#Cannabis and #Psychosis

Psychosis

Recently, there was a case of a young woman who smoked pot provided by her new boyfriend. She was unaccustomed to using pot in any form.

After taking 3 hits from a bong loaded with pot, she went to her kitchen and carried knives to the room where her boyfriend was waiting. Suddenly, she began stabbing him over 100 times. He died from his wounds.

Next, she stabbed her dog to death and then began to stab and cut herself on her face and neck.

The police came and demanded that she stop cutting herself and put the knife down. They described her as having an odd expression on her face. They had to use force to control her.

When she got to the police station she acknowledged that she had killed her boyfriend and her dog, and she had no idea why. There had been no conflict with her new boyfriend, and she was not upset with her dog.

She was charged with first degree murder. After an evaluation by a forensic psychologist or psychiatrist, she was diagnosed as having an acute psychotic reaction to cannabis.

Consequently, her charge was changed to involuntary manslaughter. The family of the boyfriend who was stabbed is outraged at the change in the charge.

Is the assessment that she had an acute psychotic episode resulting from smoking pot (cannabis) a real possibility?

The answer is clear. According to the National Institute on Drug Abuse “Cannabis intoxication can also induce a temporary psychotic episode in some individuals, especially at high doses” (NIDA 2023, May 8).

If cannabis is mixed with another drug such as PCP (“Angel Dust”), a person can have a psychotic break from the combination of the two drugs or either of them by themselves.

It has not been unusual for PCP to be added to pot. PCP can cause psychosis including hallucinations, delusions (including paranoid delusions), and intense panic.

She has no history of violent behavior in the past. The diagnosis by the mental health expert makes sense. A non-psychotic person would not stab a boyfriend over 100 times, kill her own dog, then try to kill herself for no reason.

Becoming psychotic with paranoid thoughts could explain her unprecedented, bizarre behavior. It is clear that cannabis by itself can cause that reaction.

It appears that she was not acting in her “right mind” when she became violent. Thus, involuntary manslaughter is an understandable charge.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Antiviral Medications for Outpatients with #COVID-19

Sick with COVID-19

There are 3 antiviral medications shown to benefit outpatients who get COVID-19. The goal is to reduce “progression to severe illness, hospitalization, and death” (JAMA September 29, 2023).

Paxlovid (generic name is nirmatrelvir-ritonavir) is an effective antiviral taken by mouth twice a day for 5 days. It reduces the risk of “hospitalization or death by 86%” (JAMA 2023).

It is recommended for patients with a “high risk for progression to severe COVID-19 and who are within 5 days of symptom onset” (JAMA 2023).

Paxlovid has drug interactions with a number of medications. Fortunately, they can be managed. It is considered safe to use during pregnancy.

Paxlovid is not recommended for patients with severe kidney disease and is not approved for children.

Paxlovid is the preferred antiviral for most adult patients with COVID-19. The next recommended option, when Paxlovid cannot be used or is unavailable, is Veklury (remdesivir).

Veklury reduces “hospitalization or death by 87% compared with placebo“ (JAMA 2023). Unlike Paxlovid, it may be given to patients as young as “28 days, weighing at least 3kg, who are at high risk for progression to severe COVID-19 and within 7 days of symptom onset …” (JAMA 2023).

Veklury must be given IV once a day for 3 days. It may not be accessible for all patients and, because of the need for IV infusion, may be unacceptable to others.

The third antiviral option is Lageviro (molnupiravir), which is given by mouth twice a day for 5 days. It reduces “hospitalization or death by 30% compared with placebo;” thus, it is less effective than the first two options (JAMA 2023).

It is for adults age 18 and older who are at risk of “progression to severe COVID-19 and within 5 days of onset of symptoms, and for whom alternative treatment options are not available or appropriate” (JAMA 2023).

It should not be used during pregnancy; patients who could become pregnant are advised to use birth control.

These medications have shown benefit in unvaccinated patients, and there is good evidence for effectiveness in vaccinated patients. For example, Paxlovid reduced hospitalizations by 73% in vaccinated patients.

The bottom line is that outpatients age 50 or older, “younger patients with” pre-existing chronic medical disorders or obesity, and “immunocompromised individuals of any age” should be treated with an antiviral medication whether or not they are vaccinated (JAMA 2023).

After treatment there can be a rebound of symptoms. This also occurs in untreated patients. Luckily, “severe illness has not been observed” (JAMA 2023). Patients with rebound symptoms do not need additional doses, with the exception of of patients who are severely immunocompromised.

Do not rely solely on this blog to make your healthcare decisions. It is intended for educational purposes only. You should consult a physician before making a decision about the best option for your care.

This blog is based on an excellent review on the topic by Chew K, Malani P, Gandhi R. published online in JAMA on September 29, 2023. doi:10.1001/jama.2033.19542

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Ivermectin for #COVID

Sick from COVID

Does ivermectin shorten the length of sick time from COVID in adult outpatients? This question was answered by a controlled research study of non-hospitalized adults over age 30 with COVID.

There was no difference in length of illness nor rates of hospitalization in patients given ivermectin vs those given a placebo (inactive fake pill).

The bottom line: ivermectin was no better than a placebo in reducing illness time or severity of illness.

These results are helpful as another example of careful research evaluation of ivermectin in the treatment of COVID. So far, all of the research I have seen demonstrates that ivermectin is of no benefit for COVID patients.

Taking ivermectin for COVID is a complete waste of money.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Right Where I Am!

If you could live anywhere in the world, where would it be?

Gulf of Mexico

Where would I live if I could live anywhere? I am already living there! My home is less than 10 minutes from two beaches by the Gulf of Mexico. And, yes, we do see dolphins when we boat a short distance off shore.

We love our house, which is in a safe neighborhood with friendly neighbors. We love slipping into our backyard swimming pool on a hot day. We love the fact that we are within a short drive from friends, stores, a great gym, and our church.

Our church was a great find for us. When you enter the building to attend a service you get a feeling of authenticity, of people who walk the talk and care for those in need. It provides my need for spiritual meaning in my life.

The bottom line: I am blessed to be already living where I would live anywhere in the world that I could. We chose it consciously after learning about it from friends who moved there and after checking it out in person.

You could feel blessed if you do likewise.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Mental Illness and Adverse #Childhood Experiences

Anxious and Depressed

“Children who do not develop mental health problems early in life despite exposure to multiple adversities may experience such challenges in early adulthood…”

An article in Psychiatric News (Nov. 13, 2023) discussed research published in the American Journal of Psychiatry that compared outcomes among children with multiple adverse childhood experiences (ACEs), e.g., violence, neglect, poverty, etc.

If you compare adults who had multiple adverse childhood experiences (ACEs) and did did not have mental health issues as children to adults who did not have ACEs, the former group had 4.5 times the rate of depression and 3 times the rate of anxiety than the latter group.

However, the adults who had multiple ACEs and had mental health problems as children had the worst “health and mental functioning.” They also had worse physical and financial health.

Adverse Childhood Experiences (ACEs) are major examples of the social determinants of health.

The information in this blog is from Psychiatric News Nov. 13, 2023.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Favorite Subject in School

What was your favorite subject in school?

College Student in Class

What was my favorite subject in school? I was a biology major in college, and genetics was my favorite subject.

Why? One main reason was my teacher. He was a genetics expert who trained under a pioneer in the field. My professor made difficult topics easy to understand (relatively speaking). He was interesting and engaging.

Another reason I enjoyed genetics was because it addressed important issues such as evolution, mental and physical illness, family structure, anthropology, and more.

One fun idea we were told was that the purpose of the whole organism was to reproduce DNA. Notice that DNA is the reason for reproduction, not the whole organism. That exists as a container for the DNA.

Of course, reproduction is a defining feature of living things (not just for DNA). If a species does not reproduce, it becomes extinct.

The idea that the primary purpose of any organism, such as a human being, is just to reproduce DNA is not to be taken literally. It is just a fun way to express its importance to a species.

After college I went to medical school. I had to take the Medical College Aptitude Test. It seemed to me that a significant number of questions involved genetics. I thought I did well on them because I had a great teacher.

Years after becoming a physician, I was teaching full-time in a medical school and had an opportunity to visit the college I attended. I took that opportunity to track down my genetics professor.

I told him that I was now a medical school professor, and I was grateful that he had played a meaningful role in my becoming a physician. He was beaming when I told him how thankful I was.

I suggest you tell someone who made an important impact on your life what that meant to you. You will both enjoy it.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Mask Use and Spread of #COVID

Wearing a Mask to Stop COVID

Does wearing a face mask reduce the risk of getting COVID?

Different opinions on this topic have been rampant on social media. Their use became controversial.

What does observational research show?

According to a comprehensive article in JAMA Network Open on October 31, 2023, “many high-quality observational studies” demonstrate that “face mask use in the community and of mask mandates” reduced the “spread of SARS-CoV-2.”

So, the answer is “Yes,” face masks do reduce COVID infections. Mandating the use of face masks also reduces its spread.

In fact, a study in Germany showed a “45% reduction in SARS-CoV-2 infections” when face masks were mandated compared to parts of the country where they were voluntary.

The article that was reported in this blog was by Cash-Goldwasser S and colleagues, Masks during pandemics caused by respiratory pathogens – Evidence and implications for action. JAMA Network Open. 2023; 6(10):e2339443. doi:10.1001/jamanetworkopen.2023.39443

Peter M. Hartmann, MD

Family Medicine & Psychiatry