From the Editor
He smokes before bed to help with sleep; she finds that the edibles take an edge off from her lows.
Our patients routinely tell us about the benefits of cannabis for mood disorders. But is there any evidence in the literature? In the first selection from The Canadian Journal of Psychiatry, Dr. Smadar V. Tourjman (of the Université de Montréal) and her co-authors consider that question with a systematic review, drawing on data from 56 studies, focused on bipolar and major depressive disorders, for a CANMAT task force report. They conclude: “cannabis use is associated with worsened course and functioning of bipolar disorder and major depressive disorder.” We consider the paper and its implications.
In this week’s second selection, we look at new Quick Takes podcast interview with Dr. Thomas Insel (of the Steinberg Institute). Dr. Insel, a psychiatrist and former director of NIMH, speaks about the progress in neuroscience but the need for mental health reform. “We must think about more than just the classic medical model borrowed from infectious disease: simple bug, simple drug.”
Finally, in the third selection, Mila Kingsbury (of the University of Ottawa) and her co-authors consider the risk of suicidality among trangender and sexual minority adolescents; they draw from a nationally representative, cross-sectional survey. “Gender and sexual minority adolescents, particularly those who identify as transgender and gender-nonconforming, appear to be at greater risk of suicidal ideation and suicide attempt than their cisgender and heterosexual peers.”
There will be no Reading next week.
Selection 1: “Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Report: A Systematic Review and Recommendations of Cannabis use in Bipolar Disorder and Major Depressive Disorder”
Smadar V. Tourjman, Gabriella Buck, Didier Jutras-Aswad, et al.
The Canadian Journal of Psychiatry, 19 June 2022 Online First
Bipolar disorder (BD) and major depressive disorder (MDD) are common conditions, with a Canadian lifetime prevalence of 11.3% for major depressive episodes globally and 0.87% for BD-I and 0.57% for BD-II. Interactions between cannabis use (CU) and mood disorders are complex: CU may contribute to psychopathology, which may in turn lead to CU. In addition, underlying factors may contribute to both mood disorder psychopathology and CU. In the United States, past-year CU by adults more than doubled between 1991 and 1992 and 2001 and 2002 (4.4% – 9.5%) and increased in more recent studies. In Europe, reported lifetime CU (LT-CU) varies from 0.7% in Turkey to 40.9% in France.
In view of the prevalence of CU, the Canadian Network for Mood and Anxiety Treatments (CANMAT) constituted a task force to assess the association between CU and BD and/or MDD, with the aim of providing recommendations regarding CU for people with mood disorders.
Here’s what they did:
“We conducted a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials from inception to October 2020 focusing on cannabis use and bipolar disorder or major depressive disorder, and treatment of comorbid cannabis use disorder. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence and clinical considerations were integrated to generate Canadian Network for Mood and Anxiety Treatments recommendations.”
Here’s what they found:
- The database review yielded 12,691 studies.
- With the elimination of duplications and review of the texts, they selected 56 studies: 23 on bipolar disorder, 21 on major depressive disorder, 11 on both diagnoses and 1 on treatment of comorbid cannabis use disorder and major depressive disorder.
- “Of those with cannabis use, 2,761 had bipolar disorder and 5,044 major depressive disorder.”
- Prevalence. “The lifetime prevalence of cannabis use was 52% – 71% and 6% – 50% in bipolar disorder and major depressive disorder, respectively.”
- Course. “Cannabis use was associated with worsening course and symptoms of both mood disorders, with more consistent associations in bipolar disorder than major depressive disorder: increased severity of depressive, manic and psychotic symptoms in bipolar disorder and depressive symptoms in major depressive disorder. Cannabis use was associated with increased suicidality and decreased functioning in both bipolar disorder and major depressive disorder.”
- The recommendation. “Considering the consistent signal for the deleterious effects of cannabis in BD and based on the clinical experience of experts, CANMAT provides a strong recommendation against CU use in this disorder. On the other hand, the inconsistency of the signal regarding the effects of cannabis in MDD contributes to a qualified level of recommendation against its use in this disorder”
A few thoughts:
1. This is a big paper.
2. It’s also well written and well researched, with 75 citations.
3. The CANMAT recommendations are clear.
4. Clinicians may find it useful to read this paper; we may also choose to give it to our patients.
5. The authors note several limitations, including: “Although this review was rigorous and systematic, the data available was highly variable and of mostly low quality. The amount of cannabis used was variably quantified, with different cut-off points to determine frequency of use, and often relied on retrospective recall.” The authors also note that CBD wasn’t considered separately from THC.
6. In terms of cannabis research, then, we are in the early days. Still, the study is consistent with other work in the area.
7. Cannabis has been considered in past Readings; for example, the Hill et al. review, published in The American Journal of Psychiatry, which included 850 papers. You can find that Reading here:
The full CJP paper can be found here:
Selection 2: “An Interview with Dr. Thomas Insel, former NIMH director”
Quick Takes, June 2022
In this episode of Quick Takes, I speak with Dr. Thomas Insel, a psychiatrist who served as the director of NIMH. Dr. Insel oversaw $20 billion of funding during his years at NIMH and advised several US Presidents. But if he feels that neuroscience has advanced, he notes the deep problems with mental health care. We discuss this problem. And, yes, we do talk about being on a first name basis with President Obama.
I highlight from the conversation:
On his epiphany
“[During my presentation,] I showed how we had made great advances with stem cells, genomics and the Brain Initiative…
“Afterwards, somebody got up and said, ‘Man, you just don’t get it. My son has schizophrenia. He’s 23. He’s been hospitalised several times. He’s been in jail several times. He’s currently homeless, eating out of a trash can. Our house is on fire, and you’re talking about the chemistry of the paint.’ And that was really kind of an epiphany for me…”
On mental health care
“In the years I was at NIMH, the suicide rate in the United States went up 30 percent, and overdose death went up 300 percent. The number of people with serious mental illness who were working, who were housed, who were not incarcerated, all those numbers went down, not up.”
On the 3 P’s of recovery
“I was talking to a psychiatrist who works on Skid Row in Los Angeles and he said, ‘You know, Tom, if you really want to make a difference, stop thinking about diagnosis and symptoms, start thinking about recovery.’ He said, ‘it’s simple. It’s just the three P’s.’ And I thought, you got Prozac, you got Paxil or psychotherapy. He said, ‘No, it’s people, place and purpose. Social support, a decent environment with housing and food and things that help people to prosper. And people will have to have something to live for.’”
On a different approach
“The problems that we’re dealing with are categorically different. That was not where I was when I started the book, which was to make the case that there’s nothing different about mental illness – it is just a medical problem like diabetes or hypertension. That’s not where I ended up. I think it is different and we should be different. But that means preserving what we do really well, and that includes this kind of whole-person approach. That’s just thinking about more than a reduction of symptoms (what medicine does). Thinking about more than just the classic medical model borrowed from infectious disease: simple bug, simple drug. We should be doing that as well, but we can, and we should do so much more.”
The above answers have been edited for length.
The podcast can be found here, and is just over 22 minutes long:
Selection 3: “Suicidality among sexual minority and transgender adolescents: a nationally representative population-based study of youth in Canada”
Mila Kingsbury, Nicole G. Hammond, Fae Johnstone and Ian Colman
CMAJ, 6 June 2022 Online First
Transgender youth are those whose gender identity does not match their sex assigned at birth. Among other terms, gender-nonconforming, nonbinary, genderqueer and genderfluid are used to describe the gender identity of a subset of young people who identify outside the gender binary (i.e., as neither male nor female) or who experience fluidity between genders. Suicidality among transgender and gender-nonconforming adolescents is not as well studied. In a Canadian survey of transgender and gender-nonconforming youth aged 14 – 25 years, 64% of participants reported that they had seriously considered suicide in the previous 12 months. Transgender and gender-nonconforming youth seem to have a higher probability of many risk factors for suicidality, including peer victimization, family dysfunction and barriers to accessing mental health care. However, the epidemiology of suicidality among transgender and gender-nonconforming youth remains understudied in population-based samples; most research on the mental health of transgender youth comes from small community samples of help-seeking youth or targeted surveys of transgender adolescents. Two population-based studies from California and New Zealand suggested that transgender youth are at increased risk of suicidal ideation and suicide attempt. However, only the New Zealand study used the gold-standard measure of gender identity, contrasting adolescents’ sex assigned at birth with their self-identified gender.
So begins a paper by Kingsbury et al.
Here’s what they did:
“We analyzed a subsample of adolescents aged 15 – 17 years from the 2019 Canadian Health Survey on Children and Youth, a nationally representative, cross-sectional survey. We defined participants’ transgender identity (self-reported gender different from sex assigned at birth) and sexual minority status (self-reported attraction to people of the same gender) as exposures, and their self-reported previous-year suicidal ideation and lifetime suicide attempt as outcomes.”
Here’s what they found:
- 6800 adolescents were included, aged 15 – 17 years.
- Most were cisgender (99.4%); some (0.6%) were transgender.
- Sexuality and gender. “Most respondents were classified as heterosexual (78.6%). The largest sexual minority category identified was of adolescents attracted to multiple genders (14.7%), followed by those unsure of their attraction (4.3%)…”
- Suicidal ideation. “Overall, 14.0% adolescents experienced previous-year suicidal ideation, and 6.8% had attempted suicide in their life.”
- “Compared with cisgender, heterosexual adolescents, transgender adolescents showed 5 times the risk of suicidal ideation (58% v. 10%) and 7.6 times the risk of suicide attempt (40% v. 5%).”
- “Among cisgender adolescents, girls attracted to girls had 3.6 times the risk of previous-year suicidal ideation (2.59 to 5.08) and 3.3 times the risk of having ever attempted suicide (1.81 to 6.06), compared with their heterosexual peers.”
- “Adolescents attracted to multiple genders had 2.5 times the risk of suicidal ideation (2.12 to 2.98) and 2.8 times the risk of suicide attempt (2.18 to 3.68).”
- Risk of suicide attempts. “Youth questioning their sexual orientation had twice the risk of having attempted suicide in their lifetime (1.23 to 3.36).”
A few thoughts:
1. This is good and important paper in an under-researched area.
2. A one-sentence summary: “Gender and sexual minority adolescents, particularly those who identify as transgender and gender-nonconforming, appear to be at greater risk of suicidal ideation and suicide attempt than their cisgender and heterosexual peers.”
3. Practical implications? “Suicide prevention programs specifically targeted to transgender, gender-nonconforming and sexual minority adolescents, as well as gender-affirming care for transgender adolescents, may help reduce the burden of suicidality among this group.” Thoughtful.
The full CMAJ paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.