Steroid Induced Psychosis

Will taking prednisone make you psychotic?

How about other steroids?

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What is Psychosis?

Patients with psychosis are not in touch with the real world. They display symptoms of hallucinations and or delusions. They may also speak incoherently or behave in ways that do not fit their current surroundings.

Hallucinations occur when a person senses something that is not there. This can happen with sight, hearing, touch, and smell. 

At times, the patient may experience two or more hallucinations simultaneously. For example, a psychotic patient may kneel to pet a dog that doesn’t exist. They can see the dog and feel the dog as they pet it. They may also hear or smell the non-existent animal.

Delusions happen when a person firmly believes something untrue. They may be convinced they are an influential person or someone famous when, in fact, they are not. Delusional patients may think they are younger than their actual age and in better health. They may also suffer from paranoia and swear that people are out to get them.

These patients may only eat packaged food or stop eating entirely due to fear of being poisoned. Delusions are very hard to treat with medication.

Drugs As A Cause Of Psychosis

When a patient presents with new-onset psychosis, it is vital to obtain a thorough history. If a family member has been diagnosed with a psychiatric disorder, there is an increased chance of the illness spreading to other genetic relatives. We also know a patient often responds to the same medications that were effective for family members. 

One of the first things I look for as a pharmacist is possible drugs that can cause psychosis. There are several potential agents to consider, but I classify them into two broad groups.


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Drugs Of Abuse

These are drugs that are not prescribed by a physician and have a higher incidence of precipitating psychosis. This is true because of the properties of the substance and the erratic dose the patient receives. 

Street drugs are not regulated, so drug content is sporadic. The drugs are usually addictive, and individuals take an increasing dose trying to reach the desired effect. Some examples of these agents are:

Cocaine
Methamphetamine
Marijuana
LSD
PCP
Ecstasy
Ethanol

Prescription Medications

The other group contains medications that are available as prescriptions. It is essential to point out that many of these drugs are also available on the street. Any substance that has the ability to alter mood or perception is a candidate for sale on the black market. Some of these agents are:

Antidepressants
Antipsychotics
Anti-seizure medications
Anticholinergic Drugs (Click to read post on anticholinergics)

Isotretinoin
Dopamine agonists for Parkinsons Disease
Corticosteroids

We will concentrate on corticosteroids for this post.

Types Of Steroids

Anabolic Steroids

These include testosterone as well as synthetic substances that are similar in structure to testosterone and have comparable effects. Testosterone is used to treat specific hormone problems in men. The synthetic molecules are often abused by bodybuilders and athletes to build muscle and boost athletic abilities. These are generally not associated with psychosis. Some examples of this type of steroid are:

Dianabol
Winstrol
Deca-durabolin
Equipoise
Anadrol

Corticosteroids

Corticosteroids are used in modern medicine to remedy a variety of conditions.

They are used in the emergency department to treat asthma attacks, COPD, and croup in children.

They can be used to treat Crohn’s disease, gout, lupus, multiple sclerosis, and other autoimmune disorders. Corticosteroids have an important role in reducing inflammation.

These steroids are also utilized in the treatment of skin conditions such as eczema and rash. They play an essential role in some cancer therapies. Corticosteroids come in a variety of forms including injections, tablets, liquids, creams, ointments, and inhalers. Some examples include:

Prednisone
Prednisolone
Dexamethasone
Betamethasone
Triamcinolone
Methylprednisolone


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Corticosteroid Adverse Effects

Unfortunately, although corticosteroids are useful in many of the conditions described above, they can also cause adverse effects. A few common side effects include:

Weight gain
Agitation
Nausea and vomiting
Insomnia
Headache
Mood swings
Euphoria
Psychosis

Steroid Induced Psychosis

Psychosis is a side effect of corticosteroid use and most commonly occurs at prednisone doses above 20mg/day given over a long period. 1 

2 3 

Roughly ten percent of patients remain psychotic after the steroid dose is decreased. 4 

Patients are usually clear after a two-week course of antipsychotic medications.

Although prednisone is often described as the main corticosteroid involved, other members of the steroid family can also cause psychosis.

Dexamethasone

Dexamethasone is often used in place of prednisone due to its longer duration of action. This glucocorticoid is six times more potent than prednisone.

It is unknown what dose of dexamethasone is most likely to cause psychosis, but it has occurred post-operatively after a single dose.

We should anticipate a psychotic reaction after administering dexamethasone, and for surgery cases, it may be prudent to utilize restraints to prevent self-extubation.

Pre-medicating with haloperidol or olanzapine may prove beneficial in this situation. 5 

Dexamethasone will accumulate in the body more quickly than prednisone due to its longer half-life. For this reason, careful monitoring should occur when giving this agent over a more extended period of time.

Methylprednisolone

An article published in European Psychiatry in March of 2016 describes a case where a thirty-year-old female received three, 80mg daily doses of methylprednisolone following lumbar surgery. This patient had no personal or family history of any psychiatric disorder.

One week after the methylprednisolone was completed, the patient was admitted to the hospital for bizarre delusions, visual and auditory hallucinations, and disorganized thinking.

She was treated with risperidone (up to 6mg/day) and a very short course of diazepam (10mg/day). The patient was discharged several weeks later when the psychosis cleared up. 6 

Treatment

The first thing to attempt when treating corticosteroid-induced psychosis is to stop the offending agent. Unfortunately, this is not always possible. 

There are circumstances when the steroids must be continued. In these cases, our best option is to treat the patient with an antipsychotic medication. 

Which agent we choose is based mostly on the characteristics of the patient. I could write an entire chapter on this subject but will list the agents we utilize most commonly for psychosis on our unit. I will also explain reasons to choose one agent over the other.

Haloperidol

Haloperidol is still widely used due to its familiarity. Physicians like to use what they are most comfortable with. 

Some patients should never receive haloperidol. This medication is contraindicated in Parkinson’s patients. Due to its high dopamine (D2) blocking properties, it makes the movement disorder worse. 

Haloperidol is still very effective and is often used for delirium as well as psychosis. It is available in oral, injectable and long-acting injectable forms

Quetiapine

Quetiapine is the first choice in a patient who has Parkinson’s disease. This drug is also helpful in patients who are having trouble sleeping as it is one of the most sedating antipsychotics available. Quetiapine is only available in oral dosage forms which limits its usefulness in acute situations.

Olanzapine

Olanzapine is one of the most effective medications we have for delirium as well as psychosis. Like haloperidol, it is also available in all dosage forms. 

The main problem with this agent is weight gain. This can be a positive attribute in patients that have a poor appetite, but these days patients tend to be overweight. Olanzapine is usually the medication I initially recommend.

Risperidone

Risperidone is also an effective agent for psychosis, but it is not available in a quick acting injectable form. It can also cause movement disorder side effects, especially at higher doses.

Ziprasidone

Ziprasidone is popular in the emergency department for acute agitation and psychosis due to its availability as a fast-acting injectable. The powder in the vial does take longer to dissolve than olanzapine, and it has cardiac side effects that make it undesirable for elderly patients.

Final Thoughts

There is evidence linking corticosteroid use to psychosis. These medications are used for a variety of ailments. At times, they are needed to treat life-threatening conditions.

Although prednisone is the agent most commonly associated with corticosteroid-induced psychosis, other agents in this class can also lead to psychotic behavior.

It is essential to be aware of the signs of psychosis and seek treatment if you or someone you know is being treated with any of these drugs.

I suggest having someone check on you periodically if you live alone and are taking these medications. Psychotic patients often have no idea they are having a problem until it is discovered by someone else.

If possible, the corticosteroid should be stopped if psychosis develops. If this isn’t prudent, antipsychotic agents can be used based on patient characteristics.

In severe cases, the patient may need to be hospitalized until stable. Most patients will clear after a few days to a couple of weeks.

I hope you have enjoyed this review of corticosteroid-induced psychosis. If you have any questions or comments, please send me an email.

My goal is to make this site as informative and enjoyable as possible for my readers. We can learn the best way to make that happen together.

As always, live a happy, healthy, healing life and remember to HAVE FUN!

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Michael Pharmacist

Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
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  3. Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric
    complications of glucocorticoid use: steroid psychosis revisited. Psychosomatics.
    2012 Mar-Apr;53(2):103-15. doi: 10.1016/j.psym.2011.12.007. Review.

  4. Kershner P, Wang-Cheng R. Psychiatric side effects of steroid therapy.
    Psychosomatics. 1989 Spring;30(2):135-9. Review.

  5. Patnaik P, Koteswara CM, Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery, J Anaesthesiol Clin Pharmacol, 30, 2014, 94– 96.

  6. Andrei IA, Cristache AM, Parfene-Banu ME, Frunza AA, Boer MC, Puiu MG, Patrichi BE et al, Acute psychosis induced by short-term treatment with methylprednisolone – a case report, European Psychiatry, 33, 2016, S626.

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