The many faces of psilocybin-related psychosis: A case series

Psilocybin use has been increasingly popular in the United States, and its use as a novel therapeutic treatment for psychiatric conditions has led to greater public acceptance as a recreational substance. Consequently, clinicians are faced with managing complications and adverse effects associated with psilocybin use. We present three cases seen in a dual diagnosis inpatient psychiatry unit during a four-week period in 2023: Case 1: the case of intermittent psilocybin use associated with a particularly prolonged psychosis requiring treatment with higher doses and a longer course of neuroleptic medication; Case 2: the case of a short period of frequent psilocybin use culminating into increasing paranoia and a medically serious suicide attempt treated with neuroleptics; and Case 3: the case of long-term “microdosing” followed by mania-like symptoms including grandiosity, irritability, and physical aggression towards others, but with resolution of symptoms after discontinuing psilocybin use. Amidst psilocybin's increasing prevalence and acceptance, clinicians are faced with managing the complications and adverse effects of psilocybin use with minimal guidelines or evidence. This case series aims to highlight varied presentations, management strategies, and treatment responses to contribute some insight into this unknown territory.