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[From the revised edition of Marihuana: The Forbidden Medicine (Harvard University Press), by Dr. Lester Grinspoon, Associate Professor of Psychiatry at Harvard Medical School; and James B. Bakalar, Associate Editor of the Harvard Mental Health Letter and a Lecturer in Law in the Department of Psychiatry at Harvard Medical School. Originally published in 1993, the complete 1997 revised edition can be obtained from The National Organization for the Reform of Marijuana Laws with a credit card by calling (202) 483-5500. Or print out the form at http://www.norml.org/merch/oform.shtml and snail-mail it with a check or money order for $22.50, which covers shipping and handling. The revised and expanded edition - including the paperback version - is also available from the authors' Web site.]
Depression And Other Mood Disorders
For most people, depression is a passing mood; for some, it is a debilitating chronic illness with severe physical as well as emotional symptoms. When it is deep and persistent enough to interfere with work, friendships, family life, or even physical health, depression is regarded as a psychiatric disorder -- one of the most common and one of the most serious.
An episode of severe, or major, depression may last several weeks to several years. One set of symptoms is inconsolable misery accompanied by despair and guilt. Victims feel worthless and inadequate; they have no hope for the future and ruminate about death and suicide. They may think that they have lost all their money, or are being punished for grave sins, or dying of incurable diseases. Some depressed persons do not admit sadness or guilt; instead they withdraw from human contacts, lose all interest in life, and become incapable of feeling pleasure. Time passes slowly for them and the world seems dreary and meaningless. Normal emotional responses, even ordinary despondency or grief, become impossible. They are fretful and irritable. They cannot concentrate or make even minor decisions. They turn the same few ideas over and over in their minds. Some depressed patients are listless and lethargic, with slow movements, toneless speech, and an expressionless face -- in extreme cases, muteness and immobility resembling catatonic stupor. Others pace, weep, moan, and wring their hands in anxious agitation.
Depression is not simply a disorder of mood. Depressed people lack energy in every sense, physical as well as emotional and intellectual. The dominant symptoms may be loss of appetite and insomnia (or, sometimes, oversleeping and a ravenous appetite), backaches, headaches, upset stomachs, constipation, and above all chronic fatigue. People who claim to be "tired all the time" may be depressed even if they acknowledge no sadness or despair. Manic persons, on the other hand, are sleepless and tireless -- until they become exhausted and break down.
The standard treatments for depression are the many antidepressant drugs introduced in the last forty years. For a long time the most popular group of antidepressants was the tricyclics, including imipramine (Tofranil), amitryptiline (Elavil), desipramine (Norpramin), and several other drugs. Their most common side effects are dry mouth and blurred vision. Others are weight gain, constipation, difficulty in urinating, and orthostatic or postural hypotension (dizziness caused by a reduced blood flow to the brain on sitting up or standing up). They can be risky for patients with cardiovascular disease, because they increase the heart rate and may disturb cardiac rhythm.
Another group of antidepressants is the monoamine oxidase (MAO) inhibitors: isocarboxazid (Marplan), tranylcypromine (Parnate) and phenelzine (Nardil). They may cause dizziness, insomnia, and impotence, and when used in combination with foods such as red wines, pickles, and certain cheeses which contain the substance tyramine, can produce dangerously high blood pressure. Because of these potentially serious side effects, they are rarely a first choice in treating depression, but they may be helpful for some patients who do not improve on other drugs.
An increasingly popular new group of antidepressants with fewer and less serious side effects is the selective serotonin reuptake inhibitors (SSRIs). The most popular of these drugs are fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Their side effects include nausea, weight loss, and agitation (or, in some cases, drowsiness), and loss of sexual interest or capacity.
In bipolar or manic-depressive disorder, the inconsolable misery of major depression alternates with mania or uncontrolled elation. In the manic phase people with bipolar disorder are cheerful, gregarious, talkative, energetic, and hyperactive. Their spending is often extravagant and their behavior reckless. They may imagine that they have extraordinary talents and are or soon will be rich and powerful. This reckless, restless cheerfulness and expansiveness can suddenly turn into incoherent agitation, irritability, rage, paranoia, or grandiose delusions.
Antidepressants alone are not a good treatment for bipolar disorder and may even make it worse. Lithium carbonate, introduced into medicine at about the same time as tricyclics, has revolutionized the treatment of bipolar disorder. It prevents mania and to a lesser extent bipolar depression. Although lithium takes several weeks to start working, its success rate is about 70 percent and 20 percent of patients are completely freed of their symptoms. Patients generally require long-term maintenance treatment, and because lithium can be toxic it must be used carefully. Chronic use may endanger the heart, kidneys, and thyroid gland. Usually the dose is gradually increased until the drug begins to work and then periodically readjusted according to the patient's age, medical condition, and psychiatric symptoms. The amount of lithium in the blood must be checked regularly because it is ineffective if too low and risky if too high. Some side effects are weight gain, hand tremors, drowsiness, and excessive thirst or urination. Patients often cannot tolerate lithium either because of the side effects or because it takes some of the joy from their lives along with the manic episodes. It has been described as a "loose-fitting emotional straitjacket." Only 20 percent of patients with bipolar disorder take lithium alone. Other drugs used in the treatment of bipolar disorder are the anticonvulsants carbamazepine (Tegretol) and valproic acid (Depakote), which may be used either alone or in combination with lithium.
Cannabis first appeared in the Western medical literature as a suggested treatment for depression in the middle of the nineteenth century. In 1845, Jacques-Joseph Moreau de Tours proposed its use in melancholia (especially with obsessive rumination) and chronic mental illness in general. 1 In the next hundred years medical papers supported and disputed the utility of cannabis in the treatment of depression. In 1947 G.T. Stockings, an English physician, administered a synthetic THC to fifty depressed patients and thirty-six showed definite improvement. Obsessive ruminations were significantly reduced in six out of seven patients. 2 In 1948, D.A. Pond failed to replicate these results. 3 In 1950 C.S. Parker and F.W. Wrigley conducted a double-blind study involving fifty-seven patients suffering from severe melancholia or milder depression, and found no difference between the synthetic THC and a placebo, but they used a smaller dose than Stockings, 10-20 mg as opposed to 15-90 mg. 4
The most recent study on cannabis and depression was undertaken in 1973. Eight hospitalized patients were given either THC or a placebo for up to a week. The THC did not relieve their depression, and in four of the patients it produced discomfort and anxiety so serious it had to be withdrawn. The authors questioned whether "different effects might be observed in other settings or in patients with less severe depressive symptoms." They also noted that "the administration of THC under double-blind conditions in this trial precluded the establishment of any positive expectations in the patient. The fact that the patients could not have prepared themselves for the experience of an altered state of consciousness may also have contributed to the predominantly negative effects of the drug in these depressed patients. Finally, the relatively brief duration of the trial (one week) must be kept in mind since standard antidepressants require two to three weeks to produce clinical improvement." 5
Today, among the minority of depressed patients who do not respond to any of the standard antidepressants or find the side effects unbearable, some have discovered that cannabis is more useful than any legal drug. We first learned about the following patient's use of cannabis from her psychiatrist. She called us because she was puzzled to find that marihuana was more useful than the drugs she had prescribed, and she wanted to be reassured of its safety. The patient gives her account below:
I am a thirty-nine-year-old health professional who suffers from chronic depression. I have been able to graduate from college, receive a postgraduate degree with highest honors, and establish a successful professional career, but it has been a constant struggle. No matter how much I accomplished, how much praise I received, none of it registered. I could only ruminate about my shortcomings, and I seemed to have no control over my unrealistic negative thoughts.
My first major episode of depression occurred in 1969, when I went away to college. I withdrew halfway through my freshman year and began semi-weekly therapy sessions with a psychiatrist. With her help and the use of a tricyclic antidepressant, I was able to return to a college closer to home the following September. I continued to see her once a week until I left the East in August of 1976. While at school in the Midwest, I saw a psychiatrist renowned for his expertise in the pharmacological treatment of depression. Since I returned to the East in 1981, I have been in therapy once again with my original psychiatrist, either once a week or every two weeks.
Under the guidance of these therapists I have tried more than a dozen different drugs, including several types of tricyclic antidepressants, Prozac, lithium, Ritalin [methylphenidate, a stimulant related to amphetamine], synthetic thyroid hormone, and probably others I have forgotten. The only ones that have affected my moods significantly are Elavil at high doses, and combinations of Dexedrine [dextroamphetamine] and a barbiturate. Elavil works only during an incapacitating episode of depression, and its side effects, especially constipation, are distressing. Since use of Dexedrine and barbiturates as antidepressants is considered unorthodox, my therapist and I have been uneasy about it, but it was the only medication that worked. Several prominent psychiatrists have verified this and recommended that I use whatever helps. But now I am becoming tolerant to both of these drugs (I have been careful not to increase the dose, because I know the dangers).
In the spring of 1990 I smoked marihuana for the first time since 1973. To my amazement, a quarter of a joint changed my self-perception to match the person others saw. It was like night and day. I had experienced a similar change only a few times before, when Elavil kicked in and lifted me out of the depths. But with Elavil it took four days of rapidly increasing doses; with marihuana it took less than five minutes, every time. Since then I have been using marihuana to think clearly, to concentrate, and simply to enjoy the beauty of the world in a way I couldn't for years.
I try to carry the same positive feelings with me while I am not directly under the influence of marihuana. I now use marihuana as an antidepressant once or at most twice a day. No one realizes I am smoking it, because I don't act stoned. I have been cutting back on my other medications and often forget to take them. After smoking some cannabis in the morning, I no longer dread the responsibility of going to work but actually look forward to it. I have always awakened in the morning more exhausted than when I went to sleep. Even during weekends and vacations, I have found it difficult to get dressed and get moving. Immediately after I smoke marihuana, all that changes. I feel energetic and loquacious; I want to socialize, exercise, or do whatever needs to be done. I feel a passion for life. I even see myself differently in the mirror, and realize that I am not the homely beast I usually see. While using marihuana I realized that I was not spending time with the person I wanted to be with, so I ended an unsatisfying relationship of two and a half years. I am now with someone I love dearly. Without marihuana I have an orgasm only through masturbation or after heroic efforts during intercourse. Cannabis transforms me into a fully developed sexual human being. I can easily shut out inappropriate thoughts and enjoy what I am feeling. I can have orgasms by stimulation practically anywhere on my body, even just through kissing -- amazing!
It is unfair and cruel that the antidepressant that helps me most (and is probably, in its pure form, least toxic) is unavailable for legal prescription. I have to break the law to obtain it and pay exorbitant prices for a drug whose cost of production is minimal.
Another patient who suffers from episodic depression writes as follows:
I am a forty-seven-year-old white male, a partner in a multi-million dollar company. . . . As soon as I started school my emotional problems became apparent, and an endless trek to various health professionals began. My school phobia made me sneak away from school, sometimes by climbing out windows. I spent much time being interviewed by "special ed" teachers and social workers. From early on I was examined by a continuous flow of physicians. My earliest recollection is the one who prescribed special arches for my shoes (to relieve headaches) and a syrup at night to make me sleep.
The headaches persisted; the depressions became paralyzing episodes that occurred several times a year and lasted days to weeks. Because of them I missed much of grade school and junior high.
In my sophomore year of high school things got worse. I was given a prescription for Miltown [meprobamate, an anti-anxiety drug]. I took it in varying dosages for several months. It caused me to become drowsy and dizzy; my speech slurred, and I developed chronic diarrhea. My poor performance in school worsened. I started to lose my coordination. My depressions continued, perhaps made worse. I was glad to stop using it.
My experience with Miltown was so unpleasant that I refused to take any other "mental" drugs for the next two years. I did see a therapist on a weekly basis. His diagnosis was "episodes of acute depression."
During this period I managed to just barely complete high school, and got accepted at a small local college. During my second semester I attempted suicide. I was told by a doctor that I had an "obsessive-compulsive personality." It was suggested that I take Librium. I started taking this drug and found myself in a continuing state of depression, confusion, and lethargy. I had to leave school. When my speech started slurring I abandoned the Librium.
I got a job driving a truck, and started seeing a new doctor, a psychiatrist. After nine months I reapplied to college and was accepted. The doctor convinced me to try another drug, Tofranil, that he said was very effective in treating depression. I started using it and soon found I was losing all power of concentration. I became restless, full of anxiety. It became almost impossible to urinate. I developed a lump the size of a marble in my left nipple. The doctor ascribed these symptoms to the Tofranil. I stopped using it and again left school. My depression was still there, and I was desperate for some relief. I also started getting pains in my stomach. A GI series revealed a duodenal ulcer. I constantly chewed antacids and took tablets called Zantac [ranitidine, an ulcer treatment].
Life was becoming more difficult, and the doctor suggested another medicine, Vivactil [protriptyline, a tricyclic antidepressant]. Again, the side effects were disastrous. I became more agitated than before, had great trouble urinating, and a chronic skin disease I have (atopic dermatitis) started to itch with a fury. I developed a peculiar taste in my mouth that would not leave and had a continual feeling of nausea. Shortly after discontinuing Vivactil I was in the psychiatric ward of a New York hospital, suffering from "atypical depression."
In the hospital I was put on lithium. After two days my hands started to shake. This tremor became so intense that after one week I was unable to write, or hold a glass without spilling the contents. I had diarrhea and nausea; my vision started to blur.
I ceased using the lithium and left the hospital after a stay of two weeks. When I saw my therapist again he made an unusual statement: "I'm not suggesting this," he said, "if I did I could lose my license, but have you ever tried marihuana?" I had smoked something alleged to be marihuana once in high school and had been unaffected. I thought it might be worth another try. I called a friend I suspected would know where or how to obtain some, and the next day she brought me two joints. I later learned that her husband (who is a dentist) used marihuana to ease the pain of chronic depression.
Remembering my previous experience, I had low expectations. Alone in my room I lit the first joint. Soon I found myself lost in reverie. Previously, when I was depressed, the sadness became the focal point of my existence. Now my mind was being distracted by neutral, and even funny or pleasant thoughts. The constant pain of the depression was reduced to an occasional nagging ache. I slept well and awoke feeling refreshed, not "doped up" and lethargic. It soon became apparent that when I was in the throes of a depressive episode, a marihuana cigarette was a greater source of relief than anything I had ever tried before -- not a cure, but something that diluted the pain. The marihuana permitted me to function better than any licit drug. I didn't become drowsy, develop tremors, or have any of the side effects associated with the drugs I had previously taken. I gained an appetite I never had, and put needed weight on an emaciated frame. I found myself having ideas that would not ordinarily have come to me, some practical, some not. I was able to pierce the black cloud that surrounded me and climb out far enough to meet my responsibilities. The use of marihuana makes it impossible for depressive thoughts to become the total focus of my life.
The fact that marihuana is illegal made me search for a licit medicine that was at least as effective. The next one I was given was Norpramin. This chemical offered no relief and came with an assortment of side effects that aggravated my prostate, gave me diarrhea, left a terrible, lingering taste in my mouth, and colored my tongue black. For about a year I was given Adapin [doxepin, another tricyclic] with only minor side effects, but it did little or nothing to change my condition. I was also given Buspar [buspirone, an anti-anxiety drug], which seems to have no effect at all. Perhaps the very worst of them all was Prozac, which actually made me more anxious, nauseous, dizzy to the point of fainting, and unable to achieve orgasm. I have also had Desyrel [trazodone], which causes only minor side effects, but again seems to do little good.
As of this writing, I have smoked marihuana for more than two decades. In addition to dampening the pain of depression, I have found it reduces nausea and burning in the stomach due to the production of acid. It allows me to sleep peacefully. It stimulates my imagination when working on creative projects. It enhances simple joys, such as eating M&Ms or walking in the woods. Since its use jeopardizes my freedom, I would prefer a legal substitute. So far I have found none.
I use no other illicit substances. I do not use tobacco. My alcohol intake is no more than an occasional drink on a Saturday night out. I usually have one cup of tea a day, and two glasses of Coca-Cola. I take several aspirins a week.
Ron Leifer, M.D., is a psychiatrist who practices in Ithaca, New York. He reports on two of his patients who found cannabis useful for the treatment of depression:
In more than thirty years of practicing psychiatry in a small university town, I have encountered many patients who use marihuana, and in most cases this use is unrelated to the problem for which they seek therapy. But a few of my patients have used marihuana for the relief of chronic depression, as the following examples indicate.
Mr. T was a forty-four-year-old history teacher at a local college who came in looking unhappy and complaining about all aspects of his life -- his work, his marriage, his house, his finances. He said he saw no hope of improving his situation. He was angry, cynical, and critical of others. He stated half in jest that he often thought of committing homicide or suicide. He asked for medication to relieve his depression.
Mr. T's father was a Polish Jew who escaped before World War II, while his own father died at Auschwitz. He worked as an upholsterer in Florida. The patient was terrified of his stern father but also greatly loved him. In 1958, when the patient was eight years old, his father became depressed and was given electroshock therapy. He died of a heart attack five years later, when the patient was fourteen, and he traces his own depression to that time.
He first consulted a psychiatrist in 1970, and since then has been given Desyrel [trazodone], Elavil [amitryptiline], Prozac [fluoxetine], Wellbutrin [bupropion], lithium, and three or four other antidepressants whose names he cannot remember. None of them brought relief. He first tried marihuana in 1986, when he was in Amsterdam with his wife and her dance troupe. It gave him immediate relief, but he was reluctant to continue using it because it irritated his lungs.
The day after his initial consultation, Mr. B.T. called for an emergency appointment and begged for anxiety medication. I prescribed Valium [diazepam]. At the next meeting a week later he said he did not like Valium and asked for an antidepressant. I now prescribed Prozac [fluoxetine] along with Xanax [alprazolam] for anxiety. He said the Prozac made him jumpy and within a month had stopped taking it. He now asked for Marinol, saying he did not want to smoke marihuana because he feared the legal consequences and because it aggravated his bronchial problems.
I arranged a consultation with Dr. Grinspoon, who prescribed Marinol, 5 mg twice a day. Three days later he called to say he was feeling much better. He was more energetic and thinking more clearly. A month later he reported that he felt great; his depression was gone, his negative thoughts had disappeared, and he was no longer cranky and angry. He loved his work, he was getting along with his wife, and he was sleeping well. Since he was no longer anxious, he had stopped taking Xanax. Three months after the initial consultation he described Marinol (which he was now taking three times a day) as a "miracle drug."
After six months his insurance ran out and he was unable to afford Marinol. He turned to street marihuana, although he was unhappy about this because of the expense and the bronchial irritation. Then he was granted Medicaid and asked me to prescribe Marinol again, but I was reluctant because I could not get prior approval and feared the reaction of the state government. Mr. T is still successfully using street marihuana to treat his depression.
The following is another example:
Mr. F, a sixty-five-year-old retired college professor, was referred by a psychopharmacologist from New York City. Dr. Grinspoon had recommended Marinol, and the patient was looking for a physician closer to his home who would prescribe it for him.
Mr. F said that he had been depressed for the past twenty years. He had been in psychotherapy all that time with a local psychiatrist who says that he suffers from "characterological depression." He had been unsuccessfully treated with a variety of antidepressants including Prozac, Tofranil [imipramine], and desipramine. He had been in psychiatric hospitals several times, and nine months before seeing me he had received ECT [electroconvulsive treatment], which was also ineffective.
When he first tried marihuana, in 1975, it had no effect. But later it was given to him by fellow patients on the psychiatric ward of a local hospital, producing "the first authentic depression-free moment of my life." He did not want to use marihuana habitually because it was difficult to obtain and legally risky and he was worried about the effect on his heart and lungs. He says the Marinol prescribed by Dr. Grinspoon gave him instant relief from his depression. He calls it "a miracle drug."
He had an angioplasty in July of this year, and since that time has been following a strict low-fat diet with yogic exercises. He has chronic atrial fibrillation, for which he has refused all prescribed medication.
After consulting with Dr. Grinspoon, I prescribed 5 mg of Marinol three times a day. The patient says he is no longer depressed and suffers from no confusion, memory loss, or other negative side effects.
Thirty to 40 percent of patients with bipolar disorder are not consistently helped by conventional treatment. For some of them cannabis may be useful in ameliorating the symptoms, reducing side effects of lithium, or both. The following account is written by a forty-one-year-old woman with apparent bipolar disorder:
I was born on Friday, October 13, 1950, a few months before my father had his first serious bout with manic depression. My mother said he was taking valuable art objects they owned and throwing them down the trash chute in their New York apartment building.
I enjoyed my youth with a great deal of abandon. How much of this would be mood disorder I could not tell you. As a single person I didn't notice; I just rode the waves of emotional highs and lows and didn't think much about it. I was an old pro at this by the time I was nineteen and met my husband. It was only through my association with him that I came to terms with my mood problems, although right before I met him I had checked myself in at a mental health clinic complaining that I sometimes felt unable to concentrate on one thing at a time.
I think I was twenty-two years old when my troubles cropped up again. At one point my husband and I went to see a psychologist. We talked about my mood swings and spells of nervousness, anger, and depression. The tiniest negative thing happening would cause long-lasting rage, very hard to quell. We told the psychologist of my father's history, even longer and grislier by then. He must have been in every state mental institution along the east coast. My grandmother, his mother, was wasting away by this time, losing her lifelong battle with chronic depression. I don't know much about her case except that she was chronically sad and starved herself to death after her husband passed away.
This man said my husband and I needed to lose weight; that was the extent of his advice. We did not see him much longer. By this time I was experiencing most of the symptoms I have today, although they have strengthened year by year. Sometimes I feel elated, exhilarated, with a great deal of energy. It sounds great, but you can get to be feeling so good that you scare the people around you, believe me! This is accompanied by light sleeping and nocturnal habits. I tend to become angry or aggressive when it is not appropriate, or just talk too loud. I often have a low self-image or feel sad. I sometimes have a hard time getting up to work, a heaviness that keeps me from moving. I get racing thoughts that make concentration hard. I have strong emotions that change rapidly. I tend to be physically clumsy. I develop unexplained skin rashes, and sometimes feel like I'm generating electricity and shooting it out my fingers and toes. My judgment is often poor.
It was in my early twenties that I first used the herb cannabis for my condition. I had been exposed to it several times, the first when I was quite young. My mother had taken me to a mental health center after my initial signs of trouble as a child. After a group therapy session there some of the other kids took me riding and gave me a joint. Nothing at all happened, and I concluded it must be a mild drug.
When I was exposed to it later, I would actually choose it over alcohol because it didn't have such strong and negative effects on me. This is how I discovered that it was effective against most of my symptoms. Suppose I am in a fit of manic rage -- the most destructive behavior of all. A few puffs of this herb and I can be calm. My husband and I have both noticed this; it is quite dramatic. One minute out of control in a mad rage over a meaningless detail, seemingly in need of a strait jacket, and somewhere, deep in my mind, asking myself why this is happening and why I can't get a handle on my own emotions. Then, within a few minutes, the time it takes to smoke a few pinches -- why, I could even, after a round of apologies, laugh at myself!
But this herb is illegal and I have a strong desire to abide by the law. My father was having great success with a new drug, lithium carbonate. I saw my father's physician and he recommended that I try it. I took lithium for six months and experienced several adverse side effects -- shaking, skin rashes, and loss of control over my speech. But I would still be taking it if it had worked for me as it did for my father. It literally restored his life. I had gotten worse, if anything.
The combination of lithium side effects and increased manic depressive symptoms drove me back to the use of cannabis. Some years later I tried to go without it again, this time because of increased social pressure against illegal drug use. It was a very difficult time for my family. Whenever I started to become manic, my husband and son would get scared and cower, triggering rage and making matters worse. When depression struck it was a black funk on our household. And I can tell you from the experience with my father that this can really destroy a family. After a while the knowledge that a little bit of herb would help me so much became irresistible. At first I tried eating cannabis, but soon returned to smoking because I could control the dose better.
The legal situation now is worse than ever. I jeopardize my freedom and property in order to control my condition. Do I have a choice? I don't at all consider myself a drug abuser. I am doing what any rational person in my position would do. Cannabis does not cure my condition and over the years it has probably continued to worsen. But with judicious use of this medicine my life is fine. I can control things with this drug that seems so harmless compared to the others I've tried, including tranquilizers as well as lithium. I am constantly concerned that I will be cut off from my supply of marihuana or caught with it in my possession. I feel my sanity may depend on it. Cannabis lessens what is troubling me and returns me to a more normal state. Often I do not experience a "high" at all, just a return to normal.
Here is the account of another woman who suffers from bipolar disorder and finds that cannabis is more useful than conventional medications:
I am a thirty-five-year-old woman with severe manic depression. When I was growing up I was hypersensitive, cried all the time, and fought with my brothers and sister. My parents always said they had to handle me with kid gloves. I had more energy than most and used it to the hilt. I was an agile gymnast and one of the fastest swimmers in my school. I was also at the top of my class in algebra and good at art and creative writing. I used to stay awake at night and dream up stories.
Around age fourteen my mood swings began to get more intense. I was agitated, restless, and constantly fighting at home. I lay awake at night and lost a lot of weight. Eventually I snapped and was sent to a mental hospital, where I was diagnosed as having manic-depressive disorder. They put me on lithium and told me I would have take it the rest of my life. But lithium made me lethargic. I had trouble communicating and lost all my animation and creativity. Eventually I quit taking it. Recently I have also tried Tegretol [carbamazepine] and Depakote [valproic acid], neither of which helped. Tegretol started a manic episode, and Depakote had some very bad side effects. I'd like to find something else, but I don't have health insurance or the money to spend trying out new medications.
Since the age of fourteen I have had manic episodes regularly about once every six months. It would always start with not being able to sleep or eat. After two weeks I would just break down and seem to trip out into another world. Usually I ended up in a mental hospital.
I smoked marihuana for the first time in high school and couldn't believe how good it made me feel. My normally chaotic emotions subsided and I had a sudden sense of calm, peace, and well-being. My perceptions of others and life changed dramatically. The world no longer seemed hostile but more within my control. I could sleep easily and actually had cravings for food. There were practically no side effects. When I had enough marihuana I would just naturally stop, because once you've gotten a certain effect you really don't want any more.
Only another manic-depressive using marihuana could possibly know how much this has changed the quality of my life. Although they don't know it, my family actually like me better when I'm stoned than when I'm taking lithium or not taking anything. When I'm stoned they can predict my moods and actually get close to me. But I can't tell my family or the doctors because it's illegal. I have to live a double life to get along.
I've often tried to quit marihuana, but I have a manic episode every time. Last year I decided I could control my emotional ups and downs without marihuana, but it led to one of the worst episodes I've ever experienced. I had been having trouble sleeping as usual. I began to get super clear vision that a disastrous earthquake was going to hit Los Angeles. I was feeling so good I was sure I was right. Soon I had my roommate convinced that we didn't have much time and would have to buy as many supplies as possible and then leave. We thought that after the quake the New World Order would be implemented and everyone would have to take the number that Revelations talks about in the Bible. We planned to go to El Salvador, where her family lives, and hide out for the next three and a half years. Crazy! But I really believed it. I maxed out all my credit cards, quit my job, and packed up all my things, including disguises I thought we were going to need. Eventually I had to return home with no job and major bills.
I knew then and there that I would have to go back on marihuana. It's been seven months now since I resumed smoking marihuana, and I don't know what else to do. I have to choose between obeying the law and staying sick or breaking the law and being well.
Jacci Papi is a forty-five-year-old health professional and the mother of a twenty-year-old son:
In late 1994 and early 1995 my son Michael, age eighteen, began to go out of control. He was unable to sleep, attend school, or function in a normal fashion. He was running around nonstop, acting on impulse without any sense of normal judgment. He was in serious danger of accidentally harming himself or others. There was no way to reason with him, because he was unable to think or listen long enough to understand what you were trying to say. He had become a human time-bomb.
Then, on February 14, 1995, he had a full-blown psychotic manic episode and refused treatment. I had to petition a court to commit him to a psychiatric hospital in Portland, Maine, where he was given a diagnosis of manic-depressive disorder. Both Michael's father and my grandmother suffered from the same disorder, which is now called bipolar disorder.
During his nine days in the hospital (the time allotted by my insurance company) Michael was given lithium and Trilafon [perphenazine, an antipsychotic drug]. We were told that he would need lithium for the rest of his life. They explained that it worked very well in 60% of people with this disorder.
We returned home, and for the first month or two, the mania seemed to have ended. At the end of the second month the Trilafon was discontinued, but Michael was still taking a high dose of lithium. At that point he developed a rash on his neck and chest; he also had dark circles under his eyes, and he was incoherent most of the time. The lithium level in his blood was exactly where the doctor wanted it, but now he was acting like an Alzheimer's patient. He couldn't read or comprehend a paragraph, let alone finish school. He was detached from his surrounding and himself. There was no emotional content left in him. He was becoming unrecognizable. He had always been very much like Robin Williams in personality and extremely athletic -- a skier, football player, and weight lifter. It was heartbreaking to watch him lose himself in a medicated stupor. I became convinced that lithium did not eliminate the disease but instead was drowning his brain so the symptoms could not be activated. I could still see tiny mood swings and moments of complete restlessness, but in a body that was unable to become hypomanic.
Michael decided to cut his lithium in half. I knew this would be dangerous but I agreed that something had to be done. Soon he was more himself, laughing and talking and almost back among the living. Then he started to become more hypomanic, and I knew we were headed for trouble. He was back to the energy level of someone on high doses of speed, and this lasted for months. He was running through life like a high-breed stallion, while I was gathering everything ever written on manic-depressive disorder.
Then one day he came home and was perfectly normal in every respect. I thought that maybe he was in remission because the disease is known to do that, and I was thrilled at the possibility. Later that night he was back to full speed ahead, and all hope sank within me. This continued as the weeks passed. There would be times when he was perfectly normal, but only for short intervals. I could not figure it out. I started to chart his sleep pattern, his food intake, the kinds of foods, what chemicals he was subjecting himself to, and so on. Finally one day I discovered that he was smoking pot. Of course I freaked out. We talked about it at length and he told me point blank, "I only feel normal when I smoke a joint." By this time I was ready to blame the disease on his pot smoking. I was totally irrational about this. Michael and I fought constantly for a month about it. Finally he asked me to research cannabis and let him know what I found. I figured I would be able to find enough damaging information to put the subject to rest. The next week was my week of discovery. Not only could I not find what I was looking for, but I became convinced that there was no permanent damage, and that cannabis was actually helpful for people with mood disorders.
I went on-line on the computer to talk to other people suffering from bipolar disorder, and I was overwhelmed by first-person stories of the benefits that others had found.
The hardest part of this entire thing was rearranging my value system. I was raised to be a law-abiding citizen. Although I grew up in the '60s and had tried pot and inhaled, I was never a regular user because it was illegal. I raised Mike right. He was taught to respect elders, do what you are supposed to do, and above all follow the law.
It is hard enough to live with an eighteen- year-old during a naturally rebellious time, but to be forced to participate in an illegal activity is the absolute worst scenario. But that is exactly what I'm doing. Mike has been smoking pot for two months now. He does not smoke daily, but when the mania begins he smokes and within five minutes he is fine. He never appears to be "high," just happy and relaxed. We don't have to deal with mood swings anymore. He can work on his home-schooling program, and I don't doubt that he will finish by the end of summer. He has been repairing lobster traps with a friend and will be lobstering six days a week by the end of April.
At this point I expect to be arrested some day, because if Mike gets arrested, they will have to take me right along with him. I plan to grow a plant this summer for his use. I know I could end up in jail, but I also know that without some kind of medication that works, my son could end up in jail, institutionalized, or dead. What choice do I have?
Except for the eight who have Compassionate INDs, every one of the many thousands of Americans who use marihuana as a medicine runs a risk of being arrested. They have to worry about financial ruin, the loss of their careers, and forfeiture of their automobiles and homes. Some have an additional burden, because mandatory school drug programs and Parents for a Drug-Free America advertisements have given their children an exaggerated idea of the dangers of using marihuana. Many of these children become concerned about the health and well-being of their marihuana-using parents. A few of those parents have been arrested because their worried children informed on them to the police officers who serve as instructors in the popular school drug program known as Drug Abuse Resistance Education (DARE). The following accounts are by a forty-year-old software engineer and his thirty-seven-year-old wife, who suffers from bipolar disorder. He speaks first:
My wife and I and our two boys live in Tyngsboro, Massachusetts. My wife was given a diagnosis of bipolar disorder in 1982 and has been taking lithium since 1992. She also uses marihuana for her symptoms. She has had six psychiatrists in the past fourteen years and has been interviewed by many more. I have always told them that she uses marihuana regularly, and not one of them has told her to stop. They do not even seem to care or pay attention.
Now his wife:
I posted a question about this to the alt.support.depression.manic newsgroup on the Internet. I asked whether doctors knew something about marihuana but could not recommend it because of its illegality. The responses were varied, but most people who were manic-depressive said marihuana helped them, and one said that some doctors considered it effective in controlling mood disorders.
My wife functions much better when she uses marihuana. When she is hypomanic, it relaxes her, helps her sleep, and slows her speech down. When she is depressed and would otherwise lie in bed all day, the marihuana makes her more active. When she runs out of marihuana and can't get more, she becomes more irritable and hard to live with. Lithium is also effective, but it doesn't always keep her in control during seasonal mood changes.
Our dilemma is that our thirteen-year-old has been through the DARE program and has learned about the evils of drugs and alcohol. He opposes all substance use, legal or illegal --- and I want it that way. But he knows that my wife uses marihuana and it "eats" at him, although he also knows about her illness and how marihuana helps. Understandably, all this confuses him.
I believe that marihuana could help some people if it were made available as a prescription medicine. Certainly there are other health and social issues involved, and I can't decide what would be right for the country as a whole. All I know is that in this family it has relieved us all of much suffering.
I am thirty-seven, and I have been using marihuana for twenty years. I was diagnosed bipolar in 1982. I take lithium and Wellbutrin [bupropion], although I dislike these drugs.
I've gained about forty pounds since I started taking lithium, but otherwise there are no side effects.
My thirteen-year-old son knows about my illness. He has also known about my marihuana smoking for about five years. He realized what I was doing after he participated in the DARE program in school. It bothers me when he comes home and says they talked about drugs and he was thinking that his mother is "one of them". He doesn't want anyone to know his mother is a "druggie," and until now we've kept it as our secret. I don't think he would tell anyone, but I'm still afraid something might get out. Sometimes these programs use tricks to get kids to inform on their friends and relatives. They say, "If you really care about this person, the only way you can help them is to report them." My husband has talked to him about it. He has explained that lithium and the other medications I'm taking are drugs. He also explained that many legal drugs are far more dangerous than marihuana and that no one has ever died from using marihuana. But my son insists that if it is illegal, then it is wrong. This bothers me so much that I have considered stopping.
The trouble is that at times when I feel tired and run-down, just a couple puffs of
marihuana bring me back to life. Sometimes I think it brings me to a level of normalcy that everyone else achieves naturally. At other times, when everything seems to be going like a whirlwind around me and I can't keep track of what I'm thinking about or saying or feeling, the marihuana just seems to slow the world down a bit. When I have trouble sleeping, it helps zonk me out, but if I have trouble waking up it brings me to life. I don't like being thought of as a "drug-abusing mother," but I actually think I'm a better mom when I'm feeling in control because of marihuana.
Here is another account of cannabis use by a person with bipolar disorder, emphasizing the reduction of lithium side effects:
I am twenty-nine years old, born and raised in North Carolina. My academic background is in English literature, computer science, and law; I now work as a technology consultant and writer, although I am contemplating returning to graduate school. I am divorced. I am reasonably active in my community, though work takes much of my time these days.
I was first diagnosed with bipolar disorder about five years ago, when I was in law school (a psychiatrist also tentatively ventured this diagnosis during my undergraduate years), but I suspect that I have had a mood disorder for most of my life. I was certainly clinically depressed as early as age nine, and my first hypomanic episode occurred at seventeen. There is also a family history of mood disorders, especially on my mother's side. All three of her brothers had
"mercurial" personalities, and they all experienced tremendous successes and notable failures in business. Their extravagance and outgoing personalities resemble my behavior while manic or hypomanic. Although none of them were formally diagnosed with a mood disorder, both my parents have been treated for clinical depression.
Before I was diagnosed and found the right treatment, I had the typical symptoms of bipolar disorder. During depressive phases I became withdrawn, uncommunicative, and preoccupied with suicide. I found it nearly impossible to function in school or at work. During hypomanic or manic phases I spent freely, traveled all over the country (and world), made poor personal and business decisions, engaged in risky sexual behavior, and so forth. The illness has caused me a great deal of personal pain as well as financial woes. I separated from my wife (who eventually divorced me) the summer before I was diagnosed. I've lost jobs, ruined friendships, and alienated members of my family. Fortunately, much of this damage has been repaired with time and understanding. I thank God that my ruined credit rating is the only apparent lasting harm.
Thanks to lithium and sensible therapy, including the judicious use of cannabis, I have been relatively stable and sane for the past three years, although my sleep is often disturbed and I still have (very much milder) hypomania and depression in much the same cyclic pattern as before.
I first used cannabis in my freshman year of college (1984). I preferred it to alcohol as an intoxicant, and used it a few times a week, almost always by smoking (I still prefer to take it that way.) In retrospect, it seems clear to me that I was medicating myself for bipolar disorder even then. When depressed and anxious, I found that cannabis was soothing and enhanced my ability to enjoy life. When I was in a manic phase, it relaxed me and helped me get to sleep. I often felt as though I had so much energy inside me that I would jump out of my skin; the cannabis helped tremendously with that. But there was a downside. Manics have a big problem with impulse control, and cannabis seemed to exacerbate it. ("Drive to Canada? Great idea. Let's go!") It also ratcheted up my already overactive libido a notch or two, which wasn't the healthiest thing in the world.
When I was diagnosed and began treatment with lithium, I got almost immediate relief, but I also suffered from nausea, pounding headaches, hand tremors, and excess production of saliva. A
friend suggested that I try getting high, reasoning that if cannabis helped chemotherapy patients deal with their nausea and discomfort, it might help me too. My doctors thought the idea was absurd but admitted that it would be safe to take cannabis together with lithium. So I tried it, and the results were remarkable. The hand tremors subsided, the headaches vanished, and the saliva factory resumed normal production levels. All I needed was one or two puffs on a marihuana cigarette. When lithium side effects get bad, the availability of cannabis has been an absolute godsend. It is also nice to be able to use cannabis as an intoxicant, knowing that, unlike the combination of lithium and alcohol, it cannot damage my kidneys.
Bipolar disorder is naturally cyclical; manic and depressive episodes come and go, so it is essential not to confuse natural remission with cannabis-induced improvement. And of course, the proportion of patients with mood disorders who would get the kinds of benefits described here is unknown. As usual, promising anecdotal evidence points to the need for more systematic clinical investigation.
1 J.-J. Moreau de Tours, "Lypemanie avec stupeur; tendance à la démence. -- traîtement par l'extrait (principe resineux) de cannabis indica -- Guérison," Lancette Gazette Hôpital 30 (1857):391.
2 G.T. Stockings, "A New Euphoriant for Depressive Mental States," British Medical Journal 1 (1947):918-922.
3 D.A. Pond, "Psychological Effects in Depressive Patients of the Marihuana Homologue Synhexyl," Journal of Neurology, Neurosurgery and Psychiatry 11 (1948):279.
4 C.S. Parker and F.W. Wrigley, "Synthetic Cannabis Preparations in Psychiatry: I. Synhexyl," Journal of Mental Science 96 (1950):276-279.
5 J. Kotin, R.M. Post, and F.K. Goodwin, "Delta-9-tetrahydrocannabinol in Depressed Patients," Archives of General Psychiatry 28 (1973):345-348.
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