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Amphetamine-Related Psychiatric Disorders Follow-up

  • Author: Amy Barnhorst, MD; Chief Editor: Eduardo Dunayevich, MD  more...
 
Updated: Dec 03, 2015
 

Further Outpatient Care

The patient should be monitored closely for recurring psychosis, depression, mania, anxiety, sleep disturbances, and relapse of amphetamine abuse.

Psychiatric follow-up care should occur within, at most, 2 weeks of the initial evaluation to ensure compliance.

Depending on the complications of amphetamine abuse in the specific patient, consider a follow-up examination with a neurologist and an internal medicine specialist.

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Further Inpatient Care

Admit the patient for observation in the event of mania, severe depression, psychosis, delirium, or if he or she is suicidal or homicidal.

A patient who is in a state of delirium should be placed in a quiet, cool (not cold), dimly lit (not dark) room and, if uncontrollable, placed in restraints.

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Inpatient & Outpatient Medications

If psychosis persists after the offending substance is eliminated, use of an atypical antipsychotic (risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone) may be considered. No single atypical antipsychotic has been proven to be more beneficial than the others in managing prolonged amphetamine-induced psychosis.

Antimanic agents may be continued if mania persists longer than 2 weeks.

Antidepressants can be useful if depression persists for 2 weeks after withdrawal. Antidepressants alone may not be as effective as other options in amphetamine-induced depression due to neuronal damage. Medication regimens for treatment-resistant organic mood disorders are the applicable approach.

If anxiety persists longer than 2 weeks, consider the use of nonbenzodiazepine drugs. Medications such as beta-blockers, valproic acid, carbamazepine, or gabapentin have shown promise in patients with substance abuse who also have anxiety.

Sleep medication may help patients adjust their circadian rhythm and can be used for approximately 1-2 weeks. If sleep medication is required for long periods, a referral to a sleep clinic is recommended.

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Transfer

If psychiatric conditions persist, causing social and occupational impairment, inpatient treatment may be required.

Medical or neurologic complications require treatment in an inpatient medical or neurologic unit.

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Deterrence/Prevention

Abstinence prevents disorders and is the primary treatment.

Relapse prevention occurs though patient education, individual psychotherapy, appropriate medical treatment of continuing psychiatric illness (eg, major depression, panic disorder), and attendance at substance abuse meetings.

Mandatory weekly urine drug screens help prevent relapse or expose relapse early so that aggressive treatment intervention can be pursued.

If psychiatric conditions arise during prescription amphetamine use for ADHD, lower doses may be tried and/or nonamphetamine treatments can be pursued, such as bupropion (Wellbutrin), desipramine, venlafaxine (Effexor), or clonidine. Please refer to the Attention Deficit Hyperactivity Disorder article for a full discussion of treatment options.

Early medication treatments have been tried with desipramine and lithium[12] ; aripiprazole vs. methylphenidate vs. placebo[13] ; bupropion[14] ; and naltrexone.[15]

The most recent published study at the time of this review assessed the efficacy of extended-release methylphenidate. The intention-to-treat analysis failed to demonstrate statistical difference between extended-release methylphenidate (n=40) compared with placebo (n=39). The authors noted that the study was limited by significantly higher dropout rates in the placebo arm.[16]

Currently, there are no medications that are routinely prescribed as standard-of-care or approved by the FDA for the treatment of amphetamine use disorder.

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Complications

Complications include an increased risk of the following:

  • Psychosis
  • Depression
  • Anxiety disorder
  • Sleep disturbance
  • Memory impairment
  • Medical complications
  • Neurologic complications
  • Abuse of another or several substances
  • Psychosocial impairment
  • Affect dysregulation and aggression [17]

If amphetamine abuse and amphetamine-related psychiatric disorders occur in the context of 1 or more personality disorders, the amphetamine-related disorder is more difficult to successfully treat than it is in other contexts.

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Prognosis

The patient's prognosis depends on the severity of psychiatric impairment and on the medical complications.

Overall, the prognosis is good if the patient abstains from drug use after the initial psychiatric impairment occurs.

The prognosis worsens if personality disorders are present.

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Patient Education

Instruct the patient to abstain from alcohol and illicit drugs, especially because dual diagnosis is a real issue. The only effective treatment is abstinence.

Patients should be in a support group.

The family must be educated about the patient's addiction and its dangers.

Refer the patient for psychosocial counseling.

Hospitalize the patient if he or she is suicidal or homicidal.

Refer the patient for substance abuse counseling.

Helpful Web sites include the following

For excellent patient and family education resources, see eMedicineHealth's patient education articles Drug Dependence and Abuse and Substance Abuse.

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Contributor Information and Disclosures
Author

Amy Barnhorst, MD Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Medical Center; Medical Director of Crisis Services, County of Sacramento

Amy Barnhorst, MD is a member of the following medical societies: Association for Academic Psychiatry, California Medical Association, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Eduardo Dunayevich, MD Executive Director, Clinical Development, Amgen

Eduardo Dunayevich, MD is a member of the following medical societies: Schizophrenia International Research Society

Disclosure: Received salary from Amgen for employment; Received stock from Amgen for employment.

Additional Contributors

Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

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