PTSD and Marijuana: Therapy or Risk?

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Post-Traumatic Stress Disorder (PTSD) and Marijuana: Therapy or Risk?
by Bertha K. Madras, PhD
Bertha Madras (the honorable) is a Professor of Psychobiology at Harvard Medical School (at Harvard 39 years), based at McLean Hospital and cross-appointed at the Massachusetts General Hospital. Her research has focused on neuroscience, addiction biology and drug policy. She is author of more than 200 scientific manuscripts, articles, book chapters and co-editor of books: “The Cell Biology of Addiction”; “Effects of Drug Abuse on the Human Nervous System”; “Imaging of the Human Brain in Health and Disease”. As an inventor, she is recipient of 19 U.S. and 27 international issued patents with collaborators. She served as Deputy Director for Demand Reduction in the White House Office of National Drug Control Policy, in the Executive Office of the President, a presidential appointment confirmed unanimously by the U.S. Senate, and was one of six commissioners on President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis. She is a member of the American Academy of Sciences and Letters and recipient of research and public service awards.

The medicalization of marijuana has outpaced the scientific evidence supporting its safety and efficacy. Through ballot initiatives and legislative measures, states have authorized marijuana for the treatment of more than 100 medical conditions. Yet, the U.S. Food and Drug Administration (FDA) – the federal agency responsible for ensuring the safety and effectiveness of medical treatments – has not approved marijuana for any
of these indications.

Nevertheless, in 2023, the Department of Health and Human Services recommended reclassifying marijuana from Schedule I to Schedule III under the Controlled Substances Act.1 Such a move would lend a veneer of medical legitimacy to marijuana use for a broad range of conditions, including posttraumatic stress disorder (PTSD). Yet, as with many other purported indications, the scientific evidence supporting marijuana as a treatment for PTSD remains inconclusive or may worsen PTSD symptoms and hinder long-term recovery.

PTSD is a chronic and often debilitating psychiatric condition that can develop after witnessing or experiencing traumatic events involving threatened or actual death, serious injury, sexual or other forms of interpersonal violence. Veterans constitute a
particularly visible and severely affected population, owing largely to the enduring psychological effects of combat trauma. While veterans remain a key focus of PTSD related concern, the disorder is a pervasive public health issue affecting diverse
populations across society.

PTSD is characterized by at least one traumatic event that serves as the basis for four persistent symptom clusters: intrusion or reexperiencing of trauma, avoidance of trauma
cues, persisting negative emotional states with distorted beliefs, and hyperarousal/exaggerated startle response. Symptom severity is greater if PTSD co occurs with other psychiatric conditions and substance use disorders. Risks for PTSD
are shaped by an interplay of personal vulnerabilities (e.g., genetics, early-life adversity, preexisting mental health conditions, and maladaptive coping strategies), severity of
trauma, and post-trauma environment (e.g., lack of social support, continued exposure to stress).

Given its substantial prevalence and burden, PTSD exerts profound effects on individuals and society: suicidal behavior, reduced quality of life, increased medical morbidity, and substance misuse. Treatment for PTSD typically involves a combination of medications and psychological interventions, focusing on helping patients process and confront distressing memories, thoughts, and emotions. Despite evidence-based
benefits, current treatments remain suboptimal. Approximately 40% of patients show limited or no response to medications, and dropout rates from psychotherapy are high. Some go on to develop chronic, treatment-resistant PTSD, along with complicated psychiatric and medical conditions.

Some have speculated that this treatment gap could be filled by marijuana or its primary constituents Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Speculation is based on the brain’s endocannabinoid system which modulates stress responses and helps to extinguish fear memories. Despite sparse scientific validation, marijuana use and use disorder is increasingly common among those with PTSD – nearly 3 and 4
times the rates of those without PTSD.2,3

Is marijuana effective in easing PTSD symptoms? Retrospective studies in individuals with PTSD self-reported that it helped with their symptoms or improved their overall life and functioning. Yet, rigorous scientific evidence is inconclusive and limited by serious
methodological shortcomings.4 While some observational studies and self-reported data suggest temporary relief of certain symptoms (e.g., anxiety, insomnia),5 the findings are inconsistent, are hindered by poor study design, lack of a standardized
marijuana product, dose, and a high risk of bias. Randomized controlled trials (RCTs), the gold standard for clinical evidence, are sparse and have not provided robust support for marijuana as a safe or effective treatment for PTSD. Among the most significant weaknesses are limited data on long-term effectiveness and increasing evidence for adverse outcomes. For example, marijuana may improve sleep and anxiety in the short
term6 but may worsen these symptoms after long term use. A recent systematic review of 14 studies of cannabis effects on PTSD symptoms did not endorse the use of cannabis for improving overall PTSD symptoms.7 In patients with cannabis use disorder, 100% of studies suggested that cannabis may contribute to worsening of overall PTSD symptoms.

The overall risks of marijuana use for PTSD include: (1) developing cannabis use disorder (CUD).3 (2) Marijuana use may decrease engagement in and continuing effective PTSD treatment. One study found that baseline marijuana use predicted a doubled risk of dropout from behavioral and pharmacological treatments for PTSD, as well as poor adherence to trauma-focused psychotherapy.8 Veterans with a cannabis
use disorder who discontinue use and receive PTSD treatment have poorer PTSD treatment outcomes than those without a cannabis use disorder.9 (3) As marijuana withdrawal symptoms overlap with PTSD symptoms (anxiety, sleep problems), users
may experience withdrawal as particularly aversive and be more likely to continue using marijuana at higher rates than non-PTSD users. (4) Marijuana may worsen PTSD symptoms, nullifying the benefits of specialized, intensive treatment, and negatively
impacting other outcomes. Marijuana use after the start of conventional treatment in Veterans was associated with worse PTSD symptoms, more violent behavior, and greater alcohol use.10 (5) Chronic use of marijuana, especially high-THC formulations, has been associated with increased anxiety, cognitive impairment, heightened risk of cannabis use disorder, and in some individuals, the onset or worsening of psychosis.

For these reasons, the Veterans Administration has recommended against treating PTSD with marijuana or marijuana derivatives for lack of evidence for their efficacy,
known adverse side effects and associated risks.11

Conclusion
Marijuana is not an evidence-based treatment for PTSD. Its use in PTSD remains highly controversial and is hindered by the overall low-quality research, of limited duration and methodological weaknesses. Recent systematic reviews have failed to demonstrate substantial benefits of cannabinoids in reducing core PTSD symptoms. There is an urgent need for rigorous, large-scale, and long-term research to clarify its safety and efficacy. While research continues, current clinical guidelines continue to support evidence-based psychotherapies and selected pharmacological agents as first-line treatments.

The growing push to medicalize marijuana, and more recently, psychedelics, through politically driven approval processes, rather than through rigorous scientific validation, poses serious risks to the integrity of the nation’s drug regulatory system and the safety of its therapeutic landscape.

References:
1 Madras BK and Larkin P. Rescheduling Cannabis-Medicine or Politics? JAMA Psychiatry, in press June, 2025
2 Bilevicius E, Sommer JL, Asmundson GJG, El-Gabalawy R. Associations of PTSD, chronic pain, and their comorbidity on cannabis use disorder: Results from an American nationally representative study. Depress Anxiety. 2019 Nov;36(11):1036-1046.
3 Hill, M. L., Loflin, M., Nichter, B., Norman, S. B., & Pietrzak, R. H. (2021). Prevalence of cannabis use, disorder, and medical card possession in U.S. military Veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study. Addictive Behaviors, 120, 106963.
4 Roberts L, Sorial E, Budgeon CA, Lee K, Preen DB, Cumming C. Medicinal cannabis in the management of anxiety disorders: A systematic review. Psychiatry Res. 2025 May 17;350:116552
5 Hindocha, C., Cousijn, J., Rall, M., Bloomfield, M.A.P., 2020. The effectiveness of cannabinoids in the treatment of posttraumatic stress disorder (PTSD): a systematic review. J. Dual. Diagn. 16 (1), 120–139.
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7 Rodas JD, George TP, Hassan AN. A Systematic Review of the Clinical Effects of Cannabis and Cannabinoids in Posttraumatic Stress Disorder Symptoms and Symptom Clusters. J Clin Psychiatry. 2024 Feb 14;85(1):23r14862.
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9 Bonn-Miller MO, Boden MT, Vujanovic AA, Drescher KD. A prospective investigation of the impact of cannabis use disorders on posttraumatic stress disorder symptoms among veterans in residential treatment. Psycholog Trauma: Theory Res Pract Policy 2013;5:193–200.
10 Wilkinson ST, Stefanovics E, Rosenheck RA. Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder. J Clin Psychiatry. 2015 Sep;76(9):1174-80.
11 Schnurr PP, Hamblen JL, Wolf J, Coller R, Collie C, Fuller MA, Holtzheimer PE, Kelly U, Lang AJ, McGraw K, Morganstein JC, Norman SB, Papke K, Petrakis I, Riggs D, Sall JA, Shiner B, Wiechers I, Kelber MS. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of
the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2024 Mar;177(3):363-374.