Psychiatry & Psychotherapy Podcast - Cannabis and Depression, Anxiety, PTSD, Sleep, and Cognitive Function Update and Review

Episode Date: August 29, 2025

In this episode, we explore the latest 2025 research on cannabis and mental health. Our discussion covers how cannabis use impacts depression, anxiety, PTSD, sleep, cognitive function, and cannabis use disorder (CUD). While many patients report short-term relief from symptoms, studies reveal complex risks, including increased odds of mood disorders, suicidality, impaired cognition, and withdrawal challenges. We also examine the evidence behind medical marijuana for PTSD and anxiety, the role of CBD and terpenes, and the long-term effects of cannabis on brain development, academic performance, and overall health. Whether you are a clinician, researcher, or someone curious about cannabis and psychiatry, this update will help you better understand the science, myths, and clinical realities of cannabis use. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with three guests. We have Liam Browning, returning. Danielle Liu and Daniel Guevas. We are going to be talking about cannabis, depression, anxiety, cognitive function. I'm going to be letting Liam ask some questions and jump in a little bit more than usual today. We have an amazing handout on this. If anything that we say is remotely interesting to you. Currently it's at 51 pages. We are going to try to not get into the weeds too much, but present up to date what we know about this. So let's begin. Liam, what's the first question? Yeah, the first question, I just wanted to first start off by saying, like, just as we talked about in last episode, cannabis is being used at unprecedented rate. So we really wanted to

dive into this discussion from the perspective of trying to understand and where patients are coming from with this as well, you know, going in between, you know, a lot of the different perspectives out there because there's the perspective that's overly negative and then there's an overly positive perspective. And before we start, I just wanted to share, like, what a lot of patients are seeing from dispensaries. I thought it would be interesting to pull up a product from the first dispensary that I found. I just Googled dispensary near me and then clicked on the first thing. And they're marketing the effects as energetic, happy, creative, focused, and inspired for these gummies.

And then I pulled up a flower that's 28% THC. So again, this is far higher than we've seen historically, whereas more so like 5%. And they're marketing this product as something that helps make you calm, happy, relaxed, and energetic. And then it also gives us breakdown of all these different. turpines that they say are associated with different mood profiles and that you have to find your right fit based on the turpine profile. So I just want to open the discussion saying like a lot of patients are turning to these substances for relief from anxiety, relief from depression and to improve their mood. So, you know, with that being said, I just wanted to give providers and anyone who's interested a look at what patients are seeing, then also for us to dive into what the evidence is actually

saying so far. So Danielle, did you want to open us up with what we found about cannabis and depression? Yeah, so I think to start with, there is good evidence that like depression and cannabis use, disorder in cannabis use are associated with you. each other. It's been seeing time and time again in pretty sizable studies. One big cross-sectional study that collected information from 2005 to 2016. And over 16,000 adults found that people with moderate to severe depression had almost two times the odds of using cannabis in the past month. And over three times the odds of using cannabis daily or almost day. And it's interesting because later in this, as the study went on, the association that was

seen between cannabis use and depression actually got stronger and marijuana was legalized during this time. And maybe people started perceiving that, you know, cannabis can be helpful for depression, like just like the dispensary that you were just talking about, demonstrates, like what patients are seeing. And so more patients started turning to cannabis. when they started feeling depressed and the association was stronger over time. We also see like there's a new meta-analysis published this February on 22 studies that showed that compared to people who didn't use cannabis, people who use cannabis are 1.2-29 times more likely to have self-reported or clinical depression.

And then there's a meta-analysis done in 2021 of epidemiological studies in the United States. and that show that people who are dependent on cannabis or who abuse cannabis are anywhere from 2.3 to 4.83 times more likely to have a depressive disorder than people who don't have this dependence. It does raise the question like, is this just an association? It doesn't take, and these studies don't take into account a lot of other factors, like what came first, are people who are depressed just have the tendency to use more cannabis, or is it like the cannabis that's causing the depression? And like Liam was saying, a lot of people have either an overly negative view or an overly positive view, neither of which are really fully supported

by the literature. Yeah. So again, with these studies, they're cross-sectional nature. they're looking at one time point, people who are using cannabis right now and defining them based on if they have use disorder, comparing that to people without use disorder. And they're essentially seeing that they have a three to fivefold increased risk for having depression. And then some of the other studies are saying looking at depression patients, comparing those with people without depression, and then saying, yeah, they're far more likely to use cannabis by about two to threefold.

But again, as Danielle was mentioning that these studies are cross-examination. So it doesn't necessarily tell us what happened first as someone using cannabis and then becoming depressed or vice versa. So that's why we got to look at other studies that look at some of the Bradford Hill Criterium, as we discussed in last episode, where the Bradford Hill criteria is good for cross-sectional and epidemiological research, where it's looking at the dose response relationship between a risk factor and an outcome. And then also looking at temporality does cause, precede effect, strength of association,

are we looking at a very strong association between the two outcomes and then also biological gradient and so on. So Danielle, did you want to break down some of the studies that did look at some of these Bradford Hill criteria? Yeah, there are just a few studies that are really highlighted these temporality and dose response relationship more than the other studies. And that helps us to establish like causality a little bit more if we can establish this temporality where cannabis came first and then depression that helps to contribute to the argument that perhaps cannabis contributes to depression or with a dose response. More cannabis is associated with the depression that also contributes to the argument that perhaps there is this causality.

So thinking about the studies through the lens of Bradford Hill, there was one meta-analysis done in 2014 that looked at 14 longitudinal studies, studies that follow people over time. And this study showed modest dose response relationship between cannabis and depression. And like I said, dose responses, one of those Bradford Hill criteria that we look at. So people who were heavier, marijuana users had an increased risk of developing depression. And from 1.17 was the odds ratio risk for people who were lighter marijuana users and those who were heavier marijuana users had an odds risk ratio of 1.62 times increased risk of developing depression. And then another study that we wanted to highlight is a twin study that's commonly cited. And the special thing about twin studies is that they can control.

for confounding factors that in ways that like a lot of other studies can't know the twins are raised by the same parents often raised in similar environments and similar genetic makeup were the same if they're monosygodic twins and there's a twin study that was done on over 6,000 twins and this study demonstrated that the twins who used cannabis more frequently had a significantly higher incidence of major depressive disorder. Even after adjusting for covariates, this odds risk ratio was still significant. So it does show the dose response relationship and it's comparing twins. And that was even with when looking at the monosygotic twins only, so those with the same genetic makeup, this significance was still.

seen in of an increased incidence of major depressive disorder for people who were using cannabis more frequently. There's also another study that was done in Minnesota that looked at more than 3,000 adolescents. And again, it's twin study, similar environments, similar genetic makeup. And this study showed, even though it didn't show changes in the incidence of depression, it showed that there were significant changes in outcomes of educational achievement. So people would have who used cannabis more or who used cannabis would have decreased GPA,

decreased motivation for academic achievement, and increased problem behaviors in their academics, and increased disciplinary issues as well. Yeah, again, and these twin studies, they're looking at twins, monosogetic twins, one twin who smoked more versus the twin who smoked less or used weed less. And essentially, they found that the twin who used more, they had a lower GPA, lower academic achievement, lower educational outcomes, but no differences in psychiatric outcomes later in life. So that tells us, or at least suggest that if someone is using cannabis at a young age, they're far more likely to develop some of the academic outcomes as opposed to depressed outcomes potentially.

But then again, as Danielle just mentioned with the meta-analysis from 2014 that looked at these 14 longitudinal studies, that the more cannabis that's used during adolescence, the more likely that they were able to find that someone was depressed. So you're seeing kind of both sides of the same coin here where increased use can be associated with depression, but if you control for some of the genetic confounds, then potentially you don't see that same effect. But the one study that really jumps out at me is when you get to more potent use, more frequent use, that increases the odds even more. And not all studies look at potency. And I think what we're seeing now in clinical practice is patients who are used.

using 90%, you know, vaping, 90% THC, vaping, very, very potent stuff, you know. And so higher potency, I think, needs to be factored in. Actually, recently, I was having a long discussion with a news reporter, and he showed me the email of a cannabis lobbyist. And the cannabis lobbyist had, these are quotes from scientific studies, that promote that it doesn't cause an issue like psychosis.

And I look study by study, I showed Liam this as well. And I wrote him back, I spent like two hours, probably way too long, replying to him, going point by point, you know, putting out the counter arguments that I think are truthful counter arguments. We'll see if the reporter uses them or not. But in this, I may need to publish my email at some point, depending on how the final paper comes out,

But my points were like, hey, this guy is not paying attention to potency at all. Yeah, like I mentioned at the start of the podcast, we're really at unprecedented times with potency. Like the flower example that I gave was 28%. That's just the first example that I could find. So, you know, the studies that we're referencing are from the early 2000s. So that's not necessarily capturing that potency for sure. And we're having potency issues in other drugs as well. with fentanyl, for example, compared to normal heroin,

I mean, the amount of fentanyl deaths, which I did an episode on probably about five years ago, like foreseeing that this was going to be a huge problem in the U.S., and it has grown to be a huge problem, a huger, hugeer problem than it was when I first posted on it. Fentanyl is so much more potent than heroin and morphine, you know. And so we are just becoming too smart for ourselves. You know, it's almost like the invention of the atomic bomb.

It's like we are, sure, it's great if you're a country that uses it to win a battle. But if everyone's using it, not great, you know? Right. And I think the scary thing about cannabis is that the effects are delayed. So it's not like opioids where you see with a third wave of opioids when fentanyl became, Like the first wave was when people were being prescribed it from physicians, then heroin came in, and then fentanyl came in. And you can see drastic graphs of overdose-related deaths and the amount of people who are addicted. And then now with cannabis, we're not seeing the same trends because I think the effects are just delayed on society.

And we talked about last episode how it does affect brain development. I think one of the stronger studies showed that there's a decreased prefrontal cortical thickening when adolescent. since begin use. But I think the fact of the matter is at this point, we don't have enough evidence to make really big, really good claims. So I think there's just a positive in the research that's out there. And I think as we move forward in the next decade or so, I think some of these, you know, these questions will clear up. I think the evidence, though, like we see in these depression studies, is for increased potency, increased issues. That seems pretty clear. Okay, let's keep moving because we got a long way to go here.

Yeah, Danielle, did you want to talk about suicide? I know that, at least from my perspective, I've heard people say that cannabis is one of the only substances that doesn't increase risk for suicide. So could you maybe clear up some of that discussion? Okay, yeah, sure. Speaking very broadly, like there's a lot of studies that have shown that actually, actually, marijuana users have an increased risk of suicide compared to non-users. There are a lot of confounding factors. It's difficult to parse out cannabis individually as an independent factor that increases suicide risk.

For example, like people with lower socioeconomic status may have increased risk of suicide and also increased risk of cannabis use. There's also the confounding factors of like, drug use and increased stressors, depression itself. For the most part, when studies did control for other confounding factors, sometimes it was found that marijuana users were not found to have increased risk of suicide, but there are two well-designed longitudinal studies that do control for exterior factors, confounding factors, and still do show some increased risk of suicide with cannabis use.

There's one study on almost 7,000 adolescents that was based on national survey data, followed participants starting from like age 14 to 15 through ages 16 to 17. And the study found that for people who used cannabis, at least monthly, they were more likely to have suicidal ideation or to attempt suicide two years later. And this study controlled for recent depression. and other covariates suggesting that the effect of cannabis on suicidal ideation may actually be independent of depressive symptoms themselves, which is really significant, especially given how associated depression is with suicidal ideation. And there was also another study that followed over 3,000 adolescents for over a year that looked to identify, like, what is, what are the most important predictors for suicidal attempts.

And interestingly, this study found that marijuana use and caregiver suicide attempts were out of the predictors that they looked at. These were the only two predictors of a person's first suicide attempt that were independent. No-dose response relationship was investigated in this study, but still a really notable study to look at. And the twin study we looked at also showed that, like, suicidality for the twin who used cannabis more frequently was also had had an higher incidence. So there is definitely evidence for that speaks to the contrary of the statement that cannabis is the only substance that does not increase suicidality. Right.

So I think that in cases, people can be a little bit more dissociated. with increased cannabis use, and I think that can kind of take them out of reality or can maybe increase some of their depressive symptoms. Dr. Peter, did you have any patients in mind when this might have been the case where, you know, they had increased suicidal ideation with cannabis use because I can think of a couple at least? Yeah, definitely. I think that most stoned people maybe that I know they don't get motivated to actually complete suicide, but I think it kind of adds to the, just the anhedonia, the passive desire to die. I don't think any of these studies were actually looking at suicide completions,

right? Just suicidal ideation. Okay. Yeah, suicide ideation. Which is suicide completion is a lot more rare. Interestingly, I was thinking, as I was looking at these studies, you know, we know that SSRI's increased risk of suicidal ideation, not completion, suicidal ideation, and it's around the same odds, you know, unfortunately. And yeah, so it's like, okay, once again, is it the people that are more depressed, use more THC, and then have more passive SI,

or is it the people that are just using the THC going to be developing more passive SI because they're using the THC. Any thoughts on that, Liam? How to... Yeah, I think that's difficult to parse out. But one of the studies did control for depression or the history of depression. They still did find increased risk. And of course, you can't control for every confound. Like, what is it that's leading to an adolescent beginning to use cannabis or some adult is beginning to use cannabis? So I think the literature that's out there is limited. Like I couldn't find any studies looking at suicide completion. And if anyone finds one,

let me know. And if it controls for confounds, then that's awesome. I think that's needed. But next, I think we can move to anxiety. So Danielle, did you want to walk us through what we found? Yeah. So what we found on anxiety, most of the research is really on depression and psychosis. There's not so much research on the anxiety, but there was one perspective, epidemiological analysis that adjusted for comorbid psychiatric disorders and socio-demographic factors. And it found very specifically that past year weekly cannabis use predicted panic disorder with agoraphobia, but not without agoraphobia. And then there was also another study that noted daily or almost daily cannabis use marginally, predicted the onset of social anxiety disorder even after adjustments.

But there's, like I was saying, there's not that much data on or not that many studies that investigate like generalized anxiety disorder and other more common anxiety disorders. These were the two stronger, more controlled studies that showed these very particular associations with very particular anxiety disorders. But other than that, odds risk ratios are just not very impressive and predictive relationships have been really sparse in the literature. So that's pretty much what we found with anxiety. Interesting that it would be with agoraphobia, meaning these patients have had panic

to the degree that their panic has caused. cause them to change their behaviors. They don't wanna go out, be around a lot of people, you know, when people are panic attacks, they're looking for a reason for why they're having panic attacks, and then they reduce whatever they consider to be that which is causing the panic. Okay, so if they were driving when they had a panic attack,

they will stop driving. If it's being in a large crowd, they will stop being in a large crowd. They're really, so they're changing their behavior. So that specifically is what was linked to more frequent use of cannabis. Yes. Okay. Yeah, I think clinically too, one thing that I'll add is I've seen a couple of patients with increased somatic symptoms with their increased cannabis use.

So I think that's, I haven't seen any studies on that particularly, but I think that is something that's important to look into potentially. I think the story so far is that we really don't have that much evidence clinically about cannabis use and especially the high potency, which is unfortunate at this point. Well, it's new, right? It's new. But there are a lot of studies on these things. I mean, these reviews are, you know, when you read through the reviews, they're citing many reviews, you know, these meta-analysis, there's many studies that have been done. But specifically what you're saying is when looking at low potency versus high potency in the difference. Is that correct?

Yeah, correct. Like the way that cannabis is used currently, there's not many studies on. A lot of the older literature, if it is using THC in a randomized control trial, for example, they're using weak potency cannabis, like the NIDA drone cannabis, which is about 10 to 12%. So even in the controlled trials that seem to be stronger studies, you're not actually using the naturalistic, you know, what's used out in society nowadays. Yeah. And one example of a randomized control trial that did use cannabis that I thought was interesting is for PTSD. So this was for using cannabis to treat PTSD symptoms. And,

you know, working at the VA where I've been at, I've seen so many veterans that they use cannabis to help their nightmares, help their hypervigilance. Sometimes it makes their hypervigilance worse, but for the most part, it can calm with their anxiety and help treat their nightmares according to them. But there was this one randomized control trial that followed 80 veterans, and they essentially allowed them to smoke cannabis ad libidum.

So they were allowed up to 1.8 grams, which is about two joints per day, using either high-THC, high-C, high-c-BD, a balanced T-HC to CBD cannabis, and then a placebo cannabis. And they looked at PTSD symptoms over, I think, three weeks. And they found a significant reduction in all treatment arms, and even in the placebo, with the effect size, was over one for the placebo and the T-HC, the high-THC group. So that doesn't really tell us that T-H-C is actually helping.

it seems like it's comparable to placebo, at least for treating PTSD symptoms. For those on YouTube, I'm pulling up the figure here. And really interesting that the initial high CBD seems a little bit different on this side. Do you see that? But then in the end, oh, this is post-c cessation. But they all cross.

The confidence intervals all cross, right? Right. So that's what you're saying, is that the placebo is the same, essentially. Yeah, they're all improving on their PTSD symptoms. And I think what's notable about the study, too, is that there's a high break blind rate. It was about 60%. So obviously, you know that you're smoking placebo versus a THC compound. So I think that's something to note as well.

Yeah, so I think in a more nuanced research design, they would do probably like 3% THC in like the control arm and then like more like a 23% in the active arm. Yeah. And I think what would be more helpful even is to use it naturalistically because I think a lot of veterans I talk to, they don't use just two joints a day. Sometimes it's all day every day. So I think looking at that approach as well, using a more naturalistic, using the high potency, and then high dose as well. So I think if you use the high potency and then the high dose,

then I think that's going to have a way more accurate representation of what's going on here. Yeah. Yeah. Okay. But the other thing that just in clinical practice, when someone smokes, or let's say someone drinks for 40 years,

the moment that they get sober, the PTSD is right there again, right? So it's like the alcohol may have helped them cope for 40 years, and they may have been like heavy drinker. But then the moment that they stop drinking, it's like their dreams are just right there as traumatic as ever. These are like Vietnam vets that I worked with in the VA

that I'm thinking about. And I think the same is true for marijuana. It's like for some people it helps temporarily. And so they do it. But then what really helps is getting them into partial, getting them sober, and then having them process. and their trauma on a sober brain with a group,

that seems to be what's helped people get back to life, overcome. So it's kind of like, I give this analogy sometimes to patients who are heavy marijuana users. It's kind of like you're floating in the ocean. Marijuana was that life raft that you saw, but there's a boat that came. And so you have to leave the life raft

to get onto the boat. and the boat is partial IOP treatment, psychotherapy, you know. It's really hard to make progress with your cognitive processing, you know, how do you handle emotions when you're totally high all the time, right? Right, and we know that THC can suppress REM sleep, and that's important for emotional processing. So there are some studies looking at treatment outcomes for PTSD patients with engaging in trauma focus therapy.

There are a couple trials that show those who use THC more likely to drop out, which I think adds up to what we see in the real world. But then there are also some other studies that show if the patients do show up and they actually get equivalent outcomes to non-users of THC. So I, but I think in clinical practice, it's probably better to have patients come off the THC. When I would run this IOP program, partial program that I did for like 10 years, the therapists, week three would be like, okay, this person's using marijuana,

it's getting in the way of them being congruent with their emotional world. They couldn't get access to their true emotion. And so we would have that conversation with the patient. Hopefully the connectedness that they felt, with the group was strong enough for them to quit the connectedness they felt with marijuana, because there is an attachment and a connectedness that often people feel with the drug. So, okay, let's keep going. Yeah, so kind of along those same lines talking about, does THC improve anxiety and depression

over the long term and PTSD as well? Danielle, did you want to tell us about some of the studies that I think we're really interesting and that they allowed people to use them naturalistically. So do you want to tell us about what the design of the study was and then what some of the outcomes were? Yeah. So the first study is an observational study that used data actually from medical cannabis app. And the users of the app could put in their symptoms of depression, anxiety, stress, and then track those symptoms over time with the app.

And because it's a medical marijuana app, they also would input their, marijuana use into the app. And the study took this data and found that 20 minutes after using cannabis, the patients would report alleviations in their symptoms of depression and of anxiety. But when the longer term results were tracked, like two months later, these baseline symptoms were unchanged for anxiety and for depression, the... the depression baseline symptoms were actually worsened over time. And then there was a single blind, randomized control trial in Massachusetts that found

that getting a medical marijuana card led to increased cannabis use, which makes sense. When you have a medical marijuana card, you would use it more and see it as a medical thing, and actually to the point that it increased rates of cannabis use disorder. However, over a 12-week span, there were no significant improvements in pain, and there were no significant improvements in depression. So overall, evidence is suggesting that patients do experience, like this alleviation of depressive symptoms in the short term, but these longer-term improvements are not seen. And as Dr. Pryder was mentioning earlier, like there's this therapeutic work and and work that needs to be done that can actually lead to a healing process. And if people are

turning to cannabis instead to deal with depressive symptoms, anxiety symptoms, that prevents us from being able to actually work through those things. things and have a healing process. It's an analogy that I like to use and that I used, Danny and I recently taught a class for an adolescent PhP. And that was about cannabis use because it was so common. Like, I think all of the adolescents who were in the Ph.P were using cannabis. And it was finding, saying that it was helpful for their anxiety, for their anxiety, for their

depression and I told them, can you imagine that you had like a really huge open wound on your leg and you found a product that makes the pain go away of the wound. You can put it on and it helps you to feel better in a moment, but your legs are not actually healing, but you just keep using this product. What do you think is going to happen if you just keep using this product, which stops you, like prevents you from healing that makes you feel better in that moment? And one of the high school kids was like, ew, that's gross. The wound's just going to faster. And I think that's exactly how I think about this. If cannabis helps people to feel better in the short term without the long-term benefits, it prevents them from engaging in the healing process that can require both therapeutic work

and medications. Great, great. Yeah, really good. This is exactly what I've seen in my practice and also you can see why people would want to use it short term it alleviates and now with you know the ease of a high potency THC pen that you can hide easily and take out between classes take a puff it's like the addictive potential is much higher than it used to be okay cannabis and sleep yeah so like i mentioned a lot of veterans that i have worked with they use it because they're using night terrors, or they're experiencing night terrors. One veteran that I talked to recently, he had such severe night tears that he would wake up on top of his wife and choking her.

So, and he found that cannabis was one of the only things that actually helped his night tear as we tried him on chondine, prososin, Syracul, any sleep aide wasn't cutting it for him. But the only thing that seemed to help was the cannabis. And it seems like that's due to the fact that cannabis can reduce REM latency and duration so that, you know, night tears are happening during REM sleep. And we see that there's actually a decreased amount of sleep latency. So for people with insomnia, they can perhaps fall asleep a little bit more quickly with using cannabis if they smoke before bed. But I think other cases, other people would just be more anxious and wired. So knowing how the patient responds to it's important.

But these effects also might not persist due to tolerance over time because just like any drug, people develop a tolerance. And it's not really clear whether that will lead to any changes in sleep long term. There haven't been any long-term RCTs in this topic. And of the studies that have been done, there is about 50 studies so far, according to a scoping review. and 21% of these studies showed an improvement in sleep, 48% showed worse sleep, 14% showed mixed results, and 17% showed, cannabis had no impact. To this point, it seems somewhat neutral for sleep,

but at the same time, clinically talking to patients who have used it, they tend to say that it helps with night terrors, but they feel groggy the next day. And again, we know that the reductions in REM sleep are probably not good long-term for emotional processing. and just for feeling rejuvenated and energized. Yeah, so night tears, sleep-related violence, a part of PTSD, very scary to this spouse.

I know multiple spouses that ended up sleeping in different rooms, different beds, which I would actually advise, that's a good thing. It's a REM sleep behavior disorder, a type of parisomnia, which, you know, we normally do, not move at all, we're completely immobilized in REM sleep. But in some people, they move, they act, they do things that they would, they act out dreams. And so someone like that, you know, they're acting,

they could be acting out a violent dream, a trauma, traumatic dream, right? And so decreasing the REM sleep would be, would be a goal. Now, other things can do that too. Benzos, you know, someone's choking their wife. Maybe you're a little bit more aggressive with how you treat them. If marijuana is the one thing that's keeping them from choking their wife and they want to sleep together, I don't know if I'd be wanting to decrease it. Maybe that's just me being practical, but I also would want them to be in, get their PTSD actually treated.

Some people, when they take certain medications, they'll have, they'll do different sleep. behaviors as well. During REM sleep, they'll go cook. They'll clean, they'll wake up. Dishes will be out. Brownies will be burnt. Sometimes that's unlike the different

like Linesta Ambien type medications. So I've had patients wake up different types of sleep like where they feel immobilized. So they'll still have the REM immobilization but they'll be awake with the panic, the panic of some nightmare.

that's very scary for people as well. So thanks for covering that. Yeah, decreased REM sleep with cannabis, right? That's one thing you can remember. Yeah, and I think that's also sort of a link to how cannabis can lead to reduced cognition. If someone isn't sleeping that well, you imagine that if someone's groggy throughout the day, they're not going to be engaging in the activities that they normally would want to do, that can also increase the risk for depression as well.

So in talking about cognition, we hear a lot in pop culture about how weed will fry your brain, how you'll reduce your IQ points significantly and become a pot-headed lazy all day. So Danny, did you want to add some context to this discussion with what the research is saying at this point? For sure, yeah. With regards to the idea of like weed is the devil and it will be cause of all your problems, The evidence doesn't paint that picture. That's because the evidence, what does exist, is pretty limited with regards to strength in either direction. I think a literature review that exemplifies this was done by Scott and colleagues back in 2018.

They did find that THC can have statistically significant effects on cognitive functioning, but these effects, while statistically significant, were clinically negligible. Furthermore, these effects, the difference between the two groups, did diminish given periods of abstinence longer than 72 hours. So thus, those who used cannabis but were absent and for that time period had outcomes that were not measurably different from those who didn't use cannabis. So what is the team for patients? To be frank, like I said, it doesn't mean you can say that cannabis is the devil and the cause of all the problems. But if cognitive concern is a function and the patient's been using cannabis pretty, pretty. heavily and regularly, you could say it could help to like abstain, but in terms of like

clinical guideline grades, I would give this a solid C. But there was one study that I found that was pretty strong and it was a prospective cohort study done by Meyer and colleagues back in 2012. And they'd had a finding that was worth noting. They found that persistent cannabis use was associated with decline broadly across different domains of neuropsychological functioning, and some of the participants who had consistent cannabis dependence experienced a decline in IQ points about half a standard deviation, which translates to roughly six to eight IQ points, and that's even one controlling for use of education. Furthermore, and this is important for adolescents, ceasing cannabis use in adulthood was not shown to fully restore neuropsychological

of functioning for those who started persistently using cannabis in adolescence. And that's consistent with the hypothesis that cannabis can have neurotoxic effects, especially adolescence, when the brain is undergoing crucial development. And again, this is a single study, so I wouldn't make a definitive statement or, like, try to make a case for rewriting clinical practice guidelines for anyone who's ever smoked adjoined before, but it's worth noting so that clinicians can have conversations with their patients about the potential risk for decreasing IQ, it did decide to start cannabis,

especially in adolescence. Yeah, I think this kind of echoes the point about starting cannabis use during adolescence has been shown to be linked to the produced educational outcomes and occupational achievement, too. So it's not to say that, you know, cannabis does not affect cognition. I think that it does in the short-term sense,

because if you look at studies where you have prolonged periods of abstinence greater than three weeks. Any study looking at less than three weeks, there's a chance that you'll see some effects in executive functioning and different types of cognitive tasks. But then when you take out the abstinence for three weeks in adults, then the effects tend to go away.

But in adolescence, if someone's using it and they need to be on top of their game during school, you know, they're not going to want to pursue school if they're using cannabis daily, not able to focus on their homework. So I think that is definitely something concerning. to see in adolescent populations. Yeah.

For example, I took the SAT three times because I was trying to get a specific score to get a full-rise scholarship. I definitely wouldn't have done that if I was smoking pot that time. You wouldn't have tried three times, right? I would not have tried three times. I would have been like, once, I'm like,

it is what it is. I'll get what I get. Yeah, and some of that apathy, like, think about the opposite of anxiety is apathy. So if you're anxious, you're stressed out about taking the SAT and then you turn to marijuana, maybe you get some apathy.

Maybe that's like better or sort of reinforcing to decrease that anxiety. But the apathy inevitably makes you miss out on years of learning, right? So you may miss that. Think about like the eight years

of like learning from the age of 14 to 24 and I guess it's, you know, how important that is, right? Very critical. So that's just like long-term life outcomes. Those years are very, very important. Very important. Yeah. I also think it's really important for shaping identity.

So I'm sure each of us know someone when we're growing up in high school that got caught up in their wrong crowd, so to speak, where, you know, they're associating themselves with people who tend to use drugs and are a little bit. more rebellious or deviant. So I think that's also important for shaping someone's identity during that critical period of identity formation. If someone starts using cannabis and realizes, yeah, it's better for me socially to keep using the drugs and to hang out with those types of people, then that's how the life trajectory is going to be shaped versus someone who tends to stay away from those and focuses more on school than that person's life trajectory

because they've developed that identity during those years, then they're more likely to stick with that over time. And so I think that's a really crucial aspect of, you know, good parenting to be able to, you know, help your kid decide who are good people to hang out with and whatnot. Yeah, so any, what are some of the larger discussion points that we should have kind of wrapping up our time together? Yeah, I really wanted to talk about treating cannabis use disorder.

And that's, I think it's a little bit, tricky a lot of times because now we see more daily cannabis users than alcohol. And I think that is mostly because of the culture around cannabis is so positive. And like I mentioned earlier, the effects of cannabis are delayed. So it's a little bit harder for people to see the downsides of their use. It seems like something that's going to add up over time. So in approaching patients who have cannabis use disorders, or if you're trying to get a history of, you know, their cannabis use, you really want to approach it from the perspective of how is this helping you? You know, that's crucial for motivational interviewing is to be able to understand from their

perspective what's going on. And they're going to be far more likely if you approach it that way as opposed to being paternalistic and saying you can't smoke, you can't do this and this and this. So in treating cannabis use disorder again, we want to focus on, you know, how is this affecting your sleep? How do you feel energy wise? What are the context that you're using it? Are you using it just with your friends?

Are you using it by yourself? How have things changed over time? Maybe helping them recognize some of the downsides of the use. Again, that's a little bit difficult, but approaching it from their perspective is really important in this case. Has the potency of their use changed over time? Does the, do they feel like they're needing to use it or they have a choice if they're going to use it? is it um is it something that they're doing without even thinking about doing it like they just pull the pen out of their pocket take a quick puff without even like like even thinking that

they're going to pull it out and take a puff right oftentimes you'll see someone they'll because it's so easy to use they'll start using it before every event that they have like oh i got to see a movie got to smoke i'm going to the gym got to smoke got to hang out with my friends i have to smoke so You'll see this pervasive pattern of use before any meaningful event because it helps them enjoy it more because otherwise the withdrawal symptoms are anhedonia like with other substances, irritability, anxiety, and then insomnia as well. So the withdrawal symptoms, they're seen in up to 50% of patients who use regularly. And I think that's a little bit underreported too because it can be hard to recognize for patients that, yes, I'm actually withdrawing. So discussing with patients

have you gone a week without using in the past couple of months? And did you notice any trends in how you're feeling at that time? I think that can be pretty eliminating to some patients that's work for me at least. And in terms of treating withdrawal symptoms, there aren't any FDA-approved medications at this point, more so just treating the symptoms of anxiety, insomnia, with gabapen's often used, tracidone, any sleeping medication. And then I've also seen clinically in a Sud IOP program using an acetylcysteine, which is essentially an amino acid. And that seems to help cravings in some patients.

The downside to it is that there is, it's very hard to take. It's like imagine creatine, but even more scoops than creatine. You have to take, I think it's about 2.4 grams per day and splitting. up between evening and morning doses. So it is quite a bit much for patients who aren't that motivated, but for patients who are highly motivated, it seems to be decently beneficial. There aren't many trials on it. There's a couple weaker trials, but there's a lot of dropout in those studies. So if you find someone who is very motivated to stop using, then that could be a potential option to look into. Yeah, I would say if I can tell you.

why they want to decrease to what brought them in. I'm going to be able to find a win. So like what brought them into treatment? What were they hoping to accomplish? And if it's stuff like I want to move forward in my career, I want to do better in college, I want to, you know, you can tie those things to their use. I had one patient who had three car accidents

in the last two years. And we were able to tie, his heavy use to the car accidents. Now this is this one person, you know, but once he realized that and he was like, oh, if I get into another car accident, I could get my license completely taken away forever, you know? And so, yeah, it's finding what is that win for them?

A lot of them have a lot of anxiety about getting off. And so this is where maybe some gabapentin, in topiramate. There was one study that they used toopiramate, but I'm always worried about cognitive function with topirimate as well.

These effect sizes are not huge. CBT, you know, with motivational enhancement therapy, had a reasonable effect size, 0.44 in one study, first controls. It's not huge effect size, you know. This is where I think

if you can build that connectedness with that person, over time, talk to them, have them listen to an episode like this, maybe that would help. Maybe it wouldn't help. But family therapy has some effectiveness as well. I'd like to this year have a family therapist come on and talk about family therapy so you can look forward to that. And, you know, getting the family on board is sometimes helpful. Sometimes it's a dynamite keg and you need to know how to do it properly.

so we'll talk about that yeah one other point that I did want to make too is that if you're if you're an outpatient provider working with a patient long term you want to be able to have them stay off of cannabis for months and I think that's where you really see the true effects potentially emerge because we know that someone using daily multiple times daily it can take up to a month

or more for them to have a negative urine drug screen and that's just for it to stop clearing from their body. And that doesn't mean that it's actually out of their brain too, because we talked about last episode how lipophilic THC is. And there's the potential that it's in their brain for multiple months. So I think that's really important to keep in mind that it may take a couple of months to actually see the real effects of becoming abstinent off this drug. Yeah, the brain is mostly fat, right? So if it gets into the brain and it gets released, it's going to be released slowly. Right? Yeah. And then, yeah, so it may take time. And I think there's a hopeful message. I get some people that message me occasionally that's like, hey, I'm quitting marijuana. Is my cognitive function going to return? What would you say to that person?

I would say most likely, according to the studies that we've seen so far. But again, there's always a chance with the high potency. But I think I'm pretty optimistic about, you know, if they've been using a lot and then they stop, it's no longer in their brain, the brain is very adaptive. So I think that, yeah, most likely that their cognitive function is gonna return. Yeah. And they can learn new skills.

I tell them in therapy, like look, there's skills that we're gonna learn in therapy. You doing the therapy, learning how to process things in deeper ways, that you're not gonna need it like you used to, right? And if you feel like you need it, let's look at like what emotion is happening and you write then in that moment that leads to you needing it.

Because I think a lot of people, they feel this bad emotion, and then they have like, oh, I'm gonna defend against this, however I can, right? And instead, like, let's be curious about that. Like, what is that bad emotion? What is the meaning of that emotion? Let's increase our reflectiveness about what's going on in that moment. I think this is why high reflective function therapists are some of the best therapists that we have.

it's they're increasing their patience reflectiveness, right? Instead of just going, like using, I'm feeling, if you're feeling an emotion and you immediately use a substance, that is a very low reflective function position to be in, right? Because it's like, I'm not thinking about why I feel this bad emotion, why I feel this anxiety. So like Daniel, if you're feeling anxiety about a big test coming up or something like that or applying to residency,

it's like, well, maybe it's because that's important. That's your career. That's your job. Maybe there should be some anxiety about that. Maybe that's okay. Maybe that's because it's meaningful, you know? An anxiety in and in of itself, it's a human emotion and it's there for a reason. If I'm anxious about completing my application, it's probably because there's a part

my application that isn't done yet. But if it's like, oh, I'm feeling anxious. I'll just like smoke weed. That thing that needs to get done just might not get done, you know? it can be helpful to be a little bit on it if there's things that need to be accomplished. And I'm reminded of like the optimal stress curve. You know, there's a significant amount of stress that we need and that is helpful for us to accomplish what needs to get done.

We can't just, and it's so common, like I can't say the number of times that I've talked to a patient and they'll say they go to whatever substances it is because that's what they've been used to since adolescence, and it's just like what they need to function and to stop the emotions, and that's what they're used to. But I think it's a risky place to be in, for sure. Yeah. Or you'll have a patient who is like maybe they feel bad. They did something that maybe is bad. They feel guilt. It's like, well, this takes away my guilt. This makes me feel better. it's like, well, what values are underneath the guilt, the values that you have, things that you believe, right?

And if I can help them see that that guilt is actually teaching, it's a good teacher. Like, these are the values that I have, this is how I want to live my life in the future, moving forward, and see that as like a good thing. It's aspirational, right? These are the things that are around my identity, right? It teaches you about who you are sometimes to have some guilt

or to have some negative emotions as well. It's like, okay, this is part of, like, who I am, who I want to become. And so that sort of exploration, sometimes it's a little bit painful, but usually it's not as painful as people imagine it to be. That's one of the things I'm seen in my practice a lot lately. It's like we'll sit with the most anxious, provoking thoughts or feelings that they have. And then I'll be like, okay, after sitting with that, did you think it was going to be worse to try to sit with it?

Yeah, I thought it was going to be, I thought I was going to die thinking about it. Okay, isn't that interesting? There's this discrepancy between how you thought you were going to be thinking about your anxiety and how it turned out when we actually did it. And look, it wasn't quite as bad. And so, or the other thing is like, okay, now that we looked at it, Is it going to be easier to look at it again? Yeah, it will be.

And so they may not need the substance like they needed it before. That being said, I think people have an attachment with Mary Jane, Mary Jane's products. There's a relationship going on. It's almost like when I talk to some people about it, it's like this is my partner. This is a physical relationship I have with this.

product. And so we have to also be aware of how attachment dynamics work, you know, and they will break up with someone that's threatening their attachment. You know, they will push you away potentially if you're threatening their attachment too early. And so this is where it takes some nuance. And I think as practitioners, we should treat people who are in the midst of addiction. We shouldn't just say, I'm going to wait to treat you until after your addiction is done, then come back. It's like, ah, that's not realistic, right? People are in the midst of whatever they're in their midst of.

We need to be there for them. And it needs to be not contingent on like the short-term place that they're at, right? That being said, I may not give certain controlled substances to someone who's heavily using THC. I may, you know, early on, there was one client in particular who had a medical marijuana card. wanted Xanax one milligram three times a day and wanted other things as well, Adderall. And I was just pretty up front with her. I said, look, I feel very uncomfortable

with the amount of marijuana you're using, the amount of benz-O, the amount of Adderall. And I actually think all of these combined are leading to your current struggle with your cognitive function, with your memory, with moving forward in life, with, and I went through all the things and I said for me to treat you

and I need you to go detox. Like I'm not going to write you this script starting off treatment. And it was a way of having a boundary early on with like, hey, you're going to have to decide to work in a context in which I actually know you will get better. Like I'm not going to go into treatment

with someone in a context in which I think, think that they will not be successful, if that makes sense. And you can do that as a provider. You can set that context from the beginning. And then if they storm out, you know, maybe it's the third person they storm out from that. They're like, okay, maybe all of these people are trying to tell me something that's true and I'm just not ready to hear it, right? So I try to say it in a way that's the most connecting possible and like try to make myself not the obstacle towards their goal. If their goal is just the substance, it's really hard. So if I'm the obstacle towards that substance, Adderall, X, you know,

that's really where they get very angry at me. But instead, I try to put the obstacle. I try to change the obstacle to the substance itself. And then I'm part of the solution in reaching their goals. So the goals are things that they've already told me. And this is why it's so important in the history to start from a place of really pulling out from them what their goals are. And if their parents brought them in, they didn't come on their own fruition, you can still pull out from them what they would want to accomplish. Okay, if your

parents weren't in the picture, like, what would you want to accomplish? What would be different? Well, I just want to be able to do whatever I want to do. Okay, so what does that look like? Well, I need to be able to make money so I don't have to live under my parents' house. Okay, great. So a goal for us, if we were to work together, would be for you to be financially independent, be able to provide for yourself and be living on your own. Yeah, so I could smoke as much marijuana as I want. Okay, well, you could see where there's a conflict, right? But, you know, ideally, you try to find the goals

and you try to work with them and try to move them towards those goals, right? Well, okay, if you were to smoke marijuana, what would you accomplish? That's even more important than smoking marijuana. Well, I would have peace. Okay, so if we were to bring you peace and allow you to get to a place of peace with out marijuana, would that be as good as smoking marijuana? Well, I don't think I could ever do that because this is the only thing that brings me peace. Well, okay, now we're moving somewhere, right?

We have some goals that we can target that we can both agree our important goals. You want to be financially independent, you want to live on your own, and you want to have peace. like so if we were to work towards these could we work together well i'm only here because my parents brought me okay but like if i was to be separate from them not kind of on team parents but on team you accomplishing those goals could we work together and so i think it's very important when you're working with someone to go in with therapeutic alliance common goals bond attachment right otherwise it's not going to be successful. So there was one patient who I said,

you know, I could tell your parents that you don't need this anymore, that you don't need to meet with me anymore, that you're good, and like I could do that. Would you like me to do that for you? And that kind of took off, and I knew she was going to want to continue to meet with me, you know?

But like I knew it was like there was a part of her that thought, like she's only meeting because of the parents and being forced to. So I said, look, I could advocate for you, not have to have to meet with me at all. Do you want me to do that? And so it kind of like shifted the dynamic, you know, and she then started showing up and started expressing herself and started showing her emotions. So this is a little bit how I work with this type of population. I think it's

good to put in this practical clinical things. Yeah, any questions from you guys on any of these things? No, I really like how you frame it as an attachment, you know, maybe framing it as a breakup because a of times there's going to be a lot of grief with leaving behind the substance that, you know, maybe they made friends on it with. Maybe it's just something that they looked forward to at the end of the day or or so on. It serves some purpose for them. Just like a really bad boyfriend or girlfriend, like, yes, they can be, they can have some positives, but the long-term downside are there. So I think framing it in that perspective of attachment and understanding that there's a grieving process behind it too is really important.

Yeah, there's a grieving and there's going to be increased anxiety at times from not using it, right? Because in the moment it does drop anxiety acutely for some people, not all people. Some people increases anxiety. Some people increases psychosis risk, right? Like we talked about previous episode. And sometimes people go from it, and this is I've also seen, where it for a while helps anxiety, but then it causes increased anxiety.

and increase to those psychotic-like symptoms. That's also, there's a grief there of here I had something that was helping me, and now I don't have anything, you know? Yeah, it's like an attachment like food. Like if you're trying to eat healthy, sometimes it's really hard because we have an attachment with soothing ourselves with food, right? So people have attachments with things, yeah,

and seeing it that way I think is helpful. and then focusing on your attachment with them and being patient in that process. I think that's my message and helping them reflect on the emotions that precede the desire to use the substance. That's where you spend the time. And interestingly, with a lot of these substances,

like let's say they're driving home and they decide, oh, I'm going to go home and I'm going to use this thing. The anxiety actually decreases the moment they decide to go home and use the substance. Okay? So they found this with alcoholics as well. Like, it's the moment of decreased anxiety

is not the first sip. It's when they chose, I'm going to go home and I'm going to drink. That's when the anxiety drops. Because it's not just the substance. It's the idea of the substance. It's the meaning that they attribute to the substance. And so that's also where we can do some, that's where I think a lot of the fruitful psychotherapy

takes place. I do have a question with regards to, I love the finding a win and a shared goal, shared wins with the patient in the therapeutic alliance. Do you ever, have you ever used like other physical risks other than the psychiatric risks as part of your counseling with the patient. Especially if they want to get pregnant, right? Like, this is the time when usually men and women are at peak willingness to make sacrifices,

exercise, eat healthy, and I would say they should stop smoking marijuana. So I'll go over some of the side effects of that. Yeah, sometimes, like, some of their goals that are more aesthetically oriented. Some people, especially in their early 20s, are very geared towards like aesthetic beauty. That's a huge motivator.

And so to talk about how like, it seems that when you're smoking a lot, you have very low interest to go work out. And so it kind of like decreases their goals there. So yeah, sometimes I'll use different things that are not just psychiatric. people tend to not be motivated largely by psychiatric fear. Like, oh, I'm scared, I'm going to go psychotic.

Like, very few people actually have that as like the reason why they're going to stop smoking marijuana. In my experience. So, yeah, I think people want to not be dependent on substances. And so there's a general desire to not need something. Interestingly, people don't see marijuana as a substance. And so, like, that's not a substance. That's naturally, that's a natural thing.

Well, me, the THC content is no longer in a natural realm. That's not something you would find in like a plant in the middle of, you know, a forest. That's something that's genetically been modified. So it is a substance. All right, guys, we got to wrap up our time. Liam, any final thoughts, any final reflections? Daniel? Daniel?

Yeah. I thought this is a great episode, and I hope that it gave some people an understanding of how to approach the cannabis use disorder clinically, and then also armed them with some of the research about depression, anxiety, PTSD, for them to have some of those discussions with patients. Yeah, and I would highly recommend. Go check out this handout guys on Psychiatrypodcast.com. All the handouts are.

for free. You can print them out. You can give them to patients. We do not have any financial skin in the game. We're not paid by pharmaceutical reps. We're not paid by cannabis reps, you know, which is a nice place to be. And I would say, having used AI and experimented with it, how good are the handouts that AI can produce? And sometimes their citations are wrong. Sometimes their data is wrong. And I would say, this is the highest quality handout you can possibly make because it is human-made and sometimes I run it right in the end through AI as well to see if we made any mistakes.

And so sometimes we use AI to kind of like double-check ourselves, but I would say there is no LLM that can make a handout like this at this point in my experience. So I appreciate you guys, appreciate the quality of the work that you did digging into this. Thank you for coming on. And if you're a psychiatry residency program director, Daniel Liu, Daniel Kuevas, are both in the pipe this fall.

So please look for their application. Look at this handout. Look at the hard work that they did. They did amazing sections on this. And we'll leave it there for today.