eMedicine Specialties > Psychiatry > Addiction

Alcohol-Related Psychosis: Follow-up

Author: Michael Larson, DO, Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard University
Contributor Information and Disclosures

Updated: Oct 9, 2008

Follow-up

Further Inpatient Care

Admit for observation if further withdrawal, cognitive impairment, psychosis, and medical complications occur.

Further Outpatient Care

  • A day treatment program or partial hospitalization can be used for those who do not require a highly structured inpatient environment. Daily individual, group, and weekly family therapy provide intensive treatment that is similar to inpatient settings. Programs specifically designed for substance abuse also provide daily substance abuse meetings and education. Medication evaluations and monitoring assure stabilization in the least restrictive environment.
  • Institute a psychiatric follow-up visit within 2 weeks of the initial evaluation to assure compliance.
  • Consider a follow-up examination with a neurologist or internal medicine specialist, depending on the complications of alcohol abuse.
  • Carefully monitor patients for recurring psychosis, depression, and relapse of alcohol use.

Inpatient & Outpatient Medications

  • If the psychosis has resolved and the patient is medically stable, no further medication is needed.
  • If psychosis persists beyond elimination of the offending substance, an atypical antipsychotic drug (eg, risperidone, olanzapine, quetiapine) may be considered. No single atypical antipsychotic drug has been proven most beneficial for treatment of persistent alcohol-related psychosis.
  • Once thiamine levels have been restored, daily multivitamins are recommended to maintain appropriate levels of essential vitamins that often are depleted in patients with alcoholism.
  • Disulfiram (Antabuse) is an agent indicated to facilitate abstinence from alcohol. This can be started 12 hours after a patient consumes alcohol (125-500 mg/d).
  • Continue thiamine (100 mg PO tid).

Transfer

  • If psychosis persists past initial treatment, the patient may be suffering from an undiagnosed psychotic disorder, such as schizophrenia or bipolar affective disorder. Inpatient psychiatric hospitalization may be required for diagnosis and psychopharmacological treatment.
  • If a risk of delirium tremens or suicide is present, transferring the patient to a psychiatric inpatient unit might be required.
  • A day treatment program or partial hospitalization can be used for those who do not require a highly structured inpatient environment. Daily individual, group, and weekly family therapy is provided. Programs specifically designed for substance abuse also provide daily substance abuse meetings and education. Medication evaluations and monitoring assure stabilization in the least restrictive environment.

Deterrence/Prevention

  • Prevention is a result of abstinence and is the primary treatment of choice. Some patients may achieve success by attending 90 AA meetings in 90 days.
  • A sponsor (a recovering alcoholic committed to sobriety) helps provide a support network for attending meetings and seeking community resources.

Complications

  • Theoretically, alcohol may potentiate or initiate a psychotic disorder, such as schizophrenia, through kindling, a process where repetitive neurological insult results in greater expression of disease.
  • In some instances, psychosis may persist and may be considered by DSM-IV-TR criteria as a substance-induced psychotic disorder.
  • Other complications may include the following:
    • Increased risk of suicide
    • Increased risk of depression
    • Increased psychosocial impairment

Prognosis

  • Alcohol-related psychosis is indicative of severe alcohol abuse and suggests a poor prognosis. The prognosis is similar to that of severe alcoholism.
  • Of all psychosis cases, 10-20% tend to become permanent.
  • Symptoms of any accompanying Korsakoff syndrome (amnestic disorder) are highly resistant to treatment because of the irreversible neurological damage.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize and treat associated conditions, delirium tremens, Wernicke-Korsakoff syndrome, subdural hematoma, and medical complications
  • Failure to evaluate for ingestion of potentially dangerous illicit drugs or medications
  • Failure to evaluate patient's potential for suicide and homicide
  • Discharging an intoxicated patient
  • Allowing an intoxicated patient to drive
 


More on Alcohol-Related Psychosis

Overview: Alcohol-Related Psychosis
Differential Diagnoses & Workup: Alcohol-Related Psychosis
Treatment & Medication: Alcohol-Related Psychosis
Follow-up: Alcohol-Related Psychosis
References
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References

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  4. Kaplan HI, Sadock BJ, eds. Pocket Handbook of Emergency Psychiatric Medicine. Baltimore, Md: Lippincott Williams & Wilkins; 1993:93-4.

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  7. Fogel B, Schiffer R, Rao S. Neuropsychiatry. Baltimore, Md: Lippincott Williams & Wilkins; 1996:309-310, 336, 378, 685-7, 704.

  8. Galanter M, Kleber HD, eds. The American Psychiatric Press Textbook of Substance Abuse Treatment. 2nd ed. Washington, DC: American Psychiatric Press; 1999:7-8,155, 283-5.

  9. Guze BH, Ferng H, Szuba MP, Richeimer SH. The Psychiatric Drug Handbook. 2nd ed. St. Louis, Mo: Mosby-Year Book; 1995:14-15, 178-9, 222 -5.

  10. Johnson BA, Rosenthal N, Capece JA, Wiegand F, Mao L, Beyers K, et al. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. Oct 10 2007;298(14):1641-51. [Medline].

  11. Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1995:784-5, 792-5, 1046, 1053.

  12. Krausz M, Mass R, Haasen C, Gross J. Psychopathology in patients with schizophrenia and substance abuse: a comparative clinical study. Psychopathology. 1996;29(2):95-103. [Medline].

  13. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. Jul 9 1997;278(2):144-51. [Medline].

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Further Reading

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Keywords

alcoholic psychosis, alcohol psychosis, alcohol withdrawal, Wernicke-Korsakoff syndrome, Korsakoff psychosis, thiamine deficiency, hallucinations, alcohol idiosyncratic intoxication, Alcoholics Anonymous, AA

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Contributor Information and Disclosures

Author

Michael Larson, DO, Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard University
Michael Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Medical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Jennifer S Morse, MD, Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego
Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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