Steroid-induced psychosis: Difference between revisions

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==Background==
==Background==
 
*~5% of patients on ≥40 mg daily of [[prednisone]] have psychiatric symptoms<ref>Acute adverse reactions to [[prednisone]] in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.</ref>
**Incidence rises to just under 20% for patients receiving more ≥80 mg per day
*Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids<ref>J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.</ref>


==Clinical Features==
==Clinical Features==
 
*Time of onset variable
**Median onset after 11.5-12.5 days<ref>Lewis DA, Smith RE. Steroid-Induced Psychiatric Syndromes. J Affect Disord. 1983;5(4):319-332.</ref><ref>Nishimura K, Harigai M, Omori M, Sato E, Hara M. Blood-Brain Barrier Damage as a Risk Factor for Corticosteroid-Induced Psychiatric Disorders in Systemic Lupus Erythematosus. Psychoneuroendocrinology. 2008;33(3):395-403.</ref>
**Case reports of psychosis within one day after exposure
*Wide range of possible psychiatric symptoms
**[[Delusions]] or [[hallucinations]]
**Euphoria
**[[Mania]], [[depression]], [[anxiety]]
**Severe cases may present with [[suicidal ideation]], violence, aggression


==Differential Diagnosis==
==Differential Diagnosis==
 
{{AMS DDX}}


==Evaluation==
==Evaluation==
===Workup===
===Workup===
*Diagnosis of exclusion
*DSM 5 diagnostic criteria
**Must include hallucinations or delusions after steroid exposure<ref>American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders: Substance/Medication-Induced Psychotic Disorder. DSM-5-TR. Published 2022.</ref>
**Other causes cannot explain symptoms


===Diagnosis===
===Diagnosis===
*Consider [[AMS]] workup


==Management==
==Management==
 
*Cease offending agent or taper depending on clinical need for [[corticosteroids]] vs psychiatric complications
**Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest
**Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms
*Antipsychotics mediate dopamine D2 receptor, correlating with possible mechanism of steroid induced psychosis
**2nd generation [[antipsychotics]], low-moderate dosage - [[risperdone]], [[olanzapine]], [[quetiapine]]<ref>Huhn M, Nikolakopoulou A, Schneider-Thoma J, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019;394:939-951.</ref>
**Severe may require IM/IV doses
*Consult psychiatry for duration of medication treatment


==Disposition==
==Disposition==
 
*Admission for severe cases
*Possible discharge for mild cases, consider short supply atypical [[antipsychotics]] and close follow up


==See Also==
==See Also==
Line 27: Line 48:
==References==
==References==
<references/>
<references/>
[[Category:Neurology]]

Latest revision as of 22:55, 29 January 2025

Background

  • ~5% of patients on ≥40 mg daily of prednisone have psychiatric symptoms[1]
    • Incidence rises to just under 20% for patients receiving more ≥80 mg per day
  • Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids[2]

Clinical Features

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

Workup

  • Diagnosis of exclusion
  • DSM 5 diagnostic criteria
    • Must include hallucinations or delusions after steroid exposure[5]
    • Other causes cannot explain symptoms

Diagnosis

  • Consider AMS workup

Management

  • Cease offending agent or taper depending on clinical need for corticosteroids vs psychiatric complications
    • Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest
    • Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms
  • Antipsychotics mediate dopamine D2 receptor, correlating with possible mechanism of steroid induced psychosis
  • Consult psychiatry for duration of medication treatment

Disposition

  • Admission for severe cases
  • Possible discharge for mild cases, consider short supply atypical antipsychotics and close follow up

See Also

External Links

References

  1. ↑ Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.
  2. ↑ J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.
  3. ↑ Lewis DA, Smith RE. Steroid-Induced Psychiatric Syndromes. J Affect Disord. 1983;5(4):319-332.
  4. ↑ Nishimura K, Harigai M, Omori M, Sato E, Hara M. Blood-Brain Barrier Damage as a Risk Factor for Corticosteroid-Induced Psychiatric Disorders in Systemic Lupus Erythematosus. Psychoneuroendocrinology. 2008;33(3):395-403.
  5. ↑ American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders: Substance/Medication-Induced Psychotic Disorder. DSM-5-TR. Published 2022.
  6. ↑ Huhn M, Nikolakopoulou A, Schneider-Thoma J, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019;394:939-951.
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