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General Hospital Psychiatry 33 (2011) 640.e3 – 640.e4

Case Report

Marijuana-induced mania in a healthy adolescent: a case report

Joseph W. Iskandar, D.O.a,⁎, Benjamin Griffeth, M.D.b , Taral Sharma, M.D.a
a
Carilion Clinic-Virginia Tech Carilion School of Medicine Psychiatry Residency Program, Roanoke, VA 24014, USA
b
Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
Received 17 February 2011; accepted 19 April 2011

Abstract

Marijuana is the most commonly used illegal substance by adolescents in the United States. According to a 2009 survey conducted by
Monitoring the Future, there were about 11.8% of 8th graders, 26.7% of 10th graders and 32.8% of 12th graders who had abused marijuana at
least once in the year (Johnston L.D., Bachman J.G., O'Malley P.M., Schulenberg J.E. Monitoring the Future: A Continuing Study of
American Youth (12th-Grade Survey), 2009 [Computer file]. ICPSR28401-v1. Ann Arbor, MI: Interuniversity Consortium for Political and
Social Research [distributor], 2010-10-27. doi:10.3886/ICPSR28401). A retrospective review of published literature disclosed case reports of
marijuana-induced mania in adult patients with no prior psychiatric history (Bonnet U., Chang D.I., Wiltfang J., Scherbaum N., Weber R. A
case of cannabis-induced mania. Fortschr Neurol Psychiatr. 2010 Apr; 78(4):223–5. Epub 2010 Feb3; Henquet C., Krabbendam L., de
Graaf R., ten Have M., van Os J. Cannabis use and expression of mania in the general population. J Affect Disord. 2006 Oct;95(1–3):103–
10. Epub 2006 Jun 21). To the best of our knowledge, this is the first report to document that marijuana induced manic symptoms in an
adolescent with no known prior psychiatric history.
© 2011 Elsevier Inc. All rights reserved.

Keywords: Marijuana; Cannabis; Acute mania; Adolescent

Marijuana is the most commonly used illegal substance
by adolescents in the United States. According to a 2009
survey conducted by Monitoring the Future; there were
about 11.8% of 8th graders, 26.7% of 10th graders and
32.8% of 12th graders who had abused marijuana at least
once in the year [1]. To the best of our knowledge, this
is the first report to document that marijuana induced
manic symptoms in an adolescent with no known prior
psychiatric history.
1. Case report
A.B.C. is a 17-year-old African-American adolescent
male with no previously documented psychiatric history,
who was brought to the emergency room by his mother
for increased level of energy, decreased need for sleep,
increased verbal output with a disorganized thought process
⁎ Corresponding author. Tel.: +1 540 206 8958; fax: +1 540 982 3442.
E-mail address: jwiskandar@carilionclinic.org (J.W. Iskandar).
0163-8343/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.genhosppsych.2011.04.007
and impulsive behavior. Upon further questioning, the
patient also admitted to having auditory hallucinations and
paranoid delusions. A.B.C.'s symptoms of mania began
approximately 2 days before admission.
A.B.C.'s past medical and psychiatric histories were
unremarkable. Family history was also noncontributory to
his recent hospitalization especially with no documented
history of mood disorder including bipolar disorder or
schizophrenia. He admitted to using alcohol (few beers)and
marijuana about once a month for approximately 1 year.
Moreover, the patient reported a substantial increase in
consumption of marijuana to continuous daily use (about a
quarter of an ounce daily) without any use of alcohol
approximately a week prior to hospitalization after receiving
a rejection letter from this first-choice university. The patient
did not have any known drug allergies. Initial laboratory
investigations were negative except for a positive urine
toxicology screen for cannabis and negative urine toxicology
for stimulants, cocaine, opiates, benzodiazepines, phency-
clidine and barbiturates.
On mental status examination, the patient was restless and
agitated with poor eye contact. His speech was pressured
with elevated volume. His mood was “agitated,” with angry
640.e4 J.W. Iskandar et al. / General Hospital Psychiatry 33 (2011) 640.e3–640.e4
and irritated affect. His attention and concentration were
limited. The patient denied any suicidal and homicidal
ideation, intent or plan. he reported having active auditory
hallucinations, racing thoughts and flight of ideas. He had
poor insight and judgment.
The patient was admitted to the child and adolescence
acute psychiatric unit for medication management and crisis
stabilization. The admission lasted for 29 days. The hospital
course was complicated by the development of neuroleptic
malignant syndrome as a side effect of medications
(olanzapine and haloperidol). The complete resolution of
the patient's manic episode after 3 weeks from the admission
day was achieved by the use of mood stabilizer (lithium 1500
mg daily) and antipsychotic agent (quetiapine 500 mg daily)
after the patient failed an initial trial of quetiapine and
divalproex sodium that were used for the first 2 weeks. No
sign or symptom of mania, depression or psychosis was
noted of discharge day.
2. Discussion
To the best of our knowledge, this is the first case report to
document that marijuana induced manic symptoms in an
adolescent patient with no known prior psychiatric history.
A.B.C. had consumed marijuana once a month for a year
with major increase in consumption in the week prior to the
admission that induced this manic episode for about 3 weeks.
A retrospective review of published literature disclosed case
reports of marijuana-induced mania in adult patients with no
prior psychiatric history [2–4]. Moreover, marijuana could
increase the risk of developing psychosis, manic symptoms
and bipolar disorder [5–7]. Based on pharmacokinetics, a
single dose of 9-tetrahydrocannabinol may last for an
absolute period of 30 days that could explain the persistence
of the mania symptoms for about 3 weeks in our case [8].
Lithium showed significant reductions in symptoms of
depression and anxiety and cannabis-related problems.
Moreover, there is published evidence for the potential
clinical utility and safety of lithium in the management of
cannabis withdrawal [9]. Moreover, the possibility that the
patient was going to improve without the use of any
medication could be a valid hypothesis.
3. Conclusion
It is well documented that marijuana may induce manic
episode associated with psychosis among adults. As reported
in our case, continued and heavy use of marijuana may
induce full manic episode with psychotic symptoms among
adolescents that could last for about 3 weeks.
4. Key points
- First reported case of marijuana-induced mania in an
otherwise healthy adolescent.
- In this case, lithium was successful in treating acute
mania induced by marijuana.
- If practitioners recognize this association, extensive
use of bipolar diagnosis may be prevented.
References
[1] Johnston, Lloyd D, Jerald G. Bachman, Patrick M. O'Malley, and
John E. Schulenberg. Monitoring the Future: a continuing study of
American youth (12th-grade survey), 2009 [computer file].
ICPSR28401-v1. Ann Arbor, MI: Inter-university Consortium for
Political and Social Research [distributor], 2010-10-27. doi:10.3886/
ICPSR28401.
[2] Bonnet U, Chang DI, Wiltfang J, Scherbaum N, Weber R. A case of
cannabis-induced mania. Fortschr Neurol Psychiatr 2010;78(4):223–5
[Epub 2010 Feb3].
[3] Henquet C, Krabbendam L, de Graaf R, ten Have M, van Os J. Cannabis
use and expression of mania in the general population. J Affect Disord
2006;95(1–3):103–10. Epub 2006 Jun 21.
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