Treatment of refractory substance-induced psychosis in adolescent males with a genetic predisposition to mental illness

Abstract

This article presents two cases of adolescent males who were admitted to our inpatient psychiatric unit with a psychotic, disorganized presentation. Both males had a genetic vulnerability to mental illness and reported significant substance use. Their symptoms were refractory to treatment and required the use of clozapine. Both patients experienced significant side effects, which limited the maximum daily dose of clozapine. However, they responded to a dose that was much lower than that typically used in adults. There is significant evidence in the literature about cannabis use triggering psychotic breaks in vulnerable individuals. We speculate that substance use (including synthetic cannabinoids) triggers treatment-resistant psychosis that requires the use of clozapine. Further, lower doses of clozapine may be sufficient to treat the substance-induced psychotic symptoms than those typically used in adult schizophrenia.

Substance-Induced Psychoses: An Updated Literature Review

“…Lastly, Rahmani et al ( 66 ) described psychotic symptoms after using SCs in two adolescent males with a family history of schizophrenia, alcoholism, depression, and anxiety.…”

The Bridge Between Classical and “Synthetic”/Chemical Psychoses: Towards a Clinical, Psychopathological, and Therapeutic Perspective

“…Rahmani et al (67) described two cases with a strong family psychiatric history who developed a SC-induced psychosis following the intake of “Spice.” Psychopathological pattern comprised the onset of paranoia, bizarre and disorganized behavior and speech, and visual hallucinations. No further data have been provided regarding treatment duration and/or dosage(s) of clozapine prescribed in both cases (67).…”

“…However, several findings documented here show that SC-induced psychoses may persist even in those subjects without a previous history of mental illness and may induce the development of a schizophrenia-like symptomatology, named “Spiceophrenia” (7, 25, 111, 122–125). In addition, there is evidence of a worsening/recrudescence of a mental health disorder (i.e., mainly an affective and/or a psychotic disorder) in those subjects with a preexisting mental condition (29, 34, 35, 50, 56–59, 61, 67, 69, 80, 84, 85, 111, 122). Some studies reported that SC may influence psychiatric course and prognosis, depending on the first age of SC exposure, psychiatric vulnerability/predisposition, a history of a childhood trauma or other traumatic experiences, and specific genetic factors (67, 69, 124).…”

“…In addition, there is evidence of a worsening/recrudescence of a mental health disorder (i.e., mainly an affective and/or a psychotic disorder) in those subjects with a preexisting mental condition (29, 34, 35, 50, 56–59, 61, 67, 69, 80, 84, 85, 111, 122). Some studies reported that SC may influence psychiatric course and prognosis, depending on the first age of SC exposure, psychiatric vulnerability/predisposition, a history of a childhood trauma or other traumatic experiences, and specific genetic factors (67, 69, 124). Furthermore, SC have been supposed to determine a more severe psychosis, accompanied with agitation and significant sympathomimetic effects, compared to “classical” cannabis as SC are more potent full receptor agonists at cannabinoid receptors and do not contain cannabidiol, which possesses anxiolytic and antipsychotic properties (1, 7, 70, 126).…”

“…From a therapeutic perspective, benzodiazepines are useful for managing anxiety, agitation, and seizure risk, together with a supportive/symptomatic therapy (1, 7, 30, 32, 36, 39, 41, 46, 48, 59–61, 71, 79, 81). Olanzapine, clozapine, quetiapine, and aripiprazole represent the main prescribed antipsychotic treatments in SC-induced psychoses (1, 7, 37, 50, 57, 60, 62, 65–67, 70, 75, 85, 86), while haloperidol, risperidone, and paliperidone have been prescribed/used in isolated cases (45, 53, 63, 73, 85).…”