To the editor,
There is a growing debate regarding the decriminalization and legalization of cannabis for medicinal and recreational use. Several novel tetrahydrocannabinol (THC) derivatives have gained popularity in recent years. Delta-8-THC (Δ8-THC), an isomer of Δ9-THC, is primarily produced by the cyclization of Cannabidiol, an inactive compound extracted from hemp. 1 The recreational use of Δ8-THC is constantly growing. Except for reports of acute toxicity, the psychiatric side effects of Δ8-THC are largely unknown.2,3 We report a case of Δ8-THC associated affective switch in a young adult. Informed consent was taken to report this case.
Case Description
Mr S is a 26-year-old single gentleman from South India working as an Engineer in the United States. He has a well- adjusted premorbid personality and his family history is significant for organic mood disorder in his father and major depression in his younger brother. The onset of psychiatric illness was at the age of 25 years. It was characterized by sad mood, anhedonia, anergia, loss of appetite, disturbed sleep, and low self-esteem which lasted for more than a month. He was advised 10 mg of escitalopram by a telepsychiatry consultation. After four weeks of treatment, the patient noticed a minor improvement in his mood and energy levels and subsequently discontinued medications. On the suggestion of a friend, the patient began consuming delta-8-tetrahydrocannabinol (Δ8-THC) gummies on a regular basis in order to improve his mood (3–4 per day, individual dosage not clear). After one month of use, the patient developed irritability, fearfulness, and suspiciousness over his flatmate. This was followed by decreased need for sleep, elevated mood, increased self-esteem, anger, and increased activities and energy levels. The patient was hospitalized in the United States for acute management of symptoms. The routine biochemical evaluation and Computed Tomography of Brain were normal. He was treated with 20 mg of tablet Olanzapine. There was an improvement in manic symptoms within two weeks. He did not continue to use Δ8-THC gummies thereafter.
After four months, he returned to India and presented to our center with complaints of pervasive low mood, reduced energy levels, reduced appetite, suicidal ideations, and disturbed sleep. After a detailed examination, a diagnosis of Bipolar Affective Disorder, severe depression without psychotic symptoms was considered as per the International Classification of Diseases. 10th edition. The past manic episode was considered as Δ8-THC associated affective switch. He was started on 900 mg/day of lithium along with bupropion with gradual dose titration up to 300 mg/day. There was a gradual improvement in symptoms with improvement in functioning.
Discussion
In this report, we have described Δ8-THC associated affective switch in a young patient with a depressive episode in the past. This conclusion can be speculative, as patient’s symptoms could be explained by escitalopram-induced affective switch or primary bipolar disorder in our patient. However, the temporal association with Δ8-THC use and the extant evidence on the association between cannabis (Δ9-THC) and mood disorder cannot be ignored. 4 Cannabis has long been recognized as a risk factor for mania and subsequent bipolar disorder. 4 Cannabis use at baseline has been associated with an elevated risk of manic symptoms regardless of the prevalence and incidence of psychotic symptoms. The possible mechanism is dopaminergic receptor sensitization via cannabinoid receptors. 4 However, there is limited evidence for similar effects with Δ8-THC.
The euphoric and psychoactive effects of Δ8-THC are mediated by cannabinoid CB1 and CB2 receptors similar to Δ9-THC, albeit with a weaker affinity at CB1 receptors. Common adverse effects of Δ8-THC are confusion, anxiety, drowsiness, and bradycardia.2,3 There have been earlier reports of psychotic symptoms secondary to the use of Δ8-THC.5,6 The similarities between Δ8-THC and Δ9-THC have been implicated behind the psychotomimetic effects of the former. 6
Various Δ8-THC compounds are being increasing marketed on many online platforms without adequate regulation. A wide range of Δ8-THC products (gummies, tinctures, oil, vaporizing pens) are available for use with no adequate caution or awareness. Even in India, there is an absence of legislation and restrictions for age limits for purchase. Healthcare professionals should be cautious about the potential adverse effects including the risk of psychosis and mood disorders with Δ8-THC and the other legal THC derivatives.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
References
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