Steroid induced psychosis


  • In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of prednisone had psychiatric symptoms[1]
    • Incidence rises to 18.4% for patients receiving more than 80 mg per day
  • Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids[2]

Clinical Features

  • Time of onset variable
    • Median onset after 11.5-12.5 days[3][4]
    • Case reports of psychosis within one day after exposure to steroids
  • Wide range of possible psychiatric symptoms
    • Delusions or hallucinations
    • Euphoria
    • Mania, depression, anxiety
    • Severe cases may present with suicidal ideation, violence, aggression

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma




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


  • Consider AMS workup


  • 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


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

See Also

External Links


  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.