Substance-Induced Psychosis

[PistolPete]

Recently I've had a string of patients come in to the VA with VH and AH. Then I noted +UDS for amphetamines. We get decent leeway in patient care, so one one patient I decided not to start an anti-psychotic, my rationale being that the psychosis will resolve as the pt withdraws from the meth. My attending however suggests that whatever disturbance a pt has, in this case psychosis, should be treated.

What have others experiences been with this? Do you normally treat substance-induced psychosis, or do you let it runs its course? What are the pros and cons of each?

---

Members don't see this ad.

 

[OldPsychDoc]

Recently I've had a string of patients come in to the VA with VH and AH. Then I noted +UDS for amphetamines. We get decent leeway in patient care, so one one patient I decided not to start an anti-psychotic, my rationale being that the psychosis will resolve as the pt withdraws from the meth. My attending however suggests that whatever disturbance a pt has, in this case psychosis, should be treated.

What have others experiences been with this? Do you normally treat substance-induced psychosis, or do you let it runs its course? What are the pros and cons of each?

What's your rationale for NOT treating highly distressing, potentially dangerous symptoms?
Saving the government money for a few doses of olanzapine?

 

[notdeadyet]

What have others experiences been with this? Do you normally treat substance-induced psychosis, or do you let it runs its course? What are the pros and cons of each?

Run its course being the "walk it off" strategy?

The psych e.r. where I moonlight gets lots of meth-induced psychosis. Once I'm sure it's meth-induced (it's worth remembering that unmedicated schizophrenics use meth too), I evaluate whether or not the AH/VH are distressing to the patient (they aren't always). If the patient is in distress, I treat the symptoms. If he's not, and his symptoms aren't impacting other patients or staff, I don't, as I know they will fade with tincture of time.

Not treating a patient in pain/distress just because I don't like their choice of drugs or their pattern of use is unethical, in my opinion. The argument of unnecessary risks of side effects is pretty phantom as the punitive types also often seem to be the ones tossing Haldol 5mg at the angry old guy.

 

[BobA]

Recently I've had a string of patients come in to the VA with VH and AH. Then I noted +UDS for amphetamines. We get decent leeway in patient care, so one one patient I decided not to start an anti-psychotic, my rationale being that the psychosis will resolve as the pt withdraws from the meth. My attending however suggests that whatever disturbance a pt has, in this case psychosis, should be treated.

What have others experiences been with this? Do you normally treat substance-induced psychosis, or do you let it runs its course? What are the pros and cons of each?

I see bath salt psychosis from time to time, and I've been instructed by our Addiction Medicine chief to treat it for the palliative reasons OPD and NDY raised.

You just need to document your thinking so that it's clear to all involved that you treated substance-induced psychosis so that other providers feel comfortable discontinuing the anti-psychotic later.

 

[billypilgrim37]

Psychosis is neurotoxic. As long as the illness is worse than the cure, treat.

 

[bob1234]

Is thorazine used much anymore or are you mainly pushing benzo's and atypical anti-psychotics for these patients?

 

[DD214_DOC]

So we like to get into this debate about psychotic symptoms during intoxication of a substance. It's more mental masturbation than anything, but is the diagnosis, "Substance-Induced Psychosis", "Ampehtamine Intoxication", or both? We have attendings who argue that you cannot diagnose SIP during a period of intoxication and that it only applies to persistent psychosis within 30 days of cessation of that substance.

I just looked on the DSM and it appears that it could apply to either.

 

[DD214_DOC]

Is thorazine used much anymore or are you mainly pushing benzo's and atypical anti-psychotics for these patients?

I tend to use benzos because it also address the autonomic hyperactivity. You're not really getting an antipsychotic effect from antipsychotics anyway with such a short duration of treatment; you're just sedating the hell out of them, so why not just use a benzo that will treat the physical symptoms as well?

 

[bob1234]

I tend to use benzos because it also address the autonomic hyperactivity. You're not really getting an antipsychotic effect from antipsychotics anyway with such a short duration of treatment; you're just sedating the hell out of them, so why not just use a benzo that will treat the physical symptoms as well?

Do you have a protocol for Benzo administration? I've seen the local attending titrate a crazy meth junkie up to 20mg valium iv via 2mg/ml over 2 hours. These patients just scream, fight, and spit incessantly for the entire time of the titration. Are you not "allowed" to hit them with a real dose of valium or thorazine, or do you just work them up to the desired dose to keep your ass covered just in case they have a bad reaction.

PUSH DOWN THAT GABA TONE!

 

[DD214_DOC]

Do you have a protocol for Benzo administration? I've seen the local attending titrate a crazy meth junkie up to 20mg valium iv via 2mg/ml over 2 hours. These patients just scream, fight, and spit incessantly for the entire time of the titration. Are you not "allowed" to hit them with a real dose of valium or thorazine, or do you just work them up to the desired dose to keep your ass covered just in case they have a bad reaction.

PUSH DOWN THAT GABA TONE!

I don't really have a protocol. Sometimes I will add haldol acutely for the typical reasons, but benzos alone in patients without any pulmonary compromise are surprisingly safe. I would just be careful on using long-acting benzos because of uber sedation from meth withdrawal.

 

[PikminOC]

i could really use whops advice.

 

[Fastball32]

VH is usually substance induced psychosis.
Substance induced psychosis is often more like a delirium, thus I would tend to lean more towards an antipsychotic.
I would be cautious to treat substance induced psychosis with benzos

 

[PistolPete]

Thanks for all the great replies!

 

[Indodo]

BUMP:

So I have a patient who is on a depot for this exact same condition. I don't see evidence of schizophrenia. The diagnosis is psychosis NOS because medi-CAL won't pay for SIPD.
He comes in to get his shot because it levels him out.

You have to wonder if this is an enabling behavior. Also, there are the side effects of the anti-psychotic.
I am not quite willing to hand out Provigil.

 

[Shikima]

Admit with psychosis NOS disorder to ensure hospitalization and payment. Can add on qualifier such as r/o SIPD on AI to help you remember. Recommend using the 'ol B52/G52 standby q4-6h until psychosis breaks. Then further evaluate with more detailed history and collateral.... as they would be in a safe environment during this transition on your InPt unit.

 

[Indodo]

This is outpatient.

 

[Shikima]

This is outpatient.

Ah, my mistake. Totally misread it but I was also distracted too...
Could get him to sign a release to obtain further collateral. UDS each visit and see him pretty frequently by using Risperdal Consta 25mg q2w. I wouldn't worry too much about side effects as you can use a anticholinergics from a variety of sources. Keep the atypical going never-the-less because he does report getting benefit from it. Perhaps there is a dual diagnosis paradigm occurring with him that hasn't been fully uncovered?

 

[Indodo]

He has no EPS and he was taken off anticholinergics because of abuse. No need for collateral, we know the whole family and this is the CMHC, he has been coming here for years. No need for regular UDS either, he freely admits to using.

Still keep the antipsychotics going?

 

[Shikima]

I wouldn't. Discharge from CMHC because he's a primary substance use disorder? - - not sure about your bylaws and what administration wants for numbers. This is only one opinion which is coming from a concrete thinker.

 

[HarryMTieboutMD]

What attempts have been made to treat his substance use disorder?

 

[Indodo]

I have referred him to NA, CMA etc. but he has not used those resources, nor does he seem so inclined. Probably pre-contemplative, at best contemplative.
The CMHC doesn't have any other resources for substance abuse treatment.

 

[F0nzie]

If someone is a long term patient and is psychotic and has a substance use disorder I treat them as if they have both a psychotic disorder and substance use disorder and document that there is no significant length of drug abstinence to clarify the diagnosis. I also document the efforts that were made to engage the person in substance abuse treatment.

 

[shan564]

What's your rationale for NOT treating highly distressing, potentially dangerous symptoms?
Saving the government money for a few doses of olanzapine?

I know I'm two years late to this debate (and I'm not saying that this is necessarily the right thing to do, just that I've seen people do it), but I think the rationale would be to avoid condemning the patient to a long-term course of a highly distressing, potentially dangerous drug. If you give him an antipsychotic, you don't know if the psychosis broke from the antipsychotic or from sobriety, and the patient will probably have to continue a drug that carries a high risk of causing either tardive or diabetes.

 

[splik]

I know I'm two years late to this debate (and I'm not saying that this is necessarily the right thing to do, just that I've seen people do it), but I think the rationale would be to avoid condemning the patient to a long-term course of a highly distressing, potentially dangerous drug. If you give him an antipsychotic, you don't know if the psychosis broke from the antipsychotic or from sobriety, and the patient will probably have to continue a drug that carries a high risk of causing either tardive or diabetes.

why? i give a single dose and if they miraculously recompensate no more. also there is almost never a reason for patients to be on antipsychotics long term. we are talking about a tiny minority of psychotic patients here.

 

[st2205]

I know I'm two years late to this debate (and I'm not saying that this is necessarily the right thing to do, just that I've seen people do it), but I think the rationale would be to avoid condemning the patient to a long-term course of a highly distressing, potentially dangerous drug. If you give him an antipsychotic, you don't know if the psychosis broke from the antipsychotic or from sobriety, and the patient will probably have to continue a drug that carries a high risk of causing either tardive or diabetes.

I'd just do what splik said above. I believe the biggest problem is whoever picks the person back up. Medicine, in general, has some kind of reluctance about discontinuing medications other providers have started. Simply document a no longer need to utilize antipsychotics as presently constituted and make sure that gets conveyed to the next level of care. Just today I DCd a guy who was presumed substance-induced and informed him clearly that we'd give him a rx for 10 days and at that point he should be quite clear, but to make sure to follow up with the CMHC.

On the flip side, of course, you've probably got a mindless provider picking this guy up at the CMHC and thinking "OMG recently discharged for psychosis and not being treated with antipsychotic! Rx antipsychotic, mood stabilizer, antidepressant, trazodone and hydroxyzine just to be safe and document all the great work I did so the next guy/gal can continue more of the same! And add more if needed."

 

[st2205]

also there is almost never a reason for patients to be on antipsychotics long term. we are talking about a tiny minority of psychotic patients here.

I think it's important to clarify who/why, though. The answer is that most people running around on antipsychotics don't have a psychotic disorder. Or at least their provider is oblivious to the fact that they don't have a psychotic disorder. The truly psychotic are another story.

 

[splik]

to clarify: i believe that only a tiny minority of people with psychosis need long-term neuroleptics. i wasn't even thinking about all those people with insomnia, personality disorder etc on these drugs.

 

[st2205]

to clarify: i believe that only a tiny minority of people with psychosis need long-term neuroleptics. i wasn't even thinking about all those people with insomnia, personality disorder etc on these drugs.

I'm not specifically talking about insomnia or using it to treat a PD. I'm more referring to people that may have PDs or just very poor functioning people that somehow fly under the radar of their practitioner and keep getting labeled as having some kind of bipolar or psychotic disorder. My argument is that most psychotic people don't need antipsychotics because they're not really psychotic.

 

[splik]

ah okay. my argument is more most psychotic people with correct diagnoses of schizophrenia or bipolar disorder do not need longterm treatment with antipsychotics. there is no evidence to support this practice and some evidence to suggest it worsens the illness course which is entirely biologically plausible.

 

[bashir]

to clarify: i believe that only a tiny minority of people with psychosis need long-term neuroleptics. i wasn't even thinking about all those people with insomnia, personality disorder etc on these drugs.

Splik, care to elaborate on this? I'm interested in hearing how you reached this conclusion.

 

[shan564]

why? i give a single dose and if they miraculously recompensate no more. also there is almost never a reason for patients to be on antipsychotics long term. we are talking about a tiny minority of psychotic patients here.

I agree that it's reasonable to use a single dose - I usually try to use as little antipsychotic as possible in this situation and try to avoid using more if they respond miraculously.

As for the lack of need for long-term neuroleptic therapy in patients with genuine schizophrenia - as you can imagine, that'll take some convincing. I have to admit that I'm not familiar with the specific literature to which you're referring, but I'm sure you can understand why most people would be apprehensive.
Plus, if you start somebody on an antipsychotic as an inpatient, 95% of the time their outpatient psychiatrist will continue it for an extended period even if it's not clearly indicated.

 

[splik]

There is a symposium at the APA annual meeting this year in May on this I would highly recommend those interested attend.

As luck would have it I am putting together the list for our reading group on this topic at this moment so here you go... These papers cover the problems with long-term use, the supersensitivity psychosis, the fact the prognosis of schizophrenia is much better than has been claimed, that many people do fine going off meds, that prognosis is poorer for those on long term meds, that some patients do better without meds at all, that a subset of patients do not benefit from these drugs because there is nothing dysfunctional about their dopaminergic system, and that patients can do well with extended/intermitted dosing where the neuroleptic burden is less.

From my 100 papers thread:

Andreasen NC, Liu D, Ziebell S, Vora A, Ho BC. Relapse duration, treatment intensity, and brain tissue loss in schizophrenia: a progressive longitudinal MRI study. Am J Psychiatry 2013; 170:609-615

Chouinard G, Jones BD. Neuroleptic-induced supersensitivity psychosis: clinical and pharmacologic characteristics. Am J Psychiatry 1980; 137:16-21

Demjaha A, Murray RM, McGuire PK, Kapur S, Howes OD. Dopamine synthesis capacity in patients with treatment-resistant schizophrenia. Am J Psychiatry 2012; 169:1203-1210

Leff J, Sartorium N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med 1992; 22:131-145

Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry 2013; 70:913-920

Additional readings:

Warner R. Recovery from schizophrenia: psychiatry and political economy. 3rd ed. New York: Brunner-Routledge, 2004 *highly recommended*

Moncrieff J. The Bitterest Pills: the troubling story of antipsychotic drugs. London: Palgrave Macmillan, 2013

Harrow M, Jobe TH, Faull RN. Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. Psychol Med 2002; 17:1-11

summary of long-term studies of course of schizophrenia: http://www.isps-us.org/koehler/longterm_followup.htm

Harrow M, Jobe TH, Faull RN. Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study. Psychol Med 2014; 44:3007-3016

Ciompi L, Harding CM, Lehtinen K. Deep concern. Schizophr Bull 2010; 36:437-439

Stephens JH. Long-term prognosis and followup in schizophrenia. Schizophr Bull 1978; 4:25-47

Bola JR, Mosher LR. Treatment of acute psychosis without neuroleptics: two-year outcomes from the Soteria project. J Nerv Ment Dis 2003; 191:219-29

Bola JR, Mosher LR. At issue: predicting drug-free treatment response in acute psychosis from the Soteria project. Schizophr Bull 2002; 28:559-575

Remington G, Seeman P, Feingold A, Mann S, Shammi C, Kapur S. “Extended” antipsychotic dosing in the maintenance treatment of schizophrenia: a double-blind, placebo-controlled trial J Clin Psychiatry 2011; 72:1042-1048

Boshes RA, Manschreck TC. Review of antipsychotic medication administration: a proposal of intermittent dosing. Schizophr Bull 2002; 28: 203-222

 

[notdeadyet]

I think folks over prescribe antipsychotics. And I think that folks that take a strong stand on not using them do a disservice.

Psychosis gets misdiagnosed and over diagnosed. Most folks in psychiatry residencies don't have specific training via early psychosis clinics so they are left to their own politics and prejudices or inherit them from mentors. They haven't had the experience of working in clinics where they have seen what psychosis looks like medicated and not medicated. If your residency offers an early psychosis clinic training, please take it.

If someone experiences auditory hallucinations and/or other psychotic symptoms, you arrive at a decision point. Often the patient's family is pulling for medications and the patient is not ("but he'll have to take time off from school!"). Roughly half of psychotic episodes with no clear source (e.g. Not from drugs, trauma, metabolic causes) will clear and not return. If the patient is willing and able to tolerate the effects of psychosis more so than the effects of the medication and can do so safely, this is a very sensible route. This is often the approach taken in an early psychosis clinic.

But often, the symptoms do not remit. Or the symptoms get worse. As with any medication option, you continuously have the risk-benefit discussion. At a certain point with schizophrenia (or any chronic and progressive illness), taking the medication for improvement of symptoms and quality of life becomes a preferred choice. That is when you medicate.

I get uncomfortable with folks that have blanket opinions about the use of medications without looking at the individual circumstances. I know many people who will flat out refused to use nefazodone, even in cases that are refractory to other medications. Same with ECT. These are decisions that reflect much more about the prejudices of the provider, rather than the circumstances of the patient.

There are several treatment modalities for schizophrenia. Medications are one. CBT for psychosis protocols can also be effective. But there are patients whose auditory hallucinations, including command auditory hallucinations to hurt themselves or others, combined with their paranoia, make the decision to not medicate one that becomes increasingly a poor choice and one that can lead to suicidal actions or acts of violence that have the potential to place them in prison. Also, when you work with psychosis long enough, you will learn that auditory hallucinations, while troubling, can often be the easiest symptoms to treat. Delusions can become increasingly fixed with time. The longer patients to go without appropriate treatment, the more fixed and sometimes permanent delusions become. These delusions can be extremely time-consuming and can reduce the patients quality of life. They can inhibit normal social development via isolation and avoidance of school, work, or other activities. Delay appropriate treatment too long in patients with schizophrenia, and you can put permanent dampers on peoples' lives.

There is a long literature indicating medications for psychosis is a bad choice. There is also a long literature list of studies indicating medication is a good choice. At the end of the day, look at each patient individually and make up your judgment. But please base it on the symptoms and circumstances of the patients, do not make it a political or position statement ("I don't medicate psychosis" is about as wise as "Zyprexa is my favorite antipsychotic I always use"). Watching a patient suffer increasingly worse psychosis that puts them at great risk physically, legally, emotionally, and intellectually while withholding a medication that may/will reduce symptoms is an ethically dodgy and paternalistic approach at best.

Edit: I do want to say that I love that SDN can be a place where we challenge community-based standards. Even if it doesn't change our practice, it further informs it.

 

[whopper]

Pros of treating
1-Could cut down hospital stay
2-Ease distress

Cons
1-Could cloud diagnosis (e.g. maybe it was schizophrenia after all or drug exacerbated schizophrenia)
2-side effects of meds
3-As Nemeroff states, when people without mental illness take an antipsychotic, it disrupts what would be a normal functioning system. Hence that's why residents that experimented with antipsychotics (used to happen a few decades ago, doesn't happen now)-e.g. take Haldol 2 mg and be sick for 3 days. Sure it can help while they're psychotic, but then the argument is will it screw them up once the substance-induced psychosis wears off? (I don't know the answer to this myself, in theory it should, but I've seen people do okay after being treated even if it was substance induced).

Of course, if you medicate you have to bear in mind their health status too. E.g. if they have a PCP psychosis, you want to in general avoid antipsychotic treatment and use a benzo.

IMHO depends, and there is more than one right answer. If the person's psychosis is greatly distressing, dangerous, etc. treat. If not that bad, tell them to wait it out and hopefully it'll clear in a few hours, maybe a day or two. Of course the management afterwards depends on what you did in the first place. If you gave meds and they stabilized, the question now becomes do you wean them off in inpatient? I recommend no. Why? It'll extend hospital stay. This can be done as an outpatient.

If the person was treated, and you can't tell if it's primary psychosis (e.g. schizophrenia) or substance-induced, wean the person off very slowly. E.g if on Risperdal 4 mg Q BID, lower it to 3 mg Q BID after a week to month, then follow-up, Then lower it a little more, then follow up. Each step of the way follow it up. This way if it's schizophrenia, you'll see some slightly worsening that can easily be corrected by reversing course on the antipsychotic-taper. When? Depends on the drug. If cocaine do this within days to a few weeks, if K2 or bath salts wait months.
I had a case of a guy with K2 induced psychosis. The guy was not schizophrenic before. He was placed on Risperdal 4 mg Q BID, Depakote, and Seroquel by an inpatient doctor to stabilize his auditory hallucinations and delusions the FBI was after him. Waited one month, weaned off the Seroquel and the Depakote but weaning off the Risperdal led to psychosis again. We waited 6 months. We weaned his Risperdal and was doing fine until about 1-2 months later. At Risperdal 2 mg Q BID he was fine but below that he was psychotic again. We tried 6 months later and the same problem happened. Below that amount he went psychotic.

I told the patient I theorized he may now have schizophrenia, but that given the data on K2 is not in-depth and we don't have studies on this phenomenon to a great extent, I told him every 6 months we could try a taper again, it was up to him. Each time we tapered, and thanks to Risperdal being easily breakable into 1/2 tabs he was able to easily do this on his own while reporting to me over the phone what was going on. If he ever worsened he had enough at home to reverse course and get back onto a higher dosage.

This is a phenomenon that's usually not taught. The effect of a long-term psychosis (meaning months) as a result of psychosis with objective markers showing that it was decreasing in intensity evidenced by the need for less meds but I couldn't tell if it was permanent. Given it was over a year, likely IMHO but I have no strong science to back that up especially since it was K2 induced.

I'm not disagreeing or IMHO significantly adding to what's already been said.

 

[Merovinge]

8mg risperidone, Depakote, AND Seroquel for first episode psychosis, likely substance induced?

 

[st2205]

8mg risperidone, Depakote, AND Seroquel for first episode psychosis, likely substance induced?

My thoughts as well.

Also, I think definition is rather important. If we're waiting hours for something to clear, I'd simply call that an intoxication. I wouldn't label something a substance induced psychosis if they're intoxicated and, when I use the definition, in talking about lingering effects for many days/weeks/months and not hours or a day. In that case I believe letting the delirium/intoxication resolve, unless they're agitated. Typically by the time they've been picked up by police and sat in the ED forever then I'd imagine a lot of that intoxication should have resolved.

 

[clusterF]

There is some data that shows that use of antipsychotics will decrease the frequency of meth use. I have also noted that it increases functionality. Chronic meth users also have psychosis that began with meth, will not necessarily dissipate after remission.

I would be against cessation of antipsychotics in the outpatient setting in the patient who is having active psychosis, even if they are actively using meth (assuming the antipsychotics are helping of course). The judgment needs to be based as purely as possible on risk vs benefit. However, I think the judgment is colored too strongly and too often by the devaluation of drug users in a socioeconomic context.

 

[whopper]

8mg risperidone, Depakote, AND Seroquel for first episode psychosis, likely substance induced?

In a patient I had been seeing for 2 years with no prior psychosis. I was treating him for depression.

K2 is nasty stuff.

I had another guy, in his late 40s, also used synthetic cannabis, became psychotic, and it took another heavy duty regimen to stabilize him. Told him the same thing. I didn't know if it was permanent. Thankfully, in that later guy, his psychosis eventually did go completely away without the use of meds about 3-4 months later.

 

[Indodo]

#1 @whopper what about outpatient?
There is not one but a herd of elephants in the room playa! (I won't mention what ******* movie I just got done watching).

#2 Anwho, you really can't mention nemeroff and be serious anymore these days right? Or did I miss something.

#3 How do all you inpatient guys have so much time on your hands. You post every single day.

 

[shan564]

Roughly half of psychotic episodes with no clear source (e.g. Not from drugs, trauma, metabolic causes) will clear and not return.

I've been wondering recently about this point. I've seen the data that seem to confirm this notion, but as you suggested, I don't have personal experience in an early psychosis clinic. Most of us end up only seeing the patients that progress to schizophrenia. I have seen several early psychosis patients in the ER, and on the occasions that I was able to follow up on their longitudinal course, they all turned out to be schizophrenic or bipolar (of course, that's a self-fulfilling argument - the ones who don't end up developing a chronic illness will probably never see us again, and I'll probably forget about them). Based on that skewed anecdotal experience, many people develop the impression that these "psychotic episodes with no clear source" actually do have a clear source that we were just unable to identify. That's also somewhat reinforced by the idea that some studies say that brief psychotic disorder has a 30-50% chance of progressing to schizophrenia, while others find a 70% chance - I've always just averaged them to 50% for the purpose of counseling patients and teaching students, but I wonder if study methodology (i.e. doing an adequate job of finding an underlying drug-induced or medical etiology, or adequately ruling out people who are having a first episode of a bipolar illness) contributes to that.

As an intern, I once cared for a patient with a brief psychotic disorder in context of a lot of severe psychosocial stressors. His psychosis cleared up pretty quickly with treatment. I was really optimistic that he might be in the 50ish% of people who resolve completely. I counseled the patient and his mom extensively that it could go either way. Several months later, I just so happened to run into his mom again because I was taking care of her husband on inpatient internal medicine. She said that he'd stopped taking his risperidone and was more psychotic than ever. I was really quite disappointed...

So I guess my question is - does your clinical experience in early psychosis clinic line up with this published data? If so, that's a pretty strong argument to suggest that an early psychosis clinic should be a bigger part of residency training.

 

[notdeadyet]

Based on that skewed anecdotal experience, many people develop the impression that these "psychotic episodes with no clear source" actually do have a clear source that we were just unable to identify. That's also somewhat reinforced by the idea that some studies say that brief psychotic disorder has a 30-50% chance of progressing to schizophrenia, while others find a 70% chance - I've always just averaged them to 50% for the purpose of counseling patients and teaching students, but I wonder if study methodology (i.e. doing an adequate job of finding an underlying drug-induced or medical etiology, or adequately ruling out people who are having a first episode of a bipolar illness) contributes to that.

I think you're right that some of the brief psychotic episodes likely have some etiology we just never discover. I think for the rest of it, it's just the nature of psychosis. Some folks just have a genetic load for psychosis and will never experience symptoms. Others will have an event or trigger that causes a psychotic episode that will go away and they will never have another. Others will have an event or trigger that causes an episode that develops into a chronic condition.

That's not a great explanation for you or for patients, but it has some utility. I basically draw out an X/Y relationship with X being time and Y being trigger threshold at which folks will have a psychotic episode. Most of us are very low on the Y axis and even with intense stressors/triggers, we will not experience psychosis. But others are higher on that Y axis and it doesn't take as much of a stressor/trigger. When folks have their first episode, we decide whether or not medications are necessary but then we also look at what we can do to protect people from the stressors or triggers that would contribute to a second episode or developing chronicity. No weed, no meth, no cocaine. Improved sleep/wake cycles. Etc. There's a reason why you get such a high predominance of schizophrenia cases in the VA who had their first break in basic training. There's a reason why you can do a great job of stabilizing a patient after their first episode, think you're out of the woods, only to have them out in the community and have a second one months later ("I was with some friends, smoking some weed...").

As an intern, I once cared for a patient with a brief psychotic disorder in context of a lot of severe psychosocial stressors. His psychosis cleared up pretty quickly with treatment. I was really optimistic that he might be in the 50ish% of people who resolve completely. I counseled the patient and his mom extensively that it could go either way. Several months later, I just so happened to run into his mom again because I was taking care of her husband on inpatient internal medicine. She said that he'd stopped taking his risperidone and was more psychotic than ever. I was really quite disappointed...

Yeah, that happens. Senior faculty who've worked at this clinic for years sometimes eyeball the quality of someone's first break and make a guess as to whether or not it's going to develop into schizophrenia, but when you press them they admit that it's mostly an exercise. They look at how well-formed the hallucinations are, how complex the paranoia, etc., but they admit that it's mostly tea leaf reading. I've been fooled by folks I thought surely would get schizophrenia who didn't and folks who I thought wouldn't who did. Family history is the only fairly damning factor I've really seen in psychosis of unknown etiology.

So I guess my question is - does your clinical experience in early psychosis clinic line up with this published data? If so, that's a pretty strong argument to suggest that an early psychosis clinic should be a bigger part of residency training.

Yes, to the first (if you mean the percentage of who develops schizophrenia), though my n is not what it should be to say that with any authority. The folks with a lot more experience seem to agree with those numbers though.

The nice thing about working in an early psychosis clinic is that you don't lose nearly as many to follow-up as you would otherwise. EPCs tend to be at tertiary care centers, so there's a hurdle just to get there. We tend not to lose folks to follow-up because folks who develop into schizophrenia want the services an EPC offers (lots of studies so there is brain stimulation software, CBT-psychosis, novel use of other medications, etc. plus a supportive clinic environment in which times are a little loose and we fit people in PRN) and folks that want the sort of reassurances we can't provide, so we'll follow folks who are well for a few years, having them stop by quarterly then semi-annually for evaluation and testing. This gives a longitudinality that you don't often get if your experience is tracking from the ED/PES.

I do thing early psychosis clinics should be a bigger part of residency. I'm in the reserve corps in the Army and the first thing I stress to all of the mental health providers I train is how to recognize early psychosis. Catching it early can prevent a lot of pain, violence, lost quality of life, and incarceration. My working at an early psychosis clinic didn't give me a good feel for detecting what will and won't develop into schizophrenia (at least not yet) but it has given me a pretty good skill for recognizing psychosis in the early stages, which a lot of folks misdiagnose as Axis II, mood, or any number of things. A full blown psychotic episode is often easy to spot, but early psychosis is usually more insidious. Very rarely do you have someone all of a sudden hear voices and have delusions that didn't show some of the negative signs or mild disorganization first. If you catch it early, it is helpful to prevent a full blown episode and all the disruption and trauma that causes. Even for folks that will develop schizophrenia, if you can stave off a major break for just a few more years, that's often the difference between attending college and not. That difference can mean a lifetime of better employment and better social interaction that comes from being well in your early 20's and learning to make adult-level relationships independently.

We get a lot of folks that we eyeball in other clinics that were misdiagnosed with bipolar. You get to the point that you can sort of eyeball who is your patient in the waiting room by some very soft signs. I wish more residencies had clinics like these not just for the sake of resident training but for improved services for patients. You can do a lot of good by helping folks early with any disease, but especially psychosis. But these clinics take funding, which can be hard to come by, especially when you're advocating for schizophrenia instead of, say, PTSD or Eating Disorders.

 

[whopper]

#2 Anwho, you really can't mention nemeroff and be serious anymore these days right? Or did I miss something.

Nemeroff got in trouble and he deserved the flack he received, but he is still brilliant, and he's done some incredible teaching. I do fault him for his breach of ethics. I've always said that one deserves to make money so long as they are following the rules and it's not unethical. He made the money but he did breach the ethics and rules.
That said, I'd still rather go to his lectures than many others cause his stuff is cutting edge and he is a very good speaker. You just got to factor in his past and keep perspective but I've never seen him endorse any specific meds at any of the lectures I've seen.

I do both inpatient and outpatient and the jail that is kind of a combination of both. The serious patients go to an infirmary that is the equivalent of an inpatient, the not so bad ones go to the clinic that is kind of like outpatient.

 

[smalltownpsych]

ah okay. my argument is more most psychotic people with correct diagnoses of schizophrenia or bipolar disorder do not need longterm treatment with antipsychotics. there is no evidence to support this practice and some evidence to suggest it worsens the illness course which is entirely biologically plausible.

One challenge with this approach is that our entire mental health system is organized around "Did you take your meds?" as being the solution to everything. I love that you are versed in the research that points to life-long medication not being the only or even the best answer for serious mental illness. Mental illness is not analogous to diabetes no matter how much the sales force for the pharmaceuticals would like to promote it as such.

 

[st2205]

One challenge with this approach is that our entire mental health system is organized around "Did you take your meds?" as being the solution to everything. I love that you are versed in the research that points to life-long medication not being the only or even the best answer for serious mental illness. Mental illness is not analogous to diabetes no matter how much the sales force for the pharmaceuticals would like to promote it as such.

I think mental illness is actually quite analogous to diabetes. The perception of mental illness in society is polarized between people thinking people's problems are just poor coping skills and those who feel that there are no bad or maladaptive people, just people who have a disease they can't control. I find diabetes a suitable comparison. Diabetes has vastly different etiologies. You've got type I diabetes which would fit more along the "you've got a legit disease" end where, though lifestyle is clearly important, you've got a legitimate underlying pathology that isn't fixed by lifestyle. On the other hand, you've got this whole spectrum of insulin resistance where it's mostly lifestyle that is the ideal treatment and throwing oral hypoglycemics (or even insulin) is just trying to mitigate the problems that should ideally be managed with lifestyle. Naturally, this is an oversimplification but you get the idea. The vast majority of diabetics, by a significantly large margin, are type II. I see this similar to mental illness and axis I and axis II pathology. Unfortunately with both diabetes and mental health, we tend to throw medications at it. And typically society and patients view it as a medication problem that the physician is responsible for controlling and not something they need to take as much ownership of.

 

[smalltownpsych]

I think mental illness is actually quite analogous to diabetes. The perception of mental illness in society is polarized between people thinking people's problems are just poor coping skills and those who feel that there are no bad or maladaptive people, just people who have a disease they can't control. I find diabetes a suitable comparison. Diabetes has vastly different etiologies. You've got type I diabetes which would fit more along the "you've got a legit disease" end where, though lifestyle is clearly important, you've got a legitimate underlying pathology that isn't fixed by lifestyle. On the other hand, you've got this whole spectrum of insulin resistance where it's mostly lifestyle that is the ideal treatment and throwing oral hypoglycemics (or even insulin) is just trying to mitigate the problems that should ideally be managed with lifestyle. Naturally, this is an oversimplification but you get the idea. The vast majority of diabetics, by a significantly large margin, are type II. I see this similar to mental illness and axis I and axis II pathology. Unfortunately with both diabetes and mental health, we tend to throw medications at it. And typically society and patients view it as a medication problem that the physician is responsible for controlling and not something they need to take as much ownership of.

I also use diabetes management as an analogy to other types of behaviors so am comfortable with that. I was referring more to the message that the brain doesn't make enough serotonin just like the pancreas doesn't make insulin in diabetes. The brain is a bit more complex than the pancreas.

 

[st2205]

I also use diabetes management as an analogy to other types of behaviors so am comfortable with that. I was referring more to the message that the brain doesn't make enough serotonin just like the pancreas doesn't make insulin in diabetes. The brain is a bit more complex than the pancreas.

But DM most often has very little to do with your pancreas not making enough insulin but rather your tissues too resistant to its effect as a result of lifestyle-modifiable factors.

So people too often see their poor life as a result of a serotonin problem just as much as a type II diabetic would see his problem as not making insulin (both of which are rather inaccurate, particularly in the latter).

 

[smalltownpsych]

But DM most often has very little to do with your pancreas not making enough insulin but rather your tissues too resistant to its effect as a result of lifestyle-modifiable factors.

So people too often see their poor life as a result of a serotonin problem just as much as a type II diabetic would see his problem as not making insulin (both of which are rather inaccurate, particularly in the latter).

Exactly. Most people see it in more simplistic terms and that's what they are marketing. I was merely pointing out one of the fallacies that pharmaceutical companies use to keep selling their medications even when people don't need it, but for a more extensive treatise, Splik has the info. The Soteria research on psychotic disorders is very enlightening and thought provoking. I believe medications can be an integral part of treatment, I just think that various heuristics often lead to an over-emphasis of this aspect of mental health. Like the severe attachment disorder kid who has serious emotional dysregulation and rage who gets the cocktail of meds to little avail because the research wasn't done on that kid anyway.

 

[Indodo]

Roughly half of psychotic episodes with no clear source (e.g. Not from drugs, trauma, metabolic causes) will clear and not return. If the patient is willing and able to tolerate the effects of psychosis more so than the effects of the medication and can do so safely, this is a very sensible route. This is often the approach taken in an early psychosis clinic.

So what about the theory of psychosis as a toxic state?
What if someone has brief relapses but intermittently does well.
Put them on an antipsychotic or wait for the psychosis to return each time and see if it clears again.