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In this case report, the patient’s history of bipolar disorder, regular cannabis use, and request for a psychostimulant for suspected ADD made it imperative to evaluate her lifetime clinical history to determine the onset of her cognitive complaints relative to her mood symptoms and cannabis (or other possible substance) use. This would aid in forming a provisional working diagnosis about the etiology of her symptoms that, in turn, affect treatment options and outcome.
Prescribing a stimulant based on her self-reported concern about ADD without thorough evaluation could exacerbate her bipolar symptoms and conducting formal neurocognitive testing based on patient’s self-reported cognitive and attention issues alone would be premature. Hence, basic clinical assessment including clinical history and symptoms were used to eliminate ADD as a diagnosis as she achieved normal developmental milestones as a toddler, performed well both academically and socially from grade school through high school, and denies having had trouble paying attention in class or in social settings. Moreover, her Wender Utah Rating Scale for Childhood ADHD score was 22, well below the normed threshold for ADHD of 46.
It was determined that patient’s subjective cognitive complaints related to the intrinsic cognitive deficits of bipolar disorder itself or possibly the neurotoxic/cognitive adverse effects of past and current cannabis use. Cannabis use was identified as a potentially modifiable risk factor for both cognitive dysfunction and worsening of mood symptoms. Since bipolar disorder is complicated by substance use disorders in approximately 50% of cases and cannabis use can adversely affect efficacy and treatment outcomes in bipolar disorder, this case offers important insights for identifying and treating cannabinoid addiction that may be exacerbating bipolar symptoms due to neurotoxicity.