Medication-Induced Psychosis: Recognizing Symptoms and What to Do in an Emergency

When someone suddenly starts seeing things that aren’t there, believing they’re being watched, or speaking in ways that don’t make sense, it’s easy to assume it’s schizophrenia or another mental illness. But what if the cause isn’t their brain chemistry-it’s a pill they took yesterday? Medication-induced psychosis is real, often misunderstood, and can happen to anyone-even someone taking a prescription exactly as directed. It’s not rare. It’s not always obvious. And if you don’t recognize it, you could delay life-saving care.

What Exactly Is Medication-Induced Psychosis?

Medication-induced psychosis is when psychotic symptoms-like hallucinations, delusions, or disorganized thinking-show up because of a drug’s effect on the brain. These symptoms aren’t just side effects. They’re full-blown breaks from reality. The DSM-5 defines it clearly: the psychosis must start during or within a month after taking the substance or going through withdrawal. It’s not a personality flaw. It’s a physiological reaction.

Think of it like an allergic reaction-but to your nervous system. One person takes a steroid for a flare-up and starts hearing voices. Another takes an antimalarial before a trip and becomes convinced their family is plotting against them. A third person on an antidepressant suddenly believes their thoughts are being broadcast on TV. These aren’t coincidences. They’re documented, predictable reactions to specific drugs.

Common Symptoms to Watch For

The signs don’t always come all at once. Often, they creep in. Early warning signs might be mood swings, anxiety, or trouble sleeping. Then comes the shift:

• Delusions-false, fixed beliefs that aren’t based in reality. Persecutory delusions (thinking someone is out to hurt you) are the most common.
• Hallucinations-seeing, hearing, smelling, or feeling things that aren’t there. Auditory hallucinations (hearing voices) are the most frequent.
• Incoherent speech-jumping between unrelated topics, repeating phrases, or using made-up words.
• Disorganized behavior-acting in ways that don’t fit the situation, like stripping off clothes in public or yelling at empty corners.
• Memory lapses and poor concentration-struggling to follow conversations or remember simple tasks.

These symptoms can appear within minutes (like after snorting cocaine) or take weeks (like after long-term steroid use). The timing tells you something about the drug involved. But the symptoms themselves? They look almost identical to schizophrenia. That’s why misdiagnosis is so common.

Which Medications Can Trigger This?

It’s not just street drugs. Many legal, prescribed medications carry this risk. Here are the most common culprits:

• Corticosteroids (like prednisone)-up to 5.7% of people on high doses develop psychosis. Mood changes often come first.
• Antimalarials (especially mefloquine)-used for travel, it’s been linked to over 1,200 reported psychotic episodes since the 1980s.
• Antiretrovirals (like efavirenz for HIV)-about 2.3% of users experience hallucinations or paranoia.
• Antidepressants (SSRIs, SNRIs)-rare, but documented. Often happens early in treatment or after a dose increase.
• Stimulants (Adderall, Ritalin, methamphetamine)-up to 96% of chronic cocaine users report hallucinations. Amphetamines are similarly risky.
• Antiepileptics (vigabatrin)-around 1.1% of users develop psychosis.
• First-generation antihistamines (like diphenhydramine in sleep aids)-can cause delirium and hallucinations, especially in older adults.
• Opioids and NSAIDs (in high doses)-rare, but possible.

Even over-the-counter drugs like cold medicines containing dextromethorphan can trigger psychosis if taken in large amounts. The key isn’t the drug’s purpose-it’s how it affects dopamine, glutamate, or serotonin pathways in the brain.

Who’s Most at Risk?

It’s not random. Certain people are far more vulnerable:

• Those with a personal or family history of psychiatric illness-especially schizophrenia or bipolar disorder.
• Women-studies show higher susceptibility across multiple drug classes.
• People with substance use disorders-74% of those hospitalized for first-episode psychosis have a history of drug or alcohol abuse.
• Older adults-slower metabolism and existing brain changes make them more sensitive.
• Those taking multiple medications-drug interactions can amplify risks.

One study found that only 38% of primary care doctors feel confident spotting medication-induced psychosis. That means many cases fly under the radar until it’s an emergency.

Emergency Management: What to Do Right Now

If someone is actively psychotic and unsafe-threatening harm, disoriented, or unable to care for themselves-call 911 or go to the ER. Don’t wait. Don’t try to reason with them. Their brain isn’t working normally.

Here’s what happens in the emergency room:

1. Stop the drug. The first and most critical step. If it’s a steroid, they’ll taper it. If it’s an illicit stimulant, they’ll monitor withdrawal.
2. Supportive care. IV fluids, electrolyte balance, and monitoring for complications like rhabdomyolysis (muscle breakdown from stimulants).
3. Calming the episode. Atypical antipsychotics like olanzapine or quetiapine are often given to reduce hallucinations and delusions quickly. But they’re not always needed-if the drug is stopped, symptoms often fade within hours or days.
4. Withdrawal management. If the psychosis came from alcohol or benzodiazepine withdrawal, they’ll use benzodiazepines to prevent delirium tremens.
5. Assess safety. If the person is a danger to themselves or others, temporary involuntary hold may be required under mental health laws.

It’s not about sedating them. It’s about removing the trigger and letting the brain reset. Most people recover fully once the drug is out of their system.

How Long Does It Last?

Recovery time depends on the drug:

• Cocaine or methamphetamine: Symptoms often clear in 24 to 72 hours.
• Steroids: Take 4 to 6 weeks to fully resolve after stopping.
• Alcohol withdrawal: Psychosis can last days to weeks; may evolve into delirium tremens if not treated.
• Antidepressants or antihistamines: Usually resolve within days after discontinuation.

But here’s the catch: if symptoms last longer than a month after stopping the drug, it’s no longer classified as medication-induced. That’s when doctors start looking for an underlying psychotic disorder like schizophrenia. That’s why follow-up is non-negotiable.

Why This Gets Missed-and Why It Matters

Doctors aren’t trained to think, “Could this be a pill?” They’re trained to think, “Could this be schizophrenia?” That’s dangerous. A person with medication-induced psychosis might be wrongly prescribed lifelong antipsychotics. They might be labeled as “non-compliant” or “difficult.” They might lose custody of their kids, their job, or their freedom-all because the root cause wasn’t recognized.

And the numbers are rising. Emergency visits for drug-induced psychiatric symptoms increased 17% per year between 2015 and 2020. More people are on more meds. More people are self-medicating. More people are unaware of the risks.

The FDA requires warning labels on drugs like efavirenz and mefloquine. But patients rarely read them. Doctors don’t always ask about them. That’s why you need to be your own advocate.

What You Can Do to Prevent It

Prevention starts with awareness:

• Keep a list of every medication you take-including supplements and OTC drugs.
• Ask your doctor: “Can this cause hallucinations or paranoia?” before starting anything new.
• If you’re on steroids, antimalarials, or antiretrovirals, watch for mood changes, sleep problems, or anxiety in the first week.
• If you or a loved one starts acting strangely after starting a new drug, don’t wait. Call your doctor today.
• Never stop a medication cold turkey-especially antidepressants or benzodiazepines-without medical supervision.

There’s no magic test for medication-induced psychosis. It’s diagnosed by elimination: symptoms appeared after a drug, improved after stopping, and no other cause is found. That’s why honesty with your doctor matters.

What Happens After the Emergency?

Once the acute phase passes, you need follow-up care. A psychiatrist should evaluate you within 1 to 2 weeks. They’ll check:

• Are the symptoms truly gone?
• Is there an underlying disorder that was masked by the drug?
• What’s the safest way to restart any necessary medications?

Many people can safely resume their original treatment-just at a lower dose, or with a different drug. Others need to avoid certain classes entirely. Genetic testing for drug metabolism is still emerging, but it’s becoming more common in specialized clinics.

Recovery isn’t just about stopping the drug. It’s about rebuilding trust in your own mind. Many people feel ashamed after a psychotic episode-even if it wasn’t their fault. That’s normal. But it’s not permanent.

Medication-induced psychosis is treatable. It’s reversible. And with the right care, most people go on to live full, healthy lives-without ever needing long-term psychiatric drugs.