Mental Health Monthly #14: Substance-Induced Psychosis (Part II)

In this second episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the various treatment modalities for substance-induced psychosis. They explore pharmacologic treatments, inpatient and outpatient treatments, and ways that emergency providers can improve their care for psychiatric patients with comorbid medical conditions. Lastly, they consider the different causes for repeat visits from mentally ill patients. Key Points: Pharmacologic treatments for substance-induced psychosis are similar to those for other types of psychosis; these include medications like Zyprexa, Haldol, and, as a third-line treatment, IM Thorazine. Droperidol is used more commonly in the emergency setting, compared with the psychiatric setting. Given the risk for respiratory depression from Zyprexa combined with benzodiazepines, psychiatrists may choose to use Thorazine or Haldol/Ativan/Benadryl instead. It is important to reassess patients after substances wear off to determine whether they meet criteria for admission to inpatient psychiatry, though psychiatric assessments are limited by geographic constraints. The admitting psychiatry team will reassess the patient to differentiate substance-induced psychosis vs other psychoses; often this includes obtaining collateral. Helpful notes from the ED include: medications administered or restraints placed (can help extrapolate a patient's level of agitation), vital signs, prior records. Some people will be more open about suicidality while intoxicated and less open about it while sober so it is important to obtain additional information for corroboration. On average, patients stay in the detox unit for 3-4 days, though some may stay longer for protracted substance-induced psychosis if they have a long-standing history of daily substance use. It is important to discharge patients with quick follow-up and potential placement into the various mental health programs including partial hospitalization, residential, or outpatient programs. Emergency rooms can improve by taking psychiatric patients seriously, especially when they are transferred to the hospital from a psychiatric facility for medical management. Repeat visits stem partially from the ambivalence that accompanies substance use disorders, including patients' difficulty in giving up the substance due the purpose it may serve in their lives. Many substance use disorder programs are siloed from the medical system, which pose a challenge to interdisciplinary communication.