Corticosteroid-induced mania: Prepare for the unpredictable
Head off this common psychiatric side effect.
Although intriguing, these case reports are inconclusive. Because bipolar type I incidence in the general population is 1.5%,13 many persons with bipolar disorder undergo corticosteroid treatment. Nevertheless, these results—especially from the retrospective review12—suggest that corticosteroid use may contribute to the onset of bipolar I illness.
Symptomatic treatment
Corticosteroid-induced side effects are usually managed by tapering off the steroids and treating the psychiatric symptoms.2,3 Simply tapering off the steroids—without additional treatments—led to recovery in 33 of 36 patients.2 Stopping corticosteroids is not always possible or desirable, however, especially in many medically complicated cases seen by psychiatric consult services.
In a recent case, I was asked to see a man, age 69, on the oncology service who was receiving corticosteroids every 2 weeks as part of his chemotherapy. The patient was admitted to the hospital for acute mental status changes 2 days after his last corticosteroid dose. He had pressured speech, grandiosity, and had not slept in 2 days. We started risperidone, 1 mg bid, and most of his manic symptoms resolved within 2 days. His chemotherapy was continued without corticosteroids. If this had not been not possible, I would have recommended continuing risperidone prophylactically.
No double-blind, placebo-controlled studies have examined prevention or treatment of steroid-induced mania or other psychiatric symptoms. Uncontrolled trials and case reports suggest benefit from some symptomatic and preventive treatments (Table 2).
Table 2
Mood stabilizers with evidence of benefit in treating corticosteroid-induced mania
| Indication | Medication | Dosage/blood level | Evidence |
|---|---|---|---|
| Preventing psychiatric effects in patients requiring long-term corticosteroids | Lithium | 0.8 to 1.2 mEq/L | Prospective trial (27 with multiple sclerosis)24 |
| Preventing recurrence of manic symptoms in patients requiring additional steroid pulses | Carbamazepine | 600 mg qd (to therapeutic range of 8 to 12 μg/mL)* | Case report16 |
| Gabapentin | 300 mg tid | Case report26 | |
| Treating steroid-induced manic symptoms | Olanzapine | Initially 2.5 mg/d, titrated to 20 mg/d | Open-label trial (12 patients)14 |
| Lithium | 0.7 mEq/L | Case report15 | |
| Quetiapine | 25 mg qhs and 12.5 mg bid prn | Case report17 | |
| Carbamazepine | 600 mg qd (to therapeutic range of 8 to 12 μg/mL)* | Case reports12,16 | |
| Haloperidol | 2 to 20 mg/d* | Case reports12,16 | |
| Treating steroid-induced depressive symptoms | Fluoxetine | 20 mg/d | Case report18 |
| Amitriptyline | 30 mg/d (usual effective range is 50 to 300 mg/d)* | Case report12 | |
| Lamotrigine | Up to 400 mg/d | Case report19 | |
| Lithium | 0.1 to 0.8 mEq/L | Case reports20,21 | |
| Treating steroid-induced psychotic symptoms | Haloperidol | 5 mg IV on day 1, then 2 mg po bid | Case report22 |
| Risperidone | 1.5 mg/d | Case report23 | |
| *Dosage not included in published report; recommendation based on experience or anecdotal information | |||
Treating manic and mixed mood symptoms. Twelve outpatients with manic or mixed symptoms from corticosteroid use received olanzapine in a 5-week, open-label trial. Flexible dosing started at 2.5 mg/d and was increased as needed (maximum 20 mg/d). One patient dropped out for lack of efficacy. For the others, manic and mixed symptoms improved significantly, as indicated by scores on the Young Mania Rating Scale, Hamilton Rating Scale for Depression, and Brief Psychotic Rating Scale.14 Patient weight, blood glucose, and involuntary movements did not change significantly.
Evidence from case reports indicates that lithium,15 carbamazepine,12,16 haloperidol,12,16 or quetiapine17 also can successfully treat steroid-induced manic symptoms.
Continue to: Treating other psychiatric symptoms
