EDITORIAL AMPHETAMINE TYPE STIMULANT (ATS) INDUCED PSYCHOSIS: A RISING PROBLEMS IN MALAYSIA Ahmad Hatim S Department of Psychological Medicine,

Faculty of Medicine, University of Malaya, Kuala Lumpur The past decade has seen a marked increase in the popularity of ATS use, particularly methamphetamine, within East Asia, and the Pacific region (1) In Malaysia, the National Anti Drug Agency has identified 8,870 addicts (from January till August 2008) out of which 1,126 was ATS dependence. During the same period, the police have arrested 46,388 people under the Dangerous Drug Act 1952. They also has seize 283kg of syabu, 545kg of ecstacy powder, 66194 tablets of esctacy pills and 222,376 tablets of yaba pills from Jan till August this year.(2) The occurrence of psychosis arising from the use of ATS was first reported in the late 1930s. With growing ATS use, particularly methamphetamine, ATS-induced psychosis has become a major impact on public health. Symptoms of ATS-induced psychosis Methamphetamine use produces a variety of effects, ranging from irritability, to physical aggression, hyperawareness, hypervigilance, and psychomotor agitation. Repeated or high-dose use of the stimulant can cause drug-induced psychosis resembling paranoid schizophrenia, characterized by hallucinations, delusions and thought disorders. When used in long term, methamphetamine may lead to development of psychiatric symptoms due to dopamine depletion in the striatum. The most common lifetime psychotic symptoms among methamphetamine psychotic patients as reported in a cross-country study (3) involving Australia, Japan, the Philippines and Thailand are persecutory delusion, auditory hallucinations, strange or unusual beliefs and thought reading. Those patients were also reported to suffer from impaired speech, psychomotor retardation, depression and anxiety. An ATS psychosis can be distinguished from primary psychotic disorders by time. In ATS-induced psychosis symptoms usually resolve after the drug is discontinued. If symptoms do not resolve within 2 weeks after cessation of stimulant use, a primary psychiatric disorder should be suspected.(4) When compared with other stimulants, such as cocaine, psychosis is induced more commonly by ATS, possibly due to the longer duration of action produced by amphetamines. For example, while smoking cocaine produces a high that lasts for 2030 minutes, smoking methamphetamine produces a high that lasts 8-24 hours.(5)

Other symptoms of ATS-induced psychosis reported include affective blunting,(6) violent behavior, and self-mutilation and self-injurious behavior.(7) Duration of ATS-induced psychotic state Duration of amphetamine and methamphetamine-induced psychoses varies considerably. ATS-induced psychoses can be transient or persistent based on the duration of psychoses. In general, there are two types of methamphetamine psychosis.(8, 9) Transient type The majority of ATS-induced psychosis is a shorter psychotic state that begins to improve along with changes in the acute central action of the stimulant. The psychotic symptoms of transient type ATS psychoses last only hours, and usually abate within a week of withdrawal from the drug. However, prolonged symptom episodes have been observed in some individuals. Persistent type With this type of ATS psychoses, individuals experience psychotic symptoms for a considerably longer period of time. The psychotic state may last for more than 3 months and up to or beyond 6 months after cessation of drug use. Prevalence of ATS-induced psychosis ATS users are a high-risk population for psychosis.(10) Heavier methamphetamines users have been indicated to be at higher risk of psychosis compared with the general population.(9, 11) Methamphetamine users who already have a pre-existing proneness to psychosis are at particularly high risk of experiencing symptoms of psychosis. Besides at risk of developing an ATS-induced psychosis, ATS users are also more prone to developing schizophrenia and other psychotic disorders.(10) Similarly, in people who are suffering from schizophrenia, methamphetamine use can precipitate and exacerbate psychotic symptoms.(12) The high level of methamphetamine use has been associated with an increased prevalence in functional psychosis. This was demonstrated in two separate studies involving prison inmates who use stimulant drugs(11) and psychiatric patients (13) with a concurrent diagnosis of amphetamine abuse, respectively. Within these contexts, the prevalence of psychosis among individuals with amphetamine use disorder was up to 28%. A more recent Australian study (14) further showed an alarmingly high prevalence of psychosis among methamphetamine users when compared with the general population, even among those who had no known history of schizophrenia or other psychotic disorders. Among participants screened, 13% were positive for psychosis compared with 1.2% in the general population (11 times greater in prevalence), and 23% had experienced a clinically significant symptom of suspiciousness, unusual thought content or hallucinations in the past year. In addition, dependent methamphetamine users were noted to be three times more likely to have experienced psychotic symptoms than their non-dependent counterparts, even

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Associate Professor Dr Ahmad Hatim Sulaiman. hatim@um.edu.my Editorial Board Member