CASE

PRESENTATION
Dr Jayasree Cherukat
CT 1 to Dr Abhinav Rastogi
 Demographics
• 21 year old
• Caucasian male
• In a relationship
• Third year engineering student
 Presentation
• Self referral in July 2021

• Suicide attempt- tied hands with towel and tried to submerge in bathtub

• Currently on Quetiapine and medical cannabis (ADHD service)

 Presentation continued..
• ACCESS team
• Diagnosed with ADHD Nov 2020
• Does not like his meds/GP mentioned ? bipolar.
• MSE:
Mood- subjectively low mood with mood swings of anger and irritation. No elation
or feeling energetic
Thought-N
Perceptions-Can occasionally see people walk past him and then no one is there
 Presentation continued..
• Risk- impulsive act /no plans currently

• Impression: ADHD alongside depression

• Mx: Advised may need antidepressants alongside ADHD medication.

• Discharged to GP
 Presentation continued..
• Referred by ADHD Service again in same month
• Fluctuating. Mood ,Recent suicidal attempt (same incident)
• Taking medicinal cannabis-seems to help with anxiety/makes him calmer
• Ran out of Quetiapine and not maintaining ADHD medicine
• “In a lot of cases with ADHD there are comorbidities with cyclothymia
/mood disorder which can benefit from a trial of a mood stabiliser”
• Quetiapine increased, Elvanse stopped and Lamotrigine discussed
 Presentation continued…
Referral letter mentioned
• Did quite well with the trial of stimulants
• Mood fluctuations have continued
• Past use- illicit cannabis - found helpful /sought to trial it legally through
Schedule 2 prescribing of private medicinal cannabis oil / takes
intermittently/seems to help him in emotional dysregulation.
• Referral for further evaluation : possible underlying mood disorder
 Presentation continued…
• Also referred by GP due to same self harm presentation prior to self-
referral

• Referred by ACCESS for OPA

 ADHD clinic correspondence
• Only sent since December 2020

• December’20: Difficult to tolerate elvanse: poor sleep, appetite and no

benefit on concentration: stopped/ commenced Atomoxetine

• Jan’21: Sleep problems with atomoxetine, discontinued

 Presentation continued…
• Mar’21: Poor sleep hygiene. Restarted on Elvanse .quetiapine for
sedation. May need stronger medications

• Apr’21: started on THC and CBD oil privately, pt had discontinued

Elvanse. Quetiapine increased ?indication, reported CBD helping with
mood and irritability
 Presentation continued..
• Aug’21: Elvanse had been discontinued as worsening lability, presents
with mood symptoms more than cyclothymia and possible part of ADHD
though better than before, finding CBD oil helpful. Lamotrigine increased
to help with mood and quetiapine maintained

• Aug’21: Mood much stable, not suicidal, maintained on CBD oil,

Lamotrigine and quetiapine (finding quetiapine sedating)
 Psychiatric ASSESSMENT
• Sep’21
• Intermittent low mood, nil pervasive
• Anhedonia, chronic problems with sleep, decreased appetite
• Decreased self care.Thoughts of life not worth living in July’21
• Felt that this was reactive to social stressors
• Past trial of antidepressants: didn’t take as no point: will only be
depressed for “one day”
 Psychiatric assessment
• No evidence of hypomania or mania
• H/o suggestive of ADHD (concentration, sleep, impulsivity, emotional
dysregulation)
• Mental state stable since stressors have resolved, no current depressive
symptoms/ suicidal ideation
• finding cannabis useful
• Spending all week in Coventry, in Telford only over weekends
 Past psychiatric history
• CBT / anger, sleep disturbances, nightmares / end of 2020

• ADHD clinic since Nov 2020

• Previously on Citalopram , Amitriptyline for low mood

• Private clinic – March 2021 – Medical Cannabinoids

 Past medical history
• Nil medical issues / allergies
 Current Medications
1. Quetiapine XL 100 mg Nocte and Immediate release 50 mg PRN
2. Lamotrigine 100 mg Nocte
3. Medical Cannabis oil THC 18% CBD < 2% 0.5 ml Mane
4. Elvanse/Lisdexamphetamine : discontinued
 Personal History
• Premature /Incubator

• Parents separated /8 yrs

• Dad lived in France/ spoilt him

• Close to grandparents
 Personal history continued..
• School: struggled to maintain friendships

• Energetic, fidgety, loud

• Engineering college / initially kicked out

• Warehouse / frequent arguments with colleagues

 Family history
• Mum :doesn’t’ know diagnosis

• Father : PTSD

• Paternal aunt :BPD

• Elder brother :depression

 Social history
• Apprentice / 3’rd year Engineering

• New relationship for a few weeks/ supportive

 Drug and alcohol / Forensic
• Alcohol- 1-2 bottles of Jack Daniel over 1-2 days (cut down 1 year ago, no
current harmful use)

• Cocaine and cannabis from 14-17 years / last use of recreational cannabis 2020

• Nil forensic
 Mental state examination
• Appearance- casually dressed, kempt

• Speech- N

• Mood – euthymic

• No thought/ perceptual issues

• Insight, cognition, capacity +

 Risk Assessment
• Walking onto oncoming traffic from childhood

• Punching walls

• Alcohol- climbs big buildings- 5-6 times / year / decreased 1 year back

• 1 Suicide attempt July 2021

• No SH thoughts now / current risks low

 Management
• Diagnosis : ADHD
Recent adjustment disorder with depressive features/
resolved

• Discharged back to GP and ADHD services

 Areas of discussion
- Use of medicinal cannabis in ADHD
- ADHD treatment in people with comorbidity: treat which first?
- Interphase between private and NHS psychiatry: Whose responsibility and
whose problems
- Medico-legal aspects
- Out of area patients: practical considerations
Medicinal Cannabis in ADHD
Literature review
 Methodology
• Conducted Medline search
• Combining cannabis, thc, cannabinoids with “or” operator and combining
with ADHD with “and” operator.
• Search limited to English language
• Returned papers searched for suitability
• This only provides an overview as not all papers critically appraised
 Results
• 56 papers Identified

• Only 1 RCT

• Most studies cross sectional

 ADHD and Cannabis
• Notzon et al applied Conners Adult ADHD Diagnostic Interview on 99
adults with cannabis misuse :Prevalence of ADHD in adults seeking
treatment for cannabis use disorders : between 34% and 46%

• ADHD patients are more likely to use Cannabis : most studies indicate 2
to 3 times higher than general population
 Understanding associations
• Petker et al : 1000 adults in community
• severity of cannabis involvement - significantly associated with greater
endorsement of both hyperactive-impulsive and inattentive ADHD
symptoms
• ADHD predates cannabis effects on cognition
• Self-selection pathway ( individuals with ADHD seeking out cannabis)
• Romo et al:1500 French students: ADHD- substance (alcohol, cannabis,
tobacco) behavioral addictions (gambling, compulsive buying disorder,
eating disorders,Internet addiction)
• Cross-sectional study > 5000 people/self-reported symptoms/ Kola et al
Hyperactivity , particularly impulsivity associated with higher cannabis
misuse in men with ADHD symptoms
• Childhood oppositional behaviour in pts with ADHD -associated with
cannabis misuse in early adulthood
 Genomics
• Examined overlap between genomics of ADHD and cannabis initiation
• Four loci
• Soler et al

• ADHD is causal for lifetime cannabis use: odds ratio of 7.9 for cannabis
use in individuals with ADHD in comparison to individuals without
ADHD (95% CI (3.72, 15.51), P = 5.88 × 10-5).
 ADHD and Cannabis
• Goldstein et al
• Relationship between cannabis use motives (coping, boredom, and sleep) and
consequences and the impact of ADHD symptoms on these relationships
• Participants - 62 emerging adults (ages 19-25 years)who used cannabis regularly (two or
more times in the past 2 weeks) and completed a screener assessing past-6-months ADHD
symptoms at baseline followed by 14 daily reports on cannabis use, consequences, and
motives
• ADHD symptoms, along with sleep and boredom motives, contribute to increased daily
cannabis consequences and should be considered in developing interventions for emerging
adults.
 ADHD and Cannabis
• Online survey of students (n=1738) :Students with ADHD reported improvement in
ADHD medication related anxiety and irritability with cannabis 1. (All self reported,
no objective assessment.)
• Cross sectional survey of ADHD patients-to evaluate differences in reported
parameters between low (20-30 g, n=18) and high (40-70 g, n=35) MC monthly
dose and low adult ADHD self-report scale (ASRS, 0-5) score (i.e. ≤3.17 score,
n=30) or high ASRS score (i.e. ≥3.18 score, n=29) subgroups. N=59, cannabis dose
known for only 27. High dose of cannabis associated with lower scores for
ADHD symptoms. (low numbers, self reported, doesn’t establish treatment effect)
 Imaging studies
• Rasmussen et al
• Compared fMRI for Go/No-go task in children with history of ADHD with and
without cannabis misuse with comparative normal group
• ADHD participants : impaired response inhibition combined with less fronto-
parietal/striatal activity
• Cannabis use -did not impact behavioural response inhibition.Was associated with
hippocampal and cerebellar activation, areas rich in cannabinoid receptors, in
LNCG but not ADHD participants-may reflect recruitment of compensatory
circuitry in cannabis using controls but not ADHD participants
 Cannabis and ADHD
• Kelly et al :task-independent intrinsic functional connectivity (iFC) within
9 functional networks using a 2 × 2 design in young adults with or without
h/o childhood ADHD and with or without cannabis misuse.
• Childhood ADHD -weakened iFC in networks supporting executive
function and somatomotor control
• Cannabis-no interactions (small numbers)
 Early Initiation of Cannabis
• Tamm et al :compared neurocognitive profile of Young adults (24.2 ± 1.2
years) with childhood ADHD who did (n=42) and did not (n=45) use
cannabis use with a N group who did (n=20) and did not (n=21)
• poor cognitive outcomes
• Krista et al : greater right hemisphere superior frontal and postcentral
cortical thickness.
 Cannabis and ADHD
• A systematic review of Neurodevelopmental Effects of Cannabis Use in
Adolescents and Emerging Adults with ADHD : evidence is insufficient
and potentially underpowered to support the hypothesis that cannabis
use has a deleterious impact on neuropsychological tasks in transitional
age youth with ADHD
 ADHD and Cannabis
• Retrospective study/US: inpatients stay of adolescents with ADHD, Patel et al
• increases the risk and prolongs inpatient stay

• decreases the utilization of psychotropic medications and behavioral therapy

• pts with cannabis misuse also had high alcohol misuse rates
• Study using the Wave 2 of the National Epidemiologic Survey on Alcohol
and Related Conditions (2004-2005), Bradnt et al
• Diagnosis of any psychiatric disorder was significantly higher among
those with ADHD and concurrent cannabis use compared with nonusers
(adjusted odds ratio [AOR], 2.8; 95% confidence interval [CI], 1.08-6.41),
as were odds of a lifetime personality disorder (AOR, 4.04; 95% CI,
1.84-8.84)
 RCT
• Cooper et al
• 6 weeks/ Single centre/Double blinded

• 100 microliter spraySativex Oromucosal spray -1:1 delta 9 tetrahydro cannabinol and
Cannabidiol

• Outcomes at - baseline, 2 weeks and 6 weeks

• Baseline and 6 week assessments at centre and 2 week assessment using mailed
questionnaire
 Inclusion criteria
• 18-55 years
• Combined ADHD
• Baseline score > 24 on Conner’s adult ADHD scale
• Unmedicated/ medicated with stimulants only and willing to come off for
1 wk before and for 6 weeks of study
• Willing to not use any prescription/non prescription recreational drugs
during study
 Exclusion criteria
• First degree relative with psychotic disorder
• Current/ primary diagnosis of ASD, recurrent major depression, anxiety,
BPD type 1, Psychosis, OCD, Tourette’s, Learning disabilities/ IQ <
70,neurological problems, known/ suspected alcohol/ drug dependence
• Use of non stimulant ADHD medicine
 Exclusion criteria
• Use of Cannabis/ CBD based medicines in 30 day period prior to study
• Concurrent renal, hepatic, CVS,neurologic disorders
• Pregnant/ breastfeeding females
• Female participants of child bearing potential , male subjects whose
partners where in child bearing age group and who were unwilling to
provide evidence that they were using two forms of effective
contraception
 Results

• 233 patients- 30 randomized

• Primary end point : cognitive performance and activity level / Qb
Qualitative behavioural test-Not statistically significant difference (p 0.16
in favour of active group vs placebo group)
 Results
• Secondary end points: ADHD symptoms and emotional dysregulation
- Not significant / hyperactivity, impulsivity, Inattention and emotional
lability
 Limitations

- Underpowered
-Increased drop out in placebo group
- Short follow up period
 Summary
• Very poor evidence: cross sectional studies, underpowered or inconsistent methodologies
• Pts with ADHD at much higher risks of comorbid cannabis misuse
• on background of increased risks of other substance/alcohol misuse, gambling and other compulsive
behaviours
• Whether cannabis worsens adhd symptoms or adhd causes cannabis misuse in not clear
• Possibility of genetic overlap in causality
• Some poor quality studies on benefits of cannabis in ADHD: underpowered and self
reported improvement
• Only 1 RCT which didn’t support any benefits
 References
• Stueber A, Cuttler C. Self-Reported Effects of Cannabis on ADHD Symptoms, ADHD Medication Side Effects, and ADHD-Related Executive Dysfunction.
Journal of Attention Disorders. October 2021.
• Hergenrather JY, Aviram J, Vysotski Y, Campisi-Pinto S, Lewitus GM, Meiri D. Cannabinoid and Terpenoid Doses are Associated with Adult ADHD Status of
Medical Cannabis Patients. Rambam Maimonides Med J 2020;11 (1):e0001. doi:10.5041/RMMJ.10384
• Rasmussen, Jerod; Casey, B J; van Erp, Theo G; M; Tamm, Leanne; Epstein, Jeffery N; et al. ADHD and cannabis use in young adults examined using fMRI
of a Go/NoGo task, Brain Imaging and Behavior; Indianapolis Vol. 10, Iss. 3, (Sep 2016): 761-771.
• Goldstein, Abby L; Shifrin, Alexandra; Katz, Jasmin L; Iu, Lap K; Kofler, Danielle Exploring the Relationship Between ADHD Symptoms and Daily
Cannabis Consequences in Emerging Adulthood: The Role of Cannabis Motives. Journal of studies on alcohol and drugs; Mar 2021; vol. 82 (no. 2); p. 228-
236
• Kelly, Clare; Castellanos, F Xavier; Tomaselli, Olivia; Lisdahl, Krista; Tamm, Leanne et al. Distinct effects of childhood ADHD and cannabis use on brain
functional architecture in young adults. NeuroImage. Clinical; 2017; vol. 13 ; p. 188-200
• Lisdahl, Krista M; Tamm, Leanne; Epstein, Jeffery N; Jernigan, Terry; Molina, Brooke S G et al. The impact of ADHD persistence, recent cannabis use, and
age of regular cannabis use onset on subcortical volume and cortical thickness in young adults. Drug and alcohol dependence; Apr 2016; vol. 161 ; p. 135-146
• Cawkwell, Philip B. MD; Hong, David S. MD; Leikauf, John E. MD Neurodevelopmental Effects of Cannabis Use in Adolescents and Emerging Adults with
ADHD: A Systematic Review Harvard Review of Psychiatry: 7/8 2021 - Volume 29 - Issue 4 - p 251-261
• Notzon, Daniel P; Pavlicova, Martina; Glass, Andrew; Mariani, John J; Mahony, Amy L et al. ADHD Is Highly Prevalent in Patients Seeking Treatment for
Cannabis Use Disorders. Journal of attention disorders; Sep 2020; vol. 24 (no. 11); p. 1487-1492
 References
• Kolla, Nathan J; van der Maas, Mark; Toplak, Maggie E; Erickson, Patricia G; Mann, Robert E et al. Adult attention deficit hyperactivity
disorder symptom profiles and concurrent problems with alcohol and cannabis: sex differences in a representative, population survey.
BMC psychiatry; Feb 2016; vol. 16 ; p. 50
• Soler Artigas Et al, Attention-deficit/hyperactivity disorder and lifetime cannabis use: genetic overlap and causality. Molecular psychiatry;
Oct 2020; vol. 25 (no. 10); p. 2493-2503
• Patel, Rikinkumar S et al. Is Cannabis Use Associated With the Worst Inpatient Outcomes in Attention Deficit Hyperactivity Disorder
Adolescents? Cureus; Jan 2018; vol. 10 (no. 1); p. e2033
• Attention-deficit hyperactivity disorder and addictions (substance and behavioral): Prevalence and characteristics in a multicenter study in
France. Romo, Lucia; Ladner, Joel; Kotbagi, Gayatri; Morvan, Yannick; Saleh, Dalia et al. Journal of behavioral addictions; Sep 2018;
vol. 7 (no. 3); p. 743-751
• Childhood trajectories of inattention, hyperactivity and oppositional behaviors and prediction of substance abuse/dependence: a 15-year
longitudinal population-based study. Pingault, J-B; Côté, S M; Galéra, C; Genolini, C; Falissard, B et al. Molecular psychiatry; Jul 2013;
vol. 18 (no. 7); p. 806-812
• Cooper RE, Williams E, Seegobin S, Tye C, Kuntsi J, Asherson P. Cannabinoids in attention-deficit/hyperactivity disorder: A randomised-
controlled trial. Eur Neuropsychopharmacol. 2017 Aug;27(8):795-808
THANK YOU!!!
Open to questions/ discussion