Marijuana and the Psychiatric Patient
Marijuana and the Psychiatric Patient
In a widely cited 2014 article, Nora Volkow and her colleagues at the National Institute on Drug Abuse highlighted the evidence that connects marijuana use with psychosis, anxiety, depression, and addiction.1 A second article examined its harmful effects on cognition, psychosis, and motivation.2 The American Psychiatric Association’s position statement begins, “There is no current scientific evidence that marijuana is in any way beneficial for the treatment of any psychiatric disorder.”3[PDF]
Despite near-unanimous medical warnings, marijuana use is widespread among psychiatric patients,4 including those with psychotic disorders.5 Advocates tout its benefits for anxiety, depression, and bipolar disorder6; and medical marijuana regulations in 9 states include PTSD as a qualifying condition. Psychiatry’s apprehension plainly disagrees with more favorable attitudes in patients and the public. How can psychiatrists best address their patients’ marijuana use in this contentious environment?
What follows is a critical summary of the evidence now available that connects marijuana with cognitive problems, psychosis, anxiety, PTSD, depression, and addiction. I have relied on published reviews, supplemented by PubMed searches for more recent data. Be forewarned—this is an evolving picture, since credible research about the psychiatric effects of cannabis is only now emerging after decades of legal constraint. I argue that patients benefit when psychiatrists attend to their marijuana use—a hands-off approach is likely to miss an important influence on their symptoms—and that a collaborative approach can steer between the Scylla of harsh admonition and the Charybdis of naive acceptance.
The psychopharmacology of marijuana is complex. Delta-9 tetrahydrocannabinol (THC), the most psychoactive of its many cannabinoid constituents, acts on endogenous cannabinoid receptors, which, like those for monoamines and endogenous opioids, are found in brain areas subserving memory, cognition, emotions, and motivation. Cannabidiol (CBD), another cannabinoid found in marijuana, appears to counteract the psychedelic effects of THC; it is being investigated as a treatment for a number of medical and psychiatric conditions.7 Samples of illegal marijuana these days have very low CBD:THC ratios, which maximizes psychedelic effects, while medical marijuana is advertised with CBD:THC ratios as high as 20:1.8 Thus, it may be important to understand the source and purported characteristics of the marijuana a patient is using.
Extensive laboratory, clinical, and epidemiological evidence connects marijuana use to cognitive impairment, and both clinical and epidemiological data link it to psychosis. The correlations with addiction, anxiety, and depression, however, are based mainly on interviews of national population samples, which are likely to differ from patients who present for treatment. The evidence that marijuana benefits PTSD comes mostly from animal data. Table 1 summarizes this evidence, along with treatment recommendations.
Non-intoxicated regular cannabis users perform worse on global neuropsychological tests by a third of a standard deviation or less. Some evidence suggests this cognitive impairment may be short-term, with recovery occurring over days to months after cessation of use. Its extent and persistence are worse with early age of onset, high frequency, and long duration of use.2 Marijuana-induced cognitive dysfunction may account for its association with motor vehicle accidents at a level approaching that of alcohol, as well as with reduced life achievement.1 Discussing patients’ marijuana use in high-risk situations, including driving and sexual activity, may be lifesaving, and exploring its effects on academic and work performance may improve outcomes.
For decades, marijuana has been associated with the emergence of schizophrenia and other psychotic disorders. Recent data show that in genetically vulnerable individuals, psychotic disorders are more likely to emerge and to emerge earlier if marijuana is used.2 Ongoing marijuana use by patients with schizophrenia is associated with worse outcomes.5 Thus, patients with individual or family histories of psychosis can be counseled that marijuana use puts them at greater risk for the development or exacerbation of a psychotic illness.
The widely quoted statistic about marijuana’s addictive propensity—that a cannabis use disorder will develop in 9% of people who try marijuana—comes from a national epidemiological sample of 34,653 individuals interviewed in 2001 to 2002 and again in 2004 to 2005. The researchers found marijuana less addictive than nicotine (the corresponding figure is 68%), alcohol (23%), and cocaine (21%). For psychiatric patients, however, the picture is far bleaker. In the study, individuals with psychotic or conduct disorders who used marijuana had double the risk of addiction; triple the risk of mood, anxiety, and attention deficit disorders; quadruple the risk of personality disorders and alcohol dependence; and cocaine dependence increased the risk by a factor of 6.4 In clinical practice, patients with cannabis use disorder may have great difficulty limiting or abstaining from marijuana use, which exacerbates psychiatric problems, and treatment may need to target marijuana use as well as other issues.