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- Steroid-induced psychiatric symptoms: What you need to know | MDedge Psychiatry
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. N, age 30, presents to the emergency department for altered mental status, insomnia, and behavioral changes, which she has experienced for 1 week. One week earlier, Ms. N was hospitalized for sudden-onset chest pain, weakness, and dizziness.
She received 45 minutes of cardiopulmonary resuscitation prior to presentation and was found to have a ST-segment elevation myocardial infarction that required emergent left anterior descending coronary artery and right coronary artery percutaneous coronary intervention to place drug-eluting stents. Her recovery was complicated by acute cardiogenic shock, pulmonary edema, and hypoxic respiratory failure.
Subsequently, she was intubated, admitted to the ICU, and received high-dose corticosteroids, including IV methylprednisolone, 40 mg every 12 hours, which was tapered prior to discharge. Her husband reports that since Ms.
She has also been endorsing visual and auditory hallucinations, with increased praying and listening to religious music. The manifestations of steroid-induced psychiatric symptoms are broad and can involve affective, behavioral, and cognitive domains. While the current mechanism is unknown, this phenomenon may be related to decreased levels of corticotropin, norepinephrine, and beta-endorphin immunoreactivity, as well as effects on brain regions such as the hippocampus and amygdala.
The best interventions for steroid-induced psychiatric symptoms are awareness and early diagnosis. There are no FDA-approved treatments for steroid-induced psychiatric symptoms; initial measures should include tapering or discontinuing corticosteroids.
In this article, we review the literature on the incidence, characteristics, differential diagnoses, proposed mechanism, risk factors, and proposed treatments of steroid-induced psychiatric symptoms. The incidence of steroid-induced psychiatric symptoms is difficult to assess because there can be a wide range of reactions that are dose- and time-related. Psychiatric symptoms that are induced by steroids can mimic metabolic, neurologic, or toxic disorders.
Skip to main content. Steroid-induced psychiatric symptoms: What you need to know. Current Psychiatry. Early recognition of these symptoms is key to initiating effective interventions. PDF Download. Pages 1 2 3 4 last ». Next Article: Reproductive safety of treatments for women with bipolar disorder.
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She received 45 minutes of cardiopulmonary resuscitation prior to presentation and was found to have a ST-segment elevation myocardial infarction that required emergent left anterior descending coronary artery and right coronary artery percutaneous coronary intervention to place drug-eluting stents.
Her recovery was complicated by acute cardiogenic shock, pulmonary edema, and hypoxic respiratory failure. Subsequently, she was intubated, admitted to the ICU, and received high-dose corticosteroids, including IV methylprednisolone, 40 mg every 12 hours, which was tapered prior to discharge.
Her husband reports that since Ms. She has also been endorsing visual and auditory hallucinations, with increased praying and listening to religious music. Pediatr Nephrol — Mol Psychiatry 22 4 — Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Florence Thibaut. Reprints and Permissions. Thibaut, F. Corticosteroid-induced psychiatric disorders: genetic studies are needed. Eur Arch Psychiatry Clin Neurosci , — Download citation.
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Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search SpringerLink Search. Download PDF. Rights and permissions Reprints and Permissions. About this article. Of note, since many older adults taking corticosteroids have autoimmune illnesses that affect renal function, lithium may be difficult to use safely in this patient population.
Anticonvulsants : For patients in whom atypical antipsychotics or lithium are not tolerated, the use of valproic acid or carbamazepine with appropriate monitoring may be considered as alternatives. Antidepressants: The use of selective serotonin reuptake inhibitors SSRIs may be helpful in individuals with depressive symptomatology in whom there is no history of mania; some evidence exists that tricyclic antidepressants may exacerbate the symptoms.
While clear guidelines regarding when to start preventive treatments do not exist, there are potential candidates for pretreatment with lithium or other agents, including patients who have developed psychiatric symptoms multiple times after repeated corticosteroid use or who are at high risk if psychiatric side effects occur. Of note, antipsychotics should be used only for psychosis, as their use in nonpsychotic, agitated patients has been only marginally better than placebo in controlling symptoms e.
Studies have shown that in patients with dementia, antipsychotic agents increased mortality and risk of stroke—thus the FDA black box warning regarding their use in this patient population. A baseline personal and family history, along with measurements of body-mass index, waist circumference, blood pressure, fasting plasma glucose, and fasting lipid profile, should be obtained prior to initiating an atypical antipsychotic; appropriate ongoing monitoring e.
Note that while there are no clear monitoring recommendations, all antipsychotics can prolong the QTc interval. Medication therapy for corticosteroid-induced psychosis poses additional risk in the geriatric population. Discontinuation of long-term glucocorticoid therapy is associated with an increased risk of both depression and delirium or confusion, with older adults found to be at higher risk.
In addition to having an awareness of this condition with its spectrum of symptoms, collaboration among clinicians regarding prevention and treatment is of the utmost importance. Cerullo MA. Corticosteroid-induced mania: Prepare for the unpredictable. Current Psychiatry. June Accessed June 22, Mood changes during prednisone bursts in outpatients with asthma.
J Clin Psychopharmacol. Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. Mania triggered by a steroid nasal spray in a patient with stable bipolar disorder.
Am J Psychiatry. Adverse effects of systemic glucocorticosteroid therapy in infants with hemangiomas. Arch Dermatol. Hippocampal volume, spectroscopy, cognition, and mood in patients receiving corticosteroid therapy. Biol Psychiatry. Their clinical characteristics and treatments were examined. Results: All 9 corticosteroid-treated patients had a clinical course of bipolar disorder. Seven patients initially developed a manic or hypomanic state with subacute onset ranging from 1 to 3 months.
Systemic corticosteroid use—such as treatment with prednisone, commonly used in respiratory disorders, rheumatoid arthritis, and other conditions common in older adults—has been associated with psychiatric adverse effects. Since corticosteroids were first introduced in the s, they have been associated with a spectrum of psychiatric symptoms.
Following cessation of corticosteroid therapy, it is reported that depressive symptoms persist for approximately 4 weeks; mania for 3 weeks; and delirium, for a few days.
This prospective study identified a subset of patients—individuals meeting criteria for posttraumatic stress disorder—who developed dysphoric symptoms and were more likely to discontinue corticosteroids due to difficulties tolerating the mood symptoms.
Whenever possible, tapering corticosteroids—ideally to less than 40 mg daily—is recommended as a first step to manage corticosteroid-induced psychosis; tapering and discontinuation of steroids may be sufficient to improve psychiatric symptoms without requiring additional medications. According to experts, while the lack of high-quality prospective trials makes it difficult to establish an algorithm for the treatment of corticosteroid-induced psychosis, most case reports describe benefit from atypical antipsychotics and lithium.
Atypical antipsychotic agents : A low-dose atypical antipsychotic e. Lithium: In selected individuals in whom renal insufficiency is not an issue, or in whom there is no need for a diuretic, ACE inhibitor, or non-steroidal anti-inflammatory drug NSAID therapy, lithium therapy may be an option; careful monitoring and vigilance for signs of toxicity is of the utmost importance in these patients.
Of note, since many older adults taking corticosteroids have autoimmune illnesses that affect renal function, lithium may be difficult to use safely in this patient population. Anticonvulsants : For patients in whom atypical antipsychotics or lithium are not tolerated, the use of valproic acid or carbamazepine with appropriate monitoring may be considered as alternatives. Antidepressants: The use of selective serotonin reuptake inhibitors SSRIs may be helpful in individuals with depressive symptomatology in whom there is no history of mania; some evidence exists that tricyclic antidepressants may exacerbate the symptoms.
While clear guidelines regarding when to start preventive treatments do not exist, there are potential candidates for pretreatment with lithium or other agents, including patients who have developed psychiatric symptoms multiple times after repeated corticosteroid use or who are at high risk if psychiatric side effects occur.
Of note, antipsychotics should be used only for psychosis, as their use in nonpsychotic, agitated patients has been only marginally better than placebo in controlling symptoms e. Studies have shown that in patients with dementia, antipsychotic agents increased mortality and risk of stroke—thus the FDA black box warning regarding their use in this patient population.
A baseline personal and family history, along with measurements of body-mass index, waist circumference, blood pressure, fasting plasma glucose, and fasting lipid profile, should be obtained prior to initiating an atypical antipsychotic; appropriate ongoing monitoring e. Note that while there are no clear monitoring recommendations, all antipsychotics can prolong the QTc interval.
Medication therapy for corticosteroid-induced psychosis poses additional risk in the geriatric population. Discontinuation of long-term glucocorticoid therapy is associated with an increased risk of both depression and delirium or confusion, with older adults found to be at higher risk.
In addition to having an awareness of this condition with its spectrum of symptoms, collaboration among clinicians regarding prevention and treatment is of the utmost importance. Cerullo MA. Corticosteroid-induced mania: Prepare for the unpredictable. Current Psychiatry. June Accessed June 22, Mood changes during prednisone bursts in outpatients with asthma.
J Clin Psychopharmacol. Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. Mania triggered by a steroid nasal spray in a patient with stable bipolar disorder. Am J Psychiatry. Adverse effects of systemic glucocorticosteroid therapy in infants with hemangiomas. Arch Dermatol. Hippocampal volume, spectroscopy, cognition, and mood in patients receiving corticosteroid therapy. Biol Psychiatry. J Psychiatr Res. Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects.
When steroids cause psychosis. October 1, Accessed June 9, Sirois F. Steroid psychosis: a review. Gen Hosp Psychiatry. Psychiatric adverse effect of corticosteroids. Mayo Clin Proc. McEwen BS. Allostasis, allostatic load, and the aging nervous system: role of excitatory amino acids and excitotoxicity.
Neurochem Res. Side effects of corticosteroid therapy. Psychiatric aspects. Arch Psychiatry. Corticosteroid-related central nervous system side effects. J Pharmacol Pharmacother. Steroid-induced psychiatric syndromes. A report of 14 cases and a review of the literature. J Affect Disord. Presentation of the steroid psychoses. J Nerv Ment Dis. Severe neuropsychiatric outcomes following discontinuation of long-term glucocorticoid therapy: a cohort study.
J Clin Psychiatry. Br J Clin Pharmacol. Effect of phenytoin on mood and declarative memory during prescription corticosteroid therapy. Bio Psychiatry. Impact of levetiracetam on mood and cognition during prednisone therapy. Eur Psychiatry. Effect of lamotrigine on mood and cognition in patients receiving chronic exogenous corticosteroids. Lithium prophylaxis of corticotropin-induced psychosis. Goldman LS, Goveas J. Olanzapine treatment of corticosteroid-induced mood disorders.
Treatment of corticosteroid-induced mood changes with olanzapine. An open-label trial of olanzapine for corticosteroid-induced mood symptoms. Budur K, Pozuelo L. Olanzapine for corticosteroid-induced mood disorders. Steroid-induced psychosis in an adolescent: treatment and prophylaxis with risperidone. Turk J Pediatr. Steroid-induced psychosis treated with risperidone. Can J Psychiatry. Kato O, Misawa H. Steroid-induced psychosis treated with valproic acid and risperidone in a patient with systemic lupus erythematosus.
Risperidone in the treatment of steroid-induced psychosis. J Child Adolesc Psychopharmacol. Quetiapine therapy for corticosteroid-induced mania.
Accessed June 7, Geriatric Dosage Handbook. Hudson, OH: Lexicomp; Epocrates Plus Version Updated May 9, Accessed June 15, Whalen K. Adrenal hormones.
In: Pharmacology. Philadelphia, PA: Wolters Kluwer. Fitzgerald PA. Endocrine disorders. Current Medical Diagnosis and Treatment. Corticosteroid induced psychosis in the pain management setting. Pain Physician. Featured Issue Featured Supplements. US Pharm. Preventing Steroid-Induced Symptoms While clear guidelines regarding when to start preventive treatments do not exist, there are potential candidates for pretreatment with lithium or other agents, including patients who have developed psychiatric symptoms multiple times after repeated corticosteroid use or who are at high risk if psychiatric side effects occur.
To date, no study has focused specifically on recurrent corticosteroid-induced mood disorders and considered their long-term outcome and treatment strategies. Symptoms such as euphoria, insomnia, mood swings, personality changes, severe depression, and psychosis—referred to as corticosteroid-induced. Symptom measures returned to baseline levels an average of 10 days after stopping prednisone therapy, except for depression scores, which were. but only 14% (11/79) had 'a psychotic disorder without evidence of Patients who experience corticosteroid-induced depression during one. To date, no study has focused specifically on recurrent corticosteroid-induced mood disorders and considered their long-term outcome and treatment strategies. An open-label trial of olanzapine for corticosteroid-induced mood symptoms. Whenever possible, tapering corticosteroids—ideally to less than 40 mg daily—is recommended as a first step to manage corticosteroid-induced psychosis; tapering and discontinuation of steroids may be sufficient to improve psychiatric symptoms without requiring additional medications.Background: Corticosteroids often induce steroid psychosis, a collection of heterogeneous syndromes with different pathophysiologic mechanisms. To date, no study has focused specifically on recurrent corticosteroid-induced mood disorders and considered their long-term outcome and treatment strategies. Method: Nine patients whose initial clinical presentation met DSM-IV criteria for a substance-induced mood disorder were identified by a review of medical records.
Their clinical characteristics and treatments were examined. Results: All 9 corticosteroid-treated patients had a clinical course of bipolar disorder. Seven patients initially developed a manic or hypomanic state with subacute onset ranging from 1 to 3 months.
Six patients had manic episodes accompanied by psychotic features. The proportion of manic episodes relative to total mood episodes of the 9 patients was Seven patients showed mood episodes that had no direct relationship to corticosteroid therapy and were preceded by various psychosocial stressors.
Four of 5 patients who received steroid pulse therapy rapidly became manic or hypomanic. Antidepressants as well as mood stabilizers were useful for treatment of the present 9 patients. Conclusion: Recurrent cases of corticosteroid-induced mood disorder have interesting clinical features, such as subacute onset, manic predominance, frequent accompanying psychotic features, and similar recurrent episodes in association with psychosocial stressors and corticosteroid use.
Management, including psychopharmacologic intervention, should be indicated by a consideration of the underlying illnesses and psychosocial stressors. Abstract Background: Corticosteroids often induce steroid psychosis, a collection of heterogeneous syndromes with different pathophysiologic mechanisms. Publication types Case Reports.
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