Considering Cannabinoid-Based Medicines for Mental Health

By Lucile Rapin, PhD

Today I woke up feeling blue, feeling stressed. I consider myself privileged, I have a job I enjoy, a healthy family and social circle I love and a comfortable house to live in. So why from one day to another, can I feel happy, ready to get things done, then anxious and stressed about my day to come? This is all part of mental health; mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO). Mental health affects the emotional, social and psychological domains of our life. It has an impact on how we think, how we feel, how we act, how we communicate.

Mental health used to be only considered in terms of disorders, such as those described in the Diagnostic and Statistical Manual of mental disorders (DSM-V, 2013). However, mental illnesses and mental health are different. You can be free of a mental illness and still have poor mental health.

The COVID-19 pandemic emphasized the importance of mental health in every individual as billions of people fell into confinement, greatly affecting their mental health status. Health workers and essential workers on the front-line during the pandemic were even more affected. A survey conducted in Canada showed that “one in four (25%) Canadians aged 18 and older screened positive for symptoms of depression, anxiety or posttraumatic stress disorder (PTSD) in spring 2021, up from one in five (21%) in fall 2020”(Statistic Canada, 2021).

The pandemic also highlighted the critical need for the government to provide better, more affordable, and faster access to mental health services. In Quebec, the current wait time for a public sector psychological consultation can be up to two years, which is problematic, as people seeking help may be in crises, and mental health conditions are likely to deteriorate during that time.

This is why the theme for the 2021 world mental health day was “Mental health care for all: let’s make it a reality”.

At Santé Cannabis we recognize the need for multi prong approaches to mental health and wellbeing; that there is a need for therapy, medication, community, education, mindfulness, support and more in an individualized approach for each specific person. At Santé Cannabis we try to provide our patients and their community with as many of these supports as possible, but our primary ability is in providing access to trained professionals who can help people navigate medical cannabis to improve their mental health.

How can Cannabinoid-Based Medicines (CBMs) Help?

After years of tabous and marginalisation, mental health issues are now being discussed at the forefront and finally considered. CBM research is riding the wave with an increasing number of studies on the topic. Whereas we acknowledge many mental health symptoms and mental illnesses exist, the following sections will detail research on cannabinoid-based medicines (CBMs) and anxiety, depression, and post-traumatic stress disorder (PTSD). For those interested in reading more about current evidence on other mental health and psychiatric disorders, such as schizophrenia, attention-deficit hyperactivity deficit or bipolar disorder, several recent reviews have been published (Black et al., 2019; Sarris et al., 2020; Scherma et al., 2018).

Anxiety and Depression in the Literature

As seen in the recent Statistic Canada survey, anxiety and depression are the most frequent mental health conditions experienced by Canadians. Despite limited clinical evidence from randomized clinical trials many observational studies show that mental health symptoms are the second reason for CBM use after chronic pain (Bonn-Miller et al., 2014; Lintzeris et al., 2020; Lucas et al., 2017).

Santé Cannabis recently published a blog post on anxiety and CBMs, discussing what anxiety is and how CBMs may be a treatment to consider. CBMs generally contain diverse concentrations of the primary cannabinoids, Δ9-tetrahydrocannabinol (THC), and cannabidiol (CBD). Even though the exact mechanism of action is still not fully understood, CBD has shown to have anxiolytic (anti-anxiety) effects (Campos et al., 2012). Multiple clinical trials indicate a reduction in subjective anxiety ratings with CBD intake compared to placebo in response to an anxiety-provoking stimulus (Zuardi et al., 2017; Bergamaschi et al., 2011; Skelley et al., 2020 for a review on CBD and anxiety disorders).

There is scarce scientific literature to address the relevance of CBMs for the treatment of depressive disorders (Turna et al., 2017). On the other hand, patients frequently use cannabis for medical purposes for the relief of depressive symptoms, and 7 out of 9 cross-sectional studies on medical cannabis reported mood improvement (Walsh et al., 2017).

Besides, improvements in mood were generally reported in studies assessing medical cannabis for chronic pain, multiple sclerosis, HIV, and other conditions (Ellis et al., 2009; Lahat et al., 2012; Page & Verhoef, 2006; Ware et al., 2015)

Anxiety and Depression in our Clinical Experience

Observational evidence from Santé Cannabis patients are in line with the literature. Across the dataset of 1,342 Santé Cannabis patients assessed between 2017 and 2019, 5.4 % of patients have a primary diagnosis related to mental health. However, 59% of patients have identified anxiety or mood-related secondary symptoms. Furthermore, anxious and depressive symptoms frequently co-occur in patients with a primary diagnosis related to chronic pain: 73% of Santé Cannabis patients with a primary diagnosis of chronic pain also have anxiety or mood-related secondary symptoms.

In a recent study, we also showed that patients reported decreased anxiety scores after three months of CBD treatment (Rapin et al., 2021).

Post-Traumatic Stress Disorder in the literature

Post-Traumatic Stress Disorder (PTSD) is characterized by the exposure to trauma and symptoms such as intrusive memories, avoidance of distressing factors, increased arousal and alteration of mood/cognition. Nightmares and sleep disturbances are very frequent. PTSD can affect an estimated 9.2% of Canadians in their lifetime, with the disorder twice as prevalent in women compared to men (Katzman et al. 2014).

CBMs are becoming more recognized as a potential treatment for PTSD symptoms; trials conducted on nabilone and THC have demonstrated some benefits in improving sleep disturbances, but larger and longer trials (and more randomized controlled trials) are needed to provide good-quality evidence for cannabinoids’ use in PTSD.

That being said, there are increasing reports of patients self-treating with cannabis as well as anecdotal evidence and case reports that cannabis could reduce PTSD symptoms (Hindocha et al., 2020; Fernández-Ruiz et al., 2020). Anecdotal evidence may not be as scientifically or clinically lauded; but when little evidence from randomized controlled trials is available, anecdotal data should not be disregarded. Even-though, research is still in its infancy and has not yet found the exact cannabinoid formulation to alleviate patients’ PTSD-related symptoms, current trial results indicate promising therapeutic avenues that should be considered.

Post-Traumatic Stress Disorder in our Clinical Experience

“I feel a tremendous amount of compassion for people living with post-traumatic stress disorder.

Since working at Santé Cannabis, I’ve been fortunate to be able to learn so much more about this condition during my interviews with patients with this diagnosis. What has stuck with me the most is all the areas of life that are affected by this disorder. I think of the nightmares, the anger, the pain, the vivid images that keep coming back, and the severe anxiety that prevents one from functioning but also makes interpersonal relationships very difficult.

I think of one veteran in particular that I interviewed several years ago. He told me about having to make a few rounds around his house every night before he could go to bed. He also told me about all his former colleagues and friends that had PTSD and took their own lives because they couldn’t find a way to regain a reasonable quality of life. He had heard about medical cannabis from a veteran friend who said he had found a lot of relief from taking CBD oil. The patient I was evaluating was very shocked by this as he had been against cannabis all his life and after 20 years of researching and trying to find what would help him with his PTSD symptoms, he could not believe that the answer could be cannabis!

What I can say is that, In my practice and that of many of my colleagues, we indeed see significant improvement in many of these patients with medical cannabis.” – Andrée Charbonneau, RN

During Dr. Howard Mitnick’s workshop at the Conference on Cannabinoid-based medicine on May 5th, 2021, Dr. Mitnick also shared his clinical experience with medical cannabis and post-traumatic stress disorder. In his clinical practice, particularly in 2016 when many soldiers deployed to Afghanistan returned, Dr. Mitnick said he was impressed by the very significant impact medical cannabis had on patients that were struggling with PTSD-related anxiety, grasping at anything to just stop their brain.

Despite this, statistics show that the Quebec population is under-represented in Canada’s pool of patients with access to medical cannabis and veterans are no exception, regardless of the extensive Veterans Affairs Canada coverage.

We also know that many veterans who have had a prescription do not have support from medical professionals to navigate their medical cannabis. We want to help improve this situation. That’s why we offer educational presentations open to the public to inform people living with post-traumatic stress disorder about this treatment option, and to let them know about our services and our mission.

Next for CBMs and Mental Health Disorders

This brief overview on a few mental health disorders and symptoms demonstrates the pressing need of more research to evaluate and assert the impact of CBMs on such disorders. Increasing evidence points towards a beneficial effect of CBD on anxiety symptoms, however there is still little evidence for depression. THC may reduce PTSD symptoms but again, current evidence is too low to definitively conclude.

We know that regardless of the formal, scientific evidence, people are using medical cannabis to treat their mental illness and try and improve mental health. We believe in empowering people to make the best decisions with the best evidence, and therefore we need continued study in this critical area.

While evidence is still weak, results are encouraging for future research to take place. The favorable safety profile of CBMs, compared to anxiolytics and antipsychotics for example, as well as the observational reports of patients mentioning decreased symptoms and improved quality of life following CBMs are to be considered to those resistant to further pursuing research on the topic.

While we wait for strong clinical evidence to support the potential of CBMs in mental health disorders, mental health symptoms are still occurring in many people, negatively affecting their everyday life.

The testimony of one of our patients illustrates accurately the impact of mental health symptoms on everyday life:

“It took me a while to admit it to myself, but I have lived with a lot of anxiety since a very young age. This anxiety has had an impact on my ability to work and on my interpersonal relationships, not to mention the immense impact on my body: from daily painful tensions to gastrointestinal difficulties. However, I can say that recognizing anxiety has allowed me to better manage it, to regain my quality of life and my self-esteem.

I had to learn to say no to others, but also to myself. I learned to reduce my financial needs so that I could work less and have more time to invest in my general health.

I felt guilty about this and felt like an “imposter” who could have done better. However, my family doctor was very helpful in validating my feelings and praising me for taking care of myself. Just the fact that she took this approach with me was very helpful in accepting myself and my limitations.

I think the support of my friends and my doctor made all the difference.”

– Nancy Raymond, Santé Cannabis patient

We know that mental health is extremely complex and even with treatments demonstrated for use through rigorous research people regularly need to trial and error a combination of treatments to find what works for them and this may change over their lifetime. Adding another treatment to this cause could be the treatment that works for the next person.

In our clinical practice we have enough data to make informed decisions with our patients, understand drug interactions, and watch for contraindications. We spend time learning about each person before providing an individualized treatment plan and providing regular follow-up – with the objective to ensure that their CBM plan is working towards their mental health goals without side effects. We also know that many people continue to self-treat and may not understand the complexity of using CBMs to treat mental health issues. Mental health is health and needs to be treated with the same level of care and follow up as any other health condition and new medication treatment. We encourage the training of healthcare professionals to understand medical cannabis in the treatment of mental health issues, and support research to improve our evidence-base as we all work together to ensure that patients’ mental health is treated properly.

Conclusion

Mental health plays a significant role in our life, it is crucial that it is taken seriously by both the individuals and governments. Health is not simply the absence of disease, it is a complete state of physical, mental and social wellbeing (WHO) and for many of us, the past 2 years have highlighted the important role our mental and social wellbeing play in our daily experience.

For me, when I start feeling anxious, I step away from screens, take a walk in my neighbourhood and try to put things into perspective – these are strategies I developed that work for me. Some days even that is hard to prioritize, yet I have learned that it is essential to listen to my wellbeing and adjust my day to ensure favorable mental health.

I’m fortunate that these strategies work for me, but in my life, work and research, I know that these strategies don’t work for everyone. For some, it can be helpful to have positive and good-hearted social interactions, satisfying sleep and eating habits, exercise, outdoors, work-family balance, and mindfulness. For others it may be the support of professionals with group or individualized therapy, and/or medication. At Santé Cannabis we hope that among the medications considered for mental health are CBMs, and we encourage further research, and for those interested in trying CBMs to reach out to their doctor.

If you feel deterioration in your mental health it is important to seek help:

At Santé Cannabis, our clinicians and nurses are here to help our patients find the right treatment for their symptoms. We also offer our patients support groups, presentations and tools including stress management and mindfulness.

Santé Cannabis is committed to advancing knowledge about mental health and cannabinoid-based treatments, and as such, we offer research services to companies and institutions interested in developing clinical studies.

For clinicians currently treating people with mental health symptoms who wish to include medical cannabis in their practice, our preceptorships are available to all local and international physicians. For prescribers in Quebec, we also offer a free training program on cannabinoid-based treatments and how to prescribe them.

Author: Lucile Rapin avec le soutien de Charlotte Bastin et Eva McMillan