Profesionalism in Management Bipolar Disorder (BD) and Cannabis Use

Azimatul Karimah(oe_tjie@yahoo.com)

Epidemiology

• The rates of cannabis abuse have been reported to be 10.1% higher in schizophrenia, 14.5% among patients in a manic episode, 4.1% in major depression, 4.3% in panic disorder, and 2.4% in patients with phobias

• Twice as likely to use marijuana in life (34% vs. 64%) and to develop manic symptoms

Diehl A, Cordeiro DC, Laranjeira R, 2010. Revista Brasileira de Psiquiatria • vol 32• Suppl IAshton et al, 2005. Cannabinoids in bipolar affective disorder: a review and discussion of their therapeutic potential . Journal of

psychopharmacology (19)3 : 293-300

Cannabis

• 9-tetrahydrocannabinol ( 9-THC)

• lipid soluble

• peak concentrations = 4 to 5 days

• High concentrations in the neocortical, limbic, sensory, and motor areas.

• The tissue elimination half-life of 9- THC is about seven days, and absolute elimination of a single dose may take up to 30 days

Khan MA, Akella SA, 2009. Cannabis-Induced Bipolar Disorder with Psychotic Features: A Case Report. Psychiatry (Edgemont) 2009;6(12):44–48

Wayne D. Hall WD, Degenhardt L, 2009. Cannabis-Related Disorders in Sadock BJ.; Sadock VA.; Ruiz P. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition. Lippincott Williams & Wilkins, 1309-1318.

is between 15 and 20 percent.

Three theories Explaining the Use of Marijuana by BAD patients

1. possible hypersensitivity to illicit substances in this

2. self-medication or not related to self medication ?

3. multiple factor” theory

Diehl A ,Cordeiro DC ,Laranjeira R. Revista Brasileira de Psiquiatria • vol 32• Suppl I • may2010Henquet C, Krabbendam L, de Graaf R, Have M, van Os J. Cannabis use and expression of mania in the general

population. Journal of Affective Disorders 95 (2006) 103–110

Cannabis and BD• Cannabis use and manic symptoms ~ the long-term effects of

cannabis exposure• The risk for manic symptoms ~ frequency of cannabis use. • Largest in individuals using cannabis 3 to 4 days/week• The use of substances precedes the onset of BD• Baseline cannabis exposure and follow-up manic symptoms

remained large and statistically significantHenquet C, Krabbendam L, de Graaf R, Have M, van Os J. Cannabis use and expression of mania in the general population. Journal of Affective Disorders 95 (2006) 103–110

• No increased risk for depression associated with the occasional use of marijuana but the heavy and regular use of the drug co-occurs with depression in a greater frequency than at random.

Diehl A ,Cordeiro DC ,Laranjeira R. Revista Brasileira de Psiquiatria • vol 32• Suppl I • may2010

Comorbid Cannabis and Mania + psychotic

• the complex interactions involving dopamine, gamma aminobutyric acid (GABA), and glutamate transmission or other factors that cause psychotic disorders.

• a genetic vulnerability to dysregulation of the dopaminergic system due to social or pharmacological stress

• Sensitisation, intermittent stimulant exposure produces a permanent change in dopaminergic responses .

• A dysregulated hyperdopaminergic leads to stimulus-independent release of dopamine which may take over the normal process of contextually driven salience attribution.

Henquet C, Krabbendam L, de Graaf R, Have M, van Os J. Cannabis use and expression of mania in the general population. Journal of Affective Disorders 95 (2006) 103–110

Khan MA, Akella SA, 2009. Cannabis-Induced Bipolar Disorder with Psychotic Features: A Case Report. Psychiatry (Edgemont) 2009;6(12):44–48

Clinical Feature BD + Cannabis Use

• cannabis use was consistently associated with relapse and nonadherence with increasing relapses, hospitalizations, and progressive worsening of symptoms. Khan MA, Akella SA, 2009. Cannabis-Induced Bipolar Disorder with Psychotic Features: A Case Report. Psychiatry (Edgemont) 2009;6(12):44–48

• substance use in these patients is associated with poor treatment response and poorer clinical outcome

• patients may start using cannabis to moderate their manic symptoms (Grinspoon and Bakalar, 1998; Khantzian, 1997; Strakowski and DelBello, 2000).Henquet C, Krabbendam L, de Graaf R, Have M, van Os J. Cannabis use and expression of mania in the general population. Journal of Affective Disorders 95 (2006) 103–110

How to manage?

• Screening• Assessment• Feedback• Treatment

Principal

• Early recognition of concurring disorders contributes to the planning

• No wrong door• Integrated treatment motivational interviewing techniques

are paramount to establishing and maintaining engagement• the key behavioural task is to monitor high-risk situations,

such as via mood monitoring for depression, suicidality, etc• relapse prevention• maintain liaison with mental health teams and GP• Suicidal behavior monitoring

Jan Copeland, Amie Frewen, & Kathryn Elkins, 2009. Management of cannabis use disorder and related issuesa clinician’s guide. National Cannabis Prevention and Information Centre, University of New South Wales, Sydney

Screening for cannabis use in a mentalhealth setting

Validated tools

Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (WHO ASSIST Working Group 2002)

Severity of Dependence Scale (SDS) (Gossop et al., 1995)

Modified Simple Screening

Urine drug screen

Jan Copeland, Amie Frewen, & Kathryn Elkins, 2009. Management of cannabis use disorder and related issuesa clinician’s guide. National Cannabis Prevention and Information Centre, University of New South Wales, Sydney

Diagnostic Assessment in DSM-5

• Separate chapters Bipolar and related conditions, and depressive disorders.

• BD not otherwise specified (NOS) has been replaced with bipolar conditions not elsewhere classified.

• Addition : Substance induced BD and BD associated with a general medical condition

Yatham, et al. 2013 Canadian Network for Mood and Anxiety Treatments (CANMAT) and InternationalSociety for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

Substance/Medication-InducedBipolar and Related Disorder

Substance/Medication-InducedBipolar and Related Disorder

Phase and Strategy Treatment

Psycho-education for comorbidity

• “Critical as there is much to learn regarding mental health, substance use and the interaction between them” (Mueser et al., 2002)

• Study with young people with first-episode psychosis who abused cannabis, those receiving 10 sessions of psycho-education reduced their cannabis use and maintained reductions over six months equivalent to those who received integrated motivational interviewing and CBT (Edwards etal., 2006)

Jan Copeland, Amie Frewen, & Kathryn Elkins, 2009. Management of cannabis use disorder and related issuesa clinician’s guide. National Cannabis Prevention and Information Centre, University of New South Wales, Sydney

Components of evidenced-basedinterventions for cannabis

Mood Regulation Training

Recent StudiesCanabidiol (CBD) and Anandamide (arachidonylethanolamide)

• CBD binds to CB1 receptor antipsychotic, anxiolytic, anticonvulsant and other psychological effects

• block the reuptake of anandamide• CBD also reduces the hydroxylation of THC to its more

psychoactive metabolite, 11-OHTHC• inhibit serotonin reuptake and to increase catecholamine

activity in rat brain synaptosomes , an action also shown by anandamide

• CBD is a potent antioxidative agent and is protective against glutamate toxicity, an action which is not affected by cannabinoid receptor antagonistsAshton et al, 2005. Cannabinoids in bipolar affective disorder: a review and discussion of their therapeutic potential . Journal of psychopharmacology (19)3 : 293-300

Endocannabinoid Effects

• Modulation of brain reward systems mood, anxiety and sleep, pain, cognition and memory, appetite, endocrine activity, cardiovascular regulation and other vital functions.

• The basic function of the endogenous system appears to be the regulation of interneuronal signalling, involving complex interactions with many neurotransmitters and neuromodulators, including monoamines, acetylcholine, opioids, GABA and glutamate.

Ashton et al, 2005. Cannabinoids in bipolar affective disorder: a review and discussion of their therapeutic potential . Journal of psychopharmacology (19)3 : 293-300

Summary

• Cannabis abuse has been reported as comorbidity on BD• Intoxication and withdrawal of cannabis could lead to manic

and other psychotic symptoms and could preseed to BD• Management strategy : from screening to treatment• Recent studies showed treatment effects of endocannabinoid

but still needs further investigation.