cbd oil recommended dosage for depression

Dosing Cannabis/Medical Marijuana: 10 Key Things to Consider

People often don’t know where to start when dosing cannabis, particularly for several applicable conditions and each person’s unique physiology. People ask what ratio of THC: CBD to take, what strain they should choose, and what’s best for their condition(s).

In some ways, this questioning is good: because patients are becoming increasingly aware of the concept of chemovariance. Chemovariance refers to the various compounds and ratios in different cannabis strains that could be more or less beneficial for a particular condition. The combination of the cannabis plant’s flavors (flavonoids), smells (terpenes), and cannabinoids all contribute to its unique effects – referred to as the entourage effect.

On the other hand, we still have much to learn when it comes to understanding ratios of cannabis’ many compounds for certain uses. But research is growing, and while we lack studies, there are some key things a patient can consider when deciding what profiles and strains may benefit them.

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Table of Contents

1. Why are you using cannabis? Do you suffer from more than one (comorbid) condition?

As an example, many people go to the doctor’s seeking to use cannabis to help with something like irritable bowel syndrome (IBS) and, by the end of the appointment, mention they also suffer from depression. This problem proliferates all medicine, not just the medical cannabis world.

Perhaps two of the most common comorbid conditions are anxiety and depression. Many research studies indicate that people who suffer from depression also suffer from anxiety.

Anecdotally, we’ve observed certain patterns in preference that those who suffer from depression tend to prefer energizing cannabis strains, while those who suffer from anxiety tend to prefer strains that relax. Yet, a person who suffers from anxiety may want to limit their THC intake, as it can trigger anxiety in high doses.

Bearing all this in mind, the anxious-depressive will likely need the THC for mood elevation in order to combat depression, but be aware that too much THC may trigger anxiety. Learning how to "balance" the THC with CBD and other cannabinoids seems to be key.

One solution for someone with comorbid anxiety and depression? Microdosing a small amount of THC via tincture or edible (say, around 3 mg), or taking the dose in a vape pen for situations when more immediate relief is needed (e.g. a sudden anxiety attack). Another option would be to try and find Sativa/indica hybrids in the right ratio to help with both disorders.

We can use a similar line of thinking with other comorbid conditions, where microdosing a therapeutic level allows users to slowly find the dose where they’re most comfortable. A total of 2.5 mg of cannabinoids may be a good place to start.

2. The difference between strain names, indicas vs. sativas, and cannabinoid content

At this point, it is worth asking, "What precisely makes a particular strain what it is?" To try and break down what is a complicated subject matter, keep the following in mind:

Rather than trying to think "what strain do I need for which condition?", look instead at the measurement of cannabinoid-terpenoid ratios. Strains can have the same name and entirely different ratios, and lab test results are a better indication of effect.

Touching on the indica vs. sativa debate, while these names refer only to the characteristics of the plants’ growth, we do see patterns across their cannabinoid and terpene profiles. Indicas generally do (but not necessarily always) contain more CBD (as well as terpenes such as myrcene) than sativas. Sativas from equatorial regions, meanwhile, seem to generally contain more tetrahydrocannabivarin (THCV) than indicas, and often contain terpenes such as limonene and beta-caryophyllene. Alpha- and beta-pinene seem to be present in both types of cannabis to varying extents. Ruderalis plants have often been tested to have high amounts of CBD.

Decades of industry hybridization have blurred the lines between cannabis varietals, meaning that the same genotype can express distinct phenotypes with their own cannabinoid-terpenoid ratios. Certain strains may contain very unique and beneficial (or sometimes potentially even neutral or harmful) cannabinoids. Remember, there are around 150 different identified cannabinoids/sub-cannabinoids, and around 212 terpenes in the cannabis plant. Different growing environments and conditions will affect what ratios are expressed in the plant. Measuring all of them accurately in a plant that expresses high amounts of variation is extremely difficult.

To reiterate: different people suffering from different conditions are likely to require different cannabinoid-terpenoid ratios and dosages. There may be patterns regarding condition and commonalities in physiology, but overall, everyone has a unique ECS, and to which degree there is a difference remains unknown.

3. Are you taking any other medications alongside cannabis?

CBD inhibits a liver enzyme, cytochrome P450, which metabolizes many prescription drugs. In fact, over 50% of drugs are metabolized via the cytochrome P450 and other CYP enzyme pathways. THC and CBN are thought to desensitize cytochrome P450 as well, but to a lesser extent than CBD. By inhibiting these enzymes, the effects of these medications can either lessen or be greatly increased with a longer duration.

This means that care must be taken if other pharmaceutical drugs are used in combination with cannabis, though cannabis may, in turn, allow patients to lessen their dependence on these medications. For example, a person who is suffering from epilepsy may need to taper the amount of AEDs they need to take.

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4. What do I hope to achieve with the help of cannabis?

Do you want to be able to walk a mile? Do you want to be able to walk around during the day without a cloud over your head? Do you want to be able to sleep or eat properly? A clear wellness goal will help you figure out the best dosing strategy for your needs.

5. Remember, everyone’s endocannabinoid system (ECS) is different.

Some people may need high doses of a particular cannabinoid or set of cannabinoids to achieve the same results with the same condition. Moreover, as everyone has a different endocannabinoid system, what works for one person may not work for another. Although it’s definitely worth asking about others’ preferences, it’s more important to find your own therapeutic range.

Although everyone has a different ECS, we can make some generalizations. The patient’s age makes a difference: younger people may be more prone to the negative effects of THC, whereas older people may benefit from a small dose of THC. Due to hormonal differences, women may also be more sensitive (as well as potentially more tolerant) to the effects of THC. Interestingly, cannabinoids’ effects don’t seem to be influenced by weight or body-mass index (BMI).

The Endocannabinoid System (ECS). By Echo. Source , April 18, 2017.

6. Starting with a wide range of cannabinoids and terpenes may be best.

Anecdotally, some of the most popular strains have very wide terpene profiles.

The cannabis plant, just like the human body, has its own checks and balances. Should one particular compound overproduce, another compound will be released to mitigate the effects of the other.

Choosing a strain with a wide terpene and cannabinoid profile may help mitigate the negative effects of other compounds. Again, much of this is condition-dependent, but it is a concept worth remembering when hunting for a particular cannabinoid.

We must be careful of stating that a strain (e.g. Blue Dream) will definitely contain these terpenoids and cannabinoids, every time Yes, some strains of cannabis follow certain patterns, but this can change significantly over time with generational breeding. Even cannabis plants that are reproduced asexually can differ, as mutations arise."

Growing the same genetics in a different environment can also affect the cannabinoids and terpenes it contains. The cannabinoid-terpenoid profile of a cannabis plant also depends upon when it was harvested during its flowering cycle – it makes a difference if a plant was harvested at nine weeks or ten weeks.

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7. Don’t forget the acidic cannabinoids, like THCA and CBDA.

These molecules are the acidic, non-decarboxylated precursors to THC and CBD: tetrahydrocannabinolic acid (THCA) and cannabidiolic acid (CBDA). "Decarboxylation" refers to the loss of a carbon dioxide (CO2) molecule. Losing CO2 via light, heat or pressure converts THCA into THC and CBDA into CBD.

THCA and CBDA work synergistically with other cannabinoids and increase their therapeutic effects by several magnitudes. THCA combined with CBD, for example, may have significant anti-inflammatory properties – more than just using one or the other alone.

Also, acidic cannabinoids are often very volatile, meaning heat, light, and air will convert them into THC, CBD, etc., and degrade them over time. This means that the only feasible way for patients to consume these compounds is to ingest whole plant preparations that have not been extracted using heat. High-quality, tested ethanol extractions, oil extractions, and pressure extractions are likely best to preserve these cannabinoids for medically-minded people.

Although there is some debate around how useful the acidic cannabinoids are, some evidence suggests that they have their uses, such as showing that cannabinoids like CBDA have significant anti-inflammatory properties.

8. On "cannabinoid hunting".

We often see the marketing machine go into overdrive, and certain cannabinoids and terpenoids become the flavor of the month. CBD is perhaps the biggest example of this, and many people say they only want CBD without any THC. This is an unscientific way of going about things, like some people, for example, those who suffer from cancer or neurological conditions such as multiple sclerosis may need THC in order to beat pain and/or spasms.

Also, without the THC, the CBD generally doesn’t do as good a job. CBD is a powerful antiemetic. Combine it with a little THC and CBDA, and the CBD becomes an even more powerful antiemetic with fewer side effects. For a person with ADD/ADHD, a sativa with THC and terpenes like limonene, pinene, and beta-caryophyllene may be helpful, although those who are prone to anxiety may wish to give such a profile a wide berth. Resist good marketing, and pay no heed to those who speak ill of THC or any other cannabinoid or terpene. The entourage effect is very real.

Yet, for all the problems associated with "hunting" for specific cannabinoids and terpenoids, some conditions do respond best to certain profiles. We do not yet know precisely which profile is best for which condition, but we’ve recognized some patterns.

The following table will hopefully illustrate these patterns, but please be warned that this is more theoretical and based upon observation rather than any definitive clinical evidence. We recommend taking any advice on strains with a pinch of salt, but we hope this provides a good starting point.

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9. When are you using medical cannabis?

Many patients will want to keep awake and have their wits about them during the day, and will likely want to avoid too much THC. Conversely, at nighttime, THC, linalool, and myrcene may be more helpful to combat insomnia (high amounts of CBD can actually help many people keep awake).

As an example, some patients may use a CBD:THC ratio of 3:1 during the day, and then a 1:3 ratio at night in order to help them sleep. The terpenoids matter, too: where limonene and beta-caryophyllene may promote wakefulness in combination with THC and CBD, linalool and myrcene may promote restfulness in combination with THC and CBD.

10. Remember: not all products are the same!

Think that all 3:1 CBD:THC preparations (or indeed any other ratio) are the same? Not quite: different extraction methods will likely have different effects, making a 3:1 CBD:THC ratio from one company will vary quite significantly from another company’s preparation. Both companies will likely be using different plants to make their products, adding or subtracting other cannabinoids and terpenoids from the preparation, on top of any differences in extraction technique.

With tinctures specifically, the carrier oil used as a base will affect absorption rate to some extent, too. Olive oil and MCT oil are the usual choices, due to them being more readily absorbed by the body and their potential health benefits.

Ingestion methods also vary widely in their results, even with the same ratio of cannabinoids. Remember: eating cannabis can be more powerful than vaping, and tinctures can be similar in strength to edibles. Microdosing tinctures & edibles is ideal for longer-term relief, while vapes can provide more immediate relief. You can learn how to make your own cannabis oil or cannabutter here and check out more about the pros and cons of each ingestion method here.

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Although we cannot provide definitive advice on what type of cannabis or what cannabinoid profile may be best for you, both scientifically and legally, we hope this information provides a useful framework for self-discernment. Start slow and low, and work to a level where you feel most comfortable without necessarily being too intoxicated.

Cannabidiol treatment in an adolescent with multiple substance abuse, social anxiety and depression

In this report, we present a case of a 16,9-year-old patient with multiple substance use disorder (cannabis, MDMA, cocaine, ecstacy), severe depression, social phobia and narcissistic personality disorder.

We administered Cannabidiol (CBD) capsules in different dosages (starting dosage 100 mg up to 600 mg over 8 weeks) after unsuccessful treatment with antidepressants.

CBD was a safe and well tolerated medication for this patient. Upon treatment with CBD and cessation of the antidepressant medication, the patient improved regarding depressive as well as anxiety symptoms including simple phobias and symptoms of paranoia and dissociation. Furthermore, the patient quit abusing illegal drugs including THC without showing withdrawal symptoms. This is the first report of CBD medication in a patient with multiple substance use disorder with a positive outcome.

Until today it is not clear if CBD holds promise as a therapeutic option in substance use disorder as RCTs are lacking, but in this single case the substance seems to work in various domains.

Zusammenfassung

Wir präsentieren den Fall eines 16,9 Jahre alten Patienten, der aufgrund eines multiplen Substanzmissbrauches (Cannabis, MDMA, Kokain, Ecstacy), schwerer depressiver Symptomatik, einer Sozialphobie und einer narzisstischen Persönlichkeitsstörung behandelt wurde.

Wir verschrieben Cannabidiol (CBD) in Kapselform in unterschiedlichen Dosierungen (100 mg bis 600 mg pro Tag über 8 Wochen), nachdem die antidepressive Medikation keine Symptomreduktion brachte.

CBD wurde zu allen Zeiten gut vertragen. Auch nach Beendigung der antidepressiven Medikation profitierte der Patient bezüglich der depressiven Symptomatik, der Angstsymptomatik sowie paranoider und dissoziativer Symptomatik. Außerdem konsumierte der Patient während der Behandlung keine weiteren Substanzen wie THC oder andere illegalen Drogen, ohne dass es zum Auftreten von Entzugserscheinungen kam.

Es ist noch nicht erwiesen, ob CBD eine alternative Therapieoption bei Patienten mit multiplem Substanzabusus darstellt, da keine randomisiert-kontrollierten Studien publiziert sind. Bei unserer Fallstudie konnten wir eine Wirksamkeit in verschiedenen Bereichen der Psychopathologie beobachten.

Introduction

Cannabis sativa contains more than 100 phytocannabinoids; one of them, ∆9-tetrahydrocannabinol (THC), is considered responsible for the psychotropic effects, known as a “high” as well as for diverse side effects, for example anxiety and/or panic attacks, altered body image, auditory and/or visual illusions and pseudohallucinations.

One other major component, cannabidiol (CBD), attenuates the psychotomimetic and anxiogenic side effects of THC [1] and is, thus, thought to contain anxiolytic and antipsychotic properties.

First randomised controlled trials (RCTs) among psychiatric populations predominantly focused on patients with psychotic disorders [2,3,4], who mostly showed significant improvement, as well as on patients with ultra-high risk for schizophrenia [5], with less anxiety and paranoia in the CBD group.

In contrast, only little is known about the effect in patients with anxiety disorder [6,7,8,9,10]. Similarly, regarding substance use disorders, there are only few studies on patients with cannabis dependence indicating a larger reduction of withdrawal symptom severity when compared to placebo [11,12,13]. Data pertaining to multiple substance use disorder and psychiatric comorbidities are still lacking. The reader is referred to the literature for a recent review on CBD and psychiatric and mental disorders [14, 15].

In the hitherto published data, CBD was mostly well tolerated with side effects similar to placebo except for mild sedation [14].

In this report, we present a case of a patient with multiple substance use disorder, severe depression, social phobia and narcissistic personality disorder according to ICD-10 criteria. The diagnosis of personality disorder was based on clinical observation as well as the STIPO Interview [16] for diagnosing the structural level of personality organization, which indicated a borderline structure with predominantly narcissistic personality traits.

We administered CBD capsules in different dosages (starting dosage 100 mg and increasing up to 600 mg) after ineffective treatment with antidepressants (sertraline) for over 6 months.

The 16.9-year-old male patient sought help at a large, urban and public clinic in December 2018. He presented with the symptoms of paranoia, derealization, attention deficit, severe depression, social anxiety and social withdrawal as well as multiple substance abuse. At his first appointment, he was using THC on a daily basis and indicated to consume MDMA, cocaine and ecstasy once a week. He had a history of psychiatric treatment over the last 2 years and had been treated with sertraline 100 mg administered orally once daily for 6 months. No other medication was given to the patient.

After written informed consent was provided by the patient and his legal guardians, we started the administration of CBD with an initial dosage of 50 mg twice daily, in the morning and evening. Within 3 weeks, we increased the dosage gradually to 300 mg twice daily (TD 600 mg/day), evaluating adverse effects and clinical improvement. The patient was treated in a day clinic setting, where he received group therapies and individual psychotherapy as well as social cognition training, occupational therapy and physiotherapy. The patient’s parents had support via weekly meetings with the treating psychiatrist.

Cannabidiol was well tolerated at all times and the patient showed good adherence. By his request, he discontinued sertraline after 3 weeks of CBD treatment from one day to the other. Prior intake of sertraline was documented by drug monitoring. Plasma levels were 84.9 ng/mL (therapeutic range 10–150 ng/mL). Sertraline was initially chosen because of the predominant symptoms of social anxiety und depressive mood. Clinically, he showed no difference in mood and anxiety symptoms after abrupt cessation of the antidepressant medication.

There were no side effects regarding heart rate, blood pressure, and weight. Urine drug screenings performed once a week revealed no further usage of chemical drugs. Screenings were positive for THC as known for chronic THC abuse and turned mostly negative after 6 weeks of treatment. Routine blood analysis showed normal values for blood count, liver enzymes, electrolytes, kidney function and inflammatory enzymes. The patient reported no side effects.

Psychological assessments

We evaluated symptoms of depression, anxiety and early psychosis using a pre–post design. Consequently, the patient was assessed prior to CBD administration and after 8 weeks. Moreover, depressive symptoms were measured twice after 4 weeks and 8 weeks respectively. We used the Beck Depression Inventory II [17] and the German version of the Fear Survey Schedule for Children—Revised [18] to assess depression and anxiety symptoms. The short screening Checklist of the Early Recognition Inventory [19] was used as screening instrument for risk of psychosis. Additionally, the German version of the Wechsler Intelligence Scale for adults [20] was used for the measurement of cognitive functions at baseline level. Results are presented in Table 1.

Summary and conclusion

In this case, CBD was a safe and well-tolerated medication for a patient with multiple substance abuse, social phobia, depression and a comorbid personality disorder. Upon treatment with CBD and cessation of the antidepressant medication, the patient improved regarding depressive as well as anxiety symptoms including simple phobias and symptoms of paranoia and dissociation. Furthermore, the patient stopped abusing illegal drugs including THC without showing withdrawal symptoms. The absence of illegal drug intake was assessed via daily clinical evaluation and confirmed using urine tests showing continuously negative results for a broad range of substances.

To date, two RCT studies have been published regarding cannabis dependency and withdrawal using a combination of CBD and THC [11, 12]. Allsop et al. [11] used a dosage of max 86.4 mg of THC and 80 mg of CBD/day. They reported a reduction of the withdrawal symptoms in the treatment group including irritability, depression and craving. Similarly, Trigo et al. [12] used a combination of THC and CBD (up to a dosage of 108 mg THC/100 mg CBD) and their findings replicated the efficacy with regards to withdrawal symptoms, but not regarding craving [12]. In a follow-up study, the authors found no significant differences between the treatment vs. placebo group on withdrawal scores [13]. In comparison, one case of a young adult with cannabis addiction was treated with CBD oil only with good results in abstinence, anxiety and sleep [21].

In sum, however, empirical evidence regarding multiple substance abuse and psychiatric comorbidities is still lacking. Bhattacharayya et al. [5] showed that after administration of 600 mg/day of CBD in patients with ultra-high risk presented with significantly less paranoia and anxiety compared to the placebo-treated patients. Hence, we decided to use greater dosages of CBD only, reflecting on the data for individuals with ultra-high risk for psychosis, since our patient presented with these symptoms additionally to substance use disorder. The rapid improvement of paranoid symptoms and dissociative symptoms may also be due to cessation of cannabis usage while in treatment in the day clinic setting. Improvements in depressive and anxiety symptoms, especially social anxiety and withdrawal, were seen gradually while increasing the CBD dosage. Since the patient reported good tolerability and no adverse effects, we increased the dosage to 600 mg/day. Concerning antipsychotic properties of CBD, Leweke et al. [2] reported clinical improvement at similar CBD dosages (600–800 mg/day). This improvement was significantly associated with elevated anandamide serum levels, reflecting a possible mode of action [22]. Cannabidiol does not activate cannabinoid receptors, but moderately inhibits the degradation of the endocannabinoid anandamide. Further research should consider examining serum anandamide levels.

To date, it is not clear whether CBD holds promise as pharmacotherapy for substance use disorder as RCTs are lacking and further investigation into CBD’s mechanism of action and its efficacy are warranted.

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