Substance/Medication-induced psychotic disorder (SIPD) involves the onset of the presence of psychotic features that have been triggered by the use of a substance or medication. It is a psychosis that results from the effects of chemicals or drugs, including those produced by the body itself. Various psychoactive substances have been implicated in either causing or worsening psychosis in some users. In these situations, psychosis manifests as disorientation, visual hallucinations, and/or haptic hallucinations (involving touch and sensations of the skin). In this state, a person’s mental capacity to recognize reality, communicate, and relate to others is impaired and interferes with the capacity to deal with daily tasks and living.

Figure 1. Some people who smoke marijuana experience hallucinations.

There are a variety of chemical substances and drugs that have been known to induce psychosis:

• Alcohol is a common cause of psychotic disorders or episodes, which may occur through acute intoxication, chronic alcoholism, withdrawal, exacerbation of existing disorders, or acute idiosyncratic reactions. Often times, alcohol-induced psychosis is misdiagnosed as schizophrenia or another related mental illness with similar features and symptoms.
• Cannabis and opioids have also been found to cause psychosis, specifically hallucinations.
• Sedatives and hypnotics such as benzodiazepines and barbiturates can also cause depression, aggressiveness, and symptoms that can be misdiagnosed as psychosis.
• Stimulants such as cocaine and amphetamines have also been reported to cause psychosis. Stimulants are drugs that increase the body’s functions by increasing the speed of activity in the central nervous system (CNS). Familiar examples of stimulants include caffeine, cocaine, amphetamines, methamphetamines, and nicotine. All these substances share common side effects due to their similar influence on the CNS. These include, but are not limited to, appetite suppression, sleep disturbances, increased blood pressure, agitation, and psychosis.
• Additionally, medications such as fluoroquinolone drugs (antibiotic drugs like Cipro) and other prescription drugs such as antidepressants, L-dopa, prednisone, and anticholinergic drugs (medications such as Cogentin and Ditropan) have all been found to potentially induce psychosis, some of which are reported to be irreversible and permanent.
• Illicit substances, such as hallucinogenic or psychedelic substances, can also induce psychosis such as MDMA, PCP, and ketamine.

Diagnostic Criteria

Figure 2. Substance/medication-induced psychotic disorder is diagnosed as the presence of delusions and/or hallucinations, with symptoms occurring soon after the intoxication or withdrawal of a substance or soon after exposure to a medication.

The DSM-5 defines substance/medication-induced psychotic disorder as the presence of delusions and/or hallucinations, with symptoms occurring soon after the intoxication or withdrawal of a substance or soon after exposure to a medication. The substance must have the potential to produce delusions or hallucinations that result in clinically significant impairment. Impairment as a result of delusions or hallucinations is a prevalent side effect of stimulants, and one reason why people who use them are more frequently referred to the emergency department or psychiatric ward than those who do not.

A Closer Look at Stimulant-Induced Psychosis

Acute psychosis induced by stimulants occurs within a period of four to five days after intoxication. The symptoms typically resolve with abstinence. However, recovery may be incomplete. Japan, where methamphetamines were first developed, has experienced major epidemics of stimulant-induced psychosis. This has provided further knowledge on the subject and has led to the realization that patients suffering from this disorder can be separated into three groups.^[1] The first group includes patients experiencing transient psychosis after stimulant use that lasts for a period of four to five days following intoxication. The second group consists of patients who experience psychotic symptoms for as long as one month. The third group comprises patients who will not fully recover from their symptoms. In the Yui et al. study, 64% of patients gained full recovery from their psychosis within 10 days, 82% recovered within a month, and 18% suffered symptoms for over a month. In a more recent study by Zarrabi et al., the percentage of patients who experienced persistent symptoms for over one month was 31.6%. This phenomenon has resulted in a necessary increase of beds and resources available to health care systems worldwide.^[2]

It should be noted that numerous studies have found a comorbidity of mental illness with stimulant-induced psychosis. However, the cause of stimulant-induced psychosis where there is no family history or prior personal history of mental illness remains unclear.

More research identifying the patient population most susceptible to stimulant-induced psychosis and/or a more exact determination of the minimum dosage of each stimulant drug necessary to trigger psychotic symptoms would assist in providing better patient care through a determination of whether the benefits of the prescription outweigh the risks. Answers to these questions could also alert those patients susceptible to acute psychosis—along with their family members—to watch for changes in behavior while the patient is on the medication. Additionally, if the general population is made more aware of the risk factors associated with psychosis, it may help prevent those who are vulnerable from abusing stimulants.

Etiology

It is important to note that the consumption of medicines and drugs will not cause psychosis in everyone who uses them. As the diathesis-stress model suggests, there are genetic factors at play, which may make it more likely that an individual with a genetic predisposition to a mental disorder, especially that of schizophrenia and similar diagnoses, will be at greater risk for substance/medication-induced psychosis. Other factors such as duration of use, withdrawal, and the presence of other mental health disorders influence whether or not an individual will experience psychosis due to substance or medication use.

These conclusions are supported by research that has found that individuals with schizophrenia and schizophreniform disorder were at a greater risk for substance use disorders than non-psychotic individuals. There is also an increased risk for psychosis among substance-dependent individuals and a link between adolescent substance use and the onset of psychosis in young adulthood.^[4]

Having a genetic risk (diathesis) for developing schizophrenia may also be associated with a stronger psychotic response to certain drugs. In a study of patients admitted to the hospital with first-episode psychosis, 74% had been diagnosed with a substance use disorder at some point in their lives, and 62% met the criteria for a substance use disorder at the time of the psychotic episode.^[5]

Treatment

Acute psychotic symptoms may be managed through the use of medications such as antipsychotics. Because treatment often involves treating both the psychosis and the co-occurring disorders (called a dual diagnosis), then comprehensive treatment for both the drug addiction and the mental illness is recommended. This sometimes includes residential treatment and detox medications.

Psychotherapy such as CBT can help individuals with the disorder learn what may trigger a psychotic episode. CBT may help them to avoid relapse and develop healthier coping mechanisms. Family therapy programs focus on the entire family as a whole and not just on the individual battling mental illness and/or substance abuse. This type of therapy can help to restore stability and positive connection within the family unit. Recovery support groups are also usually incorporated into treatment and recommended as an ongoing relapse prevention strategy once treatment ends. These groups provide a continuous connection to the sober community and can help provide an environment where you can be honest about your journey and any struggles along the way.^[6]