THE STAKES OF STIMULANT USE, PSYCHOSIS, AND ANTIPSYCHOTIC TREATMENT AMONG YOUTH WHO USE DRUGS: A LONGITUDINAL QUALITATIVE STUDY

Abstract

Psychosis among youth who use drugs in the context of entrenched poverty is often addressed through aggressive forms of psychiatric intervention. Clinicians must carefully consider the benefits and drawbacks of this approach with this population because of how institutionalization and the sedating and numbing effects and affects of antipsychotics may be distinctly constraining. This study aims to increase understanding of the benefits, drawbacks, and socio-material and political contexts of antipsychotic treatment for youth who use drugs. We draw on in-depth, longitudinal qualitative interviews conducted between 2018 and 2021 with 116 youth who used drugs while contending with entrenched poverty in Metro Vancouver, Canada. Our analysis leverages a reflexive thematic approach and ideas from critical psychiatry and mad studies. We begin by outlining a ‘psychopolitical landscape’ wherein youth could become swept up in mental health certification and antipsychotic treatment with particular and oftentimes negative effects and affects. We then explore how, in the constant shadow of this psychopolitical landscape and socio-material deprivation, youth often sought to balance slippages away from and toward more stable senses of reality engendered by regular stimulant use. Finally, we examine how young people’s lived experiences of stimulant use and psychosis shaped their psychiatric treatment trajectories, including through dynamics of refusal, self-management, and performed sanity under the gaze of the psychopolitical landscape. From these findings, we underscore the need to prioritize self-determination – as much as is possible and safe – and equity-focused approaches that address the socio-material conditions of youths’ lives in mental health and substance use care. Providers should continually open conversations with youth about lived realities of substance use and psychosis alongside broader desires for the future, finding ways of working with youth within and beyond psychiatric treatment.

1. INTRODUCTION

In North America, drug toxicity is a leading cause of death for youth (Chang et al., 2024; Lim et al., 2021). Data from the United States document a 760 % increase in polysubstance-involved overdose deaths among youth aged 13 to 25 from 1999 to 2018, with stimulants being the most often involved substances other than opioids (Lim et al., 2021). This is also the case for youth in Canada (Chang et al., 2024). Youth experiencing socio-material inequity – in particular, entrenched poverty, homelessness, and unstable housing, alongside other intersecting oppressions – are inequitably impacted by the drug toxicity crisis and mental health and substance use (MHSU) challenges more broadly (Fast, 2024; Chang et al., 2024; Liu et al., 2022). In Vancouver, British Columbia (BC), Canada, where the current study is set, a prospective study with approximately 1200 street-involved youth found that, between 2005 and 2016, they frequently reported hospitalization, in large part for mental illness (38 % of hospitalizations) and drug-related issues (13 % of hospitalizations) (Chang et al., 2018).

In BC, the 2016 declaration of an overdose public health emergency has led to the expansion of MHSU services for youth, fueled by a desperate desire to address substance use harms and curb the unprecedented loss of life (Giang et al., 2020, Fast, 2024; Public Safety Solicitor General, 2024). Within this shifting service delivery landscape, there has been enhanced integration of MHSU services, providing some important benefits such as increased access to treatment, greater potential to address co-occurring issues, and more centralized access to care (Government of British Columbia, 2021). New challenges have also emerged, including the potential to further medicalize poverty, addiction, and other structurally-produced crises (Fast, 2024; Bryant et al., 2022; Hansen et al., 2014; Knight, 2015; Luhrmann, 2008; Ralph, 2015; Van Veen et al., 2019). Indeed, psychiatric treatment and institutionalization have become a leading mechanism for addressing concurrent MHSU disorders among youth in BC (Representative for Children and Youth, 2021) and people who drugs across Canada (Russolillo, 2025), and in particular those experiencing socio-material inequity.

Substance use in adolescence and emerging adulthood is an established determinant of earlier and more severe mental illness (Degenhardt et al., 2016). Many studies detail the relationship between substance use and risk for mental illness as well as the neurobiology of substance use, noting, for example, the significant release of dopamine caused by – and pursued through – stimulant use (Beckmann et al., 2020; Degenhardt et al., 2016; Matheson et al., 2023). This body of work has identified links between the use of stimulants and other substances (e.g., cannabis, psychedelics) and risk for psychosis, a condition characterized by disorganized thoughts and behaviour, hallucinations, delusions, and other symptoms (e.g., restricted speech and activity), leading to a distorted sense of reality. One systematic review and meta-analysis identified that around two-in-five adolescents who used substances developed “psychotic-like experiences,” and that they were nearly twice as likely to do so when compared to youth who did not use substances (Matheson et al., 2023). Co-occurrence of polysubstance use and mental illness, including psychosis, is prevalent among youth experiencing homelessness and unstable housing (Hodgson et al., 2013; Liu et al., 2022). This is not only because MHSU challenges frequently precede and prolong homelessness for youth, but because they are exacerbated by the distress of entrenched and oftentimes intergenerational poverty and other forms of socio-material inequity (Fast, 2024; Bryant et al., 2022). Research at the nexus of these issues has primarily addressed questions surrounding housing and MHSU treatment access and engagement, directing less attention to everyday strategies of maintenance, care, and resistance among people navigating substance use, psychosis, and intervention responses (Ralph, 2015). These strategies constitute important “hidden truths” about the lived experiences and socio-material and political dimensions of psychosis in the context of substance use, which may be critical for reimagining youth MHSU treatment and care (Beneduce, 2019).

Among youth who use drugs, colonial, racial, gendered, and socio-material inequities heighten risks for substance use and mental disorders, as well as the likelihood of being medicalized and institutionalized via psychiatric treatment (Luhrmann, 2008; Manuel et al., 2024; Ralph, 2015; Van Veen et al., 2018). In general, there is growing use of provincial mental health legislation to hospitalize (voluntarily or not) and treat youth experiencing co-occurring MHSU issues in BC. Detainments of children and adolescents aged 10 to 18 via the BC Mental Health Act (referred to as “certifications”) increased by 162 percent between 2008 and 2018 (Representative for Children and Youth, 2021). Once certified, the BC Mental Health Act allows for “extended leave” plans in which youth are discharged from hospital after acute stabilization and treatment but with mandated conditions, usually focused on medication adherence, participation in MHSU appointments, and residence in supportive social housing. Youth on extended leave are carefully monitored by MHSU teams and can be re-hospitalized – by police escort, if necessary – if they do not comply with their extended leave plan. While acute stabilization is sometimes necessary to keep youth and others safe and interrupt a period of acute psychosis, approaches that restrict individual rights can produce harm, particularly among equity-owed youth (Goodyear et al., 2023, Fast, 2024; O’Brien and Hudson-Breen, 2023; Representative for Children and Youth, 2021).

A mainstay of treatment for psychosis are second- and third-generation antipsychotics (Bramness et al., 2012; Fluyau et al., 2019). These are often utilized with youth experiencing drug-induced and other forms of psychosis (Beckmann et al., 2020), including persistent psychotic disorders, which are frequently managed with depot (i.e., long-acting) injectable antipsychotic medications, administered every few weeks (Hodgson et al., 2013). Antipsychotic medications are helpful for reducing delusions, hallucinations, and blunted emotions, and are an important component of MHSU treatment plans, including those addressing safety concerns related to suicidality, violence, impulsivity, and impaired judgement (Bramness et al., 2012; Fluyau et al., 2019). There are important side effects of antipsychotics, however. Antipsychotics have sedative and emotive effects and affects including somnolence, anxiety, and anhedonia (an impaired ability to feel pleasure), sometimes coupled with weight gain (Bramness et al., 2012; Fluyau et al., 2019). The benefits and drawbacks of antipsychotic treatment are important stakes to consider, especially among youth navigating entrenched poverty, homelessness, unstable housing, and substance use, for whom the embodied and affective intensities of antipsychotics (e.g., sedation, numbing) may be distinctly constraining. Adverse antipsychotic effects can be experienced as at odds with the bodily effects and affects produced through substance use and in particular intensive stimulant use. Stimulants can engender distinct kinds of possibilities and potentially desirable affects, including physical alertness, mental focus and clarity, and senses of excitement, forward momentum, and “being in the centre of something rife with potential” (Fast et al., 2014, Fast, 2024, p. 45). The tension between the often-inhibiting effects of prescribed psychiatric medication and the often-exhilarating effects of criminalized stimulant and other substance use can powerfully shape young people’s treatment experiences and trajectories. Indeed, youth in one qualitative study indicated that antipsychotics made them feel “less like [themselves]” (Murphy et al., 2015, p. 64) and described using drugs in part to overcome this discordance.

The purpose of this study is to increase understanding of the benefits, drawbacks, and socio-material and political contexts of antipsychotic treatment for youth who use drugs while contending with entrenched poverty, homelessness, unstable housing, institutionalization, and overlapping structural oppressions. Drawing on longitudinal qualitative interviews with youth navigating these contexts in Vancouver, Canada, our analysis begins by outlining a ‘psychopolitical landscape’ wherein youth could become swept up in mental health certification and antipsychotic treatment with particular and oftentimes negative effects and affects. We then explore how, in the constant shadow of this psychopolitical landscape and socio-material deprivation, youth often sought to balance slippages away from and toward more stable senses of reality engendered by regular stimulant use. While the youth in this study were engaged in various forms of polysubstance use, the present investigation mirrors our study participants’ strong focus on the connection between their intensive use of crystal methamphetamine (meth), crack cocaine, and other stimulants and psychosis experiences and care trajectories. We conclude by examining how youths’ lived experiences of stimulant use and psychosis shaped their psychiatric treatment trajectories, including through dynamics of refusal, self-management, and performed sanity under the gaze of the psychopolitical landscape.

The study is informed theoretically by critical psychiatry and mad studies, fields that question the assumptions of psychiatric knowledge and practice, and centre lived experiences and perspectives (Beneduce, 2019; LeBlanc and Kinsella, 2016; Ralph, 2015). From this standpoint, we conceptualize psychosis in biomedical as well as socio-material and political terms. We recognize that psychosis can be defined clinically by a continuum of disorganized speech and behaviour; perceptual and thought disturbances such as hallucinations, delusions, and paranoia; and blunted emotions and cognitive impairments (Luhrmann, 2018). Yet, we also recognize that these are only “partial truths” of psychosis (Beneduce, 2019, p. 711), as psychosis has much broader effects on wellbeing, functioning, and access to social determinants of health, including housing, income, and family (biological, adoptive, chosen) and community connectedness. Indeed, prior work details the socio-material dimensions of psychic experiences and symptoms, including how psychosis and reactions to it are shaped by place, context, history, social location, and inequity (D’Arcy, 2019; Luhrmann, 2008; Ralph, 2015). Building on this work, we view young people’s lived realities and subjective experiences of substance use, psychosis, and antipsychotic treatment as inseparable from the socio-material circumstances of their lives, including contexts of entrenched and often intergenerational poverty, homelessness, and unstable housing. Further, we recognize how sanism – the systematic subjugation and oppression of people perceived mentally ill (LeBlanc and Kinsella, 2016) – intersects with racism, colonialism, classism, sexism, and other forms of oppression to govern youth, including by medicalizing and psychiatrizing poverty, homelessness, addiction, and “public disorder.” In this study, we sought to “make room for [the] madness” (Ralph, 2015, p. 36) that characterizes many young people’s lives and worlds, while advancing a critical analysis of the contexts through and under which they are navigating psychosis and associated treatment and care.

2. METHODS

2.1. Study overview

This study is part of an ongoing program of community-based qualitative and ethnographic research with youth who use drugs in Metro Vancouver, Canada, led by the senior author (DF) since 2008. We approach this study as an interdisciplinary team of health researchers, clinicians, and community members with expertise in youth mental health and substance use, including as registered nurses, psychiatrists, a public health scientist, a medical anthropologist, a law student, and people with lived experience of substance use and psychosis and related caregiving. Our research team also includes the Youth Health Advisory Council: a group of ten youth with lived experience of substance use, mental health challenges, and homelessness and unstable housing, many of whom joined the group when it was first established in 2018. This group was actively involved in designing the current study and our interview guide and research questions. Over the course of the study, we met biweekly to discuss youth MHSU in connection with homelessness and unstable housing. This member checking helped with continually centering how the study findings could inform psychosis treatment and care with equity-owed youth – a focus that the Youth Health Advisory Council has insisted on across our work together.

2.2. Recruitment and data collection

Data collection between April 2018 and December 2021 involved longitudinal, in-depth, qualitative interviews with 116 young people recruited from youth drop-in, clinical, treatment, and frontline research settings across Metro Vancouver. These were all sites of both qualitative interviews and ongoing fieldwork. More informal conversations and observations occurring as part of this fieldwork have helped to triangulate and deepen the analysis presented herein.

The average age of the study sample was 21 years old, and this analysis focuses on youth aged 16 to 26 at the time of enrolment in the study. All participants had lived experiences of poverty, homelessness, and unstable housing. All had participated in MHSU treatment and care and engaged in various forms of polysubstance use over time, including intensive stimulant use. Youth told us about diagnoses of psychosis and related bipolar, schizophrenia, and schizoaffective disorders, alongside mood and anxiety disorders. Symptoms and experiences of psychosis were most often discussed in connection with youths’ intensive use of meth, crack cocaine, and other stimulants. Of the youth, 67 identified as white and 33 as Indigenous, including youth who reported mixed Indigenous and non-Indigenous ethnocultural backgrounds; nine youth reported other ethnicities and seven preferred not to say. There were 57 boys/men (two of whom identified as transgender), 53 girls/women (one of whom identified as transgender), and six non-binary, genderqueer, and genderfluid youth. This paper includes data from the full sample of 116 youth, though descriptions of institutionalized psychiatric treatment were especially salient among Indigenous and racialized youth, as well as girls/women and gender minorities. As described above, this finding can be understood in relation to a robust literature demonstrating how colonial, racial, gendered, and socio-material inequities shape a person’s risk for psychosis and MHSU disorders, as well as the likelihood of being medicalized and institutionalized via psychiatric treatment and care (Luhrmann, 2008; Manuel et al., 2024; Raikhel and Garriott, 2013; Ralph, 2015; Van Veen et al., 2018).

Interviews with youth lasted approximately one hour. Most were interviewed more than once, with eight times being the most any one person was interviewed. The study averaged around two interviews per enrolled youth, for a total of 209 interviews. Interviews were conducted by a medical anthropologist (DF) and two qualitative research coordinators (including MT), and sought to explore and contextualize youths’ substance use, mental health, and treatment and care trajectories. A focus on “trajectories” alerts us to shifting patterns, understandings, and experiences of these phenomena across time and place, shaped by a complex interplay of contexts at the individual (e.g., mental health diagnoses, forms of self-care), social (e.g., family and other relationships), institutional (e.g., the evolving MHSU treatment landscape), and structural (e.g., entrenched poverty and homelessness) levels. Participants provided informed consent and received a $40 CAD honorarium. Study approval was granted by the University of British Columbia Behavioural Research Ethics Board (H17–01726; H18–03529).

2.3. Data analysis

This analysis focuses on audio-recorded interviews conducted with youth, triangulated with insights gained from fieldwork conducted by DF and MT. Interviews were transcribed verbatim, anonymized using pseudonyms, and accuracy checked. Data were managed using NVivo 12 software. Analysis followed a reflexive thematic approach (Braun and Clarke, 2019). Early analysis involved reviewing transcripts and fieldnotes to support data immersion and develop an initial coding framework that organized the large volume of data. This analysis focuses on data broadly coded as “mental health,” “institutionalization and surveillance,” and “medicalization and intervention.” These codes captured patterns, understandings, and experiences of psychosis (largely in relation to stimulant use), regularly encountered approaches to mental health treatment and care, an etic sub-category of “going crazy” (using youths’ words), and analytical concepts such as sanism, medicalization, and relational care. We compared and combined the coded data to conceptualize overarching themes, refining the analysis through discussion during subsequent youth interviews and fieldwork. Ongoing conversation with the Youth Health Advisory Council allowed us to member check, triangulate, and further contextualize our interpretations of the data. The analysis was additionally triangulated by drawing on lead author TG’s clinical expertise as a registered nurse who worked in emergency and inpatient child and adolescent mental health units, as well as TG’s and senior author DF’s wider programs of research with youth who use drugs. TG and DF had several analysis meetings together as well as a writing day focused on constructing, debriefing, and refining emerging themes. Reflexivity was further advanced through collaboration with our interdisciplinary authorship team, who provided clinical knowledge, policy insights, and lived expertise to add depth and context as the analysis progressed. Our analysis focused on points of cohesion and occasional discordance in our team’s interpretations of diverse participant narratives, culminating in the development of four key themes. These themes are reported below and substantiated with selected interview excerpts, which were lightly edited for clarity and flow.

3. FINDINGS

3.1. The psychopolitical landscape

Each young person in this study had some form of contact with the MHSU treatment and care system, and most were actively connected to it. Many were frequently swept up in a nexus of psychiatric treatment, certification, and institutionalization as they cycled between “highs and lows” with their stimulant use and psychic states. Mental health intervention amid the drug toxicity crisis in BC can be highly reactive: young people described being certified, hospitalized, and medicated during major psychotic episodes and as they encountered acute crises related to overdose and detoxification. Youth were simultaneously under the everyday gaze of broader MHSU, poverty, housing, and criminal legal apparatuses in Vancouver (Fast and Cunningham, 2018, Fast, 2024; Van Veen et al., 2019), meaning that any changes in substance use (e.g., stimulant use binges) and the effects thereof (e.g., worsening paranoia) materialized under the surveillance of providers, workers, probation and police officers, and others. Hence, it was not uncommon for youth – especially those experiencing street-based homelessness and spending large amounts of time outdoors – to be picked up by police cars as well as ambulances during periods of suspected psychosis, ahead of being brought to hospital for assessment and treatment.

Beyond instances of acute hospitalization, youth described becoming ensnared in a wider and seemingly endless “churn of intervention” characterized by, on the one hand, fragile senses of success in accessing services and achieving improved wellbeing for periods of time, and on the other, broken promises of meaningful help in the absence of efforts to address entrenched poverty and inequity (Fast, 2024, p. 124). Intervention was experienced acutely (e.g., with police pick-ups and forced hospitalization) yet also involved more routine, everyday measures, including as youth navigated regular and “as-needed” appointments with the various actors in charge of their files, cases, and records. Psychopharmaceutical treatment was central to these encounters; youth were very commonly prescribed sleep aids (e.g., trazodone, zopiclone), antidepressants, and antipsychotics to improve their mental health and stabilize them enough to stay out of hospital and keep their social housing, for example. Adherence to these medications could be closely monitored and enforced, particularly for youth who were entangled in child welfare and housing systems, and who were prescribed long-acting injectable antipsychotics as part of mandated community MHSU treatment plans or extended leave. Dave, a 25-year-old Black cisgender man who smoked meth and illicitly manufactured fentanyl (which has largely displaced heroin in our setting), commented on the stakes of becoming drawn into a nexus of antipsychotic treatment and mental health certification as well as habitual forms of control, including through long-acting injectables:

If you don’t take your [antipsychotic] shot, they can even put you back in the hospital – if you’re on extended leave, right? And if you’re on methadone – they’ll threaten to take your methadone away! People will buckle and give in and take the shot. A lot of my friends are on that shot, and I see what it does to them! They’re like zombies and shit.

Donotha, a 21-year-old transgender woman (ethnicity not disclosed), similarly reflected: The antipsychotic, Abilify [i.e., aripiprazole], is, like, a heavy tranquilizer. I need to be the opposite of that, to be able to get by, honestly. My stimulants [use] went up after [experiencing] the crash [from the Abilify injection]. And [meth] barely even can overtake it, honestly. It’s so powerful. [But my physician] is the only one who could change my mental health medication. I can’t say no, or the cops will, like, come and drag me to the hospital to give me an [antipsychotic] injection, so…

Donotha, Dave, and other young people underscored the negative affective and embodied intensities of antipsychotic medications, which they described as “tranquilizing” and sedating a person to the point of feeling and acting like “zombies.” Prescribed psychopharmaceuticals could inadvertently but severely limit young people’s control and autonomy over their bodies, emotions, and overall wellbeing and functioning. The solution to these undesirable effects and affects was oftentimes the very thing that had precipitated in youth a period of psychosis and mandated psychiatric intervention: intensive stimulant use. As we documented through fieldnotes and heard in interviews, several youth described being trapped in a cycle of stimulant use contributing to psychic deterioration and safety risks, subsequent aggressive psychiatric treatment, certification, and institutionalization, followed by resumed use of stimulants to “wake themselves up” from their antipsychotic medications, then another instance of mandated intervention, and so on.

It must be noted that youth sometimes welcomed and pursued mental health intervention in the context of accelerating stimulant use, growing psychic unrest (e.g., increasing paranoia and scattered thoughts), and episodes of psychosis. Mental health intervention allowed some youth to connect with providers and workers who “treated them like family,” “truly got what they were going through,” and worked hard to get youth what they needed, including social housing and connections to different kinds of programming, including and beyond supports for substance use and mental health. Medications and even hospitalizations could provide opportunities to sleep, stabilize emotions, quiet troubling thoughts, take a break from intensive substance use, and get a few days of respite from the everyday emergencies of poverty, homelessness, unstable housing, and addiction. For example, Josephine, an 18-year-old Indigenous cisgender woman, described the beneficial impacts of treatment with an antipsychotic (quetiapine), antidepressant (sertraline), and mood stabilizer (lamotrigine), commenting, “It just kind of stabilizes me and helps me go to sleep, and I can still feel like myself and, like, be happy throughout the day.” Even still, Josephine acknowledged similar drawbacks to those described above: “It’s not perfect on medication. I’m completely different. I feel like it’s just blanking your mind out, just to live with yourself.”

For many young people, these negative impacts of becoming embroiled in the psychopolitical landscape meant that treatment could be highly contested and actively avoided, leading youth to self-manage psychosis, as we return to below. Before this, we describe how, in the constant shadow of this psychopolitical landscape and socio-material deprivation, youth sought to balance slippages away from and toward more stable senses of reality engendered by regular stimulant use.

3.2. Slippages

Youth described “slipping away” into psychosis amid intensive stimulant and other substance use, yet simultaneously explained how stimulant use could engender intense focus, energy, and presence (e.g., with friends and romantic partners). Youths’ descriptions of these slippages – into and out of more stable senses of reality – variously underscored moments of possibility, ambivalence, fear, and liminality. As they “slipped” into psychosis, youth described “losing their minds” and “losing time” to increasingly scattered thoughts and growing paranoia. They recalled slipping away not only in terms of a loss of stable senses of reality but also as a diminished ability to form and maintain relationships, meet commitments (e.g., appointments with providers and workers, income-generating activities), and keep social housing. Slipping away encompassed acute episodes of psychosis as well as milder symptoms leading up to and following these episodes. Yet, stimulant use also generated periods of clarity. Youth often cycled between highs and lows in terms of their stimulant use and psychic states (e.g., “I’m coming up and down, up and down, up and down …”).

Many youth diagnosed themselves with psychosis (e.g., “I don’t know if it was psychosis, but it felt like psychosis”), while others recalled being formally diagnosed by providers. Regardless of duration and intensity, experiences of psychosis were often described by youth as shocking, saddening, and frightening. Bailey, a 22-year-old Indigenous cisgender woman, initially developed psychosis after binging on crack cocaine over several days. She framed this psychic state and its aftermath as completely unanticipated, describing how her use of a relatively small amount of crack cocaine had sent her “into a whirlwind of a major episode of psychosis.” She described herself as “a shadow walking around” for the following two months, up until she was hospitalized for treatment. Anna, a 17-year-old white cisgender woman, similarly explained how, during an episode of psychosis and the subsequent “comedown” after a period of binging on methylenedioxy-methamphetamine (MDMA), “days would just be missing to me.” Interestingly, accounts such as these echoed participants’ descriptions of the negative effects and affects of extended periods of antipsychotic treatment detailed above. In talking about psychosis, specifically, Bailey emphasized that meaningful recovery from this whirlwind of losing time, psychic stability, and an embodied, cohesive sense of self could take years: My brain was fried, completely. [During the major episode] I-I basically blacked out and was, like, an empty shell walking around, ‘cause of how bad my psychosis was. Such a-a tragic event, right? Just after that, I – my, like, mind started slipping away. Basically, between a month to two and a half months, I was completely gone.

Stimulant and other substance use that took youth to the very edge of slipping away was nevertheless often experienced positively by youth as it engendered desired focus, energy, and presence. In navigating the demands of day-to-day functioning and survival, young people’s stimulant use was closely linked to affective gains and bodily vigilance and autonomy, particularly as they used stimulants to stay awake outside when unable to secure a local shelter bed, to generate energy for street-based income-generating activities such as binning (collecting recyclable cans and bottles) and shoplifting, to self-medicate undiagnosed or untreated attention deficit hyperactivity disorder (ADHD), and to enhance confidence while attending appointments with social workers, healthcare providers, probation officers, and others. Long periods of stimulant use to “get by” in these ways were marked by shifting psychic states, including periods of slipping into and out of psychosis and periods of slipping into and out of greater focus, energy, and presence that many participants talked about relying upon for their day-to-day functioning and survival. The possibilities of stimulant use were continually contemplated against – and sometimes positioned as superseding – the psychic and psychiatric harms that were also engendered, including psychosis and the intervention responses detailed above. For example, even as she emphasized the tragedy of psychosis in her life, Bailey weighed the positive effects and affects of stimulant use – initially crack cocaine, and later the regular use of meth:

A weird thing is, when I did [crack cocaine at age 15], it kind of – like, it flipped a switch in my brain. Like, I mean, yeah, I did go into psychosis every now and then, when I did drugs, but it kind of, like – it filled in the blanks of my immaturity. The way I’m speaking [as a result of using stimulants] is sociable now. I was never like that before. Like, I don’t know how drugs ended up doing that for me, but they did do something like that. And it’s not completely a negative thing.

Bailey and other youth described attempting to balance the various slippages engendered by stimulant use, which included both slipping away from reality and toward greater clarity – in the form of enhanced social connection, for example. Youth talked about how this balance could be lost; they slipped too far from reality for too long. The result could be intolerable. John, a 22-year-old white transgender man, explained that a protracted meth-induced period of psychosis led him to the understanding that this was something that would “slowly kill [him].” Katie, a 25-year-old Métis and white cisgender woman, similarly came to understand that psychosis secondary to crack cocaine and meth use could be a matter of “life or death.” These stakes were powerfully inflected by the socio-material circumstances that were both a cause and consequence of Katie’s poor health. She described a five-year period of heavy stimulant use and poorly managed bipolar disorder while simultaneously contending with homeless and unstable housing in downtown Vancouver, noting that she eventually “aged out” of the youth-focused services that had helped her to get through several frightening health emergencies while homeless, including psychotic episodes, injection-related infections, and the deaths of family members as a result of overdose. In reflecting back and looking ahead, Katie shared:

It’s hard for me to even place it all. Because it’s just, like, especially with bipolar, when you’re manic, it’s, like, so much shit happened to me, and my mind seems to block stuff [out]. Even to this day, sometimes I’ll have, like, a memory of being homeless on Hastings [Street] that I-I couldn’t – I’ve never even had before. It’s, like, a flashback. It was, like, life or death. It was really, like, “Okay, I could die …”

Katie’s comments reflect the ephemerality and clear dangers of young people’s shifting psychic states. Slipping away could persist even as youth slowed down on or stopped using drugs and began taking antipsychotics. And youth were not always able to take these steps, as the demands of entrenched poverty, homelessness, and unstable housing required them to use stimulants to keep going, stay safe, and blunt the edges of ongoing socio-material deprivation and a lack of forward momentum in their lives. Intensive stimulant use in these contexts led some youth to feel as though they were at risk for irreparable psychic harms, including “mis-wired” and “ruined” brains beyond repair (Fast, 2024). Eliot, a 20-year-old cisgender man, shared the following in relation to past multi-day binges of meth, alongside use of ketamine, gamma-hydroxybutyrate (GHB), cannabis, and alcohol:

I still get those things – residual episodes [of psychosis], kind of. And [when those episodes happen] you’ll believe that all these substances that you had done – it has just, like, wired your brain incorrectly.

Interviewer: Yeah. So, you’re a little, like, concerned that that might be where you’re at?

Yeah, I’m concerned if, like, there is a way to like revert it [my brain] back. Fully.

Eliot and a few others wondered if it was possible to “revert” or “fix” their brains following intensive stimulant use and experiences of slipping away that ranged from days to weeks to months to even years. Fortunately, the psychic slippages young people described went in multiple directions, and many recalled transitioning to more consistent psychic stability after adjusting or ceasing their stimulant use and following engagement with mental health care, including antipsychotic treatment. This engagement was seldom straightforward, however, and youth often had serious misgivings about engaging with the local psychopolitical landscape and in particular more extreme and mandated forms of psychiatric intervention.

3.3. Self-management and refusal

Young people’s lived experiences of stimulant use and psychosis in the constant shadow of a psychopolitical landscape that could engender aggressive intervention responses shaped moments of self-management and refusal. As youth used stimulants to buoy the weight of socio-material pressures and pursue greater focus, energy and presence, some refused the abstinence that was often indicated as part of their psychiatric treatment plans, emphasizing that ceasing to use substances was undesirable or impossible given their lived realities. We observed and heard about numerous instances when youth outright refused to stop using simulants and other drugs, take antipsychotic medications (or take them as prescribed), stay in the hospital, and attend follow-up appointments. As discussed above, even as Josephine and others acknowledged the benefits of medications, they were highly reticent about the “blanking out” effects and affects these medications often produced. The emotional blunting and sedating qualities of antipsychotics were usually powerfully at odds with the desired effects and affects listed above. This reticence was deepened by the fact that many participants perceived or were told that they may need to take antipsychotics indefinitely, which conflicted with many young people’s desires for futures not defined by taking medications (Fast, 2024). As Josephine put it: “I feel like there’s so much more to life than just having to take medication.”

We also noted young people’s efforts to titrate their use of stimulants and antipsychotics on their own, in ways that allowed them to continue managing and surviving the exigencies of life on the street and grinding poverty, pursue desired affective states, and reduce or avoid episodes of psychosis. For example, youth experimented with psychopharmaceutical pill dosages and avoided and delayed their long-acting injectable antipsychotics, often seeking to take just enough medication to temper the onset and progression of psychosis and mania, but not so much that they experienced unwanted side effects and affects. Youth simultaneously experimented with their use of stimulants and other drugs to achieve desired balances of psychic stability and affective states. Bailey described attenuating her use of meth in connection with experiences of stimulant-induced psychosis. She decreased her use whenever she started to “feel the psychosis coming on” and “slowly creep[ing] up on me.”

In undertaking these self-management strategies and refusals, youth attempted to mediate the undesirable effects and affects of antipsychotics as well as losses of autonomy and self-determination – that is, the right to fully participate in healthcare and governance decisions that concern them (Halseth and Murdock, 2020) – that could occur as they were swept up in psychiatric treatment, certification, and institutionalization. Self-management strategies such as titration were less constraining and highly pragmatic means of managing their psychic states. Young people’s goals regarding psychosis and mania were seldom focused on a “cure” or complete reprieve from symptoms, but on the palliation and reduction of symptoms. One participant expressed this as a desire to “just try to help put a lid on the mania – like, simmer it down a little bit.” Some youth even recounted times when they had wanted experiences of psychosis and mania to persist because they felt that these psychic states and the stimulant use that fueled them effectively moderated experiences of entrenched poverty, stagnation, social isolation, and loneliness (Fast, 2024). In these ways, youth countered medicalizing and pathologizing framings of mental illness. Skylar, a 16-year-old white woman, reflected:

When I was using [meth], I had really bad voices and stuff in my head. And I still do have voices in my head sometimes, but they’re definitely not as bad. But so – I don’t know – I was really lonely at the time. I mean, like, I had nobody to talk to, right? So, a lot of the time I would talk to myself, or the voices or whatever. And it would give me somebody to talk to, right? So, I didn’t necessarily want to get rid of them.

As youth fine-tuned their engagement with antipsychotic medications and stimulants, many described living in constant fear of being apprehended by police and involuntarily hospitalized for not taking their antipsychotic medications – especially long-acting injectables – as prescribed, or otherwise not adhering to extended leave plans. As noted above, youth described positive relationships with MHSU care providers who “truly got what they were going through”; these providers were generally skilled at acknowledging youths’ own self-management strategies and socio-material realities, and attempted to work with them to reduce harms. However, more often young people described avoiding their mental health teams and psychiatrists for the reason that such engagement carried the risk of institutionalization. Emily, a 20-year-old Indigenous cisgender woman who smoked meth and sometimes heroin, detailed the stakes of avoiding appointments as she struggled to get off an antipsychotic medication that she experienced as completely debilitating:

My doctor keeps on saying I have to keep up with my appointments first [before they can take me off the long-acting aripiprazole injections]. But it’s really hard. Because, like, I don’t really want to go and talk about my problems because then it puts me in a bad mood. Sometimes, I just don’t go see [my mental health team] every month. And then they come to my place [looking for me]. And if I don’t answer, then they send the cops there. And then they say, “That looks really bad, and I can’t take you off the [antipsychotic] shot if the cops are the ones that brought you in.” So, I have to kind of just go there all the time [if I want to get off the antipsychotic medication].

Emily’s reflections surface the limits and potential consequences of refusals, evasions, and self-management strategies in the context of a psychopolitical landscape characterized by rigidity and high levels of both acute and everyday surveillance and monitoring. Deviations from mental health care teams’ prescribed treatment regimens and plans were often met with aggressive intervention responses, consistent with BC’s Mental Health Act extended leave legislation. Another way that youth sought to bypass and mitigate such responses was by performing sanity.

3.4. Performing sanity under the gaze of the psychopolitical landscape

While psychosis treatment could certainty benefit youth, drawbacks such as the embodied and affective intensities of antipsychotics (e.g., sedation, numbing), the imperative of abstinence from substances that generated numerous benefits (e.g., increased focus, energy, and presence), and systemic practices of surveillance and control led many to actively avoid treatment and the places where it was delivered. Youth discussed the need to perform sanity under the gaze of the psychopolitical landscape as a means of avoiding (re)institutionalization and asserting their capacities for self-managing substance use, psychic stability, and the trade-offs of antipsychotic treatment. This need must be understood in the context of young people’s socio-material circumstances, including individual, peer, and intergenerational histories of involvement with coercive MHSU treatment and poverty-management systems. Under conditions of surveillance and control, psychosis treatment via institutionalization could signal danger more than help (Fast, 2024). Alongside other participants, Oni, a 23-year-old white cisgender man who predominantly used cocaine, ketamine, and cannabis, described deep suspicions of the local psychopolitical landscape. Suspicions and fear were only bolstered by the psychosis symptoms youth were experiencing – namely, paranoia and hallucinations. Reflecting on his ambivalence about seeking help for substance use, Oni shared:

Every time I would think of going to treatment, what would happen was – is – my demon would be like, “Oh, don’t!” ‘Cause what it told me was, “Oh, they’ll kill” – It-it basically told me – it’s like, “Oh, they’ll try and kill me.”

We observed and heard about youths’ attempts to (re)assert themselves as mentally well enough to avoid institutionalization, including being released from voluntary and involuntary hospital stays and mandated community-based psychiatric treatment as well as requirements to take long-acting injectable antipsychotics and attend MHSU appointments. They described “playing along” and showing – often only transiently – that they could follow normative scripts of psychiatric treatment compliance and anticipated benefits of medication adherence and abstinence from or reduced substance use. As Katie reflected:

[Being involuntarily hospitalized] was horrible. And that’s why I’ve always been so scared. Especially coming to Vancouver, and, like, [my youth mental health team] tried to admit me twice, and I talked my way out of it. I was in the [locked down psychiatric emergency and assessment unit at an inner-city hospital], like, before they send you up to the psych ward. And I-I’m a good talker, so I talked my way out of [involuntary hospitalization]. They’d ask me questions – like, “Are you experiencing irritability?” or anything like this. And I’m like, “No, no, no.” Right? Just kind of playing along, and trying to, like – being aware of, like, how I was talking. Trying to play it like, “Oh, no, I’m not as crazy as I am right now!”

Junior, a 19-year-old white cisgender man, recounted a past involuntary hospitalization for psychosis, lasting six months. Facilitating his eventual discharge, he recalled, “I realized after a long time, it’s about giving [care providers] the right answer. Really, you’ve got to give that right answer.” Junior did not equate “right” with “truthful,” however. He emphasized that, had he responded to in-hospital mental health assessments truthfully, “I don’t think I ever would have got out of there.”

Junior, Katie, and others framed the possibility of re-experiencing involuntary hospitalization as one of their “biggest fears”; it signaled danger and could also mean the loss of much-needed and deeply desired focus, energy, and presence. Lengthy hospitalizations could also lead to the loss of social housing and the supportive programing and relationships with staff embedded in some of these places. Youth described such fears, potential losses, and a corresponding need to perform sanity as everyday concerns that constantly loomed “in the back of their minds,” as one young person put it, driving them to try to self-manage their substance use and psychic states as “the only option.”

In addition to the self-management strategies outlined thus far, youth generally went to great lengths to shield themselves from the gaze of systems. They commonly described using drugs in places of relative isolation such as alleys, beaches, and social housing units to avoid detection and the threat of police apprehension or ambulance intervention, should they develop or exacerbate drug-induced psychosis. For example, Dave described intentionally crossing the bridge out of downtown Vancouver to use meth so that he would be far away from the collective gaze of youth services in the neighborhood in the event that he had a “psychotic breakdown” (his words). Dave elaborated:

[It’s] because the moment I freak out, I know that they’re gonna call the ambulance or call the police. They’re gonna come and take me [to the psychiatric ward], and then I’ll be screwed.”

Even more common than playing along and being careful with regards to surveillance of mental health and substance use, youth described performing sanity through routinized acts of compliance. This involved taking medications as prescribed, showing up for appointments, and trying their best to “act nice” with care providers while concealing or downplaying the extent of their substance use and any ongoing psychic unrest. These performances were sometimes effective for mitigating risks of institutionalization, and young people’s partial buy-in to their treatment plans could yield some psychiatric and social benefits, such as alleviated psychosis symptoms, improved sleep, and maintained social housing. Still, partial and guarded participation in care had limitations. Performing sanity could forestall and shut down open and honest conversations with providers, including meaningful discussion of life-or-death issues such as suicidality, substance use relapses and binging, and housing instability. In some cases, youth were also reticent to discuss treatment and harm reduction because doing so would mean admitting that they were still using drugs. In sum, performing sanity under the gaze of the psychopolitical landscape could powerfully inhibit meaningful psychiatric care engagement and the potential life-saving benefits thereof.

4. DISCUSSION

This study highlights the wide-ranging stakes of stimulant use, psychosis, and antipsychotic treatment and care among youth who must also contend with entrenched poverty, homelessness and unstable housing, institutionalization, and overlapping structural oppressions. Like others, we document locally salient ways that under-resourced communities experience and respond to mental health crisis and intervention (Luhrmann, 2008; Manuel et al., 2024; Ralph, 2015; Van Veen et al., 2018). We also detail how the pharmacotherapies used to treat stimulant-induced psychosis can result in losses of desirable affective states (e.g., focus, energy, and presence) and bodily vigilance and autonomy. In outlining the complex benefits and drawbacks of antipsychotic treatment for youth who use stimulants and other substances, we show how youths’ MHSU treatment trajectories were marked by dynamics of refusal, self-management, evasion, and performed sanity under the gaze of systems. From these findings, we discuss implications for providers striving to keep youth safer and alive amid the devastation of the drug toxicity crisis and severe MHSU challenges.

Taking inspiration from critical psychiatry and mad studies (Beneduce, 2019; LeBlanc and Kinsella, 2016; Ralph, 2015), this study draws attention to the socio-material and political significance of substance use and psychosis symptoms among equity-owed youth. Aligned with other work in this area (Ralph, 2015, p. 38), intensive stimulant and other substance use among the youth in this study can be framed as practices of care that make “mourning the past,” navigating the everyday emergencies of entrenched deprivation, and holding out hope for different futures more bearable. This remains so even as these care practices tip into frightening, deeply saddening, and shocking psychic conditions such as psychosis and mania, often exacerbated by growing “aggrievement” with socio-material inequities (Ralph, 2015). For example, Skylar described continuing to use meth despite escalating auditory hallucinations, in part because the voices she was hearing offered some comfort as she bore the weight of intersecting oppressions. These “sounds of madness” (Luhrmann, 2018) can be understood along continua and are not always experienced and framed by youth as entirely harmful – in fact, research has shown that “going crazy,” “acting crazy,” and “becoming aggrieved” can be understood by individuals as generative of new lines of potential, including forms of self-care (Fast, 2024; Ralph, 2015). Here, there is an implication for providers to continually prompt dialogue with youth about lived realities of substance use, psychosis, and mania alongside broader desires for their wellbeing and futures, while finding ways of working with youth within and beyond the context of treatment (Giang et al., 2020, Thulien et al., 2022, Goodyear et al., 2023; Bryant et al., 2022; MacLean et al., 2024; Moensted et al., 2024). Opening up these conversations may help to counter more paternalistic and coercive logics of care. Many youth in this study sought to evade these logics through whatever means necessary. They also expressed fears of being overly sedated via antipsychotic medications that could make them feel like “zombies” – an experience that can potentially engender or deepen feelings of dehumanization among those using drugs in the margins (Sumnall et al., 2025).

This study underscores opportunities for more structurally-responsive care with youth who use drugs. The churn of youth MHSU intervention in our study setting continues to be fueled by a desperate desire to curb harms and deaths in the context of an unprecedented drug toxicity crisis (Fast, 2024). This can manifest as highly reactive, acute models of care focused on addressing the MHSU emergency at hand via psychiatric treatment and institutionalization; alternatively, the surveillance and control that youth are drawn into may be more mundane, such as the constant imperative to attend appointments or regular visits by teams to social housing buildings. Importantly, previous research has demonstrated that both of these aspects of the psychopolitical landscape can signal danger to youth who have experienced psychiatric and other forms of institutionalization across their lives, leading to their systems-avoidance and dynamics of self-management described above (Thulien et al., 2022; Manuel et al., 2024). Many of the youth in this study were keenly aware that the line between routine and acute forms of intervention was a thin one they could quickly cross – as, for example, when failure to regularly attend appointments triggered a decision to re-hospitalize a young person on an extended leave plan. Future work should examine the forms of governance embedded within integrated youth MHSU care and potentially competing treatment logics, values, and desires.

To effectively work with youth within and beyond the context of treatment, MHSU interventions must address socio-material inequity, the shifting lived realities of substance use among youth, and intersecting needs (Fast, 2024; Caluzzi et al., 2023; Moensted et al., 2024). Such structurally-responsive logics of care have garnered increased attention in psychiatry and other health disciplines as a means of directing the mental health workforce to support equity-owed populations more comprehensively. Hansen and colleagues’ (2018) “structural competency” approach, for example, calls for three shifts in psychiatric practice: first, to understand patients’ experiences of illness in the context of structural factors; second, to intervene to address structural factors at institutional levels; and third, to develop community connectivity and structural humility to foster long-term social justice change. Applied to our study context, a structural competency approach might involve providers working with youth to address immediate needs and safety concerns related to stimulant use and psychosis, including via medical interventions, while at the same time asking about and meaningfully considering the socio-material issues shaping fluctuations in youths’ substance use and medication adherence, taking steps to support them in securing or maintaining housing, and fostering greater social and community support and momentum, such as through connections made with community drop-in spaces. This is already occurring in many settings, including integrated youth services, where care is based on young people’s holistic needs, readiness, and preferences, alongside providers’ input and clinical judgment (Bryant et al., 2025; MacLean et al., 2024; Providence Health Care Society d.b.a. Foundry, 2023). Here and elsewhere, it is sometimes necessary to temporarily limit young people’s choice and autonomy when addressing immediate safety concerns such as with acute psychosis, yet the goal must always be to return to the kinds of collaborative care that honour youths’ self-determination, as much as is possible and safe.

Building on previous work (D’Arcy, 2019; Luhrmann, 2008; Murphy et al., 2015; Ralph, 2015), our study highlights nuanced tactics and capacities for self-management and care, including the monitoring and adjustment that youth undertook in relation to their use of stimulants, other substances, and psychopharmaceuticals, as well as their guarded engagement with the MHSU treatment system. These dynamics were seldom explicitly framed as harm reduction yet were clearly connected to past, present, and anticipated harms, as well as losses of desirable affective states and bodily vigilance and autonomy tied to pharmacotherapies and mandated treatment plans. Following Luhrmann (2008), we view these harm reduction dynamics as meaningful social signals that can help us to think differently about the way mental health care is offered to youth who use drugs in the context of entrenched poverty and other intersecting oppressions. Calls for MHSU systems and providers to better “meet youth where they’re at” abound, but we occasionally struggle to specify the pragmatics of doing so. Our findings suggest that this can look like being highly cautious with overly medicalizing, psychiatrizing, and pathologizing forms of MHSU treatment, which can signal danger to youth (in particular, those with long and intergenerational histories of institutionalization) and lead to poorer engagement in care. Instead, there is a need to continue investing in care approaches that build on young people’s existing self-management strategies (e.g., planning with youth about making small adjustments to their substance use and possibly medications) and leverage communal care (e.g., via provider-youth relationships, but also including bolstering relationships with wider supports such as peers, Elders, and other trusted adults and places, including drop-in and community centers). Youth need access to supportive medical interventions at various points along the continuum of psychic “slippages” associated with stimulant use and psychosis. Related to this, youth in this study identified lessening but not eliminating psychosis symptoms and achieving greater balance between stimulant use and psychic stability as important goals. Committing to a mental health harm reduction approach means providing support regardless of adherence to antipsychotic medications (D’Arcy, 2019), as we know is already occurring in many practice settings.

5. CONCLUSION

In sum, this study attempts to move away from questions of treatment access and engagement, to elucidate some of the complexities of intersecting stimulant and other substance use, psychosis, and related interventions among youth who use drugs in the context of entrenched poverty, homelessness, and unstable housing. Our findings detail the benefits, drawbacks, and socio-material dimensions of antipsychotic treatment for youth who use drug in such milieus, and how well-intentioned MHSU interventions can inadvertently leave some youth more distrusting of, and disengaged from, a system that is attempting to help them. From these findings, we underscore opportunities for the MHSU treatment landscape to further prioritize young people’s self-determination – as much as is possible and safe – and equity-focused approaches that address the socio-material contexts of youths’ lives.

HIGHLIGHTS.

• Clinicians struggle to effectively treat psychosis in youth who use drugs.

• Poverty, homelessness, and substance use complicate antipsychotic treatment adherence.

• Youth avoid psychiatric interventions that feel like surveillance and control.

• Treatment planning should prioritize youth self-determination, as much as is possible and safe.

• Psychosis supports should address youths’ immediate needs, such as housing.

Data availability

The datasets analyzed for the current studies are not publicly available due to them containing sensitive information that could compromise research participant privacy and consent.