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Binge drinking is defined as consumption of 5 or more standard drinks on 1 occasion for males, or 4 or more for females, bringing blood alcohol concentration to 0.08 grams of alcohol per deciliter or higher.

 These drinking patterns lead to serious health and safety risks, including 

 from unintentional injuries such as motor vehicle crashes,

 suicide attempts as well as other mental health issues, legal charges, and, over the long term, damage to the liver and other organs.

Perhaps not surprisingly, national surveys have found that half of full-time 

 aged 18 to 22 years consumed alcohol in the previous month, and one-third engaged in binge drinking.

 In addition to the previously noted negative impacts, academic performance is also compromised, with 1 in 4 students endorsing academic difficulties (ie, missing class or falling behind on assignments) due to alcohol consumption.

 to perform poorly on tests and projects compared with those who drink but do not binge (40% vs 7%) and are 5 times more likely to miss a class.

 Although not all individuals who drink develop an addiction, consumption and especially binge drinking patterns are often preludes to an addiction, with approximately 9% of college students meeting criteria for alcohol use disorder.

 Lack of screening may also underestimate the magnitude of the problem.

The first few weeks of freshman year are often a period of heavy drinking and alcohol-related consequences. Social pressures and expectations during new-found independence, widespread availability and access to alcohol, unstructured schedules with mounting academic pressure, and lack of parental interactions all play a role. Alongside these stressors, many students have preexisting personality traits that may account for the use and misuse of alcohol during college.

Neuroticism, 1 of the 5 higher order personality traits, is defined by high emotional instability, depressed mood, low frustration tolerance, and anxiety. It also has been found to positively predict alcohol consumption (social intake within recommended parameters)

 and alcohol use (intake beyond recommended parameters that can lead to addiction).

 Only 1 previous study of 200 college students evaluated the implications of personality types; that study found high neuroticism and low conscientiousness predicted more 

aimed to better understand the role of personality and neuroticism in college alcohol use/misuse among freshman, above and beyond the reported levels of stress. The starting hypothesis revolved around the notion that negative affect faces of neuroticism, and primarily 

, are more strongly associated with alcohol use and misuse than stress when accounting for other personality domains.

 conducted a cross-sectional outpatient study, which was approved by the Institutional Review Board. Survey data was collected from participants during the first 8 weeks of their first college semester. Participants included 211 female and 90 male matriculating college freshmen with an average age of 18.58 years (SD = 0.39) from 2 campuses of a private university in the southeastern United States, spanning both urban and rural areas. Students were recruited via fliers posted on campus and during frequent in-person undergraduate events.

Data was acquired via online surveys of behavioral, health questionnaires, and cognitive assessments. Most surveys were completed within 3 weeks of the study initiation, and participants received a $15 gift card for completion. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Alcohol Use Disorders Identification Test (AUDIT) were used to assess alcohol use and misuse (

Endorsement of use 1 or more times on the ASSIST prompted the administration of the AUDIT, a 10-item questionnaire with a maximum score of 40 for which the higher scores indicate more severe and hazardous, harmful, excessive alcohol use/misuse. Stress was assessed using the Perceived Stress Scale (PSS), a 14-item self-reported measure of stress with each stress symptom scored on a 4-point Likert scale, where 0 = never and 4 = very often (maximum score of 56). Personality was assessed using the 44-item version of the Big Five Inventory (BFI), which measures 5 dimensions of personality (openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism).

Ten facet traits were also calculated to assess more specific personality characterization within the 5 domains: openness, aesthetics, and ideas; conscientiousness, order, and self-discipline; extraversion, assertiveness, and activity; agreeableness, altruism, and compliance; and neuroticism, anxiety, and depression.

Analyses controlled for campus site (rural vs urban), sex, and individual week of study enrollment (school obligations as potential stressors fluctuated between study weeks). The investigators examined partial correlations between predictions while controlling for covariates. They used multiple regression analysis to examine the conditional and joint effect of personality and stress on alcohol use and misuse.

Of the sample, 54% (or 164 individuals) endorsed use of 

 at least once in their lifetime. Descriptive statistics of all covariates were accounted for, and across covariates sex and week of study enrollment were only modestly associated with AUDIT scores (male gender and more weeks since college commencement somewhat associated with higher AUDIT scores); site of the campus was not. Despite this, a t-test concluded that there were no gender differences between alcohol use and misuse (t(161) = -1.89, P = .06). Among partial correlations, the participants’ AUDIT scores were positively correlated with PSS scores (r = .17, P = .003) and neuroticism (r =.31, P < .001), and negatively correlated with agreeableness (r = −.12, P = .031). Stress was significantly correlated with all the personality domain scores except for openness to experience.

Regression analyses provided less biased estimates of personality and stress on AUDIT. To elucidate the relationship between neuroticism, stress, and 

 and misuse (given the discrepancy between the partial correlation results and the multiple regression model), the neuroticism facets were explored as outcome measures. Analyses that used the neuroticism facets (depression or anxiety) in place of the neuroticism domain found that neuroticism-depression was positively associated with higher AUDIT scores when accounting for PSS and domain-level 5 personality traits (β = .23, P = .028; adjusted R

Exclusion of all personality traits except for neuroticism-depression did not explain more variance in AUDIT (adjusted R

= .10, F (5, 152) = 4.56, P < .001). Interaction effects found that neuroticism as a domain moderated the relationship between PSS and AUDIT (β = .16, P = .040; adjusted R

 = .12, F (10, 146) = 3.16, P = 0.001). This interaction was found to be unique. Neuroticism-depression score moderated the relationship between PSS and AUDIT-T (β = .18, P = .020; adjusted R

 = .14, F(11, 145) = 3.22, P < .001. At low levels of the depression facet, stress was negatively associated with alcohol use and misuse, but at high levels of the depression facet, stress was positively associated with alcohol use and misuse (

This study supports the notion that neuroticism, and specifically the neuroticism-depression facet, appear to be the most robust predictors of alcohol use and misuse among incoming freshmen and could serve as useful population risk indicators. At low levels of the depression facet, stress was negatively associated with 

 and misuse; at high levels of the depression facet, however, stress was positively associated with alcohol use and misuse.

Investigators branched off previous studies exploring the roles of personality or stress on college drinking. They analyzed survey results data from Wave I of the MAPme Project, a longitudinal study of biobehavioral health and substance use during college. Those findings showed that personality characteristics and 

 play a significant role in the severity of problematic alcohol use and misuse, but certain traits are more significantly associated with alcohol involvement than others. The neuroticism-depression facet was a better predictor of alcohol use and misuse than the neuroticism domain, and this facet accounted for unique variance even when controlling for stress and other personality facets and domains. Stress did not account for unique variance in harmful and hazardous alcohol use and misuse beyond personality traits.

Unfortunately, this study had a number of limitations. Due to issues with the sample population, the findings may not generalize to other student populations. This study was conducted using a primarily Caucasian group from a private university located in the southeast US, without ensuring varied socioeconomic statuses. Similarly, although the sample encompassed both urban and rural participants, they were located in the same part of the country. The study also included a greater proportion of women compared to men, which may have skewed the baseline starting characteristics and outcomes.

Other issues can impact the findings. For instance, there were fairly low numbers of reported alcohol use among the sample to confidently generalize findings. Compensation offered to participants may add external biases and contribute to participant selection and participation.

The authors used a single-domain, self-reported assessment of stress, associated with increased likelihood of response bias and social desirability bias. More comprehensive and objective measures of stress levels might include physiological assessment, such as skin conductivity, heart rate, or cortisol measures that have shown be strongly associated with perceived stress.

The study employed the AUDIT-Total score, which confounds alcohol consumption and problematic alcohol use behaviors. The study participants reported low alcohol use and misuse behaviors, but the tool was not well prepared to detect unique effects of each of these constructs. Thus, future research could expand on this study by examining alcohol consumption and problems separately.

This study is limited by its cross-sectional design. To best examine the relationship between stress and personality on alcohol use and misuse, future studies could take a longitudinal state-trait perspective, treating personality and neuroticism specifically as stable traits and stress as a state.

Fortunately, data from this sample will continue to be collected until the students graduate, allowing longitudinal examinations into alcohol use and misuse trajectories, and the associations between stress, personality traits, and hazardous and harmful alcohol use.

So what does this mean for clinical practice? When presented with highly stressful circumstances, high neuroticism-depression in individuals predicts propensity to use and misuse alcohol. Similarly, people with high neuroticism-depression are likely to drink more when stressed, but low neuroticism-depression seems to be protective, with these individuals using and misusing alcohol at lower rates. Finally, the BFI domains and faces seem to have a role in alcohol use/misuse, above stress levels. These could be used as screeners for population risk indicators among incoming freshmen.

is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for

The author reports no conflicts of interest concerning the subject of this article.

An earlier version of this article appeared online on February 10, 2021, under the title Neuroticism-Depression: What Is It and Does It Play a Role in College Drinking? and has since been updated for print. -Ed

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3. Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24: changes from 1998 to 2001. 

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5. Wechsler H, Lee JE, Kuo M, et al. Trends in college binge drinking during a period of increased prevention efforts. Findings from 4 Harvard School of Public Health college alcohol study surveys: 1993-2001. 

The introduction of the heavy and frequent drinker: a proposed classification to increase accuracy of alcohol assessments in postsecondary educational settings

7. US Department of Health and Human Services. Center for Behavioral Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2019 National Survey on Drug Use and Health. Table 6.23B—Alcohol Use Disorder in Past Year among Persons Aged 18 to 22, by College Enrollment Status and Demographic Characteristics: Percentages, 2018 and 2019. Accessed February 5, 2021. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect6pe2019.htm#tab6-23b

8. Stanciu CN, Penders TM, Wuensch KL, et al. Underutilization of screening tools for alcohol use disorders – part I: results from survey of practices among North Carolina mental health providers and brief review of available instruments. J Alcohol Drug Depend. 2017;5(5):100282. Accessed February 5, 2021. 

https://www.longdom.org/open-access/underutilization-of-screening-tools-for-alcohol-use-disorderspart-iresults-from-survey-of-practices-among-north-carolina-mental-he-2329-6488-1000282.pdf

9. Allen MS, Vella SA, Laborde S. Health-related behaviour and personality trait development in adulthood. J Res Pers. 2015;59:104–110.

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13. Ruiz MA, Pincus AL, Dickinson KA. NEO PI-R predictors of alcohol use and alcohol-related problems. J Pers Assess. 2003;81(3):226-236.

14. Martin KP, Benca-Bachman CE, Palmer RHC. Risk for alcohol use/misuse among entering college students: The role of personality and stress. Addict Behav Rep. 2020;13:100330. ❒

Although not all college students who drink develop an addiction, consumption and especially binge drinking patterns are often preludes to an addiction, with approximately 1 in 10 students meeting criteria for alcohol use disorder.

Exploring the Link Between Neuroticism-Depression and College Drinking

In 2018 more than 20 million Americans met criteria for substance use disorder, particularly alcohol abuse (73%). During the COVID-19 pandemic, alcohol sales have risen sharply, up 54% from the previous year.

In this Mental Health Minute, Judith J. Prochaska, PhD, MPH points out that the pandemic has made it difficult for patients to seek traditional forms of counseling. She discusses a digital therapeutic that can be an adjunct for traditional therapies, and 

 on the treatment’s efficacy for substance abuse and mood disorders.

 is a professor in the department of medicine at Stanford University with the Stanford Prevention Research Center and a member of the Stanford Cancer Institute.

Would you recommend a digital therapeutic to your patients? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

A recent study tested a new digital therapeutic for effectiveness on both substance abuse and depression. 

Could Artificial Intelligence Improve Cognitive Behavioral Therapy?

The Biden Administration revealed its first-year plan to address the nation’s addiction crisis, with 7 priorities highlighted and a focus on the inequality of treatment access. 

“The overdose and addiction crisis has taken a heartbreaking toll on far too many Americans and their families. Since 2015, overdose death numbers have risen 35 percent, reaching a historic high of 70,630 deaths in 2019. This is a greater rate of increase than for any other type of injury death in the United States. Though illicitly manufactured fentanyl and synthetic opioids other than methadone (SOOTM) have been the primary driver behind the increase, overdose deaths involving cocaine and other psychostimulants, like methamphetamine, have also risen in recent years, particularly in combination with SOOTM,” the Biden Administration statement read.

 “New data suggest that COVID-19 has exacerbated the epidemic, and increases in overdose mortality have underscored systemic inequities in our nation’s approach to criminal justice and prevention, treatment, and recovery.”

1) Expanding access to evidence-based treatment 

2) Advancing racial equity in our approach to drug policy 

3) Enhancing evidence-based harm reduction efforts 

4) Supporting evidence-based prevention efforts to reduce youth substance use 

5) Reducing the supply of illicit substances 

6) Advancing recovery-ready workplaces and expanding the addiction workforce; and 

7) Expand access to recovery support services.

Susan R. Bailey, MD, American Medical Association President, had this to say: “The agenda outlined today by the Biden Administration tackles overdoses and substance use disorder head-on in ways that will reduce stigma and remove barriers to treatment. The AMA strongly supports the approaches outlined, including: increasing access to evidence-based treatment for patients with substance use disorders—with particular emphasis on removing unnecessary barriers to prescribing buprenorphine—enforcing mental health and substance use parity, advancing racial equity, and enhancing harm-reduction efforts.”

The Substance Abuse and Mental Health Services Administration (SAMHSA) will direct $1.65 billion in Substance Abuse Prevention and Treatment Block Grant funding and $825 million in Community Mental Health Services Block Grant funding to states and territories.

“Focusing on both mental and substance use disorders—challenges that pre-date the COVID-19 pandemic but that have worsened over the past year—will be a crucial part of SAMHSA’s approach to helping the nation move forward,” said Acting Assistant Secretary for Mental Health and Substance Use Tom Coderre.

The Substance Abuse Prevention and Treatment Block Grant program will allow states to focus and evaluate measures to prevent and treat substance use disorder. Specifically, funding will allow recipients to maximize the efficiency of current treatments and address local needs to ensure substance use disorder prevention.

The Community Mental Health Services Block Grant program will allow states to provide comprehensive community mental health services and address gaps in treatment services for those with severe mental illnesses.

1. Executive Office of the President, Office of National Drug Control Policy. The Biden-Harris Administration’s statement of drug policy priorities for year one. Accessed April 1, 2021. 

https://www.whitehouse.gov/wp-content/uploads/2021/03/BidenHarris-Statement-of-Drug-Policy-Priorities-April-1.pdf

2. American Medical Association. AMA applauds Biden Administration’s first-year drug policy priorities. News release. April 1, 2021. 

https://www.ama-assn.org/press-center/ama-statements/ama-applauds-biden-administration-s-first-year-drug-policy-priorities

3. The Substance Abuse and Mental Health Services Administration. With pandemic worsening the mental illness and addiction crisis, Biden Administration to provide nearly $2.5 billion to states, territories for treatment, prevention aid. News release. March 11, 2021. 

https://www.samhsa.gov/newsroom/press-announcements/202103110230

Government funding for the drug addiction crisis is on the way. 

Biden Administration Plan Tackles Drug Addiction Crisis

Enlightening survey results reveal what psychiatrists think about medical marijuana/cannabis use, how or whether to discuss with their patients, and what biases might get in the way of such conversations.

You Spoke, We Listened. Psychiatry's Cannabis Survey

Lost in the various public policy arguments fueling cannabis decriminalization and legalization 

 across the United States is the fact that a percentage of individuals who use cannabis will experience negative effects, ranging from bothersome to the catastrophic. These difficulties arise from a sharply decreasing perception of risk, easy availability of the drug, and increased potency of Δ-9-tetrahydrocannabinol (THC) preparations. The arithmetic of cannabis remains immutable: Best 

 are that about 9% of individuals who use cannabis will become dependent on the substance at some point in their life,

 and if the number of those who use cannabis goes up, the total number of those experiencing problems with the substance will rise also. Clinicians must learn to manage cannabis-related problems in this growing population.

 cannabis-dependent individuals face are serious, disheartening, and deserving of treatment. National Survey on Drug Use and Health (NSDUH) data on 505,796 Americans

 show that between 2008 and 2016 individuals aged 12 to 17, who met criteria for a cannabis use disorder (CUD), were 25% more common in states that had enacted Recreational marijuana laws (RMLs) as opposed to those who did not. In addition, the THC content of the various preparations of cannabis has risen over the past 10 years. Studies show that the mean THC concentration in smokable marijuana increased from 8.9% in 2008 to 17.1% in 2017,

 and half of those who frequently use marijuana ingest concentrates of at least 80% THC.

 in Colorado had an average THC percentage of 56.6%, while by 2017 the average was 68.6%, with some retail stores cheerfully advertising a 95% THC rate in their products.

Cannabis-related problems, like lack of motivation, usually become apparent after many years of use. Given cannabis’ pharmacological designation as a sedative-hypnotic substance, it is hardly surprising that common complaints on presentation to treatment include acute intoxication with high-potency 

; psychiatric phenomena such as depression, anxiety, and 

; and cannabinoid hyperemesis syndrome (CHS).

Clinicians should at least consider their patients’ cannabis use as a precipitating or exacerbating factor in any psychiatric or medical syndrome. Also, although the DSM-5

 contains a useful list of cannabis-related signs and symptoms, many individuals with cannabis-related problems do not meet the full criteria for CUD. For instance, while the casual cannabis smoker may present with a depressive picture but meet no other criteria for CUD, cessation of cannabis use may be necessary to achieve resolution of the patient’s dysphoria, anhedonia, and fatigue. CHS, cyclic episodes of nausea and vomiting often relieved with hot baths, can be a confusing emergency department presentation. Other medical presentations of heavy cannabis smoking include cough, bronchitis, lung hyperinflation,

 as well as acute lung injury from vaping.

 concerns related to cannabis may also generate first visits with a clinician.

, the DSM-5 criteria list the myriad problems that can arise from cannabis use. To fulfill criteria for CUD, the patient must demonstrate at least a yearlong “problematic pattern of cannabis use” and meet at least 2 of the criteria. However, the clinician would do well to consider any cannabis-related problem as a possible contributor to the patient’s reason for presentation.

The patient should be offered a coherent psychotherapy aimed at first minimizing the harms of cannabis use, and then achieving abstinence from the substance. Treatment of any co-occurring psychiatric conditions should be initiated concurrently with the below strategies, focused on cannabis cessation. Manualized techniques like cognitive behavioral therapy,

 have shown measurable, if modest, improvements in outcome criteria such as frequency of cannabis use, number of dependence symptoms, quantity of cannabis use, and negative consequences of cannabis use. These effective treatments share a good understanding of the addictive process, practical and easily deployed interventions, and a focus on small gains. Most clinicians use a mix of therapeutic techniques, which often include cannabis-specific

Peer-led support groups like Alcoholics Anonymous, although commonly recommended as an adjunct to the treatment of substance use disorders, should be carefully selected if recommended for the individual who uses cannabis. Members of peer support groups can be wrongly dismissive of those who only use cannabis. If possible, clinicians should recommend groups like 

 or specific groups which are known to understand the seriousness of CUD. Similarly, inpatient treatment or intensive outpatient programs should be carefully selected for their focus on or at least understanding of CUD.

A common—and counterproductive—fallacy about cannabis is that the substance does not cause withdrawal. In fact, the withdrawal syndrome from cannabis, though unlikely to cause serious medical problems, is uncomfortable and a leading reason that individuals who use cannabis do not stop their use of the substance. Withdrawal therefore requires treatment. Common phenomena associated with cannabis withdrawal include irritability, anxiety, depression, insomnia, disturbing dreams, anorexia, abdominal pain, tremors, sweating, fever, chills, headache,

A powerful first step in engaging the patient in treatment to beat their dependence on the drug is the clinician’s acknowledgement of the withdrawal syndrome and offer to find symptomatic relief. Patients should remain well-hydrated, eat a healthy diet, and exercise regularly during the withdrawal period. Although no medications have been approved by the US Food and Drug Administration (FDA) to treat cannabis withdrawal, symptom-relief medications like gabapentin

 to relieve anxiety and insomnia is indicated in some cases.

Treatment of cooccurring psychiatric illnesses with the appropriate medications is vital to the treatment of CUD. Although no medications have FDA-approved indications for the specific treatment of CUD, 2 have shown suggestive data in studies, and can be prescribed for patients needing additional pharmacological support. In small studies, the anticonvulsant topiramate

 demonstrated improved retention in treatment over placebo and gabapentin

 showed better treatment retention and a decrease in cannabis use and depressive symptoms. Various trials of dronabinol and nabilone, both THC analogues; nabiximols, a combination of THC and CBD; and N-acetylcysteine, a glutamatergic modulating dietary supplement, have shown little efficacy in the treatment of CUD.

Individuals who use cannabis may question any need for addressing their use by noting the ongoing success of cannabis legalization in the US, cannabis’ lack of lethality (as compared to opioids), and the natural provenance of the smokable varieties of cannabis. Clinicians should focus instead on the clinical issues that have brought the individual to treatment. Has the drug contributed to problems at work or school? Is there a psychiatric condition that would be better treated by psychotherapy or an actual medication? Have medical problems like hyperemesis developed? Although some individuals who use cannabis arrive in the clinic simply because a family member disapproves of cannabis use, the vast majority come in became they are being harmed in some way by their 

Despite the changing cultural ethos regarding cannabis, many individuals will suffer from problems related to their use of the substance. Some will meet criteria for CUD, and some will find their educational achievement, work lives, health, and relationships profoundly damaged by the drug. Along with the clinician’s attitude of encouragement and hope about recovery, effective relapse prevention therapies should be deployed. When necessary, medications for co-occurring psychiatric conditions should be used, as should the few available pharmacologic remedies for cannabis withdrawal. Clinicians engaging with patients should model a non-judgemental attitude about the substance, be realistic about the effects of cannabis, and encourage the path for reducing or stopping its use.

is an associate professor of clinical psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine in New York, New York. He also serves as the consultant on behavioral health to the commissioner of Major League Baseball.

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Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

2. Cerdá M, Mauro C, Hamilton A, et al. 

Association between recreational marijuana legalization in the United States and changes in marijuana use and cannabis use disorder from 2008 to 2016

3. Chandra S, Radwan MM, Majumdar CG, et al. New trends in cannabis potency in USA and Europe during the last decade (2008-2017). 

4. Bidwell LC, YorkWilliams SL, Mueller RL, et al. Exploring cannabis concentrates on the legal market: User profiles, product strength, and health-related outcomes. 

5. Colorado Department of Public Health and Environment. Colorado monitoring health concerns related to marijuana. Accessed January 22, 2021. 

The disproportionate rate of acute clinical illness associated with cannabis edible use

7. Hindley G, Beck K, Borgan F, et al. Psychiatric symptoms abused by cannabis constituents: a systematic review and meta-analysis. 

8. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. 

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

10. Yayan J, Rasche K. Damaging effects of cannabis use on the lungs. 

11. Abeles M, Popofsky S, Wen A, et al. Vaping-associated lung injury caused by inhalation of cannabis oil. 

12. Mead A. Legal and regulatory issues governing cannabis and cannabis-derived products in the United States. 

13. Hazle MC, Hill KP, Westreich LM. Workplace cannabis policies: a moving target. 

14. Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. 

15. Stein MD, Hagerty CE, Herman DS, et al. A brief marijuana intervention for non-treatment-seeking young adult women. 

16. Budney AJ, Higgins ST, Radanovich KJ, Navy PL. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. 

17. Marijuana Anonymous World Services. Service Manual. Updated 2012. Accessed January 22, 2020. 

https://madistrict4.org/docs/MAServiceManualrev4_1.pdf

18. Budney AJ, Stanger C. Cannabis use and misuse. In: Rey JM, ed. IACAPAP e-Textbook of Child and Adolescent Mental Health. International Association for Child and Adolescent Psychiatry and Allied Professions; 2012.

19. Lee D, Schroeder JR, Karschner EL, et al. Cannabis withdrawal in chronic, frequent cannabis smokers during sustained abstinence within a closed residential environment. 

20. Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis dependent adults. 

21. Levin FR, Mariani JJ, Brooks DJ, et al. Dronabinol for the treatment of cannabis dependence: A randomized, double-blind, placebo-controlled trial. 

22. Miranda R Jr , Treloar H , Blanchard A , et al. Topiramate and motivational enhancement therapy for cannabis use among youth: a randomized placebo-controlled pilot study. 

23. Kondo KK, Morasco BJ, Nugent SM, et al. Pharmacotherapy for the treatment of cannabis use disorder: a systematic review. 

24. SAMHSA. Brief counseling for marijuana dependence: a manual for treating adults. 2015. 

http://store.samhsa.gov/product/Brief-Counseling-for-Marijuana-Dependence-A-Manual-for-Treating-Adults/sma15-4211

25. Budney AJ, Roffman R, Stephens RS, Walker D. Marijuana dependence and its treatment. 

The sharply decreasing perception of risk and easy accessibility of cannabis has many patients turning towards it, despite the potential negative effects. 

Cannabis 2021: What Clinicians Need to Know

Two companies received warning letters from the US Food and Drug Administration (FDA) for selling products labeled as cannabidiol (CBD) in ways that violate the Federal Food, Drug, and Cosmetic Act (FD&C Act). Unapproved drugs labeled as containing CBD are using illegal marketing, as the FDA has not approved any over-the-counter drugs with CBD.

“The FDA continues to alert the public to potential safety and efficacy concerns with unapproved CBD products sold online and in stores across the country,” FDA Principal Deputy Commissioner Amy Abernethy, MD, PhD, said to the press. “It’s important that consumers understand that the FDA has only approved 1 drug containing CBD as an ingredient. These other, unapproved, CBD products may have dangerous health impacts and side effects. We remain focused on exploring potential pathways for CBD products to be lawfully marketed while also educating the public about these outstanding questions of CBD’s safety. Meanwhile, we will continue to monitor and take action, as needed, against companies that unlawfully market their products — prioritizing those that pose a risk to public health.”

None of the CBD products in question from Honest Globe Inc and Biolyte Laboratories LLC meet the requirements to be legally marketed without an approved new drug application, nor have they gone through the FDA drug approval process. No FDA evaluation has been conducted to determine whether these products are effective for the claimed uses, what appropriate dosages would be, how they interact with other drugs, or what side effects they may have.

Additionally, the letters cited the 2 companies for substandard manufacturing practices, specifically failure to comply with current good manufacturing practices. The FDA requested written responses from the companies, to be provided within 15 workdays. These responses must detail how the companies intend to address the violations, or provide reasoning and supporting evidence as to why these products are not illegal. Should the companies fail to timely and appropriately address the violations, they may face legal action, such as product seizure and injunction.

This is not the first time the FDA has issued warnings to companies whose products violated the FD&C Act.

Selling CBD products that claim to prevent, diagnose, mitigate, treat or cure various diseases is illegal, and the FDA warns consumers to be wary of such products.

For more information on CBD and its impact on patients with mental illness, please see the 

1. US Food and Drug Administration. FDA warns companies illegally selling over-the-counter CBD products for pain relief. News release. March 22, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-warns-companies-illegally-selling-over-counter-cbd-products-pain-relief?utm_medium=email&utm_source=govdelivery

2. US Food and Drug Administration. Warning letters and test results for cannabidiol-related products. Updated March 22, 2021. 

https://www.fda.gov/news-events/public-health-focus/warning-letters-and-test-results-cannabidiol-related-products

As patients flock to CBD as a “natural alternative” to medications, the FDA continues to crack down on false claims.

FDA Says: No Approval, No Label, No Service

What is addiction, and how can psychiatrists best respond to the opioid (and other drug) epidemic? What have we done wrong about it in the medication and other effective treatments for addiction? What does addiction do to the brain?

Lloyd I Sederer, MD, a psychiatrist, public health expert, and writer provides key insights on what we can do to save more lives from overdose deaths.

Dr Sederer is adjunct professor at the Columbia University School of Public Health; director of Columbia Psychiatry Media; Chief Medical Officer of 

. He has been chief medical officer of McLean Hospital; affiliated with Harvard; Mental Health Commissioner of New York City; and Chief Medical Officer of the New York State Office of Mental Health, the nation’s largest state mental health agency. The mission of 

 is to find the causes of and cures for mental illness.

Ink Stained for Life: Coming of Age in the 1950s. A Bronx Tale

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.



Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.

How can we save more lives and prevent overdose deaths? Lloyd I Sederer, MD, a psychiatrist, expert in public health, and author provides insights.

Lloyd Sederer, MD: A Conversation About Addiction and the Opioid Epidemic

“Mr Green” is a 39 year-old African-American male with a history of chronic schizophrenia, cannabis use disorder, and alcohol use disorder. He started smoking cannabis almost daily at age 20. When he was 22, he was in a motor vehicle accident while under the influence of substances and suffered a head injury. Several months later, he was hospitalized for a first episode of psychosis (FEP). Thereafter, he participated in a long-term antipsychotic clinical trial.

For more than a decade, he has been maintained on a long-acting injectable antipsychotic and is adherent with appointments. He tends to get paranoid during stressful times, but he has not had any subsequent psychiatric hospitalizations. However, he has continued to use cannabis regularly—daily to weekly—for almost 20 years. Although he worked prior to the onset of his psychotic disorder, he has since been chronically unemployed. He lives at home with his parents, has never married, and does not have any children. He remains precontemplative regarding the need for treatment for alcohol and cannabis use disorder.

Mr Green’s case is (sadly) all too familiar for clinical practitioners in psychiatry. Substance use comorbidity in psychotic disorders has been described as the rule rather than the exception, and it is often deleterious to the clinical course of 

 Cannabis (marijuana) is one of the most commonly used substances by patients with schizophrenia and related psychoses. Modulation of the endocannabinoid system by the main psychoactive component in marijuana, Δ9-tetrahydrocannabinol, can induce acute psychosis and 

 Over the past 2 decades, there has been extensive research on the association between cannabis and psychosis.

To better understand the relationship, it is important to synthesize recent research—through the lens of systematic quantitative reviews—including associations between cannabis and psychosis risk; the epidemiology and phenomenology of psychosis and comorbid cannabis use; associations between cannabis use and clinical course; and outcomes in psychosis. Dichotomous outcomes are reported as odds ratios (OR) with 95% confidence intervals (95% CI). Continuous measures are reported as effect sizes (ES), where an ES of 0.2 is small, 0.5 is medium, and 0.8 is large.

 investigated cannabis use and psychotic experiences in a meta-analysis of 61 cohorts. They found a significantly increased prevalence (OR=2.41, 95% CI 1.84-3.43) and incidence (OR=1.77, 95% CI 1.20-2.61) of psychotic experiences in participants who used cannabis. This association is important given that 7.4% of people with psychotic experiences at baseline developed a psychotic disorder.

 meta-analyzed 29 studies of cannabis use and schizotypy (attenuated psychosis). Lifetime cannabis users had significantly greater scores for total (ES=0.42), positive (ES=0.44), negative (ES=0.18), and disorganized (ES=0.33) schizotypy versus never users. Furthermore, current cannabis users had significantly greater scores for total (ES=0.21), positive (ES=0.23), and disorganized (ES=0.27), but not negative schizotypy scores versus subjects that do not currently use cannabis.

 investigated the prevalence of cannabis use and its association with symptoms in participants at ultra-high risk (UHR) for psychosis. Across 30 studies (n=4205 UHR), there was a 27% current and 53% lifetime prevalence of cannabis use, and a 13% prevalence of cannabis use disorders (CUD). This corresponded to a 2.09-fold and 5.45-fold increased odds of lifetime use and CUD, respectively, in patients at UHR compared to n=667 controls. Furthermore, UHR cannabis users had a higher prevalence of both suspiciousness (ES=0.21) and unusual thought content (ES=0.27).

Furthermore, a recent comprehensive review by 

 which included 36 studies, found a 26% current and 49% lifetime prevalence of cannabis use, and a 15% prevalence of CUD in those at clinical high-risk for psychosis.

 reviewed the association between cannabis use and transition to psychosis in people at UHR across 7 studies. They found that lifetime cannabis use was not significantly associated with transition to psychosis in people at UHR (n=1171, OR=1.14, 95% CI 0.86-1.52). However, they found that current CUD was associated with significant, increased odds of transition to psychosis (OR=1.75, 95% CI 1.14-2.71).

A synthesis of quantitative reviews on the relationship between cannabis use and psychosis.

Addiction & Substance Use