Marijuana, Suicide, and Cognitive Dysfunction

In response to:

Colorado father: “Marijuana killed my son” – SmartColorado.org – March, 2019

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This story is tragic and hits particularly close to home because it happened in our community. We’ve seen firsthand how the legalization of cannabis in Colorado has lead to unintended consequences and in this case made this person’s mental illnesses worse, more severe, and contributed to a psychotic episode. In an effort to help some good come from this tragedy we have laid out our approach to treatment which incorporates our addiction psychiatry experience and the latest mental health research and technologies.

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We would have taken a three pronged approach (medication, therapy, and technologies such as TMS) to this patient’s illnesses as we have increasingly been conceptualizing treatment for our patients based on stabilization of the neurochemistry of the brain and the neurocircuitry of brain. Our clinics and clinicians have increasingly evolved beyond seeing patients as a series of diagnostic criteria, symptom lists, and/or phenomenological approach to mental health (ie. we have this cluster of symptom that have lasted this long therefore it must be this phenomenon).  We get to the “core” or “source” of these problems which is best summarized by this TED talk a patient described to me once: 

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“The opposite of depression is not happiness, but vitality, and it was vitality that seemed to seep away from me in that moment.”                                                                                                          

Andrew Solomon, Depression, the secret we share; TED Talk 

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Depression is not just “sad” it is the sapping of vitality in the form of growing cognitive dysfunction; and our clinic aggressively addresses this dysfunction via the three pronged approach listed above to address this two pronged problem: dysfunction in neurochemistry and neurocircuitry. 

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So from the neurochemical view point we would be looking at what are the components that are dysregulating the neurochemical “soup” in which the brain “lives” in and needs in order to do what it does.  This would include stabilizing neurotransmitter systems that are being dysregulated by either genetic/endogenous illness (e.g. Major Depressive Disorder, Generalized Anxiety Disorder) as well as “exogenously introduced” illnesses (that interestingly also have a genetic/biological component) called addictive disorders (cannabis dependence in this case).  We would stabilize the dysregulation caused by these “co-occurring conditions.”  However, just like in other fields of medicine (but unlike other clinics in mental health and substance abuse), we don’t ignore one set of illnesses until the other one is “stable;” in this way it is just like how the primary care physician does not just ignore the diabetes until the hypertension is better, we would address both simultaneously.  We would address both the cannabis use disorder AND what sounds like Major Depressive Disorder for this patient simultaneously.  And we would be looking at the MDD as more than “is the patient happy or sad” we would be assessing the patient’s cognitive functioning along the way as that is the problem with ALL psychiatric illnesses: it is not whether or not the patient is “happy” “sad” “nervous” (as those are normal emotions) we would see in what way anxiety, depression, and cannabis usage are adversely affecting brain functioning.  In order to improve brain functioning, though, we go beyond just addressing the “soup” like other clinics, we look at and address the “wiring” or neurocircuitry of the patient. 

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That is why we dive into evidence-based therapies for our patients, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Motivational Interviewing (MI), and Acceptance and Commitment Therapy (ACT) and other mindfulness based therapies.  Using these therapies helps to improve the neurocircuitry.   Additionally, we use cutting edge technology such as Transcranial Magnetic Stimulation (TMS) to further stabilize the “neurocircuitry” as well.   Again we look beyond “happy” and “sad” because those aren’t problems.  We look at what is called “executive functioning” meaning the circuits of the front part of the patient’s brain that are involved in decision making, impulse control, and is the seat of personality for patients and address those areas through therapies and TMS. By addressing both the neurochemistry and neurocircuitry we improve how the patient’s brain is functioning in all the arenas that do truly lead to “happiness” and “serenity.”   By improving cognition we improve how the patient “works” “plays” and “loves” as these areas of life are what truly determine “happiness” and “serenity;” we see “pills” as the tools to improving cognition, and improved cognition (not just pills) leads to true “happiness” and “serenity.”