Within this Independent study drug induced psychosis will be looked at. Within the first two pages a definition will be given as well as a brief history. This will be followed by a discussion on drug induced psychosis how individual is a affected and what is the cause. The author will then look at the drugs and how they affect people mentally and physically as well as how they affect the brain. When the final few pages it the author will look at the evidence and literature available for drug induced psychosis before then commenting on personal recommendations and the conclusion of all findings. The rationale behind choosing this topic was simply that more and more people through subculture and their own vulnerabilities are accepting of drug however through their own naiveté and lack of understanding are consequences he consequences and consequences
According to Mosby (2009), drug induced psychosis is a psychotic state caused by an excessive dose of both illegal and therapeutic drugs. This is supported by the West Australian Department of Health [WADOH](2009) who defines stimulant-induced psychosis, as an episode where the use of a legal or illicit drug has caused a psychiatric illness where the reality of the patient is impaired. The impairment of the patient can also include hallucinations or delusions, which can cause additional communication problems or social interaction difficulties. The drug induced psychosis according to WADOH (2009) may also be as a result of the overuse or abuse of prescription medication, or the outcome of a history of illicit drug abuse.
Razool (1998) describes the historical evidence for substance abuse dating back thousands of years. Tobacco, alcohol and other psychoactive drugs have bee used by different societies for medical, religious, cultural and religious purposes and acts as a social lubricant. Today there is no lack of interest in the use of psychoactive substances and plants. Alcohol and drug use remain part of the social and psychological fabrics of our society and are now regarded as a public health problem. Attitudes towards drug use have changed during various stages historically and even with harsh laws, there still remains problems in society where drug education and drug treatment is required by society (Razool, 2008). Tea, coffee and tobacco have all been illegal in Britain at some stage (Whitaker, 1987 cited by Razzol, 2008). Alcohol and drug use can cause a host of physical, social, psychological and economic harm, not only to the individual, but also to the family and the wider community. If the individual has previously had psychosis the use of drugs or alcohol can increase the likelihood of another psychotic event. This is due to the fact that the individual can become emotionally unstable, due to their drug use along with their loss of cognitive processing and therefore, inhibits the chemical balance of the brain (Royal Brisbane and Women’s Hospital, 2009).
Within this section use critical analysis and relevant referencing to show a lack of information provided and the difficulty clinical nurses face while battling this.
Drug induced psychosis
According to studies by REF, Psychosis can be induced by the misuse of drugs, such as Cocaine and Amphetamine and Cannabis, which according to Arendt (2005), has been linked with the development of early onset psychosis. However, these drugs can trigger psychosis, particularly in someone who is already an increased risk because they have “vulnerability”. This is then known as drug induced psychosis WADOH (2009); Royal Brisbane and Women’s Hospital,( 2009). National Health Service [NHS] (2009). This type of psychosis which is normally the result of long term or heavy drug use, generally lasts only a couple of days and is characterised by confusion, memory loss, delusions and hallucinations, that responds well to treatment (WADOH,2009). While the majority of drug induced psychosis responds well to treatment there are individuals who from their drug use develop persistent psychosis.
Early intervention program (Canada Health 2004)
The diagram above depicts how an individual with the vulnerability factors can combine, to cause psychosis. The full jar represents a person with psychosis. As the individual has a predisposition towards psychosis, the addition of environmental factors, increases the individual’s risk of developing psychosis to increase, and over time, this can lead to the development of full psychosis.
Early intervention program (Canada Health 2004)
When the individual reduces the environmental factors such as illegal drugs their jar of risk comes to a point where the individual is not affected by psychosis. Additionally, the second diagram indicates how the psychosis can be overcome and managed, using medication and coping strategies, thus enabling the individual to continue with their every day life in the community.
How drugs affects individual’s mental and physical health
Marijuana, weed, and dope, skunk (cannabis): people smoke cannabis to relax and get high, however the short term affects of this can make it difficult to remember things, even if they’ve only just happened. According to Barnes (2008), cannabis can cause anxiety attacks or feelings of paranoia, and using a lot of cannabis regularly, may be putting oneself at risk of suffering confusion or delusions. However, as a long term affect the individual who smokes cannabis might trigger long-term mental health problems, according to Barnes (2008; Nutt, 2007) including psychosis, schizophrenia and depression. Rounsaville’s (2007) research indicates that if the drug addiction is treated, the psychosis level will be reduced. The environmental factor of cannabis and its effects in relation to schizophrenia, needs further research according to Rounsaville (2007); as there appears to be some long term implications, indicating that use of high strength cannabis, triggers schizophrenia.
Methylenedioxymethamphetamine (MDMA, also known as Ecstasy)
MDMA (Ecstasy) in the short term can provide relaxation and energy to users but can also have the opposite effect where the individual will become paranoid, aggressive and anxious (Barnes, 2008). Nutt (1996; 2005) highlights that regular long term usage of MDMA can cause sleep imbalance problems, lethargy, and anxiety. However, there is some debate over whether MDMA causes depression. While Barnes (2008, Nutt, 1996 & 2005) states MDMA can cause depression, Gillette et al(2006) found that within their study, MDMA on its own, does not cause depression in male or female participants. Gillette et al (2006) found that MDMA may contribute to depression symptoms, if the individual was female and a heavy cannabis user. They report, that dose specific connection between MDMA and depression was most likely due to women having lower body weights then men. Nutt (2005) advises that MDMA users with depression, once they discontinue taking MDMA, are likely to improve their mental state of mind.
Amphetamine and methamphetamines (Speed and crystal meth)
These drugs provide the user with initially an energetic feeling, along with confidence but, along with highs, there can be panic attacks, irritability and paranoia, according to Barnes (2008).
Methamphetamine can provide an intensive and prolonged high, but also known for severe comedowns, where individuals may experience feelings of sadness or depression.
Nutt (2003; Nutt, 1996) has indicated that there is some evidence of individuals who appear to be permanently depressed, due to the long term use of intravenous amphetamines.
BNF (2008) states that benzodiazepines are routinely used within clinical care, as a sedative to calm patients down who are distressed. One of side effects of benzodiazepine usage is that, the body develops resistance, therefore an increased dosage may be needed, in order to experience the same effect. This medication is highly addictive, and withdrawal can be difficult to manage without medical supervision. Rapid withdrawal from high dosages according to the BNF (2008), can cause severe convulsions. Ashton (2005) advises, that benzodiazepines can cause cognitive impairments and have the paradoxical effect of aggression and inhabitation. The use of benzodiazepines, according to Ashton (2005), has been controversial, due to concerns about the adverse psychological and physical effects that they can cause, along with the tolerance. Once the individual has completed the withdrawal from benzodiazepines according to Ashton (2009) they generally have improved mental health. However, the elderly seem to have an increased risk of experiencing short term and long term adverse effects from this drug.
According to Barnes (2008), cocaine can have a tendency to make the individual feel elated in mood, over confident, as well as energetic. This however, according to Nutt (2005), can also create feelings of anxiety, paranoia and panic. Some of the side effects from cocaine usage include depression, lethargy and mood imbalances (Nutt, 2005; Barnes,2008).
As a member of the opioid family, Barnes (2008) states that heroin provides the user with cessation of physical pain and provides emotional detachment. Murphy (2006) declares, that heroin is physically addictive and that overcoming this addiction is difficult. Maintaining sobriety for former heroin users, can be very difficult due to its high level dependence.
Figure 1: Dependence Levels of psychoactive drugs vs Physical Harm
(Nutt et al 2007)
Figure 1 above, demonstrates the scale of physical harm that each drug can inflict on the user with 0 indicating little or relatively no harm and 3 being serious harm including death. The addictive nature of the drug is also measured on the same scale where dependence is described as 0 for little or no dependence, to 3 as highly addictive.
How drugs affect the brain
The various drugs listed above have an effect on the brain chemistry. Psychotropic substances are substances which act upon the brain function to change perception, mood, consciousness and behaviour. Johnson (2009), believes that psychotropic drugs are often associated with addiction; these can be divided into two types; psychological and physical addiction. Psychological addiction is where the user feels that they have to use the drug, although they may be aware of negative, physical or emotional consequences. Physical dependence, is where a user must use a drug to avoid physical, uncomfortable or medically harmful symptoms. However, not all drugs are physically addictive. Nevertheless, any activity that stimulates the brain’s dopaminergic system with a pleasurable activity, can lead to a psychological addition (Zhang, 2001).
National Institute on Drug Abuse (2009)
Literature to evidence
In a mental health setting, 20 percent of the admissions of patients according to Thompson et al (2004), are as a result of psychosis. A further 1.7 percent of patients, are admitted to mental health facilities, as a result of substance misuse (Thompson et al, 2004), with this high number of patients who are experiencing psychosis, the nurse practitioner, needs to be aware of possible reasons for the psychosis. According to Shaner et al (1987), 74 percent of patients in his study, were difficult to characterise, due to diagnostic confusion. These patients had chronic psychosis and a history of substance abuse. The researchers had difficulty in determining a definitive diagnosis as to what was causing the patient’s psychosis. The most common factors that made the diagnosis unclear was that there was continued drug use (78%), reduced memory (24%), and conflicting reporting of symptoms (20%). This difficulty in diagnosis, transfers to difficulty in developing treatment plans and the management of patients on the ward. If the individual is only treated for their mental health without addressing the addiction, the treatment plan is not addressing the cause of the mental health imbalance. Rounsville (2007) identifies that the failure to consider the comorbidity of psychotic disorders and substance misuse, undermines the treatment of individuals with mental health needs.
The Department of Health [DoH] (2006) states that clients/patients who endure more server and complex substances use will require specialist interventions such as opiate dependence, the management of severe cannabis dependence, for drug or alcohol use in the circumstances of more complex problems. In these situations, integrated, joint or coordinated working with substance misuse services, is to be expected.
Nevertheless the National Alliance for Mental Illness [NAMI] (2008) highlights that it can be very difficult to find appropriate treatment opportunities. Unfortunately many substance-abuse centres do not accept people with serious psychiatric conditions, and inversely many psychiatric centres do not have the required expertise with substance abuse.
What my recommendations would
The potential reasons for the individual’s mental health need to be addressed and thus both the mental illness and the substance misuse must be treated. A recommendation from the research is that services for substance misuse should be provided for mental health patients. Although the biggest substance misuse service within in the Merseyside region is the lighthouse project they are not officially on the wards and patients in secure environments have to be referred to them off the ward. This situation does not help those patients who have a substance misuse problem and who are unable to access the service since they are unable to leave the ward as they do not have Section 17 leave under the Mental Health Act [MHA] 1983 which was updated in 2007. If the substance misuses treatment program was sponsored and available on the ward this could potentially reduce the number of psychotic incidences and the revolving door admittance patterns of a number of patients. For some patients the ward environment is an opportunity for them to be removed from their substance and thus they are able to gain better mental health due to drug abstinence but as these individual patients do not have the coping strategies for dealing with their addiction they struggle when released from the ward. There are patients who routinely are admitted on a regular basis and it seem that sometimes the mental health support provided is just patching up the underlying problems and not dealing with it. By having services on the wards to address the substance misuse problem it would allow patients to identify their own weakness and develop coping strategies through the service. With coping strategies in place the patient would be enabled transition to an external service with support when they are discharged, so they can cope with the temptation and the addiction off the ward.
If there was more integration and multi-agency working the lives of many individuals would have the potential improvement as they hopefully could be less dependant on health and social services and thus have greater participation in the community.
With greater interagency working and access to substance misuse services while in the community some of the patients’ mental health would not have deteriorated to the point where they were sectioned. There appears to be a well known division between mental health services and substance abuse services. If there was more integration and interagency working within the community and on the wards the better potential long term outcomes for a large percentage of the patients who have a dual diagnosis of mental health and substance misuse.
Nursing and other medical staff members on the wards need to have a greater awareness of the reasons why their patients may have a secondary mental problem from substance misuse and thus be aware of the issues the issues patients are battling with on and off the wards. With more awareness about the impact of drug misuse on mental health better treatment plans can be developed. Another recommendation is that there needs to be further funding into the effects of drug misuse has on individual’s mental health along with research in developing treatment plans which are effective for patients with dual diagnosis. From the additional research further training and practice development could be implemented so that mental health practitioners are better tooled to support their patients.
Throughout this independent study the conclusion reached was that drug induced psychosis is not caused by the misuse of substances alone but by many triggering factors such as environmental factors and vulnerabilities such as a family history of mental health. However during this study it was made clear to the author that drugs do play an important part of this psychosis because of there properties (stimulating the dopaminergic system) and side affects (needing due to physical discomforts) which causes the individual who may already have vulnerabilities to continue drug use therefore increasing there risk of psychosis. Nevertheless through this independent study it has been made clear to the author although drug induced psychosis is common within the mental health field due to the present culture there has still been little research into it. Most articles that where found where out dated, as there appears to be a gap of research interest and funding into substance misuse and long term mental health illnesses. As a result nurses often lack detailed understanding and knowledge of this type of patients’ needs and treatments they require such as psychologically and physical.
If there was any one recommendation that the author would be able to make happen it would be the integration of drug counselling and therapies within the mental health hospital setting therefore allowing those patients who do not have access to Section 17 (MHA, 1983&2007) leave a chance to also access these specialised services. This would be part of the treatment plan and patients as a must should be encouraged to engage with these services or run the risk of losing leave personally there are to many revolving door patients which to an extent shows how the current system is failing them rather than dealing with there mental health we also have to deal with there drug addiction.