Cannabis use and psychiatric disorders

Board-certified physician at Stanford Medicine, Smita Das, MD, PhD, MPH, and professor and director of Addiction Sciences at the Medical University of South Carolina, Kevin Gray, MD, discuss cannabis use and its effects on mental health and psychiatric disorders, including psychosocial outcomes from use and potentiation of psychiatric disorders. Common perceptions of use of cannabis for mental health are also discussed.

Speakers

• Smita Das, MD, PhD, MPH, board-certified physician, Stanford Medicine 
• Kevin Gray, MD, professor and director, Addiction Sciences, Medical University of South Carolina
• Jesse Ehrenfeld, MD, immediate past president, American Medical Association
• Michael Suk, MD, JD, MPH, MBA, professor and chair, Musculoskeletal Institute and the Department of Orthopedic Surgery, Geisinger Health System; chair, AMA Board of Trustees

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Dr. Ehrenfeld: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is part of the Cannabis Education series, brought to you by the AMA Cannabis Task Force. 

I'm Dr. Jesse Ehrenfeld, senior associate dean, tenured professor of anesthesiology and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin. I'm also the immediate past president of the AMA and co-chair of the AMA Cannabis Task Force. Michael, take it away!

Dr. Suk: Thanks, Jesse. I'm Dr. Michael Suk, professor and chair of the Musculoskeletal Institute and the Department of Orthopedic Surgery at Geisinger Health System. I'm chair of the AMA Board of Trustees and your co-chair of the AMA Cannabis Task Force.

Through expert discussions and insights, this podcast series features information that can help physicians of all specialties understand cannabis and the health effects of cannabis use.

Dr. Ehrenfeld: The AMA forms mission-specific task forces like this one to tackle current medical issues in our nation. Make your voice heard by becoming a member today. Visit ama-assn.org/more. And now, on to the show. 

Joining me today to talk about cannabis use and psychiatric disorders are Dr. Kevin M. Gray, who is professor and director of Addiction Sciences in the Department of Psychiatry and Behavioral Sciences and assistant vice president for Advancing Research Partnerships at the Medical University of South Carolina. He is also a distinguished fellow of the American Academy of Child and Adolescent Psychiatry and serves on the executive committee of the American Academy of Addiction Psychiatry. He is board certified in psychiatry and child and adolescent psychiatry. 

Also joining me is Dr. Smita Das, a clinical associate professor of psychiatry and behavioral sciences at Stanford University School of Medicine. She was also chair of the American Psychiatric Association's Council on Addiction Psychiatry.

She is board certified in psychiatry, addiction psychiatry and addiction. Welcome both of you.

Dr. Das: Thank you.

Dr. Gray: Thanks so much for having us.

Dr. Ehrenfeld: Well, I'd like to start with you, Dr. Das. Could you discuss some common perceptions of people regarding cannabis use as it relates to mental health and psychiatric disorders?

Dr. Das: That's an excellent question. I think it's helpful to step back and to understand that cannabis is one of the most widely used psychoactive substances worldwide. And so, it's just very available and very much used. And so, people with psychiatric conditions may have more access to it. There are common perceptions. I also will go over some of those misperceptions. So, misperceptions are that cannabis is helpful for treating mental health conditions. We know from population survey data that folks are using cannabis for a number of mental health conditions. Half of people in surveys will report using it for anxiety, many more for depression, PTSD, some even for bipolar and mania, and some for psychosis, which is really interesting because cannabis can have a relationship with worsening psychosis. 

It's also interesting to note that people who are young will generally be using cannabis for the idea that they're treating mental health conditions. In another survey, nearly 50% of people reported their belief of cannabis that cannabis is beneficial for anxiety and depression, while only 15% believe that cannabis increases the risk for these conditions. And these are both misperceptions. What we do know, as I alluded to earlier, is that cannabis can actually make things like depression and anxiety worse. 

And a concern that I have is that if somebody is turning to cannabis to treat a mental health condition where there is no evidence, then they are perhaps losing out or missing out on evidence-based practices that we have for treating things like anxiety and depression, things that are effective, safe and life-changing. For example, for depression and anxiety, we know cognitive behavioral therapy under medications like SSRIs are very effective and they are underused. And so, with less than half of people with a mental illness getting treatment, it is concerning that there are these misperceptions of cannabis being useful to treat mental illness.

Dr. Ehrenfeld: Well, it certainly seems like there's a bit of a disconnect in terms of how people are using cannabis to treat psychiatric disorders and the potential link between psychiatric disorders and cannabis use. So, Dr. Gray, can you speak to what we do know about cannabis use and psychiatric disorders?

Dr. Gray: Yes, it's like we say with a lot of things, it's complicated. But relatively straightforward in terms of the direction as we understand things. Individuals with a psychiatric disorder are more likely than those without to use cannabis. Individuals who use cannabis are also more likely to develop a psychiatric disorder. It goes in both directions. And so, if you look at epidemiologic studies over time, particularly individuals who start using cannabis at an early age, particularly in adolescence, especially high potency strains of THC, have a higher likelihood of developing mental illness later.

Similarly, people who have an existing psychiatric disorder are more likely to use cannabis generally, but also to develop what we call cannabis use disorder, which is a problematic pattern of cannabis use and continued use despite adverse consequences. So, it's in both directions. It's messy in some ways in that people may legitimately feel short-term relief of a symptom during intoxication.

But long term, what we see time and time again is it tends to complicate the picture of the underlying psychiatric illness. Be it anxiety, be it depression, it complicates the course. And so, the two are so inextricably linked.

And there is healthy debate in terms of directionality as to whether the psychiatric illness came first, the cannabis use came first. The best answer we have now is there's some of both. There's more to disentangle, but what is dangerous is this assumption that cannabis is benign and/or is treating these conditions. And with lack of evidence for that, what we're seeing is actually worsening of symptoms over time, which in our current times is a really difficult issue because we have a high prevalence in terms of people suffering with depression, anxiety, psychosis and we don't want to complicate that.

Dr. Ehrenfeld: So, I was reading some information recently about cannabis being the cause of some psychiatric disorders. Maybe both of you could comment on what we know about cannabis potentially causing psychiatric disorders.

Dr. Das: Yes, as noted, cannabis use and psychiatric disorders, it's a complex relationship. I'll focus in on psychosis, specifically, because that's an area of major concern. So, let's just step back though and understand something about cannabis that is a fact now, is that cannabis composition is changing. Whereas, you know, in the 1960s and 70s, or even 90s, the cannabis that was considered top grade would be 20% delta-9 THC, tetrahydrocannabinol. That's the psychoactive component of cannabis, the part of cannabis that exerts an effect on the brain and mind and can affect things like mood and so on. Now in dispensaries, people can access cannabis that is 80% THC. 

And so, this is a very strong and potent form of cannabis in many different forms than just dried cannabis leaves that are rolled up. There's so many different options. So, I just want to emphasize that that is in particular changing how we're understanding the impacts on mental health. And so, the reason why I mentioned that is in Europe where they have excellent data tracking of some of these things, they looked at cannabis potency and onset of psychotic disorders and found that high potency or daily use was associated with developing psychotic disorders.

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And so, this sort of large data set is very concerning. Cannabis use is associated with an increased risk for earlier onset of psychotic disorders, such as schizophrenia in people with other risk factors, as well as things like family history. So, that's important for folks to be mindful of. It's also useful to know about just temporary cannabis intoxication. It can induce a temporary psychotic episode in some people, especially at these high doses. And so, this might be linked with a risk for later developing a psychotic disorder. So, all of these things are about the risk of psychotic disorders.

Dr. Gray: And I'd certainly like to jump in and talk a bit about, so risk-benefit with any substance, medication otherwise, is different based on a number of factors, including age, other contextual factors. We're certainly both, as psychiatrists, very sensitive to the risk of worsening of psychiatric symptoms with cannabis use. One other factor that's really important, and I say this as a child and adolescent psychiatrist, is the earlier the onset of cannabis use, the higher the risk of psychosocial impairment.

And there are some youth-specific and young adult specific studies indicating a higher risk of suicidality, everything ranging from suicidal ideation to attempts to complete suicide with cannabis versus, between users versus non-users. And again, it's, I hesitate to say a cause and effect, but there's an association where the same theme occurs where if you add cannabis to the mix of struggling with mental health symptoms, it tends to worsen the course and especially with devastating consequences like suicidality.

And really across the board, if you talk about adolescent onset use, the associations are very strong of doubling or even more in terms of likelihood of developing major depression, suicidal ideation, slowed cognition. You know, one of the biggest developmental tasks of adolescents is education and learning, and impairing that is really problematic. As well as, you know, difficulties with aggression and truancy.

It’s complicated in that there's not always a cause and effect, but the scales always tip in the direction of the earlier the onset, the higher the potency, the more frequent the use, the higher likelihood that it's associated with adverse psychosocial outcomes across the board. We tend to see a lot of this in psychiatric practice. We recognize in some ways we may be biased because we see it in psychiatric practice, but also, I would say that our voices are really important to the general public because I think a lot of folks don't hear this perspective, but we see this often and it’s tragic when early onset cannabis use worsens the course and there's an adverse outcome.

Dr. Ehrenfeld: So, if I can reflect back what I've heard is that the relationship between cannabis use and psychiatric disorders is complicated. It's not totally straightforward as we think about the short- and long-term impacts of cannabis use on mental health. If I heard Dr. Das correctly, it sounds like the amount of drug, the potency of the drug, the frequency of use probably influences what that relationship between cannabis use and mental health is. But probably with other factors that influence mental health, genes, stress, trauma, it's going to influence how people are using these drugs. Did I get that correctly?

Dr. Das: Yes.

Dr. Gray: Absolutely.

Dr. Ehrenfeld: Perfect. So, I did want to ask a question as we think about the symptoms, right? So, mental health symptoms caused by cannabis use. What kinds of things do people see? What kinds of things should people watch out for?

Dr. Gray: So acutely with symptoms, so I think, I'm sure many listeners are familiar with what's typically associated with cannabis intoxication. So, there can be euphoria, et cetera. But Dr. Das had mentioned, and I agree with, is that sometimes, depending on context and dose and prior level of exposure, people may have adverse effects with cannabis.

So, some people have overt panic episodes with the first use of cannabis at high potency. Some people may exhibit psychotic symptoms, especially at high potency. And so really across things like psychosis, delusions, anxiety, hallucinations can occur acutely. And this kind of really cuts across different psychiatric symptoms with acute use. Again, people generally associate with euphoria, which is often the case, but with higher potency, I think this is a recurring theme for us, is that we're concerned about people getting exposed to very high potency THC, and the higher the dose and the less experienced someone is with using, the more likely it is that an adverse outcome can occur, which is part of the worry about adolescents and also children getting access to cannabis products.

Dr. Das: I'll echo, all of those symptoms I think are very important in terms of intoxication, euphoria, sensory perception changes, anxiety, fear, distressed panic, paranoia, psychosis in some cases. I also like to highlight a couple of other things with the symptoms is that they will generally last a few hours. It depends also on how the cannabis is used. If they're edibles, then that effect may be longer. And so that can sometimes complicate presentations because people may use more than intended because they're not getting an immediate effect. 

In addition to symptoms of intoxication, I also like to remind the community of cannabis withdrawal symptoms because they can manifest as things that we may see as psychiatrists. Mood changes, irritability, difficulty sleeping, trouble concentrating. And so, I like to remind my patients that withdrawal will pass, and they will feel better from those things. And it can complicate just general mental health presentations because a lot of what I mentioned overlaps with other mental health conditions.

Dr. Ehrenfeld: Perfect, that makes a lot of sense. So, Dr. Das, Dr. Gray, thank you so much for sharing your knowledge of cannabis use and psychiatric disorders. Could you each summarize key points you'd like to leave our audience with? And maybe I'll turn to Dr. Gray first and then Dr. Das.

Dr. Gray: I think we should all be open-minded and really try to learn as much as we can about cannabis and its risks and benefits and cannabinoids. As we learn more about the endocannabinoid system, it's a very exciting topic for science. At the same time, we're faced with ready access across populations with cannabis and with potentially misleading messages. So, I like to keep an open mind so I can better understand risk and benefit and be able to tailor messaging to patients and to families.

One of the take homes for me is, you know, higher potency exposure earlier in age is associated with higher risks, and we ought not dismiss the risk of both short and long-term adverse outcomes with cannabis. I think we should be very clear-headed in terms of understanding that there are both risks and benefits associated with cannabis and with modulating the endocannabinoid system. At the same time, we know enough to be very cautious, particularly in those who may be already exhibiting psychiatric symptoms and young in age, it could be more problematic for them than for others.

Dr. Ehrenfeld: Dr. Das.

Dr. Das: Yeah, I'll start by saying in my role at the American Psychiatric Association, we've created several position statements with regards to cannabis, one including the position statement in opposition to cannabis as medicine and another position statement against the use of cannabis for PTSD. Anecdotally and clinically, as an addiction psychiatrist who works with patients who both have substance use disorders and those without, I see a rise in the use of cannabis and in cannabis use disorders.

I have more people presenting for treatment of cannabis use disorder. And in the general mental health clinics where I work, more and more patients report using cannabis thinking that they will help treat their primary psychiatric diagnosis. So, my main take home point is that we do have evidence-based ways that are safe, well-researched and available and underused to treat mental health conditions. And I would recommend that those are considered before using cannabis. Cannabis may be faster and feel like an easier fix, but for many of my patients it ends up coming back in a way that is more negative than positive.

Dr. Ehrenfeld: Dr. Das, Dr. Gray, thank you so much for being a part of this cannabis use and psychiatric disorders session as a part of the AMA's Cannabis Educational Series. Again, I'm Dr. Jesse Ehrenfeld, we hope that our listeners will tune into other episodes in this Cannabis Educational Series.

Don’t miss the next episode in this series—be sure to subscribe to Moving Medicine on your favorite podcast platform. This content is for educational and informational purposes only and does not constitute medical or legal advice. The viewpoints expressed in this podcast are those of the participants and do not reflect the views and policies of the AMA, unless otherwise indicated. 

Dr. Suk: And this has been Moving Medicine. Thanks for listening.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.