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Clinical Features, Course and Treatment of Methamphetamine-Induced Zarrabi et al. BMC Psychiatry (2016) 16:44 DOI 10.1186/s12888-016-0745-5 RESEARCHARTICLE Open Access Clinical features, course and treatment of methamphetamine-induced psychosis in psychiatric inpatients Homa Zarrabi, Mohammadrasoul Khalkhali*, Azam Hamidi, Reza Ahmadi and Maryam Zavarmousavi Abstract Background: Over the past few years, methamphetamine-induced psychosis (MIP) has increased in Iran, accounting for a significant percentage of psychiatry hospital admissions. The present study was conducted with an aim to investigate clinical symptoms, and course and treatment methods of MIP inpatients in Shafa Psychiatry Hospital in northern Iran. Methods: Participants were 152 MIP inpatients. Brief Psychiatric Rating Scale (BPRS) subscales of suspiciousness, unusual thought content; hallucinations and hostility were used to measure psychiatric symptoms. Data regarding suicide and homicide and violence were also obtained through interviews with the inpatients and their family. Based on their lengths of recovery time, the inpatients were categorized into 3 clinical groups. These inpatients received their usual treatments and were monitored for their psychiatric symptoms and clinical course of illness. The data were analyzed by descriptive statistics. Results: The most frequent psychiatric symptoms were violence (75.6 %), intimate partner violence (61.2 %), delusions of persecution (85.5 %), delusions of reference (38.5 %), delusions of grandiosity (32.9 %), delusions of infidelity (30.2 %), auditory hallucinations (51.3 %), visual hallucinations (18.4 %), suicidal thoughts (14.5 %), homicidal thoughts (3.9 %), suicide attempts (10.5 %) and homicide attempts (0.7 %). Recovery from psychotic symptoms in 31.6 % of the inpatients took more than one month. 46.1% of the inpatients were treated with Risperidone and 37.5 % with Olanzapine. Persecutory delusion and auditory hallucination were the most frequent persistent psychotic symptoms. 20.8 % of the inpatients with duration of psychosis more than one month were treated with electroconvulsive therapy (ECT) along with antipsychotics. Conclusion: All forms of violence are highly frequent in MIP inpatients. Our finding agrees with many other studies suggesting that recovery from MIP can take more than a month. Initial promising findings were found regarding the efficacy of Electroconvulsive therapy in MIP patients. Keywords: Methamphetamine, Psychotic disorders, Inpatients, Violence Background and tactile hallucinations, and a tendency toward vio- Acute psychotic disorder is a common phenomenon in lence [4–6]. In certain cases, even after the symptoms of the abuse of amphetamines and methamphetamine, and intoxication disappear and the substance abuse is not re- one of the most important reasons for referring to and peated, these symptoms are seen again in prolonged hospitalization in emergency or psychiatric wards [1–3]. manners. These symptoms cannot be differentiated from The psychotic symptoms in acute intoxication are perse- other psychotic symptoms of schizophrenia spectrum cutory, influence and control delusions, auditory, visual disorders [4–9]. Acute psychosis induced by amphetamines is limited to a maximum period of 4 to 5 days after the intoxica- * Correspondence: [email protected] Department of Psychiatry, Shafa University Hospital, Guilan University of tion, and appears to resolve with abstinence; although Medical Sciences, Panzdah Khordad Ave., 4165863795 Rasht, Iran the recovery may be incomplete [9]. Japan is the origin © 2016 Zarrabi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zarrabi et al. BMC Psychiatry (2016) 16:44 Page 2 of 8 of methamphetamine. This country has experienced sev- and substance abuse and dependency. The family obser- eral major epidemics of the substance. Japanese psychia- vations of intoxication periods and substance related be- trists believe that stimulants-induced psychosis can be haviors in the preceding month of admission were divided into different clinical groups. The first group is obtained in separate face-to-face interviews and were the transient psychosis group in which the incidence used to determine the abuse of any probable substances. and duration of symptoms are limited to a maximum The medical records were used to determine schizophre- period of 4 to 5 days after the intoxication, which can be nia, bipolar disorder, antisocial and borderline personal- seen in the withdrawal or intoxication periods. In the ity disorder. If positive urine tests or any history of second group, psychotic symptoms can be resolved in less abuse of alcohol, cannabis or morphine in the preceding than a month [7, 8]. In the third group, symptoms could month of admission was detected or if the patients were be of much longer duration of up to several months, or of diagnosed with any of the above-mentioned primary psy- several years [7–10]. Some experts believe that 5 to 10 % chiatric disorders, they were excluded from the study. of the MIP patients may not fully recover from their Fixed doses of methadone were accepted. All of the pa- psychotic symptoms even after a long time [7, 8]. The tients of this study had positive urine tests for metham- studies recently carried out as well as those in Iran have phetamine. A psychiatrist evaluated the patients and provided strong clinical evidence to support such a classi- concluded that they met the DSMIV-TR diagnostic cri- fication [6, 7, 11, 12]. In Yui K et al. [7] study, 64 % of pa- teria for amphetamine-like use disorders (dependence; tients recovered from their symptoms within ten days, 304.40 or abuse; 305.70) and amphetamine-like induced and 82 % gained full recovery within a month, and in 18 psychotic disorders (292.11, 292.12). %, psychosis persisted more than a month. In a previous BPRS was administered according to the guidelines pro- study in Iran, 8.75 % of the cases with MIP had symptoms vided by Lukoff [13] at admission time and then twice that continued more than a month [6]. In the 3 major epi- weekly to assess psychiatric symptoms and to monitor the demics in Japan, a significant number of patients still had patients’ improvement. After the patients were admitted the psychotic symptoms after a month [7, 8]. Some re- to the psychiatric wards and the primary evaluations were searchers believe that MIP can imitate both positive and completed, treatment was undertaken by certified psychia- negative symptoms of schizophrenia, and some consider trists. The inpatients were monitored for primary psychi- it, a short-term psychosis with positive symptoms. It is dif- atric symptoms and clinical course of treatment, and they ficult to distinguish the Japanese persistent psychosis from received usual evaluation and treatment for psychotic dis- a primary psychosis like schizophrenia triggered by the orders. There was no intervention or compromise regard- use of amphetamines [9, 12]. ing treatment methods, whether medicinal or otherwise. There are still many unanswered questions regarding In order to be able to compare the results of this study clinical characteristics of MIP. Unfortunately, Iran has with other studies, considering the patterns of recovery of experienced an epidemic of methamphetamine use in re- patients in the previous studies, we divided the patients in cent years, which has provided an opportunity to study into 3 clinical groups: clinical symptoms, and course and treatment methods of Group 1 (full recovery equal or less than one week), MIP inpatients. Group 2 (full recovery more than one week but equal or less than one month), and Group 3 (full recovery more Methods than one month). Considering that there is no global This cross sectional study was conducted at Shafa Psych- agreement and clear definition for the terms “transient” iatry Hospital, the only psychiatric hospital, referral and and “persistent”, we preferred to use numbered groups psychiatric emergencies center in Rasht, the capital of in this paper. Achieving a score of 3 or lower in any of Guilan Province, with a population of 2.5 million, in the mentioned subscales was the criteria for the inpa- northern Iran, from August 2013 to August 2014. tient’s recovery in that particular subscale, and full re- Participants were 152 MIP inpatients who were admit- covery was determined by recovery in all of the ted to Shafa Hospital due to clinically significant symp- subscales of BPRS. BPRS is a tool developed for asses- toms of hostility, grandiosity or suspiciousness according sing the degree of severity of psychiatric symptoms and to a score of 5 or above, and hallucinations, unusual is widely used in clinical and research assessments, and thought content or suicidality according to a score of 6 enjoys a high degree of inter-rater reliability when used or above on the Brief Psychiatric Rating Scale (BPRS) by skilled clinical specialists. Certified psychiatrists and [13]. The hostility in the month preceding admission an experienced clinical psychologist who had been was considered violence.
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