Medication-Induced Psychosis: Recognizing Symptoms and Getting Emergency Help

When someone suddenly starts seeing things that aren’t there, believing they’re being followed, or speaking in ways that don’t make sense, it’s easy to assume it’s schizophrenia or another mental illness. But what if it’s not their brain-it’s their medicine?

Medication-induced psychosis isn’t rare. It happens more often than most people realize, and it’s often mistaken for something far more serious. The good news? In most cases, it goes away once the drug is stopped. The bad news? If no one recognizes it for what it is, the person might get locked into years of unnecessary treatment-or worse, end up in crisis because the real cause was ignored.

What Does Medication-Induced Psychosis Look Like?

It doesn’t look like one thing. It looks like confusion, fear, and a mind that’s lost its grip on reality. Common signs include:

• Delusions-strong false beliefs, like thinking neighbors are spying on you or that food is poisoned
• Hallucinations-hearing voices, seeing shadows move when no one’s there, or feeling bugs crawling under your skin
• Disorganized speech-jumping between topics, using made-up words, or repeating phrases
• Extreme agitation or aggression
• Severe anxiety or paranoia that comes out of nowhere
• Memory gaps or trouble focusing, even if the person was sharp before

These symptoms don’t show up slowly. They often appear within hours or days after starting a new drug-or sometimes after stopping one. Steroids, for example, can trigger paranoia and hallucinations in about 1 in 20 people taking high doses. Antimalarials like mefloquine have caused psychotic episodes in travelers who never had mental health issues before. Even common meds like diphenhydramine (Benadryl) or certain antidepressants can do it, especially in older adults or those with existing brain changes.

Which Medications Can Trigger Psychosis?

It’s not just street drugs. Prescription and over-the-counter medicines are the leading cause of medication-induced psychosis in hospitals. Here are the most common culprits:

• Corticosteroids (prednisone, dexamethasone): Used for inflammation, asthma, autoimmune diseases. Psychosis risk: up to 5.7% at high doses.
• Antimalarials (mefloquine): Often taken by travelers. The European Medicines Agency has logged over 1,200 psychosis cases since 1985.
• Antiretrovirals (efavirenz): Used for HIV. About 2.3% of users report hallucinations or severe anxiety.
• Antiepileptics (vigabatrin): Can cause psychosis in 1.1% of patients.
• Stimulants (methylphenidate, amphetamines): Used for ADHD. Up to 15% of users report psychotic symptoms.
• Antidepressants (SSRIs, SNRIs): Rare, but possible-especially in young people or those with undiagnosed bipolar disorder.
• Anticholinergics (diphenhydramine, scopolamine): Found in sleep aids, allergy meds, motion sickness pills. Can cause confusion and hallucinations in seniors.
• Alcohol and benzodiazepine withdrawal: After long-term use, stopping suddenly can trigger hallucinations and delusions that mimic psychosis.

And yes-even ibuprofen, in very high doses, has been linked to psychosis in rare cases. The key isn’t always the drug itself, but how your body reacts to it. Genetics, age, brain chemistry, and prior mental health history all play a role.

Why Is It So Often Misdiagnosed?

Doctors aren’t trained to suspect medication-induced psychosis unless it’s obvious. Most assume psychosis = schizophrenia. But here’s the difference:

• Medication-induced psychosis starts within hours or days of taking a drug-or within a month of quitting it. Symptoms usually fade within days to weeks after stopping the drug.
• Primary psychosis (like schizophrenia) develops slowly, lasts longer than a month, and doesn’t improve just because you stop a medicine.

Studies show that 7-10% of people brought to emergency rooms with their first psychotic episode are actually reacting to a medication. Yet, only 38% of primary care doctors feel confident spotting it. That’s why people end up on antipsychotics for years, when all they needed was to stop a steroid or switch a sleep aid.

And then there’s delirium-the confusion and hallucinations that come with infection, dehydration, or organ failure. It looks similar. But delirium usually comes with physical signs: fever, low blood pressure, shaking, or trouble staying awake. Psychosis from meds? The person might look perfectly healthy physically-just mentally unraveling.

What Happens in an Emergency?

If someone is having a psychotic episode from a medication, time matters. Here’s what emergency teams do:

1. Stop the drug-immediately. This is the single most important step. No more prednisone. No more mefloquine. No more Benadryl if it’s the trigger.
2. Stabilize the person-check vital signs, hydration, electrolytes. Stimulant-induced psychosis can cause dangerous muscle breakdown (rhabdomyolysis). Alcohol withdrawal can lead to seizures or delirium tremens.
3. Use antipsychotics only if needed-medications like olanzapine or quetiapine can calm severe agitation or hallucinations. But they’re not always necessary. If the drug is stopped and symptoms fade in 24-48 hours, you don’t need them.
4. Monitor closely-some cases take days to clear. Hospitalization isn’t always required, but it’s needed if the person is a danger to themselves or others.

For alcohol or benzodiazepine withdrawal psychosis, doctors give benzodiazepines slowly to prevent seizures. For steroid-induced psychosis, symptoms usually lift within 4-6 weeks after stopping the drug. Cocaine-induced psychosis? Often gone in under 72 hours.

Who’s Most at Risk?

Not everyone who takes these drugs gets psychosis. But some people are far more vulnerable:

• People with a personal or family history of mental illness, especially schizophrenia or bipolar disorder
• Women-studies show higher rates of medication-induced psychosis in females
• Older adults-brains are more sensitive to drug effects, especially anticholinergics
• People with substance use disorders-62% of those hospitalized for first-episode psychosis had an active substance use disorder at the time
• Those on multiple medications-drug interactions can amplify side effects

And here’s something few know: if you’ve had a psychotic episode from a drug once, you’re more likely to have it again-even with a different medication. Your brain remembers.

What Happens After the Crisis?

Stopping the drug is just the start. The next 3 months are critical.

Most people recover fully. But doctors need to watch for signs that this wasn’t just a drug reaction. If hallucinations or delusions come back after 4-6 weeks-even without taking the drug-it could mean an underlying condition like schizophrenia is emerging. That’s why follow-up with a psychiatrist is essential.

Patients should also get a full medication review. What else are they taking? Over-the-counter? Herbal? Supplements? Even St. John’s Wort can interact with antidepressants and trigger psychosis. And if the person was on steroids for months, they may need a slow taper to avoid adrenal crashes.

For people who used stimulants or alcohol long-term, brain damage from chronic use (like Wernicke-Korsakoff syndrome from thiamine deficiency) can leave lasting memory and perception problems. That’s not medication-induced psychosis-it’s brain injury. But the symptoms look the same.

How to Prevent It

Prevention is simple: ask the right questions.

• If you’re prescribed a new drug, ask: “Can this cause hallucinations or paranoia?”
• If you start feeling strange after a new med-don’t wait. Call your doctor today.
• Keep a list of all your meds-including supplements and OTC pills-and bring it to every appointment.
• If you’re going on steroids, tell your doctor if you’ve ever had depression, anxiety, or mood swings.
• If you’re traveling to a malaria zone, ask about alternatives to mefloquine. It’s not the only option.
• For seniors: avoid first-generation antihistamines like diphenhydramine. They’re a known risk.

The FDA requires warning labels on drugs like efavirenz and mefloquine. But many patients never read them. If your doctor doesn’t mention psychosis as a possible side effect, ask. It’s your right to know.

When to Go to the ER

You don’t need to wait until someone is screaming or violent. If any of these happen, get help immediately:

• They believe someone is trying to kill them-and are acting on it
• They’re hearing voices telling them to hurt themselves or others
• They can’t recognize family members or remember their own name
• They’re so agitated they can’t sit still, sleep, or eat
• They’ve just stopped alcohol or benzodiazepines and are hallucinating

Don’t try to reason with them. Don’t argue. Call 911 or take them to the nearest ER. Say clearly: “They started this drug two weeks ago and now they’re not acting like themselves.” That one sentence can save a life.

Medication-induced psychosis isn’t a life sentence. It’s a warning sign. And if you catch it early, the person can go back to normal-without labels, without lifelong meds, without stigma.