Psychiatry & Psychotherapy Podcast - Marijuana and Mental Health

Episode Date: May 2, 2019

On today's episode of of the podcast, I will discuss marijuana use and how it affects mental health with Daniel Binus, the chief psychiatrist at Beautiful Minds, near Sacramento, California. Also joining us is a third-year medical student, Victoria Agee. There are a few reasons we believe this is important to talk about. First, as medical professionals, we often see patients who want help with their anxiety, depression, ADD and suicidality. They say they use cannabis, and that they need cannabis, to help calm those symptoms. When we explain the research to them, it still takes them awhile to let go of their habits and embrace other forms of therapy and medication that is a better long-term option. Also, we head into a time when marijuana is being legalized, there are tons of THC companies that will benefit from suppressing this information and even suppress these studies we will reference here. Hiding this information could be detrimental to society's mental health. While there are some potential benefits to one component of marijuana (CBD), something I will review in the future (evidence is fairly young in that field), the THC component can be highly damaging to mental health. Whether or not people are willing to admit it, cannabis is actually highly addictive. One of the symptoms of addiction is intellectualizing reasons for use. Not only does it change the way the brain functions, it changes the way we see and perceive the world. It also changes our visual and spatial abilities. If you're an architect or use math in your job, it deeply affects those abilities as well. THC stays in your brain a long time—it can be weeks (or even a month) before people get the full function of their brain back and the fog has cleared. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder    

Hello and welcome to the psychiatry and psychotherapy podcast with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. Welcome back to the podcast. This is Dr. Puter. I am here with Dr. Daniel Bynes. Dr. Bynes was one of the first psychiatry people that I connected with here at Lomelinda when I was thinking about going into psychiatry. He was a resident at the time. Now he's working near Sacramento in Auburn. He's a chief psychiatrist at Beautiful Minds. It's a company he started.

And he runs an intensive outpatient program. He sees a lot of med management. He has a TMS machine. He does a lot of lifestyle integration. and, you know, talks a lot about diet and exercise and gets his patients into psychotherapy. So he really has a holistic view. We actually send medical students down to him to do rotations.

They come back. They tell me very positive things, which is always a good thing. And so Dr. Bynas and I have continued our friendship. At one time, he tried to recruit me down there. And, yeah, we just really enjoy being friends. So it's really good to have you on. Thank you. It's good to be on.

And I think I'm going to keep trying to recruit, but we'll see how that goes. And I'm also here with a third-year medical student, Victoria AG, who is a third-year medical student going into psychiatry? Possibly. Possibly. Okay. And who wanted to do a little project with me. And so she has dug into a lot of the research. I have dug into the research.

Dr. Bynes is actually presented at a conference on this topic before. And so today we're going to be talking about marijuana. We're going to be talking about the active component, THC. Maybe we'll have a future episode where we go into cannabidiol, CBD. And so Dr. Vines, where would you like to begin? Well, it'd be nice to maybe talk a little bit about where the research is on cannabis and why up to this point things have been a little bit ambiguous. us because a lot of people have been confused. There's a lot of special interest groups out there.

A lot of people that say that cannabis is the cure for just about everything out there. I have a lot of patients that come to me and they'll say, okay, I'm using medical cannabis. And I'll ask them, well, you know, why are you here to, or why are you using the medical cannabis? And they'll say, oh, yeah, it's to treat anxiety, depression, ADD. And then I'll ask them why they're there to see me and they'll say well it's because of my anxiety depression ADD. And so, you know, I have to ask them, well, do you think it's really working that well? And a lot of them say, well, you know, honestly, it's not. And so I think we need to be really careful about how we just buy into kind of the mainstream

media and really look a little more carefully at what the research really shows to help us understand what to recommend to our patients. Yeah, you know, I have a lot of discussions. with patients who are totally sold out on cannabis, they think it's really, really effective for them. But yeah, once again, they come in and they're still suicidal. They're still very depressed. They're still very anxious.

They still, you know, can't focus in school. And at the same time, they're very focused that cannabis is going to be part of the solution. So what do you say when you have one of those patients come through your door? Well, what I usually ask them to look at is where, their symptoms are now and how cannabis actually hasn't helped their symptoms. And then I also try to explain to them that oftentimes cannabis actually initially does help the acute symptoms of anxiety or depression or ADD. But then the brain goes through changes that will actually offset the effect of the cannabis. And then in the end, it will actually worsen the disorder in the long run. So a lot of people

can can kind of understand that at least a bit, but they still have a hard time letting it go. And the reason for that in most cases is because cannabis, whether people like to admit it or not, is actually highly addictive. And because of that addiction component, well, what's one of the symptoms of addiction? Well, it's denial. It's saying, you know, this isn't really a big problem for me. And so they're going to try to rationalize. And so it can be challenging, but, you know, through different things like motivational,

interviewing and helping people to really look at how far cannabis or maybe not so far it's gotten them, they often do take a look at making some possible changes. Yeah, that's really helpful. And I wonder if we could talk a little bit about how cannabis does change the brain, not just the short term, but the long term changes. And so I'm wondering, Victoria, if you can talk a little bit about what you were surprised about when you started reading this and what you found? Sure. So marijuana has multiple effects on the brain. First of all, it changes the brain morphology itself. It reduces hippocampal size and amygdala volumes.

The hippocampus is known to be associated with short-term memory, going into long-term memory, and the amygdala is where we really process most of our emotions. The long-term changes that we see are due to changes in the epigenetics, so how DNA is expressed within the brain. And while this is still fairly new research we've found in animal models that there are specific genes that have been identified. One of these is the pank gene, which is upregulated with increased marijuana use, and the pank gene is for an opioid-like neuropeptide, and this has been shown to increase susceptibility to an opioid addiction. What's really interesting is that not only were the original rats affected by this upregulation, but further generations,

were also affected. Their progeny had increased tendency to have susceptibility to morphine and showed increased work effort to self-administer heroin. And this was regardless of whether or not they had ever been exposed to THC in their life. Increased marijuana use is also associated with increased expression of dopaminergic receptors within the brain. Of course, dopamine is known to modulate drug-seeking behavior and it's also something we block when treating schizophrenia. and something we can touch on later is kind of the correlation between marijuana and early onset psychosis. It's also interesting to note that increased marijuana use was noted to show hypermethalation

of a specific gene, the RGS7 gene, which is for G-protein-coupled regulation in the brain. And this was associated with spatial memory and memory impairment with respect to fear conditioning. Right. So one thing that they found is that when you use... use heavy cannabis, your IQ does decrease. Have you seen that study as well? Actually, there's a lot of studies that support that. And what's interesting is that they thought that it was largely reversible, the IQ problem.

But what they found in further studies is that, yes, it is reversible if you don't use heavy and too long. but it actually the IQ damage can become permanent if people use heavily for 20 or more years. And we're actually talking about a pretty large drop of IQ. How large? Six to eight points. Six to eight points, yeah. So that's a big deal.

So yeah, seven points is actually almost, you know, half a standard deviation. So what that means is you move from potentially being, you know, average to being below average IQ or if you're if you know your IQ is really high like one you know 115 one one standard deviation of the above the mean which is you know your average college student it could go down to you know 107 which is not as good which is not as good I remember telling someone this and they got so angry at me they got so angry they got so angry well and that shows you how defensive people can get when it's something that they cherish. And it's so interesting because people are like, oh, yeah, cannabis isn't addicting. But, you know, it really is. And those are

the sorts of signs that are like, okay, wait a minute. Why are you getting so defensive if you're not really addicted to it and needing it? And, you know, it's interesting, too, because another thing that they find with cannabis use, and this is true for drug use in general, but specifically for cannabis use, is that there's actually something that takes place, which is a lack of awareness. And in psychiatry, we call that, and you'll have to help me with the pronunciation because I always get it wrong,

but anisognosia, did I say that about right? Sounds good. Sounds good. And so basically it's this lack of awareness where people don't even realize the impact that the drug is having on their lives and how addicted they really are. Yeah.

Yeah. And I think when you have like decreased frontal lobe function, there is that sort of not knowing how this is affecting us type of thing that goes on, which is what you're talking about. Exactly. It's this lack of awareness, which is actually foundational for emotional intelligence. The first foundational thing that we need to have good emotional intelligence is to actually be self-aware and aware of others' emotional. states. Yeah. And one of the things is when I have like a new patient who wants to go through therapy, I highly recommend for them to get off. And sometimes like, it's like, I'll say to them things like, hey, look, go through the therapy, see if you feel better. If you don't feel better, go back on the marijuana. But at least stop while you're going through the therapy because you're, you will be more present and you'll have that ability to be aware, right, that you're talking about. Absolutely. Absolutely. And that's, and that's, and that's,

really key. And at first, when they go through that initial withdrawal phase, that can be tremendously difficult for a lot of patients. But the ones that actually do take the challenge, they end up benefiting so much because what's interesting is any kind of drug, cannabis included, is going to tend to mask a lot of the negative emotion and the things that are actually underlying. And so when they take that mask away or that barrier away, now all of a sudden, this flood of emotion and oftentimes even memories and things that they've kind of stuffed away and hid with the drug use is going to start coming up. And so even though there can be a lot of difficult emotions and irritability and anxiety that accompanies that, it's also very fruitful to actually

be able to address those things in therapy and start working through them so you can start addressing those underlying issues instead of just staying on the surface. Yeah, sometimes I'll say to people were using marijuana you know i don't there there's no shame in coming and and and and talking to me about this and like i see it as um marijuana was kind of a log when you were you know in the open ocean and there was like this one log that was floating by and you were like well i'm going to grab that log so i can float but then you get to a boat and like they're bringing down the the ladder to you And they're like, here's the ladder. And you're like, well, I got to bring up this log, you know.

And then you try to bring up the log up the ladder, but you just can't lift it, right? Because it's this huge water sunken log. And so you have to like let go of the log to be able to climb up the ladder in order to get on the boat, you know. And maybe that's the process of psychotherapy. That's the process of, you know, doing these healthy things for our body so that our brain can repair. Absolutely. I love that analogy because it really helps us. see that if you just let go of the log, I could actually help you a lot more. And I love it, too,

because it's a really empathic way of looking at it. It's not criticizing or condemning and saying, hey, look, that's the best you could find in the moment. Yet maybe there's better ways of actually dealing with your pain. Yeah. What was the biggest thing that jumped out to Victoria when you were reading through the literature? I think one of the biggest things, particularly, is how that persistent use of marijuana will not only change how your brain functions, but it really kind of changes your perception of the world and how you can really function throughout your day-to-day. There was a study that was done looking at giving synthetic cannabinoids to adolescent mice,

because typically when studies are done, we try to use animal models first before we apply it to humans. And it showed that an increased exposure of cannabinoids, again, change the DNA hypermetallation, or it basically turned off the DNA in a signaling pathway within the brain that codes for proteins that are regulators of different coupled protein receptor signaling. so basically going on about how your brain can really communicate. And so that could really change how in humans the adolescent brain works as well. And within this animal model, it showed not only but not only spatial memory disturbances, but also dose-dependent memory impairment that was seen in fear conditioning.

Yeah. So basically the visual spatial abilities decreased. and, you know, if you're an architect, if you're working in places where you need those visual spatial abilities like math requires a lot of that, it can be more difficult. And also these people who are struggling with math and they'll come to me, hey, Dr. Peter,

I'm struggling with math. And then, you know, from their history, they're also on marijuana. And then they're like, but I don't use the marijuana right before I do the math, Dr. Peter. What they don't realize is that marijuana, Then THC stays in your brain a long time. And so it may be, you know, weeks before you get that sort of full function of your brain back.

Oh, yeah. A lot of people that I talk to, when they stop using cannabis, it takes, generally speaking, at least a month before they really feel like the fog clears from their brains and they can start thinking more clearly. And again, a lot of them don't even realize how much they're living in this fog. and it has to do with that fancy word that I have a hard time saying, the anisognosia. In other words, that awareness, you often don't even realize that you're in a haze.

Yeah, I think another interesting aspect to make sure we hit is that it changes sexual function. And so, you know, we include in our article that'll go with this, but I want Victoria to kind of say a little bit about this and what she found. Okay, so there was a study. of over 8,000 people regarding cannabis use among men and women to see what kind of sexual problems they had regarding the use that they had noticed. For men, there were significant associations between daily cannabis use and reporting an inability to reach orgasm, orgasming too quickly, orgasming too slowly. And then among the men who reported reaching

orgasm too quickly, there was an association between frequent cannabis use and the extent to which it took to reach an orgasm as being problematic. Okay. And for women, not so much? For women, there was no association between cannabis use and sexual problems, interestingly enough. Yeah. And then there was also reduced sperm concentration and sperm count. So if you're trying to get pregnant, you might want to get off that.

Probably a good idea. Yeah, for other reasons as well. So, you know, one of the things I think, is really interesting and important is that the risk for psychotic disorders really goes up dramatically with cannabis use. And there's especially vulnerable populations that that's the case. But overall, in general, the risk of developing psychosis roughly doubles from around 7 in 1,000 non-users to 14 in 1,000 for regular cannabis users. And, you know, if you think about that, especially for people that have like a first degree relative, then your risk when you

have a first degree relative of developing a psychotic disorder is 10%. But if you, if that doubles now, that goes up to 20% if you're using cannabis regularly. So I think that's something really important to keep in mind. And the other piece, you know, people have looked at this in the literature and at first it was a little bit unclear is cannabis use just a result of being predisposed to psychotic disorder? In other words, do people that have psychotic disorders are they drawn to using cannabis? Or does it actually cause it?

Is it causal? So is it just associate or causal? And now in recent years, the research has been very, very clear that it is actually causal in triggering psychotic disorders. Yeah, and one of the feedbacks I've gotten from people when I present this data is, well, you're talking about big pharma in the U.S. And my response to them is actually, I'm talking, about Northern European countries who have databases of everyone in their country.

And if they're, you know, what they're doing, if they're on drugs, if they're off drugs, and they're able to create these incredible databases because they have universal health care. And they're just looking at the databases. Yeah. And so these are studies in some cases of, you know, 66,000 individuals, right? These are big meta-analysis. These are big studies. and I'm going to put this all up on my resource library for you guys to look at in more detail.

One of the other big things is the higher rate of unemployment. So, you know, someone once asked me recently, like, does marijuana really decrease motivation? And, well, I can tell you for sure that it decreases unemployment. The unemployment rate for persistent marijuana users is around 6.4 to 10% compared to non-users, which is around 1.7%. It does something to you, which causes the people who use to not want to work as much.

Absolutely. And it's interesting because they actually did a study not too long ago. It came out in 2018 where they looked at a motivational syndrome because they wanted to see, you know, does cannabis actually cause a motivational syndrome?

And what they found is that it actually longitudinally predicted lower self-efficacy even after controlling for demographics, personality, and alcohol and cigarette use. And so it, and what it did it was, again, that it longitudinally prompted lower initiative and persistence, which is a motivation, right? Right. So let me just highlight that. Like, so self-efficacy is the, sort of the perception that you have the ability to change your own outcome. Absolutely. And so it really puts you in kind of the sense of almost external locus of control.

Like I don't have, I don't feel empowered. I don't have control over my destiny. And it really makes you wanna give up before you even really start. Because why should I try if I can't do it kind of thing? Right. And so when we want someone to launch into their life, you know, if we're doing therapy with them and they're not launching, they feel stuck,

they feel like they're not moving forward, they feel like they can't do anything to move forward. And they're on marijuana, maybe the marijuana is part of the problem. Absolutely. And so along with doing some of the other psychotherapy techniques, getting them off of the substance that could be decreasing their motivation and decreasing that natural drive. And what we're talking about is self-efficacy, though,

which is the thought that they have, that they could even accomplish stuff. Exactly. So again, why even start? But then if they do start, there's also that aspect of lower persistence, too. And so we can really see that cannabis is not only going to make, get harder for people to start things, but even if they start, seeing it through is very difficult.

And persistence is really, really important because, like, let's say you're starting a new venture. It may take you seven years of really, really working hard to get to that point, you know, where it's actually producing fruit. Absolutely. You know, it's, as they say, you know, success is what, 90% the perspiration and 10% the inspiration, right? Ideas are cheap. Exactly.

Execution of ideas, very expensive. Exactly. Very difficult. Exactly. A good idea of like a well-formed company costs about $2,000 to $20,000, depending on how much the, you know, how worthy the idea is. But, you know, a company that's well executed, that could be upwards around, you know, the millions to billions of dollars, you know.

So, yeah, anything else jumping at your mind? I think we should talk about depression and anxiety. Yeah, that's actually what was just coming up for me, is I really wanting to talk about that because, again, this is one of those areas where it's been unclear whether marijuana actually predisposes people to depression, anxiety, or if people are just using marijuana because they're depressed and anxious. And it's not been until just recently that we're starting to get answers to those questions.

In the past, that there's a clear association between cannabis use and depressive disorders, bipolar disorders, PTSD and anxiety disorders, and also suicidal thoughts as well. I know Victoria found some of those studies, and I'd love to hear a little bit from her what she found on that. Sure. So as you're talking about kind of those big meta-analysis studies, and these are studies that look at a bunch of different studies and kind of compile the data, there was a study that looked over 11 different studies and comprised about 23,000 individuals. And for these cannabis users, the odds of them developing depression when they were young adults compared to users or

compared to non-users was about 1.3 times higher. The odds of them developing suicidal ideation or the thoughts of suicide was 1.5 times higher than someone who didn't use. And the actual thoughts of suicide and having a suicidal attempt was 3.46 times higher than someone who does not use marijuana or cannabis. You know, one of the things that I found really interesting here recently is that they're actually starting to do studies where they're falling people over time longitudinally to see if the cannabis does increase the risk of depression. And one study that was just published in February of this year, shows that teen use of marijuana does raise the risk of major depression and suicidal thoughts later in life. And so researchers basically found

that cannabis use during the teenage years was associated with about a 40% increase in the risk of depression and about 50% increase in risk of suicidal thoughts in adulthood. So again, you know, that prospective, longitudinal type of data that shows the causal effect of cannabis with depression. One of the other things that is interesting to think about is people often say, okay, well, if I use just a little bit, then it's not going to make that big of a difference. But they're now actually finding in some European studies that even a little bit of cannabis is not safe for teens.

They looked at the brains of 46, 14-year-old girls and boys in Europe, and they found that low levels of marijuana use, as few as one or two times actually do start changing the brain. And so these are kids that just reported using recreational marijuana just once or twice, and they actually showed increased volume on MRI, images and numerous brain regions involved in emotion-related processing, learning, and forming memories. Now, you might think, oh, it increased brain volume, so it must have helped them. But during that time, what's going on in the brain? Well, during that time, actually,

pruning. Exactly. Right. Exactly. And so if the brain size is actually increasing, that could possibly, and they're not 100% on this, but it very likely could be that that shows the pruning is not taking place properly, and the brain is actually malforming, which could be one of the reasons why later on in life, they're more predisposed to psychotic disorders, depressive disorders, anxiety disorders, suicidal thoughts, etc. Yeah, so, I mean, this is an important discussion to have,

and we're in a time where marijuana is being legalized. And so as we're going into this next phase of America, where it becomes, basically, there's going to be a lot of companies that are financially benefiting from suppressing this information. Dr. Bynes, do you have any concerns about, like, you know, research coming out that might be the opposite, being funded by these companies, or how the research is done, or any thoughts on that? Absolutely. I think one of the important things to take note of is if you back up what,

like 50 years or so, we're really kind of going through a similar process as happened with big tobacco, that there was a lot of studies that were kind of put in a hidden away or or not published or not done correctly that really didn't show us the truth about what cigarette smoking and big tobacco was actually doing to people. And I think there's a lot of that happening today. So as a provider, speaking to mental health providers, what do you think are some good steps if someone does come in with marijuana dependence? Well, I think one of the most important things when someone comes in with marijuana dependence is to really connect with them and try to understand why is it that they're using in the first place.

Is it just truly just for fun? In my experience, there's almost always a bigger reason. It's not just for fun. In other words, they're usually trying to be. to medicate something, some kind of pain. Now, a lot of people say it's physical pain, but I would say that most of the time there's at least a degree of emotional pain

that people are really trying to medicate too. And I think it's important to connect with them, to empathize with them, to really say, like you said earlier, hey, I know you're doing the best you can with this, but let's see how it's really working for you. Is it truly helping you? And really exploring that with them,

Instead of telling them, oh, all these facts about how negative marijuana is, you want to gain their trust first. You want to show them that you really have their best interest in mind. And then you want to empower them to look at the data themselves to come up with the conclusion. Because it's not very helpful to practice this autocratic type of medicine where we're just telling people what to do because really that doesn't give that sense of empowerment, which is key to a healthy psyche. We want to actually move them out of that a motivational syndrome

into more of a sense of being able to be efficacious and being able to be persistent, but that requires them making those choices and us giving them the information they need to empower them to make those healthy choices for change. That is very well said, Dr. Bynes, and I think I've learned a little bit from you in this. I look forward to other discussions in the future.

And if you're curious about the data, there'll be links in the show notes. There'll be links on my website. We'll have some, you know, like a blog written about this and then more detailed notes in the resource library. So I'd love to hear your thoughts. Shoot me a direct message on Instagram or Facebook or Twitter or reach out to me. and Dr. Bynas, are there ways that I can post in the show notes if someone wants to connect with you? Absolutely. We can put our website and there's a contact email on our website as well,

and we'd love for you to connect with what we're doing there in the Auburn, Sacramento area. All right. Thanks you, and thank you as well. Thank you. Thank you. And, you know, I was wondering, is there a couple other things that I could say just in case you want to put those in, just in case. I mean, when we talk about the effect of marijuana on social functioning, for example,

what we see is that marijuana actually increases the amount of impulsivity and hostility in daily life. There were 43 participants that were college age, and they actually showed that marijuana use was, associated with increased impulsivity on the same day and the following day of use, and that it was also associated with increased hostile behaviors and perceptions of hostility and others. So people that use cannabis actually will often be hostile towards others because they're paranoid that they're being hostile towards them, which is really interesting.

And so marijuana really has a negative effect on social functioning. The one other thing I did want to comment on is pain, because I think there's a misconception as far as the pain relief that can occur with marijuana. And one of the things that they found is that the pain relief effect for people is actually minimal, and in the long run, there's some studies, there was actually a large, longitudinal study that was done from Australia last year that actually showed that in the long run, it didn't help physical pain at all. And it didn't decrease the use of opioids either. And so a lot of people excuse cannabis and they say, oh, well, you know, maybe, okay, I see what you're

saying about the mental health part, but they don't really realize that, and they say, well, I'm still using it for pain, physical pain, but they don't realize in the long run, it doesn't really help physical pain either. Yeah. I'll have people come into my program and they want help with physical pain and getting them off of, you know, the marijuana and allowing them to process through psychological ways of actually addressing the pain has been really, really helpful. And, you know, I'm not saying that all pain occurs, you know, in the mind as in people are making it up. I'm just saying that there are psychotherapy techniques and ways of addressing emotions and the meaning of emotions that changes the way we experience pain. Absolutely. And that's really what we need to be

looking at is helping people to deal with those root factors as best we can and not just medicating it away with cannabis, which in the long run sometimes can worsen the problems, both emotionally and even physically. All right. Well, let's leave it there. Thank you.