Can prednisone (corticosteroid) induce psychosis?

From the Guidelines

Yes, prednisone can induce psychosis in some individuals, typically at higher doses, with symptoms including hallucinations, delusions, and mood changes, and the risk increases with higher doses and longer treatment duration. According to the most recent and highest quality study, 1, corticosteroid-induced psychiatric disease, including psychosis, occurs in a small percentage of patients treated with prednisone. The study notes that the risk of psychosis is higher with prolonged treatment and at doses above 40mg per day of prednisone.

Key Points to Consider

• The risk of prednisone-induced psychosis is generally low, but it can occur, especially in individuals with a personal or family history of psychiatric disorders, older adults, and those taking certain medications.
• Symptoms of steroid-induced psychosis may include hallucinations, delusions, mood changes, agitation, insomnia, and impaired thinking.
• If psychotic symptoms develop while taking prednisone, patients should contact their healthcare provider immediately but should not stop the medication abruptly.
• Treatment typically involves reducing the steroid dose if possible, adding antipsychotic medications temporarily, and providing supportive care.
• The psychosis usually resolves once the steroid is discontinued or reduced, though recovery may take days to weeks.

Management and Prevention

• To minimize the risk of prednisone-induced psychosis, the lowest effective dose of prednisone should be used, and treatment should be tapered off gradually when possible.
• Patients should be monitored closely for signs of psychosis, especially during the first two weeks of treatment.
• Antipsychotic medications may be prescribed temporarily to manage psychotic symptoms.
• Supportive care, including counseling and therapy, may also be beneficial in managing steroid-induced psychosis. As noted in 1, management involves antidepressive and/or antipsychotic agents as indicated, and biofeedback-assisted cognitive behavioral treatment has a favorable impact on depressive symptoms.

From the FDA Drug Label

Psychiatric derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychotic manifestations. Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids.

Yes, prednisone can induce psychosis. Psychotic manifestations are listed as a possible adverse reaction to corticosteroids, including prednisone 2. Additionally, the drug label for prednisone lists "psychiatric disorders including steroid psychoses or aggravation of preexisting psychiatric conditions" as a possible adverse reaction 2.

From the Research

Prednisone and Psychosis

• Prednisone, a corticosteroid, has been implicated in causing neuropsychiatric symptoms, including psychosis, as reported in a study published in 2021 3.
• The literature suggests that patients on high doses (40 mg or more) of prednisone per day are at a greater risk for steroid-induced psychosis, but those on lower doses are still at risk 3.
• A meta-analysis found that severe psychiatric reactions, including psychosis, occurred in nearly 6% of patients taking corticosteroids, while mild to moderate reactions occurred in about 28% 4.
• Psychiatric adverse effects, such as psychosis, can occur early in a treatment cycle and typically resolve with dosage reduction or discontinuation of corticosteroids 4.
• In some cases, antipsychotics or mood stabilizers may be required to manage corticosteroid-induced psychiatric syndromes 4.

Risk Factors and Treatment

• The incidence of severe psychiatric symptoms, including psychosis, has been estimated to be 5.7% in patients receiving high doses of prednisone 5.
• Dose is not predictive of time of onset, severity, type, or duration of symptoms, and symptoms can develop rapidly following exposure to even low doses 5.
• Treatment includes early recognition, steroid withdrawal when appropriate, reduction in stimulation, and medication, with atypical antipsychotics often recommended as first-line treatment 5.
• Glucocorticoids can have permanent effects on the brain, and excessive exposure may result in decreased production of endogenous neurosteroid molecules, leading to unopposed glucocorticoid effects 5.
• The elderly and those with previous psychiatric diagnoses are not at increased risk for psychiatric side effects, but females and those with prior corticosteroid-induced psychiatric side effects are 6.
• Depression and mania are the most frequent behavioral side effects, followed by psychosis and delirium, and treatment involves stopping the corticosteroids, if possible, and targeting the specific psychiatric symptoms that develop 6.