorders share underlying
commonalities (e.g., elevated negative affect and anxiety sensitivity, shared genetic influences;
Clark & Watson, 1991), they carry important distinctions. Differences in affect and arousal
between depression and anxiety is purported to explain some of the dissimilarities between these
disorders (i.e., major depression combines high negative affect and low positive affect, while
anxiety combines high negative affect with hyperarousal; Clark & Watson, 1991; Cole, Truglio,
& Peeke, 1997). Researchers have also previously identified distress and fear as subfactors that
could explain differences between internalizing disorders (Clark & Watson, 2006). For example,
an exaggerated fear state might underly disorders like social phobia and panic disorder, while a
heightened distress state is more likely to underlie disorders like major depression and
generalized anxiety. In considering these different conceptualizations, it is possible that some
youths may have underlying systems that are more vulnerable to developing fear-based versus
distress-based internalizing disorders, and that, in turn, cannabis exposure could precipitate the
risk of occurrence of these different disorders.

3
More specifically, varying cannabinoid compounds (like Δ-9-tetrahydrocannabinol
(THC) or cannabidiol (CBD)) could have an influence on underlying neural structures associated
with a wide range of internalizing disorders. Researchers have previously demonstrated that
changes in the orbitofrontal cortex (a region important for processing emotional stimuli and
implicated in reward-related behaviors) are associated with cannabis use (Subramaniam et al.,
2018), as well as with major depression, panic disorder and obsessive-compulsive disorder in
adolescents (Atmaca, Yildirim, Gurok, & Akyol, 2012; Lagemann et al., 2012; Steingard et al.,
2000). Cannabis use’s potential influence on the orbitofrontal cortex region is even more relevant
when thinking about youths who experience subclinical internalizing disorder symptoms. In this
case, adolescents might use cannabis in order to appease subclinical symptoms, yet, that might
precipitate the emergence of clinically significant symptoms by having an effect on an already
vulnerable neural structure. Researchers have previously found associations between
adolescents’ cannabis-related emergency department visits and new diagnoses of generalized
anxiety, panic disorder, phobia and major depression disorder (Wang, Davies, Halmo, Sass, &
Mistry, 2018). These findings suggest that cannabis use might have an influence on a vast array
of underlying systems, thus leading to different internalizing disorder outcomes in adolescents.
An additional factor that may alter the potential risk of internalizing disorders conferred
by cannabis use is the method of cannabis administration. Along with a higher prevalence of
cannabis use in recent years, recent reports show that adolescents are consuming cannabis
through a larger spread of cannabis products, including alternative, or non-combustible, products
(e.g., vaporized, edible; Borodovsky, Crosier, Lee, Sargent, & Budney, 2016; Knapp et al.,
2018). Such growing trends might be due to the changing legal landscape surrounding medical
and recreational cannabis, as well as businesses marketing cannabis products in youth-friendly

4
preparations (e.g., cotton-candy flavored vape oils; MacCoun & Mello, 2015; Morean, Kong,
Camenga, Cavallo, & Krishnan-Sarin, 2015). Appeal to adolescents might also come from the
fact that many of these alternative products, such as edibles, seem less harmful to adolescent
users, and confer methods of consumption that are more subtle than traditional combustible
products (Friese, Slater, & Battle, 2017). What is more, researchers have also reported poly-use
of different cannabis products among youth in recent years (Kowitt et al., 2019; Meier, Docherty,
Leischow, Grimm, & Pardini, 2019; Nguyen et al., 2019). Overall, increasing availability,
appeal, use and poly-use of cannabis products amongst adolescent populations is concerning due
to the health consequences, as noted above, that can result from cannabis consumption in youth.
Furthermore, it is unknown whether different products have differential consequences on youth
health outcomes.
Different methods of administration might confer differential risks on internalizing
disorder outcomes. For example, methods of administration that confer rapid bioavailability, and
thus, potentially more reinforcing effects (e.g., combustible compared to edible), might
contribute to differential internalizing disorder outcomes, or even more severe outcomes (e.g.,
comorbid internalizing disorders). Researchers have previously shown that adolescents and
adults report differential subjective effects from varying cannabis products (Boisvert et al., 2020;
Spindle et al., 2018), which might indicate differential cross-product influences on underlying
systems. For example, previous reports show that youth report more positive subjective effects
from combustible cannabis use (i.e., feeling happier, more social, more creative), than from
edible or vaporized cannabis (Boisvert et al., 2020). Based on these positive subjective reports, it
might be possible that combustible cannabis use (vs. other cannabis product use) is uniquely
associated with differential risks of developing internalizing disorder symptoms. Previous studies

5
have also shown that adolescents report more negative subjective effects from edible cannabis
use (i.e., feeling unable to concentrate, out of control), compared to combustible or vaporized
cannabis (Boisvert et al., 2020). Similarly, these reports might highlight edible cannabis’ unique
relationship to internalizing disorder risk. It is also possible that youth who are predisposed to, or
experience subclinical symptoms of, certain internalizing disorders, would be more likely to use
certain cannabis products versus others, based on the subjective effects they confer (i.e., youth
who are predisposed to major depression might be drawn to using combustible cannabis for its
positive subjective effects).
Poly-use of different cannabis products might also alter the risk of developing
internalizing symptoms. Poly-use of cannabis products might expose adolescents to a wider array
of cannabinoids, which might alter risks of developing subsequent internalizing disorders, or
increase risk of developing comorbid internalizing disorders. Adolescents with certain
subclinical symptoms might also be drawn to co-using certain products versus others (e.g., youth
with subclinical symptoms of social phobia might be drawn to using cannabis products that are
easier to conceal, such as vaporized and edible). In their cross-sectional analysis, Leventhal and
colleagues (2020) have recently shown that poly-use of cannabis products (i.e., use of 2 or more
cannabis products) is associated with elevated depression symptoms in adolescents (Leventhal,
Bae, Kechter, & Trimis, 2020). To our knowledge, no previous research has examined the
prospective association between adolescent cannabis use by product, or poly-use of different
cannabis products, and occurrence of internalizing disorders in later adolescence. While recent
research established a relationship between poly-use of cannabis products and internalizing
disorder symptoms, investigating directionality through longitudinal research remains crucial in
order to better inform and design health prevention and intervention programs for youth.

6
The goal of the study was to examine whether cannabis use in a population-based
adolescent sample is associated with mental health outcomes in later adolescence. Specifically,
the aim was to examine whether methods of cannabis use in grade 11 students (i.e., combustible,
vaporized, edible, blunt) is differentially associated with internalizing disorders outcomes in
grade 12 (i.e., major depressive disorder, general anxiety disorder, panic disorder, social phobia,
obsessive-compulsive disorder). Our baseline sample excluded youth with any significant
internalizing disorder symptom in order to identify new occurrence of symptom at follow-up.
Methods

Participants and Procedures
The study utilized data from the ongoing Health and Happiness Study, a longitudinal
investigation of mental health and substance use amongst baseline 9
th
grade students in 2013
recruited in 10 high schools in the Los Angeles metropolitan area. A total of 3,396 of the 4,100
(82.8%) eligible students participated in the baseline data collection. Self-report paper-and-pencil
questionnaires were administered on site once every 6 months from grades 9 (Wave 1; Fall
Semester, 2013; N = 3,383) to 12 (Wave 8; Spring Semester, 2017; N = 3,140). Those absent
during data collections completed shorter versions of the questionnaire by telephone, Internet, or
mail. On average across the ten schools, 31.1% (SD = 19.7, range: 8.0% - 68.2%) of students
were eligible for free lunch within each school (i.e., student’s parental income < 185% of the
national poverty level). The study was approved by the University of Southern California
Institutional Review Board.
The current study’s analytic sample was comprised of participants with no clinical
internalizing disorder symptoms in 11
th
grade, and complete cannabis and internalizing disorder
symptom data at 1-year follow-up. A total of 3232 participants were eligible to participate in 11
th

7
grade (baseline for this analysis). At baseline, 660 participants were missing internalizing
disorder symptoms data, 580 participants were excluded due to meeting clinical criteria on one
or more internalizing disorder, and 40 participants were missing cannabis use data (see Figure 1
for detailed study flow chart). At 1-year follow-up, 286 participants were missing internalizing
disorder symptoms data; the final analytic sample included 1666 participants.
Measures
Lifetime Cannabis Use
Students were provided with general questions about their substance use (i.e.,“Have you
ever used the following substances in your life?”), followed by a list of substances. For each
substance, 3 response items were included, each requiring a unique response (response options:
“no”; “yes, but not in the last 6 months”; or “yes, in the last 6 months.”). Four cannabis products
were selected as main predictors: combustible cannabis, vaporized cannabis, edible cannabis and
blunts. Two additional predictors included use of any of these four products, and number of
cannabis products use (range: 0-4). Each method of cannabis administration was phrased as
follows: “smoking marijuana” for combustible cannabis, “electronic device to vape liquid THC
or hash oil” for vaporized cannabis, “marijuana or THC food of drinks” for edible cannabis, and
“marijuana rolled in tobacco leaf or cigar casing” for blunts. Cannabis use variables were
dichotomized into two groups based on patterns of use of each product for main analyses: (1)
never users (i.e., no lifetime use of cannabis products); (2) ever users (i.e., lifetime use of
cannabis product).
The survey also asked students about cannabis use in the past 30 days (response options:
0, 1-2, 3-5, 6-9, 10-14, 15-19, 20-24, 25-29, 30 days). For supplemental analyses, cannabis use
variables were trichotomized, using responses about lifetime and past 30 days cannabis use: (1)

8
never users (i.e., no lifetime use of product); (2) prior users (i.e., lifetime use of product, but not
in past 30 days); (3) current users (i.e., use of product in past 30 days). These analyses were
included as supplementary material due to small cell sizes in internalizing symptoms outcomes
for prior users or current users of certain products (<5 participants).
Internalizing Disorder Symptoms
Students were provided with the Revised Children's Anxiety and Depression Scale
(RCADS) (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000), which contains 47-items across
5 subscales, 4 of which are used for anxiety disorders (i.e., generalized anxiety disorder, panic
disorder, social phobia and obsessive-compulsive disorder), and 1 of which is used for major
depressive disorder based on DSM-IV criteria. On each scale, participants report how often
symptoms occurred (response options ranging from “never” [0] to “always” [3]). Raw scores of
each subscale are converted to T-scores based on grade level of the adolescents. T-scores
between 65 and 70 are considered borderline to the clinical threshold, while T-scores of 70 or
higher indicate symptoms past the clinical threshold. Reliability coefficients for the subscales
range from α=.73 to .82. The RCADS has shown high convergent validity with the Child
Behavior Checklist (r=.78;), as well as a good ability to discriminate between youth with
depression and anxiety disorders versus other mood disorders (Ebesutani et al., 2010). All
RCADS subscale variables were divided into binary outcomes (0= no symptoms vs. 1= clinical),
and participants with scores at or above clinical threshold on any RCADS at baseline were
excluded. For the primary outcome, we examined the odds of scoring above the clinical
threshold on any of the RCADS outcomes (0= no symptoms on all RCADS vs. 1= clinical on
any of the RCADS). A secondary outcome examined the odds of scoring above clinical threshold

9
on each of the 5 RCADS individually. The third outcome used a trichotomous variable to
investigate the odds of scoring above clinical threshold on 1 RCADS, or 2 or more RCADS.
Covariates
Sociodemographic Characteristics
Participants self-reported their age, gender, race/ethnicity (response options: White,
Black, Hispanic, Asian, Multiethnic or Multiracial, or other), and eligibility for free/subsidized
school lunch program (yes/no; yes indicates family income 185% of federal poverty limit).
Socioeconomic status (SES) was measured based on eligibility for free lunch, a commonly used
measure of adolescent SES (Nicholson, Slater, Chriqui, & Chaloupka, 2014). Participants were
categorized as high SES if they were ineligible for free lunch.
Attention Deficit/Hyperactivity Disorder
Students completed the Current Symptoms Self-Report Form measure of ADHD
symptom criteria (Barkley & Murphy, 2006), which contains 18 items about inattention and
hyperactivity/impulsivity symptoms. Participants reported how often they experienced each
symptom in the past 6 months (response options ranging from “never or rare” [0] to “very often”
[3]). Participants who reported experiencing 6 or more symptoms of either inattention or
hyperactivity/impulsivity were classified as having ADHD symptoms over the past 6 months.
The Current Symptoms Self-Report Form has good diagnostic sensitivity and specificity (Adler
et al., 2012; Sonnby et al., 2015). Considering previous findings showing correlations between
ADHD, cannabis use and internalizing disorder symptoms, it was important to include the
measure as a covariate, in order to address possible cofounding influences. Specifically,
researchers have previously identified associations between ADHD and earlier initiation of
cannabis use (Galera et al., 2010). Researchers have also previously shown that youth with

10
ADHD are at higher risk of developing major disorder (Meinzer et al., 2013; Meinzer, Pettit, &
Viswesvaran, 2014). Finally, recent findings from Murray et al. (2020) have revealed reciprocal
developmental pathways during adolescence between ADHD and anxiety symptoms (Murray et
al., 2020).
Conduct Problems
Students completed a commonly used adolescent conduct problems questionnaire
(Resnick et al., 1997; Thompson, Ho, & Kingree, 2007). The measure contains 11 items about
delinquent behavior occurrence in the past 6 months (response options range from “never” [1] to
“10 times or more” [6]). The association between delinquency and cannabis use, as well as
delinquency and anxiety and/or depression symptoms in adolescence is well documented
(Fontaine et al., 2019; Tucker et al., 2019), thus justifying the inclusion of this measure as a
covariate in an effort to control for confounding associations in our sample.
Lifetime Substance Use
Lifetime use of tobacco products and other drugs were included as covariates (i.e., a few
puffs of cigarette, a cigarette, smokeless tobacco, little and big cigars, hookah, other forms of
tobacco, one full drink of alcohol, inhalants, cocaine, methamphetamine,
LSD/mushrooms/psychedelics, ecstasy, heroin, salvia, prescription painkillers,
tranquilizers/sedatives, diet pills, prescription stimulants and bath salts). Similarly to cannabis
use variables, tobacco and other drug use variables were dichotomized into two groups based on
patterns of use (i.e., never users vs. ever users).
Statistical Analyses
Descriptive analyses

11
All analyses were conducted in SPSS Version 24 (IBM, 2016) and Stata Version 15.1.
For descriptive statistics, we ran omnibus tests of differences in demographic characteristics,
cannabis product ever use, and poly-use of cannabis products (0-4 products) by internalizing
disorder symptoms at baseline (no RCADS symptoms vs. Any RCADS symptoms).
Primary Analyses
The primary analyses used a series of logistic regression models to test the association
between cannabis use (never users [reference group], ever users) for each product (combustible,
vaporized, edible, blunt, any cannabis product) and the subsequent odds of meeting clinical
threshold (vs. no symptoms) for any internalizing disorders symptoms (major depressive
disorder, generalized anxiety disorder, panic disorder, social phobia and obsessive-compulsive
disorder). Secondary outcomes used Firth’s logistic regression to test the association between
cannabis use at baseline, and the subsequent odds of meetings clinical threshold for each specific
internalizing disorder. Firth’s logistic regression is a penalized likelihood estimation method
which allows for reduced small-sample bias in maximum likelihood estimations, and prevents
complete separation or quasi-separation due to small cell sizes (Firth, 1993; Heinze & Schemper,
2002). A third outcome used multinomial logistic regression to examine the association between
cannabis use at baseline, and subsequent odds of reporting clinical symptoms on any 1
internalizing disorder, or 2 or more disorders, compared to none. Each model included control
for demographics (i.e., age, gender, socio-economic status and race/ethnicity), conduct problems,
ADHD symptoms, lifetime use of tobacco products, lifetime use of other substances and school
effects. Missing-indicator adjustment was used to handle missing data on covariates. This
method uses a dummy variable for cofounders, wherein all missing values are set to the same
value. This allows for participants to remain in the analysis, thus retaining statistical power

12
(Groenwold et al., 2012). Odds ratios (ORs) and 95% confidence intervals (CI) are reported.
Significance was set to 0.05 (two-tailed) and raw p-values for the logistic regression models
were considered statistically significant after correction for multiple testing using the Benjamini-
Hochberg method to control for the false discovery rate (Benjamini & Hochberg, 1995).
Supplementary and Sensitivity Analyses
Supplementary analyses were conducted in order to test whether cannabis use frequency
is associated with internalizing disorder symptom outcomes. Cannabis use frequency was
trichotomized as follows: never users (i.e., no lifetime use of product); (2) prior users (i.e.,
lifetime use of product, but not in past 30 days); (3) current users (i.e., use of product in past 30
days). The results were included as supplementary materials due small cell sizes for prior and
current users of certain cannabis products. We conducted logistic regression analyses to test the
association between cannabis use frequency for each cannabis product, and subsequent odds of
developing any internalizing disorder symptoms. Additionally, we conducted Firth’s logistic
regressions to test the association between cannabis use frequency and the subsequent odds of
meeting clinical threshold for each specific internalizing disorder. Finally, we conducted
multinomial logistic regression models to test the association between cannabis use frequency,
and the subsequent odds of meeting clinical threshold for any 1 internalizing disorder, or 2 or
more disorders, compared to none. Each model included all covariates previously mentioned.
In considering the limitations of dichotomizing the internalizing disorder outcome
variables, we conducted an additional sensitivity analysis which included participants with
clinical symptoms at baseline. Precisely, we ran linear regression models to examine the
association between baseline cannabis product use (never vs. ever), and RCADS score on each

13
specific internalizing disorder at 1-year follow-up, and controlled for baseline RCADS score for
each respective disorder. Results are appended in the supplemental section.
Results
Participants
The analytic sample of 1666 students reported lifetime use of at least one cannabis
product (Mean age [SD]= 17.22 [.19] years; 55% female). The sample was racially/ethnically
diverse (Native Hawaiian or Pacific Islander, 3.3%; Black, 4%; Multiracial 5.4%; Other, 6.8%;
White, 15.6%; Asian, 19.4%; Hispanic, 43.6%;), and most students were categorized as high
SES (52.9%). A majority of the sample reported more than 1 delinquent behavior over the past 6
months (63.5%), while a small portion met criteria for ADHD (either inattention or
hyperactivity) over the past 6 months (3.7%). A third of the sample reported lifetime use of
tobacco products (30.8%), while half reported lifetime use of any other substance (50.8%).
Overall, 465 (27.9%) participants reported ever use of combustible cannabis, 165 (10.1%)
reported ever use of vaporized cannabis, 325 (19.5%) reported ever use of edible cannabis, and
317 (19%) reported ever use of blunts. Regarding cannabis poly-product use, 128 (7.7%)
participants reported ever use of only 1 cannabis product, compared to 124 (7.4%) participants
who reported ever use of 2 cannabis products, 145 (8.7%) participants who reported ever use of 3
cannabis products, and 116 (7.0%) participants who reported ever use of 4 cannabis products.
Tests of differences in demographic characteristics and cannabis product use by internalizing
disorder symptoms at follow-up are presented in Table 1.
Primary Analyses
Associations between Cannabis Use and Clinical Symptoms for Any Internalizing Disorder

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Odds of meeting clinical threshold for any internalizing disorder, by cannabis
administration method, are presented in Table 2. In all adjusted models (including when
controlling for use of other cannabis products), there were no associations between baseline
cannabis use and reporting of any clinical symptoms at follow-up for users of combustible
cannabis (any internalizing symptoms at follow-up in ever vs. never users of combustible: 11.2%
vs. 15.5%), vaporized cannabis (11.8% vs. 17.3%), edible cannabis (11.8% vs. 14.8%) or blunts
(11.7% vs. 15.5%). There were also no associations between baseline use of any cannabis
product and clinical symptoms on any internalizing disorder at follow-up (11.3% vs. 14.8%).
We found no associations between number of cannabis product use at baseline and any
clinical symptoms at follow-up for users of 1 product (ever vs. never users: 13.3% vs. 11.3%), 2
products (16.1% vs. 11.3%), 3 products (10.3% vs. 11.3%) or 4 products (20.7% vs. 11.3%).
Associations between Cannabis Use and Specific Internalizing Disorder Symptoms
Odds of meeting clinical threshold on specific internalizing disorders by cannabis
administration method are presented in Table 3. In all adjusted models, we found no associations
between baseline cannabis use and subsequent reporting of major depressive disorder,
generalized anxiety disorder, panic disorder and obsessive-compulsive disorder symptoms at
follow-up. We found a significant, negative association between edible and blunt use at baseline
and odds of social phobia at follow-up.
Major Depressive Disorder Symptoms at Follow-up. There were no associations
between baseline cannabis use and clinical symptoms of depression at follow-up for users of
combustible cannabis (ever vs. never users: 3.8% vs. 9.0%), vaporized cannabis (4.6% vs.
10.7%), edible cannabis (4.5% vs. 8.3%) or blunts (4.2% vs. 9.5%). Additionally, no association

15
was observed between baseline use of any cannabis product and subsequent emergence of
depressive symptoms (3.6% vs. 8.8%).
Generalized Anxiety Disorder Symptoms at Follow-up. There were no associations
between baseline cannabis use and subsequent clinical symptoms of generalized anxiety disorder
for users of combustible cannabis (ever vs. never users: 4.0% vs. 3.9%), vaporized cannabis
(3.7% vs. 5.9%), edible cannabis (3.9% vs. 4.3%) or blunts (3.8% vs. 4.7%). We also observed
no association between baseline use of any cannabis product and clinical symptoms of
generalized anxiety disorder at follow-up (3.9% vs. 4.1%).
Panic Disorder Symptoms at Follow-up. There were no associations between baseline
cannabis use and clinical symptoms of panic disorder at follow-up for users of combustible
cannabis (ever vs. never users: 3.5% vs. 6.5%), vaporized cannabis (.9% vs. 8.3%), edible
cannabis (3.8% vs. 6.5%) or blunts (3.9% vs. 6.3%). We also found no association between
baseline use of any cannabis product and subsequent emergence of panic disorder symptoms
(3.6% vs. 5.9%).
Social Phobia Symptoms at Follow-up. We found no associations between baseline
cannabis use and clinical symptoms of social phobia at follow-up for users of combustible
cannabis (ever vs. never users: 4.8% vs. 2.6%). We observed significant, negative associations
between baseline cannabis use and clinical symptoms of social phobia at follow-up for users of
edible cannabis (4.8% vs. 1.5%), blunts (4.8% vs. 1.6%.) and any cannabis product (5.0% vs.
2.3%). Results could not be computed for users of vaporized cannabis due to small cell sizes
(ever users of vaporized cannabis who reported clinical symptoms at follow-up for <5).
Obsessive-Compulsive Disorder Symptoms at Follow-up. We found no association
between baseline cannabis use and clinical symptoms of obsessive-compulsive disorder at

16
follow-up in users of combustible cannabis (ever vs. never users: 1.0% vs. 2.2%), edible
cannabis (1.2% vs. 1.9%) and any cannabis product (0.9% vs. 2.3%). Results could not be
computed for users of vaporized cannabis and blunts due to small cell sizes (ever users of
vaporized cannabis and blunts who reported clinical symptoms at follow-up <5).
Associations between Cannabis Use and Clinical Symptoms on Any One, or Two or More,
Internalizing Disorders
Odds of meeting clinical threshold on any one internalizing disorder, or on two or more
internalizing disorders, by cannabis administration method, are presented in Table 4. In all
adjusted models, we observed no association between cannabis use at baseline and clinical
symptoms on any one, or two or more internalizing disorders at follow-up.
Clinical Symptoms on Any One Internalizing Disorder. There were no associations
between baseline cannabis use and clinical symptoms on any one internalizing disorder for users
of combustible cannabis (ever vs. never users: 6.7% vs. 9.7%), vaporized cannabis (7.3% vs.
9.5%), edible cannabis (7.2% vs. 8.9%), blunts (7.0% vs. 9.8%), or any cannabis product (6.7%
vs. 9.2%).
Clinical Symptoms on Two or More Internalizing Disorders. We observed no
associations between baseline cannabis use and subsequent clinical symptoms on two or more
internalizing disorders for users of combustible cannabis (ever vs. never users: 4.5% vs. 5.8%),
vaporized cannabis (4.5% vs. 7.7%), edible cannabis (4.6% vs. 5.9%), blunts (4.7% vs. 5.7%), or
any cannabis product (4.6% vs. 5.7%).
Supplementary Analyses
For all products, we found no association between cannabis use frequency at baseline and
occurrence of any internalizing disorder at follow-up (ORs range: 0.67-1.35; Supplemental Table

17
1). We also found no association between cannabis use frequency at baseline and later
occurrence of specific internalizing disorders (ORs range: 0.17-2.88; Supplemental Table 2), or
later occurrence of any 1, or 2 or more internalizing disorders (ORs range: 0.49-1.33
Supplemental Table 3).
Linear regression models revealed no associations between any cannabis use at baseline
and internalizing disorder symptoms scores at follow-up for major depression (F[31, 2117] =
22.35, p> .05; R
2
= .25, B= .01), generalized anxiety (F[31, 2117] = 15.39, p> .05; R
2
= .18, B= -
.04), panic disorder (F[31, 2117] = 17.58, p> .05; R
2
= .25, B= .006) and obsessive-compulsive
disorder (F[31, 2117] = 11.00, p> .05; R
2
=.14, B= -.005) (see Supplemental Table 4). We found
significant, negative associations between social phobia scores at follow-up and baseline ever
use of combustible cannabis (F[31, 2117] = 25.23, p< .05; R
2
= .27 , B= -.06,), vaporized
cannabis (F[31, 2117] = 25.23, p< .05; R
2
= .27, B= -.05), blunt cannabis (F[31, 2117] = 25.67,
p< .001; R
2
= .27 B= -.09), and any cannabis product (F[31, 2117] = 25.40, p< .05; R
2
= .27, B=
-.08).
Discussion
The aim of this study was to examine whether the use and poly-use of different cannabis
products in late adolescence (combustible, vaporized, edible or blunts) is associated with the
emergence of clinically significant symptoms of either major depressive disorder, generalized
anxiety disorder, panic disorder, social phobia or obsessive-compulsive disorder at 1-year
follow-up. Only a few recent reports have previously examined the cross-sectional associations
of adolescent cannabis use and poly-use by internalizing symptoms (Girgis, Pringsheim,
Williams, Shafiq, & Patten, 2020; Leventhal et al., 2020), and to our knowledge, this is the first
study to examine longitudinal associations between a wide array of cannabis products and a wide

18
array of internalizing disorder symptom outcomes. This study provides new evidence that ever
use of any cannabis product is negatively associated with risk of social phobia symptoms one
year later. We found no significant associations between use or poly-use of different cannabis
products and subsequent risk of occurrence of clinical symptoms of major depression,
generalized anxiety, panic disorder or obsessive-compulsive disorder.
While most internalizing disorder outcomes were not associated with cannabis use at
baseline, social phobia emerged as an exception. Any cannabis product use at baseline was
associated with lower risk of occurrence of social phobia at follow-up. To our knowledge, these
are the first findings to establish directionality between cannabis use at baseline and later risk of
occurrence of social phobia in adolescents. Previous findings have mostly focused on the cross-
sectional association between social phobia and cannabis use, or on the longitudinal association
between baseline social phobia and later symptoms of cannabis use disorder (Buckner, Crosby,
Wonderlich, & Schmidt, 2012; Buckner, Ecker, & Vinci, 2013; Buckner & Zvolensky, 2014;
Buckner, Zvolensky, Farris, & Hogan, 2014). Considering our baseline sample includes youths
with subclinical symptoms, it is possible that teens who are experiencing some symptoms of
social phobia are drawn to cannabis use for its perceived anxiolytic effects, which is in line with
the self-medication hypothesis among socially anxious individuals (Buckner et al., 2014;
Giombi, Kosa, Rains, & Cates, 2018). In turn, cannabis use might facilitate social exposure for
these adolescents, thereby aiding in preventing later occurrence of clinical symptoms of social
phobia. Important to note, though, is that after controlling for clinical symptoms at baseline, we
still found a significant negative association between cannabis use and social phobia at follow-
up. This might indicate that cannabis use can carry robust social effects regardless of symptom
status. Previous reports have shown that adult cannabis users with no psychiatric symptoms

19
report tempered social anxiety, and enhanced feelings of sociability and connectedness following
cannabis consumption (Wei, Allsop, Tye, & Piomelli, 2017).
When examining specific cannabis product use at baseline and associations with later risk
of occurrence of social phobia, edible cannabis and blunt use were each associated with lower
odds of occurrence of social phobia at follow-up. There were no associations found for
combustible cannabis users, and too few users of vaporized cannabis met criteria for social
phobia at follow-up to investigate the association for this product.
There are two potential hypotheses that might explain why edibles and blunt cannabis are
associated to lower risk of social phobia, compared to combustible cannabis: (1) these two
products have potentially higher potency, and thus more robust effects on the neural systems
linked to social behavior; (2) these two products are more likely to enhance social exposure, and
thus contribute to a protective effect against clinical symptoms of social phobia.
Compared to combustible cannabis, edible and blunt cannabis are methods that might facilitate
higher intake of cannabis. Blunts typically use a larger casing than joints, leaving room for more
cannabis to be introduced into the product (Sifaneck, Johnson, & Dunlap, 2006). Similarly, while
the THC content of edible cannabis is difficult to control, adolescents often will consume more
in response to feeling little or no effects soon after consumption (Russell, Rueda, Room, Tyndall,
& Fischer, 2018). As such, both edible and blunt cannabis might be exposing youths’ neural
systems to a larger spread and amount of cannabinoids, which could in turn significantly disrupt
the regulation of their endocannabinoid systems. Researchers have previously shown that
consumption of THC is associated with decreased amygdala reactivity in response to social
threat (Gorka, Fitzgerald, de Wit, & Phan, 2015; Phan et al., 2008). Since adolescence is a
critical period for neuromaturation, it is possible that the potentially higher potency of

20
cannabinoids present in edible and blunt cannabis more seriously disturbs amygdala reactivity to
a point that prevents the occurrence of clinical symptoms of social phobia.
Edible and blunt cannabis might also facilitate enhanced social exposure, compared to
other methods of administration. Blunts preparation is a more laborious process, thus requiring
the collaboration of many users. Additionally, the larger amount of cannabis used and rolled in
the cigar casing is usually meant to serve many users all at once (Sifaneck et al., 2006). Users of
blunts in our sample might be more likely to go through social exposure before, during and after
consumption, thereby potentially protecting them from developing social phobia at the 1-year
follow-up. Edible cannabis’ discreetness might allow for consumption in settings where using
combustible cannabis would be more difficult (e.g., at school, at the mall). Whether adolescents
consume edible cannabis in a group setting or by themselves, the increased feelings of sociability
and relaxedness might be conducive to heightened social exposure, especially given the fact that
the product can be consumed in environment where others are not necessarily consuming as
well.
In examining the associations between cannabis use and specific internalizing disorders,
we did find a small, positive association between combustible cannabis use, or any product use,
and symptoms of major depression and generalized anxiety at follow-up, before post-hoc
adjustments. These findings warrant further investigation of these relationships, especially
considering previous findings that show correlations between cannabis use and maintenance or
later occurrence of depression and anxiety symptoms (Duperrouzel et al., 2018; Lev-Ran et al.,
2014; Leventhal et al., 2020). Our current study might have lacked enough power to detect
robust effects.

21
The lack of association between cannabis use and later occurrence of clinical symptoms
of major depression, generalized anxiety, panic disorder or obsessive-compulsive disorder might
shed light on the temporal effects of cannabis use on the risk of later occurrence of internalizing
disorder symptoms. Previous studies that have found associations between adolescent cannabis
use and later occurrence of internalizing disorder symptoms examined outcomes in adulthood
(Hayatbakhsh et al., 2007; Patton et al., 2002; Van Laar et al., 2007). This might mean that the 1-
year follow-up window in our current study fell short in the developmental pathway, and that
internalizing symptoms are more likely to develop post-high school for youth who use cannabis.
We also found no association between cannabis use and comorbid symptoms outcomes, or poly-
use of cannabis products (i.e., use of 2, 3 or 4 products) and later risk of occurrence of any
internalizing disorder symptoms. Considering that recent cross-sectional observations showed
that adolescent cannabis use and poly-use are associated with increased depressive symptoms,
and increased comorbidity between internalizing outcomes (Leventhal et al., 2020), our findings
might inform the literature on the directionality of the relationship between internalizing
symptoms and cannabis use, wherein the former precedes the latter. It is important to note that
this cross-sectional study found no substantial difference in association whether adolescents were
single, dual or poly-product users. This might mean that cannabis use, regardless of product type
or number of products, is associated with internalizing symptom outcomes.
Limitations

The proposed research has several limitations. First, the generalizability of the findings to
the U.S. might be limited by the fact that the sample from the Health & Happiness Study,
although ethnically and socioeconomically diverse, yields from the restricted geographic region
of Los Angeles, California. Second, we do not have data available on the amounts, composition

22
or potency (e.g., THC percentage, strain of cannabis) of what the participants report consuming,
which might limit our understanding of the correlation between cannabis use and mental disorder
outcomes. We also have limited data on frequency of cannabis use, which might play an
important role in the potential effects of exposure. Third, some of the covariates included in the
analyses showed some unadjusted, significant associations with our outcomes, which might
inform us on potential mediation relationships. For example, it is possible that cannabis use
could lead to the occurrence of attention-deficit disorder symptoms, which could be associated
with depression or generalized anxiety. Fourth, our analyses do not include data on covariates
that would precede our baseline, such as early adolescence cannabis use or psychiatric
symptoms. This limits our understanding of the factors that might have influenced our outcomes
before our selected baseline. Lastly, data for cannabis use and internalizing disorder
symptomatology are based on self-report measures, which are subject to misclassifications, and
are not clinical diagnoses.
Conclusion
Our study is the first to examine the prospective association between baseline use of
different cannabis products and risk of occurrence of clinically significant internalizing disorder
symptoms. Specifically, this study shows that Los Angeles area adolescent users of edible
cannabis and blunts in grade 11 are at lesser risk of developing clinical symptoms of social
phobia in grade 12. There were no associations found between single or poly-use of cannabis
product and later occurrence of major depression, generalized anxiety, panic disorder or
obsessive-compulsive disorder. Policy and prevention efforts should continue to monitor the
legal and marketing landscapes of different cannabis products, and be aware of the differential
effects these products may have on youth health and mental health.

23
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32
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Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on
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Figure 1. Flow chart of study participants
1

Note.
1
Data depicts flow of participants in the study of cannabis use and internalizing disorder symptoms outcome.
33

Table 1. Demographic Characteristics for Total Sample, and by RCADS Symptomatology at Follow-up (N = 1, 666)

Any RCADS Symptomatology
b
Omnibus Test of
Differences
c

Total Sample
a
(N = 1, 666)
N (column %)
Below Clinical
Threshold

(N = 1460)
N (row %)
Above Clinical
Threshold

(N = 206)
N (row %)
P value

Age n(%)

.18
15 167 (10.0) 139 (83.2) 28 (16.7)
16 1357 (81.4) 1199 (88.4) 158 (11.6)
17 127 (7.6) 108 (85.0) 19 (15.0)
Gender n(%)
.26
Males 749 (45.0) 664 (88.7) 85 (11.3)
Females 917 (55.0) 796 (86.8) 121 (3.2)
Race/Ethnicity n(%)

.26
Hispanic or Latino 727 (43.6) 628 (86.4) 99 (13.6)
Asian 323 (19.4) 289 (89.5) 34 (10.5)
Black or African American 67 (4.0) 63 (94.0) 4 (6.0)
Native Hawaiian or Pacific Islander 55 (3.3) 46 (83.6) 9 (16.4)
White 260 (15.6) 228 (87.7) 32 (12.3)
Multiracial 90 (5.4) 75 (83.3) 15 (16.7)
Other 113 (6.8) 104 (92.0) 9 (8.0)
SES n(%)
d

.15
Low 712 (42.7) 611 (85.8) 101 (14.2)
High 881 (52.9) 784 (89.0) 97 (11.0)
Conduct Problems n(%)
e

.01
More than 1 delinquent behavior 1058 (63.5) 913 (86.3) 145 (13.7)
1 delinquent behavior 561 (31.7) 509 (90.7) 52 (9.3)
Attention Deficit/Hyperactivity Disorder n(%)
f

<.001
Yes 62 (3.7) 44 (71.0) 18 (29.0)
No 1558 (93.5) 1379 (88.5) 179 (11.5)
Ever substance use n(%)

.003
Any Tobacco Products
g

Yes 529 (31.8) 445 (84.1) 84 (15.9)
No 1137 (68.25) 1015 (89.3) 122 (10.7)
Any Other Substance
h

34

Note.
a
Column
percents may not
add up to 100%,
owing to missing data
b
Participants who scored above or below the clinical threshold for internalizing disorder symptoms at follow-up on any one of the following: major depressive disorder,
generalized anxiety disorder, panic disorder, social anxiety and/or obsessive-compulsive disorder.
c
Tests of differences in demographic characteristics by RCADS symptomatology status at follow-up.
d
High SES is defined as family income higher than 185% the US poverty line (i.e., respondents who are not eligible for free or reduced lunch). Low SES is defined as the other
respondents.
e
Conduct Problems = number of delinquent behaviors reported over past 6 months, on a scale from 1 to 6.
f
ADHD = number of participants who scored above clinical cut-off for either inattention or hyperactivity.
g
Any tobacco products = a few puffs of cigarette, a cigarette, smokeless tobacco, little and big cigars, hookah, other forms of tobacco.
h
Other drugs = one full drink of alcohol, inhalants, cocaine, methamphetamine, LSD/mushrooms/psychedelics, ecstasy, heroin, salvia, prescription painkillers,
tranquilizers/sedatives, diet pills, prescription stimulants, bath salts.

Yes 848 (50.8) 725 (85.5) 123 (14.5)
.02 No 800 (48.0) 720 (90.0) 80 (10.0)
Combustible cannabis
Yes 465 (27.9) 393 (84.5) 72 (15.5)
No 1201 (72.1) 1067 (88.8) 134 (11.2) .02
Vaporized cannabis
Yes 168 (10.1) 139 (82.7) 29 (17.3)
No 1498 (89.9) 1321 (88.2) 77 (11.8) .04
Edible cannabis
Yes 325 (19.5) 277 (85.2) 48 (14.8)
No 1341 (80.5) 1183 (88.2) 158 (11.8) .14
Blunts
Yes 317 (19.0) 268 (84.5) 49 (15.5)
No 1349 (81.0) 1192 (88.4) 157 (11.6) .06
Number of Cannabis Products
0 Product 1153 (69.2) 1023 (88.7) 130 (11.3)
1 Product 128 (7.7) 111 (86.7) 17 (13.3)
2 Products 124 (7.4) 104 (83.9) 20 (16.1)
3 Products 145 (8.7) 130 (89.7) 15 (10.3)
4 Products 116 (7.0) 92 (79.3) 24 (20.7) .03
35

Table 2. Binary Logistic Regression Model for the Association between Ever Cannabis Use Status at Baseline and Any Internalizing
Disorder Symptoms at Follow-up (N = 1,666)

Note.
a
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Prior Users= Lifetime use of cannabis product. Current users= Past 30
days use of cannabis product.
b
Participants who scored above or below the clinical threshold for internalizing disorder symptoms on any one of the following: major depressive disorder, generalized anxiety
disorder, panic disorder, social anxiety and/or obsessive-compulsive disorder.
c
Adjusted logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD (above clinical cut-off
on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and school attended.
Any RCADS Symptomatology
b
Binary Logistic Regression

Method of Administration
a
Above Clinical
Threshold

(N = 206)
N (row %)

Adjusted ORs
(95% CI)
c

Adjusted ORs
(95% CI)
d

Combustible
Never Users (N=1201) 134 (11.2) Ref Ref
Ever Users (N=465) 72 (15.5) 1.03 (0.68, 1.58) 1.31 (0.76, 2.27)
Vaporized
Never Users (N=1498) 177 (11.8) Ref Ref
Ever Users (N=168) 29 (17.3) 1.08 (0.66, 1.80) 1.25 (0.72, 2.17)
Edible
Never Users (N=1341) 158 (11.8) Ref Ref
Ever Users (N=325) 48 (14.8) 0.81 (0.53, 1.26) 0.73 (0.42, 1.29)
Blunt
Never Users (N=1349) 157 (11.7) Ref Ref
Ever Users (N=317) 49 (15.5) 0.86 (0.55, 1.32) 0.81 (0.46, 1.43)
Any Cannabis Product
Never Users (N=1153) 130 (11.3) Ref Ref
Ever Users (N=513) 76 (14.8) 0.89 (0.58, 1.37) ‡
Number of Cannabis Products
0 Product (N=1153) 130 (11.3) Ref Ref
1 Product (N=128) 17 (13.3) 0.92 (0.50, 1.68) ‡
2 Products (N=124) 20 (16.1) 1.12 (0.62, 2.03) ‡
3 Products (N=145) 15 (10.3) 0.54 (0.28, 1.05) ‡
4 Products (N=116) 24 (20.7) 1.15 (0.62, 2.16) ‡
36

d
Adjusted logistic regression models include all other methods of administration as additional covariates (e.g., when running model with combustible cannabis as predictor,
includes vaporized, edible and blunt as covariates).
‡Models were not conducted due to high collinearity between predictors and additional covariates (i.e., individual cannabis products).

37

Table 3. Binary Logistic Regression Model for the Association between Ever Cannabis Use Status at Baseline and Clinical Symptoms
for Specific Internalizing Disorders at Follow-up (N =1666)
a

Note.
a
Adjusted Firth’s logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD (above
clinical cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and school attended.
b
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Ever Users= Lifetime use of cannabis product.
b
Participants who scored above the clinical threshold for said internalizing disorder symptoms
§ Statistical analysis not conducted due to cell size <5
*p <.05 ; **p <.01
† Indicates statistical significance after correction using the Benjamini-Hochberg procedure.

Method of Administration
b
Major Depressive Disorder
(N=87, 5%)
Generalized Anxiety Disorder
(N=66, 4%)
Panic Disorder
(N=72, 4%)
Social Phobia
(N=70, 4%)
Obsessive-Compulsive Disorder
(N=22, 1%)

Above
Clinical
Threshold
(N, row %)

Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold
(N, row %)
Adjusted
ORs
(95% Cis)
Combustible
Never Users (N=1201) 45 (3.8) Ref 48 (4.0) Ref 42 (3.5) Ref 58 (4.8) Ref 12 (1.0) Ref
Ever Users (N=465)

42 (9.0) 2.21 (1.17, 4.17)*
18 (3.9) 0.50
(0.25, 0.99)*
30 (6.5)
1.44 (0.76, 2.75)
12 (2.6)
0.41 (0.19, 0.90)*
10 (2.2) 1.32 (0.41, 4.31)
Vaporized
Never Users (N=1498) 69 (4.6) Ref 56 (3.7) Ref 58 (3.9) Ref 67 (4.5) Ref 21 (1.4) Ref
Ever Users (N=168) 18 (10.7) 1.55 (0.82, 2.95) 10 (5.9) 1.19 (0.54, 2.61) 14 (8.3) 1.66 (0.81, 3.40) 3 (1.8) § 1 (0.6) §
Edible
Never Users (N=1341) 60 (4.5) Ref 52 (3.9) Ref 51 (3.8) Ref 65 (4.8) Ref 16 (1.2) Ref
Ever Users (N=325) 27 (8.3) 1.12 (0.62, 2.01) 14 (4.3) 0.68 (0.34, 1.37) 21 (6.5) 1.20 (0.63, 2.27) 5 (1.5) 0.24 (0.09, 0.63)**† 6 (1.9) 0.59 (0.18, 1.96)
Blunt
Never Users (N=1349) 57 (4.2) Ref 51 (3.8) Ref 52 (3.9) Ref 65 (4.8) Ref 18 (1.3) Ref
Ever Users (N=317) 30 (9.5) 1.49 (0.82, 2.71) 15 (4.7) 0.73 (0.36, 1.48) 20 (6.3) 1.02 (0.53, 1.95) 5 (1.6) 0.22 (0.08, 0.60)**† 4 (1.3) §
Any Cannabis Product
Never Users (N=1153) 42 (3.6) Ref 45 (3.9) Ref 42 (3.6) Ref 58 (5.0) Ref 10 (0.9) Ref
Ever Users (N=513) 45 (8.8) 2.21 (1.16, 4.20)* 21 (4.1) 0.54 (0.27, 1.09) 30 (5.9) 1.08 (0.57, 2.06) 12 (2.3) 0.31 (0.14, 0.69)**† 12 (2.3) 1.90 (0.58, 6.2)
38

Table 4. Multinomial Logistic Regression Model for the Association between Ever Cannabis Use Status at Baseline and Clinical
Symptoms for Any 1 Internalizing Disorder, or 2 or More Internalizing Disorders at Follow-up (N = 1,666)
a

Note.
a
Adjusted logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD (above clinical
cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and school attended.
b
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Ever Users= Lifetime use of cannabis product.
c
Participants who scored above the threshold for clinical symptoms for one of the following internalizing disorders: major depressive disorder, generalized anxiety disorder, panic
disorder, social anxiety and/or obsessive-compulsive disorder.
d
Participants who scored above the threshold for clinical symptoms for 2 or more of the following internalizing disorders: major depressive disorder, generalized anxiety disorder,
panic disorder, social anxiety and/or obsessive-compulsive disorder.

Any 1 RCAD (vs. None)
c
2 or more RCADS (vs. None)
d

Method of Administration
b
Above
Clinical
Threshold

(N=125)
N (row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N=81)
N (row %)
Adjusted
ORs
(95% CI)
Combustible
Never Users (N=1201) 80 (6.7) Ref 54 (4.5) Ref
Ever Users (N=465) 45 (9.7) 1.12 (0.66, 1.88) 27 (5.8) 0.90 (0.46, 1.74)
Vaporized
Never Users (N=1498) 109 (7.3) Ref 68 (4.5) Ref
Ever Users (N=168) 16 (9.5) 0.93 (0.49, 1.75) 13 (7.7) 1.36 (0.64, 2.88)
Edible
Never Users (N=1341) 96 (7.2) Ref 62 (4.6) Ref
Ever Users (N=325) 29 (8.9) 0.82 (0.48, 1.40) 19 (5.9) 0.79 (0.40, 1.54)
Blunt
Never Users (N=1349) 94 (7.0) Ref 63 (4.7) Ref
Ever Users (N=317) 31 (9.8) 0.98 (0.58, 1.67) 18 (5.7) 0.67 (0.33, 1.33)
Any Cannabis Product
Never Users (N=1153) 78 (6.7) Ref 52 (4.6) Ref
Ever Users (N=513) 47 (9.2) 0.95 (0.56, 1.60) 29 (5.7) 0.80 (0.41, 1.55)
39

Supplemental Table 1. Binary Logistic Regression Model for the Association between Cannabis Use Frequency at Baseline and Any
Internalizing Disorder Symptoms at Follow-up (N = 1,666)

Note.
a
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Prior Users= Lifetime use of cannabis product, but not
in past 30 days. Current users= Past 30 days use of cannabis product.
b
Participants who scored above or below the clinical threshold for internalizing disorder symptoms on any one of the following: major depressive disorder,
generalized anxiety disorder, panic disorder, social anxiety and/or obsessive-compulsive disorder.
c
Adjusted logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD
(above clinical cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and
school attended.
Any RCADS Symptomatology
b
Binary Logistic Regression

Method of Administration
a
Total Sample
(N=1666)
N (column %)
Below Clinical
Threshold

(N = 1460)
N (row %)
Above Clinical
Threshold

(N = 206)
N (row %)

Adjusted ORs
(95% CI)
c

Adjusted ORs
(95% CI)
d

Combustible
Never Users 1201 (72.1) 1067 (88.8) 134 (11.2) Ref Ref
Prior Users 314 (18.8) 270 (86.0) 44 (14.0) 0.97 (0.61, 1.54) 1.35 (0.77, 2.37)
Current Users 151 (9.1) 123 (81.5) 28 (18.5) 1.18 (0.68, 2.06) 1.35 (0.58, 3.13)
Vaporized
Never Users 1498 (89.9) 1321 (88.2) 177 (11.8) Ref Ref
Prior Users 129 (7.8) 108 (83.7) 21 (16.3) 1.04 (0.59, 1.82) 1.14 (0.62, 2.09)
Current Users 39 (2.3) 31 (79.5) 8 (20.5) 1.23 (0.52, 2.89) 0.94 (0.32, 2.79)
Edible
Never Users 1341 (80.5) 1183 (88.2) 158 (11.8) Ref Ref
Prior Users 254 (15.3) 222 (87.4) 32 (12.6) 0.71 (0.44, 1.14) 0.67 (0.37, 1.19)
Current Users 71 (4.4) 55 (77.5) 16 (22.5) 1.24 (0.64, 2.39) 1.08 (0.41, 2.82)
Blunt
Never Users 1349 (81.0) 1192 (88.3) 157 (11.7) Ref Ref
Prior Users 223 (13.4) 193 (86.5) 30 (13.5) 0.75 (0.46, 1.23) 0.72 (0.39, 1.33)
Current Users 94 (5.6) 75 (79.8) 19 (20.2) 1.13 (0.61, 2.08) 0.96 (0.37, 2.49)
Any Cannabis Product
Never Users 1153 (69.2) 1023 (88.7) 130 (11.3) Ref NA
Prior Users 347 (20.8) 301 (86.7) 46 (13.3) 0.83 (0.52, 1.32) NA
Current Users 166 (10.0) 136 (81.9) 30 (18.1) 1.05 (0.61, 1.82) NA
40

Supplemental Table 2. Binary Logistic Regression Model for the Association between Cannabis Use Frequency at Baseline and
Clinical Symptoms for Specific Internalizing Disorders at Follow-up (N = 1666)
a

Note.
a
Adjusted Firth’s logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD (above
clinical cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and school attended.
b
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Prior Users= Lifetime use of cannabis product, but not in past 30 days. Current
users= Past 30 days use of cannabis product.
c
Participants who scored above the clinical threshold for said internalizing disorder symptoms
*p <.05
§ Statistical analysis not conducted due to cell size <5
† Indicates statistical significance after correction using the Benjamini-Hochberg procedure.

Method of
Administration
b
Major Depressive Disorder
(N=87, 5%)
Generalized Anxiety Disorder
(N=66, 4%)
Panic Disorder
(N=72, 4%)
Social Phobia
(N=70, 4%)
Obsessive-Compulsive Disorder
(N=22, 1%)

Above
Clinical
Threshold
c
(N, row %)

Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, row %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, %)
Adjusted
ORs
(95% CI)
Above
Clinical
Threshold

(N, %)
Adjusted
ORs
(95% CI)
Combustible
Never Users 45 (3.8) Ref 48 (4.0) Ref 42 (3.5) Ref 58 (4.8) Ref 12 (1.0) 1.51 (0.46, 4.97)
Prior Users 26 (8.3) 2.12 (1.08, 4.14)* 8 (2.6) 0.36 (0.14, 0.84)* 19 (6.1) 1.45 (0.73, 2.88) 8 (2.6) 0.45 (0.19, 1.08) 8 (2.6) 0.88 (.15, 5.28)
Current Users 16 (10.6) 2.51 (1.14, 5.52)* 10 (6.6) 0.81 (0.35, 1.88) 11 (7.3) 1.50 (0.65, 3.43) 4 (2.7) § 2 (1.3) §
Vaporized
Never Users 69 (4.6) Ref 56 (3.7) Ref 58 (3.9) Ref 67 (4.5) Ref 21 (1.4) 0.17 (0.01, 2.88)
Prior Users 14 (10.9) 1.62 (0.81, 3.22) 7 (5.4) 1.12 (0.46, 2.71) 8 (6.2) 1.31 (0.57, 3.05) 2 (1.6) § 0 (0.0) §
Current Users 4 (10.3) § 3 (7.7) § 6 (15.4) 2.88 (1.08, 7.65)* 1 (2.6) § 1 (2.6) §
Edible

Never Users 60 (4.5) Ref 52 (3.9) Ref 51 (3.8) Ref 65 (4.9) Ref 16 (1.2) 0.66 (0.20, 2.24)
Prior Users 17 (6.7) 0.91 (0.47, 1.76) 8 (3.2) 0.54 (0.24, 1.23) 14 (5.5) 1.09 (0.54, 2.20) 4 (1.6) § 5 (2.0) 0.47 (0.06, 3.87)
Current Users 10 (14.1) 1.95 (0.87, 4.39) 6 (8.5) 1.22 (0.46, 3.19) 7 (9.9) 1.63 (0.65, 4.09) 1 (1.4) § 1 (1.4) §
Blunt
Never Users 57 (4.2) Ref 51 (3.8) Ref 52 (3.9) Ref 65 (4.8) Ref 18 (1.3) 0.22 (0.04, 1.07)
Prior Users 18 (8.1) 1.33 (0.68, 2.58) 6 (2.7) 0.44 (0.18, 1.10) 12 (5.4) 0.89 (0.42, 1.86) 4 (1.8) § 2 (0.9) §
Current Users 12 (12.8) 1.96 (0.90, 4.28) 9 (9.6) 1.52 (0.65, 3.57) 8 (8.5) 1.41 (0.59, 3.37) 1 (1.1) § 2 (2.1) §
Any Cannabis Product
Never Users 42 (3.6) Ref 45 (3.9) Ref 42 (3.6) Ref 58 (5.0) Ref 10 (0.9) 2.17 (0.66, 7.12)
Prior Users 28 (8.1) 2.11 (1.07, 4.13)* 11 (3.2) 0.45 (0.20, 1.00) 18 (5.2) 1.03 (0.51, 2.07) 8 (2.3) 0.34 (0.14, 0.82)* 10 (2.9) 1.14 (0.19, 6.81)
Current Users 17 (10.2) 2.54 (1.15, 5.61)* 10 (6.0) 0.76 (0.32, 1.79) 12 (7.2) 1.24 (0.55, 2.78) 4 (2.4) § 2 (1.2) §
41

Supplemental Table 3. Multinomial Logistic Regression Model for the Association between Cannabis Use Frequency at Baseline and
Internalizing Disorder Symptoms (N = 1,666)

Note.
a
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Prior Users= Lifetime use of cannabis product, but not
in past 30 days. Current users= Past 30 days use of cannabis product.
b
Participants who scored above or below the clinical threshold for internalizing disorder symptoms on any one of the following: major depressive disorder,
generalized anxiety disorder, panic disorder, social anxiety and/or obsessive-compulsive disorder.
1 RCAD 2 or more RCADS

Method of Administration
a
Above
Clinical
Threshold
b
(N=125)
N (row %)
Adjusted
ORs
c
(95% CI)
Above
Clinical
Threshold

(N=81)
N (row %)
Adjusted
ORs
(95% CI)
Combustible
Never Users 80 (6.7) Ref 54 (4.5) Ref
Prior Users 28 (8.9) 1.05 (0.60, 1.86) 16 (5.1) 0.83 (0.40, 1.73)
Current Users 17 (11.3) 1.27 (0.64, 2.53) 11 (7.2) 1.03 (0.44, 2.42)
Vaporized
Never Users 109 (7.3) Ref 68 (4.5) Ref
Prior Users 12 (9.3) 0.88 (0.44, 1.79) 9 (7.0) 1.34 (0.58, 3.09)
Current Users 4 (10.3) § 4 (10.3) §
Edible
Never Users 96 (7.2) Ref 62 (4.6) Ref
Prior Users 19 (7.5) 0.69 (0.38, 1.26) 13 (5.1) 0.70 (0.33, 1.48)
Current Users 10 (14.1) 1.33 (0.60, 2.92) 6 (8.4) 1.10 (0.40, 3.06)
Blunt
Never Users 94 (7.0) Ref 63 (4.7) Ref
Prior Users 21 (9.5) 0.93 (0.52, 1.68) 9 (4.4) 0.49 (0.21, 1.13)
Current Users 10 (10.6) 1.11 (0.51, 2.42) 9 (9.6) 1.09 (0.45, 2.65)
Any Cannabis Product
Never Users 78 (6.7) Ref 52 (4.6) Ref
Prior Users 28 (8.1) 0.86 (0.48, 1.52) 18 (5.2) 0.77 (0.37, 1.58)
Current Users 19 (11.5) 1.17 (0.60, 2.28) 12 (6.6) 0.87 (0.37, 2.05)
42

c
Adjusted logistic regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD
(above clinical cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), and
school attended.

43

Supplemental Table 4. Bivariate Linear Regression Model for the Association between Cannabis Use Frequency at Baseline and
Clinical Symptoms Score for Specific Internalizing Disorders at Follow-up (N = 2149)
a
Note.
a
Adjusted bivariate linear regression models included the following covariates: age, gender, ethnicity, SES (defined by parental income), conduct problems, ADHD (above
clinical cut-off on either inattention or hyperactivity), ever use of any tobacco product, ever use of any other drug (excluding cannabis or tobacco), baseline clinical internalizing
disorder symptoms for each respective internalizing disorder (e.g., models predicting major depression symptoms included control for clinical major depression symptoms at
baseline) and school attended. Participants who met clinical criteria for any internalizing disorder were included at baseline.
b
Methods of cannabis administration at baseline. Never users= No lifetime use of cannabis product. Prior Users= Lifetime use of cannabis product, but not in past 30 days. Current
users= Past 30 days use of cannabis product.
c
RCADS scores range as follows: 0 to 30 for Major Depressive Disorder; 0 to 18 for Generalized Anxiety Disorder; 0 to 27 for Panic Disorder; 0 to 27 for Social Phobia; 0 to 18
for Obsessive-Compulsive Disorder. In order to determine whether score is above or below clinical threshold, raw scores are converted into T scores. T scores of 65 are considered
subclinical, and T scores of 70 or above are considered at or above clinical threshold.
*p <.05; **p<.001

Method of Administration
b
Major Depressive Disorder

Generalized Anxiety Disorder

Panic Disorder

Social Phobia

Obsessive-Compulsive Disorder

Mean Score
(SD)
c
β Mean Score
(SD)
β Mean Score
(SD)
β Mean Score
(SD)
β Mean Score
(SD)
β
Combustible
Never Users (N=1535) 7.72 (0.17) Ref 7.08 (0.12) Ref 3.92 (0.13) Ref 10.71 (0.19) Ref 3.52 (0.15) Ref
Ever Users (N=614) 8.46 (0.30) .03 7.02 (0.19) -.04 4.50 (0.22) .01 9.02 (0.30) -.06* 3.52 (0.15) .01
Vaporized
Never Users (N=1924) 7.84 (0.15) Ref 7.04 (0.1) Ref 4.01 (0.12) Ref 10.44 (0.17) Ref 3.34 (0.08) Ref
Ever Users (N=225) 8.72 (0.52) -.002 7.20 (0.32) -.02 4.68 (0.37) .006 8.42 (0.48) -.05* 3.43 (0.25) -.03
Edible
Never Users (N=1708) 7.69 (0.16) Ref 7.00 (0.11) Ref 3.91 (0.12) Ref 10.51 (0.18) Ref 3.30 (0.08) Ref
Ever Users (N=441) 8.88 (0.36) .03 7.29 (0.23) -.02 4.76 (0.26) .009 9.15 (0.34) -.04 3.57 (0.18) -.001
Blunt
Never Users (N=1718) 7.74 (0.16) Ref 7.06 (0.11) Ref 3.98 (0.12) Ref 10.62 (0.18) Ref 3.34 (0.08) Ref
Ever Users (N=431) 8.69 (0.37) .01 7.07 (0.23) -.04 4.50 (0.27) -.01 8.66 (0.34) -.09** 3.38 (0.17) -.04
Any Cannabis Product
Never Users (N=1473) 7.73 (0.17) Ref 7.08 (0.12) Ref 3.90 (0.13) Ref 10.81 (0.19) Ref 3.49 (0.14) Ref
Ever Users (N=676) 8.37 (0.28) .01 7.01 (0.18) -.04 4.47 (0.21) .006 8.97 (0.28) -.08* 3.49 (0.14) -.005
44

Abstract (if available)

Abstract Background: Evidence indicates that cannabis use in adolescence puts individuals at risk for developing mental health disorders in young adulthood. Whether cannabis use in adolescence contributes to the occurrence of mental health disorders in later adolescence is unknown. Also, with the increase in use of cannabis across different administration methods amongst adolescents, it is unknown whether cannabis products have differential consequences on mental health outcomes in youth. The current study explored the association between different methods of cannabis administration and mental health outcomes in later adolescence. ❧ Methods: Surveys were administered to students across 10 public schools in Los Angeles, CA, USA. Students (N = 1666

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Asset Metadata

Creator Ewusi Boisvert, Esthelle (author)

Core Title Depression and anxiety symptom outcomes in adolescent users of smoked, vaporized, edible and blunt cannabis

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 07/29/2020

Defense Date 04/23/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Adolescents,anxiety,Blunt,cannabis,combustible,Depression,edible,OAI-PMH Harvest,vaporized

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Leventhal, Adam (committee chair), Davison, Gerald (committee member), Monterosso, John (committee member)

Creator Email esthelle.eb@gmail.com,ewusiboi@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-349144

Unique identifier UC11664177

Identifier etd-EwusiBoisv-8810.pdf (filename),usctheses-c89-349144 (legacy record id)

Legacy Identifier etd-EwusiBoisv-8810.pdf

Dmrecord 349144

Document Type Thesis

Rights Ewusi Boisvert, Esthelle

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA