Expert: Ivan Goldberg, M.D. - 7/7/2010

Question
Hello:

My wife is 60 and was diagnosed with bi-polar disorder several years ago.  In the past when manic she has been suicidal and destroyed her car by driving her car into a pole (no recollection of what happened - had been drinking).

She is currently taking Cymbalta 30 mg daily and Giodan 30 mg daily.

She smoked a lot of marijuana over the years.

She was recently feeling depressed ("the blahs")so she smoked some marijuana as she said it makes her feel better.

Can you tell me what effect, if any, does smoking marijuana have on someone that is bi-polar and on medication?

Can you explain how marijuana effects the brain functioning of someone with bi polar disorder?

Thank you,

Answer
Hi,

It is my experience since entering psychiatry in 1960 that people with bipolar disorder who use marijuana are essentially untreatable unless they give up the marijuana. Not only does marijuana make the symptoms of bipolar disorder worse, but it also makes those who smoke it less responsive to psychiatric medication than those who do not smoke it. The reason for this is unknown.

Below are abstracts of a few research reports form the psychiatric literature.

Best regards . . .

Ivan
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1. Tijdschr Psychiatr. 2010;52(5):287-98.

[The influence of cannabis on the course of bipolar disorder: a longitudinal
analysis]

[Article in Dutch]

Winter-van Rossum I, Boomsma MM, Tenback DE, Reed C, van Os J.

Lilly Nederland B.V., Houten. winter_van_rossum_inge@lilly.com

BACKGROUND: Research shows that the use of cannabis has a negative impact on the
onset and outcome of schizophrenia, but little is known about possible effects on
mood disorders. AIM: To study the influence of cannabis use on clinical and
social treatment outcomes in patients with bipolar disorders who had been treated
for a period of 12 months. METHOD: 3459 bipolar patients were enrolled in an
observational study. The influence of cannabis on various clinical and social
treatment outcomes was examined over a period of one year. In addition, tests
were applied in order to find out whether third, mediating variables had effects
on possible associations between cannabis use and treatment outcomes. RESULTS:
During 12 months of treatment cannabis users showed less compliance and higher
levels of illness severity, mania and psychosis than did non-users. In addition,
cannabis users were less satisfied with their lives and had less chance of
forming relationships than non-users. There was little evidence that associations
between cannabis use and treatment outcomes were mediated by third variables.
CONCLUSION: Cannabis use clearly had an independent impact on clinical treatment
outcomes in patients with bipolar disorder, but the impact on social outcomes was
only modest.

PMID: 20458676 [PubMed - indexed for MEDLINE]


2. Psychiatry (Edgmont). 2009 Dec;6(12):44-8.

Cannabis-induced bipolar disorder with psychotic features: a case report.

Khan MA, Akella S.

Staff Psychiatrist at the Greater Binghamton Health Center, Binghamton, New York;
fourth year student, New York College of Osteopathic Medicine, New York, New
York.

There has been considerable debate regarding the causal relationship between
chronic cannabis abuse and psychiatric disorders. Clinicians agree that cannabis
use can cause acute adverse mental effects that mimic psychiatric disorders, such
as schizophrenia and bipolar disorder. Although there is good evidence to support
this, the connections are complex and not fully understood.As the research in the
endocannabinoid system is emerging, the neurobiological effects of cannabis are
being evaluated in the development of psychiatric illness for those individuals
who may be genetically vulnerable. Here we present a case of a college student
who initially suffered from an acute psychotic breakdown secondary to cannabis
abuse that manifested into bipolar disorder with psychosis.

PMCID: PMC2811144
PMID: 20104292 [PubMed - in process]


3. Clin Toxicol (Phila). 2009 Jul;47(6):517-24.

Chronic toxicology of cannabis.

Reece AS.

Medical School, University of Queensland, Highgate Hill, Brisbane, QLD,
Australia. sreece@bigpond.net.au

INTRODUCTION: Cannabis is the most widely used illicit drug worldwide. As
societies reconsider the legal status of cannabis, policy makers and clinicians
require sound knowledge of the acute and chronic effects of cannabis. This review
focuses on the latter. METHODS: A systematic review of Medline, PubMed,
PsychInfo, and Google Scholar using the search terms "cannabis," "marijuana,"
"marihuana," "toxicity," "complications," and "mechanisms" identified 5,198
papers. This list was screened by hand, and papers describing mechanisms and
those published in more recent years were chosen preferentially for inclusion in
this review. FINDINGS: There is evidence of psychiatric, respiratory,
cardiovascular, and bone toxicity associated with chronic cannabis use. Cannabis
has now been implicated in the etiology of many major long-term psychiatric
conditions including depression, anxiety, psychosis, bipolar disorder, and an
amotivational state. Respiratory conditions linked with cannabis include reduced
lung density, lung cysts, and chronic bronchitis. Cannabis has been linked in a
dose-dependent manner with elevated rates of myocardial infarction and cardiac
arrythmias. It is known to affect bone metabolism and also has teratogenic
effects on the developing brain following perinatal exposure. Cannabis has been
linked to cancers at eight sites, including children after in utero maternal
exposure, and multiple molecular pathways to oncogenesis exist. CONCLUSION:
Chronic cannabis use is associated with psychiatric, respiratory, cardiovascular,
and bone effects. It also has oncogenic, teratogenic, and mutagenic effects all
of which depend upon dose and duration of use.

PMID: 19586351 [PubMed - indexed for MEDLINE]


4. J Nerv Ment Dis. 2009 Jan;197(1):35-40.

Does cannabis use affect treatment outcome in bipolar disorder? A longitudinal
analysis.

van Rossum I, Boomsma M, Tenback D, Reed C, van Os J; EMBLEM Advisory Board.

Collaborators: Sabbe B, Larsen JK, Koponen H, Gasquet I, Azorin JM, Grunze H,
Cassano GB, Nolen W, van Os J, Aarre T, Arriaga F, Pinto AG, Haro JM, Vieta E,
Angst J, Cookson J, Knapp M, Tohen M.

Medical Department, Eli Lilly Nederland, Houten, The Netherlands.
van_rossum_inge@lilly.com

Research suggests that cannabis use affects negatively on onset and outcome of
schizophrenia, but less is known about possible effects in mood disorders.
Bipolar