First psychotic episodes and substance use
Psychosis is a mental state characterised by a distorted perception of reality. Symptoms may include delusions (such as believing oneself to be watched or persecuted), hallucinations (most commonly in the form of voices), disorganisation of speech, thought, and behaviour, and changes in motivation, initiative, and interest.
A psychotic episode is the onset of these symptoms. A psychotic episode is not the same as schizophrenia. A person can experience a psychotic episode at one point in their life and never have another. For a diagnosis of schizophrenia, a person must have more than one episode and other accompanying symptoms.
Psychotic symptoms are common in the general population; it has been observed that up to 3% of the population may experience them throughout their lifetime (Arango and Crespo-Facorro, 2018).
The first psychotic episode is usually more frequent in young people, between the ages of 15 and 35.
Sergi Papiol
Studies have shown that general symptoms such as decreased concentration and motivation, depressed mood, sleep problems, anxiety, social isolation, suspiciousness, and irritability, among others, may appear before a first episode. A recovery period begins after the episode. One of the goals of first-episode mental health programmes is to identify more people in the initial stages to improve intervention and prognosis.
Several factors influence the onset of psychosis. It is known that some people are more predisposed to developing psychotic symptoms than others. Regarding the factors that can trigger a psychotic episode, one of the most important to consider for both prevention and treatment is substance use.
Substance use and the onset of psychosis
Substance use is common in our society. According to data from the National Institute of Statistics, the most commonly used substances are legal. Alcohol is the most prevalent (77.2% of respondents reported consuming it in the past year), followed by tobacco (39.4% reported smoking in the past year). Cannabis is the most commonly used illegal drug (10.5% in the past year, 2019/2020), followed by cocaine (2.5%). Substance use has been linked to the onset or worsening of anxiety and psychotic symptoms, among other issues.
There are studies that attempt to demonstrate the relationship between starting consumption and experiencing an outbreak, as well as, conversely, the possibility of improvement if consumption ceases.
The drugs most frequently associated with psychosis are cannabis, cocaine, amphetamines, and hallucinogens.
Substance-induced psychotic disorders occur during periods of intoxication (use) or withdrawal (cessation of use after a period of dependence), although they can last for several weeks after the initial onset. It is important to differentiate between the effects caused by substance use or withdrawal and a substance-induced psychotic disorder. Only when the symptoms exceed those typically associated with intoxication or withdrawal syndromes can a diagnosis of a psychotic episode be made.
Substance use has been linked to an early onset of psychosis, and continued use carries a higher risk of a worse prognosis, a higher risk of relapse, and therefore a higher risk of hospitalisations.
Cannabis is a risk factor for psychosis in vulnerable individuals (Arango et al., 2015). The propensity to develop psychosis with cannabis use appears to be related to the severity of use and dependence.
The dangers of smoking marijuana during adolescence
Psychotic symptoms are one of the most common complications resulting from occasional or continued cocaine use. People who experience psychotic symptoms while using cocaine may be at greater risk of developing psychosis than those who use cocaine but do not. In predisposed individuals, it can be a contributing factor to the onset of a first psychotic episode. Furthermore, cocaine use reduces the effectiveness of treatment and increases the risk of side effects. It has also been linked to treatment non-adherence, leading to a higher number of relapses and greater symptom severity (Roncero et al. 2001).
Hallucinogens can produce alterations in perception and reality during their use. Like other drugs, they have also been linked to the possibility of triggering a first psychotic episode in vulnerable individuals.
The treatment of individuals with psychotic symptoms and substance use must focus on improving psychiatric symptoms and addressing the substance use problem. Only an open and multidisciplinary approach (involving various disciplines) that addresses both issues will improve the physical and mental health of those receiving care.
Providing information about the risks of substance use and its potential to trigger psychosis should be a priority for prevention among adolescents and young people.
