Cannabis and Mental Health: Navigating Adulthood in Uncertain Times

Transcription

1 Cannabis and Mental Health: Navigating Adulthood in Uncertain Times George Brown Mental Health Conference June 29, 2018 Abby L. Goldstein, Ph.D., C.Psych. Associate Professor Canada Research Chair in the Psychology of Emerging Adulthood OISE, University of

2 She understood that the hardest times in life to go through were when you were transitioning from one version of yourself to another. Sarah Addison Allen (Author) Maturity is the capacity to endure uncertainty. John Finley (historian, mathematician) At twenty years of age, the will reigns; at thirty, the wit; and at forty, the judgment. Benjamin Franklin Adults are just obsolete children and the hell with them. Dr. Seuss (Author)

3 First, Let s Meet Diane Diane is a first-year GBC student in nursing She is a good student, who works hard, but also enjoys time with her friends She goes out most Saturday nights it s her night to have fun or hang out About twice a month, she ll spend time at a friend s or her place She uses cannabis with friends usually smoking a joint or two

4 And Jack Jack is a 21 year-old student in his second year of the Child and Youth Care Program at GBC Jack is an average student He was diagnosed with ADHD in high school Often has to work harder than his peers to keep up with his studies But, like many students, he procrastinates, struggles with time management, gets anxious before exams/assignments Anxiety increases when he lays down for the night thoughts start swirling in his mind Uses cannabis nightly to cope with these thoughts

5 Cannabis Use Past-year cannabis use among youth (15-24) 24.4%, which is more than 3 times higher than rate for adults (8.0%) (CCSA, 2016) 30.4% of young adults who use marijuana use it daily or almost daily (but not differ from adults) Prevalence of past year cannabis use in Canada among the highest internationally (along with US, New Zealand)

6 Health Reports, Vol. 29, no. 2, pp , February 2018 Statistics Canada, Catalogue no X

7 Prevalence of Cannabis Use in Post- Secondary Context Data from Canadian Reference Group of National College Health Assessment (NCHA) 17.9% of students reported cannabis use in the past month But 58.4% had never used cannabis Perceived use was 86.4% in past month Only 7.9% perceived as never-users

8 Confluence of Factors Influencing College Student Cannabis Use Developmental Factors (EA) e.g., Neurobiology Cognitive EA markers e.g., Mental health Motives Interpersonal & Intrapersonal Factors College Student Stressors e.g, Academic stress Balancing work and school

9 Developmental Factors (EA)

10 Terminology Adolescence Emerging Adulthood (EA) 18-25/29 Adulthood?

11 What is Adulthood? Criteria for adulthood (Arnett, 2000; Nelson & Barry, 2005) Independent and self-reliant Able to form mature relationships Able to comply with societal norms Able to provide and care for a family

12 Theory of Emerging Adulthood Only 25% of year olds consider themselves adults (Arnett, 2004) Demographic shifts in the last 40+ years

13 Emerging Adulthood Is... (Arnett, 2004) Identity exploration Instability Focus on the self Feeling in-between Possibilities

14 "The rental car companies have it right" The brain isn't fully mature at 16, when we are allowed to drive, or at 18, when we are allowed to vote, or at 19, when we are allowed to drink, but closer to 25, when we are allowed to rent a car. - Rae Simpson

15 Developmental Neurobiology Changes in limbic system emotion, behaviour, motivation, learning, memory govern reward-based drives (Wilens & Rosenbaum, 2013) Prefrontal cortex continuing to develop into 20 s judgment, inhibition, decision-making

16 Challenges of EA Career Lost and found identity Isolation and lack of faith Relationships

17 A Note About SES and Culture One of the major criticisms of EA theory is whether it is a middle class Western phenomenon

18 Developmental Context as Risk (Arnett, 2004) Identity exploration experiment, confusion Age of possibility optimistic present Instability self-medication In-between legal age (alcohol, cannabis*) Self-focus less responsibility + more autonomy

19 Prolonged Addictive Pathways (Sussman & Arnett, 2014) Likely to be overdetermined for adolescents who: 1) Are neurobiologically vulnerable 2) Enter EA with backlog of exposure to risky behaviours 3) More frequent exposure to addictionrelated stimuli (e.g., raves, online gaming peer networks)

20 Risk Factors for Substance Abuse in EA Fixed gender, genes, etc. Contextual Social norms, laws, taxation Individual Externalizing, internalizing, attitudes, expectancies, etc. Interpersonal Child maltreatment, attachment, parental monitoring Stone, A. L., Becker, L. G., Huber, A. M., & Catalano, R. F. (2012). Review of risk and protective factors of substance use and problem use in emerging adulthood. Addictive behaviors, 37,

21 Cannabis Use in the Context of EA (Campbell & Goldstein, 2017) 20 EA s who reported current non-medical use of cannabis Ranged in age from (M=24.3, SD=3.31) 35% currently enrolled in post-secondary Interviewed about their experiences with cannabis use and extent to which their cannabis use fulfilled EA tasks

22 Cannabis Use in Context of EA On average, used cannabis 14 days in past month (SD=9.30, Range 2-30 days) Initiated cannabis use at 16.5 years (range years) Had used cannabis for an average of 7.75 years (range 2-15 years) Primarily used cannabis via: Smoking 50% Vaping 15% Edibles 15%

23 Is Your Cannabis Use Connected to This Time in Your Life? IS THERE A CONNECTION? yes no maybe WHAT FEATURE OF EA? Identity Exp Instability Self Focus In Between Optimism

24 On Instability Yeah, it definitely helped after I hit a stressful point in time. Those stresses usually come from not knowing if my current plan will work out or not knowing anything I m depending on will come to be. There s a lot of instability, and because there s nothing that I can really do about it - because it s all in the future and it s out of my control marijuana is definitely a good way to sort of take me out of that element. (20 year old woman, regular cannabis use for 2 years)

25 On Optimism and Possibilities I don t judge myself, and I m not beating myself up, and I m not worried about anything. I m not tearing myself apart like I usually do. It s just more about, okay, this is how to be happy in the moment. This is taking it one day at a time. This is enjoying the things you can enjoy while they re here It just makes me more centered, and it makes me more present. (28 year old woman, regular cannabis use for 4 years) [I]t affects me negatively, because I m unable to do all of the things I want to do, when I want to do it, and I know the marijuana use is holding me back. Like I could be a better person without smoking as much weed as I do. (28 year old woman, regular cannabis use for 4 years)

26 On Self-Focus [I]f you smoke you can reflect on your life and you can reflect on different things and you can kind of find answers that you re not looking for just [by] going through things in your head you find answers just through being able to go into that deeper thought. (23 year old woman, regular cannabis use 6-7 years)

27 On Identity I think it was very dependent on my search for identity because when I first experimented it was something that my parents had told me not to engage in But the second I was on my own, and figuring out what I wanted to do and how I wanted to define myself to use it was entirely something that was my decision it felt nice to do something that was just mine. And then after a while I realized that that wasn t what I wanted, and that wasn t how I wanted to define myself. I just took time to figure it out. (20 year old woman, regular cannabis use 2 years)

28 On Feeling In-Between I think because there s so many negative stereotypes around smoking weed and around being a stoner...if I go out and end up smoking - I do feel bad about it a bit, because becoming an adult comes with so many responsibilities so smoking weed feels like it s a contradiction of those new responsibilities, because an adult shouldn t be smoking weed so sometimes when I smoke, I feel like I m not supposed to be doing it, because I m becoming an adult I think it kind of makes [me] feel like I m on a teeter-totter. (18 year old woman, regular cannabis use 3 or 4 years)

29 College Student Stressors

30 College Student Mental Health American College Health Association. American College Health Association-National College Health Assessment II: Canadian Reference Group Executive Summary Spring Hanover, MD: American College Health Association; 2016.

31 Cannabis-Specific Post- Secondary Stressors Cognitive impacts Working memory, learning, information processing Academic impacts Declines in class attendance Lack of engagement with college Specific harms

32 Cannabis-Related Harm (Simons, Dvorak, Merrill, & Read, 2012) % The quality of my schoolwork has suffered because of my marijuana use 9.35 I have driven a car when I was high I have felt in a fog, sluggish, or dazed the morning after using marijuana I have gotten into a physical fight because of my marijuana use 2.88 I have spent too much time using marijuana I have felt like I needed a hit of marijuana after I d gotten up I have become very rude, obnoxious, or insulting after using marijuana 6.03 I have been less physically active because of my marijuana use When using marijuana I have done impulsive things that I regretted later I have awakened the day after using marijuana and found I could not remember a part of the evening before. I have been overweight because of my marijuana use I haven t been as sharp mentally because of my marijuana use I have received a lower grade on an exam or paper than I ordinarily could have because of my marijuana use. I have tried to quit using marijuana because I thought I was using too much I have felt anxious, irritable, lost my appetite or had stomach pain after stopping or cutting down on marijuana use I often have thought about needing to cut down or stop using marijuana I have had less energy because of my marijuana use I have lost motivation to do things because of my marijuana use

33 Intrapersonal Factors

34 Cannabis Use and Mental Health: What Do We Know? Need to rely on best available evidence in considering the relationship between cannabis and mental health

35 Cannabis and Mental Health: What is The Best Evidence? Longitudinal data Prospective findings to determine causality Meta Analysis findings The illegal status of cannabis has been a barrier to high-quality research on the relationship between mental health concerns and cannabis use Legalization increases opportunities for highquality research

36 What Do We Know Now? Is there a connection? Psychosis Depression Anxiety Bipolar Disorder?? Suicidality What is the connection? Earlier age of onset Greater odds of schizophre nia among heaviest users Greater odds of developing depression for heavier users Exacerbation of depressive symptoms Individuals with anxiety more likely to use cannabis Exacerbation of manic symptoms in those with pre-existing bipolar disorder Chronic cannabis use found to increase suicidality How s the evidence? Most reliable Mixed results Direction unclear Two studies Mixed findings References Large, Sharma, Compton, Slade, & Nielssen (2011); Marconi, Di Forti, Lewis, Murray, & Vassos (2016) Lev-Ran, Roerecke, Foll, George, McKenzie, & Rehm (2014); Degenhardt, Hall, & Lynskey (2003) Kedzior, & Laeber (2014). Gibbs, Winsper, Marwaha, Gilbert, Broome, & Singh (2015). Borges, Bagge, & Orozco (2016).

37 What Do We Know? Greatest risk for increased mental health concerns associated with earlier onset of use (prior to age 16) and heavier, more frequent use (daily or almost daily)

38 From Canada s Lower Risk Cannabis Use Guidelines Avoid cannabis use altogether if you are at risk for mental health problems Some individuals should not use cannabis because of specific risk profiles. If you or an immediate family member has a history of psychosis or substance use disorder, your risk of cannabis-related mental health problems increases and you should abstain from use

39 Motives for Cannabis Use in EA Coping To Forget My Worries Conformity Because my friends pressure me to use Enhancement Because I like the Feeling Social Because it makes social gatherings more fun Expansion To Know Myself Better Routine Our of Boredom

40 Coping Motives As Risk Other Coping Strategies Cannabis Use MH Concerns Coping Motives Cannabis- Related Harms Cannabis Use Disorder

41 Implications for Prevention and Intervention

42 Clinical-Developmental Considerations Adolescent (12-17) Emerging Adult (18-25) Adult (26+) Biological Psychological Social Developed limbic, underdeveloped prefrontal a. Fewer consequences lower motivation b. Limited coping skills, less stress c. Reward-driven decision-making d. Concurrent d/o common a. Parental/school involvement, greater social control b. Avail. non-using peers c. Parents typically involved in treatment Developing prefrontal cortex a. More consequences moderate motivation b. Developing coping skills, increasing stress c. Reward-driven decision-making d. Concurrent d/o most common a. Greater independence, less social control b. Reduced availability of non-using peers c.? parent involvement Developed limbic and prefrontal a. Accumulation of consequences greater motivation b. Coping skills, moderate stress c. Balance reward with consequences d. Concurrent d/o less common a. Independent, social reinforcement (SO) b. Availability of nonusing peers c. Spousal involvement Adapted from Bergman, B. G., Kelly, J. F., Nargiso, J. E., & McKowen, J. W. (2016). " The Age of Feeling in-between": Addressing Challenges in the Treatment of Emerging Adults With Substance Use Disorders. Cognitive and Behavioral Practice, 23,

43 Developmental Context and Treatment 31 EAs in substance abuse treatment Cannabis most common substance of concern (48%) Followed by alcohol (36%) Do you think you ve reached adulthood? Why? Or Why Not? How will you know when you re an adult? Is there a connection between your substance use and becoming an adult? How do they fit together? Goodman, I., Henderson, J., Peterson-Badali, M., & Goldstein, A. (2015). Youth Perspectives on the Transition to Adulthood Exploring the Impact of Problematic Substance Use and Treatment Seeking. Emerging Adulthood, 4,

44 Developmental Context and Treatment 65% said they were an adult in some ways and not others 77% felt their stage of life and substance use were connected Delayed developmental tasks Legitimizing delays in maturation Promoting maturation by contributing to increased self-reflection

45 Themes Regarding Substance Use and EA Theme Delayed developmental tasks Legitimizing delays in maturation Promoting maturation by contributing to increased self-reflection Example Between a year and half ago to maybe two years ago, I was doing really well for myself and could have bought lots of things, but I bought lots of drugs instead. I was basically supporting myself a lot more than I am now. I mean, the more I use, the more I m giving into this child, I guess. The more likely I am to do the things that are going to set me back and it just causes so much more pain I m choosing not to drink and I m taking responsibility for my problems. I m seeking therapists and all that. I m trying to, you know, fix my mental health problems. I feel like that s a responsible and adult-like thing to do.

46 Implications for Treatment Emerging adults least likely to engage in treatment on their own Parents influential for treatment seeking Recognition of developmentally-unique stressors Discrepancy between value of moving forward with adult roles and current engagement in substance use

47 Pitfalls with a Non-Developmental Approach Abstinence-based models No family involvement Fail to consider other critical life transitions (school, employment, housing) Access points

48 What Does EA Mean For Parents? Extending the length of time parents are engaged in parenting activities Extends the window of opportunity for parents to help facilitate healthy adaptation and transition into adulthood

49 Perceptions of the Parent-EA Relationship: EA Perspective Challenges What do you want? Barriers Changing Relationships Not seen as adult Cultural differences Generational differences Stay on the surface But many felt comfortable talking about anything Empathy Nonjudgment Discussion Respect Listen Lecturing Generational gap Parents don t understand the millennial struggle Greater skepticism no longer accept as right Recognize that parents are flawed More independence with some monitoring

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51 Perceptions of the Parent-EA Relationship: Parent Perspective Challenges Successes Barriers Changing Relationships Relationships School Peer pressure Difficult to get quality time Conflict Alcohol & drugs Mutuality in relationships Try to understand Share own experiences Give them space Not wanting to spend time together Power struggles Not want to overstep boundaries Taking responsibility Disrespectful More independent Admit your mistakes Resources Online resources Friends Professionals

52 Parent-Child Relationships in Emerging Adulthood Less attention in research literature relative to earlier stages of development Balance between relaxing control and supervision while offering continued scaffolding (Fosco, Cruthers, Dishion, 2012) How do parents hinder or support their emerging adult child s development?

53 Let s Borrow From The Alcohol Field Setting specific rules about drinking Delays onset of alcohol use Prevents heavy drinking later in adolescence Even among parents who are less strict or engage in less parental monitoring **Adolescents who are allowed to drink at home tend to drink more frequently and are more likely to engage in heavy episodic drinking later on

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55 Communicating About Cannabis- Related Concerns At the core of good communication is a good relationship (engagement) Acceptance: absolute worth, accurate empathy, autonomy support, affirmation Nonjudgmental, nonconfrontational More likely to seek out parental support Reserve judgment some of the time (even if not always) Miller, W.R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3 rd Edition). New York: Guilford Press.

56 Communicating About Cannabis- Related Concerns Be curious and interested in their emerging goals and values Highlight discrepancies between values/goals and cannabis use Shift from attempting to create or install motivation to supporting and evoking natural motivation Ask evocative, open questions

57 Back to Jack and Diane Jack Using cannabis to cope with anxiety, problems with sleep Undermines development of other coping strategies Increases likelihood of daily (nightly) use and prolonged patterns of use More difficult to take a break from using Diane Using cannabis for social, enhancement reasons Limits use to weekends and evenings Can avoid or reduce use when needed Practices protective behavioral strategies* *Pedersen, Hummer, Rinker, Traylor, & Neighbors (2016)

58 What Do Jack & Diane Need? Jack Better assessment of problems with anxiety, sleep What are the antecedents? Other strategies for managing anxiety and sleep Harm reduction perspective Diane Health promotion messaging Lower risk guidelines as prevention, education

59 Helpful Resources The ones that you ve been introduced to today! Other resources from CCSA Cannabis talk kit from drugfreekidscanada.org

60 Thank You! Funding from CRC Program Social Sciences and Humanities Research Council of Canada Support from many graduate students Natalie Vilhena-Churchill, Ph.D. Breanne Faulkner, Ph.D. Preeyam Parikh, M.A. Mallory Campbell, M.A. Julia Hussman, M.A. Danielle Kofler, M.A. Sarah Haller, M.A. Eric Karaoylas, M.A.