Substance/Medication-Induced Psychotic Disorder

Learning Objectives

  • Describe substance/medication-induced psychotic disorder

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.

A closeup of a green cannabis plant bud.

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

A person covering their mouth and nose with their hands in distress.

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.

Drugs and the Transition to Schizophrenia

A 2019 systematic review and meta-analysis by Murrie et al. estimated that the rate of persons who transitioned from substance-induced psychosis to a later diagnosis of schizophrenia was 25%, compared with 36% for a diagnosis of brief, atypical, and not otherwise specified psychoses.[3] Type of substance was the primary predictor of transition from drug-induced psychosis to schizophrenia, with the highest rates associated with cannabis (six studies, 34%), hallucinogens (three studies, 26%), and amphetamines (five studies, 22%). Lower rates were reported for opioid- (12%), alcohol- (10%), and sedative- (9%) induced psychoses. Transition rates were slightly lower in older cohorts, but were not affected by sex, country of the study, hospital or community location, urban or rural setting, diagnostic methods, or duration of follow-up.


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]

Watch It

This video explains some of the known causes of schizophrenia and psychosis, one of which is neurotransmitter dysfunction. Neurotransmitter dysfunction is affected by drug use, which helps to explain how drugs may lead to psychosis in some individuals.

You can view the transcript for “Psychosis explained simply [Introduction to Drug-Indcued Psychosis]” here (opens in new window).

Alcohol-Induced Psychosis

The majority of patients presenting with psychosis for the first time have some history of substance abuse. A detailed history is important in the assessment and evaluation of alcohol-related psychosis; specifically, it is imperative to determine the patient’s alcohol use history. It may be difficult to determine whether a patient’s psychotic symptoms are due to a primary psychotic disorder or due to substance use, including alcohol. Diagnosis may be especially difficult in the emergency department where records of prior history are frequently lacking. No family history of psychotic disorder in a patient who has a clear history of alcohol use supports the diagnosis of alcohol-related psychosis.

Alcohol-related psychosis must be differentiated from other causes of psychosis and specifically from schizophrenia. When compared to schizophrenia, patients with alcohol-related psychosis tend to have significantly lower education levels, an onset of psychosis at an older age, more intense depressive and anxiety symptoms, and fewer negative and disorganized symptoms. Patients with alcohol-related psychosis also usually have better insight and judgment.

The DSM-5 states that the diagnosis of substance-induced psychotic disorder requires the presence of significant hallucinations or delusions. There must be evidence that the hallucinations or delusions started during or soon after substance intoxication or withdrawal or the substance used is known to cause the disturbance. The symptoms are not better explained by a psychotic disorder unrelated to substance use. The psychosis does not occur only with delirium (an abrupt state of mental and emotional confusion). The symptoms cause clinically significant distress or difficulty with normal activity such as work or social interactions.

The first priority in treating an individual with alcohol-induced psychosis is to stabilize the patient, paying close attention to airway, breathing, and vital signs. If the patient requires sedation due to alcohol-related psychosis, first-generation antipsychotics (neuroleptics), such as haloperidol, have been considered the first-line medications for treatment. Benzodiazepines, such as lorazepam, are used if there is a concern for alcohol withdrawal and seizures. Certain atypical antipsychotics, such as ziprasidone and olanzpine, have also been used to help sedate patients with acute psychosis. Some patients may require the use of physical restraints to protect the patient as well as the staff. Patients with alcohol-related psychosis must also be evaluated for suicidality since it is associated with higher rates of suicidal behaviors. The prognosis for alcohol-related psychosis is less favorable than earlier studies had speculated. However, if the patient can abstain from alcohol, the prognosis is good. If patients are unable to abstain from alcohol, the risk of recurrence is high.


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]

Watch It

This video details some of the complications in treating a drug-induced psychosis. Dr. Bakti tells of a young man who develops psychosis due to his excessive Adderall dependency.

You can view the transcript for “Drug-Induced Psychosis – Steven Batki, M.D.” here (opens in new window).

Key Takeaways: Substance/Medication-Induced Psychotic Disorder

Try It


depressant: drug that tends to suppress central nervous system activity

hallucinogen: one of a class of drugs that results in profound alterations in sensory and perceptual experiences, often with vivid hallucinations

stimulant: drug that tends to increase overall levels of neural activity; includes caffeine, nicotine, amphetamines, and cocaine

substance/medication-induced psychotic disorder: 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

  1. Yui K, Ikemoto S, Ishiguro T, Goto K: Studies of amphetamine or methamphetamine psychosis in Japan: relation of methamphetamine psychosis to schizophrenia. Ann N Y Acad Sci. 2000, 914:1-12. 10.1111/j.1749-6632.2000.tb05178.x
  2. Zarrabi H, Khalkhali M, Hamidi A, Ahmadi R, Zavarmousavi M: Clinical features, course and treatment of methamphetamine-induced psychosis in psychiatric inpatients. BMC Psychiatry. 2016, 16:44. 10.1186/s12888-016-0745-5
  3. Murrie, Benjamin; Lappin, Julia; Large, Matthew; Sara, Grant (16 October 2019). "Transition of Substance-Induced, Brief, and Atypical Psychoses to Schizophrenia: A Systematic Review and Meta-analysis". Schizophrenia Bulletin. 46 (3): 505–516. doi:10.1093/schbul/sbz102. PMC 7147575. PMID 31618428.
  4. Smith, M. J., Thirthalli, J., Abdallah, A. B., Murray, R. M., & Cottler, L. B. (2009). Prevalence of psychotic symptoms in substance users: a comparison across substances. Comprehensive psychiatry, 50(3), 245–250.
  5. Lautieri, A. (n.d.). What Is Drug-Induced Psychosis? (S. Thomas, M.D., Ed.).
  6. Lautieri, A. (n.d.). What Is Drug-Induced Psychosis? (S. Thomas, M.D., Ed.).