The Treatment of Drug-Induced Psychosis Using Multidisciplinary Methods: Evaluating Effective Approaches to Care

There are numerous substances linked to psychosis. Alcohol, cocaine, methamphetamines, cannabis, and hallucinogens have all shown a correlation between use and psychotic episodes. This can be the result of undiagnosed mental health conditions, the substance itself, or a combination of both.

Cannabis use has surged in recent years, as many states have legalized recreational purchases. This is controversial, as cannabis is now much more potent than its street forms in the 70s and 80s. Cannabis has been linked to psychotic episodes due to intoxication or cannabis-induced psychotic disorder. Those who have negative environmental factors such as experiencing ACEs during childhood are more likely to experience psychosis from frequent cannabis use.

Dr. Bradley Zicherman, a consulting psychiatrist at Alta Mira, expressed his concerns about cannabis-induced psychosis:

I’m more aware of the idea of substance-induced psychosis, especially related to cannabis use. We believe that it is much more of a potential consequence of the current supply of cannabis use considering that your average teenager/young adult is vaping concentrates typically, and those concentrates are often 80-90% THC. The supply that people were using in the 80s, 90s, and early 2000s, it was maybe 2.5 to 5% THC within the actual product. So it’s very different. I believe that that higher concentration of THC in the product does lead to higher rates of psychosis concerns.

Stimulants, including methamphetamines and cocaine, have also been known to cause psychosis – primarily hallucinations and delusions. One study highlighted amphetamine or cocaine-induced psychotic disorder using the Positive and Negative Syndrome Scale (PANSS). Though the predominance was in positive symptoms, negative PANSS scores were significant at 26%. Of those, 95% experienced bizarre delusions and 63% experienced Schneiderian hallucinations.

Alcohol-induced psychotic disorder (AIPD) is not well-known, but research continues to improve. Current studies show there is a distinction between AIPD, alcohol withdrawal (delirium tremens), and schizophrenia. The dysregulation of neurotransmitter systems can be the cause of hallucinations as well as abnormalities of various brain regions seen in alcohol dependence.

Psychosis is characterized by experiencing alterations in the perceptions of reality. This is through hallucinations, delusions, and erratic emotional behaviors. A psychotic episode occurs in three phases: prodrome, acute, and recovery. The prodromal phase consists of vague signs that thoughts and perceptions are changing, and can sometimes go unnoticed. The acute phase marks the beginning of hallucinations, confused thinking, and delusions. Behaviors will be noticeably different and the person will feel distress. The recovery phase marks the end of the psychotic episode, though some acute symptoms may linger as the person regains normal cognitive function.

The Relationship Between Psychosis and Substance Use

Experiencing psychosis differs from having a psychotic disorder. Psychosis is typically a transient event that may occur only once in an individual’s lifetime. These events can be triggered by stress, substance use, or other external factors. Following a first psychotic episode, early intervention becomes critical. Determining whether the episode was drug-related or had an underlying medical cause requires a professional assessment. A proper treatment plan cannot be assembled until the episode causes are correctly identified.

The etiology of psychosis generally occurs in one of two ways:

A study published in the Journal of American Psychiatry provides evidence that drug-induced psychosis during use can lead to the development of a psychotic disorder such as schizophrenia or bipolar disorder. This is why early identification and treatment is of paramount importance.

Of the participants in the study, 32% ended up developing a psychotic disorder, with half doing so in 3 to 4.5 years. The study highlighted that substance use resulting in the highest prevalence of cases were alcohol, cannabis, and amphetamine-induced. The study analyzed data over a 20-year period, and the data showed a 47% conversion rate for cannabis, 32.3% for amphetamines, and 20-28% for alcohol and other substances. Therefore, treating substance use after the first instance of psychosis is key to preventing long-term mental health disorders.

Dr. Raghu Appasani, an addiction psychiatrist at Alta Mira, shed light on drug-induced psychosis and long-term mental health care:

Typically, we see drug-induced psychosis and paranoia in stimulant and cannabis use. Those symptoms do tend to improve as the patient maintains sobriety. However, what then comes into play is an underlying level of anxiety, depression, or another issue. What we would say at that point is the substance-induced portion is resolved, but there are other factors at play. I don’t think there is anyone in the world who has just a substance-induced psychosis right? Like something has led them to use a substance to the degree that it’s caused that. Which means they have probably been struggling with some level of trauma, depression, or anxiety. Part of the issue (drug-induced psychosis) might resolve, but then we actually get to see the root cause of what’s going on. And we really start treating that through therapy, groups, and sessions. That’s where the magic can really happen, allowing a patient to no longer feel like they need to numb things out and that they’re in a supportive environment where they can really start healing.

There is an intense interplay between substance use and psychosis, particularly in individuals with genetic vulnerabilities. Generally, either A. the substance caused the psychosis, or B. psychosis was a product of an underlying mental health condition, which then led to substance use. Effective providers must be able to accurately identify which is the case before the creation of a treatment plan.

Ruling Out Physical Conditions

It can be difficult to identify the difference between the two situations of substance-induced psychosis and psychotic disorders leading to substance use. This is where it is important to have an accurate and up-to-date medical history, including imaging of the brain and body, as well as blood tests, to rule out underlying conditions. The longer the psychosis is experienced, the more likely it is caused by something other than just substance use. Some substances such as methamphetamines can cause long-term psychosis but for the most part, drug-induced psychosis is short-lived.

The physical evaluations are just as crucial in determining psychosis causes. This is because a singular psychotic event can be caused by certain medical conditions. For example, someone who is diabetic can have a psychotic event due to hyperglycemia. This does not mean they have a psychotic disorder or even that they took substances. Again here, we see the value of a multidisciplinary approach. If a clinical team were to not include medical assessments, they could potentially misidentify the cause of the psychosis.

The Importance of Clinical Patient Observations

When a patient first comes in during a psychotic episode, stabilization is the most important first step. This is achieved through antipsychotic medications and constant observation within the first 24-hour period. Once stabilized, getting a full medical history is crucial to deciding on the next steps. We can then determine if the patient requires a medical detox from substances or if they are showing signs of a psychotic disorder. This distinction will determine the patient’s path as they move forward into treatment options.

By thoroughly assessing patients’ mental states, we can effectively determine the cause of the psychosis and potentially differentiate it from an underlying disorder. A singular psychotic event can stem from a vulnerability to cumulative trauma, substance use, or even some medical conditions.

Dr. Steven Batki, a consulting psychiatrist at Alta Mira, had this to say about psychosis and identification:

Psychosis is a psychiatric emergency, and it’s important to do something about it immediately, which consists of two things: antipsychotic medications and a protective environment like residential treatment or some other very closely monitored setting. Then the second thing we do is get back to assessment. So trying to get a longitude list, you can figure out what came first, the chicken or the egg. Was their substance use without any psychiatric problems for a while and then the development cycle? Or was there a clear psychosis and then substance use?

So, how does one go about identifying the relationship between substance use and psychosis per patient? Assessments and testing in four categories: physical, mental, neurological, and clinical.

Utilizing Physical Tests

Substance use disorder is a chronic, relapsing condition, encompassing the mind and how it acts and reacts. Therefore, treating drug-induced psychosis should start at a physical level. Medical testing is the first step in the process, consisting of blood tests and physical evaluations.

Dr. Helen “Py” Driscoll, a consulting internal medicine physician at Alta Mira, gave her take on the importance of conducting physical tests:

There’s no real protocol about what tests should be run on a patient experiencing psychosis. The goal is to rule out even the slightest chance that the psychosis is being caused by something physical rather than substances. I run a full panel of labs and order an MRI of the brain. This is to fully make sure there is no chance that this person doesn’t have lupus, a brain tumor, Wilson’s disease, or some other inflammatory problem in their brain. Patients often willingly accept the testing because they think there is something wrong. So, I do that for them.

Also, I feel like it gives families peace of mind. The patient and the families feel a little bit more comfortable knowing that every angle is being looked at. Being diagnosed with psychosis is brutal and can be scary for both the patient and their families. Putting in the extra care helps ease the diagnosing process.

By doing these tests, I did find a brain tumor in one patient. In my opinion, running the extra physical tests is just as important as the rest.

Mental Health Assessments

Mental assessments are key to understanding the overall health of the patient. The Clinical High-Risk state for Psychosis (CHR-P) is utilized to understand a patient’s risk of experiencing psychosis. Currently, it measures this across three subgroups: genetic risk, attenuated psychotic symptoms, and short-lived and remitting psychotic episodes. A study on the CHR-P shows a high probability of predicting the onset of psychotic disorders, remission or persistence of initial symptoms, and variable functional outcomes. However, it should be noted that more research will need to be conducted as the three subgroups do not encompass heterogeneity, variable outcome thresholds, and treatment options. This is one reason why a multidisciplinary approach involving extensive assessment is best.

Standard practice mental assessments also need to be conducted. Questionnaires for generalized anxiety disorder, depression, mood disorders, ADHD, PTSD, and personality disorders need to be thorough. If any of these conditions are found to be an underlying cause, they need to be addressed firsthand.

Neurological Function and Testing

Neurological testing is the next step in the treatment process. MRI scans can provide deep insight into what is happening physically in the brain. The structure of the brain can change from substance use, especially in the frontal cortex. Volume size has been seen in numerous studies to change and cause adverse reactions. Decision-making skills and cognitive function have shown a decline from these images.

Besides brain imaging, neurological testing consists of assessing mental functioning. Comprehension, concentration, memory, executive functions, motor skills, and informational processing are measured to understand how the brain functions. This tells clinicians the areas of the brain are not functioning properly, even if the MRI scan does not show any damage. MRI scans look through the brain, and microscopic damage can be missed by these scans. MRIs also do not show psychotic disorders, which is why neurological testing is necessary.

24/7 Clinical Observation and Medication Monitoring

Drug-induced psychosis involves 24/7 monitoring and is the fourth step in Alta Mira’s approach. Patients are going to respond differently to medications and the new environment. By providing round-the-clock care, we, as providers, have the ability to fully understand what is happening with each individual. Multidisciplinary practices involve the combination of physical, mental, and emotional assessments and proper pharmacology to treat underlying conditions. As we mentioned above, mental health is often a driver for substance use, and treating both at the same time is key to establishing a successful recovery.

Dr. Raghu Appasani, had this to say on the evaluation process of patients seeking care at Alta Mira:

We always start with an assessment. Typically it’s with an addiction psychiatrist working alongside an internal medicine addiction doctor. We do a joint interview typically. It’s a very collaborative experience for the patient – they don’t need to repeat things as much. We dive deep into everything, starting with why they’re in there, really building that rapport, and then diving pretty detailed into their substance use history. It is a detailed inquiry into the recent past use, everything from type, quantity, frequency, route, and context. Even if the last time they used it the experience was positive or negative. It would also analyze their relationship over the span of their life as a timeline and how these substances came in and out of their life. Was use related to certain stressors or experiences? So that timeline is really critical.

We also then use that timeline to figure out, you know, the temporal relationship between substance use as well as the onset of any types of these psychotic symptoms. Things like severe anxiety, paranoia, and hallucinations – including auditory, tactile, and visual. Then analyze the psychiatric history, current and prior history of mood disorders, anxiety disorders, and psychotic disorders. That gives us a strong history as well as whether this person has underlying issues. Then do an exam, a basic physical anthropological exam with full lab work. We include tests such as thyroid, autoimmune electrolytes, kidney, and liver function. If we suspect another dementia or neurological condition, we’ll get some more detailed labs or neuroimaging if required.

The timeline factor is really important. It allows the patient to kind of narrate their life and their story that way, and then we can start asking detailed questions as they’re explaining that. And it’s a more natural way of gathering information, data, and figuring out when certain things happened.

The first thing after evaluations is more acute treatment. If they’re coming in and they’re actually having psychosis symptoms, we provide them with management of anxiety and agitation. If they’re in detox, we provide them with the detox protocol to support that. Whether they’re coming off alcohol, stimulants, benzos, or whatever the case might be, that’s the number one priority. The safety, stabilization, and symptom management of the patient is the top priority.

Co-occurring mental health conditions along with substance use are common. It is rare that we see substance use alone without some form of depression, anxiety, or even psychotic disorder. Psychosis from substance use – especially methamphetamines and cannabis – can last for months to years after use has been discontinued. By re-evaluating these patients, we will have a stronger insight into how the brain is adjusting and what we can do in the future. Treatment modalities utilized for each individual patient also require data-tracking to understand how each method is preventing a return to use or other psychotic episodes.

Dr. Appasani shed light on drug-induced psychosis and long-term mental health care:

Typically, we see drug-induced psychosis and paranoia in stimulant and cannabis use. Those symptoms do tend to improve as the patient maintains sobriety. However, what then comes into play is an underlying level of anxiety, depression, or another issue. What we would say at that point is the substance-induced portion is resolved, but there are other factors at play. I don’t think there is anyone in the world who has just a substance-induced psychosis right? Like something has led them to use a substance to the degree that it’s caused that. Which means they have probably been struggling with some level of trauma, depression, or anxiety.

Part of the issue [drug-induced psychosis] might resolve, but then we actually get to see the root cause of what’s going on. And we really start treating that through therapy, groups, and sessions. That’s where the magic can really happen, allowing a patient to no longer feel like they need to numb things out and that they’re in a supportive environment where they can really start healing.

Dr. Batki also highlighted how the treatment process begins:

After the initial treatment of stabilization, the continuation of integrated care must continue. Treating with anti-psychotics and psychological approaches provides support for the psychosis. At the very same time, treatment to prevent relapse to the substance that was being used, which requires standard, addiction treatment approaches that combine 12-step or self-help facilitations and treatment that serves to support people attending the facility.

The multidisciplinary practice involves treating the whole patient – physically, mentally, neurologically, and chronically. Drug-induced psychosis, as we know, involves the whole being, not just one part. By combining medication, physical, and mental assessments, we are able to address all needs at once instead of separately.

Implementing the Multidisciplinary Facets of Psychosis Treatment

Psychosis is easy to identify for professionals, however, the underlying cause can be difficult to identify. Drug-induced psychosis typically only lasts for so long, which means we often have to evaluate the event after the fact. This presents challenges as the patient’s own recollections and those of their family members may not be reliable or possess the detail needed to make an accurate diagnosis. Substance use also confounds diagnosis due to the erratic or irregular behavior that can be common on high levels of a given substance. This is why comprehensive testing, including a period of observation, is needed. As a multidisciplinary treatment team, we need to be able to both make an accurate diagnosis and determine whether the subtype is drug-induced or a different etiology.

Combining pharmacological and psychosocial methods addresses both substance use and psychosis at the same time, which allows the treatment team to determine how the patient moves forward. Antipsychotic medications may be needed acutely or chronically, depending on the patient’s history and vulnerability to psychotic episodes. Addressing substance use after a psychotic episode is the first line of defense to ensure it does not occur again or develop into a psychotic disorder. The four-step process utilized at Alta Mira Recovery enables accurate diagnosis through multi-level testing and, subsequently, the creation of the most effective treatment plan.

Clinical Therapies and Medical Treatments Applied at Alta Mira

As we know, psychosocial therapies incorporate talk therapies. These are comprised of numerous methods, including widely used therapies such as dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT), motivational interviewing (MI), and more. After studying techniques throughout the United States and the United Kingdom, it was determined that taking the patient’s motivation into account while also teaching coping techniques was key in preventing a return to use. Current practice states CBT and MI are the two most effective therapy modalities when it comes to treating psychosis, substance use disorder, and both simultaneously. CBT develops coping skills and relapse prevention techniques while MI explores resolving contradictory ideas. Both therapies are performed in a safe and non-judgmental manner to promote healing.

Dr. Zicherman also shared his thoughts on motivational interviewing and the benefits he has seen:

Patients don’t respond well to threats or being told what they are doing is harmful and they have to stop. Motivational interviewing is this idea that you’re basically using very subtle, nuanced language to actually help the patient make their own decision, wanting to reduce or quit a substance, and then also allowing them to actually come up with their own plans. So, instead of me saying this is what you need to do, this is what you need to stop, this is how you’re gonna stop, it’s actually working with the patient to say ‘What do you think you can do to achieve abstinence from substances? What are some steps that you might take to achieve this?’ Then we build upon that dialogue.

Medications may be necessary for addressing psychosis in the short term as well as the long term. Antipsychotics, antidepressants, and other mental health medications may be needed to treat any underlying condition such as depression or anxiety. These medications, in combination with clinical therapies, have been proven effective in treating substance use disorders and psychosis.

Dr. Appasani specializes in somatic approaches to substance use disorder treatment:

Sleep is critical in the recovery process. I really focus on their routine at night, the wind down, and what’s going on as they’re going to bed. What’s going on in the middle of the night? What’s going on in the morning? How do they wake up? Sometimes this requires using certain meds if we need to manage that initially. I use a lot of magnesium as a supplement for sleep.

The next component is exercise. I really want to get people moving. It doesn’t mean they have to do intense workouts, but even if they can start by doing a little walk every day. I’m really trying to get them moving. It’s a very evidence-based natural antidepressant that someone can access. Really getting them to move and put fuel back into their body that they’ve been escaping from for a very long time.

With that, nutrition is critical also. For someone who’s using a lot of substances, typically nutrition falls to the back burner. We focus a lot on that, making sure they’re getting those amino acids and vitamins from a balanced diet and that their relationship with food starts to recenter.

The last piece is community and social connection. We want to help them to really approach that in a way that they can start to trust people and build positive relationships. So I focus a lot on that and those components because I believe that those are the long-term support that someone needs to sustain a life of recovery that’s healthy.

Treating Substance Use Disorder vs Psychotic Disorders

Once the initial psychosis is treated, co-occurring substance use disorder and mental health treatment begins. This may include a medical detox which is supervised 24/7. From there, therapeutic interventions begin. The therapists at Alta Mira specialize in CBT, DBT, trauma, and more. The key to treating substance use is understanding where it began and why. Therapy is the leading intervention for addressing the origin of substance use and developing healthy skills for future recovery.

Those who experienced psychosis from a psychotic disorder and no attending substance use, or from a medical condition will require long-term psychological treatment. This includes utilizing antipsychotic medications as well as connecting them with therapy and support groups. Medication monitoring will also be required to ensure a psychotic episode does not occur.

It is extremely important for patients who have suffered a psychotic break, drug-induced or otherwise, to receive continued care. Alta Mira understands that treatment does not end after a residential stay. The team sets each patient up with a plan that allows for continued maintenance, promoting long-term healing. This includes consulting with and referring to external care providers, family therapy, recovery or life coaching, case management, medication management, and more. Not only does this promote patient success, it allows the team at Alta Mira to continue studying to further our expertise in addiction medicine.

As we’ve seen, the identification and treatment of psychosis is a complex matter. There is no simple test or even series of tests that can definitively differentiate psychosis from an existing mental health disorder such as schizophrenia. Instead, extensive testing must be conducted across disciplines with an experienced treatment team to make the diagnosis.

At Alta Mira, our PhD-level clinicians and medical professionals have been working together for close to 12 years. They have the deep, collaborative expertise needed to make complex diagnoses, which then enables them to provide patients with the most accurate treatment plan for their particular condition.

If you are looking to refer a patient for psychosis-related problems, don’t hesitate to reach out. Dr. Appasani, Dr. Batki, and our team of highly-trained specialists are experts in the field of substance-induced psychosis. Our facility specializes in addressing and treating the unique needs of each patient. Call us at 866-922-1350 to learn more about referring a patient.

Alta Mira: Science-backed treatment, world-class care

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