For many people with bipolar disorder, finding a working treatment can be as hard as having to navigate the shifting landscape of unmedicated moods. Because the specific causes of mental illnesses are largely unknown, patients aren’t presented with quantifiable tests of the sort people typically experience, like blood tests and brain scans. Instead, diagnoses are established through clinical observation and the administration of test batteries, often resulting in misdiagnosis.
This is particularly the case with bipolar disorder: Numbers haven’t changed much since 1994, explains the National Center for Biotechnology Information (NCBI), when a survey showed that “69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more.”
Treatment, even after a correct diagnosis is found, can be a similar case of trial and error. For any number of these reasons—including the tempestuous nature of the illness’ clinical course—rates of self-medication among those with mood disorders, particularly bipolar I, are very high. And while the traditional understanding is that any sort of self-medication is necessarily negative, clinical research is starting to come to light that backs up anecdotal evidence of the actual benefits of one of the most frequently used substances among those with bipolar disorder: cannabis.
Complications of a Complex Disorder
Dr. Russ Federman explains in Psychology Today that the difficulty in treating bipolar disorder is a matter of the age of onset—usually somewhere in the mid-teens to –twenties—and the complex nature of mood disorders. While bipolar spectrum disorders (BSDs) can manifest similarly in different people, such clinical consistencies do not extend to responses by individuals to medications. Like with many mental illnesses and mood disorders in particular, psychopharmaceuticals can make one person feel symptomless while another feels worse, and each has its own host of side effects as well as those that emerge if medications are combined.
Unlike with unipolar depression, where moods have a certain stability to them, treatment for bipolar disorder is active and always subject to change. There’s plenty of anecdotal evidence about the tendency for people with bipolar disorder to discontinue prescribed medications in moments of feeling leveled out, and this medication noncompliance (of rates reaching up to 64 percent) can occasionally prove to be a big challenge for clinicians and patients looking to find a pharmaceutical solution.
The process of finding a working treatment course can be exhausting and seem endless, especiallysince the patient often has to cope with the onset or intensification of symptoms at an age that is already, as Dr. Federman says, “even for those without bipolar disorder […] stressful [and] rarely without emotional intensity.” Managing this stress through lifestyle changes is a big part of stabilizing the symptoms of bipolar disorder, but since the disorder is often comorbid with anxiety, panic and obsessive-compulsive disorders, traditional avenues for dealing with stress might be ineffective or impractical.
And so it’s really no surprise that bipolar individuals have been recorded using cannabis at 6.8 times the level of neurotypical people: Not only is there an abundance of anecdotal evidence as to its use as a mood stabilizer, it’s now essentially public knowledge that the compound cannabidiol (CBD) provides the plant with renowned anxiolytic and antidepressant effects.
Roadblocks to Research
Researchers have taken note that cannabis is the most frequently used illicit drug by those with bipolar disorder, a group already much more likely to use substances than the general public. But until a few years ago, most research into the relationship between mental health and cannabis focused on that long-standing propagandistic concern that cannabis use causes some sort of psychosis, a.k.a. “reefer madness.” Plenty of articles (especially ones from expensive—and ineffective—rehab facilities) still claim that cannabis can bring on bipolar disorder and other mood and anxiety disorders, a hypothesis that was disproven this year.
Although two studies did find an increased risk factor for psychosis in smokers (one specifically with daily use), this only occurred in people predisposed to psychosis due to having one of two very specific gene variations. Harvard University researchers showed in 2013 that it was, unsurprisingly, the “familial morbid risk for schizophrenia [that] is the crucial factor that underlies” what is perceived to be “the association of adolescent cannabis use with the development of schizophrenia,” and “not cannabis use by itself.” In other words, people with a family history of schizophrenia were shown to have an “increased morbid risk for schizophrenia” whether they used cannabis or not (which makes sense since we know that schizophrenia, like many mental illnesses, has a genetic component) while people who used cannabis showed “no significant difference in morbid risk for schizophrenia.”
And yet, three years later, the National Institutes of Health’s (NIH) page exploring “a link between marijuana use and psychiatric disorders” still contains the unsubstantiated claim that "it has been hypothesizes (sic) that brain changes resulting from early use of marijuana may underlie these associations, but more research is needed to verify that such links exist and better understand them (sic)." Also, at the very bottom, a qualifier about their claim of an “increased risk of schizophrenia”: “These are often reported co-occurring symptoms/disorders with chronic marijuana use. However, research has not yet determined whether marijuana is causal or just associated with these mental problems.”
The page (which as of publication is listed as having been updated in August 2016) makes no mention of the 2013 Harvard study discrediting a relationship between psychosis and cannabis use in the general population—a study that the NIH funded through their Research Project Grant (R01) program.
That the study focused on challenging the dangers, and not exploring the benefits, of cannabis use is typical of research that gets granted NIH funding and access to plants grown by the National Institute on Drug Abuse (NIDA). To be granted cannabis for study, researchers must prove that their study is “valid,” “ethically sound” and in line with “Institute priorities.” For the record, the NIDA’s “mission is to advance science on the causes and consequences of drug use and addiction and to apply that knowledge to improve individual and public health,” language that does not indicate that they are even meant to grant money to research the benefits of medical marijuana, despite being the only avenue through which to gain approval for and pursue marijuana research.
The medical community has long recognized the shortcomings of such a system which grew out of cannabis’ classification as a Schedule I controlled substance: a 2010 “mental health letter” published by the Harvard Medical School details the sparseness of research about “medical marijuana and the mind,” mentioning that the American Medical Association “urged the federal government to reconsider its classification,” something which it has still steadfastly refused to do. The letter put it very simply and succinctly: “Although anecdotal reports abound, few randomized controlled studies support the use of medical marijuana for psychiatric conditions.”
And as for the studies that do receive funding? Calling cannabis “scientific kryptonite,” the International Business Times reports: “[Executive Director of the Institute for Research on Cannabinoids (IFROC) Marcel Bonn-Miller] didn’t have trouble obtaining funding for his work […] when he focused his studies on the negative consequences of marijuana […] But he soon discovered money to increase people’s understanding of marijuana’s therapeutic potential was essentially nonexistent. There were no funding mechanisms at all, he said.”
The view is similarly bleak in the field of mental health. While it’s well known that practical, on-the-ground mental health services in America are sorely lacking—according to numbers from the Substance Abuse and Mental Health Services Administration (SAMHSA), more than half of adults “with a mental illness received no treatment in 2012-2013”—so too are funds for research.
The National Institute of Mental Health (NIMH) published a letter in 2015 on the dearth of biomedical research funding, explaining that there was more to the problem than just a broken public funding structure under the NIH that can fund “less than one in five grants.” The private sector, the NIMH wrote, was proving to be just as unhelpful: “Over the past five years, among the eleven major pharmaceutical companies producing drugs for brain disorders, portfolios have dropped more than 50 percent, from 267 projects in 2009 to 129 projects in 2014.” What was meant to be a two-pronged funding system has petered out into nothing.
And so, little research is being done into specifically how cannabis might be leveraged as a beneficial treatment for certain mental illnesses. All that abounds are basic, preliminary studies—like this one from 2011 “demonstrating a possibly important relationship between PTSD and [an ‘increased risk’ of] cannabis use”—and lots of patient-reported evidence.
The Science Emerges
Behavioral studies about cannabis can be messy for reasons other than funding and obtaining federal approval: Methodology is complex and often betrays that researchers frequently seem to know less about cannabis than even the most casually curious pothead.
This is especially clear when the barebones studies are compared to a research paper by a team under Dr. Staci Gruber that was published in the Public Library of Science journal this June. The study, a collaboration between Harvard Medical School and the Japanese Chiba University Center for Forensic Mental Health, among others, was the “first study to examine the effects of MJ [marijuana] on both mood and neuropsychological performance in BPD [bipolar disorder] patients.”
Its methodology included records (made on a Palm PDA, in a surprising cameo from the early ʼ00s) about each “episode” of cannabis use, things like amount consumed in grams, frequency and method of consumption. Though this seems like the absolute minimum a cannabis researcher should be recording (there is no mention of strain types, species [indica vs. sativa] or cannabinoid levels), other studies simply note the presence or absence of cannabis use, sometimes as far back as “within the last six months.” Additionally, many of these other studies used populations that were hospitalized, skewing the sample group towards those with a particularly severe clinical course or those who had not managed their symptoms.
Perhaps because the bipolar populations studied by Dr. Gruber’s team were pulled from the general population (and were purposefully similar to control groups selected), their findings seem more willing to consider a subjective view of wellness than the studies that rely on hospitalized individuals or otherwise severe clinical cases.
Indeed, asymptomatic remission as an ideal (the intended “positive outcome”) is mismatched with what many cannabis-using bipolar individuals themselves seem to be looking for out of treatment, which is some level of acceptance of neurodiversity that may or may not aim to eradicate symptoms: “Despite claims of [various] negative outcomes associated with MJ use, whether patients view [their] MJ use as successful in symptom improvement is rarely assessed [in studies]. In a single study of BPD patients […] the majority of patients reported improvement that was attributable to substance use for at least one symptom. Further, in a review of anecdotal reports of MJ use among BPD patients, the authors concluded that MJ was not utilized for the ‘high’ sought out by recreational users.”
This study is one of, if not the only, to raise subjectivity in improvement and hints at what bipolar activist Tom Wootton calls “the illness paradigm,” the pathologization needed “to make medicine the central tool” of dealing with what many in his camp simply refer to as “bipolarity.” There are vocal and passionate pro- and anti-medication advocates alike, showing that when it comes to producing worthwhile research on whether something is making bipolar individuals feel better, there must be an incorporation of the individual’s personal metric of wellness in with the standard, objective expectation of functionality.
Measuring bipolar individuals against traditional universalized markers of wellness like medication compliance and remission rates might be ignoring a person’s desires and expectations for their own treatment course, especially since not everyone can find a consistently useful psychopharmaceutical solution. Moreover, how a bipolar individual feels is greatly contextual, Wootton explains, and varies based on whether the person is in a state of “order” or “dis-order”:
“In both cases, there is clear indication of high or low states, but the bipolar condition is the context, not disorder itself. In the case of Bipolar Disorder there is suffering and/or incapacitation, but with Bipolar IN Order there is not. When we lump all of the elements of the experience into a single bucket of ‘symptoms’ we end up making a major mistake. We see disease where no suffering or incapacitation exists. And that is why I am against remission/recovery as the end goal of treatment. They throw the baby out with the bathwater; the baby [being the] non-disordered aspects of the states that give advantages to us. […] Being depressed or manic helps explain the pathology in those who are not IN Order, but is not the disorder itself.”
Wootton makes an important point: Because even the right medication can become unreliable occasionally, being functional as a bipolar individual is often about adapting to live with, rather than in spite of, mercurial moods. It is true of both the most traditional medication-endorsing groups and those insistent on self-care that practical preparation for inevitable and episodic relapse is necessary, and part of that means coming to terms with the realities of emotional variations and intensities that are neurodivergent. Coping, as Wootton explains, means increasing “your awareness, understanding, functionality, comfort and perceived value in having highs and lows. You also need to understand how long you can function at each intensity level before it escalates.”
Because the intended outcome of treatment is deeply personal and subjective, the end-goal scale of wellness is understandably best defined on an individual level. Not only are individuals equipped with completely different capacities and mechanisms for dealing with symptoms, every bipolar person has their own unique baseline and exceptional levels of mania and depression to contend with.
All of these variations between traditional and subjective measures of wellness explain the seeming paradox of the 2016 Harvard study: that “patients with BPD who use MJ have been shown to have higher illness severity and poorer outcome, yet report subjective improvement in symptoms after using MJ […] provid[ing] evidence that some patients with BPD may derive a clinical benefit from using MJ.”
The study stops short of discussing what it means that patients say they are feeling better but are reported as having “negative outcomes,” but it does cite quantifiable evidence to support what bipolar individuals experience when they say that marijuana helps them function.
Researchers elsewhere found that at a baseline, bipolar individuals displayed similar “cognitive deficits [as those] associated with MJ use” in individuals without any Axis I psychiatric disorders: That is, neurotypical stoned people and not-stoned bipolar people alike (regardless of whether they otherwise smoke regularly or not at all) had “impairments across a wide range of areas, including attention, memory, IQ, and executive function.”
But once cannabis was introduced into the mix, the two studies independently “reported a positive association between neuropsychological functioning and MJ use in BPD patients” (emphasis theirs). A 2010 study by the University of Oslo “examined a variety of cognitive domains, including psychomotor speed, attention, working memory, executive functioning and verbal learning [and found that] overall, BPD patients who used MJ demonstrated better performance than patients who did not use MJ […] on tests of executive function” (again, emphasis theirs).
It was on top of this evidence of “improved neurocognition in bipolar disorder” that Dr. Gruber’s team made their own findings about the mood stabilizing potential of cannabis. Looking at “direct analyses of [mood scores of] the MJ-smoking BPD patients (MJBP) before and after MJ use revealed notable symptom alleviation within four hours of smoking[:] significantly lower scores of anger, tension, depression, as well as higher levels of vigor.” All of these findings corroborate the anecdotal evidence from those bipolar individuals who had for years claimed, to little receptiveness from the public, that cannabis has a mood stabilizing or otherwise positive effect on them.
The study concludes with an affirming sentiment for bipolar individuals who have had to defend self-medication: “The current study highlights preliminary evidence that patients with BPD who regularly smoked MJ reported at least short-term clinical symptom alleviation following MJ use, indicating potential mood-stabilizing properties of MJ in at least a subset of patients with BPD. Furthermore, despite previous research showing that MJ use and BPD individually can have a negative impact on cognition, MJ use in BPD patients may not result in additional impairment. Further research is warranted to explore the impact of MJ on mood in clinical and non-clinical populations.”
Waiting for the Future
The study’s unexpectedly positive findings led researchers to urge that “additional studies are needed to help shape public policy regarding conditions that may be amenable to MMJ treatment, especially with regard to psychiatric illnesses.”
The challenge to reaching the logical next step—more research—is clear. The intention of the 2016 Harvard study was framed with the requisite negative language, examining “whether marijuana confers an additional negative impact on [the] cognitive function” of bipolar individuals; since the study’s findings were positive, it’s ironically unclear to see a way forward when funding relies on being in keeping with the National Institute on Drug Abuse’s “priorities.” Arguably the findings so far suggest that the matter is already out of the purview of an institute on “drug abuse.”
Naturally the hope is that further research, when it does occur, will turn both public opinion and legislation in states that have or are considering adopting medical marijuana laws. Of the 39 states and one federal district that have any MMJ program (including the most bare-bones), six allow explicitly for medication of PTSD while only three (California, Washington, D.C. and Massachusetts) have allowances for chronic and “debilitating” conditions that can hypothetically include non-PTSD mental illnesses.
Certainly the growing acceptance of medical marijuana for PTSD is encouraging for neuroatypical people who are waiting for the legal and medical community to accept their treatment of choice, but for many bipolar individuals who are hoping to find an integrative and holistic treatment plan that includes both a doctor and cannabis, patience—and hope for some serious systemic change—will have to be key. For many bipolar people who use cannabis to manage symptoms, cannabis was never intended to be unaccompanied by therapy, self-management techniques and/or traditional psychopharmaceuticals; indeed, patients have been building their own personal frameworks for care this whole time, whether the medical community wanted to join in or not.
But even though there is a wait ahead, it is certainly heartening to know that at least some bipolar individuals managing symptoms with cannabis have been on the right track with what was long referred to derisively as “self-medication.” For a group of people often faced with challenges to their agency, it’s very gratifying to have medical professionals begin to admit that this time, it’s doctors catching up to the patients’ good sense.