Cannabis is particularly risky for teenage boys

Photo by Harrison Haines on

Adapted from BMJ 25 Feb 2023

Dr Lade Smith is the first black woman president of the Royal College of Psychiatrists. She is particularly concerned about the rise in psychosis in young people. Much of this is driven by cannabis consumption, particularly from smoking it.

Far from being a benign, relaxing, recreational drug with few downsides, cannabis use in the teens can mar their future. Because cannabis is now quite potent, even use once a week, can drive a five fold increase in psychosis in male users by the age of 25.

She is concerned that recent publicity of the plus sides of cannabis oil use has increased its use overall.

If there is a family history of mental illness, if younger teenage boys use it, if it is smoked, if there are other adverse childhood experiences, then it becomes progressively unsafe. Oestrogen in girls seems to protect them somewhat from the psychotic problems that are more common in boys.

My comment: As a Police Surgeon I was very familiar with the huge increase that I saw over the years in the incidence of psychosis and drug induced psychosis in young people over the years. The brain in these people actually shrinks in size. As they usually need a lot of life long supervision from their families and medical carers, and because they usually become economically inactive for their future lives, it is not good news for the individuals, their families and society in general.

Anxiety is learned from the same sex parent as the child

Photo by Vlada Karpovich on

Adapted from Medscape News by Megan Brooks July 13 2022

Transmission of anxiety appears to be sex specific. It spreads from mothers to daughters and from fathers to sons, new research shows.

Dr Barbara Pavlova from Nova Scotia says that findings suggest that anxiety is a learned behaviour from parents. Therefore, perhaps it is preventable. Effective treatment of anxiety in young adults, prior to parenthood, could make a difference to children too.

Anxiety disorders are known to run in families. Both genes and environment are thought to be at play.

If a mother for instance has an anxiety disorder, the chance of a daughter developing it, by an average age of 11 years old, is 2.85 times normal, but this is not the case for her son, who would have a normal risk.

Of 398 children studied 27% had been diagnosed with some sort of anxiety disorder including generalised anxiety disorder, social anxiety disorder, separation anxiety disorder or a specific phobia.

The rates increased with the age of the child from 14% in the under 9s to 52% in the over 14s. There was a similar rate of anxiety in both boys and girls. Rates were lower if one parent had the disorder and higher if two parents had the disorder. Dr Pavlova thinks that a child will tend to model themselves on their same sex parent.

Anxiety disorders are the most common psychiatric disorder and emerge earlier than mood disorders.

My comment: I was interested to see this information. My mother had GAD, generalised anxiety disorder, and I have had a specific phobia since I was about 9 (Spiders!). If I was going to get something I suspect that a common specific phobia is a lot less disruptive to life than GAD. The good news is that I’m not a pilot on a jet plane!

A ketogenic drink has been found to improve cognitive performance in those with mild cognitive impairment

Photo by Ronit HaNegby on

Adapted from A ketogenic drink improves cognition in mild cognitive impairment: Results of a 6 month RCT by Melanie Fortier et al. Alzheimer’s and Dementia. 2021.

Brain energy rescue is being tested to see if it can reduce cognitive decline in patients with mild cognitive impairment. It has previously been discovered that the brain has problems using glucose for fuel even before symptoms develop, but brain ketone use remains constant in both Alzheimers (A) and Mild Cognitive Impairment (MCI). Increasing ketones available to the brain has been shown to improve cognitive symptoms.

A really easy way to increase blood ketone levels is to give a drink containing ketogenic medium chain fatty acids. This has been found to increase brain energy uptake via PET scans. This follow on trial was done to assess whether improvement in cognition after six months occurred.

This study was conducted in Quebec Canada. Very strict entry criteria were applied and the patients were randomised to the ketogenic drink or to a placebo drink. The drinks appeared and tasted identical.

122 participants were enrolled. In total 39 completed the ketogenic arm and 44 the placebo arm. They were well matched regarding age, sex, education, functional ability and cognitive scores, absence of depressive features, blood pressure, blood chemistry and APOE 4 status. ( A genetic variability that greatly increases the chance of developing dementia).

More participants dropped out of the ketogenic group mainly due to gastrointestinal side effects. The drop out rate overall was 32% and 38% in the ketogenic group. None of the side effects were serious.

The results showed that performance on widely used tests of episodic memory, executive function and language improved over 6 months in the ketogenic group compared to the placebo group. Improvement was directly correlated with the plasma level of ketones.

The dose used was 15g of kMCT twice a day.

This seems to be a very reasonable intervention for early cognitive decline particularly since no drugs are approved for MCI and drugs used for Alzheimers do not delay cognitive decline in MCI. It is possible that effects would be enhanced if patients also undertook a ketogenic diet. Further trials are now warranted to see if diagnosis of Alzheimers can be delayed in those suffering from mild cognitive impairment.

Writing down your thoughts can boost your mood

Photo by Suzy Hazelwood on

Adapted from Human Givens No 1 2013 Brinol P et al. Treating thoughts as material objects can increase or decrease their impact on evaluation. Psychological Science 24.1, 41-7. 2013.

Writing down negative thoughts, crumpling them up, and throwing them away, as often advocated by therapists, really does reduce negative thinking. Conversely, writing positive thoughts down, and keeping them safe in a purse or pocket helps you feel better.

Teenage School students in Spain were asked to write down either positive or negative thoughts about their bodies and then Mediterranean diet and they were then evaluated on how much they became influenced by their lists later on.

What they found was that people who threw the list in the trash right away were not influenced, those who kept the list in their desk were somewhat influenced, but that those who kept the list more personally in a pocket or purse were most influenced.

To see if the effect worked with word lists via a computer, the experiment was repeated. The thoughts were put into storage or the trash list. Repeating the experiment but simply asking the students to imagine putting the list in a particular location without physically doing anything was also done.

Professor Richard Petty, a co-author of the paper from Ohio University said, ” The more convinced the person is that negative thoughts are really gone, the better. Just imagining that you throw them away doesn’t seem to work”.

So, to get over a difficult event, write it down, and then bin it and be physical.

If you want to boost your mood, write positive facts or feelings and keep it close and personal.

Nick Norwitz:Ketogenic diets may be used to treat mental illness in the future

Photo by cottonbro on

Adapted from Ketogenic diet as a metabolic treatment for mental illness by Nicholas Norwitz et al

Wolters Kluwer Health Inc. 2020

Ketogenic diets have been used to treat drug resistant epilepsy in children for over one hundred years.

Now they are being used for other neurological conditions such as schizophrenia, depression, bipolar disorder and binge eating disorder.

There is strong evidence that common biological pathologies underlie these conditions such as abnormal glucose metabolism, neurotransmitter imbalances, oxidative stress and inflammation. These factors are all improved with a ketogenic diet.

Controlled clinical trials have shown improvement in: Obesity, Type Two Diabetes, Multiple Sclerosis, Epilepsy, Alzheimer’s disease and Autistic Spectrum Disorder.

Uncontrolled clinical trials have shown improvement in: Parkinson’s disease and Schizophrenia.

Case series and animal models have shown improvement in: Cardiovascular Disease, Binge eating disorder, Major Depressive disorder, Bipolar disorder and ADHD.

It is estimated that people who have mental illness live around 7 to 10 years less than those who do not have a mental illness. Sometimes this is due to suicide, but more often it is due to concurrent diabetes, heart disease, respiratory disease, infectious disease and cancer. All of these conditions are raised in people with mental illness. Sometimes this is due to poor health behaviours such as smoking or other lifestyle issues, and drug side effects can also cause problems. But even in people of a healthy weight and who are not on drugs, if they have mental illness, they are also more likely to have physical illness. Could switching the body and brain away from glucose use towards fat and ketone use improve matters?

Cerebral glucose hypometabolism and insulin resistance are features of Alzheimer’s disease, Parkinson’s disease, Schizophrenia, and Epilepsy. In one recent Cochrane review of epilepsy, as many as 55% of patients had complete remission of their fits on a ketogenic diet.

GABA/glutamate imbalance is a feature of Epilepsy and Schizophrenia. Oxidative stress is a feature of Schizophrenia, Bipolar disorder and Major Depressive Disorder. Oxidative stress and inflammation are mutually reinforcing processes. Major Depressive Disorder, Schizophrenia have these issues.

The Virta Health Group has demonstrated that a ketogenic diet is a well tolerated and effective strategy for treating type two diabetes. It reversed the condition in 54% of patients compared to 5% who received standard care. Alzheimer’s patients also improved on a ketogenic diet and also benefitted from medium chain triglyceride supplementation. (MCTs). Parkinson’s disease, Huntington’s disease and Multiple Sclerosis patients also showed improvement in studies. About 50 to 80% of patients with Alzheimer’s disease have cross over symptoms with schizophrenia, Bipolar disorder and major depressive disorder. These conditions all share common metabolic abnormalities.

It is thought that the ketogenic diet affects the gut microbiome and gut issues are thought to influence Autistic Spectrum Disorder. Two clinical trials reported sometimes complete symptom remission in patients with Childhood Autism when treated with a ketogenic diet.

Some case studies involve psychiatric patients who embarked on ketogenic diets for weight loss and gut problems, only to find a massive improvement in their mental conditions as well. Dr Christopher Palmer reported about an elderly woman with over 50 years of schizophrenia who was able to stop all her antipsychotic medication and has been symptom free for over 12 years. Another middle aged woman who had schizophenia and depression went into complete remission and was able to get her degree and a full time job in the last four years. Both remain unmedicated and on their ketogenic diets.

Results with Binge eating disorder have also been impressive. These patients are usually on 20-30g of carbohydrate a day.

Yoga and dance give pain relief for functional abdominal pain in girls

Photo by Jaime Chambers Fausnaugh on

Abdominal pain in childhood is associated with increased risk for persistent long term pain and severe mental illness in adulthood. Therefore, it is good to see that a simple intervention of involvement in dance and yoga were considerably more effective in dealing with functional pain than in girls who received standard care.

This was a prospective, multicentre, randomised controlled trial. 121 girls aged between 9 and 13 with functional abdominal pain syndrome or irritable bowel syndrome had standard care or participated in dance and yoga intervention twice a week for 8 months. 55% of the intervention group continued for the whole 8 months of the study.

The dance group were more likely to report a decrease in the maximal abdominal pain at 4 months and 8 months. At 8 months 46% of the dance group reported less pain compared to 17% in the control group.

Hogstrom et al. Dance and yoga reduced functional abdominal pain in young girls. A randomised controlled trial. Eur J Pain. 2021 Sept 16.

Working is good for women’s brains

Adapted from BMJ 21 Nov 2020

Being employed seems to reduce the onset of dementia in women later on in life.

In the USA, 6 thousand women took part in the Health and Retirement study. Rates of memory decline were around 50% faster in those women who did not work for pay in the years after having children. Regardless of marital status and whether they had children, women who worked for pay in early adulthood and midlife showed slower rates of later life memory decline.

My comment: I wonder if the 80 years full time equivalent that I’ve racked up for the NHS will stand me in good stead then?

Once you are old, both men and women’s rates of memory decline from Alzheimer’s greatly accelerates if either experience the death of their spouse.

The Harvard Ageing Brain study did PET scans of participants’ brains at recruitment. They then had annual cognitive assessments. Those who had higher amyloid in the brain to star with deteriorated faster whether they were married or not, but the steepest drop occurred in those whose who were widowed.

Blood pressure difference between arms can be a risk factor for cognitive decline…as well as other things.

From Systolic inter-arm blood pressure difference and cognitive decline in older people, a cohort study. Christopher E Clark. BJGP July 2020


A prospective study was done in 1,113 Italians whose average age was 66.4 years. Even a difference of only 5 degrees between the arms was associated with a greater level of cognitive decline.

My comment: In UK GP practices, only one arm is used to check the blood pressure. In my case, it was the arm that was nearest to the desk. Perhaps we should check both ? Inter-arm BP differences are both associated with cardiovascular disease, and this in turn affects dementia. Then of course, is the question, what can you do about it? For a further discussion of the subject here is Pharmacist Antonio Bess from Diabetes in Control.

Cognitive Decline: Just Life, or a Preventable Disease?
Feb 22, 2020

Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

Cognitive decline is associated with many diseases and medications, but the exact mechanisms are not clearly understood.
Diabetes, obesity, and declining cognitive function are all associated with increased prevalence with increasing age.

Diabetes is a known risk factor for eye, kidney, neurological and cardiovascular diseases, but its effect on declining cognitive function has been in question. Previous studies have found associations between patients who have diabetes and poor glycemic control and significantly faster cognitive decline. Other studies have demonstrated a pattern in which diabetes, high blood pressure, and high body mass index in midlife predict dementia in late life.

In this prospective study, individuals were followed for up to ten years to find associations between indices in diabetes, insulin resistance, obesity, inflammation, and blood pressure with cognitive decline. The indices of interest were measured separately among those with and without central obesity.
The Monongahela‐Youghiogheny Healthy Aging Team is a population‐based cohort of participants recruited randomly from 2006 to 2008, who were 65 and older, and were from a group of small towns in southwestern Pennsylvania. The study is focused on the epidemiology of cognitive decline and dementia in an area that still has not recovered economically from the collapse of the steel industry in the 1970s.

Participants were analyzed at study entry, and annual follow up. To measure cognitive function, participants were given a panel of neuropsychological tests tapping the domains of attention/processing speed, executive function, memory, language, and visuospatial function. At study entry and annually, BP, BMI, waist‐hip ratio, and depressive symptoms  were measured.
Key variables at the time of blood draw, including age, sex, race (white vs. nonwhite), education (high school [HS] or less vs. more than HS), APOE*4 allele carrier status, mCES‐D score, BMI, WHR, systolic BP (SBP), and the following laboratory assay variables: CRP, glucose, HbA1c, insulin, HOMA‐IR, resistin, adiponectin, and GLP‐1 were all reviewed to identify predictors of cognitive decline.
Among 1982 participants who were recruited and underwent full assessment at baseline from 2006 to 2008, only 478 individuals were able to provide fasting blood samples. Of this group of individuals, the median age was 82 years; 66.7% were women; 96.7% were white, and 49.0% had more than HS education.

Compared to the 1504 original participants without fasting blood data, at baseline, these 478 were significantly younger (74.6 vs. 78.6 years; P < .001); more likely to be women (66.7% vs. 59.2%; P = .004); more likely to be of European descent (96.7% vs. 94.1%; P < .001); more likely to have at least HS education (49.0% vs. 38.6%; P < .001); but about equally likely to be APOE*4 carriers (19.3% vs. 21.5%; P = .350).
In unadjusted analysis in the sample as a whole, faster cognitive decline was associated with greater age, less education, APOE*4 carriage, higher depression symptoms (mCES‐D score), and higher adiponectin level. HbA1c was significantly associated with cognitive decline.

After stratifying by the median waist-hip ratio, HbA1c remained related to cognitive decline in those with higher waist-hip ratios. Faster cognitive decline was associated, in lower waist-hip ratio participants younger than 87 years, with adiponectin of 11 or greater; and in higher waist-hip ratio participants younger than 88 years, with HbA1c of 6.2% or greater. Higher adiponectin levels predicted a steeper cognitive decline in the lower waist-hip ratio group.
Abdominal obesity plays a crucial role in cognitive decline in those with diabetes. The microvascular disease may play a more significant role than macrovascular disease. Midlife obesity contributes to cognitive decline but there was no midlife data in this study. Future studies should include a large minority, midlife population. Adiponectin levels need to be carefully assessed as well.

Practice Pearls:
In individuals younger than 88 years old, central obesity can lead to faster cognitive declines.
Obesity, diabetes, and aging contribute to cognitive decline, so it’s hard to distinguish the most significant risk.
Adiponectin may be a novel independent risk factor for cognitive decline and should be reviewed.

Ganguli, Mary, et al. “Aging, Diabetes, Obesity, and Cognitive Decline: A Population‐Based Study.” Journal of the American Geriatrics Society, John Wiley & Sons, Ltd, Feb. 2020, p. jgs.16321, doi:10.1111/jgs.16321.
Ganguli, Mary, et al. Aging, Diabetes, Obesity, and Cognitive Decline: A Population-Based Study. 2020, pp. 1–8, doi:10.1111/jgs.16321.
Tuligenga, Richard H., et al. “Midlife Type 2 Diabetes and Poor Glycaemic Control as Risk Factors for Cognitive Decline in Early Old Age: A Post-Hoc Analysis of the Whitehall II Cohort Study.” The Lancet Diabetes and Endocrinology, vol. 2, no. 3, Elsevier Limited, Mar. 2014, pp. 228–35, doi:10.1016/S2213-8587(13)70192-X.
Cukierman, T., et al. “Cognitive Decline and Dementia in Diabetes – Systematic Overview of Prospective Observational Studies.” Diabetologia, vol. 48, no. 12, Springer, 8 Dec. 2005, pp. 2460–69, doi:10.1007/s00125-005-0023-4.

Antonio Bess, Florida Agricultural and Mechanical University College of Pharmacy

It’s not usual to have perfect mental health

A study of children from birth until they were well into middle age showed that 86% of them met the criteria for a psychiatric disorder at least once during nine assessments undertaken by a psychiatrist from the age of 11 to 45.

The study was undertaken in the South island of New Zealand. Most of them had multiple diagnoses.

The conclusion was that sustained good mental health is the exception rather than the rule and that people often manifest their mental health difficulties in different ways over their life span.

JAMA Netw Open doi:10.1001/jamanetworkopen.20203221.

Stress may damage your immune response long term

Adapted from: Stress related disorders and physical health.  Song H. et al. BMJ 26 Oct 19.

This Swedish study of almost 145,000 brothers and sisters showed that any sort of anxiety or stress disorder was associated with an increased risk of life threatening infections, even when familial background, physical and psychiatric problems were adjusted for.

The study went on between 1987 and 2013. The stresses included post traumatic stress disorder, acute stress reaction, adjustment disorder and others. The patients were matched with healthy siblings when possible or matched comparative children from the general population.  They then looked for diagnosis of severe infection in the coming years such as sepsis, endocarditis, meningitis and other infections.

Severe infection rates per 1,000 person years were 2.9 for the stressed person, 1.7 for the healthy sibling, and 1.3 for the matched person in the general population.

They found that the effects were worse the earlier the age the diagnosis of the stress occurred.

Treatment with serotonin re-uptake inhibitors for PTSD seemed to reduce the negative effects on the immune system when given within a year of the stress diagnosis.

This research builds on information that PTSD produces more gastrointestinal, skin, musculoskeletal, neurological, heart and lung disorders.  Cardiac mortality has been found to be raised 27% and autoimmune disorder by 46%.

Why this happens could be due to the interplay between biological, psychological and social factors. Increased inflammatory response is considered by Song and colleagues to be a likely mechanism. Increased levels of interleukin 6, interleukin 1 beta, tumour necrosis factor alpha and interferon gamma have been found in those with PTSD.

PTSD has a heritability factor of 5-20% which is similar to what is found in families with depression.  It is likely to be polygenic.

Talking based therapies are generally even better for PTSD than drugs, so earlier intervention may have long term benefits not just on mental health, but physical health as well.

BMJ 2019;367:16036