From the Guidelines
Mania or psychosis can present anywhere from a few days to several weeks after a steroid injection, with most cases occurring within the first 1-2 weeks, typically ranging from 3-14 days after administration. The onset of these psychiatric effects can be as early as 24 hours after injection or as late as 3-4 weeks later 1. The risk appears dose-dependent, with higher doses of steroids (such as prednisone equivalents above 40mg daily) carrying greater risk. Commonly used injectable steroids include methylprednisolone, triamcinolone, and dexamethasone. These psychiatric effects occur because steroids cross the blood-brain barrier and affect neurotransmitter systems including dopamine, serotonin, and GABA, disrupting normal brain function.
Key Points to Consider
- Patients with a personal or family history of psychiatric disorders, previous steroid-induced psychiatric reactions, or those on high doses are at increased risk.
- Healthcare providers should monitor patients for early warning signs such as insomnia, irritability, mood swings, racing thoughts, or unusual behavior in the days and weeks following steroid administration.
- The combination regimen with azathioprine is associated with much lower occurrence of corticosteroid-related adverse events, including psychiatric effects 1.
- In patients who develop steroid side effects, a switch to budesonide (6 mg/day) or an increase in azathioprine dose may be considered to minimize the risk of mania or psychosis 1.
From the FDA Drug Label
Psychic derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression to frank psychotic manifestations.
The FDA drug label does not specify the exact number of days after a steroid injection when mania or psychosis can present.
From the Research
Timing of Mania or Psychosis Presentation
- The exact timing of mania or psychosis presentation after a steroid injection is not explicitly stated in the provided studies.
- However, it is mentioned that symptoms can develop rapidly following exposure to even low doses of steroids 2.
- The studies suggest that the onset of symptoms can occur at any time, and the duration of symptoms can vary significantly 3, 4.
- In one case study, a patient developed a long-lasting psychotic episode on high-dose steroids, which lasted for nearly six months despite discontinuation and treatment 3.
- Another study found that all patients returned to their psychological baseline upon the discontinuation or decreased dose of steroids in combination with pharmacological intervention, though the time to resolution of symptoms varied significantly 4.
Risk Factors and Prevention
- The incidence of neuropsychiatric complications, including mania and psychosis, rises rapidly once the daily dose of prednisone is greater than 40mg 5.
- Other risk factors for neuropsychiatric symptoms include damaged blood-brain barrier and hypoalbuminemia 5.
- Patients with a prior history of steroid-related psychosis or mania should be considered for prophylaxis when future courses of steroids are prescribed 5.
- Lithium and olanzapine may be effective in preventing neuropsychiatric complications 5.
Treatment and Management
- Treatment of steroid-induced psychosis typically involves a combination of dose reduction or elimination of steroids and antipsychotic medication 4.
- Atypical antipsychotics like olanzapine and risperidone may be preferred over typical antipsychotics like haloperidol due to their lower risk of dystonic reactions and extrapyramidal symptoms 2, 4.