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20.1 % of the U.S. adolescent population between the ages of 12 and 17 was reported to have at least one major depressive episode in 2021 [1]. This frequency has only increased post-pandemic with the U.S. Surgeon General even declaring a significant youth mental health crisis as depression rates and symptomology have surged over the last decade [2, 3]. This crisis is so pronounced that depression screenings are now recommended for all adolescents between 12-18 at all primary care medical visits [4]. Despite this increased attention on depression prevention, depressive symptoms for youth doubled during the pandemic [3]. While these screenings and other preventative practices have been identified, depression rates continue to rise. Furthermore, negative outcomes such as psychosocial problems and suicide risk are well established, exacerbating the mental health crisis already faced by this population [5, 6, 1]. For this reason, it is important to identify factors related to adolescent depression in the hope of better understanding and addressing this national crisis.

According to [7], there is a significant association between the risk of substance use and the risk of depression. Recent statistics indicate that 41.7% of 12th graders in the U.S. had tried alcohol, 30.7% had used cannabis, and 36.8% had misused a drug [8] and these numbers are only rising. While much attention has been given to teen alcohol and opioid use and misuse, there is less research related to cannabis use among teens. Most recent statistics indicate that adolescent cannabis use has increased a staggering 245% since 2000 [9]. This has been attributed to an increase in legalization and decriminalization across the country leading to the widespread perception that cannabis is safe. Powerful identity and cultural identification elements of cannabis in popular cultural [10], along with the popularity of vaping and edibles among adolescents means that use among teens has rapidly increased despite it still be illegal for this age group [9]. Cannabis is currently one of the most widely used substances among adolescents [11].

It is well known that the teen brain is still developing until the age of 25 and cannabis use can harm this development leading to mental health problems, poor academic outcomes, negative legal consequences, and psychosocial difficulties [12]. A long-held belief is that many use cannabis to cope or self-medicate, but researchers believe that use does not alleviate symptomatology but, instead, increases difficulties and risk for harm [13]. Considering adolescents with depression are more likely to use cannabis [14], it is likely that at least some of these adolescents could be dependent on the drug for use as a coping mechanism to minimize their symptoms. Some studies have substantiated this, with findings demonstrating lowered mental health was consistently associated with current and lifetime cannabis use among youth [15], even suggesting a causal relationship between the two. Others have reported that adolescents who use cannabis experience not only an increase in acute negative mood states but also experience an increased risk of acute harm and mental health disorders [16], resulting from the lasting neurodevelopmental changes created by THC, the active ingredient in cannabis. This finding is substantiated by the well documented relationship between teen cannabis use and the later development of psychosis [12, 17]. However, given this conflicting research, it is imperative to further investigate the relationship between depression and cannabis use for adolescents.

Overall, even though there have been studies on the association between the severity of depression and substance use, there remains a lack of understanding of the relationship between depressive symptoms and cannabis use for adolescents, particularly those with a history of major depressive episodes. To better understand the nature of the relationship between adolescent cannabis use and major depressive disorder, a dataset analysis was undertaken. Adolescents who had experienced at least one major depressive episode in their lifetime were the focus on the analysis. The unique contribution of this study is to determine how the experience of each symptom, rather than the severity of depression of adolescents with a history of MDE, relates to lifetime cannabis use. Therefore, this study could provide insights into patterns that reflect a potential connection between their specific depression symptoms and cannabis use for adolescents.

The purpose of this study is to examine a dataset of adolescents who had major depression (MDE) in their lifetime to understand the association between symptoms of past depression and cannabis use. Additionally, the goal was to uncover the association between these variables as well as the impact of demographic variables such as gender, income, and race. It was hypothesized that gender, income, race, and the experience of different symptoms of depression were associated with cannabis use. The information uncovered will have practical implications for counselors who work with adolescents in counseling settings.

Literature Review

There is continued debate on the association between depression and cannabis use, with many holding a longstanding belief that this relationship is causal [18]. Earlier dataset analyses and other research has noted increased cannabis use among all adolescents, but particularly those with depression who were more than twice as likely to report cannabis use than non-using teens [19]. There have also been significant findings showing the alternate causal relationship by highlighting the negative impact of substance use on adolescents’ psychological, cognitive, and social wellbeing and development. For example, adolescents’ substance use can have a severe impact on their brain development leading to further substance abuse in adulthood as well as additional psychiatric disorders [14, 11, 21]. This finding has been substantiated by dataset researchers who found that a large sample of both adolescent and adult monthly cannabis users had a significantly greater likelihood of developing MDE [21]. So while the complex association and mixed findings of cannabis use and depression undergoes further examination, it is important to also understand these variables further as well as what other variables might be impacting this significant relationship, particularly demographic variables.

Adolescent Depression

Adolescent depression represents a critical public health issue, manifesting through a complex array of emotional, cognitive, and physical symptoms such as persistent feelings of worthlessness, irritability, mood disturbances, and anxiety, difficulties with concentration, and alterations in appetite and sleep patterns [22, 23]. Also, it has been reported that there has been a steady increase in depression among adolescents [3], which is particularly concerning for some sub-populations, such as females whose MDE increased significantly between 2009 and 2019 [24, 25]. Alarmingly, the prevalence of depression among U.S. youth aged 12 to 17 has substantially increased over recent years, escalating from 9.0% in 2004 to 15.7% by 2019 [26]. These high depression rates are concerning because of the negative impacts to psychosocial functioning, educational success, and the elevated risk of suicide [27, 4, 28]. The impact of adolescent depression extends beyond individual symptomatology, adversely affecting social relationships, academic participation, and mental health trajectories throughout development [29, 30]. Despite the demonstrated efficacy of treatments like cognitive behavioral therapy, less than half of affected adolescents receive appropriate care, underscoring the unmet need for effective intervention strategies [31].

Adolescent Cannabis Use

In general, substance use for adolescents has been very concerning since it shows a significant increase in substance use and overdose deaths among teenagers and young adults (National Center for Drug Abuse Statistics [8]. Eighth graders showed a 30% increase of drug use between 2016-2020 [8], and for adolescents in the U.S., cannabis has been reported as one of the most widely used substances [11], with reports that up to 30.7% of 12th graders indicate that they used cannabis [20]. According to [8], in 2023, 7.2 % of teenagers across the country reported that they used drugs last month while 83.9% of them reported using marijuana during that time. Adolescents’ cannabis use can negatively impact cognition, brain development, and academic achievement, while also leading to psychiatric disorders [20, 11]. Overall, because of legalization and decriminalization in many states, this drug may become more available and accessible for adolescents, making it more crucial to understand the relationship between use and depression [7].

Complex Relationship between Depression and Cannabis Use for Adolescents

Research consistently supports a significant association between adolescent depression and the use of substances, particularly cannabis. Historically, population-based studies corroborate high rates of co-occurring substance use and psychiatric disorders, with depression and conduct disorder frequently emerging as the most common comorbidities [60]. Still today, the temporal and causal relationships between depression and substance use remains complex and somewhat inconsistent across longitudinal research. Some studies suggest depressive symptoms precede and predict the initiation or exacerbation of substance use, while others indicate that early substance use increases the risk for subsequent depression [32]. Notably, research focusing on cannabis use frequently demonstrates that cannabis consumption predicts later depression, yet the reverse—depression predicting later cannabis use—is less consistently supported [32, 33]. Further complicating this relationship are findings that suggest a reciprocal interaction between depressive symptoms and substance use [34]. Some studies have found that depressive symptoms and the effort at emotional regulation and cannabis use is more reciprocal, versus directional, in nature [34]. Overall, there is a limited understanding of how different symptoms of depression relate to cannabis use in adolescents, but cannabis use is known to be “clinically problematic” in the treatment or management of depression [35], and there are known negative developmental outcomes of use among adolescents with depression [6]. 

The broader consequences of adolescent depression, especially when comorbid with substance use, include increased risks for severe and enduring adverse outcomes. Early-onset depression has been linked to increased rates of emergency department visits for self-harm among young girls, with lasting impacts on adult mental illness persistence, educational achievement, and labor market participation [36-38]. Environmental and social contexts, including family dynamics, peer influences, and school environments, further modulate these risks, potentially buffering or exacerbating depressive symptoms and related substance use behaviors [39].

Gender, Income, and Race

Previous studies have supported associations between some sociodemographic characteristics and cannabis use for the general and adolescent population [40, 41]. Even though the previous studies indicated that men are more likely to use cannabis more often and in larger quantities [42], an increase in cannabis use among women and female adolescents has been noticed [43]. More recently, the gender gap in cannabis use has become smaller, but women are still more likely to have more negative perspectives of cannabis use compared to men [44]. When considering a comparison between male and female adolescents and mental health outcomes, females using cannabis either frequently or infrequently reported higher levels of psychological distress and suicidal ideation than their male counterparts [21]. These authors suggested that gender might be a risk factor when looking at cannabis use and mental health outcomes.

In terms of the relationship between race and cannabis use, according to [41], African American and Native American adult individuals showed a higher likelihood of cannabis use. Also, the association between race and lifetime cannabis use for adolescents was reported as well. More specifically, there was a significant difference in terms of lifetime cannabis use at the age of 17, showing that Latino adolescents (40.7%) showed the highest rates compared to those of White (34.2%) and Black adolescents (34.1%) while increases in lifetime cannabis use across the adolescent period was not significantly different across the groups [40]. There have been additional findings that Native American adolescents are more likely to use marijuana and other substances compared to other racial groups [45], indicating the complex nature of using marijuana for the group, such as perception of risks, benefits of using it, and peer use [46]. Other researchers have documented the Non-Hispanic Multi-Racial adolescents had a higher prevalence of cannabis use and depression that Non-Hispanic White adolescents, but only among highest income group [47], suggesting socio-economic status as a significant variable

In general, in the US adult population, there have been findings that support a negative association between cannabis use and socioeconomic status and income [41]. However, some other studies show a complex picture of using marijuana related to income, implying the importance of neighborhood context rather than individual income in understanding the likelihood of marijuana use [48]. There have been findings that indicate disadvantaged neighborhoods and schools are more likely to relate to higher use of substances in general [48], and among adolescents [49], but also findings that seem to position higher income adolescents as more at risk [47].

In sum, the intricate and reciprocal relationship between adolescent depression and cannabis use necessitates comprehensive research that concurrently assesses disorders, their severity, and temporal fluctuations. A deeper understanding of the factors that modulate this co-occurrence can inform and enhance interventions tailored to address the complex needs of this vulnerable population.

Method

Data Overview and Variable Selection

As a secondary data analysis, the data of The National Surveys on Drug Use and Health (NSDUH), from SAMHSA, 2022 was used to answer the research question. The National Surveys on Drug Use and Health (NSDUH) focus on measuring mental health issues, substance use, and treatment from the population who are 12 or older and noninstitutionalized (NSDUH codebook, 2022). Originally, there were 59,069 participants in the survey. Since individuals aged 18 were asked to complete the Adult Depression section, only the age groups of 12-17 were used for the study, which led to 11,969 cases. To best answer this research question related to depression and cannabis use, only youth who have had a Major Depressive Episode (MDE) and clearly answered the question of having ever used cannabis or any cannabis product were included in this analysis. To identify a MDE in the dataset, eight depressive symptoms were associated with the period when they had the MDE (NSDUH codebook, 2022). The eight depressive symptoms were : Feeling sad/empty, Lost interest, Changes in appetite, Sleep problems, Restless or lethargic, Felt tired, Felt worthless, and Inability to concentrate. Youth who clearly responded to either “Has symptom” or “Doesn’t have symptom” were included. Those who responded in unclear ways such as “don’t know” and “refused” were excluded from the data analysis. Therefore, the final data set (2,914) includes only those who have ever had a Major Depressive Episode (MDE) in their lifetime and answered the question of lifetime Cannabis use clearly (either yes or no).

Statistical Data Analysis

First, descriptive statistics on gender, income, race, and depression symptoms were used. Since all the data are categorical variables, frequency and percentage of data for Cannabis use of gender, income, and race for adolescents with a history of Major Depressive Episode (MDE) are presented as descriptive statistics. [Table 1], consists of the descriptive statistics of the demographic information of the participants.

Table 1: Cannabis Use of Male and Female Adolescents

As a main analysis, a Hierarchical Logistic Regression analysis was used to investigate whether lifetime cannabis use could be associated by gender, income, race, and depression symptoms. Hierarchical Logistic Regression can be used when investigating the association between predictor variables and binary categorical outcome variable while examining the improvement of the fit of the model to the data; known predictors from the previous findings are entered in the first model and the predictors that a researcher is interested are entered in the second model [50].

Results

Descriptive Statistics

Initially, frequency, and percentages for gender, race, and income were reported for adolescents with a history of MDE in relation to their Cannabis use. Among 2914 adolescents with a history of MDE, 791 reported that they had used Cannabis in their lifetime while 2123 reported that they had not used it.

First, there was a similar pattern of Cannabis use for both male and female adolescents with a history of MDE [Table 1]; 27 % of male adolescents with a history of MDE reported using Cannabis in their lifetime while 27.2 % of female adolescents with a history of MDE reported using Cannabis.

Secondly, regarding income, there are similar patterns across adolescents from different incomes [Table 2]. Among adolescents with a history of MDE, 29% of adolescents from Less than $10,000, 32.2% of them from $10,000 - $19,999, 29.2% from $20,000 - $29,999, 27.8% from $30,000 - $39,999, 26.8% from $30,000 - $39,999, 26.8% from $40,000 - $49,999, 30.6% from $50,000 - $74,999, 24.5% from $75,000 or more reported having used Cannabis in the lifetime.

Table 2: Cannabis Use and Inco

Third, when examining race, 46.3% of non-Hispanic Native American adolescents with a history of MDE reported that they used Cannabis and had the highest reported Cannabis use among the participants. Even though non-Hispanic Native HI/ Other Pacific Islanders reported the highest percentage of Cannabis use (75%), the total number of cases in the data was only 4. Among adolescents with a history of MDE, 25.7% of Non-Hispanic White, 26.3% of Non-Hispanic Black/African, 20.8% of Non-Hispanic Asian, 30.8% of Non-Hispanic more than one race, and 28.6% of Hispanic adolescents reported having used Cannabis in the lifetime [Table 3].

Table 3: Cannabis Use and Race

Results of Hierarchical Logistic Regression

As the main analysis, hierarchical binary logistic regression was utilized. Logistic Regression analysis was used to investigate whether lifetime cannabis use could be associated by gender, income, race, and depression symptoms. To examine the unique contribution of depression symptoms on the likelihood of cannabis use, a hierarchical logistic regression was conducted, with demographic variables (age, gender) entered in the first step, then depression symptoms were added in the second step.

The initial model with sociodemographic information was significant, (-2LL= 3380.06, χ 2 (13) =27.53, p =. 011) and in the final model, the addition of depression symptoms significantly improved model fit, (-2LL= 3313.45, χ 2 (8) =66.61, p <.001). Compared to the initial model (Model 1), the results of the final model (Model 2) indicated significant improvement in the fit of the model to the data; the difference between -2LL of Model 1 and Model 2 was 66.61 (χ 2 (8) =66.61, p <.001). The overall results showed that the final model significantly explains whether the adolescents' cannabis use in life time (χ 2 (21) =94.14, p <.001). Also, the final model showed a good fit based on the Hosmer and Lemeshow test, (χ 2 (8) = 13.59, p= =.093). However, the Pseudo effect sizes were small according to Cox and Snell R2=.032 and Nagelkerke, R2=.046.

Based on results of χ 2 and the Hosmer and Lemeshow test, different symptoms of past depression were significantly associated with lifetime cannabis use for the sample.

The current study includes two models: Model 1, Gender, Income, and Race, using dummy variables, were entered as demographic information to examine association with lifetime cannabis use. The initial model with demographics was significant, (χ 2 (13) =27.53, p =. 011).

Gender, Income, and Race

Using dummy variables, gender, income, and race were entered as demographic information to associate with lifetime cannabis use or not. Gender was a not significantly associated with past use of cannabis (OR=.90, 95% CI [.75-1.08], p=.27). Also, income was not significantly associated with past use of cannabis compared to the group with Less than $10,000; $10,000 - $19,999 (OR=1.16, 95% CI [.72-1.85], p=.54), $20,000 - $29,999 (OR=.99, 95% CI [.63-1.60], p=.99), $30,000 - $39,999 (OR=.96, 95% CI [.60-1.54], p=.86, $40,000 - $49,999 (OR=.94, 95% CI [.58-1.51], p=.79), $50,000 - $74,999 (OR=1.16, 95% CI [.75-1.78], p=.51), $75,000 or more (OR=.89, 95% CI [.59-1.34], p=.58). However, race was significantly related to past use of cannabis; Compared to White adolescents with a history of MDE, Native American adolescents with a history of MDE, reported significantly higher previous cannabis use. Native American adolescents with a history of MDE, (OR=2.50, 95% CI [1.42-4.42], p <.001) is 2.5 times higher having used cannabis than White adolescents with a history of MDE. However, the sample size of Native American was smaller. There were not significant different differences between White and the other races; Black/Afr Am (OR=.99, 95% CI [.75-1.30], p=.94), Native HI (OR=.7.41, 95% CI [.77-71.70], p=.08), Asian (OR=.80, 95% CI [.48-1.32], p=.37), more than one race (OR=1.28, 95% CI [.93-1.76], p=.14), Hispanic (OR=.27, 95% CI [.92-1.39], p=1.00),

Symptoms of Depression

In Model 2, different symptoms of past depression were added. The addition of the depression symptoms significantly improved the model fit, (χ 2 (8) =66.61, p <.001). Among eight predictors, following five predictors were significant predictors of cannabis use for adolescents with a history of MDE with a significance level of 0.05;

The final model was significant (χ 2(21) =94.14, p <.001). However, to interpret how each variable relates to the outcome variable in logistic regression, the odds ratio is essential as it indicates the change in the likelihood of an event occurring, and if the odds ratio is greater than 1.0 in our study, it supports that having a symptom is related to a higher chance of previous cannabis use for the sample. Furthermore, confidence intervals provided more support for the results of odds ratios in our study as the confidence intervals for the five predictors didn’t include 1.0, which indicates a significant relationship between predictor and outcome variables [50].

In terms of different types of symptoms for adolescents with a history of MDE, the presence of the following five symptoms was significantly associated with an increase in the odds that they had engaged in cannabis use in their lifetime.

First, having the symptom “Sad/empty, depressed most of day or discouraged” in past is associated with an increase in the odds that they had engaged in cannabis use in their life time (OR=2.04, 95% CI [1.29-3.24], p=0.002); the odds of adolescents with the symptom who used cannabis are approximately twice as high as those of the adolescents without the symptom. Second, the presence of the symptom “Lost interest or pleasure in most things” in past was significantly associated with an increased odds of having engaged in cannabis use in their lifetime (OR=2.60, 95% CI [1.54-4.38], p <.001); the odds of adolescents with the symptom who used cannabis are 2.6 times higher than those of the adolescents without the symptom. Third, having the symptom “Sleep problems” in the past increases the odds that they had engaged in cannabis use in their lifetime (OR=1.90, 95% CI [1.17-3.12], p=.01); the odds of adolescents with the symptom who used cannabis are 1.9 times higher than those without the symptom. Fourth, the presence of symptom “Changes in appetite or weight” in the past is significantly associated with an increased odds of having engaged in cannabis use in their lifetime (OR=1.43, 95% CI [1.10-1.86], p=0.007); the odds of adolescents with the symptom who used cannabis are 1.4 times higher than those without the symptom. Fifth, the presence of symptom “Felt worthless nearly every day” in the past is associated with change in the odds that they had engaged in cannabis use in their life time (OR=1.27, 95% CI [1.04-1.55], p=.019); the odds of adolescents with the symptom who used cannabis are approximately 1.3 times higher than those without the symptom.

On the other hand, the following past depression symptoms “Others noticed that was restless or lethargic” (OR=1.17, 95% CI [.99-1.38], p=0.07), “Felt tired/ low energy nearly every day” (OR=1.27, 95% CI [.80-2.03], p=.307), “Inability to concentrate or make decisions” (OR=.79, 95% CI [.53-1.20], p=.271) were not significantly associated with change in the odds that they had engaged in cannabis use in their life for the sample [Table 4]

Table 4: Summary of Hierarchical Logistic Regression Analysis

Discussion

The study was conducted to determine whether lifetime cannabis use was associated with depression symptoms in adolescents who had a history of MDE. Overall, the results of the study support those different types of depressive symptoms of adolescents with a history of MDE associate with the likelihood of their lifetime cannabis use.

Gender, Income, and Race

According to the results of the analysis, gender and family income do not significantly relate to previous cannabis use among adolescents with a history of major depressive episodes. Interestingly, a similar percentage of male and female adolescents with a history of MDE reported having used cannabis before. The finding is aligned with the existing literature that among female adolescents, cannabis use could be more prevalent than is commonly known and may even trend higher than male adolescents’ use of cannabis [11]. Secondly, regarding income, it was surprising there were no significant differences among adolescents with a history of MDE from different income groups regarding cannabis use. As one of the sociodemographic characteristics, income was found to be significantly related to cannabis use. For instance, the association between higher frequency of cannabis and low income among the adult population in the US was reported [41]. Furthermore, during 2018 and 2019, an association between income inequality and the likelihood of using cannabis daily was found among Canadian secondary school students [51].

Third, overall, there is no significant difference in cannabis use between White adolescents and other racial groups. However, Native American adolescents with a history of major depression are more likely to use cannabis compared to their White peers. Also, Native Americans showed the highest percentage of use of cannabis among adolescents with a history of MDE compared to other race groups. The results aligned with the previous findings that concern the high rate of substance use of Native American adolescents. For instance, according to [41], 8th-grader American Indian adolescents who living in or near reservation communities for 2009–2012 reported much higher lifetime cannabis use compared to other adolescent groups for the other racial groups. Even in adult population, it was also reported that Native American individuals showed higher likelihood of cannabis use [41].

Symptoms of Depression

Regarding symptoms of depression, there was a significant association between depressive symptoms and lifetime cannabis use. Among eight symptoms of depression, five symptoms were significantly associated with lifetime cannabis use for adolescents with a history of MDE. These symptoms were feeling sad, empty, depressed most of the day or discouraged, feeling lost interest or pleasure in most things, having changes in appetite or weight, having sleep problems, and feeling worthless nearly every day. Overall, previous studies well supported the relationship between the severity of depression and cannabis use for adolescents [14]. However, the association between each symptom and cannabis use was less clear. In this study, two symptoms, feeling lost interest or pleasure in most things and feeling sadness, emptiness and depressed, were the most significantly associated with lifetime cannabis use for adolescents with a history of MDE. Even in the DSM-5-TR, two symptoms are considered critical factors in making a diagnosis of depression [52]. Along with two symptoms, having changes in appetite or weight, sleep problems, and feeling worthless nearly every day were also significantly associated with previous cannabis use.

Alternately, feeling restless, tired, and an inability to concentrate were not significantly associated with lifetime cannabis use for adolescents with a history of MDE. Some maintain that depressive symptoms are risk factors that can lead to substance use as a self-medication and emotional regulation strategy for adolescents [53, 54, 34]. Overall, it might imply that adolescents with a history of MDE are more likely to lean on cannabis use when they feel sad, worthless, lose interest, and have sleep issues as a coping mechanism, which could develop into comorbid depression and cannabis use. Comorbid depression and substance use could worsen the outcome of depression for adolescents with a history of MDE. There have been findings that show the critical negative impact of the comorbid on adolescents’ other psychiatric issues and cognition, even the risk of suicide [5, 20, 11]. Individuals experiencing depressive symptoms are notably more prone to engage in substance use and present with concurrent mental health conditions compared to their non-depressed peers [55]. This elevated vulnerability during adolescence—a developmental stage characterized by heightened risk-taking and experimentation—suggests that depressive symptoms may facilitate or exacerbate the initiation and escalation of substance use behaviors.

Conclusion

In conclusion, the unique contribution of this study is to examine a national dataset to investigate how the experience of past depressive symptoms, rather than the severity of depression, of adolescents with a history of MDE, relates to lifetime cannabis use. The findings suggest five symptoms are associated with an increase in lifetime cannabis use, indicating that feeling lost interest or pleasure in most things and feeling sadness, emptiness and depressed are more significantly associate with lifetime cannabis use. Even though the underlying mechanism of the association between their depressive symptoms and cannabis use in lifetime might need additional explanation such as high recurrence rate of MDE [56], environmental factors [57], and more social acceptance perspectives on cannabis use among adolescents [58], this study still provides insight into patterns of the relationship between distinctive depressive symptoms and cannabis use.

Counseling Implications

For counselors working with adolescents with a history or current diagnosis of major depressive disorder, it would be critical to consider that the client may be using cannabis as an emotional regulation strategy. This might be particularly true if the adolescent reports feeling sad, empty, depressed most of the day or discouraged, feeling a loss of interest or pleasure in most things, having changes in appetite or weight, having sleep problems, and feeling worthless nearly every day as these were associated with lifetime cannabis use. Counselors should also be mindful of the clinical complication that cannabis use can present when treating major depressive disorder in adolescents, as well as the ever-evolving increased access and social acceptance of use. It would be important for counselors to discuss with adolescents with MDE, especially those who discussed those five symptoms in sessions, since adolescents are more likely to rely on dialogue with individuals with whom they interact rather than general public information regarding education on cannabis use [59].

In addition, counselors should be considerate of the clients’ contextual information such as race and culture to best understand their coping mechanisms as there were some cultural differences in prediction present, namely with Native American youth. Therefore, it is important to fully appreciate the implications that background may have on coping and regulation behaviors. According to this data, counselors should not expect to see gender or income differences with cannabis use for adolescents with depression. However, counselors should not discount either one of these contextual variables in treatment planning. In general, it is important to have better knowledge about adolescents’ coping strategies, especially given the current mental health crisis of today’s youth. Finally, counselors should not discount the use of other drugs related to emotional regulation. This analysis only examined cannabis use but that does not mean that adolescents are not using alcohol or another drug in addition to cannabis or in place of it.

Limitations

Even though this study contributed to understanding the relationship between symptoms of depression and lifetime cannabis use for adolescents with a history of MDE, there are some limitations. Only categorical variables for predictor and outcome variables were used. In the future, it would be recommended to use continuous variables to understand a more complex picture of the relationships between cannabis use and depression symptoms. Since cannabis use was not directly tied to the time when the adolescents had MDE, there would be other reasons that could explain the relationship between symptoms of depression and their cannabis use in their lifetime. In addition, there has been a lack of understanding of the directionality between cannabis use and depression. In the future, it would be recommended to study focusing on a reciprocal relationship between those two variables and direct relationship between symptoms of depression and cannabis use as a possible coping strategy for adolescents.

Conflicts of Interest

The authors declared that there are no conflicts of interest.

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