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Corticosteroid-Induced Psychiatric Symptoms - Palliative Care Network of Wisconsin.
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.
Download PDF. Background Corticosteroids are used for a wide spectrum of palliative care indications, including pain, nausea, anorexia, fatigue, and depression 1. These agents are known to induce psychiatric adverse drug reactions, ranging from subtle mood changes and memory deficits to frank psychosis 2,3. This Fast Fact will focus on the identification and management of corticosteroid-induced psychosis. Incidence and Risk Factors In the published literature, the incidence of corticosteroid-induced psychosis has ranged from 1.
This vast range reflects a number of clinical phenomena: variation in the clinical definition, the unpredictability of the reaction, poor clinical awareness of the issue, and the lack of standardization for corticosteroid dosing Dose may be the most important risk factor for the development of steroid-induced psychosis, particularly when 80 mg of oral prednisone dexamethasone dose equivalent of 12 mg po or greater are prescribed 3, Still, even at lower doses, idiosyncratic psychiatric effects are known to occur.
Other risk factors include female sex and older age 8,10, Previous diagnosis of mental illness and prior incidence of corticosteroid-induced psychiatric effects may also be risk factors , 8,10, Pathophysiology The mechanism of action of this reaction is not known, however, it may relate to the enhanced dopamine activity triggered by glucocorticoids.
Evidence has shown patients receiving long-term corticosteroid therapy may develop decreased hippocampal volumes; it has been postulated that these neuro-anatomic changes may also contribute to the development of psychiatric symptoms 4, 5. Clinical Manifestation Early indicators of steroid-induced psychosis include confusion, perplexity, and agitation that typically occur within the first five days after initiation of treatment Patients may go on to develop hallucinations, delusions, and cognitive impairment 2.
Duration of psychiatric symptoms is dose and time-dependent; therefore, if clinicians encounter this reaction they should take prompt, appropriate clinical action see below 8. Caution is advised in aggressive tapering schedules due to the risk of corticosteroid withdrawal. In cases where the corticosteroid cannot be discontinued or significantly reduced, additional pharmacological management may be appropriate.
There are currently no FDA-approved medications with an indication for corticosteroid-induced psychosis.
❾-50%}Prednisone psychosis.Steroid Psychosis
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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.
Steroid-induced psychosis is a well-documented phenomenon. It usually occurs with oral systemic steroid treatment and is more common at. Prednisone, the prodrug of prednisolone, has been implicated as the cause of neuropsychiatric symptoms such as depression, mania, agitation. Corticosteroid-induced psychosis refers to a spectrum of psychiatric symptoms ranging from subtle mood changes to memory deficits to frank. Symptoms such as euphoria, insomnia, mood swings, personality changes, severe depression, and psychosis—referred to as corticosteroid-induced. A severe side effect that can occur with steroid use is steroid psychosis. It is most likely to develop during the first week of treatment with steroids. Psychoses can range from schizophreniform to an organic brain syndrome. Kato O, Misawa H. New Medication Options Research into new or better medication treatment options for chronic pain are happening all over the world. Download PDF. Patients may go on to develop hallucinations, delusions, and cognitive impairment 2. Clinicians should, however, be able to identify and manage these psychiatric effects, as these can significantly inhibit quality of life and meaningful interpersonal interactions for seriously ill patients.Download PDF. Background Corticosteroids are used for a wide spectrum of palliative care indications, including pain, nausea, anorexia, fatigue, and depression 1.
These agents are known to induce psychiatric adverse drug reactions, ranging from subtle mood changes and memory deficits to frank psychosis 2,3.
This Fast Fact will focus on the identification and management of corticosteroid-induced psychosis. Incidence and Risk Factors In the published literature, the incidence of corticosteroid-induced psychosis has ranged from 1. This vast range reflects a number of clinical phenomena: variation in the clinical definition, the unpredictability of the reaction, poor clinical awareness of the issue, and the lack of standardization for corticosteroid dosing Dose may be the most important risk factor for the development of steroid-induced psychosis, particularly when 80 mg of oral prednisone dexamethasone dose equivalent of 12 mg po or greater are prescribed 3, Still, even at lower doses, idiosyncratic psychiatric effects are known to occur.
Other risk factors include female sex and older age 8,10, Previous diagnosis of mental illness and prior incidence of corticosteroid-induced psychiatric effects may also be risk factors , 8,10, Pathophysiology The mechanism of action of this reaction is not known, however, it may relate to the enhanced dopamine activity triggered by glucocorticoids. Evidence has shown patients receiving long-term corticosteroid therapy may develop decreased hippocampal volumes; it has been postulated that these neuro-anatomic changes may also contribute to the development of psychiatric symptoms 4, 5.
Clinical Manifestation Early indicators of steroid-induced psychosis include confusion, perplexity, and agitation that typically occur within the first five days after initiation of treatment Patients may go on to develop hallucinations, delusions, and cognitive impairment 2. Duration of psychiatric symptoms is dose and time-dependent; therefore, if clinicians encounter this reaction they should take prompt, appropriate clinical action see below 8.
Caution is advised in aggressive tapering schedules due to the risk of corticosteroid withdrawal. In cases where the corticosteroid cannot be discontinued or significantly reduced, additional pharmacological management may be appropriate. There are currently no FDA-approved medications with an indication for corticosteroid-induced psychosis.
As evidenced in case reports, low-dose antipsychotics, such as haloperidol 0. Use of the mood stabilizer, lithium, has been described to prevent corticosteroid induced psychosis, but it is associated with more side effects.
Therefore, involvement of a consult liaison psychiatry team should be considered when utilizing lithium Other Psychiatric-Induced Symptoms In addition to psychosis, a multitude of psychiatric disorders can arise as adverse effects of corticosteroids.
These include, but are not limited to, mood disorders with depressive or manic features and delirium In addition to corticosteroid tapers, the literature provides limited evidence of medication management. The majority of patients will recover from psychiatric symptoms within several weeks after discontinuation or significant dose tapering of the corticosteroid 6.
Summary The rare complication of corticosteroid-induced psychiatric symptoms should not impede the prescribing of these agents for appropriate indications, especially when the benefits of therapy would far outweigh the risks.
Clinicians should, however, be able to identify and manage these psychiatric effects, as these can significantly inhibit quality of life and meaningful interpersonal interactions for seriously ill patients. Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know! Disclaimer: Fast Facts and Concepts provide educational information for health care professionals.
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