Comorbidity
drug and alcohol induced mental illness
What is it all about?
Drug and alcohol induced mental illnesses fall into four main categories: psychosis, delirium, dementia and mixed disorders. Serious mental illness is more commonly found with some patterns of substance use and with some drugs more than others. Make sure that you have digested the How Do Drugs Work? page and particularly take time to go through the slide show about drugs and their effects. What is important is an awareness of serious mental illnesses associated with substance use and knowing what to do when presented with a mentally ill individual. The What is Comorbidity? page looks at why serious mental illnesses, such as bipolar disorders or schizophrenia, will be managed by mental health services whereas these drug and alcohol induced disorders are likely to fall within the ambit of addiction services…
Psychosis
Psychosis is when people lose contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true or considered true within the prevailing culture (delusions). It may also involve confused (disordered) thinking and speaking. Drug or alcohol induced psychotic disorder is characterised by symptoms that develop during or soon after intoxication or withdrawal but are more intense and longer lasting than anything due to intoxication or withdrawal. In making a diagnosis it is important to distinguish whether there is a pre-existing psychotic disorder or one triggered by the substance use (such as schizophrenia).
Drugs causing psychosis
Hallucinogens
Stimulants
Dissociatives
Cannabis/ Spice
Drug or alcohol induced psychosis is quite variable in severity and duration but outcomes are generally good: on cessation of use, 60% resolve within one month, 30% between one and six months, and 10% more than six months. Hallucinogens, LSD and psilocybin, stimulants, cocaine and amphetamine, and dissociatives, ketamine and PCP, are strongly associated with psychosis. For cannabis it is the most potent varieties including synthetics that are most likely to cause psychosis. Less potent stimulants, party drugs, alcohol and sedatives are much less likely to cause psychosis.
Persistent psychotic symptoms are more common in those with a family history of mental illness, an earlier age of onset of illicit drug use and a longer history of illicit drug use. For those with symptoms lasting more than six months, about half were reassigned to a diagnosis of schizophrenia triggered by drug use. The experience did not deter further substance use: 90% restarted illicit drug use after treatment for their psychosis.
Party drugs
Alcohol
Sedatives
Use the PQ16 Questionnaire test for psychosis.
Experiencing a psychotic episode
In this video the actor David Harewood talks about his own experience of psychosis which arose from a period of heavy drinking and cannabis use. It is important to note that psychosis can happen to a person previously in good mental health and also that it is most likely to resolve completely unless the person was predisposed to serious mental illness. (7½ minute video)
David Harewood is an actor, director, author and activist.
Delirium
Delirium is characterised by confusion that develops within a short period of time. People become disorientated for time, place and, in severe cases, who they are. There may be vivid hallucinations, most commonly visual or tactile, which are often frightening. Typically there is disturbance of behaviour, emotion and sleep. There may be impaired consciousness with fever, tachycardia and sweating. It is important to distinguish other causes of delirium (such as infections or trauma). The opposite of this, drowsiness and in and out of consciousness, can also occur.
Drugs causing delirium
Stimulants
Party drugs
Alcohol
Sedatives
Intoxication delirium from excessive use of stimulant drugs is rare. The overall mortality rate is put at 8-16% but many of these deaths are associated with particular methods of restraint and tend to occur in police cells or psychiatric hospitals. Deaths occur suddenly within hours of the onset of delirium. There are thought to be genetic factors that predispose some people to poor outcomes.
Withdrawal delirium, most commonly from alcohol, is potentially fatal and a medical emergency. The overall mortality rate is put at 5-10%. Provided that treatment for the delirium is of a high standard then mortality is mainly associated with other pathology, such as liver cirrhosis, sepsis, pancreatitis, hypertension and general poor health, which may have enforced a period of abstinence which in turn led to the onset of delirium.
Dementia
Dementia symptoms typically include memory impairment alongside other losses of brain functions: attention, language, social cognition and judgment, psychomotor speed, visuoperceptual or visuospatial abilities. Behavioural changes may also be present and, in some forms of dementia, may be the presenting symptom. Impairment is not attributable to normal aging or to current substance intoxication or withdrawal.
Drugs causing dementia
Alcohol
Stimulants
Stimulant drugs cause micro-bleeds in the brain thereby destroying brain tissue. Alcohol is directly toxic to brain cells especially in the frontal lobes. Amnesia caused by intoxication with alcohol or other depressant drugs is not dementia but to do with not registering memory traces.
On standard tests of cognitive functioning heavy drinkers may score below the normal range. This may resolve completely in 2-3 months of abstinence but deficits may endure if cell damage has occurred from various causes. Longer term cognitive impairment may resolve over 2-3yrs or may be residual, possibly permanent, damage from concomitant pathology.
The picture shows a normal 43yr old brain (left) and that of a 43yr old heavy drinker (right) showing large areas of brain cell loss.
Vitamin deficiency syndromes
A thiamine deficiency syndrome is manifest by a confusional state, disorientation, ophthalmoplegia, nystagmus, diplopia, and ataxia (Wernicke encephalopathy), with severe loss of memory for recent events and confabulation (the invention of accounts of events to cover the loss of memory) (Korsakov psychosis) occurring following recovery.
Drugs causing vitamin deficiency
Alcohol
Thiamine deficiency syndrome develops over a period of months and so there is scope for prevention. Low circulating levels of thiamine have been reported in 30–80% of dependent drinkers: the incidence and the extent of depletion varies depending on the degree of malnutrition, liver damage, and alcohol intake. Recurrent ‘subclinical’ episodes of Wernicke’s may go unnoticed or there may be a single episode where untreated Wernicke’s results in permanent brain damage and memory loss. Wernicke’s must be treated urgently with Pabrinex.
This is what to do about it…
If someone has a mental illness the first people to recognise what is happening are most often family and friends, though it may be that primary care services or addiction services are the first contact. The point is, it will probably not be mental health services who are first to help with the problem. The exact nature of the mental illness does not matter, what is important is making the right response at the right time. There are several possible situations to be considered…
The person has florid symptoms such as hallucinations, delusions and confused or incoherent talk and they can be seen as a danger to themselves or others, or there may be drowsiness and disorientation. It is likely that this person will need to be in hospital. This requires immediate action: i) the police have powers to take people in this state to a place of safety ii) there may be an emergency psychiatric service or psychiatrist on the staff of the addiction service.
The person is clearly unwell but not a danger. There may be hallucinations or delusions but they are not too troublesome and the person has adequate support. This requires urgent action: i) try to find out if the person is known to mental health services and, if not, make an urgent referral ii) make an immediate care plan and revise after consultation with mental health services.
The person has a history of serious mental illness but seems currently to be well or at least symptom free. This requires timely action: i) find out if the person is known to mental health services and, if not, make an urgent referral ii) review the care plan accordingly.
For all heavy drinkers, whenever seen, check out if there has been a neglect of diet and, therefore, a risk of vitamin B1 deficiency. If ‘yes’ then there is a need for timely action to give oral vitamin supplements. If there are symptoms or signs of deficiency such as drowsiness, disorientation or double vision then this requires immediate action: i) give parenteral vitamin B1 or, if not available ii) take to A&E.
How to manage psychosis
In this video there are some more explanations of what it is like to experience an episode of psychosis. For practitioners Jessica Bird describes in some detail the research evidence for how to approach helping someone going through a psychotic episode. The guidance she gives is practical and can be implemented by all professional groups. Naturally the general guidance needs to be applied carefully to suit each individual. (15 minute video)
Dr Jessica Bird is a Research Clinical Psychologist & NIHR Research Fellow
