Abstract
Psychosis describes a set of psychological symptoms that reflect a loss of contact with reality; it arises from a variety of causes. Approximately 2% of people will have an episode of psychosis in their lifetime; however, around half of these will not have further episodes. The peak age of onset in men is in late adolescence or early 20s, and for women between late 20s and early 30s. Detailed assessment is needed to establish the cause. This article will focus on psychotic episodes associated with drug use and include presentation, diagnosis and management. Drug induced psychosis is challenging to manage, with a high incidence of relapse, self-harm and suicide.
Clinical case scenario
You have a telephone consultation with the parents of a 19-year-old male, Ben, over his increasingly bizarre behaviour. He has no significant past mental health history. He has become more withdrawn and increasingly agitated in the last few weeks. You agree to do a home visit to review him.
During the visit it becomes apparent that he is suffering from delusions. Ben believes that he is being watched and under surveillance by his neighbours; he is afraid to leave his house and believes they are tracking him. Ben reports some intermittent auditory hallucinations and reveals he has been using cannabis to help keep him calm.
Given these features, you decide he needs further tests and organise an emergency psychiatric admission.
His parents are worried and ask you what is happening to Ben.
Psychosis
Psychosis is a complex multifactorial mental health condition that encompasses a variety of symptoms that distort an individual’s ability to interpret and perceive reality. This impacts day-to-day functioning, as well as affecting their thoughts, behaviours and feelings (NHS UK, 2019). Drug induced psychosis occurs either as a result of the drug’s direct chemical effect, or due to exacerbation of an underlying known or unknown mental health condition. As many of half of people with psychosis also have a substance use disorder, and thus determining cause and effect is challenging.
Symptoms
The presentation of psychosis can vary based on the underlying cause; however, key features include hallucinations, delusions and altered thought processes. Hallucinations are altered sensory perceptions of an auditory, tactile or a visual nature. Delusions are fixed irrational beliefs that persist despite the presence of contradictory evidence. These are out of line with the patient’s cultural or social beliefs and can include persecutory thoughts, jealously-related delusions, or grandiose beliefs.
Not all individuals will present with overt symptoms. In primary care, individuals may present with a slow onset of subtle features such as a decreased ability to function in life, poorer concentration, higher paranoia, or poor self-care. They may also present with worsening mood, social isolation or poor sleep. A family member may raise a concern, rather than the patient if they notice a decline in both the mental and physical state (Archinigas, 2015).
Pathophysiology
Dopamine is suspected to increase the activity within the limbic regions leading to mislabelling of stimuli, inducing hallucinations and creating altered sensory states. Many antipsychotics work by inhibiting or lowering the dopamine within the mesolimbic pathway (Ham et al., 2017).
Causes
Psychosis can arise due to a single event, such as acute drug use, or have multifactorial causes. Pre-existing mental health disorders are associated with psychotic episodes, in particular depression, bipolar disorder, schizophrenia, schizoaffective disorder and delusional disorder. There is a genetic component to psychosis risk; having a first-degree relative with a psychotic disorder increases an individual’s lifetime risk of developing psychosis from 1% to 10%. Adverse life events can also contribute, such as a recent bereavement or adverse childhood experiences.
Some medical conditions are associated with psychotic episodes. Examples include human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), malaria, Alzheimer’s disease, Lewy-body dementia, encephalitis, Parkinson’s disease, systemic lupus erythematosus, Huntington’s disease, multiple sclerosis, Wilsons disease and certain cancers (Archinigas, 2015). Childbirth is also associated with an increased risk of psychosis. Postpartum psychosis affects up to 1/1000 women within the first 2 weeks of birth (NHS UK, 2019).
Drug induced psychosis
Drug induced psychosis presents with similar symptoms as described, but may also present with signs of drug ingestion, withdrawal, or dependency. These may also present with post use features of sleep disturbance, headaches, paranoia, hallucinations, confusion, memory issues, mood lability, anxiety and depression, which can make it hard to distinguish from the onset of a mental health disorder. Prescription medications that can cause psychosis include dopamine agonists (levodopa) as well as the cessation of dopamine antagonists such as aripiprazole. Other causes include opioids steroids, antiepileptic drugs, antimalarial drugs and antiretroviral medications. Medication-induced psychosis is rare. Drug-induced psychosis is typically associated with recreational drug use, and these drugs are outlined below. It is worth noting that although alcohol is not formally discussed within this article it can exacerbate the effects of recreational drugs.
Amphetamines
This is a stimulant drug that exists as a powder, crystal or capsule. Onset of symptoms is immediate if injected or smoked, or after about 30 minutes if snorted or swallowed. Individuals experience increased energy, libido and mood, dilated pupils, dry mouth, tachycardia, decreased appetite. Frequent use or high doses can result in symptoms of psychosis that typically reverse once the drug is stopped (Alcohol and Drug Foundation (ADF) 2021).
Cannabis or ‘marijuana’
A plant derived cannabinoid drug that can be smoked/vaporised for immediate effect or ingested for delayed onset. In small amounts individuals report feeling relaxed, euphoric and have an increased appetite. Larger amounts can lead to paranoia and anxiety. Cannabis is associated with 50% of psychotic episodes, although whether cannabis causes psychosis is contentious (ADF 2022a).
Cocaine
A plant-derived white powder stimulant drug that is snorted, smoked, or injected. Having a quick onset it increases energy, confidence, libido as well as paranoia, anxiety and violence. Cocaine-induced psychosis occurs shortly after using cocaine, with transitory paranoia being the most common feature. Of those who regularly use cocaine, approximately half will experience some psychotic symptoms (ADF 2022b).
Ketamine
A synthetic drug with anaesthetic properties that creates a dissociative effect, found as a white powder or liquid for injecting, snorting, smoking or ingestion. Individuals experience elevated mood, euphoria, dissociation, hallucinations, and increased anxiety and aggression. Regular use is associated with flashbacks, mood and personality changes, poor memory, psychotic symptoms and ketamine bladder syndrome (ADF 2022c).
LSD (lysergic acid diethylamide)
LSD is a hallucinogen made from a substance found in ergot (a natural fungus on rye and grains) and exists as a clear odourless liquid. Effects include euphoria, changes in sensory perception, hallucinations, alongside paranoia, increased risky behaviour and psychosis (ADF 2022d).
MDMA (3,4-methylenedioxy-methamphetamine) ‘Ecstasy’
MDMA is a stimulant hallucinogenic. Effects last up to 4 hours with elevated mood and energy, altered sensory perception. Larger doses are associated with raised core body temperatures and altered sodium states, which can result in seizures and death (ADF 2022e).
Psilocybin – ‘magic mushrooms’
Psilocybin is a natural psychedelic that can cause hallucinogenic affects and altered sensory perception. Synthetic versions also exist in powder or tablet form. Symptoms include euphoria, altered mood and perception (ADF 2022f).
Clinical case discussion (continued)
You take a detailed history from Ben and conduct a mental health examination.
You are concerned that Ben is displaying signs and symptoms of a psychotic episode and he lacks insight into his condition. You conduct a risk assessment and Ben says he would not hurt others but feels very overwhelmed when he is hearing voices and sometimes wants to hurt himself to make them stop.
You refer him urgently to the mental health crisis team. A psychiatrist confirms a provisional diagnosis of a psychotic episode and that this may be related to cannabis used. He is commenced on an antipsychotic medication, and once stable, is discharged for community follow up.
Ben’s parents are worried about long-term treatment and complications. They wish to discuss this with you.
Diagnosis
A detailed history and mental state examination are vital when a patient presents with possible psychosis. These are outlined in Box 1 and Box 2, respectively. History for psychosis - consider examples. Useful questions to consider during the consultation:
What are the key features of this episode?
When did this episode start?
Are there any softer features of neglect?
○ Self-neglect
○ Poor sleep
○ Poor concentration
○ Increasing paranoia or social isolation
Are there any hallucinations present?
○ If so, auditory, visual, tactile: Are they threatening?
○ What do they say? What do they see?
Are there any delusions present?
Is the patient at risk to themselves or others?
○ Any history of self-harm or suicide attempts
○ Any current self-harm or suicidal attempts or thoughts?
○ If there any hallucinations or delusions, on which they may be compelled to act?
○ Any family or social support or triggers?
○ Are there any unintentional risks due to neglect or poor judgement?
○ Is there a safeguarding required?
○ Any risk to others, domestic violence?
Does the patient have insight?
Any substance misuse history?
○ What substance? Quantity? Frequency? When last ingested?
○ Route? Other drugs? Any alcohol?
○ Past historical use of drugs?
Past medical history and mental health history
Is there any family history of mental health?
Is there any other Medication used?
○ Any anticonvulsant, steroids, dopamine agonists?
Are there any recent psycho-social triggers?
○ Recent bereavement? Poor sleep?
○ Sexual abuse domestic violence – historical or present? Mental health examination. Note the patients appearance:
Signs of drug use? What is their personal hygiene? What are they wearing? Any unusual objects they are carrying? Is there anything else that stands out? Note the patients behaviour:
Are they engaged? Good rapport? Eye contact? What is their facial expression and body language?
Any evidence of psychomotor activity – any restlessness? Abnormal Postures? Tics? Rocking? Note the patients speech:
What is the rate, pressured or slow?
Quantity of speech? Tone? Volume? Fluency and rhythm? Note the patients mood and affect
What emotions are immediately expressed by them – review their facial experience, their view, demeanour Note the patients thought:
Review form – looking at speed of thoughts, flow of thoughts and if they are coherent
○ Any flight of ideas, circumstantial, thought blocking, preservation?
Is there any content such as delusions and obsessions, overvalued ideas, compulsions, thoughts re suicidal and violence?
Any thoughts of possession such as thought insertion withdrawal and broadcasting? Note the patients perception:
Are there any hallucinations, derealisation, illusions, depersonalisation? Note the patients cognition:
Are they orientated in time space place, short-term memory, attention space and concertation Note the patients insight and judgment:
If they are aware there is a problem? What the problem is? If they understand they need help
Judgement via safety scenarios and seeing they are appropriately acting in situations
The history should review current and historic substance misuse, see Box 1. It is also important to consider psychosocial aspects that may have contributed to the episode such as domestic violence, sexual abuse or other psychosocial stressors. The history should incorporate an assessment of risk, including intent or awareness of any danger to themselves or others and any violent delusions.
A mental state examination is vital to establish diagnosis, to further assess risk and to determine whether the individual has capacity or not (National Institute for Health and Care Excellence (NICE) 2021). See Box 2 for further details.
Individuals with suspected psychosis need to have bloods, urine cultures, a urine drug screen and neuro imaging to exclude organic pathology that may be treatable or reversible. Suggested blood tests include a full blood count, urea and electrolytes, thyroid function tests, liver function tests and C reactive peptide, a HIV screen and syphilis screen may also be considered, as these conditions can present with neuropsychiatric features (NICE, 2021).
Management
In all cases of suspected psychosis there is a need for early referral to the early intervention in psychosis or crisis teams, depending on local service pathways.
Mental health teams organise a detailed assessment via an approved mental health professional to make an initial diagnosis, review if a psychiatrist is required and consider if detention is needed under the Mental Health Act. For those aged less than 18 years old, same-day referral to child and adolescent mental health services is required. Pregnant women or those considering a pregnancy with a history of psychosis should be managed in secondary care, given the risk of deterioration in pregnancy.
If inpatient treatment is required, voluntary admission is encouraged. If this not feasible or is refused, then admission can occur under the Mental Health Act under sections 2 and 4, as described in Box 3. Mental Health Act classification 1983. This Act governs the compulsory admission, detention, and treatment of patients with suspected mental health conditions in their best interests. Section 2. An assessment section to establish a diagnosis which requires two doctors and is applied for by AMHP. Lasting for 28 days it cannot be extended but may be converted to a section 3 for treatment. Section 3. A treatment section which requires a known diagnosis in order for application and again requires two doctors. Lasting for 6 months initially but can be extended for another 6 months. Section 4. An emergency admission section only used within hospital wards while waiting for a section 2 to be applied for and lasts only 72 hours Section 5. An emergency admission section only used by a nurse within hospital wards while waiting for a doctor and allows detention for a maximum of 6 hours only Section 135. This enables the police to enter a patient’s home and take them to a place of safety for assessment within a 24 hour period. It needs a warrant which is applied for by approved mental health professional (AMPH). Section 136. This enables police to take a patient to a place of safety (hospital, care home or a police station) from anywhere outside of the house. It does not require a warrant, but does need a doctor and AMPH and lasts for 24 hours again.
It is important to tell individuals that they must not drive during an acute episode of psychosis and must notify the Driver and Vehicle Licensing Agency (DVLA) about their illness (NICE, 2021).
Antipsychotic medications
Patients may require antipsychotic medications to inhibit distressing features, such as hallucinations and help patients feel safe. It is worth noting that these are not initiated within primary care and require the supervision of a psychiatrist.
Antipsychotic medications work by blocking the release of dopamine and are grouped into the ‘typical’ older generation of drugs and the newer ‘atypical’ drugs. Box 4 outlines these medications and their common side effects. Typically, secondary care initiates, titrates and stabilises patients on these medications. Local shared care agreements describe how and when responsibility for prescribing and monitoring of antipsychotics is transferred to primary care. Antipsychotics. Typical antipsychotics are drugs that crudely block the dopamine D2 receptors and include haloperidol, chlorpromazine and flupentixol. They typically have various side effects such as:
Extrapyramidal features of parkinsonism, dystonia’s, and dyskinesia
Hyperprolactinaemia causing menstrual irregularities, galactorrhoea, gynaecomastia, sexual dysfunction
Metabolic features of weight gain, increased risk of type 2 diabetes mellitus, hyperlipidaemia
Anticholinergic features of tachycardia, blurred vision, constipation, urinary retention, and dry mouth
Others such as seizures and neuroleptic malignant syndrome Atypical antipsychotics are drugs that selective block D2 dopamine receptions and also serotonin receptors and include olanzapine, risperidone, clozapine, quetiapine. The side effects are the same as above, but in much reduced quantity and effect leading to better compliance as well as the fact they target the negative features much better. It is worth noting that clozapine requires regular blood tests due to its higher risk of agranulocytosis.
Regular monitoring of antipsychotics is required in primary care. This typically includes weight, body mass index, HbA1c and lipids at baseline, 3 month, 6 months and annually. Full blood count, renal function, liver function, blood pressure and pulse are required at baseline and annually. Prolactin, thyroid function tests and an electrocardiogram are required at baseline and may require more frequent monitoring depending on the clinical context. It is important to remind patients that they must not drive and must notify the DVLA accordingly ( NICE, 2021; Stroup, 2018).
Patients may need to be referred back to secondary care if there are signs of relapse, little response to treatment, poor compliance, or if they develop adverse effects from the medications. Patients also warrant referral back to secondary care if alcohol or drug misuse is occurring or if there is further risk to others. It is also worth noting that any female who is pregnant or considering a pregnancy should be under community mental health team (CMHT) care given the high risk of mental health deterioration in pregnancy.
Other therapies
Individuals may also require medically assisted withdrawal detoxification programmes if indicated. Psychological therapies also form a key area of treatment and involve problem-solving talking therapy, cognitive behavioural therapy, as well as family therapies for the first year. Art therapy is also considered to be used to aid those with more negative features.
These therapies can be useful in supporting individuals to manage emotions and paranoia more readily, to be aware of their triggers, and play a key role in preventing and managing relapses. Treatment of any coexisting disorders such as anxiety, depression, personality disorders or substance misuse is also given concurrently (NHS UK, 2019; WebMD, 2021).
Patients will usually require a care programme afterwards which looks at their health and social needs and ensures there is a key worker for a first point of contact. It also includes a crisis plan, and an advance statement that details how the patient would want to be treated if they become ill, as well holding key contacts information.
Support for family
It is important to recognise the increased strain on families and loved ones during these episodes, and thereafter, particularly around physical care and financial strain. Families should be encouraged to have CMHT and local social care services assess their needs and become involved in the formulation of the care plan. They should also be signposted to key support organisations and local mental health services, such as Rethink (www.rethink.org) or the charity MIND (www.mind.org.uk).
Long-term complications and challenges for GPs
Individuals with episodes of psychosis are associated with increasing rates of suicide and self-harm, as well as an increased risk of further relapses of both the psychosis and of any associated substance abuse. They are also at a higher risk of violence during these episodes and safeguarding must always be assessed, particularly, if there are any children or other vulnerable adults present within the family structure.
Given mental health incidence is increasing and contributing towards a large proportion of primary care workload, it is important to be able to place these individuals on the appropriate registers for regular reviews and to consider the impact on their carers and family members. It is also worth setting up additional searches on the practice register to check for compliance with medication and attendance for health reviews.
Key points
About 2% of the population will experience an episode of psychosis with the peak incidence in young adults
There are a variety of causes of psychosis ranging from medical disease, underlying mental health conditions and drug-induced psychosis
It is important to assess patients thoroughly with consideration of all causes as part of the diagnostic process, not least to ensure appropriate treatment is offered
Drug-induced psychosis can be challenging to manage and may require long-term psychological therapies, as well as medication
Local shared care agreements describe how and when responsibility for prescribing and monitoring of antipsychotics is transferred to primary care
The long-term sequalae of psychosis include a high risk of relapse, self-harm and suicide, which can be detrimental to the patient, their families and society
