Evidence-Based Reviews

Corticosteroid-induced mania: Prepare for the unpredictable

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Head off this common psychiatric side effect.



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.

‘Steroid psychosis’

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

Steroid-induced symptoms emerge from 3 to 4 days to a median of 11 days after a patient starts corticosteroid therapy. After steroids are discontinued, depressive symptoms persist approximately 4 weeks, mania 3 weeks, and delirium a few days. Approximately one-half of patients with steroid psychosis improve in 4 days and one-half within 2 weeks.2,6

Continue to: Who is at risk?


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