What is the treatment approach for a patient experiencing steroid-induced psychosis?

Treatment of Steroid-Induced Psychosis

The primary treatment for steroid-induced psychosis is immediate dose reduction or discontinuation of the corticosteroid combined with antipsychotic medication if symptoms are severe. 1, 2

Immediate Management Steps

Corticosteroid Modification

• Discontinue or rapidly taper the corticosteroid as the first-line intervention, as symptoms typically resolve with steroid withdrawal 2, 3
• If the underlying condition absolutely requires continued steroid therapy, reduce to the minimum effective dose (ideally <20 mg/day prednisone equivalent) 4
• Consider switching to budesonide 9 mg/day in appropriate patients (non-cirrhotic), as this has significantly fewer psychiatric side effects than systemic prednisolone 1, 5

Pharmacological Treatment

For acute psychotic symptoms (hallucinations, delusions, severe agitation):

• Haloperidol is the most commonly used antipsychotic in steroid-induced psychosis, followed by risperidone 2
• Risperidone (dose typically 1-4 mg/day) has been successfully used, particularly in younger patients 6, 2
• Atypical antipsychotics are generally preferred over typical antipsychotics due to better side effect profiles 7
• Treatment should continue until steroid dose is reduced/discontinued and symptoms fully resolve 2

For milder symptoms (mood instability, insomnia, agitation without psychosis):

• Consider mood stabilizers or benzodiazepines as alternatives to antipsychotics 3
• Lithium combined with clonazepam has been used successfully in isolated cases 2

Timeline and Monitoring

• Symptom onset typically occurs within days to weeks of starting steroids, though can occur even with very low doses (as low as 2.5-10 mg prednisone) 8
• Resolution time varies significantly (7-17 days after steroid discontinuation in most cases) but depends on steroid half-life and severity 9
• Close monitoring is mandatory with evaluation at 2-4 weeks for psychiatric side effects including mood instability, sleep disturbances, agitation, and psychotic symptoms 5

Critical Clinical Pitfalls

Avoid these common errors:

• Do NOT assume low doses are safe—psychosis can occur with doses as low as 2.5 mg prednisone daily 8
• Do NOT continue high-dose steroids (>20 mg/day) for >18 months without compelling indication, as severe psychiatric effects are most common in this scenario 4
• Do NOT restart steroids at the same dose after psychosis resolves—if steroids must be continued, use the lowest possible dose with prophylactic antipsychotic coverage 6, 3

Prevention in High-Risk Patients

For patients requiring future steroid therapy who have experienced steroid-induced psychosis:

• Avoid systemic corticosteroids entirely if possible—this is the strongest recommendation from gastroenterology guidelines 1
• If steroids are absolutely necessary, use budesonide 9 mg/day plus azathioprine 1-2 mg/kg/day as this combination has significantly fewer psychiatric side effects 1, 5
• Consider prophylactic antipsychotic therapy (e.g., low-dose risperidone) if systemic steroids cannot be avoided 6
• Limit steroid duration to 7-10 days maximum in acute conditions, as extending beyond this carries no additional benefit and increases psychiatric risk 1

Special Populations

Patients with pre-existing psychiatric conditions (bipolar disorder, schizophrenia):

• These patients are at substantially higher risk and require even more aggressive avoidance strategies 5
• Mandatory psychiatric consultation before initiating steroids 5
• Consider alternative immunosuppression (azathioprine, methotrexate) as first-line therapy 7

Pediatric and adolescent patients:

• Steroid-induced psychosis is underrecognized in this population 6
• Risperidone has demonstrated safety and efficacy in adolescents with steroid psychosis 6
• Growth suppression is an additional concern requiring close monitoring 4