Tag Archives: Bipolar

Emerging research on the mental health risks associated with cannabis consumption

Rates of cannabis usage have more than doubled in the past decade. Medical marijuana is now legal in half of the United States and is increasing in accessibility to current and future users. Cannabis is now the most widely used illicit substance in the US, more popular than alcohol and cigarettes. Frequent use of cannabis is now twice as common among young people in the 16-24 year old age range. In spite of government and media warnings about health risks, many people believe cannabis to be a harmless substance that helps people to relax and, unlike, alcohol and cigarettes, might even be good for you. Although it is controversial, I believe cannabis should be avoided by the mental health patient and anyone who wants to prevent possible brain dysfunction that can significantly impact basic functioning.

Here are some facts to consider before reaching for cannabis:

What is the chemical makeup of cannabis?  

There are about 400 chemical compounds in an average cannabis plant. The four main ones are delta-9 tetrahydrocannabinol (delta-9-THC), cannabidiol (CBD), delta-8-tetrahydrocannabinol and cannabinol. All but the CBD are psychoactive (known to affect brain function).

What about stronger varieties?

In herbal cannabis, the concentration of the main psychoactive ingredient, THC, varies hugely — from 1% to 15%. The newer strains can have up to 20%. The newer varieties on the whole are 2-3 times stronger than those available 30 years ago.  Some users may even use these stronger varieties as substitutes for Ecstasy or LSD.

Immediate pleasant effects:

A “high” — a sense of relaxation, happiness, sleepiness. Colors appear more intense, music sounds better.

Unpleasant effects:

Even though THC can produce relaxation in many people, that isn’t the case with all people, particularly those who have a family history of mental illness.  In some people, it can have the opposite effect and may cause unpleasant experiences including confusion, hallucinations, anxiety, and paranoia, depending on mood and circumstances. Some people may experience psychotic symptoms with hallucinations and delusions lasting a few hours. Even though these unpleasant effects typically don’t last long, the drug can stay in the system for weeks and have longer lasting effects than users realize. In some genetically predisposed people, it may trigger the onset of Schizophrenia or Bipolar Disorder. This is a bigger risk for people who started using cannabis in childhood or adolescence and into the mid twenties, critical brain development stages.

Long term risks:

Over time, cannabis can have a depressant effect and reduce motivation and the abilities to concentrate, organize information, and use information. A recent review of the literature on cannabis’s effect on pilots showed that those who used cannabis made far more mistakes, both major and minor. The worst were in the first four hours after use, though mistakes persisted for at least 24 hours when the pilot had no sense of “feeling high.”  Recent research published in the Journal of Alzheimer’s Disease found that cannabis users have noticeable deficiencies of blood flow in the brain. Notably, the research showed diminished blood flow in the right hippocampus, the area of the brain that helps with memory formation and learning. This is the area severely affected in those that have Alzheimer’s Disease. Other smaller studies of perfusion imaging in marijuana users show lower amounts of frontal, temporal, and occipital lobe blood flow.

Is cannabis addictive?

Yes, it can be. Current evidence now suggests that it can be, particularly if used regularly. Cannabis has the same features of other addictive drugs, such as the development of:

Tolerance: Tolerance means having to take more and more to get the same effect. Heavy users can experience withdrawal symptoms such as anxiety, cravings, decreased appetite, sleep difficulty, weight loss, aggression, irritability, restlessness, and strange dreams. For regular long-term users, 3 out of 4 experience cravings, half become irritable, and 7 out of 10 switch to tobacco in an attempt to stay off cannabis.  The irritability, anxiety, and insomnia usually appear 10 hours after the last joint and peak around one week after last usage.

Compulsive use: Eventually, many regular users become more compulsive in their usage. The user feels they have to have it and spends much of their life seeking, buying, and using cannabis. They cannot stop even when other important parts of their life such as family, friends, school, and work suffer.

How to know if you have a dependency and/or addiction:

Cannabis can become a significant problem for some people. Marijuana-anonymous.org says people have realized they have an addiction when “cannabis controls our lives and our thinking, and … our desires center around marijuana — scoring it, dealing it, and finding ways to stay high so that we lose interest in all else.”

Cannabis is similar to alcohol addiction.  Here are some questions to ask oneself to see if cannabis is a problem. Yes to any of these questions indicates a problem:

  1. Has smoking pot stopped being fun?
  2. Do you ever get high alone?
  3. Is it hard to imagine a life without marijuana?
  4. Do you choose or lose friends based on your marijuana usage?
  5. Do you smoke marijuana to avoid dealing with your problems?
  6. Do you smoke pot to cope with your feelings?
  7. Does your marijuana use let you live in a privately defined world?
  8. Have you ever failed to keep promises you made about cutting back or controlling your pot smoking?
  9. Has marijuana caused problems with memory, concentration, or motivation?
  10. When your stash is nearly empty, do you feel anxious or worried about how to get more?
  11. Do you plan your life around your marijuana use?
  12. Have friends or relatives ever complained that your pot smoking is damaging your relationship with them?

Other reasons not to use cannabis (even if you are not addicted):

Besides the reasons mentioned above, street cannabis may be laced with other more dangerous drugs that could be deadly.  Additionally, there are drug-drug interactions that may make  it unsafe to use with other types of medications. As cannabis over time tends to have a depressant effect and may even increase anxiety, it can counteract any medication your provider prescribes for you. Your provider may ask or even require that you drastically cut down or discontinue your pot use (along with other drugs and alcohol).  Additionally, as it affects motivation, it interferes with the ability to eat healthy, exercise, do psychotherapy, and practice other healthy habits that contribute to mental health.

In conclusion, although cannabis may show short-term alleviation of anxiety symptoms, I believe in the long run it has more risks than benefits and do not recommend mental health patients use cannabis or medical marijuana.

Satu Woodland is owner and clinician of Mental Health Solutions, an integrative mental health practice located at Bown Crossing in Boise, Idaho. She sees children, adolescents, and adults. Information in this blog is not intended as medical advice. Please consult your health care provider about decisions regarding your health.

Stimulants not always the answer for Attentive Deficit Hyperactivity Disorder

In my practice, I’m amazed about how many people come to me and have taken some test online and have self-diagnosed themselves with ADHD or ADD and want me to give them stimulants. It happens every week. I also don’t know how many times I’ve had to tell these same people that stimulants may not be the answer to their problems and can even make their mental health symptoms worse! Let me give you a case in point of when stimulants may have done more harm than good.

Larry, (not his real name) is a 53 year old male who reports that he has taken Adderall or the equivalent for 30 years. He reports it makes him organized. It makes him be able to focus and concentrate and complete tasks. I take careful note but also observe that this same guy is very rigid, angry and irritable during our visit. He has a history of attempted suicide and has been hospitalized several times. He also tries to hide the fact that he lived in a reclusive situation away from civilization for years and has been unable to work for authority figures. He also reports he is estranged from friends and family.

Yes, it is true that stimulants help many people with focus and concentration. It is also the fact that ADHD is not the only condition that makes a person disorganized, unfocused and unable to complete tasks. For instance the guy above ended up being diagnosed with Schizophrenia. Other conditions like Bipolar Disorder, Depression, anxiety disorders and Thyroid Disorders can look like ADHD. Giving the above patient stimulants can bring out his rigidness, his anger and irritability and even psychotic symptoms. If one has tendencies toward obsessive compulsive disorder it would be especially important to avoid taking stimulants. Stimulants can make the OCD worse. A better way to go might be to effectively treat the OCD symptoms and the patient may find that their ADHD like symptoms greatly improve.

Sadly, years of stimulant misuse for the above patient made him so rigid in his expectations that he was psychologically unable to consider other possibilities for his problems. This is why it is so important that when suffering from ADHD like symptoms that a specialist who works regularly with the various mental illnesses be called upon to do the initial evaluation. It can potentially prevent years of problems and help a person become quickly more functional to reach his goals. I wish this guy could have been spared all the pain he went through! Can you imagine the implications for posterity and other family members?

Little known differences between bipolar depression and unipolar depression

In my practice I often see patients self referred or sent in by their general practitioner who tell me that he or she has Major Depressive Disorder. Problem is, medications and therapy have had little success so my expert advice is needed.

When evaluating a patient it is crucial not to miss the diagnosis of bipolar depression. A recent article in a Chilean medical journal (Rev Med Chili 2010 Jun) identifies suggestions of how a proper diagnosis can be achieved. This information resonates with my practical experience seeing patients through the years.

First it is important to use standardized diagnostic criteria such as the DSM-IV or ICD 10 manuals. Second it is important to check whether certain clinical features are present. These features tend to be less known to the general practitioner and population. These criteria include whether there are previous episodes of mood elevation. Mood elevation can include times when mood is either positively elevated as in euphoria or high energy that is distinct from other times, or it can be negatively elevated. An example of the latter would be “road rage”. One is driving and the person in front of him lingers a little too long at the stop sign and the drivers gets unusually angry and wants to punch the guy out. We all have heard of that happening.

Another lesser known criteria is current or past episodes of psychotic depression which are episodes of depression that are so severe and debilitating that a person has great difficulty getting out of bed in the morning and functioning.

Recurrent depressive disorder before the age of 25 and a strong family history of mood disorder and suicide are other red flags for Bipolar Disorder.

Finally there are the signs related to past antidepressant usage that can be valuable information in proper diagnosis. If a patient has had a lack of response or “wearing off” to well conducted antidepressant treatment, or an unusually fast response to antidepressants with features of elation these are all red flags of Bipolar Disorder.

Finally, it is important that the proper professionals are utilized in making the diagnosis. While it can be a starting place, it can not be adequately done by self-diagnoses through the internet!

Insomnia: Who should I see for help?

When I see patients in my office I would say that 75% have as a major complaint of insomnia or having difficulty going to sleep and/or staying asleep. Many times the problem has been going on for years. How does one know who to see about their insomnia? The general practitioner? The Sleep Specialist? The Mental Health Specialist?

Questions to ask yourself: How long have you had this problem? If it’s only been a few days or weeks then I would say it would be ok to see your general practitioner or mental health practitioner. Both have the knowledge to help you get to sleep. If you say all your life or since I put on a lot of weight, that is work for the specialist. There could be a mental health disorder or a physical structural disorder that is causing a disorder called “Sleep Apnea.” This is a condition where a person stops breathing in the middle of the night sometimes thousands of times resulting in a restless or inadequate sleep. A major symptom of this is if a person snores loudly and a sleep partner observes the person actually stopping breathing for seconds at a time. Another major symptom is extreme fatigue during the day.

In the mental health category, if a person has been experiencing anxiety or depression and he/she is having trouble sleeping then a mental health evaluation may be appropriate.

Major Depression, General Anxiety Disorder, PTSD and Bipolar Disorder are all conditions that interfere with sleep. These are treated in different ways. In my practice I teach my patients “Sleep Hygiene.” This is a program to help the body cue itself that it is time for sleep. We often lose that cue with bad habits and lack of routine over time.

What kind of medications are the best for insomnia? I always start with the mildest remedies that are not addictive. Melatonin and antihistamines top my list. Second tier would include medications in the antidepressant class such as Trazadone. One does not
have to be depressed to use Trazadone. It is very effective. Third tier would be other antidepressants and mood stabilizers according to what are the diagnoses. I totally avoid the Benzodiazepine class. Benzodiazepines are only meant for the occasional sleep problem. If one has issues with addictions of any kind, or has it in their family, then I would recommend avoiding this class altogether.  The problem is Benzos can cause addictions but also can cause Depression when used long-term.