Can chronic steroid use cause increased anxiety in patients, particularly those with a history of anxiety or mood disorders?

Can Chronic Steroid Use Cause Increased Anxiety?

Yes, chronic steroid use definitively causes increased anxiety and other mood disturbances, with anxiety occurring in over 30% of patients on prolonged corticosteroid therapy. 1, 2

Evidence for Steroid-Induced Anxiety

Mood disturbances, including anxiety, are well-documented side effects of both short- and long-term corticosteroid therapy. 1 The American Academy of Otolaryngology-Head and Neck Surgery explicitly lists "mood disorder" as a documented side effect of steroid therapy, and multiple guidelines confirm that sleep disturbances and mood changes occur in more than 30% of patients taking corticosteroids. 1, 2

Prevalence and Timing

• Anxiety disorders develop in approximately 27% of patients on prolonged corticosteroid therapy, with onset typically occurring during the first weeks of treatment. 3
• In a prospective study of patients on chronic corticosteroid therapy for skin diseases, anxiety disorders were identified in 11% of cases as a standalone diagnosis, with an additional 16% experiencing depressive disorders. 3
• A large US claims database analysis found that glucocorticoid users (as adjunctive therapy) had significantly higher risk for depression (adjusted hazard ratio 1.5) and a trend toward increased anxiety (adjusted hazard ratio 1.3). 1

Mechanism and Risk Factors

The anxiety-inducing effects of corticosteroids appear to be dose-dependent and related to duration of therapy. 3 Key risk factors include:

• Higher doses of corticosteroids significantly increase risk 3
• Personal psychiatric history is a statistically significant risk factor 3
• Age over 40 years and female gender show higher prevalence of anxiety disorders 3
• Duration exceeding 6 weeks substantially increases adverse psychiatric effects 1, 2

Clinical Manifestations

Neuropsychiatric effects include insomnia, restlessness, nervousness, and anxiety ranging from mild to moderate severity. 2 The American Society of Hematology specifically notes that treating physicians should assess health-related quality of life including mental status while patients receive corticosteroids, given their significant impact on mental health. 1

Special Considerations for Patients with Pre-existing Anxiety

Patients with a history of anxiety or mood disorders are at particularly high risk for steroid-induced psychiatric complications. 3 The prospective study found that personal psychiatric history was one of only two statistically significant risk factors for developing anxiety and depressive disorders during corticosteroid therapy. 3

Monitoring Recommendations

• Close monitoring for hypertension, hyperglycemia, sleep and mood disturbances is required regardless of steroid duration or type. 1
• Assessment of health-related quality of life, including depression, fatigue, and mental status, should occur throughout corticosteroid treatment. 1
• Psychiatric examination prior to prescribing long-term corticosteroid therapy should be standard practice to identify at-risk patients. 3

Management Implications

The American Society of Hematology strongly recommends against prolonged courses (>6 weeks) of corticosteroids due to increased risk of side effects, including psychiatric complications. 1 The balance of effects favors shorter courses of corticosteroids (≤6 weeks) over longer courses, even with very low certainty in the evidence, because high-quality evidence demonstrates harm with prolonged exposure. 1

Treatment Approach

• When anxiety or mood disturbances develop, pharmacological treatment and supportive psychotherapy show favorable outcomes in most patients. 3
• Consider steroid-sparing agents when long-term therapy is anticipated to reduce corticosteroid-related psychiatric complications. 2
• Educate patients about potential psychiatric risks and encourage them to seek medical attention if they experience mental health symptoms. 4

Common Pitfalls to Avoid

Underestimating the impact of sleep disturbances and mood changes on quality of life is a significant clinical pitfall. 1 Healthcare providers must recognize that patients may use medically prescribed corticosteroids for non-pain-related conditions such as anxiety, depression, and insomnia, despite evidence that long-term use can worsen these conditions. 1

Psychiatric symptoms including mood swings, anxiety, and depression may also occur during steroid withdrawal, not just during active treatment. 5 This withdrawal syndrome must be distinguished from the underlying condition being treated and from active steroid-induced psychiatric effects.