Can corticosteroids “unlock” hidden potential for mania, or are steroid-induced mood symptoms a temporary reaction? And when these mood symptoms occur, what is the best way to treat them?
Psychiatric symptoms develop in 5% to 18% of patients treated with corticosteroids. These effects—most often mania or depression—emerge within days to weeks of starting steroids. To help you head off manic and mixed mood symptoms, this paper examines how to:
- treat steroid-induced mania or mixed bipolar symptoms
- reduce the risk of a mood episode in patients who require sustained corticosteroid therapy.
Jane Pauley, NBC’s Today Show broadcaster, described in her autobiography how hypomania developed within weeks after she started corticosteroids for idiopathic urticaria edema: “I was so energized that I didn’t just walk down the hall, I felt like I was motoring down the hall. I was suddenly the equal of my high-energy friends who move fast and talk fast and loud. I told everyone that I could understand why men felt like they could run the world, because I felt like that. This was a new me, and I liked her!”1
Pauley’s hypomania led to a manic episode and eventually to depression. She was started on antidepressants, which triggered another manic episode. Pauley—who had no history of bipolar disorder—spent 3 weeks in a New York psychiatric hospital.1
Diagnostic symptoms. Corticosteroids’ psychiatric effects—cognitive, mood, anxiety, and psychotic symptoms—were first described as “steroid psychosis.” Psychosis can occur, but mood symptoms are more common:
- Among 122 patients, 40% experienced depression, followed by mania (28%), psychosis (14%), delirium (10%), and mixed mood episodes (8%).2
- Among 130 patients, mania was most prevalent (35%), followed by depression (28%), mixed mood episodes (12%), delirium (13%), and psychosis (11%).3
- Corticosteroids caused 54% of organic mania cases on a hospital psychiatric consult service.4
- In a prospective study of 50 patients treated with corticosteroids, 13 developed hypomania and 5 developed depression.5
Who is at risk?
Corticosteroids include the steroids produced in the adrenal gland (such as corticosterone) and their synthetic—and often more potent—analogues (such as prednisone).7 Because of their glucocorticoid, immunosuppressant, mineralocorticoid, and anti-inflammatory properties, steroids are used as replacement therapy and to treat a wide variety of illnesses (Table 1).
Medical conditions for which corticosteroids are commonly used
|Disorder||Indications for corticosteroids|
|Acute adrenal insufficiency||Acute; replacement therapy|
|Addison’s disease||Chronic; replacement therapy|
|Asthma||Acute and chronic; anti-inflammatory|
|Inflammatory bowel disease||Acute; anti-inflammatory|
|Multiple sclerosis||Acute; exacerbations, immunosuppressant|
|Organ transplant||Chronic; immunosuppressant|
|Rheumatoid arthritis||Chronic; anti-inflammatory|
|Systemic lupus erythematosus||Acute; severe exacerbation, immunosuppressant (high doses are used)|
Dosage. Higher corticosteroid dosages increase the risk of psychiatric symptoms. In patients taking prednisone, the Boston Collaborative Drug Surveillance Project8 found the incidence of psychiatric side effects to be:
- 1.3% in patients taking
- 4.6% in those taking 41 to 80 mg
- 18.4% in those taking >80 mg.
Corticosteroid exposure. Patients who did not experience psychiatric side effects with corticosteroids in the past appear not to be protected if corticosteroids are used again. One report examined 17 cases of steroid-induced psychiatric illness in patients with previous exposure to corticosteroid therapy. Six patients had previous psychiatric side effects while taking corticosteroids, and 11 did not.2
Do corticosteroids’ acute psychiatric side effects have long-term sequelae? Longitudinal evidence is scarce, but a few reports suggest corticosteroids could play a role in the onset of primary bipolar I disorder:
- A 28-year-old woman with no known mood symptoms before a short course of prednisone experienced six episodes of mania and depression when not taking corticosteroids during the subsequent 18 months.11
- Among 16 patients with first-onset mood symptoms after corticosteroid use, a retrospective chart review found 7 had recurrent manic and depressive symptoms unrelated to additional corticosteroid use.12