Current generation students are in the threat of various substances and addictive behaviours; not only males but also females are in the trap. Despite being illegal, cannabis and other substances like LSD and Opiate lure the young and other people in current context of mobile and changing world and Nepal. When youths are in the trap of such addictions, they are bound to various consequences including dependence and complications like: disruption of study, career, work; developmental, psychiatric, physical, familial, social, financial, legal, safety and violence-related risks. Safety, violence and sexual issues are striking especially for a female substance user. This case report intends to draw attention to substance use and use disorder, mainly illicit including cannabis among growing literate Nepalese women; and also, to its implication in the course of co-morbid mental disorder, e.g., Bipolar mood. We report a 22 year old Nepalese female student with Cannabis Dependence Syndrome with LSD and Nicotine use which had a great implication in the course of her psychiatric disorder, i.e. Bipolar mood.  

Keywords: addiction, cannabis, female, Nepalese, substance

Cannabis is long known in Nepal, India and other parts of South Asia where cannabis preparations are used as a part of religious and ritual use.¹ As most of the psychoactive substances, cannabis use is more common among males than females; but gender gap is, currently, narrowing.¹ Men also report a greater variety of psychoactive substance uses (LSD, Opioid, Benzodiazepine, IV drug use) as compared to females who report the use of less potent psychoactive substances. Apart from legal, financial, occupational and other common consequences including worsening of comorbid mental disorders like Bipolar mood,^2,3 youth females are more vulnerable to sexual issues, violence and safety hazards. A recent review and other case reports from the same setting intensively highlighted ill effects of cannabis use.^4–6

According to the ICD-10, Cannabis use disorders are classified into 5 types: Acute Intoxication, Harmful Use, Dependence Syndrome, Withdrawal state and Cannabis Induced Psychotic Disorder. Cannabis dependence syndrome is indicated by the presence of at least 3 of 6 symptoms for at least 1 month period in last 12 months: 1. Craving, 2. Tolerance, 3. Withdrawal symptoms, 4. Loss of control, 5. Neglect of alternate pleasure activities and 6. Persistent use despite evidence of harm.

Miss JB, 22 year old unmarried Hindu female pursuing bachelor in hotel management, from middle socio-economic status family; with premorbid temperament of easy child and well-adjusted premorbid personality; with history of mental illness in extended family (mania like features in a sister of her grandfather) presented with total duration of cannabis use of- 3 years, of onset- acute, course- continuous, and with no identifiable stressor. She started consumption of cannabis 3 years back under peer influence, and developed craving, tolerance and withdrawal for at least 1 year. She reported experiencing pain in limbs, decreased concentration and restlessness in its withdrawal.

There is also history of nicotine use for 11 months. There is history of LSD use 1 year back, 2-3 tablets after which patient started experiencing weeping episodes, sleep disturbances, increased talk, grandiose talk, loss of inhibition, increased activity, difficult to control for which patient needed admission in a Teaching hospital in Kathmandu for 15 days and was discharged with 60-70% improvement. She gradually became noncompliant to medication while abstinent initially. In 2 months, she was using cannabis in previous pattern, and the reason was peer pressure as she reported. She presented with second episode again with increased talk, irritability, decreased need for sleep, over-religiosity, verbally abusive and physically assaultive behaviours; again requiring admission in psychiatry ward for 8 days. She was advised Lithium 900mg, Olanzapine 20mg, and Lorazepam. She went on discharge on request (DOPR), with 70-80% improvement, in the pretext of the upcoming exams. In 5 days, family members had to bring her to Emergency room in anticipation of her being verbally abusive and physically assaultive. Immediately after discharge, she went to her college city in India with her friends for some musical programs instead of exams. She had stopped medications and resumed cannabis use in her previous pattern. She was irritable on minor issues, demanding cigarettes and had decreased sleep. Hence, she was readmitted. 

During ward course, she was highly uncooperative in initial 8-10 days, motivation enhancement sessions were difficult as patient adamantly reasoned cannabis use as beneficial for its effects like- high, charge, creativity and enabling her focus on her artistic psychedelic drawings and writings. With gradual development of rapport and step-wise motivation enhancement after 10 days of ward stay with optimisation of medications, she improved gradually. She was discharged when she was in the decision phase of motivation. 

In this case, we present a young lady who met the criteria for Cannabis Dependence Syndrome (CDS) along with Harmful use of LSD and nicotine use. Cannabis use seems as a precipitating factor for symptoms of bipolarity in the background of family history of mood disorder. A systematic review showed a positive relationship between cannabis use and aggravation of mania in diagnosed bipolar disorder (BPD)^2,3 and psychosis.^4,5 Meta-analysis showed approximately 3-fold increased chances for new manic symptoms in people using cannabis.^2,3 A recent study in the same setting revealed statistically higher rates of cannabis use and dependence among males than females in both out-patient and in-patient settings. There was a statistical significance between mania and cannabis (use and dependence) among psychiatric out-patients which was not so among the in-patients.⁷ This case report intends to draw attention to the fact that cannabis problem is there among Nepalese females too, though not more than among males, as reported in a Nepali study among dental students.⁸ In that study among 78 dental students who used cannabis, females outnumbered male users of which 53 (67.95%) were females. All these show that Nepalese females are also getting into the trap of cannabis.

Cannabis use is also related to poor prognosis with higher chance of rapid cycling and mixed episodes in bipolar patients. Repeated relapses of cannabis use and refusal to comply with medication among the youths reflect the beginning of the many complications which are increasing in the society, and also affecting females. Here, we present a young female student with repeated noncompliance to medication with the heavy use of cannabis and cannabis dependence.

Belief of benefit from medicinal cannabis use seems widespread and people are less aware about its negative consequences as our highly literate creative student case. A recent review of the literature shows more evidence for harms than therapeutic benefits of cannabis in the majority of health conditions. A review from the same setting shows that its benefit lacks adequate evidence warranting for further study.⁵ And, its harms and adverse effects are clearly evidence based, mainly from the perspective of mental health effects including precipitation of psychosis and bipolar mood.^4–6 This case replicated it in a female patient.

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Authors declare that there is no conflict of interest.

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