Examining Cross-Cultural Differences in Mental Health Diagnoses

Does Location Matter?   

Why do certain psychiatric conditions share universal diagnosis criteria and treatment while others vary widely, dependent on location and culture? These discrepancies can be attributed to the lack of a gold standard for validating these conditions as well as the lack of biological markers, leading to different clinical interpretations and inconsistency across studies.[1]

Consistency across cultural studies can allow a more general understanding of conditions and how culture affects symptoms’ manifestations and diagnoses differently. By creating a clearer understanding of mental health conditions worldwide, better/more effective treatments and patient outcomes can arise. 

Should Diagnosis be Universal or Relative?   

Within the debate of why these differences occur, two main arguments exist. The first focuses on universality across cultures. The “universalistic viewpoint” emphasizes that all conditions occur equally and have a core set of symptoms - what varies is the manifestations and determination of pathology versus normalcy. “Ethnotypic consistency” was coined by Weisz et al., in 1997 to describe the idea that psychopathology is the same across locations and cultures, but varies in how symptoms are displayed.[2]  

The opposing viewpoint of universality places a larger emphasis on culture. The “relativistic viewpoint” stresses that culture shapes a person’s development and psychopathology. Symptoms and conditions can be unique and particular to specific cultures, as well as affect the magnitude and intensity of the condition.[3] 

From these two viewpoints, a combined conclusion can be established: certain disorders are seen as “universally occurring” due to their neural pathology, while others are shaped by social contexts and cultural norms.[4] 

Examining Cross-Cultural Differences 

One of the most well-researched conditions cross-culturally is attention-deficit/hyperactivity disorder (ADHD). From 1997 to 2016, attention deficit disorders in the United States has fluctuated from 6.1% to 10.2%, with debate ensuing whether the fluctuation arose from over-diagnosis, under-diagnosis and/or diagnostic disparities.[5] When comparing global prevalence, vast differences were found between North America, Africa and the Middle East. However, those differences were not found between North America, Europe, Oceania, Asia or South America. Canino and Alegria (2008) note that these discrepancies were attributed to the differences in instruments, methods, and how these disorders are defined within the different cultural studies compared.[6] 

Professor Mashai Ikeda began to research Bipolar Disorder (BD) after finding most conclusions on major psychiatric disorders were made using European samples. In 2022, Ikeda specifically looked at the genes of patients with BD type I (manic and depressive states) and BD type II (mild mania and depression) between European populations and East Asian populations.[7] He found East Asian populations containing genes of BD I were more correlated with major depression while European populations with BD I were more correlated with schizophrenia, however, no differences were found between the samples when examining BD type II. These differences were attributed to how the disorder is diagnosed in each country; East Asian psychiatrists hold that bipolar disorder is a mood disorder while European psychiatrists tend to diagnose patients with delusion and other psychotic symptoms.[8] These vast differences in definitions can later lead to issues with clinical trials, especially for drug therapy. 

Even the threshold that needed to be met to be considered pathological differs culturally. For example, Hong Kong’s rates of reported hyperactivity are double those of the United States.[9] Additionally, Chinese and Thai cultures place a high value on hiding aggression and overt behaviors, which lowers the threshold of hyperactive behaviors and raises the likelihood that parents would report it. Chinese and Indonesian clinicians also gave higher scores for hyperactive behavior problems when compared to scores given by Japanese and American clinicians.[10] A study conducted by Bird (2002) examined Italy, New Zealand, China, Germany, Brazil and Puerto Rico and found that hyperactive disorders were found in all cultures, but the prevalence and threshold of what was considered pathological is what differed. Therefore, while these conditions happen universally, the way each culture views the symptoms varies widely.[11]

These cultural distinctions of appropriateness not only occur cross-continentally but also within different communities. According to Andrade (2017), African Americans are more likely than White Americans to keep personal distress private and seek spiritual support versus seeking professional mental health treatment.[12] Further, in the United States, most minority groups are less likely than White Americans to seek mental health treatments or delay seeking help until their symptoms are severe. Many of these issues are tied to the discrimination and mistreatment minorities face when seeking help; in fact, 43% of African Americans and 28% of Latinos have felt they were mistreated in clinical settings due to their background.[13] There is also a lack of resources for non-English speakers to gain access to mental health services. These cultural factors tied with affordability and insurance coverage also create a very difficult situation for many people in certain populations to get mental health assistance at all. 

Mental health resources vary widely across the globe, depending on location. Nielsen, et al., (2022) found major differences among countries in the Far East, Middle East, and Southeast Europe, as most countries reported the need for more child psychiatrists and mental health professionals. The researchers note that 10% to 20% of adolescents experience a mental health disorder before they turn 14 years old.[14] Thus, the lack of resources in these countries poses a great risk to the population, as early intervention is key to recovery and well-being.

Future Steps: Integrating Culture and Diagnosis 

These locational and cultural challenges pose a clear threat to the reliability and validity of cross-cultural research; as we discover more about how these factors affect diagnosis and symptoms, it is essential to create instruments keeping these differences in mind. Historically, research has been based on Western diagnosis systems and definitions, but when using those definitions with other populations, concepts can become unclear.[15] Conceptual equivalence ensures the concept is identified uniformly according to the populations being studied.[16] Therefore, these disparities must be emphasized when conducting research. If not, misclassifications and incorrect conclusions about populations can be made. 

Harris (2023) stresses that with the growing importance culture plays on manifestations and diagnosis, it is important clinicians and mental healthcare professionals assess how a person’s background affects their condition. As well, adjust their assessment based on the person’s attitude towards mental health and how they express and cope with their mental health. Different populations may also have stigmas on seeking help or undergoing certain treatments, professionals must be aware of and protect those preferences.[17] 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has also embraced these strategies and highlights the impact of race and culture on disorders. Clarifications and disclaimers have been added to provide further information when specific communities had higher rates of certain disorders.[18] These considerations are fundamental in improving the disparities in diagnosis found across cultures as it allows psychiatry residents and fellows to see the effects race and culture can have on mental health and diagnosis.  

If you or someone you know is struggling with their mental health, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology & Psychiatry, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Abdelnour, E. (2022, October 1). ADHD diagnostic trends: Increased recognition or overdiagnosis? PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/#:~:text=The%20past%20couple%20of%20decades,the%20causes%20for%20this%20trend 

6 Canino & Alegría (2008)

7 Saito, T., Ikeda, M., Terao, C., Ashizawa, T., Miyata, M., Tanaka, S., Kanazawa, T., Kato, T., Kishi, T., & Iwata, N. (2022). Differential genetic correlations across major psychiatric disorders between Eastern and Western countries. Psychiatry and Clinical Neurosciences, 77(2), 118–119. https://doi.org/10.1111/pcn.13498 

8 Ibid. 

9  Ho, T.P., Leung, P.W., Luk, E.S., Taylor, E., BaconShone, J., & Mak, F.L. (1996). Establishing the constructs of childhood behavioral disturbances in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, 417–4314

10 Canino & Alegría (2008)

11 Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of ADHD. In P.S. Jensen & J. Cooper (Eds.), Attention deficit hyperactivity disorder: State of the science; best practices (pp. 12-1–12-36). Kingston, NJ: Civic Research Institute. 

12 Andrade, S. (2017). Cultural Influences on Mental Health | The Public Health Advocate. The Public Health Advocate. 

https://pha.berkeley.edu/2017/04/16/cultural-influences-on-mental-health/

13 Ibid. 

14 Nielsen, M. S., Clausen, C. E., Hirota, T., Kumperscak, H., Guerrero, A., Kaneko, H., & Skokauskas, N. (2022). A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe. Asia-Pacific Psychiatry, 14(2), 1–9. 

https://doi.org/10.1111/appy.12490

15 Canino & Alegría (2008)

16 Ibid. 

17 Harris, J. (2023, January 9). Cultural competency in mental Health Care: Why it matters. NAMI - Dominate Amazing Capabilities. https://nami-dac.org/cultural-competency-in-mental-health-care-why-it-matters/

18 Moran, M. (2022). Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR. Psychiatric News, 57(3).  https://doi.org/10.1176/appi.pn.2022.03.3.20

Schizophrenia: Cross-Cultural Comparisons of Case Management & Research Progress

A Global Enigma

While our understanding of the human brain is constantly advancing, one of the least understood psychological disorders with the most ubiquitous global impact, is schizophrenia. Schizophrenia is a chronic mental illness characterized by symptoms generally falling into three categories:[1,2] 

• Psychotic Symptoms: Hallucinations, delusions, disorganized speech and behaviors

• Negative Symptoms: Withdrawal from aspects of life, difficulty functioning normally, affective flattening, lack of motivations

• Cognitive Impairment: Problems in attention, concentration and memory. 

The prevalence of the disease is approximately 1% worldwide and accounts for a large healthcare burden. It is highly heritable (e.g., the likelihood of the disorder to aggregate among family members), estimated at around 80%.[3] Further, Degnan et al. (2018) note that the incidence rate of schizophrenia in ethnic minority populations are triple that of major White populations.[4] 

In itself, the definition and categorization throughout the history of schizophrenia has differentiated across countries. Schizophrenia was first described by Emil Kraepelin (1899), a German psychiatrist, as “attentional impairments”.[5] Eugen Bleuler (1911) later famously coined it as a disorder which originates from the splitting of different psychic functions leading to loss of unity within the personality (hence the name “schizophrenia”) from the Greek roots “split-mind.”[6] Our foundational understanding of the disease is still limited, and this article aims to review some current cross-cultural perspectives on the research and management of the disease.

The diverse faces of psychosis in schizophrenia  

Recent research has consolidated the literature on the effects of cultural and social perspectives on the framing of schizophrenic/psychotic symptoms. While psychosis is present globally as a symptom for schizophrenia, the actual content of the psychotic symptom is culturally determined.[7] For example, research conducted in India, Nigeria and Trinidad in 2016  concluded that “disruptive behaviors, wandering and decline in functioning” are more commonly thought of as psychosis rather than the “distorted perceptions and beliefs” emphasized in Western understanding of the condition.[8] 

Additionally, the interpretations of psychiatrists determine what behaviors constitute psychosis; this, too, will vary based on one’s training, education, upbringing and life experiences, which differ across cultures.[9] In a case study in 2008, a NHS psychiatric nurse in a London hospital recounted his conflict for a Nigerian patient diagnosed with schizophrenia under his care. While in Nigeria, the patient’s “psychotic symptom” of religious delusions would have been considered gifted, the patient was coerced into taking medication in the UK.[10] Therefore, it is important to consider cultural backgrounds as a crucial factor in determining the symptoms of the disease. 

Cross-national context and culturally-adapted interventions of schizophrenia

Schizophrenia has been identified as a globally-prioritized mental health problem with the magnitude of its impact on individuals’ health, economic and social hardships, increased mortality rates and human rights violation (e.g., involuntary hospitalization or imprisonment with inadequate mental health care).[11,12] Recommendations from the World Health Organization (WHO) guidelines and the Disease Control Priorities (DCP3)  have shown that there are two kinds of intervention for schizophrenia that have strong enough evidence to deem them significant: antipsychotic drugs and psychosocial treatments.[13] However, one important limitation is that there is little evidence supporting these interventions in low and middle income countries (LMIC), and few of them have been actually implemented in high income countries.[14]

Psychosocial Interventions:

The psychosocial treatments of schizophrenia with strongest empirical support are: social skills training; family psychoeducation; cognitive behavioral therapy (CBT) and cognitive rehabilitation.[15,16] 

In 2012, Lora et al. noted that among 50 LMICs, around 69% of those diagnosed with schizophrenic disorders do not have access to specialized care despite evidence that psychosocial interventions alone can alleviate symptoms of the disorder, and not all patients may require treatment with antipsychotics.[17,18] In 2018, Degnan et al. published a review on adaptations of Western psychosocial interventions to specific ethnic groups or subculture studying these adaptations in 13 different countries.[19] It was found that all cultural adaptations included language, a majority adapted to concepts and illness models, cultural norms and practices, and family. Noticeably, there were modifications to include spiritual/religious activities, adjustments to communication styles and family dynamics. The analysis demonstrated significant outcomes in support of adapted interventions, however only two studies out of 43 compared the effectiveness of adapted and non-adapted interventions, and neither found significant differences in outcomes.[20] Overall, while the study indicates positive results for culturally-adapted psychosocial interventions, the limited studies providing support for adapted over non-adapted treatments is not enough evidence of a significant increase in effectiveness.

Antipsychotic Interventions: 

While psychosocial interventions have been increasingly researched and recognized as effective care for schizophrenia, antipsychotics have long been the popular measure of intervention for medical professionals.[21] Common antipsychotic agents are classified as first-generation (chlorpromazine, haloperidol) or second-generation (clozapine), which work by blocking dopamine receptors.[22] According to Wood et al. (2003), first-generation drugs are more-likely to induce parkinsonian side effects and second-generation drugs are thought to have enhanced therapeutic efficacy.[23] However, research by Agid et al. (2006) questions if the side effects of first-generation schizophrenia drugs may actually be from unintentionally overdosing patients while searching for optimal drug efficacy (hence, inadvertently causing more-pronounced side effects).[24] 

Recent research on culturally-adapted antipsychotics and alternative drug treatments for schizophrenia has been scarce. However, a study done by Chong et al. (2004) on differences in antipsychotics usage in East Asian countries revealed that prescription patterns of antipsychotic drugs vary greatly between countries.[25] This can be explained by the differences in respective healthcare policies, preferred treatment modality, availability and cost of the drugs.[26]

For example, Japan has a long history of national health insurance and a preference for treating patients with mental health issues in psychiatric hospitals over community care. Therefore, a higher prevalence of antipsychotics is prescribed due to the longer hospitalization period for schizophrenia in the country.[27] Meanwhile, Xiang et al. (2017) also found that while community-based services are increasingly encouraged, a large number of patients in China end up receiving hospital-based services.[28] Additionally, as clozapine is the most effective and affordable antipsychotic medication in China, over one-third of schizophrenia patients have been prescribed the drug.[29] This is not the case for all countries in the surrounding regions, as the cost of second-generation antipsychotic is considerably higher, thus is often restricted and difficult to prescribe.[30] However, as first-generation antipsychotics for schizophrenia are known as “major tranquilizers” with more serious side effects, this may create a disparity in treatment of the disorder in different countries.[31] 

Alternative treatments may also prove valuable. In 2017, a study conducted by Deng et al. on Wendan decoction (WDD), a traditional Chinese medicine for schizophrenia, discovered that WDD demonstrated some short-term positive effects on its own. Further, when WDD was used alongside an antipsychotic, positive outcomes were observed with fewer adverse effects.[32] 

Future directions: beyond the “one-size-fits-all” treatment framework

While there is still more research to be done, this brings the question to whether popular antipsychotics are the ultimate pharmacological treatment for schizophrenia, or if there are alternative options we need to take into consideration. Specialists have long called for the facilitation of mental health care by traditional practitioners due to lack of resources in LMICs; research has echoed the sentiment that traditional healers are generally more accessible and affordable, and patients benefit from sharing cultural beliefs and world views with them.[33] 

Traditional healers have often been more open to collaborating with primary health care than vice versa.[34] Watt et al. (2017) studied this issue qualitatively with populations in Ghana, Kenya and Nigeria. They found that many patients and caregivers still distrust non-medical treatments; despite some medical practitioners advocating for their validity, traditional care is often met with ridicule and doubt. The study further found that there appear to be suggestions to “convert” non-medical healers to a medical paradigm, and that rivalry and perceived superiority seem to be the underlying cause of this attitude.[35] 

However, it is also important to note that patients who implore both methods of care seem to reap more benefits, overall.[36,37] Watt et al. note that non-medical healers also desire to be recognized in their validity and not be exoticized simply due to their non-Western practices and beliefs.[38] Many studies have supported that labeling these practices as “witchcraft” or “inferior” is failing to understand indigenous knowledge and meaningful perspectives, and thus a missed opportunity to improve population health.[39,40]

Social and cultural perspectives continue to inform the characteristics and future directions of both the research and treatment of schizophrenia. Yet, as we have seen, the current landscape of what we know about the disorder in a cross-cultural context is lacking. As we expand on this field of research in a broader context, it is important to note the potentials of alternative medicine, culturally-adapted measures and how they can benefit the accessibility of health care for ethnic minorities, non-Western or low/middle-income patients. Acknowledgement and deeper insight into culturally-appropriate diagnosis and care for patients with schizophrenia is crucial to shift the evolution of global mental health into a truly global discipline. 

If you or someone you know are experiencing any signs of schizophrenia, it’s best to speak with a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss your concerns and determine the underlying cause of symptoms.

Contributed by: Mai Tran

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Rahman, T., & Lauriello, J. (2016). Schizophrenia: An Overview. Focus (American Psychiatric Publishing), 14(3), 300–307. https://doi.org/10.1176/appi.focus.20160006

2 NHS. (2023, April 13). Symptoms - Schizophrenia. NHS. https://www.nhs.uk/mental-health/conditions/schizophrenia/symptoms/ 

3 McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360  

4 Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., Husain, N., Rathod, S., & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714–727. https://doi.org/10.1017/S0033291717002264

5 Kraeplin, E. (1950). Dementia praecox and paraphrenia (J. Zinkin, Trans.).

6 Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press. 

7 Shalhoub, H. (2012). Decoding schizophrenia across cultures: Clinical, epidemiological and aetiological issues (Doctoral dissertation, School of Social Sciences Theses).

8 Cohen, Alex; Padmavati, Ramachandran; Hibben, Maia; Oyewusi, Samuel; John, Sujit; Esan, Oluyomi; Patel, Vikram; Weiss, Helen; Murray, Robin; Hutchinson, Gerard; Gureje, Oye; Thara, Rangaswamy; Morgan, Craig (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project. BMC Psychiatry, 16(1), 388–. doi:10.1186/s12888-016-1090-4

9 Shalhoub (2012)

10 Ibid.

11 Wigand, M. E., Orzechowski, M., Nowak, M., Becker, T., & Steger, F. (2021). Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights. The International Journal of Social Psychiatry, 67(2), 168–174. https://doi.org/10.1177/0020764020942797

12 Patel V. (2016). Universal Health Coverage for Schizophrenia: A Global Mental Health Priority. Schizophrenia Bulletin, 42(4), 885–890. https://doi.org/10.1093/schbul/sbv107

13 Ibid. 

14 Ibid.

15 Alan. S. Bellack (2001) Psychosocial treatment in schizophrenia, Dialogues in Clinical Neuroscience, 3:2, 136-137, DOI: 10.31887/DCNS.2001.3.2/asbellack

16 Cooper, R. E., Laxhman, N., Crellin, N., Moncrieff, J., & Priebe, S. (2020). Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review. Schizophrenia Research, 225, 15–30. https://doi.org/10.1016/j.schres.2019.05.020

17 Ibid.

18 Lora, Antonio; Kohn, Robert; Levav, Itzhak; McBain, Ryan; Morris, Jodi; Saxena, Shekhar (2012). Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. doi:10.2471/BLT.11.089284  

19 Degnan et al. (2018)

20 Ibid. 

21 Guo, Xiaofeng; Zhai, Jinguo; Liu, Zhening; Fang, Maosheng; Wang, Bo; Wang, Chuanyue; Hu, Bin; Sun, Xueli; Lv, Luxian; Lu, Zheng; Ma, Cui; He, Xiaolin; Guo, Tiansheng; Xie, Shiping; Wu, Renrong; Xue, Zhimin; Chen, Jindong; Twamley, Elizabeth W.; Jin, Hua; Zhao, Jingping (2010). Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Archives of General Psychiatry, 67(9), 895–. doi:10.1001/archgenpsychiatry.2010.105 

22 Wood, Alastair J.J.; Freedman, Robert (2003). Schizophrenia. New England Journal of Medicine, 349(18), 1738–1749. doi:10.1056/NEJMra035458  

23 Ibid. 

24 Agid, O., Seeman, P., & Kapur, S. (2006). The “delayed onset” of antipsychotic action—An idea whose time has come and gone. Journal of Psychiatry & Neuroscience, 31(2), 93–100.

25 Chong, M. Y., Tan, C. H., Fujii, S., Yang, S. Y., Ungvari, G. S., Si, T., Chung, E. K., Sim, K., Tsang, H. Y., & Shinfuku, N. (2004). Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences, 58(1), 61–67. https://doi.org/10.1111/j.1440-1819.2004.01194.x

26 Ibid.

27 Ibid.

28 Xiang, Y. T., Kato, T. A., Kishimoto, T., Ungvari, G. S., Chiu, H. F. K., Si, T. M., Yang, S. Y., Fujii, S., Ng, C. H., & Shinfuku, N. (2017). Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009). Asia-Pacific Psychiatry: official journal of the Pacific Rim College of Psychiatrists, 9(4), 10.1111/appy.12277. https://doi.org/10.1111/appy.12277

29 Ibid.

30 Chong et al. (2004)

31 Ibid.

32 Deng H, Xu J. Wendan decoction (Traditional Chinese medicine) for schizophrenia. Cochrane Database Syst Rev. 2017 Jun 28;6(6):CD012217. doi: 10.1002/14651858.CD012217.pub2. PMID: 28657646; PMCID: PMC6481906.

33 van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342

34 Ibid.

35 Ibid.

36 Abbo C. (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global health action, 4, 10.3402/gha.v4i0.7117. https://doi.org/10.3402/gha.v4i0.7117

37 Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154–170. https://doi.org/10.1016/S2215-0366(15)00515-5

38 Watt et al. (2017)

39 Konadu, K. (2008) Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology. African Studies Quarterly, Vol. 10 (2&3).

40 Shaw, I., & Middleton, H. (2013). Approaches to “mental health” in low-income countries: A case study of Uganda. Mental Health Review Journal, 18, 204–213. doi:10.1108/MHRJ-07-2013-0025

Marijuana: The “Band-Aid Strategy” That May Not Heal Wounds of Anxiety

The ABC’s of THC & CBD

Produced in the form of lotions, candles, candies and oils, Cannabidiol (CBD) products have built their popular reputation as a treatment for anxiety relief. These CBD products are shown to have the ability to ease pain and induce relaxation, ultimately relieving stressful symptoms of anxiety. Some may believe that if CBD, the second most active ingredient in marijuana, is capable of bringing about anxiety relief, then marijuana as a whole substance can relieve anxiety as well. However, the presence of Tetrahydrocannabinol (THC), which is the major psychoactive ingredient in marijuana, complicates the idea that marijuana is a solely “relaxing” drug.

Cannabis is the world’s most widely-used illicit drug, with continually increasing prevalence. Despite this high prevalence, little attention has been given to the potential risk of developing mood and anxiety disorders due to regular marijuana use - especially for users later in life. A 2019 systematic review of 11 studies involving 23,317 individuals by researchers at McGill University, however, found that cannabis use during adolescence is associated with increased odds of developing anxiety in young adulthood. In addition, the risk of depression and suicidality has also been shown to increase with the usage of marijuana during adolescence. This is especially problematic, as US individuals aged 18 to 29 years who reported cannabis use roughly doubled from 2001 to 2013, from 10.5% to 21.2%. Though we’ve known the mood-elevating properties of cannabis for a long time, it may be time to delve more deeply into the long-term negative effects that cannabis can induce in terms of mental health, and especially anxiety.[1]

While marijuana may have some short-term anxiety-relieving benefits, studies have shown that a long-term use of THC at high doses will actually increase anxiety. Over the past decade, marijuana usage has significantly increased in the United States, especially since many states have legalized marijuana use in some form. Notably, the marijuana being produced has resulted in higher THC content, while the CBD content has gradually decreased. This is potentially problematic because whileas THC in its purest form can decrease anxiety at low doses, it has been shown to actually increase anxiety at high doses, and decrease anxiety at low doses. Conversely, CBD in its purest form has been shown to decrease anxiety at all doses tested.[2]

EFFECTS OF MARIJUANA INTOXICATION

Marijuana intoxication is known to have a broad range of effects, including:[3]

• Euphoria 

• Sense of calm

• Synesthesia/blending of the senses (e.g., you may be listening to music, but seeing shapes simultaneously) 

• Craving sweet/salty foods

• Belief of arriving at a transcendent insight 

• Enhanced perception

• Impaired shifting focus

• Lack of attention 

• Short-term memory loss

• Poor decision-making

• Paranoia

• Decreased motor activity 

• Lack of motivation

THE ENDOCANNABINOID SYSTEM 

The endocannabinoid system in the brain is responsible for processing feelings of anxiety, fear, and stress responses. Marijuana intoxication is often associated with calmness and being content, which increases cannabinoid and oxytocin receptor activation, and increases dopamine levels. However, once the frequent and chronic user is not intoxicated, cannabis withdrawal is mediated with stress hormone release and reduced dopamine levels. It is important to note that the endocannabinoid system plays a role in anxiety, especially because endocannabinoids modulate highly interactive stress and reward networks that create balance between pain and well-being. This means that in the long-term, the positive emotional effects of marijuana intoxication may be outweighed by negative emotional effects brought about by marijuana withdrawal.[4] 

Other factors associated with the risk of increased anxiety when consuming cannabis include:[5]

• Genetic vulnerability

• Female gender

• High usage frequency

• High dosage

• High THC/low CBD content

• History of anxiety

CANNABINOID RECEPTORS

The psychoactive effects of marijuana are related to the cannabinoid receptor CB1, while the non-psychoactive effects are related to the cannabinoid receptor CB2. THC is the main psychoactive component of marijuana, while CBD has no psychoactive effects. The CB1 receptor is strongly expressed in the brain and central nervous system (CNS). The CB2 receptor is more pertinent in peripheral immune cells and tissues. The explanation for lack of benefit derived from THC in terms of mental health could be that chronic regular use of marijuana builds a tolerance in the user. The rise in tolerance leads to the eventual downregulation of the CB1 receptor, which means some of the negative symptoms of THC that are usually felt are exacerbated even when the user is not intoxicated.[6] 

The CB1 receptor is also responsible for inhibiting the release of excitatory amino acids and GABA, which regulates other transmitter releases, such as the release of acetylcholine, dopamine, histamine, serotonin and opioid peptides. Inhibitory interneurons (GABAergic) contain high levels of CB1 receptors, while excitatory terminals (glutamatergic) contain lower levels of CB1 receptors. Dopamine receptors, which play a specific important role in emotional behavior and psychiatric disorders, also contain lower levels of CB1 receptors. THC activates the CB1 receptor to induce feelings of euphoria and even heighten negative emotions, such as anxiety. On the other hand, CBD has been shown to function as a negative allosteric regulator of CB1 receptor activation, but it does not play a role as a complete antagonist.[7] This indicates that CBD plays an inhibitory role in CB1 activation, preventing the elevated emotions that THC induced through CB1 activation. However, CBD does not completely eliminate the effects of THC when both substances are present and interacting with the CB1 receptor. 

CBD VS. THC AS AN ANXIETY TREATMENT 

Current data suggests that CBD is associated with anxiolytic activity, with acute doses having been found to reduce or manage anxiety. Anxiolytic activity indicates that this drug can be used to treat symptoms of anxiety by blocking certain chemicals in the nervous system that may be triggered as a reaction to stress. CBD’s anxiolytic effects have been studied in various animal models of generalized anxiety disorder, social phobia, panic disorder, and post-traumatic stress disorder (PTSD) in humans. The anxiolytic effects have been established in people with generalized social anxiety disorder (SAD), and other anxiety disorders, with a heavy influence on the limbic and paralimbic areas of the brain.[8] Higher doses of CBD did not prove to have anxiogenic effects (i.e., anxiety inducing), however, higher doses of THC in clinical human studies have shown to demonstrate common effects of anxiety. This is the reason why CBD is heavily incorporated in hemp and medicinal products.[9] 

Smith & Randall (2022) note that it can be more risky to administer THC-based medical marijuana treatments for anxiety disorders since the results for this treatment are more ambiguous than CBD-based treatments. This means that some may experience an increase in symptoms of anxiety with THC-dominant products, while some patients have experienced initial feelings of anxiety with use of these products.[10]

A placebo controlled, randomized study performed by researchers at Maastricht University in 2022 focused on 26 healthy recreational cannabis users to compare the effects of THC-dominant, CBD-dominant, THC/CBD-equivalent, and placebo cannabis products on anxiety. The State-Trait Anxiety Inventory (STAI) was utilized to assess the state levels of anxiety amongst these users, along with a computer-based emotional Stroop task, questionnaire, and visual analogue scale. Some of the most significant findings were that:

• THC-induced anxiety based on the STAI was independent of baseline anxiety.

• THC/CBD-equivalent products result in lower state anxiety levels than THC-dominant, alone.

• In comparison to the placebo product, both the THC and THC/CBD products increased state level anxiety significantly.

• It was also found that at low baseline states of anxiety, the CBD-dominant product was able to entirely counteract THC-induced anxiety.

• However, at a high baseline state of anxiety, the CBD-dominant product was not able to counteract THC-induced anxiety.[11]

Thus, it would appear that CBD (without the presence of THC) would work best to mitigate one’s anxiety.

BAND-AID STRATEGY

It is not uncommon for people with anxiety and mood disorders to seek medical or recreational marijuana for symptom relief, and in the short-term, users may even experience the desired symptom relief. However, the long-term effects of such usage tend not to be as positive. Mammen et al. conducted a systematic review of 12 longitudinal studies on a total of 11959 patients with a range of anxiety disorders in 2018. The researchers found that for each diagnosis, frequent cannabis users had more-severe symptoms and lower rates of remission (i.e., the total disappearance of symptoms of anxiety) than less-frequent and non-users. Some of the studies even showed that there is a link between stopping marijuana usage and symptom improvement. So while individuals with anxiety disorders may use marijuana as a temporary strategy to improve acute symptoms, the results of these studies have shown this method to actually worsen symptoms in the long run. This temporary fix is what is referred to as the “Band-Aid Strategy.”[12]

If one has been using or has previously used marijuana, and is experiencing feelings of heightened anxiety, it is crucial to contact a licensed mental health professional for guidance on how to decrease anxiety symptoms and prevent possible worsening of mental health. Before beginning to take any products with THC and/or CBD, it's also important to speak with your doctor or pharmacist to address any potential health risks.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Su, M., Luo, Y., & Wang, Y. (2021). The association between cannabis use and suicidal behavior: A systematic review and meta-analysis. Journal of Affective Disorders, 294, 256-263. doi:10.1016/j.jad.2021.07.083

2 Stoner, A. (2017) Effects of Marijuana on Mental Health: Anxiety Disorders. Alcohol and Drug Abuse Institute: University of Washington. https://adai.uw.edu/pubs/pdf/2017mjanxiety.pdf

3 Ibid.

4 Ibid.

5 Ibid.

6 Ibid.

7 Graczyk, M., Łukowicz, M., & Dzierzanowski, T. (2021). Prospects for the use of cannabinoids in psychiatric disorders. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.620073/full 

8 Ibid.

9 Berenbaum, H., & Connelly, J. (2020). The effect of cannabis use on mood and anxiety disorders: Clinical implications. Current Psychiatry Reports, 22(12), 78. doi:10.1007/s11920-020-01219-z 

10 Smith, K. P., & Randall, C. L. (2022). Anxiety disorders and cannabis use: A review. Substance Abuse and Rehabilitation, 13, 1361-1379. doi:10.2147/sar.s326480

11 Hutten, N. R. P. W., Arkell, T. R., Vinckenbosch, F., Schepers, J., Kevin, R. C., Theunissen, E. L., Kuypers, K. P. C., McGregor, I. S., & Ramaekers, J. G. (2022). Cannabis containing equivalent concentrations of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) induces less state anxiety than THC-dominant cannabis. Psychopharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9584997/ 

12 Mammen, G., Reuda, S., Roerecke, M., Bonato, S., Rev-Lan, S., & Rehm, J. (2018). Association of cannabis with long-term clinical symptoms in anxiety and mood disorders: a systematic review of prospective studies. The Journal of Clinical Psychiatry. 79(4). https://doi.org/10.4088/JCP.17r11839