The Association of Salvia divinorum and Psychotic Disorders: A Review of the Literature and Case Series, Joseph El-Khoury & Nayiri Sahakian, 2015

The Association of Salvia divinorum and Psychotic Disorders: A Review of the Literature and Case Series

Joseph El-Khoury & Nayiri Sahakian

Journal of Psychoactive Drugs, 2015, 47, 4, 286-292



The association of substance abuse and psychotic disorders is of interest to clinicians, academics, and lawmakers. Commonly abused substances, such as cannabis, cocaine, amphetamines, and alcohol, have all been associated with substance-induced psychosis. Hallucinogens can induce desired psychedelic effects and undesirable psychomimetic reactions. These are usually transient and resolve once the duration of action is over. Sometimes, these effects persist, causing distress and requiring intervention. This article focuses on the hallucinogenic substance Salvia divinorum, the use of which has been observed, particularly among youth worldwide. We present background information based on a review of the literature and on our own clinical encounters, as highlighted by two original case reports. We hypothesize that consumption of Salvia divinorum could be associated with the development of psychotic disorders. We propose that clinicians routinely inquire about the use of Salvia in patients with substance use disorders or psychotic illnesses. More research is required to assess any relationship between Salvia divinorum and psychosis. Additionally, we advocate increased public and medical awareness of this substance and other emerging drugs of abuse.

Keywords : hallucinogen, psychosis, Salvia divinorum, Salvinorin A, substance-induced psychosis


The association of substance abuse and psychotic disorders has been subject to speculation in the psychiatric literature for decades. Psychosis and substance abuse cooccur frequently (Cantor-Graae, Nordström, and McNeil 2001; Regier et al. 1990). This may be because substance abusers are at a higher risk of developing psychosis or because patients diagnosed with a psychotic disorder are at a higher risk of abusing substances than the normal population. A causal relationship remains elusive and information given to patients and caregivers by healthcare professionals is often confusing.

Estimates of the prevalence of comorbid substance use and psychotic disorders vary significantly. The 2011 USA National Survey reveals that 17.5% of adults with a mental disorder had a co-occurring substance use disorder (US Department of Health and Human Services 2011). Comorbidity for substance abuse appears higher for psychotic disorders with a 47% reported prevalence (Kessler et al. 1994). It is even higher in specialist and inpatient services, with one German study estimating a 74% lifetime
prevalence and 62% point prevalence at the time of admission (Lambert et al. 2005). Alcohol, nicotine, and cannabis were among the substances most predominantly abused by patients with psychotic disorders (Kavanagh et al. 2004). The presence of a family history of psychotic disorders, a younger age of onset of substance use, in addition to longer duration and severity of use, are all risk factors for
developing psychosis (Thirthalli and Benegal 2006).

Widely abused substances, such as cannabis, cocaine, amphetamines, and alcohol, have all been associated with substance-induced psychosis (SIP). Thirthalli and Benegal (2006) found the prevalence of psychotic symptoms lasting at least one month in a population of substance abusers to be highest for hallucinogens (85%) and lowest for sedatives (32%). These were patients presenting at various stages
of their substance use, including chronic abuse, intoxication, and withdrawal. Cannabis has also been closely linked with the development of psychosis (Arseneault et al. 2004), particularly in a subgroup of vulnerable individuals whose experience of cannabis is characterized by distorted perceptions,
thoughts, and feelings rather than euphoric effect (Verdoux et al. 2003). Prolonged psychotic symptoms following hallucinogens use have also been reported and include spontaneous recurrences of lysergic acid diethylamide (LSD)-like states with visual hallucinations and flashbacks that can occur up to five years after the last drug use (Abraham and Aldridge 1993).

A diagnosis of substance-induced psychosis carries a further risk for schizophrenia and related disorders. The risk of conversion varies from one substance to another, as supported by Niemi-Pynttari et al. (2013) in their review of Finnish inpatient records over more than a decade. An individual hospitalized with an initial diagnosis of cannabis-induced psychosis had a 46% chance of being diagnosed with schizophrenia in the eight years following his discharge. The rates for other substances were lower: amphetamines (30%), hallucinogens (24%), opioids (21%), and alcohol (5%).

Relatively little has been written in the scientific literature on the psychogenic effects of the so-called “legal highs.” Manufacturers and traders of recreational substances are always a step ahead in terms of the development and dissemination of products that are more potent and harder to detect. This article focuses on Salvia divinorum, a very potent natural hallucinogen (Ranganathan et al. 2012), the use of which has surged among subgroups of youth in Lebanon over the past year. We discuss its properties, common effects, and possible association with the onset of psychotic symptoms, illustrated by two recent clinical cases where we found the ingestion of Salvia divinorum to be potentially implicated.