that is a difficult question: it is possible/probable that symptoms will resolve on cessation of use, the course is not so different to primary psychotic disorder, although more positive symptoms, hostility and fewer negative symptoms.

In first instance may want to see how person settles before launching into antipsychotics, discuss the use of anxiolytics or similar with psychiatric colleagues . attached may be of interest. sharon

Article A comparison of the symptoms and short-term clinical course ...

One of the major issues we've faced recently is not knowing exactly which substance has been abused.... In the past several years we've had inpatients in our psychiatric facility who have taken "spice", dextromethorphan, and one person who insisted that he only used Ayuhuasca. The dextromethorphan may show up on a screen but these others often don't, and this is added to the fact that while they may think they have taken something - they didn't get it at the pharmacy - so who knows what they really took? Unless someone is very agitated or asking for treatment we usually just wait a day or two and see what transpires. Usually it will clear within that period, but if not we start trying to decide if maybe we are looking at a psychotic illness rather than just substance intoxication. By the way....the dextromethorphan abusers seem to take longer to clear mentally than you would think, based on dextromethorphan pharmacokinetics. We often use haloperidol if an antipsychotic is necessary, primarily because it's pretty specific for dopamine and if we don't know what we're dealing with it's a good idea to avoid anticholinergic effects - we might also use risperidone if the person agrees to oral medication. We also will sometimes use lorazepam.....if agitation or insomnia are major issues.....but any drug can cloud the issue because at some point you are not so sure if you are looking at effects of the intoxication or effects of the drug you've given to treat the intoxication.

I agree that it depends on what drug(s) caused the psychosis. From a medications perspective, unfortunately, there is an unmet "need" for better antipsychotic medications as there are many dangerous side effects of medications currently available. Several groups, including our own, are developing new and potentially safer compounds to treat drug-induced psychosis that selectively block certain serotonin receptors, but activate one of them. Although these compounds are still in the preclinical phase, they show promise in animal models of drug-induced psychosis. Of course, this does not always translate in humans.

http://www.sciencedirect.com/science/article/pii/S0028390813000130

http://www.sciencedirect.com/science/article/pii/S0028390813001974

http://brainposts.blogspot.com/2013/05/serotonin-2-receptor-may-be-key-cocaine.html

I'll suggest u to read d following book "Substance Abuse Treatment for Persons With Co-Occurring Disorders."

http://www.ncbi.nlm.nih.gov/books/NBK64178/

I work at a Native American reservation behavioral health center, and we have seen this more with the increased use of meth and spice. It often depends on how intense the symptoms are, whether the person is agitated, aggressive and/or disoriented, and whether or not they are incarcerated (jails tend to have less tolerance for psychotic behaviors). Plus we are in a real rural area, so there is not much in the way of treatment facilities. For these reasons, we tend to go towards anti-psychotic medication uses more quickly - haldol is fast acting, can be injected, and effective in calming aggression. Respirdal if the symptoms are less intense and the person is likely to follow through with taking meds. We treat the symptom(s) that seem to be causing the person (and their families) the most distress, and then focus in on substance abuse education and treatment right after that.

I was the former Medical Director of Maryhaven, Inc. Central Ohio's largest behavioral healthcare institution so I saw a lot of substance induced psychosis. PCP was the worst, followed by meth. . .spic wasn't around then. . but I've definitely seen it with cocaine. If symptoms were mild I would just let them comedown off of the substance, of course with careful monitoring. If they were agitated I'd use benzos. . if they were acutely agitated and aggressive I'd use antipsychotics. . .good old fashioned Thorazine there's no restraint like a chemical restraint!

It is ideal if you can provide supportive treatment including nutrition, hydration, specific withdrawal treatment if indicated. Many times the withdrawal and psychosis will resolve in 4 days. You can use benzodiazepines for agitation that may also decrease psychosis. Antipsychotics may be needed but if this is an isolated psychosis considering early discontinuation is a good idea. Unfortunately, many people developing psychotic illnesses turn to drug abuse and the psychosis gets blamed on the drug use. The opposite occurs more frequently that in apparently predisposed people they have there psychotic illness 'kicked off' by drug use.

Thank you very much for your interesting contributions. Let me pose another pair of questions: do you think it is always recommended hospitalization?; have you treated these patients on an outpatient basis?

That's kind of a hard question for me to answer since I am affiliated with an inpatient facility. Usually we end up with admissions to the psychiatry unit from the emergency department. Generally people only end up in the emergency department if they are pretty agitated or seem very psychotic or intoxicated. They also only seem to come in at night - when most of the outpatient facilities are closed. They might receive medication in the ED if it's deemed necessary. If their sensorium clears during their stay in the emergency department while waiting for possible admission to the hospital, they might be sent home if we are pretty certain they would be safe if discharged from the ED. However, mostly if they are agitated/psychotic/violent enough to be brought to the ED, they will probably end up being admitted - especially if we aren't sure what the problem is.

I agree with Sally's response above. Also, in rural areas we just don't have access to hospitalization unless a person is really in a seriously decompensated state. Mostly they go through the local ER or to the local detox, and will only be hospitalized if still seriously agitated or potentially dangerous

There is no 'always' in mental health! I tend to agree with colleagues above. True drug induced psychosis ie acute intoxication, should settle after 24-48 hours with judicious benzo (eg diazepam) use. For example, when I worked in the Netherlands one would see tourists who had taken too much 'space cake' or THC who were paranoid or deluded. These people settle quickly usually without recourse to antipsychotics.

However, more common in psychiatry (as opposed to the ED) is dual diagnosis, where antipsychotics are necessary. Also motivational interviewing + psychoed needed once rapport established.

Both of the above can be managed as an out-patient / in the community, depending on the risks posed and your community service provision

use psychotherapy - cognitive behavioral (Chomsky - Pavlov) method

One is always in trouble if admission facilities are not availiable. Agitated and dangerous behavior usually gets the proband into ER, and admission to a psychiatric ward would be to target agitation first. I spend a day a week at a rehab scntre that keeps addicts for six months or more at reasonalble cost and offers the opportunity of observation of the drug naive state. If it is the single shot permanent psychosis as mentioned by Guillermo Brito, then one would certainly iniitiate antipsychotic treatment. Again, what would be available and what would be affordable? It differs from country to country. If possible, I would go for ariprazole. But the most important thing I would like to share with colleagues is that one needs time in a controlled environment.

The question posed by Virginia Fuentes-Leonarte begs a further problem: Whether substance only induces those subjects that are genetically predisposed, or whether substans induces psychosis indiscriminately into all abusers. Experience suggests that only full withdrawal will remove the odds. But I don't know the final answer.

I have always wondered what would happen to a patient addicted and withdrawing from a drug, in a psychotic state, if the doctors let him stabilize in a hospital for a few months. Possibly, this may have been done in the 50s, but we don't have the resources now. The dangerous part is the diagnosis which puts you in a different medical category (e.g. schizophrenia) for the rest of your life.

Exactly my point. And the fact that observational facilities are so scarce to come by is acturlly compunding the cost of treatment tenfold if not more. So in Ezekiel Rehab I have the privilege of doing exxactly this, and I would be very happy to give feedback on a male with a well formed delusional syndrome, as it evolves over the next few monts. So colleagues are invited to watch this space!

From my point of view, inpatient treatment with a reasonable observation period could promote a more accurate diagnosis. As comented above, is essential to distinguish more clearly the merely induced psychosis of those that are the debut of a latent state. Resources as that comented by Jean should be promoted to improve the prognosis of these patients, above all those with dual diagnosis, more difficult to diagnose and treat.

Felix qui potuit rerum cognóscere causas

- Virgil, Georgics, Book II, line 490

Happy is the one who knows the causes of things.

Yeserday I saw this guy again. I also spoke to his usual psychiatrist (I am only his Rehab-psychiatrist).He was less adamant about his delusional thoughts. Unfortunately (as far as my knowledge goes) I cannot comment on the nature of his delusions becuse it refers to his identity and that would break confidentiality.

I am in South Africa now, but I was in Canada for fifteen years and I was able to observe delusions crumbling when patients were effectively detoxifying (some were honest about it), and being treated with antipsychotics e.g.olanzapine up to 20 mg per day. All these observations were one on a consulting room basis except for the few that were so overtly psychotic that I had to send them either two hours up the road or two hours down the road, to a psychiatric centre.

I also saw the delusions come back when they relapsed.

Correction: It was the patient who was less adamant about his delusional thoughts, not his usual psychiatrist. This clinician had him admitted and treated him as inpatient. Neither of us could say at this stage whether the patient had a psychosis before, or whether it was purely drug induced. (methcationine and cannabis).

I watched one patient in her early 70s, who's psychosis was innitially began with a reaction to prednezone, she was treated with seriquil and very quickly developed EPS and was given a bezodiazapine. She was released from hospital and a SSRI was added because she complained about anxiety. She remained in a state of anxiety with paranoid delusions for the next 10 months until on her own she discontinued the medication. She recovered to her previous level of functioning in about one week. I questioned a number of medical proffessionals about the case and eventually found one who recognized this as a drug induced delerium. The doctors and psychiatrist who were familiar with elderly patients seemed completely unaware of this as a possible diagnosis. The treatment is discontinuation of all medications and a environment that is neither over stimulating or understimulating.

This client has lead me to wonder about whether the treatment for drug induced psychosis is possibly the reasaon for poor outcomes.

We need a new category of clinical psychiatrists: the Sherlock Holmes type;

In addicted individuals who present with psychosis, one cannot readily establish a diagnosis of the cause. Acute intoxication or withdrawal are first in the differential. Behavioral and medical stabilization procedures are in order. If one is dealing with stimulant, cannabis, or ketamine/PCP induced psychosis, acute treatment with major and minor tranquilizers are indicated, and indeed may be the only to conduct a proper evaluation: ie, initial tranquilization to allow further work up.

In chronically addicted individuals, one must beware of high potency D2 receptor antagonists. for these individuals, these can be highly dysphoric, cause catatonia ad dystonia. Olanzepine, quetiapine, chlorpromazine work very well, and can be given by injections. Once the actue effects of the drugs have passed, then the chase begins to see if the presentation is likely to be drug induced. sometime this may be quite difficult to establish if there is a drug history going back some years. But a good clue is what happens to these symptoms during period of prolonged abstinence. If that history can be obtained, then you will at least have a sense of whether theses symptoms have achieved chronicity.

Thank you for the vote up Bob.

NEPTUNE have recently provided clinical guidance on treating the harms associated with substance use, including psychosis. May be of use:

http://neptune-clinical-guidance.co.uk

Thank you, Lindsey!