What is the incidence of steroid-induced psychosis in patients receiving corticosteroid (corticosteroid) therapy?

Steroid-Induced Psychosis: Incidence and Management

Steroid-induced psychosis occurs in approximately 5-6% of patients receiving corticosteroid therapy (severe reactions), with mild to moderate psychiatric reactions occurring in about 28% of patients. 1

Incidence and Risk Factors

• Severe psychiatric reactions (including psychosis) occur in approximately 5-6% of patients receiving systemic corticosteroid therapy 1
• Mild to moderate psychiatric adverse effects occur in approximately 28% of patients 1
• The risk appears to be dose-dependent but not predictable based on previous reactions 1
• Common manifestations include:
  • Short-term therapy: euphoria and hypomania
  • Long-term therapy: depressive symptoms
  • Severe cases: hallucinations, delusions, and frank psychosis

Risk Factors for Steroid-Induced Psychosis

• Higher doses of corticosteroids (particularly ≥15 mg daily) 2
• Pre-existing psychiatric conditions
• History of previous steroid-induced psychiatric reactions (though not consistently predictive) 1
• Specific patient populations at higher risk:
  • Patients with autoimmune disorders 2
  • Patients with poorly controlled diabetes 2
  • Elderly patients 2

Clinical Presentation

Steroid-induced psychosis typically presents with:

• Hallucinations (visual or auditory)
• Delusions
• Mood disturbances
• Cognitive impairment
• Behavioral changes
• Symptoms often appear early in treatment course 1

Management Approaches

First-line Management:

1. Dose reduction or discontinuation of corticosteroid therapy when possible 1, 3

   • This is the most effective intervention when clinically feasible
   • Consider alternative treatments for the underlying condition

2. For patients requiring continued corticosteroid therapy:

   • Consider switching to budesonide in non-cirrhotic patients with autoimmune hepatitis when psychosis is a concern 2
   • Use the lowest effective dose for the shortest duration possible 4

3. Pharmacological management when steroids cannot be discontinued:

   • Antipsychotics are the mainstay of treatment 3
     • Haloperidol is most commonly used 3
     • Risperidone has shown efficacy in both adults and pediatric cases 5, 6
   • Mood stabilizers may be considered in some cases 1

Special Populations:

• Pediatric patients:

  • Mean age of children with steroid-induced psychosis is approximately 12 years 7
  • Risperidone has been successfully used in pediatric cases 5, 6
  • Children with asthma, autoimmune diseases, and cancer are at risk 7

• Patients with autoimmune hepatitis:

  • Consider budesonide 9 mg/day plus azathioprine 1-2 mg/kg/day in non-cirrhotic patients with risk factors for steroid psychosis 2

• Patients with inflammatory bowel disease:

  • Careful monitoring for psychiatric symptoms is recommended when using conventional corticosteroids 2

Prevention and Monitoring

• Screen patients for risk factors before initiating corticosteroid therapy
• Consider prophylactic measures in high-risk patients:
  • Lower starting doses when possible
  • More frequent monitoring
• Monitor for early signs of psychiatric disturbance, particularly early in the treatment course
• Educate patients and families about potential psychiatric adverse effects
• Consider alternative therapies in patients with history of steroid-induced psychosis

Clinical Pitfalls and Considerations

• Steroid-induced psychosis can be difficult to distinguish from psychosis due to the underlying condition (e.g., lupus cerebritis) 7
• Neither the presence nor absence of previous reactions reliably predicts future reactions 1
• Symptoms typically resolve with dosage reduction or discontinuation, but timing varies significantly 1, 3
• In severe cases where steroids cannot be discontinued, antipsychotics or mood stabilizers may be required 1
• The risk of steroid-induced psychosis should be weighed against the benefits of therapy, particularly in patients with severe underlying conditions requiring corticosteroid treatment

By understanding the incidence, risk factors, and management approaches for steroid-induced psychosis, clinicians can better anticipate, prevent, and treat this serious adverse effect of corticosteroid therapy.