Is cannabidiol (CBD) appropriate for an otherwise healthy adult with mild to moderate anxiety, and what dosing and safety precautions are recommended?

CBD for Anxiety: Evidence-Based Recommendation

Current evidence does not support recommending CBD for anxiety in otherwise healthy adults, as high-quality guidelines and recent clinical trials show insufficient efficacy, potential psychiatric harms including worsening anxiety, and documented risks of cannabis use disorder. 1, 2

Why CBD Should Not Be Recommended

Insufficient Evidence for Efficacy

• The 2023 MASCC systematic review concluded that no recommendation was possible regarding use of cannabis for anxiety or depression in clinical populations 1
• A 2023 randomized controlled trial testing CBD doses of 150,300, and 600 mg found no effect on anxiety symptoms compared to placebo 3
• The American College of Physicians notes that cannabis may be associated with increased risk for developing anxiety and depressive disorders 1

Documented Psychiatric Risks

• Cannabis use is associated with increased risk for developing and exacerbating anxiety disorders, with approximately 10% of chronic users developing cannabis use disorder 2
• Chronic cannabis use carries long-term psychiatric risks that may be correlated with cumulative exposure, and can exacerbate psychiatric disorders in vulnerable individuals 1
• Cannabis provides no proven benefit for anxiety and carries well-documented psychiatric harms 2

Cardiovascular and Other Safety Concerns

• Cardiovascular side effects may include arrhythmias and orthostatic hypotension 1
• In older adults, acute cannabis toxicity may be associated with sedation, obtundation, and myocardial ischemia or infarction 1
• Common side effects include dizziness, confusion, dry mouth, and fatigue 1

Evidence-Based Treatment Alternatives

First-Line Pharmacotherapy

• Initiate an SSRI (escitalopram or sertraline) for moderate to severe anxiety (GAD-7 ≥10) 2
• SSRIs have robust evidence for efficacy and should be continued for at least 12 months after symptom remission 2
• Reassess at 4 weeks; if no improvement by 8 weeks at adequate dose, switch to a different SSRI or SNRI 2

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with the strongest evidence for anxiety disorders, with large effect sizes (Hedges g = 1.01 for GAD) 2
• Combining pharmacotherapy and psychotherapy may be necessary for optimal outcomes 2

Assessment Tools

• Use GAD-7 scale to establish baseline severity: 0-4 (none/mild), 5-9 (moderate), 10-14 (moderate-to-severe), 15-21 (severe) 2
• Screen for depression using PHQ-9 given high comorbidity 2

Nuances in the Evidence

Conflicting Research Data

While some older preclinical evidence (2015) suggested CBD might have potential for anxiety disorders 4, and small open-label studies showed improvements 5, 6, these findings have not been replicated in rigorous placebo-controlled trials 3. The most recent high-quality randomized controlled trial (2023) found no anxiolytic effect 3.

Cancer Population Exception

The only context where cannabinoids have limited evidence is in cancer patients with refractory chemotherapy-induced nausea and vomiting, but even here, evidence for anxiety management remains insufficient 1

Hepatotoxicity Risk

CBD doses ≥300 mg/day are associated with reversible liver enzyme abnormalities, with a nearly 6-fold increase in liver enzyme elevation and drug-induced liver injury 1

Critical Clinical Pitfalls

• Do not recommend cannabis for anxiety management—evidence is insufficient for efficacy and risks are well-documented 2
• Do not assume CBD is "natural" and therefore safe; it carries documented risks of substance use disorder, psychiatric harm, and cardiovascular events 1, 2
• Screen for current cannabis use, as cessation is essential for anxiety improvement 2
• If patients are using cannabis, counseling to achieve marijuana cessation is the mainstay of long-term management 2

Patient Education Points

• Educate that cannabis does not treat anxiety and may worsen symptoms or cause panic attacks 2
• Explain that substance cessation (cannabis, alcohol, caffeine) is essential for anxiety improvement 2
• Provide information about evidence-based treatments (SSRIs and CBT) with proven efficacy 2
• For patients insisting on trying CBD despite counseling, warn about lack of proven benefit, potential for worsening anxiety, and risk of developing cannabis use disorder 1, 2