Keywords
perceptions - motivations - cannabis - mood disorders - anxiety disorders
Introduction
In October 2018, Canada became the second nation to legalize the consumption of
cannabis [1]
[2]. This was associated with increased cannabis use (CU), particularly
among young adults, and about 6.2 million Canadians aged 15 years and above
(approximately 20%) reported using cannabis in the last three months, which
increased from 14% before legalization and from 17.5% post-enactment of legalization
[3]. A substantial proportion of cannabis
users perceive cannabis as non-harmful and even beneficial for mental health despite
limited supporting evidence [4]. Prior to the
legalization in 2018, Canada also pioneered access to medical cannabis programs more
than two decades ago [5].
The cannabis plant includes numerous cannabinoids; major constituents are
Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC induces psychotropic
effects like euphoria and relaxation [6]
[7]
[8].
THC use has been associated with cognitive dysfunction, a potential increase in
anxiety symptoms, or psychotomimetic effects, while for CBD, a non-psychotropic
cannabinoid, antioxidant, anticonvulsant, anti-inflammatory, and neuroprotective
properties, have been described [9]. Despite
some potential benefits, evidence predominately suggests that CU is linked to
negative mental health outcomes. Regular to heavy users face a quadrupled risk of
developing psychosis, with findings suggesting a dose-risk relationship [10]. Chronic CU has been linked to impairments
of motivation, energy, and cognitive function, including learning and memory [11]
[12]
[13]
[14]
[15].
Conversely, cannabinoids hold promise in treating certain conditions like chronic
pain, neuropathic pain, chemotherapy-induced nausea/vomiting, AIDS-associated
anorexia, and spasticity associated with multiple sclerosis [16]
[17]
[18]
[19]
[20].
Individuals with mood disorders show elevated rates of CU and cannabis use disorder
(CUD) compared to the general population, and multiple cross-sectional studies have
linked depression to CU [21]. Early CU
initiation (before age 18) appears to correlate with higher risk and earlier onset
of major depressive disorder (MDD) [22], and
heavy CU can increase the risk for depression [23]. Although MDD incidence does not appear to increase in cannabis
users, baseline MDD has been linked to CU initiation, suggesting a
"self-medication" approach [24].
Bipolar disorder (BD) has been associated with frequent CU and higher comorbid CUD
compared to the general population [23]
[25]
[26].
Anxiety disorders and obsessive-compulsive disorder (OCD) have been shown to be
associated with cannabis misuse, even after adjusting for anxiety, depression, and
stress [27].
To explore the patterns and motivations of CU, researchers have adopted motivational
models akin to those used in alcohol and tobacco studies [28]
[29]
[30]
[31]
[32]
[33]
[34]. These models acknowledge diverse motives
for cannabis use, considering addictive use, withdrawal, craving, and psychological
distress [28]. These results enhance
understanding of comprehensive CU behavioral models and associations with
risk/clinical factors. It has been reported that individuals with mood disorders
using cannabis for therapeutic purposes (CTP) predominantly seek relief from anxiety
(99%), sleep (93%), and depression (92%), along with other symptoms such as pain and
appetite [35]. Studies have also highlighted
expected relief of posttraumatic stress disorder (PTSD) symptoms, in particular
intrusive symptoms, with CU [36]
[37], while individuals using cannabis for PTSD
anticipate negative effects such as cognitive impairment [38]. CU as a coping strategy for negative
affect and insomnia has been linked to CUD risk in veterans with PTSD and MDD [39], though this has not been consistently
observed in non-veteran adults [40]. Reasons
for CU frequently include psychological concerns (PTSD, depression, anxiety, sleep,
chronic pain), followed by other health motives (appetite, pain, nausea, muscle
spasms, seizures) [35]
[40]
[41]
[42]
[43].
The high prevalence of CU among individuals with mood and anxiety disorders despite
opposing scientific and clinical evidence in the context of cannabis legalization
and access to medical cannabis programs in Canada indicates an urgent need to
enhance knowledge and understanding of CU in these vulnerable populations who are
potentially at higher risk of adverse effects and outcomes. Existing literature
mainly consists of correlational, quantitative studies, lacking detailed insights
into motivations, contexts, and changes over time associated with CU in individuals
with mood and anxiety disorders. Thus, our qualitative research approach employed
in-depth interviews on motivations, expectations, and effects of CU in individuals
with mood and anxiety disorders to address this knowledge gap and to inform health
care and policies, identify risk factors and patterns, and aid the development of
targeted education and intervention.
Methods
The study is reported in accordance with the Consolidated criteria for reporting
qualitative research (COREQ) [44].
Participants
Thirty-six participants were recruited and completed in-depth interviews at CAMH
between January 2022 and March 2022. Inclusion criteria were age 18 years and
older, being a patient of CAMH with a reported diagnosis of mood disorder
(depressive or bipolar disorder), anxiety disorder, OCD, or PTSD, and current
CU.
Procedure
The study was approved by the Research Ethics Board of the Centre for Addiction
and Mental Health (CAMH) in Toronto, Ontario, Canada (REB# 040/2019).
Participants were recruited from the mood and anxiety program at CAMH, and
written informed consent was obtained from all participants. Due to
COVID-19-related restrictions, written consent was obtained using
virtual/electronic platforms WebEx and RedCap. Participants completed one
qualitative interview. Interviews were conducted virtually using WebEx.
Participants received compensation for their time.
Data collection and analysis
A semi-structured interview guide consisting of 19 questions divided into three
major sections was used: A) reasons and motivations for CU, B) expectations and
perceptions of the effects of cannabis, and C) cannabis purchasing trends and
sources of information related to cannabis. Each section included suggested
prompts to stimulate the discussion. Study data was coded by a graduate research
assistant (AD) using NVivo software (NVivo 12 Plus, QSR International) and
evaluated using codebook analysis. Following the completion of data collection,
transcription, and familiarization, the codebook was inductively developed by AD
under the supervision of a senior investigator (SK). Transcripts were then coded
into codebook categories.
The first two sections of the interview (A) reasons/motivations and B)
expectations/perceptions of CU) were further explored under four broad themes:
(1) initiation phase, (2) continuation/post-initiation phase, (3) maintenance
phase, and (4) consideration to discontinue. The interview questions aimed to
explore how motivations/reasons and expectations/effects of CU changed over
time, from the time of initiation to the present. For the initiation phase, the
interview focused on the period prior to initiating CU, for the continuation
phase, it explored aspects related to continuing CU after initiation, and for
the maintenance phase, it evaluated the time period of ongoing cannabis use
until the present time/time of participation in this study. In addition,
participants were asked about considerations to discontinue cannabis. In the
third section of the interview C), three additional themes were explored: (1)
purchasing trends and Sources of cannabis products, (2) sources of information
on CU (including information on medicinal use), and (3) type and preferences of
cannabis products.
The interview was designed to allow participants to provide multiple
answers/responses to questions, e. g., various perceived effects of cannabis. In
the manuscript, we report a total number of specific responses. Results are
reported with representative participant quotes to illustrate the themes
generated from the data.
During codebook formation, interesting aspects emerged with respect to
differences in reasons/motivations of individuals who initiated cannabis before
the age of 18 compared to individuals who were older at that time, and
differences in effects of CU reported by individuals who consumed cannabis
frequently compared to individuals who consumed cannabis occasionally. Manual
coding was done to analyze and report these aspects.
Research team positionality
The interviewer and analyst of this study was a female physician with a South
Asian background with medical education completed in India, holding a position
as Graduate Research Assistant at the Centre of Addiction and Mental Health.
Results
Participant characteristics
The characteristics of participants are summarized in [Table 1].
Table 1 Participant characteristics.
|
N (%) or Mean (SD)
|
|
Reported mental health diagnosis
|
Major depressive disorder: 29 (80.55%)
|
|
Generalized anxiety disorder: 26 (77.77%)
|
|
Bipolar disorder: 5 (13.88%)
|
|
Posttraumatic stress disorder: 5 (13.88%)
|
|
Obsessive-compulsive disorder: 3 (8.33%)
|
|
Social anxiety disorder: 2 (5.55%)
|
|
Frequency of cannabis use
|
Daily to multiple times daily: 10 (27.78%)
|
|
Weekly or bi-weekly: 16 (44.45%)
|
|
Monthly: 6 (16.66%)
|
|
Duration of cannabis use
|
Mean: 13.19 years
|
|
(SD: 6.81; min 5 years, max 30 years)
|
|
Age at first/onset of cannabis use
|
Mean: 19.56 years
|
|
(SD: 8.88; min 12 years, max 60 years)
|
|
Age+<+18 years at first/onset of cannabis use
|
18 (50%)
|
|
Mental health symptoms present at the time of initiation
|
31 (86.11%)
|
SD=Standard Deviation.
Initiation Phase
Motivations and reasons to initiate cannabis use
-
Curiosity and peer pressure
Most participants (n=29, 80.6%) reported they initiated cannabis due to
peer pressure (n=11, 37.9%) or curiosity (n=18, 62.1%). For example,
participants stated “it was a cool thing to do in high school”
and that it made them feel “chill and social”, or they
“decided to partake in it because a lot of my friends were doing
it.” Participants reported using cannabis as a way to “fit
in” with their peer group.
-
Coping with mental health symptoms
Of the 31 (86.11%) participants who reported having mental health
symptoms at the time of initiation, 15 (48.4%) participants used
cannabis to cope with their mental health symptoms/conditions such as
depression, anxiety, posttraumatic stress, and sleep problems associated
with anxiety. These symptoms and conditions were reported to be in part
related to stressors in school or unpleasant situations at home. Two
participants initiated cannabis in the form of CBD oil after it was
recommended for depression by their family physician.
-
Unfavorable experiences with previous medications
Nine participants (25%) reported initiating cannabis due to limited
effects and negative experiences with pharmacotherapy for the treatment
of their mental health problems. Reported medications included
benzodiazepines such as lorazepam and clonazepam, antidepressants such
as bupropion, and mood stabilizers such as lamotrigine. Participants
described they wanted to, e. g., “give it a chance as a last resort
as it has helped other people,” as “everything else seemed to
fail,” or described their symptoms as “getting worse”, or
experienced negative side effects from medications like “chest
tightening, shortness of breath, headaches, concentration, and
memory issues, hallucinating, poor sleep.” In participants’
words, “Cannabis was the only thing that kind of calmed me back
down” or the “only thing that actually worked.” One
participant reported that cannabis helped them feel better after they
felt suicidal when taking antidepressant medications.
-
A healthier alternative to other drugs
Four participants (11.1%) described cannabis as “natural” and shared the
belief that cannabis was a “healthier alternative” to drinking alcohol.
One participant reported that they used cannabis when they “tried to cut down
on any addiction.” Another participant emphasized that they were scared
to get addicted to alcohol as difficulties with alcohol use have been present in
their family. One participant believed cannabis to be safer than crack and
heroin, which they had been using before, and thus started using cannabis.
From manual coding analysis, it was further observed that the participants who
initiated cannabis before the age of 18 cited peer pressure to feel accepted by
peers at school, curiosity, and social facilitation as the main reasons for
starting cannabis. The main reasons to start CU at age 18 and above included
mental health conditions, migraines, and insomnia, followed by recreational use
to escape from boredom and for relaxation.
Expected effects of cannabis use before initiation
-
Impairment of memory and cognition
Interestingly, 15 participants (41.7%) expected negative effects on
cognition. Participants also reported that they believed that cannabis
would reduce their self-esteem, affect them academically, and make them
lazy and unmotivated.
-
Negative effect on anxiety
Seven participants (19.4%) believed that cannabis might negatively affect
their anxiety and might make them paranoid. Among them, 2 participants
explicitly expressed fear that cannabis might increase the risk for
schizophrenia later in life.
-
Development of addiction
Seven participants (19.4%) feared that they might become addicted to
cannabis and described related concerns, such as that CU could make them
isolated from society and make them lonely.
-
Positive effects on mood
4 (11.1%) participants believed cannabis to be a mood-elevating drug.
Participants, for example, stated that cannabis could make them “happy and
giggly versus something that could make you angry” or felt cannabis
would bring them “joy, euphoria and happy moments.”
Continuation phase
Motivations and reasons to continue cannabis use
-
Euphoria/enhancement
Fourteen participants (38.9%) continued using cannabis because they
enjoyed the euphoric feeling of cannabis and found it exciting and fun.
They particularly described how cannabis made them feel. “I just
enjoyed how it made me feel. I liked being in a sort of altered
mindset, and I just enjoyed how it made me feel.”
-
Coping with mental health symptoms/conditions
Fourteen participants (38.9%) reported continuing to self-medicate with
cannabis to help with their symptoms of depression, anxiety, social
anxiety, attention deficit hyperactivity disorder, and/or PTSD without
medical advice. Among them, the two participants who were prescribed CBD
oil for depression continued to take it as their physician advised them
to continue using it consistently for a few weeks to witness the
results. Participants reported it helped them to forget the worries that
arose from adverse situations at home or at work and made them forget
about their problems temporarily. “For social anxiety as well as
depression, I do experience very severe lows sometimes. When I do
smoke, it does take me out of my depressive state for some time, but
that is also the reason why I smoke so much because I am always in a
depressive state, and I don’t want to be in a depressive state,” “At
first, it was just because I was trying something new, and then now
I’m using it to see if it helps with my depression and anxiety. I
feel like I really have no other option.” Interestingly,
participants with reported diagnosis of PTSD described using cannabis
for introspection, enabling them to directly confront the source of
trauma rather than avoiding intrusive symptoms/flashbacks.
-
Social reasons
Fewer participants (n=6, 16.7%) continued using cannabis for social
reasons. It improved participation in situations such as parties and
celebrations by making them more talkative, outgoing, and happier. They
also reported it made social gatherings more fun and mentioned using
cannabis to celebrate a special occasion with partners or friends.
“It would help with socializing and creating the right
atmosphere.”
-
Other self-reported reasons
Two participants continued using cannabis for their sleep problems, which
weren’t improved when using medications. Four other participants used
cannabis to get relief from pain symptoms; some considered cannabis to
be a safer alternative to pain medications. Two participants initially
continued having cannabis out of peer pressure. They wanted to fit in
with the group they liked without feeling left out. They reported that
later, they started enjoying the euphoria associated with CU: “I felt
popular at school. I felt older. I felt more accepted by the older
kids in school, absolutely peer pressure.”
-
Dependence
Some participants (n=3, 8.3%) also reported becoming dependent on cannabis for no
specific reason. Participants reported getting addicted to cannabis, some
reported liking the taste of cannabis, and others found the process of grinding
the dried flower and rolling very relaxing. “I believe it became an
addiction. I would wake up in the morning, and the first thing I would do is
smoke cannabis,” “I don't know if marijuana contributes to it or helps.
I have no idea. Long-term. I don't know if it's actually making it
worse. I just don't know, but I keep finding myself going back to
it.”
Effects of cannabis use after initiation
-
Enhancement and expansion
The majority of participants (n=20, 55.6%) reported feelings of
euphoria/high that they felt when using cannabis. “I remember the time
and it was really funny and mind-blowing and just like “woah,” and so I
think I had a little bit of a different view of what reality is after
doing that because I’ve never done anything like that before.” “It
helped me to just laugh and enjoy laughing.”
-
Worsening of anxiety and paranoia
Five participants (13.9%) reported feeling paranoid after initially using
cannabis. “A couple of days after taking cannabis, I would just become
really paranoid sometimes. I would see stuff, so I just would become
more paranoid about things,” “ I felt panicky and my anxiety went
through the roof, and I was pretty scared.”
-
Positive effect on sleep
Five participants (13.9%) reported that cannabis helped them with sleep.
“It helped me get through the day or it helped me to
sleep.”
-
Improved memory and concentration
In contrast to their expectations earlier, 2 (5.6%) participants
perceived CU did improve their memory. “I thought I was going to lose
my memory I thought I was going to completely forget what I did. I
thought I was going to have a blackout drunk moment, but now I could
remember everything pretty clearly, from what I did to what I said
to people.”
-
Feelings of guilt
Two (5.6%) participants felt guilty when initially using cannabis. One of them
reported: “I was still worried that I was doing something wrong, I felt
really bad. I had a huge wave of guilt.”
Maintenance phase (ongoing and current cannabis use)
Maintenance phase (ongoing and current cannabis use)
Reasons for ongoing and current cannabis use
-
Coping with and treatment of mental health symptoms
Most participants (n=23, 63.9%) reported self-medicating with cannabis to
ease symptoms of anxiety and depression and to ease tension or stress
from work. Three participants reported relief from migraine headaches
induced by stress. Five participants reported to specifically use
cannabis to treat their diagnosed mood and/or anxiety disorder.
Participants additionally mentioned how the COVID pandemic influenced
their CU and indicated increased dependence on cannabis, stating that
they required greater amounts of cannabis to relax and feel happy while
they had to be at home. “As the years progressed, it went from being
more of a recreational use to more to an after-work, just to help
relieve stress and anxiety from the workday.”
-
Sleep problems
Another reason for ongoing CU and CU at present was sleep problems (n=10,
27.8%). Some participants who had reported using cannabis for relaxation
also used cannabis to improve sleep. One participant with sleep apnoea
reported using CBD oil, which they found helpful. “If I’m feeling
depressed, I haven't really used marijuana then. It's
usually if I’m physically exhausted or really sore or something like
that from physical exercise; consuming a small amount of cannabis
can help me get to sleep,” “I would use it when I have sleeping
problems and I can't sleep.”
-
To improve use of or addiction to other drugs
3 participants (8.3%) described using cannabis to reduce addiction to other
drugs. One participant with a history of substance use (heroin, crystal meth)
continued using cannabis as they felt that cannabis “worked like medicine” in
treating their substance use disorder and helped them stay away from other
drugs. Another participant mentioned that they reached for cannabis when they
wanted to cut down on alcohol use. Another participant, who reported hostile
situations at home, revealed that they used cannabis to avoid using any other
drugs for coping.
Effects of ongoing and current cannabis use
-
Negative effects on memory
More than half of participants (n=19, 52.8%) reported that chronic CU has
negatively impacted their memory and their daily functioning as it has
interfered with their schoolwork, professional life, and personal life.
Memory was reported to get “foggy,” and they reported “trouble
recalling the words for things.” One participant described
writing things down before using cannabis to be able to recall, stating,
“My short-term memory is gone completely.”
-
Negative effects on anxiety and mood
Participants (n=30, 83.3%) reported deterioration of depressive or
anxiety symptoms after CU. They also reported feeling fatigued, having
low concentration and energy, and that they failed to carry out
responsibilities the next day. “Nowadays, I get very anxious and
jittery. Not jittery per se, but restless that's a better word.
I get restless, I get anxious, I get moody, I get snippy and snappy
and itchy and irritated definitely.” “I would say that anxiety goes
up, and I feel lethargic afterwards, probably a little bit paranoid.
Anxiety high and probably depression as well.”
Two participants observed that their anxiety/depressive symptoms
worsened, especially when cannabis was taken with medications like
antidepressants.
-
Positive effects on anxiety and mood
Interestingly, an equal number of participants (n=30, 83.3%) reported
positive effects on mood and anxiety symptoms. Participants reported
effects such as feeling much calmer, relaxed, less anxious, and less
depressed temporarily after having cannabis. They described that using
cannabis lowered their inhibitions, raised their confidence level, and
gave them greater motivation and energy to focus on daily activities
after taking cannabis.
Interestingly, 3 participants further described how cannabis has
different effects depending on their current mood state. They described
that if they use cannabis when in a relaxed mood, they would feel happy
afterwards; however, if they are in a low mood at time of use, their
mood would worsen. “When I feel low, it impacts me differently. I
notice it accentuates the bad feeling if I'm feeling really,
really low.” “Based on your mood or your feeling, it amplifies it.
If you're having a good day, yeah, you're going to feel
great; you’re going to have a good day. If you're having a
shitty day or a sad day, it will amplify that feeling; that’s what I
noticed.”
-
Introspection
Three of 5 participants with PTSD revealed how cannabis was helpful with
introspection into the source of trauma, particularly when using
cannabis during flashbacks. Two participants with MDD and GAD also
shared a similar perception and experience that cannabis would help them
decode what triggered them to feel depressed. “It will connect me to
the source of the flashback and enlighten me to that. I feel like my
system is like, there's a lot that's battling itself in
those moments because a large part of it doesn't want to
introspect, and then the cannabis opens up a window for it to
introspect.”
-
Positive effects on sleep
Nine participants (25%) reported improved sleep with cannabis. One
participant also reported paranoia and stated tolerating this adverse
effect for positive effects on sleep, “good outweighs the bad,”and
“Although sure, it makes me paranoid, I enjoy the sleep I have when
I’m high.”
-
Negative effects on sleep
Five participants (13.9%), on the other hand, reported having poor
quality of sleep and feeling groggy the next morning after CU; some of
them also described poor memory and heightened mental health
symptoms.
-
Difficulties with substance use/addiction
Ten participants (27.8%) reported becoming dependent on cannabis,
indicating that recreational use transformed into more regular use.
“I think it’s a misconception to say it’s not an addictive
drug.” Participants also reported that their tolerance of
cannabis increased, requiring higher amounts of cannabis to get the same
effects they got when they were younger.
-
Other negative effects
Eleven participants (30.6%) complained of negative effects of CU, such as
headaches, nagging cough, dry mouth, hallucinations, or problems with vision. In
addition, two participants reported increased soreness in their body. One
participant commented, “It feels like I’ve done something to my body that
made me sore when I didn’t. When I smoke, I find that any pain in my body
becomes more intense.”
Reported effects of cannabis depending on frequency of use
Participants with daily or almost daily use of cannabis (N=10, 27.8%) overall
reported dependence on cannabis effects; they reported enjoying the immediate
effects of increased relaxation and/or euphoric feelings, explaining the
frequent use up to multiple times daily. Frequent cannabis users identified
mental health conditions and sleep problems as the most common reasons for using
cannabis. Some participants with longer-term/chronic use described that paranoia
and forgetfulness increased over time. Infrequent cannabis users (N=6, 16.7%)
with more sporadic or occasional use less than monthly expected reported greater
negative impacts from cannabis, like inability to think critically, inability to
carry out activities, aggravation of anxiety, impaired memory, and low
motivation. Some infrequent users revealed that CU made them extremely dizzy,
sleepy, and withdrawn even the next day after CU.
Consideration to discontinue cannabis use
Consideration to discontinue cannabis use
Twelve participants (33.3%) expressed interest in discontinuing cannabis, nine (75%)
of them due to the negative effects they were experiencing, and three (25%), due to
personal reasons.
-
Negative effects
The negative effects contributing to the wish to discontinue cannabis
included poor sleep quality, headaches when waking up, memory impairment,
exaggeration of anxiety, increased appetite, dependence, and disruption of
personal relationships due to CU. Some participants mentioned that their
physicians advised them to refrain from using cannabis as it might affect
their mood symptoms. “It’s really the anxiety; my heart rate increases,
and I get nauseous, so it's really not an enjoyable experience
anymore.” “I feel like I am way too dependent on it. I just don't
like the fact that I can't go without it. When I'm without it,
it's very detrimental to my mental health and really and pretty
much my physical health.”
-
Personal reasons
Three participants wished to discontinue cannabis due to personal reasons. One
participant described wanting to be a role model for their child, who was also using
cannabis. Two other participants had stopped CU for 2 years during pregnancy and
breastfeeding.
Sources of cannabis products and Sources of information on cannabis
Sources of cannabis products and Sources of information on cannabis
Reported sources of cannabis products and sources of information on cannabis are
presented in [Table 2].
Table 2 Sources of cannabis products and sources of
information on cannabis.
|
Sources of cannabis products
|
N (%)
|
|
Licensed cannabis stores
|
30 (83.3%)
|
|
Online websites
|
2 (6.67%)
|
|
Self-growing cannabis plants
|
2 (5.56%)
|
|
Illicit/non-regulated sources
|
6 (16.7%)
|
|
Sources of information
|
N (%)
|
|
Websites of producers/sellers, social media
|
18 (50%)
|
|
Cannabis store sales personnel
|
8 (22.2%)
|
|
Friends/family members
|
7 (19.4%)
|
|
Medical professionals
|
3 (8.33%)
|
Preferences for cannabis products and cannabinoids
Preferences for cannabis products and cannabinoids
Reported preferences for cannabis products and cannabinoids are presented in [Table 3].
Table 3 Preferences of cannabis products and
cannabinoids.
|
Preferences of cannabis products
|
N (%)
|
|
Dried flower
|
21 (58.3%)
|
|
Edibles (drinks, sweets, candies, brownies)
|
18 (50%)
|
|
Cannabis oil
|
9 (25%)
|
|
Vaping/vape cartridges
|
5 (13.9%)
|
|
Preferences of cannabinoids
|
N (%)
|
|
Hybrid products (CBD and THC)
|
6 (16.7%) (CBD dominant: 4, THC dominant: 2)
|
|
CBD only products
|
9 (25%)
|
|
THC only products
|
8 (22.2%)
|
|
Referred to Sativa and Indica strains
|
11 (30.6%)
|
|
Not aware of cannabis product composition
|
2 (5.6%)
|
CBD=cannabidiol; THC=Δ9-tetrahydrocannabinol.
Effects of pure cannabidiol or cannabidiol -dominant products on
symptoms
Positive effects of CBD reported by participants included reduced pain, improved
mood, alleviation of anxiety, and improved sleep. Six participants perceived
cannabis with greater CBD content than THC as “medicinal” or with “no
side effects.” Four participants, however, reported that they didn’t
feel anything after taking CBD-dominant cannabis products. One participant
revealed, “It didn’t really help at all. I didn’t feel anything.” This
resonated with another participant stating, “I didn’t get any effects from
that, like zero effects.”
-
Reduction of pain
Eight participants (61.5%) used CBD-rich cannabis products for Irritable
Bowel Syndrome (IBS), muscle aches, headaches, or radiotherapy-induced
pain in cancer treatment. “You get stiff muscles, take a drop, and by
the next day, my sore is gone.”
-
Improvement of sleep
Five participants (38.5%) described improvement in sleep with CBD-rich
cannabis strains and improvement in concentration as a result of a good
night’s sleep the next day.
-
Improvement of anxiety
Three participants (23.1%) reported a positive effect of CBD-dominant products on
anxiety symptoms. They commented on how they could engage in their
responsibilities without feeling high or drowsy when comparing effects to
cannabis products containing THC. “I just feel a sense of completion. I don’t
feel anxious or nervous. I can just carry out my daily tasks and I
don't really feel like I have done a drug.”
Negative effects of CBD-dominant products were reported by three participants
(23.1%).
One participant reported sleep difficulties associated with the use of
CBD-dominant products: “Sleeping is so bad; feels like my brain is getting
heavy. It makes me confused, groggy, and unaware the next day.”
Effects of pure Δ9-tetrahydrocannabinol or Δ9-tetrahydrocannabinol-dominant
products on symptoms
Positive effects of high THC products reported by participants:
-
Positive effect on mood
Nine participants (90%) reported a positive effect on mood and reduction
of depressive symptoms with THC-dominant products; in this context,
participants mentioned, for example, enhancement of creativity, focus,
and sexual drive, and improvement with overcoming inhibitions and being
more extroverted in social situations. “It helps with the depression.
If I'm in an episode, then it does help me with my
mood.”
-
Increased appetite
Four participants (40%) reported increased appetite or “munchies.” Some
participants experienced this as having positive effects, for example,
that it was a “big factor in the appetite,” enabling them to
“taste the food again,”
-
Improvement of sleep
Two participants (20%) reported a positive effect on sleep for high THC
products.
Negative effects of high THC products reported by participants:
All participants using THC-only or THC-dominant strains reported worsening
depressive and/or anxiety symptoms when taken in higher doses. It was observed
that the dosage or tolerance levels varied among participants. For example, one
participant claimed that doses above 1 mg THC make them “anxious and
paranoid.” Similarly, another participant reported that a THC dosage
above 2.5 mg feels “more like an intoxication.” For another participant,
doses above 30 mg THC induced “real anxiety.” One participant stated,
“The higher the THC content, the more panic, tremors, and
paranoia.”
Effects of hybrid cannabis products with balanced cannabidiol and
Δ9-tetrahydrocannabinol content
Six participants reported using hybrid products containing equal proportions of
CBD and THC. They reported hybrid strains, e. g., give them a “high with the
relaxation benefits.” The participants shared the belief that 1:1 hybrid
strains created euphoria that is less long-lasting and/or less intense as with
high THC strains. Three participants mentioned that using hybrid products to
improve sleep was a recommendation by their family physician.
Effects of cannabis products from Indica and Sativa strains
Eleven participants (30.6%) referred to the differential effects of “sativa” and
“indica” cannabis products rather than levels of THC and CBD. Participants
overall reported more relaxing effects associated with indica strains and more
energizing effects with sativa strains, describing that they feel more
productive and euphoric. Six participants taking indica strain products reported
no negative effects from it and/or consumed indica strain products when they
wanted to feel relaxed. Four participants specifically used indica for the
improvement of sleep problems. While five participants reported a positive
effect on mood/depressive symptoms from sativa strain products (“increased
energy and concentration, creativity”, helpful to “stay focused”
and “stay functional.” Four participants reported negative effects on
mood and anxiety (“increased palpitations,” restlessness, “makes me
fidgety”).
Discussion
In this qualitative study, we completed in-depth interviews with 36 participants
diagnosed with mood and anxiety disorders, including PTSD and OCD with current CU.
Interviews focused on individual perceptions, motivations, experiences, and patterns
of CU from the time of initiation of CU to date. Notably, this study was conducted
in Canada, where a program to access cannabis for medical reasons was implemented
more than 20 years ago, and cannabis was legalized in 2018.
At the initiation of CU, various motivations and factors, such as peer pressure,
desire to fit in, dissatisfaction with standard mental health treatments (e. g.,
pharmacotherapy), and perceiving cannabis to be a healthier alternative to other
substances, were reported. The reasons and motivations for the initial continuation
of CU most commonly reported were coping with mental health symptoms and the typical
psychotropic effects of cannabis/THC, such as euphoria and enhancement. The main
conditions participants used cannabis for in our sample are similar to those
reported in previous studies, such as psychological/mental health problems
(depression, anxiety), sleep problems and pain [35]
[40]
[41]
[42]
[45]
[46]
[47],
or 92% to 99% of cannabis users with diagnosed mood disorders endorsing CU to
relieve mental health symptoms [35]. The
reasons for initiation of cannabis before age 18 in our study overlap with findings
in young adults without comorbidities/health conditions, i. e., enjoyment, boredom,
experimentation, altered perception, and relaxation [48]
[49]. Findings from this study
also resonated with results from a survey where cannabis use was reported as a
substitute for alcohol or as a treatment for misuse or withdrawal related to other
drugs [47]
[50].
It is of note that half the number of participants in our study initiated cannabis
before 18 years of age, with 12 years reported as the youngest age. This finding is
concerning as existing evidence indicates a higher risk of developing cannabis use
disorder in individuals starting CU in their youth or adolescence [51]. Adverse effects on neurological
development, as well as increased susceptibility, for substance use disorders and
mental health conditions, such as psychosis, depression, and anxiety, have also been
associated with early initiation of CU [52]
[53]
[54]
[55]
[56]
[57]
[58].
In addition, chronic CU during adolescence has been linked to cognitive impairment
[58]
[59]. Information from this study on motivations and reasons for
initiating CU at a young age could contribute to targeted education, awareness, and
prevention programs focusing on potential risks of early onset of CU for this age
group.
Interestingly, CU was initiated by participants despite many of them expecting
negative effects on memory, cognition, or anxiety and being concerned about
developing cannabis dependence. This was similarly observed in a study where
cannabis users with a history of depression had negative expectations of CU, e. g.,
less perceptual enhancement compared to non-depressed participants [38]. However, common negative thought content
and negative future expectations specific to depression may have contributed to this
finding. However, positive expectations of cannabis to be helpful with activation,
engagement in life, and mood were reported in other studies of adolescents with
depression [60] and veterans with depression
[61].
With ongoing CU, participants reported a shift from these initial motivations and
effects towards CU for coping with mental health symptoms and sleep problems while
concurrently reporting and acknowledging more or increased negative effects on
cognitive functioning, mood, and anxiety symptoms, and reduced sleep quality. The
shift towards CU as a coping strategy, as well as worsening of mood, anxiety, and
sleep – symptoms for which cannabis was particularly used to cope with – raises
concerns about these perceptions potentially contributing to the continuation of
maladaptive CU despite experiencing initial and/or ongoing aspects of problematic
use and CUD. This finding also aligns with previous reports on the habit-forming
potential of cannabis [62]
[63]
[64].
CU for insomnia and sleep problems was another common theme, with mixed effects
reported by participants indicating potential short-term benefits for
sleep/insomnia, but also potential disruptions of sleep with higher doses of
cannabis. These experiences appear to be congruent with previous studies indicating
potential positive effects of short-term CU sleep via a decrease of sleep onset
latency as well as disruptions at higher cannabis amounts with decreased REM and
slow wave sleep and increased sleep onset latency [65].
The study also revealed preferences for cannabinoid content of cannabis products.
CBD-dominant products were reported to be helpful for pain, insomnia, and anxiety,
while a small proportion of participants reported negative effects on anxiety and
sleep. Some participants in our study had reported that using CBD-dominant products
over longer periods was linked with worsening of anxiety symptoms, suggesting the
possibility of an optimal CBD dose range and duration of use [66]
[67]
[68]. Mood regulation, anxiety
reduction, and improved sleep were also linked with CBD-dominant cannabis in
previous studies [45]
[69]
[70].
Participants in our study reported worsening of anxiety symptoms with THC-dominant
products as observed in other studies, indicating greater anxiety and depression
scores in individuals using predominant THC cannabis products compared to low THC
cannabis products [69], reduction of
depressive symptoms with cannabis products with high CBD:THC ratio [45], and fewer psychotic symptoms with high CBD
compared to high THC cannabis [70].
The interviews revealed another interesting, though concerning aspect: The limited
involvement of participants’ healthcare providers. Although participants commonly
reported using cannabis for coping or self-treatment of mental health or other
health symptoms, the vast majority of participants obtained information on cannabis
products and effects as well as recommendations from non-medical sources, e. g.,
websites such as cannabis store websites, social media platforms, friends or family
members, or cannabis store staff. Staff at cannabis stores are commonly not medical
professionals and may not be able to provide balanced, objective, and evidence-based
information on potential risks and benefits of CU for individuals with mental health
conditions and thus may provide subjective advice and recommendations based on their
own experiences. Based on the findings from our interviews, individuals with mood
and anxiety disorders seek information on CU from these sources, education and
information of the public and staff at cannabis stores, as well as information that
has undergone medical expert review, could be potential approaches for providing
adequate and evidence-based information to individuals seeking advice for cannabis
as medical treatment to increase awareness and reduce potential risks [71]
[72].
It is further notable that the majority of participants purchased cannabis products
from approved cannabis stores, which provides them with the opportunity to
understand better and monitor the content and amount of CU and reduces the risk of
using products from non-legal sources with unknown content and potential admixtures.
On the other hand, individuals may purchase their cannabis products predominately
from cannabis stores due to improved, easier, and faster access to cannabis products
associated with legalization compared to procedures of medical cannabis programs.
This is reflected in findings from other studies, e. g., a US survey indicated that
67% of 345 older adults (65 years or older) from Colorado (where cannabis is
legalized), purchased cannabis without a prescription [43].
Only very few participants in the study reported seeking advice/information from
medical professionals. Not involving care providers in decisions on CU and not
sharing information on CU could contribute to underestimating the potential risks
and negative effects of cannabis and potential risks of interactions with other
treatments for their mental health conditions, such as pharmacotherapy or
psychotherapy, in particular of care providers are not made aware of CU. In this
context, dissatisfaction with pharmacotherapy was a factor reported to contribute to
the initiation of CU in our study. This has also been reported in other studies
where cannabis was perceived as an alternative to medications and as having fewer
side effects [35]
[46]. It was also previously reported that
cannabis helped decrease the use of other medications, such as opioids [42]. The perception of cannabis as an
alternative approach for the treatment/management of mental health conditions or
substance use in relation to conventional and evidence-based treatments indicates a
challenging situation for care providers and patient-care provider relationships.
Open and inclusive communication between patients and their care providers
acknowledging individual preferences and information on potential risks and negative
effects appear to be crucial aspects to facilitate informed decision-making by
patients in this landscape of increased access to and availability of cannabis.
Results from our study indicate the importance of raising awareness of care
providers and patients and supporting open discussion to mitigate potential
risks.
Another common aspect reported by participants is the perception of cannabis for
medical reasons, i. e., improvement of or coping with symptoms, in parallel with
recreational use. Interestingly, this overlap and blending of CU for medical and
recreational purposes was overall not commonly perceived as concerning. The presence
of the medical cannabis program, legalization and availability of cannabis,
presentation of cannabis products by industry and cannabis stores, and a societal
shift towards acceptance and normalization may have contributed to these
perceptions. It is, however, concerning if a substance or medication is used for
treatment and for recreational aspects at the same time, in particular, a substance
comprising risk for dependence and problematic use.
While our study provides initial insight into individual perceptions, experiences,
patterns, and effects of CU from individuals with mood and anxiety disorder,
limitations of this study include the absence of a control group to act as a point
of reference and that participants with different diagnoses in the mood and anxiety
disorder spectrum were included limiting interpretation of findings with respect to
a specific mental health condition. Moreover, it is of note that some of the
participants were diagnosed with more than one mood or anxiety spectrum disorder and
that various common aspects and responses were observed among participants with
different diagnoses. Due to the scope and qualitative nature of this study,
information on diagnostic criteria of cannabis use disorder or other substance use
disorders, as well as medication history or current pharmacological treatment, was
not systematically assessed or collected. As results from this study indicate that
motivations for initiating cannabis use in individuals with mood and anxiety
disorders include experiences of limited or negative effects of pharmacotherapy or
mitigation of use of other substances, future studies are warranted to
comprehensively evaluate these potential associations. In addition, participants in
our study initiated CU prior to actual legalization, though some of them initiated
CU when legalization was expected. Thus, results from our study cannot address
potential changes in the perception of CU pre- and post-legalization. As interviews
were conducted after cannabis legislation in Canada, results from this study provide
insights into specific cannabis products purchased and used by participants, e. g.,
cannabis strain or THC/CBD content, and sources participants commonly use for
information on cannabis effects and use of cannabis for medical reasons.
Conclusion
Our study provides valuable insights into individual perceptions, motivations,
patterns, and effects of CU in individuals with mood and anxiety disorders. Findings
that raise concerns and indicate potential risks include common initiation of CU
before age 18, adverse effects of CU over time, including aspects of a substance use
disorder, reported blending of recreational and medical use of cannabis products and
seeking information on CU from non-medical sources. Notably, a substantial group of
participants considered discontinuing CU, while others reported that the positive
effects continue to outweigh the adverse effects. In addition, CBD-dominant strains
were commonly perceived as helpful for pain and mood or anxiety regulation. Our
findings also point towards an important need to raise awareness among healthcare
providers about patients’ potential CU and support open and respectful patient-care
provider dialogue to improve informed decision-making and mitigate potential risks.
Results from our study indicate a need for information and education of the public
and, in particular, individuals with mood and anxiety disorders as well as youth and
adolescents, providing balanced and evidence-based information on potential risks
associated with CU. Findings from our study can also inform the development of
education/information material, risk prevention strategies, or treatment
programs.
