Frequently, I have been asked to give my medical opinion on CBD oil as it pertains to anxiety, depression, and other psychiatric symptoms. With the upcoming implementation of medical marijuana in Ohio and the increasing popularity of this question, I figured now would be a good time to review some medical research on this topic.
CBD is a non-psychoactive derivative of the Cannabis sativa plant which is typically administered in the form of oil absorbed under the tongue. Unlike THC, another component of marijuana, CBD is not associated with negative cognitive effects and psychoactive impairment. CBD acts as a CB1 and CB2 inverse agonist, monoamine uptake inhibitor, and 5HT1a agonist, which results in the observed psychiatric benefits, including anxiolytic, antipsychotic, anti-insomnia, and antidepressant effects. Other benefits include anti-inflammatory, analgesia, anti-seizure, and anti-diabetic effects.
CBD can be derived from hemp or from marijuana, with hemp being the recommended source by the FDA in order to ensure the absence of psychoactive impairment. According to federal law, any CBD product containing THC in any amount is considered marijuana and is illegal. Because these products are unregulated by the FDA, the legal murkiness becomes the issue here. It is important to specify non-THC-derived CBD if recommending this product to a patient.
Blessing et al demonstrated in a 2015 review article that preclinical evidence conclusively supports efficacy of CBD in reducing anxiety in OCD, Social Anxiety Disorder, PTSD, Panic Disorder, and Generalized Anxiety Disorder. This review further determined that most human studies that have been done support preclinical findings and also demonstrated “excellent safety profiles” with minimal sedative properties. Although this evidence is promising, the majority of studies were done in acute settings with short-term dosing. Long-term studies in humans, as well as further clinical studies in humans, will be needed before stronger opinions can be made.
As of 9/8/18, Ohio's new medical marijuana law went into effect. It clarifies that CBD oil, which can derive from either marijuana or hemp, depending on the source, is illegal. The law says CBD oil must go through the same rigorous testing procedures and comply with the same rules as actual cannabis. So, Ohio's Pharmacy Board says sales of CBD products are illegal in Ohio if they are not being sold in a licensed dispensary.
It is commonly held that stress is unhealthy. Health professionals have consistently maintained that stress contributes to a myriad of illnesses that range from the common cold to cardiovascular disease and cancer. More recent research, however, suggests that stress may not be a completely bad thing, in fact, in some instances it may be healthy. In 1998, evidence began to emerge that our understanding of stress was less straightforward than previously thought. Abiola Keller and her colleagues conducted a survey of 30,000 people and then tracked them for 8 years. The survey consisted of two primary questions: “How much stress have you experienced in the last year?” and “Do you believe that stress is harmful to your health?”. Eight years later, they reviewed public records to find out who among those 30,000 had died. Based on their findings they determined that high levels of stress increased a person’s chance of premature death by 43% but only if they believed that stress was harmful to their health. People who reported high stress but did not believe it affected their health had the lowest risk of death of all the people who participated in the study, lower than even those who reported low to moderate levels of stress. The conclusions of the study were that stress alone was a poor predictor of premature death. People also had to believe stress contributes to poor health.
The conventional view of stress is that it elicits a fight or flight response. When this response is experienced the body readies itself for some type of action-oriented response to this danger. Adrenaline is released, heart rate increases and breathing accelerates and deepens, blood vessels in the muscles dilate while other blood vessels constrict, digestion ceases and the sensory system becomes heightened. This response was intended for survival and was adaptive when people were confronted with the real danger of imminent death or severe injury. In modern times people experience a fight or flight response for events which while stressful do not reach the level of true survivalThis type of stress, when regularly experienced, is believed to contribute to health concerns. Keller’s findings suggest that your mindset about stress also matters and there are health benefits related to adopting a more positive attitude about stress.
Psychologist and researcher Alia Crum offers a three-step approach to adopting a positive attitude towards stress:
• First, acknowledge the presence of stress when you experience it and think about the ways it is impacting you both psychologically and physically.
• Second, recognize that when stress occurs it is typically a response related to something you care about. Connect to the positive motivations that are also present in your stress response.
• Third, when stress is present, the body generates an increase in energy. Figure out ways to make productive use of that energy.
It is generally believed that stress elicits only fight or flight responses, however, other types of stress have been identified, each with a unique physiological profile that motivates different strategies for coping. In contrast to the fight or flight response, these types of stress responses are viewed as beneficial to not only physical health but also mental functioning.
The challenge response results in a similar physical responses to that of the fight or flight response. Heart rate increases, breathing deepens and there is an increase in energy to improve performance. But there are differences. The hormone DHEA, which helps people thrive under stress, is released, the mind is more alert and instead of feeling fearful the individual feels focused. The challenge response has been shown to increase self-confidence and helps a person learn from experience. People who are completely absorbed in what they are doing display signs of experiencing a challenge response.
Another type of stress has been dubbed the tend and befriend response. This stress response motivates people to protect the people and communities they care about. This type of stress response if driven by oxytocin, a hormone that motivates people to connect with others. Oxytocin dampens fears and promotes courage and bravery. It strengthens social connections and helps people be more responsive to the needs of others. The tend and befriend response was most likely the stress response that was in play with the heroic efforts and willingness to come to the aid of victims of the 911 terrorist attack.
While some forms of stress have adverse health effects it is important to remember that all forms of stress have a function whether for survival, or to help achieve goals, or to protect our loved ones or to help others in need or to make social connections. Kelly McGonigal writes, “The stress response is more than a basic survival instinct. It is built into how humans operate, how we relate to one another and how we navigate our place in the world. When we understand this, the stress response is no longer something to be feared. It is something to be appreciated, harnessed, and even trusted.”
Obtaining healthy sleep is important for both physical and mental health. It can also improve productivity and overall quality of life. Everyone, from children to older adults, can benefit from practicing good sleep habits.
Your behaviors during the day, and especially before bedtime, can have major impact on your sleep. They can promote healthy sleep or contribute to sleeplessness. Your daily routines – what you eat and drink, the medications you take, how you schedule your days and how you choose to spend your evenings - can significantly impact your quality of sleep. Even a few slight adjustments can, in some cases, mean the difference between sound sleep and a restless night. Completing a two-week sleep diary can help you understand how your routines affect your sleep.
The term "sleep hygiene” refers to a series of healthy sleep habits that can improve your ability to fall asleep and stay asleep. These habits are a cornerstone of cognitive behavioral therapy for insomnia, the most effective long-term treatment for people with chronic insomnia. CBT can help you address the thoughts and behaviors that prevent you from sleeping well. It also includes techniques for stress reduction, relaxation and sleep schedule management.
Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. Cognitive behavioral therapy for insomnia, sometimes called CBT-I, is an effective treatment for chronic sleep problems and is usually recommended as the first line of treatment. Most cases of insomnia are related to poor sleep habits, depression, anxiety, lack of exercise, chronic illness, or certain medications. Symptoms may include difficulty falling or staying asleep and not feeling well-rested. Treatment for insomnia consists of improving sleep habits (see tips above), behavior therapy, and identifying and treating underlying causes. Sleeping pills may also be used, but should be monitored for side effects.
Cognitive behavioral therapy for insomnia is a structured program that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, CBT-I helps you overcome the underlying causes of your sleep problems.
How does cognitive behavioral therapy for insomnia work?
The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. This type of therapy can help you control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well. Depending on your needs, your sleep therapist may recommend some of these CBT-I techniques:
The most effective treatment approach may combine several of these methods. If you are struggling with poor sleep or insomnia, talk to your prescriber or therapist today.
Quick Sleep Tips
If you have difficulty sleeping or want to improve your sleep, try following these tips to establish healthy sleep habits. (Talk to your doctor if your sleep problem persists.):
In addition, meditation, yoga, and biofeedback may reduce tension and promote better sleep. Visualization or guided imagery, during which you hold a peaceful image in your mind before bedtime, can also be an effective path to relaxation. You can learn learn more about these techniques from your prescriber or therapist.
If you wake up at night and can't go back to sleep, remain quiet and relaxed. Even normal sleep can be punctuated by periods of restlessness or even waking. Be patient; sleep usually returns. Remember, a few nights of poor sleep do no long-term harm. Even if you toss and turn trying to get to sleep, you are probably getting more periods of sleep than you think.
What medications can cause heat-related illness?
As the weather becomes more hot and humid this summer, keep in mind that almost all psychotropic medications can decrease the body's response to heat which may put you at risk for heat-related illness. Medications that can decrease heat tolerance include common medications prescribed here at Providers For Healthy Living.
Some medications that can decrease heat tolerance include:
• Antidepressants (e.g. Zoloft, Prozac, Wellbutrin, Cymbalta, Effexor, and others)
• Antipsychotics ( e.g. Abilify, Geodon, Seroquel, Latuda, Risperdal, and others)
• Amphetamines (e.g. Adderall, Vyvanse, and others)
• Beta-Blockers (e.g.propranolol, atenolol, nadolol, and others)
• Diuretics or water pills (e.g. furosemide, hydrochlorothiazide, and others)
• Anticholinergics ( e.g. Cogentin, Artane, and others)
• Lithium - Increased perspiration and water loss can cause higher levels of lithium in your blood which puts your at risk for lithium toxicity. Signs and symptoms of lithium toxicity include: dizziness, unsteadiness, tremor, slurred speech, lethargy, and confusion. Please seek immediate treatment or go to the emergency room if signs lithium toxicity occur!
*This is not a comprehensive list. Please consult your medication provider or pharmacist about your specific medication(s).
Are some populations at increased risk of heat-related illness?
Yes. The elderly or those with medical conditions such as diabetes, respiratory disease, heart disease and alcohol use disorders may be more susceptible to heat-related illness. You should know that alcohol, benzodiazepines, and opioids (pain medications) may decrease your awareness of heat-related illness. Drugs such as cocaine, anabolic steroids, hallucinogens, and ecstasy or MDMA may also decrease your heat tolerance.
What are the signs and symptoms of heat-related illness?
Heat-related illness varies from mild forms such as heat exhaustion (with warning signs such as heavy sweating, paleness, muscle cramps, weakness, dizziness, headache, nausea or vomiting) to a severe form such as heat stroke (a deadly form of heat-related illness that occurs when we cannot control our body temperature so the temperature rises rapidly with warning signs that include confusion, unconsciousness, body temperature higher than 103 degrees Fahrenheit, red/hot/dry skin, or throbbing headache). Please call 911 or seek treatment immediately if signs of heat stroke occur!
How can heat-related illness be prevented?
You can help prevent heat-related illness by drinking plenty of fluids, eating regularly, and avoiding caffeinated beverages and alcohol. Wear sunscreen as well as loose fitting and light-colored clothing while outside. Spend time in cooler environments when possible. Try to eliminate heat in your home by keeping the drapes closed during the day. Avoid outdoor activity during the hottest hours of the day.
For more information, please consult with your medication provider about heat-related illness and request the "Heat-Related Illness in Individuals using Psychiatric Medication" pamphlet published annually by the Ohio Department of Mental Health.
Postpartum Depression (PPD) is a mood disorder that affects nearly 1 million women in the U.S. each year. Symptoms of PPD can begin during a woman's pregnancy through the first year following childbirth. PPD is beyond baby blues, which is a normal adjustment period that happens during the first 2 weeks of birth affecting 80% of new moms. Many people have heard of PPD, but did you know symptoms of PPD can expand beyond depression symptoms and include anxiety or OCD symptoms? Postpartum depression, anxiety, and OCD symptoms can impact a mother's daily functioning, potentially interfering with her ability to take care of herself or her family.
Symptoms of Postpartum Depression may include:
Symptoms of Postpartum Anxiety & OCD may include:
Any woman who is pregnant or has had a baby in the last year can be at risk for PPD. However, factors like history of mental illness, being a first time mom, ambivalence about the pregnancy, lack of support system, partner problems, infertility, complications during childbirth, and recent stressors can all increase of woman's chances of developing PPD. A woman's health care provider can help her choose the best course of treatment. Treating PPD can include individual counseling, medication, and postpartum support groups.
The Brain Injury Association of America (BIAA) defines traumatic brain injury (TBI) as “an alteration in brain function, or other evidence of brain pathology, caused by an external force.” Every year there are approximately 2.5 million ER visits, hospitalizations, or deaths associated with TBI in the United States. The leading cause of TBIs between 2006-2010 was falls. There are an estimated 1.6 to 3.8 million sports-related TBIs annually, however, only 300,000 result in loss of consciousness. Traumatic brain injuries can occur without the loss of consciousness.
Symptoms of a TBI may not appear for several days following the injury. Post-concussion syndrome (PCS) occurs 7 to 10 days after a TBI and can last for weeks, months, a year or even longer in some individuals. The severity of the injury does not correlate to the duration of PCS or type of symptoms experienced. The symptoms fall into four categories: physical, cognitive, sleep, and emotional.
1. Physical Symptoms:
2. Cognitive Symptoms:
3. Sleep Disturbance:
4. Neuropsychiatric Conditions Associated with TBI:
The mental health of patients with TBI may be greatly impacted. Neuroimaging techniques, biological markers, and neurological/cognitive screening could result in earlier detection and treatment of TBI, improving the outcome for these patients in the future.
If you’re new to therapy, or even if you already have an established relationship with a therapist, the following suggestions can help you to ensure the success of your time in therapy.
L-methylfolate is a medical food similar to a vitamin that is often used as an adjunctive treatment to antidepressant medications for people who suffer from treatment-resistant depression. L-methylfolate enhances the production of serotonin, dopamine and norepinephrine. Research shows that L-methylfolate supplementation is helpful for people with reduced ability to convert folic acid into L-methylfolate.
Reasons why folic acid conversion to L-methylfolate is reduced:
1. Genetic predisposition. For people who are able to obtain genetic testing, the specific deficiency is produced by the methylenetetrahydrofolate reductase (MTHFR C677T) polymorphism. Research shows that up to 70% of depressed people lack the ability to convert folic acid into L-methylfolate and therefore lack the ability to produce enough serotonin, norepinephrine and dopamine to alleviate depression.
2. Poor diet. An unhealthy diet can lead to problems with folic acid conversion. Research shows that L-methylfolate supplementation has been effective in depressed patients with a BMI of 30 or more.
3. Anticonvulsants. Some medications can interfere with absorption and inhibit the enzyme involved L-methylfolate production
Deplin (brand name L-methylfolate) has been FDA approved as a medicinal food for antidepressant augmentation.
Ask your provider if you would be a good candidate for L-methylfolate supplementation.
Compliance with recommended treatment, or treatment adherence, is a very important clinical issue. In fact, nonadherence to medications poses one of the greatest challenges in the treatment of patients with psychiatric illnesses. According to some studies, more than 50% of psychiatric patients do not comply with their medication regimens. Nonadherence with prescribed medications can be intentional or unintentional. Intentional nonadherence may be the result of fear of side effects, concerns regarding the stigma of mental illness, inconvenience of dosing medications, or the cost of medications.
Unintentional nonadherence, on the other hand, is more likely to be the result of forgetfulness or lack of insight as to the importance of treatment compliance. Nonadherence to recommended psychiatric medication regimens is linked to poorer outcomes, including increased hospital admission and disease relapse or exacerbation.
Talk to your provider if you have concerns that may lead to medication nonadherence. At PFHL, we believe in working with our patients to develop the most effective treatment strategies. And treatment is never effective with poor medication adherence.
Here are some tips to increase medication adherence:
1. Understand your medication. Talk to your provider about what medications you are taking and why. When you understand the benefit the medication provides, you are more likely to be adherent to your medication regimen.
2. Talk to your provider about any concerns you may have. There may be ways we can help alleviate side effects or mitigate the cost of medications.
3. Use a pill reminder app or set an alarm or calendar alert on your phone to remind you to take your medication.
4. Tie your medication doses to a daily activity. For example, keeping your medication with your toothbrush ensures that you see the medication daily (or hopefully, twice daily), which will serve as a visual reminder to take your pill. Pretty soon, taking your medication will be as routine as, well, brushing your teeth. Enlist support from family and friends. Bring a trusted friend or family member to your appointments or to the pharmacy if you feel you may need help understanding or remembering medication instructions.