Who doesn’t get nervous or anxious from time to time? Speaking in front of an audience, going for a job interview, paying bills. It happens to all of us. Fear, nervousness, anxiety — these evolutionary mechanisms represent normal, essential, and adaptive responses to help us cope with threats to our survival. Without them, we’d be totally blasé to anything that came our way. During our prairie days, we’d be so oblivious to threats, we’d get eaten by bears or mountain lions!
Present day, without a bit of “healthy” anxiety, we’d be totally oblivious to threats, we’d likely forget to pay our bills, lock our doors, or try to excel at work. However, some people suffer from too much anxiety. And, excessive or persistent anxiety can be maladaptive. In fact, in can become so frequent, or forceful, it can take over our lives, sometimes even leading to serious disability.
As the country forges ahead by legalizing medical and recreational marijuana, there has been renewed discussion around cannabis and psychiatric disorders. How does cannabis affect the brain? Is cannabis useful as a treatment for anxiety? Or, does it create more problems? These are complicated, but important questions, with no simple black and white answers. In fact, as you’ll learn in this article, evidence suggests cannabis can be a dual-edged sword: it can help or it can hurt. Ultimately, it comes down to a number of factors that are within most people’s control. But, first, let’s start by understanding some fundamental concepts, such as the different types of anxiety, the causes, prevalence, treatments, and how cannabis fits into the equation.
What is Anxiety?
Fear and anxiety are adaptive responses essential to coping with threats to survival. Excessive or persistent anxiety can be maladaptive, leading to serious disability.
There are several different types of anxiety disorders, including:
- Generalized Anxiety Disorder (GAD)
- Panic Disorder
- Social Anxiety Disorder (SAD)
- Post Traumatic Stress Disorder (PTSD) or Post Traumatic Stress Injury (PTSI)
- Obsessive-Compulsive Disorder (OCD)
Those who suffer from anxiety-related disorders may experience a variety of symptoms, including:
- Feelings of dread
- Chest pain and heart palpitations
- Shortness of breath
- Panic attacks
How prevalent is anxiety?
According to the Department of Health & Human Services (HHS), anxiety disorders are the most common form of psychiatric disorders. One in four people will experience an anxiety disorder in their lifetime. Take any 12-month period, and we’ll find that one in 10 people (10%) have a diagnosable anxiety disorder.
Anxiety disorders are the most common mental health disorder with the 12-month prevalence among Americans estimated to be 18.1% (Harvard Medical School). According to estimates, fewer than half of people affected by a mental health disorder seek treatment. Women suffer from anxiety orders at a higher rate than men.
What Causes Anxiety?
The causes of anxiety may be a mental condition, a physical condition, the effects of drugs, or a combination of these. Typically, doctors will first attempt to determine if a medical condition is to blame for the anxiety. Other issues that contribute to anxiety may include:
- Relationship issues (e.g. marital strife)
- Financial pressures
- Work-related stress
- Academic pressures
- Grief over an emotionally traumatic event (e.g. divorce or death of a loved one)
- Medication side effects
- Stress from a serious medical illness
- Illicit drug or alcohol use
- Symptom arising from medical illness (e.g. heart attack or heat stroke)
Are We Over Prescribed Drugs?
According to a report published by the American Psychological Association, from 2001 to 2010, spending on anti-anxiety and antidepressants increased by 22 percent. Remarkably, one in five adults takes at least one psychotropic medication. Many of these individuals were prescribed psychotropic medication without having ever visited a mental health professional.
Physicians, heavily marketed to by drug companies, rarely think twice before prescribing popular drugs. And, while getting a prescription may be easy, it’s not always the most appropriate therapeutic pathway, or for that matter, safe.
The problem with this strategy is that many patients get their script, without knowing their options. Pharmaceuticals are clearly not the only alternative. Other treatments like cognitive behavioral therapy (CBT) are safe, effective, and carry no risk of side effects.
What Treatments Are Available For Anxiety?
One or more of the following therapies and medications may be used to treat the various types of anxiety disorders including:
- Therapy such Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT), and Dialectical Behavioral Therapy (DBT)
- Lifestyle changes
- Benzodiazepines such as Xanax (alprazolam), Ativan (lorazepam), and Valium (diazepam)
- Selective Serotonin Reuptake Inhibitors (SSRIs) antidepressants such as Prozac (fluoxetine), Zoloft (sertraline), and Wellbutrin (bupropion)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) antidepressants such as Pristiq (desvenlafaxine), Cymbalta (duloxetine), and Effexor (venlafaxine)
- Tricyclic antidepressants such as amitriptyline, imipramine, and nortriptyline
Despite their popularity as first-line treatments, many of these drugs deliver agonizing side-effects that are often worse than the conditions they are prescribed to treat. Insomnia, constipation, depression, hallucinations, and even suicidal thoughts (especially in teens) are all-too-common with these drugs. Likewise, long-term use of benzodiazepines often leads to addiction, and benzodiazepines are involved in nearly one out of three fatal overdoses.
Can Cannabis Treat Anxiety?
With so many negative side effects associated with pharmaceutical treatments, predictably, many Americans have opted to self-medicate with other substances.
As the U.S. marches forward with an increasing number of states legalizing medical marijuana, recreational adult-use, or both, there has been renewed interest in the relationship between cannabis and anxiety. Clearly, a significant percentage of canna-consumers use cannabis to self-medicate for anxiety. Likewise, many people have had a bad experience with cannabis and found that it induced anxiety, or perhaps even a panic attack.
So, what do scientists (and the science) say about cannabis and anxiety? Dr. Ethan Russo, the neurologist who identified and coined the term, “the entourage effect,” wrote about the potential antianxiety effects of cannabis in the book, Cannabinoids as Therapeutics (edited by Dr. Raphael Mechoulam). Russo noted that in India — as far back as 1500 B.C. — cannabis was credited for helping alleviate anxiety and depression. More recently, in 1860, the Ohio State Medical Committee on Cannabis stated: "As a calmative and hypnotic, in all forms of nervous inquietude and cerebral excitement, it will be found an invaluable agent, as it produces none of those functional derangements or sequences that render many of the more customary remedies objectionable.”
No doubt, many people consume cannabis to relax, unwind, and alleviate stress, and there’s nothing wrong with that. Studies of THC (the primary psychoactive constituent and a CB1 receptor agonist) — and, CBD (the primary non-psychoactive constituent and CB1 antagonist) suggest that in acute administration, both can produce antianxiety effects. But, as mentioned, high doses of THC can induce anxiety, even panic attacks.
While consuming a THC-rich cannabis strain to occasionally reduce anxiety may be relatively benign, and possibly beneficial, given the psychotropic properties of THC, few medical practitioners would support the use of high-THC cannabis to treat chronic anxiety. (Of course, no responsible physician should recommend most anti-anxiety drugs for long-term use, given the potential of developing a use disorder.) Irrespective of what substance someone takes to treat anxiety, use should be short-term or occasional so as to avoid potential dependency issues. Likewise, just because cannabis is more benign and less addictive than alcohol, nicotine or other drugs, doesn’t mean it’s completely devoid of risk. Are there any substances that are totally risk-free?
How Do Different Cannabis Strains or Consumption Methods Affect Anxiety?
How you react to cannabis can depend on a number of variables including a method of consumption, cannabinoid concentrations and ratios, and even environment. Inhaling cannabis (smoking or vaping) produces immediate effects. Some people prefer this mode because it allows them to self-titrate (i.e. gradually increase the dosage until the desired effect is reached). While the onset of effects is fairly quick, the duration of effects is relatively short, generally a couple of hours. Oral ingestion — like edibles — takes longer to produce effects, but the effects are more steady and much longer in duration.
Further, levels and ratios of THC to CBD can have a profound effect on outcomes:
High CBD, Very Low THC: “High” effect is low to nonexistent. Consumers report a general uplifting of mood without adverse side-effects. Research suggests high therapeutic potential: antipsychotic, antianxiety, could be used in epilepsy treatments.
High THC, Very Low CBD: Produces euphoria, elevated mood, uncontrollable laughter. confused thought, uncontrolled laughs. High dosage can produce strong side-effects: elevated heart rate, anxiety, and tension.
Moderate-High THC, Moderate CBD (e.g. 2:1 ratio of THC to CBD): Pleasant euphoric effects, laughter, creativity. Potential side-effects are generally mild.
Moderate THC, Moderate CBD (e.g. 1:1 ratio): Produces mild euphoric, an overall sense of calm and tranquility. Potential side-effects are rare and few.
The Research: Is CBD The “Magical Molecule?”
Cannabis has well over a hundred active constituents called cannabinoids. The two most prominent, and well studied are THC (delta-9-tetrahydrocannabinol) and CBD (cannabidiol). THC is responsible for producing the psychoactive effects (i.e. feeling “high” or “euphoric”), while CBD is largely non-psychoactive. Both THC and CBD provide therapeutic applications, but only THC produces significant psychoactive effects.
Because CBD has an excellent safety profile and potentially a wide therapeutic spectrum, scientists have turned more attention to studying how it can be used to treat anxiety disorders. In recent years, evidence continues to emerge suggesting CBD may be effective in everything from helping opioid dependents quit, minimize withdrawal symptoms and prevent relapse — to helping treat a wide spectrum of anxiety disorders (see below).
Data from human experimental studies, some trials in a clinical setting, and epidemiological studies has been encouraging. Accumulating preclinical evidence strongly supports a role for CBD to treat a variety of anxiety-related disorders including PTSD, obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder (SAD), and generalized anxiety disorder (GAD). While encouraging, we shouldn’t “jump the gun,” as most studies have been short in duration. No doubt, future research will be longer in duration and evaluate the long-term use and benefits of CBD.
Two noteworthy systematic reviews of cannabidiol (CBD) to treat anxiety-related disorders come from researchers at the New York University School of Medicine, Cannabidiol as a Potential Treatment for Anxiety Disorders (lead by neuroscientist, Esther Blessing, MD, Ph.D.) and a group of neuroscientists and psychiatric researchers from Brazil, Cannabidiol, a Cannabis Sativa Constituent, as an Anxiolytic Drug.
CBD is therapeutically versatile
- Existing preclinical evidence strongly supports CBD as a treatment for generalized anxiety disorder (GAD), panic disorder, social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).
- Evidence from human studies strongly supports the potential for CBD as a treatment for both healthy individuals and those suffering from anxiety disorders. At oral doses ranging from 300 to 600 mg, CBD reduced anxiety in healthy subjects and patients with social anxiety disorder (SAD) who were put in stressful situations (e.g. public speaking).
- Evidence from human studies supports the role of CBD to treat anxiety in acute dosing and has considerable potential as a treatment for multiple anxiety disorders
CBD can temper potential adverse effects of THC
- Evidence suggests CBD, the most prominent non-psychoactive in Cannabis, can temper the adverse effects of THC (including anxiety)
- Higher CBD content in chronically consumed cannabis may protect against adverse effects of THC and other drugs (e.g. opioids), including psychotic symptoms (among vulnerable populations), drug cravings, and memory loss.
- Unlike THC, even at high doses, CBD does not induce anxiety or other adverse effects. In fact, researchers point to the fact that CBD has a notable absence of anxiogenic (anxiety producing) effects.
CBD may be an effective PTSD treatment
- Data supports the efficacy of CBD in promoting “aversive fear extinction” (e.g. extinguishing “traumatic memories”) suggesting CBD may be effective as an individual treatment, or as an adjunct to treatment (e.g. enhancing cognitive behavioral therapy (CBT) or other therapies).
- A retrospective study of civilian patients suffering from PTSD, and a case study of an individual who suffered severe sexual abuse-related PTSD, found chronic cannabis use to significantly reduce symptoms arising from PTSD symptoms. (Unfortunately, there was no data on THC:CBD ratios.)
Consistently, CBD demonstrates that it can be a potent antianxiety agent, with mild sedative effects and an excellent safety profile. Most studies involve acute dosing, so further research studies that are longer in duration will be important to establish evidence proving chronic dosing produces similar effects.
Bottom line: overwhelming evidence suggests CBD is very safe, and probably effective to treat anxiety. When considering cannabis strains, don’t ignore CBD, as it can be helpful for a number of reasons, and in particular, mediating any potential unwanted side effects from higher doses of THC.
Final Tips & Considerations
Most users find consuming moderate doses of cannabis produces a soothing, relaxing experience, stimulates creativity, makes them laugh (sometimes uncontrollably), and can even enhance intimacy. However, most people are unaware of how variable concentration levels of THC and CBD can profoundly influence their experience. It’s important to be mindful of your individual tolerance and sensitivity levels. Everyone reacts differently, so what may work for your friends, may affect you differently. But, as a rule of thumb, the higher the THC, the higher the risk that consuming cannabis will exacerbate anxiety — the exact opposite effect that most people desire. Higher CBD, by contrast, counteracts these effects and evidence suggests it possesses potent anti-anxiety properties.
You may find it helpful to experiment with different strains with variable concentrations and ratios until you find a strain that produces the effects you’re seeking. And, remember, always start with a lower dosage and gradually titrate up. A good rule of thumb when consuming to relieve stress is to follow the adage, “less is more.” Consume just the right amount to elicit the effect you want.