Comments&Controversies

Cannabis confiscated by law enforce- 4. Morrison P. It’s the lack of balance in cannabis that does the harm. http://www.beckleyfoundation. ment in the United States between org/2010/10/its-the-lack-of-balance-in-cannabis- that-does-the-harm. Published October 21, 2010. 1993 and 2008, revealed that the mean Accessed July 26, 2014. THC content increased from 3.4% in 1993, to 8.8% in 2008.2 The THC con- Research for 'Rx: Cannabis' tent of Cannabis is responsible for most is needed of its psychoactive effects, so that the Regarding the essay by Drs. Gershan higher the THC content, the greater and Gangahar on decriminaliza- the adverse effects on mental health. tion of Cannabis, I want to comment

July 2014 A major phytocannabinoid, can- on issues surrounding prescription nabidiol (CBD), also present in Cannabis. Cannabis abuse and THC Cannabis, appears to counteract the It is clear that Cannabis can exac- content are on the rise adverse effects of THC, particularly erbate psychosis, among other risks, The authors of the July 2014 Residents’ by means of its antipsychotic property. but its potential benefits remain Voices article (What we ought to Compared with the rising mean THC relatively unexplored. The authors talk about when we’re talking about content of Cannabis from 1993 to 2008, correctly point out that, among decriminalizing Cannabis, Current CBD content has remained relatively indications for Cannabis, none are Psychiatry, July 2014, p. 45-46 [http:// the same: a mean of 0.3% in 1993 and FDA-approved. Yet, because off- bit.ly/1uAb7iK]) highlight the mental 0.4% in 2008.3,4 label prescribing is pervasive and health complications of Cannabis and Several factors have been pos- accepted in psychiatry, lack of FDA mention that, when Cannabis is juxta- tulated for the trend toward a high approval of indications for Cannabis posed with other illicit substances, it THC–low CBD profile in recent years: is not an especially compelling argu- appears innocuous. cultivation methods, the preference ment against such prescribing. On the contrary: Data from the for cultivating seedless female plants Lack of research and funding ham- 2011 Drug Abuse Warning Network (sinsemilla) that tend to have a high pers efforts to conduct trials of the highlighted the rising involvement of THC content, and global availability therapeutic value of Cannabis, as does Cannabis in emergency department of seeds over the Internet. The high its Schedule I status (ie, “no currently (ED) visits. The report indicated that of THC–low CBD profile has been linked accepted medical use and a high the 1,252,500 ED visits involving illicit to an increased risk of Cannabis depen- potential for abuse” [language of the drugs in 2011, the most common illicit dence and increased treatment-seek- Controlled Substances Act]). There drug involved was cocaine, which ing for Cannabis-related problems.3 are reports of benefit in intractable accounted for 505,224 ED visits, with Adegboyega Oyemade, MD, FAPA epilepsy and posttraumatic stress dis- Cannabis a close second at 455,668 vis- Addiction Psychiatrist order (PTSD) that merit further inves- Maryland Treatment Centers, Inc. its—not including synthetic cannabi- Attending Psychiatrist continued noids, which came in fifth, with 28,531 Sinai Hospital ED visits.1 Baltimore, Maryland Keep in touch! Another useful point to buttress References The Editors welcome your letters on the concerns raised by the authors is 1. U.S. Department of Health and Human Services. what you’ve read in Current Psychiatry Drug Abuse Warning Network, 2011: National that the potency of delta-9-tetrahy- estimates of drug-related emergency department Write to: drocannabinol (THC), the primary visits. http://www.samhsa.gov/data/2k13/ DAWN2k11ED/DAWN2k11ED.htm. Published [email protected] psychoactive ingredient in Cannabis, May 2013. Accessed on July 26, 2014. 2. Mehmedic Z, Chandra S, Slade D, et al. Potency OR has increased gradually over the years. trends of Δ9-THC and other cannabinoids in The University of Mississippi Potency confiscated cannabis preparations from 1993 to Comments & Controversies 2008. J Forensic Sci. 2010;55(5):1209-1217. Current Psychiatry Monitoring Project, a National 3. Swift W, Wong A, Li KM, et al. Analysis of cannabis 7 Century Dr., Suite 302 Institute on Drug Abuse–funded land- seizures in NSW, Australia: cannabis potency and cannabinoid profile. PLos One. 2013;8(7):e70052. Parsippany, NJ 07054 mark project that studied samples of doi: 10.1371/journal.pone.0070052.

Current Psychiatry Vol. 13, No. 11 33 Comments&Controversies

tigation; however, such research is be in the best interest of patients, but post-residency fellowship at the National hampered, I believe, by bureaucracy. it is a fact. If by decline he means that Institutes of Health. Nowadays, residency For example, an approved study at in all instances all patients benefit programs must provide both psychother- the University of Arizona of the use of more from pills than they would from apeutic and psychopharmacologic train- Cannabis to treat PTSD has remained analysis, his viewpoint is derived from ing to psychiatric residents. in regulatory limbo for longer than misinformation. Your statement that medications have 4 years because of the immense hur- Since academic psychiatry and psy- replaced psychotherapy is inaccurate. We dles involved in performing research chiatric publications became wholly train our residents to provide each out- on this substance—despite how press- owned subsidiaries of the pharmaceu- patient with both pharmacotherapy ing such research is, given the large tical industry, this dismissive attitude (when indicated) side-by-side with number of veterans returning from about psychoanalysis has attained psychotherapy—whether supportive, active duty with this diagnosis and the the status of established wisdom. psychoeducational, psychodynamic, or paucity of treatment options. Psychoanalysts understand that one cognitive-behavioral therapy, or a combi- Perhaps, there also is something size does not fit all, no single treatment nation thereof. I continually warn residents “missing” in the debate about research is the best choice for all patients, and about reducing psychiatric care to giving into Cannabis. medications can be of great value. Why pills, which would be a travesty. Wesley Ryan, MD can’t psychopharmacologists show a In addition, I regard psychotherapy as PGY-5 Addiction Psychiatry Fellow similar respect for psychoanalysis? a neurobiological intervention because University of Washington Seattle, Washington Charles Goodstein, MD it modifies brain connectivity and neuro- Tenafly, New Jersey plasticity (see my December 2013 Editorial, The ‘decline’ of “Repositioning psychotherapy as neu- psychoanalysis Dr. Nasrallah responds robiological intervention,” available at There are many interesting aspects of Thank you, Dr. Goodstein, for expressing CurrentPsychiatry.com). Dr. Nasrallah’s review of the changes your view about my editorial. However, it Last, I wish you would not insult aca- in psychiatry in recent decades (Post- is unfair to describe the editorial as being demic psychiatry as being a “wholly World War II psychiatry: 70 years dismissive and insulting toward psycho- owned subsidiary of the pharmaceutical of momentous change, Current analysts. I was simply stating undeniable industry.” Someone must develop new Psychiatry, From the Editor, July historical facts about the evolution of and better treatments for serious psychi- 2014, p. 21-22, 49-50 [http://bit.ly/ psychiatry—one aspect was the reduced atric brain disorders. The only entities dedi- 1m8HcdC]). There is no doubt that prevalence and influence of psychoanaly- cated to doing that, in the United States, great strides have been made, particu- sis over the past few decades, which was are the pharmaceutical industry and the larly in the care of the more seriously partially because of the advent of phar- academic psychopharmacology experts. ill, and that those accomplishments macotherapy. The other reason was the Together, they generate new ideas and owe a good deal to the introduction of emergence of other psychotherapies, develop innovative mechanisms of action psychoactive agents. such as cognitive-behavioral therapy, and test them in controlled clinical trials However, his reference to the interpersonal psychotherapy, and dia- to treat disabling mental disorders. It is “decline” of psychoanalysis was unfor- lectical behavior therapy, which are not fair to impugn the integrity of aca- tunate and a gratuitous insult to those evidence-based, shorter in duration, and demic psychiatrists when they are doing of us who continue to practice psy- more cost effective. what they were trained to do. They have choanalysis and who recognize how Psychoanalysis remains an important the integrity and objectivity to criticize much psychoanalytic thinking has component of contemporary psychiatry, the industry when necessary. (See page contributed to the psychotherapeutic albeit limited to a smaller subgroup of 50 of my editorial under the subheading practices of non-analyst psychiatrists. patients. “Pharmaceutical industry debacle.”) If by decline he means that patients In my residency, I was heavily trained Henry A. Nasrallah, MD who once were in analysis now are in psychodynamic therapy, and many Professor and Chairman Department of Neurology & Psychiatry being treated with medication alone, of my supervisors were psychoanalysts. Saint Louis University School of Medicine he is correct. That might not always I developed my neuroscience skills in a St. Louis, Missouri continued on page 47

Current Psychiatry 34 November 2014 This month’s

Comments & Controversies instantpoll continued from page 34 % Why partner with clinical Mr. B, age 29, with a history of bipolar manic episodes, has started pharmacists? a new job—the second in a month. He has outbursts of energy, appears distracted and exhausted, and is visibly agitated. He denies While reading the “Opportunities suicidal ideation and psychotic symptoms. You recommend inpatient to partner with clinical pharma- treatment, but he refuses. How would you manage Mr. B as an cists in ambulatory care” (Current outpatient? Psychiatry, Evidence-Based Reviews, ■ Obtain blood work and prescribe an antipsychotic July 2014, p. 23-29 [http://bit.ly/ ■ Refer him to another provider 1s3yqmh], I became puzzled. Several ■ Agree to treat him, but discuss situations in which he must times, I asked myself, “As a psychiatrist consent to inpatient treatment reasonably well-trained in psychophar- ■ Encourage him to quit his job so that he can focus on macology, why would I need or want being treated to partner with a clinical pharmacist in this fashion?” Indeed, I was under the impression that this is what I trained to See "Treating bipolar mania in the outpatient setting: do. It called to mind a bumper sticker Risk vs reward," pages 38-46 from the feminist movement of the 1960s that read, “A woman without a man is like Visit CurrentPsychiatry.com to answer the a fish without a bicycle.” It then occurred Instant Poll and see how your colleagues responded. to me that a psychiatrist without a clinical Click on “Have more to say?” to comment. pharmacist would find himself or herself in that same lamentable position. SEPTEMBER POLL RESULTS Scott D. Mendelson, MD, PhD Roseburg, Oregon Mr. D, age 40, is admitted to the hospital after a friend finds him overdosing on methamphetamine after a 4-day binge. After 2 weeks, he reports feeling depressed since he began withdrawal. How would you treat Mr. D’s methamphetamine withdrawal?

40% Monitor Mr. D’s depressive symptoms and prescribe an antidepressant if his symptoms persist 30% 12% Add a course of cognitive-behavioral 40% therapy 18% Begin dextroamphetamine, 60 mg/d, to reduce his withdrawal 18% Keep in touch! symptoms 12% The Editors welcome your letters on 30% Prescribe an antidepressant and transfer what you’ve read in Current Psychiatry Mr. D to a residential treatment program Write to: [email protected] OR Comments & Controversies Current Psychiatry 7 Century Dr., Suite 302 Parsippany, NJ 07054 suggested reading: Ling W, Mooney L, Haglund M. Current Psychiatry. 2014;13(9):36-42, 44.

Current Psychiatry Vol. 13, No. 11 47 Data obtained via CurrentPsychiatry.com, September 2014