What are the mental effects of prednisone (corticosteroid)?

Mental Effects of Prednisone

Prednisone commonly causes psychiatric side effects ranging from mild mood changes to severe psychiatric manifestations including euphoria, insomnia, mood swings, personality changes, severe depression, and frank psychotic manifestations. 1

Common Psychiatric Side Effects

Prednisone can cause a wide spectrum of mental and psychological effects:

• Mood disturbances:

  • Euphoria (most common early effect)
  • Emotional lability
  • Mood swings
  • Depression
  • Irritability

• Sleep disturbances:

  • Insomnia
  • Altered sleep patterns

• Cognitive effects:

  • Memory impairment
  • Difficulty concentrating
  • Cognitive changes

• Severe manifestations:

  • Personality changes
  • Psychosis
  • Delirium
  • Mania

Risk Factors and Incidence

The risk of psychiatric side effects varies based on several factors:

• Dose-related: Higher doses (>40mg/day) significantly increase risk 2, 1
• Duration-related: Risk increases with longer treatment courses 2
• Gender: Females appear to have higher risk 3
• Prior history: Patients with previous corticosteroid-induced psychiatric effects are at higher risk for recurrence 3

Interestingly, contrary to what might be expected, elderly patients and those with previous psychiatric diagnoses do not appear to be at increased risk compared to the general population 3.

Timing and Pattern of Symptoms

• Most psychiatric symptoms develop within the first few weeks of therapy 4
• Symptoms are primarily manic rather than depressive during short courses 5
• Patients with pre-existing depression may actually experience improvement in depressive symptoms during prednisone therapy 5
• Some patients with PTSD may experience worsening of symptoms or increased traumatic memories 5

Monitoring Recommendations

Regular monitoring is essential when patients are on prednisone therapy:

• Mental status assessment: Regular evaluation of mood, sleep patterns, and cognitive function 6, 2
• Health-related quality of life: Assessment of depression, fatigue, and overall mental status 6, 2
• Duration of monitoring: If therapy continues beyond 6 weeks, more vigilant monitoring is needed 6, 1

Management Strategies

When psychiatric symptoms develop during prednisone therapy:

1. Dose adjustment:

   • Reduce daily dosage by 25-33% if side effects are unmanageable 6
   • Consider minimum effective daily dose (approximately 0.3 mg/kg/day for prednisone) 6
   • Consider alternate-day dosing if appropriate for the condition 6, 2

2. Timing adjustment:

   • For patients experiencing behavioral issues, administering the medication in the afternoon after school/work may be preferred 6

3. Medication changes:

   • Consider switching to deflazacort if weight gain/behavior are main issues 6
   • Consider intermittent scheduling (10 days on/10-20 days off) if side effects are severe 6

4. Pharmacological interventions:

   • Lithium and newer antipsychotics may benefit patients who must remain on corticosteroids 4
   • Serotonergic medications (like SSRIs) may help manage steroid-induced mood disorders 7

Prevention Strategies

To minimize psychiatric side effects:

• Use the lowest effective dose for the shortest duration possible 2, 1
• Consider steroid-sparing agents when appropriate 2
• Ensure proper patient education about potential psychiatric side effects 1
• Complete baseline assessment of mental status before initiating therapy 2

Special Considerations

• Discontinuation: Never discontinue prednisone abruptly as this can cause adrenal insufficiency and withdrawal symptoms 1
• Withdrawal symptoms: Following prolonged therapy, withdrawal may result in myalgia, arthralgia, and malaise 1
• Pre-existing conditions: Patients with diabetes, osteoporosis, glaucoma, or hypertension require additional monitoring 2

Psychiatric side effects of prednisone are common but generally reversible upon dose reduction or discontinuation. However, in cases where prednisone must be continued for medical necessity, psychiatric symptoms may require specific pharmacological management.