Effects of lithium on steroid-induced depression

Glucocorticoids for therapeutic immunosuppression: Clinical pearls for the practicing neurologist

Given widespread use of glucocorticoid therapy in neurologic disease, understanding glucocorticoid pharmacology and risk is paramount for the practicing neurologist. While dosing and tapering regimens vary depending on the neurological disease and indication being treated, there are important general principles of glucocorticoid prescribing and monitoring that can guide clinical decision-making. Glucocorticoid-related toxicities can occur across multiple organ systems, including hypertension; dyslipidemia; weight gain; hyperglycemia; osteoporosis and avascular necrosis; myopathy; gastrointestinal bleeding; infection; and neuropsychiatric effects with sleep, mood disturbance and cognition. This narrative review provides a practical framework for safe and responsible prescribing of this therapeutic class of medications, including appreciation of immunosuppressive consequences, risk mitigation strategies, dosing and tapering, and recognition of adrenal insufficiency and glucocorticoid withdrawal.

Optimal Management of Corticosteroids in Patients with Intracranial Malignancies

OPINION STATEMENT

Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.

Behavioral, Psychiatric, and Cognitive Adverse Events in Older Persons Treated with Glucocorticoids

Background: Since the introduction of glucocorticoids (GCs) in the physician's pharmacological arsenal, it has been known that they are a cause of behavioral or psychiatric adverse events (BPAE), as well as of cognitive problems. To the best of our knowledge, the relationship between these adverse events and GCs in older persons has never been evaluated, except through case-reports or series with few cases. In this paper, a review of the literature regarding BPAEs and cognitive disorders in older people treated with CSs is undertaken. Methods: A comprehensive literature search for BPAEs was carried out on the three main bibliographic databases: EMBASE, MEDLINE and PsycINFO (NICE HDAS interface). Emtree terms were: Steroid, steroid therapy, mental disease, mania, delirium, agitation, depression, behavior change, dementia, major cognitive impairment, elderly. The search was restricted to all clinical studies and case reports with focus on the aged (65+ years) published in any language since 1998. Results: Data on the prevalence of the various BPAEs in older patients treated with GCs were very scarse, consisting mainly of case reports and of series with small numbers of patients. It was hence not possible to perform any statistical evaluation of the data (including meta-analysis). Amongst BPAEs, he possibility that delirium can be induced by GCs has been recently been questioned. Co-morbidities and polypharmacy were additional risk factors for BPAEs in older persons. Conclusions: Data on BPAEs in older persons treated with GCs, have several unmet needs that need to be further evaluated with appropriately designed studies.

Neuropsychiatric complications of corticosteroids in older people

The neuropsychiatric effects of corticosteroids are well described in the literature but relatively little is known specifically about their effects among older people. As the population ages, and increasing numbers of older people receive assertive medical treatment for physical conditions, more patients are likely to present to psychiatric services suffering from adverse neuropsychiatric effects associated with corticosteroid use. A review of the effects of corticosteroids among older people was carried out through Medline and PubMed searches and a review of article references. Very little has been specifically written about steroid use and the effects on older people. This paper briefly outlines the current level of knowledge of neuropsychiatric effects of steroids, and relates this to general treatment considerations for older subjects. Recommendations for further research and early identification of complications are made.

Psychiatric adverse effects of pediatric corticosteroid use

Corticosteroids, highly effective drugs for myriad disease states, have considerable neuropsychiatric adverse effects that can manifest in cognitive disorders, behavioral changes, and frank psychiatric disease. Recent reviews have summarized these effects in adults, but a comprehensive review on corticosteroid effects in children has not been published since 2005. Here, we systematically review articles published since then that, we find, naturally divide into 3 main areas: (1) chronic effects of acute prenatal and neonatal exposure associated with prematurity and congenital conditions; (2) immediate behavioral effects of acute exposure via oncological protocols; and (3) acute behavioral effects of sporadic use in children and adolescents with other conditions. PsycInfo, MEDLINE, Embase, and Scopus were queried to identify articles reporting psychiatric adverse effects of corticosteroids in pediatric patients. Search terms included corticosteroids, adrenal cortex hormones, steroid psychosis, substance-induced psychoses, glucocorticoids, dexamethasone, hydrocortisone, prednisone, adverse effects, mood disorders, mental disorders, psychosis, psychotic, psychoses, side effect, chemically induced, emotions, affective symptoms, toxicity, behavior, behavioral symptoms, infant, child, adolescent, pediatric, paediatric, neonatal, children, teen, and teenager. Following guidelines for systematic reviews from the Potsdam Consultation on Meta-Analysis, we have found it difficult to draw specific conclusions that are more than general impressions owing to the quality of the available studies. We find a mixed picture with neonates exposed to dexamethasone, with some articles reporting eventual deficits in neuropsychiatric functioning and others reporting no effect. In pediatric patients with acute lymphoblastic leukemia, corticosteroid use appears to correlate with negative psychiatric and behavioral effects. In children treated with corticosteroids for noncancer conditions, adverse effects have been observed both during treatment and after cessation, although the data from article to article are not consistent enough to establish dose relationships. By and large, inhaled corticosteroids are considered safe and free of severe neuropsychiatric effects. Although both antipsychotic medications and benzodiazepines have been used to treat corticosteroid-induced mania and psychosis, no unified management strategy has emerged. Large-scale standardized investigations are needed to clarify the psychiatric effect of corticosteroids on children in all these conditions. Meanwhile, there is general agreement that patients as well as caregivers should be warned of the potential for behavioral adverse effects when patients receive these drugs.

Missing and Possible Link between Neuroendocrine Factors, Neuropsychiatric Disorders, and Microglia

Endocrine systems have long been suggested to be one of the important factors in neuropsychiatric disorders, while the underlying mechanisms have not been well understood. Traditionally, neuropsychiatric disorders have been mainly considered the consequence of abnormal conditions in neural circuitry. Beyond the neuronal doctrine, microglia, one of the glial cells with inflammatory/immunological functions in the central nervous system (CNS), have recently been suggested to play important roles in neuropsychiatric disorders. However, the crosstalk between neuroendocrine factors, neuropsychiatric disorders, and microglia has been unsolved. Therefore, we herein introduce and discuss a missing and possible link between these three factors; especially highlighting the following hormones; (1) Hypothalamic-Pituitary-Adrenal (HPA) axis-related hormones such as corticotropin-releasing hormone (CRH) and glucocorticoids, (2) sex-related hormones such as estrogen and progesterone, and (3) oxytocin. A growing body of evidence has suggested that these hormones have a direct effect on microglia. We hypothesize that hormone-induced microglial activation and the following microglia-derived mediators may lead to maladaptive neuronal networks including synaptic dysfunctions, causing neuropsychiatric disorders. Future investigations to clarify the correlation between neuroendocrine factors and microglia may contribute to a novel understanding of the pathophysiology of neuropsychiatric disorders.

Steroid psychosis: a review for neurosurgeons

Steroids are beneficial in neurological illness, but have many serious side effects. Having observed several patients with severe steroid psychoses, which greatly prolonged their hospitalizations, the authors sought to improve understanding of this entity. A literature review was conducted. The incidence of severe psychiatric symptoms was estimated in a meta-analysis of 2,555 patients to be 5.7 % and the incidence of any psychiatric symptoms was 18.6 % in patients receiving >80 mg/day of prednisone (12 mg/day dexamethasone). Dose is not predictive of time of onset, severity, type, or duration of symptoms. Symptoms can develop rapidly following exposure to even low doses and with oral, epidural, or intra-articular administration. Glucocorticoid effects on the brain fall into three categories: genomic, non-genomic, and neurotrophic/neurotoxic and can be permanent. Excessive glucocorticoid exposure may result in decreased production of endogenous neurosteroid molecules, resulting in unopposed glucocorticoid effects. Treatment includes early recognition, steroid withdrawal when appropriate, reduction in stimulation, and medication. Atypical antipsychotics like olanzapine and risperidone may cause fewer dystonic reactions and extrapyramidal symptoms than typical antipsychotics like haloperidol, and therefore, are often recommended as first line treatment. Steroids are powerful medications with many undesirable side effects. They should be used with caution. More research is needed on their effects on the human central nervous system.

Psychiatric complications of treatment with corticosteroids: review with case report

Corticosteroids are widely used in modern medicine but can result in troubling psychiatric side-effects. Physicians and other medical professionals should be aware of the potential for these side-effects, possible means of prevention, and efficacious treatments. Herein, we review adult case report data published during the past quarter-century on adverse corticosteroid-induced psychiatric effects, and present a case of corticosteroid-induced psychotic depression. PubMed and PsychLit databases were searched using the terms 'corticosteroids', 'steroids', and the generic names of corticosteroid medications with terms for psychiatric symptoms or syndromes, including psychosis, mania, hypomania, depression, apathy, anxiety, panic, depersonalization, delirium, confusion, hallucinations, delusions, paranoia, cognitive impairment and dementia. Fifty-five cases and a number of clinical trials investigating the incidence and treatment of these psychiatric symptoms and syndromes were identified. Data on incidence, drug dose, risk factors, course of illness and treatment (when present) were tabulated. We conclude that the cumulative data indicate that psychiatric complications of corticosteroid treatment are not rare and range from clinically significant anxiety and insomnia, to severe mood and psychotic disorders, delirium and dementia. While tapering or discontinuation of the corticosteroid treatment may remedy these adverse side-effects, psychotropic medications are often required because of the medical necessity of the corticosteroid or the severity of the psychiatric symptom. Further studies are needed to better understand the deleterious psychiatric effects associated with corticosteroids.

Central nervous system effects of natural and synthetic glucocorticoids

Natural glucocorticoids (NGC) physiologically modulate body homeostasis and coordinate adaptive responses to stress, involving almost all organs and tissues, including brain. Since their therapeutic availability, synthetic GC (SGC) have been successfully prescribed for a variety of diseases. Mounting evidence, however, demonstrated pleiotropic adverse effects (AE), including central nervous system (CNS) disturbances, which are often misdiagnosed or underestimated. The aim of the present study was therefore to review and discuss the CNS effects of both NGC and SGC. A detailed search was carried out of the available literature using the PubMed (US National Library of Medicine) database. Cortisolemia plays a crucial role in control of behavior, cognition, mood, and early life programming of stress reactivity. Hypercortisolemia or SGC treatments may induce behavioral, psychic and cognitive disturbances, due to functional and, over time, structural alterations in specific brain target areas. These AE are generally dose and time dependent (infrequent at prednisone-equivalent doses <20 mg/day) and usually reversible. Pediatric patients are particularly susceptible. Behavioral changes, including feeding and sleeping modifications, are common. Psychic AE are unpredictable and heterogeneous, usually mild/moderate, severe in 5-10% of cases. Manic symptoms have been mostly associated with short SGC courses, and depressive disorder with long-term treatments. Suicidality has been reported. Cognitive AE peculiarly affect declarative memory performance. Physiologic levels of NGC are essential for efficient brain functions. Otherwise, hypercortisolemia and SGC treatments may cause dose-/time-dependent neuropsychic AE and, over time, structural alterations in brain target areas. Clinicians should carefully monitor patients, especially children and/or when administering high doses SGC.

Unusual weight fluctuation under corticosteroid and psychotropic treatment

It is generally accepted that corticosteroid therapy may increase weight. Because corticosteroids may induce several psychiatric symptoms, psychotropic drugs are required to treat these symptoms in some cases. The present study describes a patient who had unusual weight fluctuation under corticosteroid and psychotropic treatment such as mianserin and aripiprazole.

Psychiatric adverse effects of corticosteroids

Psychiatric adverse effects during systemic corticosteroid therapy are common. Two large meta-analyses found that severe reactions occurred in nearly 6% of patients, and mild to moderate reactions occurred in about 28%. Although disturbances of mood, cognition, sleep, and behavior as well as frank delirium or even psychosis are possible, the most common adverse effects of short-term corticosteroid therapy are euphoria and hypomania. Conversely, long-term therapy tends to induce depressive symptoms. Dosage is directly related to the incidence of adverse effects but is not related to the timing, severity, or duration of these effects. Neither the presence nor the absence of previous reactions predicts adverse responses to subsequent courses of corticosteroids. Corticosteroid-induced symptoms frequently present early in a treatment cycle and typically resolve with dosage reduction or discontinuation of corticosterolds. In severe cases or situations in which the dose cannot be reduced, antipsychotics or mood stabilizers may be required. This review offers an approach to identifying and managing corticosteroid-induced psychiatric syndromes based on the type of symptoms and anticipated duration of corticosteroid treatment.

Steroid-induced alterations of mood and behavior in children during treatment for acute lymphoblastic leukemia

Despite their therapeutic utility, children may experience emotional and behavioral side effects from steroids during treatment for leukemia. However, clinical manifestations and treatment options have rarely been described in the pediatric literature. The aim of this current paper is to address this knowledge gap via four brief case examples and a review of the literature. In addition, we review recent data to indicate how concurrent use of antifolates may place these children at particular risk for adverse psychological reactions.

Mood stabilizers inhibit glucocorticoid receptor function in LMCAT cells

Mood stabilizers block some central effects induced by stress and glucocorticosteroids; however, little is known about interaction of these drugs with glucocorticoid receptor function. In the present study, we evaluated effects of lithium, valproate and carbamazepine on glucocorticoid receptor-mediated gene expression in mouse fibroblast cells (L929), stably transfected with mouse mammary tumor virus (MMTV)-chloramphenicol acetyltransferase reporter plasmid (LMCAT cells). Treatment of LMCAT cells with lithium (1-4 mM), valproate (0.1-3 mM) and carbamazepine (30 and 100 microM) inhibited corticosterone-induced activity of reporter gene in a time- and concentration-dependent manner. Furthermore, it was found that valproate, but not two other antimanic drugs, decreased the glucocorticoid receptor level in cytosolic and nuclear fraction, and its inhibitory effect on glucocorticoid receptor-mediated transcriptional activity was attenuated by c-Jun N-terminal kinase (JNK)-mitogen-activated protein kinase (MAPK) inhibitor. Protein kinase B (PKB), glycogen synthase kinase (GSK), p38-MAPK and depletion of inositol were not shown to be involved in the mechanism of mood-stabilizer action on glucocorticoid receptor function under present experimental condition. In contrast to mood stabilizers, amphetamine (1-100 microM) had no effect on glucocorticoid receptor-mediated transcriptional activity. These findings corroborate the hypothesis that direct effects of antidepressants and mood stabilizers on glucocorticoid receptor function is an important mechanism, by which these drugs may inhibit some deleterious effects of stress and glucocorticoids on the central nervous system.

Drug-induced depression: a systematic review to inform clinical practice

BACKGROUND

Certain medications may contribute to the etiology of depressive symptoms and disorders. Research in this area, however, has been hampered by methodological and conceptual problems. This review had two objectives: to identify evidence linking medical drugs to depressive symptoms and disorders, and to summarize this evidence in a clinically meaningful way.

METHODS

Electronic literature searches were performed and studies were reviewed with reference to critical methodological features.

RESULTS

No medications causing the typical major depressive syndrome were identified. Evidence was found linking corticosteroids, interferon-alpha, interleukin-2, gonadotropin-releasing hormone agonists, mefloquine, progestin-releasing implanted contraceptives and propranolol to the etiology of atypical depressive syndromes.

CONCLUSIONS

A small number of drugs have been shown capable of inducing depressive symptoms. Drug-induced depression appears to differ symptomatically from classical major depression.

Corticosteroid-induced psychotic and mood disorders: diagnosis defined by DSM-IV and clinical pictures

The authors investigated long-term outcome and treatment strategy of corticosteroid-induced psychotic and mood disorders as defined by DSM-IV. Review of medical records of 2,069 referral patients revealed 18 applicable patients. Their clinical characteristics, longitudinal courses, and treatments were studied. The authors identified 15 patients with mood disorder and 3 patients with psychotic disorder. Increasing doses or resumption of corticosteroids had the strongest influence on the psychiatric course. These two corticosteroid-induced psychiatric disorders may have different pathophysiological substrates closely related to patient vulnerability. Effective psychopharmacological treatment options were indicated with consideration being given to the underlying diseases.

Mood and Cognitive Changes During Systemic Corticosteroid Therapy

BACKGROUND: Physicians in the United States write approximately 10 million new prescriptions for oral corticosteroids each year. Common side effects of corticosteroids include weight gain, osteoporosis, and diabetes mellitus. This article reviews the available literature on psychiatric and cognitive changes during corticosteroid therapy. METHOD: A search of the MEDLINE and psycINFO databases was conducted to find clinically relevant articles on psychiatric and cognitive side effects with corticosteroids using search terms including corticosteroid, prednisone, mania, depression, psychosis, mood, memory, and cognition. RESULTS: Symptoms of hypomania, mania, depression, and psychosis occur during corticosteroid therapy as do cognitive changes, particularly deficits in verbal or declarative memory. Psychiatric symptoms appear to be dose-dependent and generally occur during the first few weeks of therapy. Patients who must remain on corticosteroids may benefit from pharmacotherapeutic approaches, such as lithium and the new antipsychotic medications. CONCLUSION: Mood and cognitive changes with corticosteroids appear to be common but generally mild and reversible side effects. More studies are needed to determine effective treatment for steroid-induced psychiatric disorders.

Corticosteroid-induced adverse psychiatric effects: incidence, diagnosis and management

Reports of corticosteroid-induced adverse psychiatric effects began to appear in the literature soon after the introduction of these medications in the 1950s. Unfortunately, early studies relied on informal classification and measurement procedures and tended to utilise nonspecific descriptive terminology (such as steroid psychosis'). A growing number of contemporary investigations have begun to address these problems. However, the literature remains surprisingly undeveloped from a pharmacoepidemiological perspective, consisting largely of case reports and case series. The objective of this review is to summarise published data concerning corticosteroid-induced adverse psychiatric effects. A clinical perspective will be adopted since opportunities to minimise the impact of corticosteroid-induced adverse effects tend to present themselves most readily within the sphere of clinical management. Some of the psychiatric adverse effects of corticosteroids are mild, and not necessarily clinically significant. However, several serious psychiatric syndromes can be caused by corticosteroids: substance-induced mood disorders (with depressive, manic and mixed features), substance-induced psychotic disorders and delirium. While certain clinical groups may be at greater risk of corticosteroid-induced adverse psychiatric effects, corticosteroid-induced psychiatric toxicity is remarkably unpredictable. The literature regarding prevention and treatment of corticosteroid-induced adverse psychiatric effects is poorly developed. As a result, the emphasis of this review is on clinical and epidemiological evidence linking specific adverse effects to corticosteroid medications. However, clinical reports do provide some practical guidance for prevention and treatment, and these are summarised as well. A variety of pharmacological strategies for treatment and prevention have been proposed. Education and support also appear to be important, and perhaps neglected.