What is the approach to managing a patient with steroid-induced psychosis?

Management of Steroid-Induced Psychosis

In patients with steroid-induced psychosis, the primary approach should be to discontinue or reduce the steroid dose when possible, and initiate an atypical antipsychotic medication, preferably risperidone, for symptom control. 1

Initial Assessment and Management

• Rule out other causes of psychosis including underlying medical conditions, substance use, or primary psychiatric disorders
• Evaluate severity and risk to determine appropriate treatment setting:
  • Outpatient management if low risk of self-harm/aggression and adequate support
  • Inpatient care if significant risk of self-harm, aggression, or insufficient support 1

Medication Management Algorithm

Step 1: Steroid Modification (if possible)

• Reduce or discontinue steroids if the underlying condition permits
• For conditions requiring continued steroid therapy:
  • Consider switching to budesonide if treating autoimmune hepatitis in non-cirrhotic patients 2
  • Budesonide 9 mg/day plus azathioprine 1 mg/kg/day may be used in patients with severe steroid side effects including psychosis 2

Step 2: Antipsychotic Initiation

• Start atypical antipsychotic at low dose 1
  • Risperidone is preferred based on evidence in steroid-induced psychosis 3, 4
    • Adults: Start at 1-2 mg/day
    • Adolescents: Start at 0.25-0.5 mg/day 3
  • Alternatives: Quetiapine (starting at 25-50 mg/day, can be titrated up to 900 mg/day) 5
  • Haloperidol may be used if atypicals unavailable (most commonly used in case reports) 4

Step 3: Monitoring and Dose Adjustment

• Daily monitoring for:
  • Sedation
  • Extrapyramidal symptoms
  • Behavioral changes 1
• Weekly assessment of:
  • Clinical improvement
  • Side effects 1
• Titrate antipsychotic dose based on response and tolerability
  • Increase doses at widely spaced intervals (14-21 days after initial titration) 1

Step 4: Duration of Antipsychotic Treatment

• Continue antipsychotic until:
  • Steroids are discontinued or reduced to minimal effective dose
  • Psychotic symptoms have fully resolved
• Taper antipsychotic gradually once steroids are discontinued or stabilized at lower dose

Special Considerations

For Patients Requiring Continued Steroid Therapy

• Prophylactic antipsychotic may be considered during subsequent steroid courses 3
• Budesonide alternative should be considered in non-cirrhotic patients with autoimmune hepatitis who have experienced steroid-induced psychosis 2

Family Support and Education

• Provide families with:
  • Emotional support and practical advice
  • Education about steroid-induced psychosis
  • Warning signs of recurrence
  • Expected outcomes 1

Common Pitfalls to Avoid

1. Failing to recognize steroid-induced psychosis - symptoms can develop rapidly after steroid initiation
2. Misattributing psychosis to underlying condition rather than steroid side effect
3. Continuing high-dose steroids when alternatives exist
4. Abrupt discontinuation of steroids - may worsen underlying condition
5. Using typical antipsychotics as first-line - atypicals have better side effect profiles
6. Inadequate monitoring of both psychotic symptoms and antipsychotic side effects

Prognosis

Steroid-induced psychosis typically resolves completely with appropriate management. All reported cases returned to psychological baseline upon steroid discontinuation or dose reduction in combination with antipsychotic treatment, though time to resolution varies significantly 4.