CBD Conversation with Dr Rebecca Moore

Introduction:

Joining Anuj Desai (the host) is Dr. Rebecca Moore, a consultant psychiatrist based in London. This discussion focuses on how cannabis compounds interact with anxiety. This is another fascinating conversation about CBD which is difficult to come by!

Summary:

Anxiety comes in many forms and means something different to everyone.
For example, medical anxiety and social anxiety are very different.
Symptoms for anxiety vary. Some people experience sweating, restlessness, weakness, heart palpitations, a lump in your throat, fear, and many more.
Many professionals advocate for cognitive behavioural therapy (CBT)
The most common medication prerscribed for anxiety is something called an SSRI (Selective Serotonin Reuptake Inhibitor)
Many psychiatric medicines have terrible side effects, and naturally do not work for everyone.
Dr. Rebecca has used medical grade CBD with a number of her anxiety (and menopause) patients with great success.
CBD can be used as part of a treatment strategy to combat symptoms of anxiety - for example, combined with better sleep, eating more nutritious foods, and exercising.
A daily dose of 100mg of CBD oil is frequently prescribed for patients with anxiety.
CBD is often taken through a tincture in patients with anxiety who need sustained relief.

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People have often asked us to do a podcast to help spread our knowledge and those CBD experts we are in contact with. However, we also have an obligation to use our time pushing boundaries and taboos. So we prefer to leave podcasts to seasoned industry experts who have these conversations in an attempt to empower all of us!

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The Transcript:

The Cannabis Conversation. A perspective on the emerging legal cannabis industry.

Welcome to the Cannabis Conversation with Anuj Desai where we explore the new legal cannabis industry by speaking to the professionals that are helping shape it. Been awhile since I've done a little intro, so I hope you're all very well. Next week is episode 50, which is very exciting. This week is episode 49.

When I started, never thought I'd still be doing it a year later, so it's nice to get here. Been a load of fun and I've really enjoyed meeting so many great people, as well as continually learning huge amounts about this new, crazy, exciting industry. I hope you guys have enjoyed it too.

I deliberately didn't take any sponsorship during the first year as I wanted to just see how it developed, but I feel now is the time. If you're a business looking to advertise to a good, strong, cannabis industry following, please do get in touch. I'd love to chat to you. Onto this week's show. It's one I'm really looking forward to. It's all about cannabis and anxiety. Enjoy.

On today's show, I've got Dr. Rebecca Moore, who's a consultant psychiatrist. She works privately in London but she also works at the Medical Cannabis Clinic on Holly Street. Rebecca's here today to talk to us about anxiety and how cannabis interacts with that. Welcome, Rebecca.

Thank you very much for having me here.

How are you today?

I'm very good, thank you. Very good.

Good, good. So, this is a huge topic and I'm really happy to have you on because anxiety seems to unfortunately feature in virtually everyone's lives nowadays and often, we talk about CBD as being kind of helpful in alleviating the symptoms of anxiety, so it'd be great to speak to you about that. But before we get onto that, maybe we hear a bit about your back story and what you did before and what made you start studying cannabis.

I've been a psychiatrist for a long time and actually I've got two very different main specialties. I'm a peri-natal psychiatrist as well, so I work with women through pregnancy and post-natally and I have an expertise around birth trauma. I think a couple of years ago, I was lucky enough to be a Winston Churchill fellow where you're awarded a sum of money to go and travel and learn from cutting edge research. I went to California, was lucky enough to go to Stanford and whilst I was there, I suppose that's where my interest in medical cannabis and CBD began, partly because in America, they're always a bit ahead of the curve.

There was a lot more conversation going on there, it was already widely used and you could really access it much more easily. I'm particularly interested initially around trauma because there's a lot of trials going on there around the PTSD population and how cannabis might have a role in treating PTSD in particular. That really sort of sparked my interest and it's grown from there really.

I think I work in quite a holistic way, so I suppose the other big thing for me is that I just feel we should offer all the choices. It seems to me that that is one of the choices that we should be offering. We know that medication, traditional psychiatric medication doesn't work for everybody, that it's something that a lot of people don't want to take. For some people, it can have lots of side effects which outweigh the benefits that it might bring.

For me, it's about really truly offering people lots of different choices and I think that for me, CBD and cannabis should be one of those choices.

Yeah, and how did you find that? Was it kind of an enlightenment a bit when you were in California?

Yeah.

Because we see they're quite far ahead in terms of this.

Yeah.

Coming back to the UK.

Yeah, so it's brilliant there. There's a real openness about it and also, a desire to evidence it. These are really high quality institutions, so they're not just prescribing. They're actually wanting to set up big trials to look at the impact of using CBD or cannabis. Obviously as a clinician, that's really important because you want to be able to evidence what you're prescribing.

I found coming back that at that time, three, four years ago as I'm sure you know, there were sort of pockets of people that were interested but not as much as there is today. Although I've been using CBD in my practice for quite a long time, because technically that's considered as a sort of health product and not prescribing it per se, then obviously the change in the law and being able to prescribe as well has been really helpful for me personally and now I'm really thrilled to be working with a group of clinicians that are all prescribing and we can all learn from each other. We can share best practice. So, that feels like a really good place to be part of.

Amazing, amazing. Loads to talk about there and we'll go in sort of a bit about what you're doing. Maybe it's a good idea to take a step back and just start with some sort of 101. What exactly is anxiety?

Well, that's a million dollar question. I think it depends who's defining it and who's talking about it. Anxiety is a term that's used everywhere, isn't it, nowadays, but it's going to mean something different to each individual person. You can have clinical anxiety where you're sitting with somebody and you're essentially screening them for a checklist of symptoms that if they have those symptoms, you could say this is clinical anxiety.

But anxiety itself is an umbrella term. Somebody might have a generalized anxiety, they might have panic disorder, they might have a social anxiety. You really need to be careful about the exact terms you're using because it means something very different to each person.

Are there some common threads between-

Yes, I think there's common threads and I think it's also important to say that you don't have to have a clinical diagnosis to feel the anxiety is a huge part of your life and affects you day-to-day. For me always, I suppose it's less important to diagnose and more about actually what is this feeling like and how is this affecting your day-to-day life. Because you might have three out of the five symptoms and not make a diagnosis, but actually day-to-day, that's really tough still.

The common themes for people are what we can all recognize is when we feel a bit anxious, we feel a bit panicked, we might get that butterflies in our tummy. We might feel hot, sweaty, short of breath, bit on edge, a bit uneasy, a bit scared, frightened almost and that might be tied to a certain situation. Say, standing on stage and talking in front of lots of peers and professionals or it might just be something that sits with you all the time.

It can be very variable for each person. For some people, it can have been there from very early on in childhood. Some people might have a very strong family history of anxiety. So, you've been parented and brought up by a mum or a dad who is themselves very anxious and of course that has an impact on how you see and perceive the world. It's very, very variable and I think what it always comes down to is listening to somebody's story and understanding what it means to them.

Yeah. What's some of the typical symptoms that people can get if they are suffering from anxiety?

I think it's that feeling of unease and feeling restless and just not able to switch off. So, worrying a lot either about something specific or everything feels worrying. Then that can mean you can't focus, you can't sleep. Sometimes people can't eat because they feel very nauseous or people might have full blown panic attacks as well where they feel really terrified and out of control and that they're going to die.

Then obviously if you've got an anxiety sitting there all the time, it can affect your mood because you can start to feel like I can't enjoy things, I can't go out, I can't see my friends. So, it can really affect your day-to-day work, your ability to function at work, your ability to parent, your relationships with people. If you're feeling constantly tense and not able to enjoy things and not wanting to go out, then that's going to have an impact on day-to-day life.

Sure. I mean I, like everyone, has had anxiety and I sometimes feel that it manifests in physical symptoms.

Yeah, yeah. A lot of people will get the classic sort of dry mouth, you feel like you've got a lump in your throat, tummy tumbling over. You can get very sweaty. You can really feel your heart pounding. I think also you can get more subtle things like perhaps feeling you get lots of physical symptoms full stop, so headaches, tension headaches, IBS is quite linked to anxiety or it might just be you have new symptoms and then get very anxious about them and sort of misinterpret what's going on in your body as well. You can feel things as much physically as you do mentally.

Yeah, yeah, yeah. How's anxiety been treated historically and now? Has there been a shift in the way that it's been treated?

I think for most people, it would probably be a case of you feel like you pluck up the courage to tell somebody which is usually a GP. Sometimes the response you get is absolutely brilliant, sometimes it's not. We know that it's very variable for people and in the UK for most people, it would be offering therapy and/or medication.

Often, therapy is the right place to start because it's at a degree or a level where therapy is great and it can work. Huge evidence base for therapy working really, really well with anxiety. Usually CBT, cognitive behavioral type work is what's offered most often in the UK, I would say. Then for some people, that doesn't feel enough or they don't want therapy. They don't like the idea of talking to somebody. They might choose to take medication and that would typically be with an antidepressant type medication, so one of the SSRIs. Prozac is the one that most people will have heard of.

Or there are some sort of shorter term medications you can take if you're very profoundly anxious, but that would be the sort of typical route for most people and a lot of that would be managed within primary care by the GP.

Yeah, yeah. I guess with therapy, is that effectively re-evaluating your relationship with the situations that make you anxious?

Yeah, so it's thinking about your... First of all, recognizing your thought pattern, how you respond to things, the judgments you're making about risks and threats and what might happen. Then perhaps beginning to reframe those thoughts and challenge those thoughts. How likely is that actually to happen? What would happen if that happened? What's the worst case scenario? It's really effective and the great thing about therapy is that sometimes people can feel better within a relatively short space of time.

But I think if people have had life long anxiety, say, sometimes that can help at the time but then often people feel a creep back of those symptoms. For me, that's where something like CBD comes in. It's just another thing to have as part of your toolbox and that might include exercise as well or supplements or managing your sleep but for me, we need to think about all of those bits-

Yeah.

... to really truly give somebody the tools to look at every single part of their life and think, "I can do this bit and this bit and this bit." That's really helpful for people going forward because it's things that they can do themselves and take ownership of.

Yeah. I've always found exercise very helpful.

Exercise is amazing. There's lots and lots of literature about exercise being really effective for anxiety and depression and as good as antidepressants in some big trials. I always encourage people to exercise as part of my prescription and it doesn't have to be anything fancy, it doesn't have to be anything that costs money or takes a long time. Starting small, just a 10 minute walk around the block or doing something online that's free and you can do at home. You don't have to go to the gym. You don't need to put any special clothes on. Just really small chunks that you can build in and things that you really like. Don't go running if you hate running. There's no point.

I forced myself before.

Add pressure to yourself but think about what you really, really love and do five, ten, fifteen minutes of that and just build that into your routine. I think the other thing about exercise is particularly breath based exercise and things like yoga, pilates. Breathwork is phenomenally good for anxiety because we're tapping into the parasympathetic vagal nerve and it's going to calm down our nervous system.

Is that something as simple as deep breathing?

Yes, you can do things like breathe in for four, hold for four, breathe out for four, hold for four. Sort of square box breathing and even doing that, learning to do that within two or three minutes will just be dampening down your nervous system. I use that all the time, you know? It's really, really good. If I'm feeling stressed out and I'm late and I'm on the Tube, I can just close my eyes and breathe like that. No one knows you're doing it.

I just recently learned about square breathing.

It's just amazing. It works really, really well.

Definitely. I'm going to come back to stress actually just quickly but I'm going to wing it here with my Google medical degree. Is exercise a way of burning up adrenaline or using the adrenaline in your stomach? As you said, people feel it in their stomach. Is that something?

Yeah, so I think lots of people feel that it helps them burn off that adrenalized feeling and they feel more fatigued afterwards and you've got a nice boot of endorphins, which again make you feel relaxed and calm. There's no doubt that neurochemically, it is helpful as well. I think also it distracts if you're constantly worrying. If you're doing something like a yoga sequence or a run and you can put music on, it's a good way to distract yourself from those thoughts as well. So, it's really a win win all around.

Before we get on to cannabis specifically, you mentioned the word stress and I think that is also extremely prevalent. Are the terms kind of interchangeable or is stress a type of anxiety? Is anxiety a type of stress?

Yeah, I think stress is probably something we more commonly feel was sort of less clinical per se. It's not a diagnosis as such.

Okay.

Although obviously if you're under high amounts of stress, you can become anxious or depressed. I suppose stress is just part of life for most of us. It's a common thing that we all feel at points through the day and it can cause many of the symptoms of anxiety when we feel stressed. Whereas anxiety I think is something that is more intense, usually more severe, sits with us for a longer period of time than stress per se.

Right. Okay, good. Thank you. Cool. So, cannabis. How does that fit into this? It's probably useful to maybe break it down into medical cannabis.

Yeah.

I.e. full spectrum.

Yeah.

And then CBD.

Yeah. I think to begin with, often when people come and want to seek advice about that, I think that is probably one of the misconceptions is that people don't recognize the difference between CBD and medical cannabis perhaps. I think perhaps in the last year, we've sort of been bombarded a lot in the media about CBD in particular. I suppose the view from some people that I can buy this in Holland and Barrett or Boots, so it can't really be that effective.

All CBD is not equal essentially and if you're coming for a consultation and you're thinking about taking medical grade CBD, it's very different often to what you might be buying off the street.

How exactly is that?

Well, it might be the quality of it, knowing exactly what's in that bottle, knowing the precise dosage. It's just a cleaner, more medical product so I know for sure what exactly is in that bottle and what the dose is and how to use it and what dosage that person might need. Whereas I think if you're buying... Even they, I noticed the other day, have some CBD on the shelf. I think that's probably not going to be the same quality as something that you were to buy medically.

It's about a greater assurance that you know exactly what you're prescribing and it is very well grown and manufactured and clean, so it's sort of medical. You know exactly what's in it essentially.

Yeah.

I think CBD is something that works beautifully with anxiety for a lot of people. I've used it with people who've had both lifelong and short term anxiety and for some of them, it's been utterly life changing in a way that was just quite wonderful to see. I think often people don't need to take very high doses also and the change can happen quite quickly. The other thing that's very good from the person's taking it perspective is that in my experience, the side effects are very, very minimal as well.

There's been some absolutely wonderful things to watch for me as a clinician where people have been trialed on numerous different antidepressants, have felt that their anxiety has just really been in control of them rather than the other way around and taking a relatively small dose of CBD have just felt their anxiety melt away. I think that is just fantastic to be able to offer to people as a choice.

I think it's also interesting for me working with women as well where you get a lot of women with PMS and cycle change where the research is not brilliant, there's nothing particularly new treatment wise. Often women are offered the pill or they might offer the antidepressant to take all the time or for one to two weeks of the month. The evidence for it is not great. So again, I think for them, CBD can often be really helpful in that it's something that has far less side effects but can really help them manage that premenstrual change in their mood and anxiety. It has so many different sort of uses that I think it's absolutely brilliant for.

Medical cannabis I suppose I would use less for anxiety. I think that actually CBD for most people works really, really well. Where the medical cannabis can be really helpful is if there's big issues with sleep. Often people have gotten to real difficulties with sleep when they've had long term anxiety. They can't fall to sleep because they're just lying there worrying or they wake in the night and they're just getting progressively more and more exhausted.

Then that tends to have a knock on affect on their mood of course because they're just tired all the time. I think in that situation, medical cannabis can be really helpful in terms of taking something at night to help sleep and that mixture can work really well. But it's always a very bespoke prescription to each person really.

Yeah. I mean that's kind of what makes the plant so fascinating is that the amount of active compounds is so vast that there's virtually infinite number of combinations and ratios, et cetera. If we're talking about CBD, do you typically recommend a broad spectrum CBD or an isolate?

Typically a broad spectrum for most people. I have to say here as well that I feel like there's so much I don't know yet. I am a relatively new prescriber-

There isn't a body of research, is there?

There isn't a huge body of research and I am learning as well and I think there are going to be so many things that we learn in the next five to ten years anyway. That feels really hugely exciting, so I think on the whole at the moment I tend to use more of a sort of broad spectrum. Sometimes there have been particular cases where the CBD hasn't had that effect that you want and it's actually made people feel too alert.

Sometimes that's about when you take it or the dosage, so I have found with some people, you need to shift it to earlier in the day because there does tend to be a group of people where if they take it too late at night, they can't sleep. But it - CBD still works brilliantly for their anxiety in the day. I think it's just about...

I'm very open with people about the fact that I have an experience but to a certain degree, all of us are on this journey of learning. But I believe in this wholeheartedly. I believe that it's very safe, I believe that it is a really good option. We tend to just be very careful and slow and cautious in how we work to taking it. I think that's really good for people psychologically because they don't have any concerns about side effects then and it's a constant dialog and communication and tweaking doses and times.

But on the whole, my experience has been that most people take CBD with very few side effects.

I mean, this is it. We frequently talk about this in various different guises but if you talk to someone who's more traditionalist or establishment, if you like, who often say, "Where's the body of evidence or where's the research?"

Yes.

To point to robust stuff, which I assume is going on at the moment but hasn't yet been published. However, I see so much anecdotal evidence of people who are taking high street stuff, so hopefully better than stuff in the news agent but possibly not medical grade who've genuinely said it's sort of transformed their relationship with anxiety. There's a gap of knowledge, isn't there? Something is happening here in the middle which it hasn't been written down yet, if you'd like.

Yeah. I think there's a gap of evidence, sort of RCT, controlled trials type evidence but I also think we do a real disservice to the people we're working with if we don't place their evidence as being on par with that because they are living with these chronic illnesses, so who better to know how that feels than them? To me, if I've got... You can read stories of thousands of people who've had chronic illnesses of all different kinds saying, "Oh my goodness, this was amazing." Then we have to take notice of that, right? Because they are living with this. They know better than I what it feels like to live with chronic anxiety.

If they're telling me, which they are, this is amazing then I'm going to take notice of that.

Yeah. I mean do you think the obsession with RCTS and this form of evaluation of medicine is not necessarily the definitive way that we should be looking at medicines?

Of course you want to ideally have a mixture of both. Of course it's lovely to have that beautifully trialed with all the confounding factors taken out so that you can clearly say, "Wow, look. This dose of CBD reduced all these scores by 60, 70 percent in thousands of people." That's really reassuring as a clinician, as a prescriber and for the person taking it. You want a mixture of both but I think personally that hearing from somebody with lived experience... When you hear somebody's story in this field, whether it be pain or epilepsy or gosh, you can't forget that and it's so powerful. It makes me feel really excited to be in this field because I think that is really important to me. That is as important to me. I want to hear both sides of the story.

Yeah, it's frequent topic about patient data I think, so there's lots of projects that they're sort of looking at.

I mean as a psychiatrist, the Royal College of Psychiatry have got a great project and they're looking to be able to make medical cannabis more accessible and beginning to collect large scale data. It's brilliant that we are collecting that as well but I suppose as a peri-natal psychiatrist where all my prescribing is essentially off license because women are pregnant and nothing is specifically recommended in pregnancy, per se, then I'm more versed in having to think about risks and benefits and talk about that.

It perhaps doesn't feel as terrifying to be prescribing this. It might be for some colleagues which I completely understand, because if none of your peers are prescribing or your college is saying, "We're not sure you should be prescribing", I can understand how that might feel more difficult too.

Yeah, it is not as simple as why aren't doctors prescribing it.

No, of course.

There's quite a significant... If it's not been taught previously and opposes understandings in there, it's quite naïve I suppose to expect people to suddenly just turn and change. It's a journey, isn't it?

Yeah, I think it will take time but I think as more of us are prescribing in specialist clinics and then we have more data coming through and we have our own data and outcomes from patients, then hopefully that will enable other people to feel confident to prescribe as well.

Yeah, and the patients that you see, are they on the more chronic side of the spectrum-

Yeah.

... than sort of generalized anxiety?

At the moment, usually we'd be prescribing where there's a sort of case to be made for it as a last resort. Often people will have trialed numerous different things therapy wise, medication wise. They tend to be people with more chronic illnesses and also a huge group with trauma, with PTSD, so that might be military veterans in particular.

A lot of these people are using cannabis already but they're buying it and they don't want to be. They want it to be properly prescribed and to have somebody that they can be continually touching base with. It's a very varied mix of diagnoses and presentations, I suppose, but they tend to be people that have been struggling for a very long time.

Yeah, I'm sure. What's the sort of typical dose that you would be giving in a range of...

In terms of CBD, it's very variable. I've found that for anxiety, somewhere around the 100mg mark tends to-

Per day?

Per day.

Wow, okay.

Tends to work. Sometimes it's less. It just depends on the person. Often they'll take it in divided doses so it sort of holds their anxiety through the day and then with the medical cannabis at night, then it's just a case of starting really low and titrating up to see how much they need to sleep really.

Yeah.

But for anxiety specifically, yeah, around 60 to 100 would be... I think most people would be starting to feel some benefit.

Is it typically in a tincture?

Yeah. My experience is most people prefer to take it that way for anxiety particularly. Some people vape, but most would take it as a tincture.

Yeah. I was just going to say about vaping, I guess it's more instantly absorbed into the body.

Yes.

Is it more bioavailable as well?

You just get a quicker hit for a moment if you're vaping. That's why it's so great for pain because you're getting that instant relief. I think for anxiety, because you want it to be sustained throughout the day, I find that people are more likely to find a benefit from taking the tincture.

Yeah.

Occasionally people will vape at night, but rarely actually. Tends to be mainly tincture.

Yeah.

That's funny what you're saying previously about some people being more awake off it because one of the areas people take CBD for is to help you sleep.

Yeah, no. I know, I know. But I guess-

It just shows how complex it all is.

It shows how complex it is, it shows that there is always going to be a range of response and there's always going to be people that are very sensitive to medication and have that kind of paradoxical response. It's something I've seen with a couple of people, so it's definitely not common but it definitely happens and as soon as we shifted the CBD backwards in the day, the sleep was better.

Yeah. So, it's... Yeah.

It's just a case of sort of tweaking.

Yeah. What I find fascinating about this evolution of cannabis is where it meets the evolution of personalized medicine as well.

Yes, exactly.

Very much looking at you and you as an individual rather than just...

I think that's why I'm sort of drawn to it because I suppose that's kind of how I like to practice anyway and I've always been a person that for years has given people advice on supplements, blood testing, and much more sort of functional integrative way of working I suppose. For me, this fits really beautifully with that and I don't want to sit in a room and tell people what to do. I want us to think together about what they feel would really work for them, because otherwise, it's no point.

I can tell people to go and have therapy, but if they don't really want to do it and aren't really committed to it, it's not going to work for them.

Yeah.

I want to offer as many choices as possible and then cherry pick. I really like yoga. I like the idea of CBD. I want to start with that. Perfect, fine. Let's do that.

Yeah.

Then it's just more of a collaboration.

Yeah. Yeah, yeah, yeah, yeah. On the flip side, how can cannabis be bad for anxiety? I mean, I know some people, not very well, if mum and dad are listening, who feel more anxious after consuming cannabis.

Yeah. I think it's again like we're talking about, that spectrum. It depends what people are using. Obviously if people are buying off the street, we know that probably the concentrations of the THC are going to be significantly higher and there is no doubt as a psychiatrist, I have seen for many years the effect of smoking cannabis, particularly on-

Very high THC.

Yes, particularly on young men. So, lots of psychosis. That's why I want people to come and see a specialist and have a very thorough history because we want to know about any prior history of psychosis, family history of psychosis because there's clearly a link there and we want to be very careful and cautious about that before we prescribe. Yeah, there's no doubt that for some people, it definitely heightens our anxiety, can make people feel quite paranoid and really low and just much, much worse.

Yeah.

I think again that's about possibly what people are smoking, using, that probably it's very high in THC. Again, when you swap people to CBD, often you find that it works really well and that people are surprised because understandably, you can offer it to people and they can think, "Well, my other experiences have been not that great so I'm not sure."

I think that's important to say as well is that by no means are we prescribing to everybody that we assess because sometimes it's not the right thing. People might come and ask and we might be saying no because of this family history or because actually I don't think you've tried enough on the normal guidelines pathway yet. So, it's not at all the case that everyone we see would be prescribed anyway.

But I do find that for most people, if you start with CBD, actually that is really effective for people even if they've had a bad response in the past because it's the difference between the CBD and THC is huge.

Yeah. I suppose if people are smoking, there's tobacco in there as well.

Exactly. There's so many other things in there.

It's sort of different factors.

People don't know exactly what they've bought. They don't know the strength of it. I think also when you're smoking, it's at a much higher temperature so it actually affects the quality of the THC that's in there rather than vaping it, so it would be burning at a lower temperature. You're getting lots of bitterness and different taste. There's so many variables that actually people are usually very surprised when they try something like a pure CBD.

Yeah.

It's completely different.

Again, I'm going to wing it here but I didn't read something about that actually a significant part of the negative effects of cannabis smoking, of street skunk let's call it, is not so much the very high THC content but the lack of CBD in it to sort of counteract.

Yeah. I don't know the precise amounts, but I think that is probably undoubtedly the case plus you've got the nicotine, plus you've got goodness knows what else in there, in the mix.

Yeah, cool. I think we've kind of talked about is there a new paradigm needed to evaluate this sort of stuff and 2021, the drug science guys are doing some great stuff there. There's a program in Denmark which is great, doing some great stuff. France, I think, just sort of okayed one. Israel have been doing it for years.

Yeah.

Hopefully we build a good body of evidence. Where do you see this research heading? Or is there anything you're excited about waiting to hear the results of in this area?

There are lots of trials in progress, particularly in America, that I'm aware of that are coming from big bodies like Stanford, for example. I'm really excited to see the results of those because I know that the quality of the trials will be really, really good. Again, for me, I'm really interested to see how they relate to PTSD and trauma in particular, because I think that is aside from anxiety probably the second biggest reason for people coming to have a consultation.

I'm really interested to see what it shows because there's been some preliminary data suggesting it might be able to even affect the way we consolidate memories after trauma and affect nightmares and other symptoms of PTSD. I'm really interested to see actually what it shows in big quality trials.

Yeah.

I think just being able to have a bigger pool of data from all across the world will be so helpful because I want to be able to talk through trials with people. I do in terms of peri-natal psychiatry all the time, to pull up whatever drug they're on, talk about the trials that exist. I want to be able to do that in this field as well.

So, just really excited about because I think there will be a lot coming out in the next five to ten years that will change the way that this is perceived as a choice and as a potential thing to prescribe. I really hope that people will feel confident then to be able to change their practice and prescribe.

Yeah. It's one of the issues that NICE highlighted basically needs more research.

Yeah.

Was disappointing because there's many people in need, so hopefully that research comes as soon as it can. Inevitably, this leads in to the topics of psychedelics I think and particularly around trauma and PTSD.

Yeah.

What are you seeing in that area as well?

Lots of chatter about it. I think it's really fascinating. I think at the moment, again, I would say it's too soon for us to be making definitive sweeping conclusions about these substances. But again, particularly in America, they already use ketamine as a treatment for depression, as a nasal spray. There's definitely some evidence there around that. I think the use of mushrooms, there's lots of studies going into that as well, sort of microdosing of MDMA as well.

Which I've heard has been very effective in relation to PSTD.

Really effective. There's been a really good, big study where they gave people microdosing of MDMA and the symptoms dramatically reduced to the point where I think it was over half, don't quote me, I need to check that, no longer fulfilled the criteria for PTSD.

Wow.

I think as yet, we don't know whether that holds-

Yes.

... over time and I think that's what people are concerned about. Is this a sort of immediate change, but then symptoms return? Clearly, there needs to be longer term follow up studies. I think the whole area is really fascinating and really interesting. There's a psychiatrist in the UK, Dr. Ben Sesser, who's a real leader in this area and his work is fascinating. I always looking forward to reading what he has to say about it.

I just think it's the same thing. It's another area where potentially there will be more choices for people.

Yeah. As a clinician, if you could look at your career, has this all caught you by surprise? Is this something that you never expected to see, the fact that we're talking about what had been viewed as recreational, illegal drugs now being used as therapy?

No. I just think it's really interesting. I suppose as a person, as a psychiatrist, as a doctor, I'm quite open to thinking about and considering everything. I think that's perhaps the nature of being a psychiatrist, to a certain degree, is that I've heard lots of different stories and tales and things and I suppose I'm quite open to hearing anything in the space. That's part of what I do. I'm not here to judge, I'm just here to be curious and to learn from things.

For me, I think it's really exciting because it's fascinating and the early studies seem quite hopeful. I think there's lots more work that needs to be done to clarify how these might be integrated but again, if it's another potential choice for people, then great.

As your experience as a psychiatrist, have you seen other people in your field be similarly open and do you think psychiatry sits slightly outside sort of medical doctors and their approach to it? Because I obviously speak to a lot of doctors in this area and they've faced significant-

Criticism.

... criticism or barriers. Have you find that slightly less in the field of psychiatry?

I think probably mixed would be... I think there are a lot of amazingly free thinking, perhaps shall we go so far as to say anarchic people within psychiatry. Maybe that's why I love it so much. I would not want us to be seen as separate to medicine. I think that's a battle I've faced my entire career that somehow you're not a proper doctor if you're a psychiatrist.

Right.

Which I would refute strongly.

I guess it was a way of complimenting you. You're more open minded in your field.

No offense taken at all. I think it's mixed. I think you get a group of people who are by nature very curious and they're completely open to learning more and thinking about it and are looking forward to what the next few years bring. But also as with other specialties, I think there are a lot of people that are very fearful to prescribe for, like we said, lots of different reasons. Feel there isn't an evidence base yet and I think particularly within psychiatry, like I said, when so many of us have seen the effects of using skunk and other drugs on mental illness, then there is a criticism of how can you possibly prescribe something that we know for so many people can be so detrimental.

I think often that comes from a lack of understanding of what you're actually prescribing. Sometimes when you're able to have that discussion, "Look, actually I'm mainly using CBD and this is...", then people are more open to that. But there's no doubt that a lot of people are reluctant to prescribe and very cynical about the effects.

That's understandable, as you say, if you're seeing a regular flow of patients suffering from psychosis due to street skunk-

Yes, of course.

... as a contributing factor, then you will need to learn a bit before you approach it differently.

I think we have to be clear about there are certain presentations where if you are coming with a history of schizophrenia and a very strong family history of schizophrenia, as yet, I would not be prescribing because I just feel that we don't have the evidence there to support that person at this time. That may change. It's definitely going to be focused at the moment more to people with depression, anxiety, sleep issues, and PTSD because that's the right thing to do.

As we know more, it may be that there is more a role in psychosis but I think as yet, we can't definitively conclude that.

We're still early in the journey, aren't we?

Yeah.

I think a lot of it is, as you say, it's a lack of understanding. The stigma comes from almost viewing cannabis as a homogenous product rather than a basket of many, many compounds that can be arranged in a different way, different strains and different cannabinoids et cetera. But also, quite significantly, it's not just about smoking it. It's tinctures and oils and vaping and eating it.

All kinds of things, yeah.

All these things which are delivery methods that would make more sense to people because smoking inherently doesn't feel like a thing you should be prescribing.

No, of course.

Although, on some people, it can be extremely effective but that's a different topic. I think the idea that it's much more complex than a very binary, skunk is bad and write the whole thing off.

Yeah, exactly. I think once people understand that it's much more bespoke prescribing and learn more about it, then people do become more open to it.

Yeah. Yeah. Cool. This leads me into my final question. What did your family say when you told them you were going to be working in the cannabis clinic?

Oh my gosh. My husband thinks it's brilliant, my dad thinks it's brilliant, my friends think it's hilarious and brilliant at the same time. Yeah, they've all been really... I suppose my mum, who is perhaps a little bit more Daily Mail-ish about it, shall we say, if you know what I mean.

Yes, I think they do.

She was perhaps a little more sort of, "Oh, wow." Wasn't quite expecting that, but then I think she got so excited by the fact that I was going to be on Holly Street that she kind of forgave me. So, I suppose yeah, they've been really... I think perhaps they know what I'm like and it's not unexpected for me to do something a bit different. They've all been hugely supportive.

Fantastic.

The more I've spoken to them about it, the more they've also learned and seen. Obviously I'm not talking to them about clinical cases, but when there's been stories in the press... When you read those stories of how impactful it's been for people, they can see why I want to do it.

Yeah. I suppose if you're going over to work at Stanford, then that's pretty prestigious and serious.

Yes. Yeah, I mean I'm not... That was sort of a one off part of the Winston Churchill but I'm following all the work that they're doing really closely and I think when you can say that institutions like that are trialing this, then it gives it some gravitas.

Yes, absolutely. Cool. Well, thank you, Rebecca. That's been really brilliant. I've been really wanting to do the show for ages. I'm really glad that you've filled us in on loads of stuff here. Lots more to come as well.

Yes, yes. I'm sure there'll be... Hopefully there will be a part two, three, four as we get more and more data and research. That'd be brilliant.

Absolutely. Thank you.

Thank you.