Chronic mania—A sequel of cannabis use disorder!

To the Editor

Manic episodes rarely follow a chronic course. Less than 25% of the mood episodes last beyond 1 year in duration, and generally, manic episodes recover more quickly than the depressive ones (Solomon et al., 2010). The persistence of manic symptoms for more than 2 years is described as chronic mania (Malhi et al., 2001). Here, we report a case of chronic mania in a chronic cannabis user.

A 45-year-old male was hospitalized for his complaints of increased irritability, increased talkativeness, grandiose ideations and increased physical activity over the past 6 years. He had a similar episode of illness 8 years before, which lasted for a few months but subsided of its own accord without any treatment. He had history of dependence on tobacco (bidi) for the past 20 years and cannabis (ganja) for the past 15 years. His family history was not relevant. The use of tobacco and cannabis had increased during the current episode of illness. He was investigated (neuroimaging, thyroid function tests, syphilis and HIV infection) for medical causes of his prolonged mood episode. All investigation findings were normal, except diffuse cerebral atrophy, visible on a computed tomography (CT) scan of his head.

He was diagnosed with bipolar affective disorder, current episode manic with psychotic symptoms with dependence to cannabis and tobacco. He was treated with sodium valproate 1000 mg/day, olanzapine up to 20 mg/day and lorazepam up to 4 mg/day, to which he responded well. In the protected hospital environment, he was completely abstinent to cannabis and there was a significant reduction in tobacco smoking. There was 60% reduction in the severity of manic symptoms over a period of 3 weeks as measured on Young’s Mania Rating Scale. After 2 months, he was absolutely symptom free, resumed his job and has been well.

Cannabis use and mood disorder have a bidirectional relationship. Mood disorder increases the risk of cannabis consumption and vice versa (Tyler et al., 2015). Continuation of cannabis use and remaining untreated during the current episode might be responsible for the undue prolongation of the manic episode in this patient. Remaining abstinent in a protected environment and supervised treatment helped to achieve recovery. It is important that clinicians are aware of this potential risk factor, which might lead to chronic mania.