eMedicine Specialties > Psychiatry > Addiction

Amphetamine-Related Psychiatric Disorders: Follow-up

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

Updated: Jan 29, 2008

Follow-up

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.

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.

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.

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.

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.

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
• 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.

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.

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.
• For excellent patient education resources, visit eMedicine's Substance Abuse Center. Also, see eMedicine's patient education articles Drug Dependence and Abuse and Substance Abuse.

Miscellaneous

Medicolegal Pitfalls

• Failure to identify and treat medical and neurologic complications of amphetamine intoxication and withdrawal
• Failure to evaluate for other potentially dangerous illicit drugs and medication
• Failure to evaluate the patient for suicidal or homicidal tendencies
• Failure to caution against driving when in an impaired mental state and failure to document this caution in the chart and/or medical record

Special Concerns

• Increased risk for HIV infection and acquiring other sexually transmitted diseases.
  • In large metropolitan areas, gay men are at increased risk of HIV infection because of their use of crystal methamphetamine, also called Tina.
  • Crystal methamphetamine is commonly used in conjunction with gamma-hydroxybutyrate (GHB) and/or prescription drugs to treat erectile dysfunction medications, which helps to reverse the impotence crystal methamphetamines cause.
  • During euphoria, unsafe sexual activity is common, and individuals have little awareness or concern about the risks of sexual encounters.

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