As a psychiatrist, I increasingly meet patients who come in convinced they have attention-deficit/hyperactivity disorder (ADHD). They arrive prepared: an online screening test, a list of symptoms (poor concentration, low motivation, distractibility) and often a quiet sense of relief at finally having an explanation. Then I do what physicians are trained to do. I take a careful history. I review medications. I ask about sleep, mood, anxiety, substance use, and developmental history. And very often, another piece of the puzzle appears: near-daily use of cannabis.
Sometimes it’s recreational. Sometimes it’s framed as “medical marijuana,” authorized by a clinician they have never met, through a dispensary-based process that bypasses meaningful evaluation or follow-up. Either way, the pattern is familiar.
The data on cannabis risks
We now know (far more clearly than we did a decade ago) that THC is not a benign substance, especially when used frequently. From a psychiatric standpoint, it is associated with impaired attention and memory, diminished motivation, heightened anxiety and panic symptoms, chronic nausea, and, in vulnerable individuals, psychosis and an increased risk of unmasking schizophrenia. Beyond neuropsychiatry, data continue to accumulate regarding cardiac risks and endocrine effects. This is no longer speculative or fringe science. Yet the clinical challenge is not the data. The challenge is the conversation.
Slowing down the conversation
Many of these patients report that cannabis “helps” their anxiety. And in a narrow, short-term sense, it may. But when we slow the conversation down (using a motivational interviewing approach rather than confrontation) something important often emerges. As patients begin to reflect, they notice that their anxiety has not truly improved. It has either worsened over time or been obscured by cognitive dulling, forgetfulness, and emotional blunting. When we place their anxiety in the broader context of overall cognitive functioning (attention, working memory, motivation, emotional regulation) the picture becomes clearer. What felt like relief was often avoidance. What felt like calm was sometimes disengagement.
Discussing this nonjudgmentally matters. Patients are already ambivalent. They are seeking help because something isn’t working. When that ambivalence is respected rather than attacked, they can begin to examine how cannabis fits into their lifestyle, their stressors, and their symptoms. This process alone can be therapeutic.
Distinguishing ADHD from cannabis effects
Importantly, not all of these patients are the same. Some truly do have ADHD (symptoms that began in early childhood and persisted into adulthood). Many of them turned to cannabis as a form of self-management long before they had language for their condition. Others, however, are experiencing secondary attentional problems: cognitive fragmentation driven by chronic cannabis use, sleep deprivation, constant digital stimulation, and modern patterns of distraction that mimic ADHD but are not the same disorder.
Distinguishing between these possibilities takes time, trust, and careful longitudinal assessment. It cannot be done by an online quiz. And it cannot be done while ignoring the neurocognitive effects of daily THC exposure.
As physicians, our role is not to shame patients for their coping strategies. It is to help them understand the trade-offs they are making (often unknowingly) and to support them in making informed choices. When patients are given space to reflect, many come to their own realizations: that their focus improved when they cut back, that their anxiety became more manageable, that their motivation slowly returned.
In an era where self-diagnosis is a click away and substances are marketed as medicine without medicine’s safeguards, our responsibility is to bring nuance back into the room. ADHD is real. So are the cognitive and psychiatric consequences of daily cannabis use. Holding both truths at once (and helping patients disentangle them) may be one of the most important clinical tasks we now face.
Farid Sabet-Sharghi is a psychiatrist.
