When Steroids Cause Psychosis
October 1, 2010 • By Jane P. Gagliardi, MD, MHS, Andrew J. Muzyk, PharmD, and Shannon Holt, PharmD
Mrs. J was a 31-year-old woman with a five-year history of an overlap syndrome with features of systemic lupus erythematosus and systemic sclerosis. Two months prior to the current admission, she had been hospitalized with altered mental status. At that time, she underwent brain imaging, lumbar puncture, and cerebrospinal fluid analysis and was diagnosed with lupus cerebritis. She was treated with corticosteroids, and her mental status improved to baseline. Her steroid dose was tapered over four weeks without recurrence of altered mental status.
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Mrs. J was then admitted to the general medicine service with acute renal failure that was attributed to lupus nephritis. She was started on intravenous methylprenisolone at a dose of 125 mg daily. Over the next three days, she was unable to sleep and developed rapid, pressured speech. Usually mild mannered and cooperative with the nursing staff, she became irritable and suspicious. Psychiatry consultation was requested for assistance in evaluating and managing her acute behavioral changes.
Mrs. J had no previous psychiatric history aside from her recent episode of lupus cerebritis and had not been treated with antipsychotic or antidepressant medications in the past. There was no family history of psychiatric illness or rheumatologic disorders. She was married and lived with her husband and 10-year-old son. She was currently experiencing financial difficulties related to her health problems. She denied any use of alcohol, cigarettes, or illicit drugs, and urine toxicology was negative. She had been following up with her rheumatologist and primary care provider and had been taking medications as prescribed.
Because of the activity of the renal disease, Mrs. J’s rheumatologic condition necessitated continued use of corticosteroids, although the dose of prednisone was tapered to 60 mg daily. At the same time, risperidone was added at a low dose and titrated up to 0.5 mg in the morning and 2 mg at bedtime, with complete resolution of her manic symptoms. Over the next six months, she was able to be tapered off corticosteroids and risperidone without recurrence of the manic symptoms.
The outcome of this case was fortunately favorable, with treatment decisions requiring extensive discussion between the general medicine service and the patient’s consultants, including the rheumatologist, psychiatrist, and nephrologist. As often occurs with lupus patients who develop psychiatric symptoms when treated with glucocorticoids, two major questions arise: Are the psychiatric symptoms from the steroids as opposed to the disease (e.g., cerebritis)? If they are from steroids, how can these symptoms best be treated? This article will provide a framework to decide the answers.
Corticosteroids are used to treat inflammatory manifestations of many rheumatologic conditions. Doses necessary to control disease are frequently high (e.g., 1 mg/kg or greater), and therapy may be maintained for prolonged periods of weeks to months. In this setting, one out of every two to three patients prescribed steroids may develop psychiatric symptoms including psychosis, mania, delirium, and depression. The most common symptoms reported with corticosteroid therapy are hypomania, mania, and psychosis. 1
Psychiatric Symptoms Associated with Corticosteroids
Psychiatric symptoms have been documented in association with the use of corticosteroids since these agents were first introduced in the 1950s. 2 Corticosteroid-induced psychosis refers to a spectrum of psychiatric symptoms ranging from subtle mood changes to memory deficits to frank psychosis that can occur at any time during treatment (See Figure 1, p. 40). 3 Mania and hypomania are reported most commonly (35%), followed by depressive symptoms (28%) and psychotic reactions (24%). 2 Psychiatric symptoms typically develop three to four days after the initiation of corticosteroid therapy, although symptoms can occur at any time, including after cessation of therapy.
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Ryan Hutchinson says
To whom it may concern,
This is a shot in the dark. I ended up with full blown steroid psychosis about 4 years ago. It was dismissed as GAD that I have never had before. My doctor finally admitted it was the steroids but gave little help. I did not sleep for 12 weeks strait and suffered for over 2 years with symptoms I would not wish on my worst enemy. I was put on Klonopin for 6 months and tapered rapidly for fear of causing more harm. It has been 4 years since the incident and although I am in a better place, I still suffer. I cannot find any support. The only support I found was on a page called Benzobuddies. I have lost trust in my doctors as they only want to push drugs on me. Is there anything I can do or someone I can talk with that knows what’s going on. Thanks for reading.
Mario pillare says
Ryan hang in there buddy. I just went through one hell of a roller coaster ride. I know where your coming from. Find another doctor. I’m 62 years old I was on a high dose of prednisone and after only two weeks I turned into another person (no sleep for days not even tired, my body was so full of energy. I was irritable. I would snap at the drop of a hat start yelling and ranting over anything I was in a fog for days. Wife took me to my primary doctor with all my meds. Definitely steroids he said. He sees it too many times. He rapidly weaned me off and after a few days I started to become me again. I’m still having a few side effect but things are getting better Day by day. So find a dr that understands what your going through. Lot of drs try to avoid the steroids if possible because of the side effects. Steroids do a great job for most people but if your body has a reaction to them you do pay the price. Wishing you the best, Mario
I feel your suffering! On several occasions, starting several yrs ago, I received corticosteroid injections in my knee-initially with no issues. (I am 61 now.) Once it was determined that I needed surgery (knee replacement), the surgeon decided to attempt pain relief through a similar injection. Within a few hrs of the injection, I remember nothing for a few days. My husband reported a severe mood change and irrational, and at times, aggressive behavior. I am a licensed mental health therapist. Once I returned to my pre-injection state and heard what had occurred, I immediately recognized the symptoms as some type of psychotic reaction. Fortunately I had received only one dose, so only had the reaction once-this was apparently a different drug combination than my previous injections from a different doctor. Anyway, all of this is to say that I hope your suffering will not last much longer, and that gradually the consequences of the drug will resolve. I totally believe you will continue to improve! I am no expert by any means, but after the reaction I had, I understand your pain and frustration! As the person before me said-hang in there, and don’t give up the belief that this will end!
My daughter was give a six day taper of prednisone starting at 60mg, tapering to 10mg. She was hospitalized with prednisone induced psychosis. Since her initial stay, she has had two more hospital stays. Released and diagnosed with a different mental disorder each time. There is no mental illness in our family and the only problem she had prior to this was test anxiety. She is now in a constant state of rage. She hasn’t been able to tolerate any of the medications they have put her on. Her, our families lives have been completely turned upside down because of this. It seems none of the doctors know how to treat what’s going on with her. And they try to say prednisone has nothing to do with what’s going on with her now. Nothing that anyone says will ever convince me that prednisone caused all of this. She went from being a productive college student, working a part time job, and making excellent grades to having to stay home because her emotions are out of control! We’re desperate for help.
She doesn’t need any pills it’s not a mental health problem wean her off them I tried seroquel mistakenly regular go said and the mental health Dr at hospital said it’s definitely not a mental health issue just side affects from steroids
Going on the 7th month since my daughters 6 day prednisone prescription. After about two and a half months of psychosis and mania, a psychiatrist that had been treating her called her in a prescription for lithium. With no follow up care. From my understanding she should have had lab work when taking lithium. After approximately one week on the lithium the mania finally ended , but then severe depression took its place. She then refused to take any more of the lithium. We’ve tried multiple doctors around our home town and they have tried a couple antidepressants. She was on each one for 6-8 weeks and neither one had any success in relieving this depression. She’s never experienced any type of depression remotely close to this. We eventually made her an appointment at Mayo Clinic in Minnesota. While there she had multiple appointments and saw several doctors. They knew exactly what we were going through. They were well aware of the dangerous side effects of the prednisone. Unfortunately, unless we could have stayed for several weeks, there really wasn’t much they could do except tell us to find a place that offered congnitive therapy. So we came back home trying to find this type of help. She has now developed such a fear of doctors, and distrust for psychiatrists that she is afraid to seek help. She admits her depression has taken over her life and now has no interest in anything. She tried enrolling back in college, but her anxiety wouldn’t let her go through with it. We recently tried taking her to an all girls facility for depression and anxiety, bipolar, eating disorders. We drove 9 hours to get her there. Once we were there, she was too afraid to stay. They knew of these types of psychosis and depressive reactions to prednisone. And I felt this was our only hope. She simply was too afraid for us to leave her because of the way she was treated at other hospitals.. What angers me most is that she had viral pharyngitis when a physician assistant prescribed her this prednisone. She shouldn’t have even been given such a dangerous medication for a virus. We are still desperately seeking help for her. I guess I’m hoping someone will see this and know how to help us. We’re simply desperate.
Wow my heart ❤ goes out to u I’m on this sight also looking for advice I’m on meds for depression n anxiety.bipolar.today I was so paranoid I thought bugs were on me n thought my hair was falling out if these many ppl r having such bad sideffect the must do more research of meds mixed with prednisone.again very sorry for ur daugther. Experience horrible
I have a rare auto-immune disease that requires high (160mg 2x day) dose prednisone to stop a severe blistering of mucosal tissue i.e., 2-3 degree burns of mouth, throat, sinus, eyes and even my heart. The possibility of this disease killing me without prednisone is real and my doctor explained that prior to prednisone a great majority of people with Erythema Multiforme – Major died.
So what’s the problem? Over many years and a dozen high dose treatments with prednisone I have been 302 committed and upon release my doctors where cautioned about this therapy.
During my most recent treatment, I went into a manic state or worse. I was PFA’d and removed from my home by police after scaring my wife and kids. I had to finish treatments at the hospital and I requested a psychological evaluation because I hadn’t slept in 5 days, almost lost my job, and was was manic or worse. After a discussion with a psychiatrist he added several different mood stabilizers and anti psychotic meds. I have come off the prednisone and the pshyc meds are taking effect. I cant wait until prednisone is out of my system.
My doctor now realizes after this last event a new protocol is being thought out with future treatments.
This I can tell you without a doubt in my mind that Prednisone is a miracle and a curse all rolled up into one medicine. If you are experiencing mental issues with prednisone tell your doctor immediately, insist on getting psychiatric support and PRAY.
Advising someone to not take an antipsychotic medication when they are having a psychotic episode is very poor advice. It doesn’t matter what is causing the psychosis. The symptoms need to be treated. The psychotic episode will subside if caused by the steroids. In the meantime the symptoms have to be treated.
Karen Carabio says
Thank you all for your postings. I didn’t think a steroid injection (SI joint) could cause my outbursts because was suffering with GAD and MDD prior to my two injections. But 5 days ago I received my second one, and by last night I was itching severely all over, very antsy, could not sleep, started scratching and hitting myself and had to try very hard not to break anything I touched. I googled info and was surprised to hear this has happened to others, not just those on an oral steroid regiment. It does help to KNOW now, but really, the psychiatric reaction borders on unbearable.
My sister was recently prescribed 40 mg of Prednisone. After taking it for 6 days she suffered a psychotic break (mania, delirum, ect.). We have taken she to the ER twice and doctors refuse or do not know how to treat her. I just schedule a psy eval for her so I am hoping we can get her back before it is too late.
Can all steriods cause this or can other kinds be safe?
Jan Solomon says
My mother was taken to the hospital yesterday because she was acting strange and confused. By the time I got there and saw her I started to worry about her liver function, as I’d seen the effects of the ammonia on the brain in a friend. Yesterday she knew the day and time and who she was, at 630 this morning she does not. She’s only getting worse. The hospital staff has said they think it’s a UTI, which fits to some degree as she’s not producing as normal. However in the past 2 weeks she was given a prednisone 6 day pack, an inhaler, and gone for a “spinal block”…no clue if it was a steroid or not, safe bet it maybe was. After reading all of these I’m still not sure of what’s going on but very scared it’ll be more long term than not. Her family doctor should be in to see her anytime now, and all I can hope is he has answers.
I had two facet joint injections. A week later bursa. I have been shaking..clonus. heart beating hard. I’m depressed
Robert Sackey says
This is in response to the reply, Anita posted on November 22, 2017 at 1:24 am, here above:
She said: “Advising someone to not take an antipsychotic medication when they are having a psychotic episode is very poor advice. It doesn’t matter what is causing the psychosis. The symptoms need to be treated. The psychotic episode will subside if caused by the steroids. In the meantime the symptoms have to be treated.”
My response to that is: YES, IT DOES MATTER WHAT IS CAUSING THE PSYCHOSIS!
THE ONLY sensible way to treat what is causing the psychosis in this particular case (which is known to be the side effects of a particular medication) is not to stop taking it abruptly, but to ask your physician to wean you off it if asap.
To say that it doesn’t matter – and that it is safe or better to attempt to treat the side effects of on drug with ANOTHER drug, is outrageous! And what other drug, or steps would you take to remedy the side effects of this second drug – and so forth?
A lot of the people prescribing these meds and the ones advocating for their use, very often have vested financial interests in these drug manufactures.
Some doctors are quick to prescribe meds – very often, without checking for allergies or tolerance – or whether it is suitable for a particular patient.
A lot of the time seeing a psychologist to talk things through first is much better. The vast majority of people on medication for whatever reasons could benefit from drug-free treatments involving exercise, change of diet, giving up smoking, alcohol rtf, for example, change of environment or even work, and a whole host of other drug-free choices. The world is being poisoned with these quick fix drugs which create more problems.
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