In this series of columns, we will address cannabis and mental health. Unlike other illnesses and conditions where cannabis has some good data to support its use, mental health concerns are not as clear cut. Psychiatrists and psychologists often warn of the dangers of using cannabis by people with underlying mental illness. We will look at the pros and the cons. Today we will look specifically at cannabis and
Cannabis and Depression
First, we must ask the following, very basic question: Which came first – the depression or the use of cannabis? It’s like the chicken and the egg. Because cannabis use and depression are both very common, it is hard to draw definitive conclusions about cause and effect.
One of the key issues revolves around how depression is diagnosed. We all know what it feels like to be blue or down-in-the-dumps. This is not the medical definition of depression. To be diagnosed with depression, an individual must suffer from persistent sad feelings, lack of interest in activities they once enjoyed, have feelings of worthlessness and may or may not have physical symptoms such as weight gain or loss, headaches, chronic pain or gastrointestinal complaints. These symptoms must cause distress to the individual and interfere with their daily functioning.
Suicidal ideation or having a “death wish” is not necessarily required for the diagnosis. For a formal DSM-5 diagnosis, there must be five or more of these symptoms that reflect a depressed mood and loss of interest/pleasure lasting for at least two weeks. Some of the articles about cannabis and depression refer to major depressive episodes like this, but others use much broader definitions of depression, often self-diagnosed.
There are depressed people who are high-functioning and keep their suffering inside of themselves while behaving “normally” in front of others. Some depressed people are agitated and irritable, and some are stuck in bed and cannot even muster the energy to get up and get out. These varied presentations of depression complicate both diagnosis and treatment. In addition, given the stress of the world with COVID, political strife, financial problems and global climate change, rates of situational depression have skyrocketed.
People with all types of depression often self-medicate with food, alcohol, drugs, sex and exercise to name a few, but commonly, with cannabis. They do so to avoid needing to see a doctor or because they do not have the means to go to a doctor or the thought of trying to find the right doctor is overwhelming. I often hear that these people want to avoid being offered anti-depressant medication. The stigma around mental health diagnoses and the medications used to treat these disorders interferes with seeking out treatment.
For all these reasons, depressed individuals, particularly adolescents who are suffering from depression, often turn to cannabis for relief. More than likely, the cannabis is helping to manage the sadness and mood alternations that they suffer from, but, cannabis, like some anti-depressant medications, may not treat the underlying condition, but rather flatten the emotional suffering of the depression. Think of it like a bandaid covering up a cut, but not making it heal. Unfortunately, due to the development of tolerance to THC over time, some of these sufferers end up using more and more marijuana to support their mood and this may contribute to the risk of cannabis use disorder.
There are some experts who believe that cannabis actually causes depression, or, at the very least, worsens it. This is debated. In a 2019 meta
Those who believe that cannabis use contributes to depression point to the fact that more teens who attempt suicide will report recent cannabis use. This could be true, but we need more research to be certain, and the federal government makes it almost impossible to do that research. Unfortunately, we do not have data on the number of depressed youth who never interact with the healthcare system and use cannabis successfully and then abandon it later as they mature and no longer suffer from the depression.
Age is a Factor
Looking at depression in midlife people yields different findings. In a Swedish study evaluating women and cannabis at different ages, there was definitely an association of cannabis use and anxiety and depression. A Canadian study showed that women who use cannabis very regularly also report more anxiety and depression. When reaching perimenopause, many women turn to cannabis to alleviate some of the complaints, especially mood-related issues. As a gynecologist and a cannabis physician, I have seen success. It is my belief that the cannabis helps to manage anxiety and stress which, in turn, helps tolerate things like hot flashes and irregular menstruation. This is called anecdotal medicine and is frowned upon because it is just an observation and not a proven effect by standardized research.
It will take a long time to solve the conundrum of depression and cannabis. Even if the government makes it easier to study cannabis, it is extremely complex. For example, anxiety and depression go hand in hand. How do you prove the cannabis helps to manage one over the other when they are so often found together and overlap in symptoms? Also, the many forms and strengths of cannabis used introduce even more complexity, not to mention that a lot depressed people are on a variety of allopathic medications to treat their mood that may have an impact on the way their cannabis works.
So, What Do We Know?
We may never get to the very bottom of the cannabis-depression relationship. We may have to live with the fact that many people feel cannabis helps their mood and, support their use, unless they develop cannabis use disorder. Imagine being concerned that a person who takes a daily anti-depressant pill might be “addicted” to it. Seems absurd, right? If that same person uses daily cannabis, is never impaired, performs at their job, and is a good spouse and parent, we would say that they are a cannabis addict? I think not. But we are in a transition time where people who were taught that cannabis is the same as heroin are coexisting with people who partake daily as “background noise.”
I only hope I am still around to watch the evolution. My prediction is that one day, allopathic drug companies will take this wonderful, natural remedy and compress it into a once-a-day pill, with specifically controlled dosages and add it to the current armamentarium of anti-depressants. That would make a lot of researchers very happy, but it would definitely take away from the cannabis use experience that can be an essential part of its efficacy.
Until then, if you are a wake-and-bake individual who manages their mood with daily use, consider taking a tolerance break now and again if your consumption is escalating, and use diet, exercise, therapy and personal support systems to maximize positive outcomes.