Psychiatric Side Effects of Prednisone
Prednisone commonly causes psychiatric side effects ranging from mild mood changes to severe psychosis, with approximately 28% of patients experiencing mild to moderate reactions and 6% experiencing severe reactions. 1
Common Psychiatric Manifestations
Mood Disturbances
- Euphoria and hypomania - Most common during short-term therapy 1
- Depression - More common with long-term therapy 1
- Mood swings - Can occur rapidly and unpredictably 2
- Emotional lability - Listed as a common reason for preferring combination therapy over prednisone monotherapy 3
Cognitive and Behavioral Effects
- Insomnia - Common early side effect 3
- Personality changes - Can range from mild to severe 2
- Anxiety - May present early in treatment 1
Severe Manifestations
- Psychosis - Including hallucinations and delusions 2
- Delirium - More common with higher doses 4
- Severe depression - Can be debilitating 2
Risk Factors and Timing
Dose-Related Risk
- Higher doses increase risk - Particularly doses >10mg daily 5
- Duration matters - Severe complications typically develop after 18 months of continuous therapy 3
- Dosage directly related to incidence - But not to timing, severity, or duration of effects 1
Patient-Specific Risk Factors
- Female gender - Associated with increased risk 6
- Prior corticosteroid-induced psychiatric reactions - History of previous reactions increases risk 6
- Pre-existing conditions - Patients with emotional instability or psychotic tendencies may experience aggravation of symptoms 2
Important Note on Risk Assessment
- Neither presence nor absence of previous reactions reliably predicts future adverse responses 1
- Patients with pre-existing depression may actually experience improvement in depressive symptoms during prednisone therapy 7
- Patients with PTSD may experience worsening of symptoms and traumatic memories 7
Monitoring and Assessment
Clinical Monitoring
- Regular assessment of mental status - The American Society of Hematology recommends close monitoring for sleep and mood disturbances 3
- Health-related quality of life assessment - Including depression, fatigue, and mental status while patients are receiving corticosteroids 3
Timing of Symptoms
- Early onset - Symptoms frequently present early in treatment cycle 1
- Variable duration - Can persist throughout treatment or resolve spontaneously
Management Strategies
Preventive Approaches
- Use lowest effective dose for shortest duration possible 5
- Consider combination therapy - Prednisone with steroid-sparing agents (e.g., azathioprine) reduces corticosteroid-related side effects (10% vs 44%) 3
- Consider budesonide in non-cirrhotic patients with severe (actual or anticipated) steroid-related side effects such as psychosis 3
Treatment of Psychiatric Side Effects
- Dose reduction - First-line approach when symptoms appear 1
- Medication discontinuation - If clinically feasible and symptoms are severe 1
- Pharmacologic interventions:
Special Considerations
- Tapering - Never discontinue corticosteroids abruptly 2
- Patient education - Warn patients about potential psychiatric effects and instruct them to seek medical advice promptly if symptoms develop 2
Clinical Pearls and Pitfalls
Important Considerations
- Psychiatric symptoms typically resolve with dosage reduction or discontinuation 1
- Symptoms are primarily manic rather than depressive during short-term therapy 7
- Psychiatric side effects can occur even with brief courses at modest dosages 7
Pitfalls to Avoid
- Failure to recognize symptoms - Psychiatric symptoms may be misattributed to underlying disease
- Abrupt discontinuation - Can lead to adrenal insufficiency and withdrawal syndrome 2
- Inadequate monitoring - Regular assessment of mental status is essential 3
By understanding the psychiatric side effects of prednisone and implementing appropriate monitoring and management strategies, clinicians can minimize the impact of these adverse effects on patient morbidity, mortality, and quality of life.