Treatment of depression with fluoxetine in corticosteroid-dependent central nervous system Sjögren's syndrome

Neuropsychiatric manifestation of the drugs used in the treatment of SARS-2-CoV-2019 (COVID-19) infection and their management: An overview and practice implications

Treatment guidelines for the COVID-19 treatment are still evolving, moreover, the changing variants of the virus with varying virulence, pose challenges for the healthcare professionals (HCP) not only in managing the primary infection but also a myriad of physical and neuropsychiatric complications. The neuropsychiatric adverse consequences associated with the COVID-19 are attributable to the direct effect of the virus, secondary complications, drug-drug interaction, and neuropsychiatric manifestations of drugs used in its treatment. These neuropsychiatric manifestations not only complicate the ongoing treatment but also adversely affect the prognosis. As the treatment guidelines for the management of the COVID are still evolving, the use of non-evidence-based medications, including their off-label use, are rampant that often extend to their non-judicious or irrational use (more than the recommended dose, multiple medications, etc.). Despite the significance of the topic, literature is sparse. Knowing about the risk factors and the potential neuropsychiatric adverse effects with various anti-COVID-19 medications would help HCPs in effectively preventing, early identifying, and promptly managing these neuropsychiatric symptoms. Therefore, this narrative review is aimed to highlight the neuropsychiatric symptoms associated with medications/interventions used in the management of COVID-19 and how to manage them, especially in view of the world facing the third wave of COVID-19.

Mood disorder induced by prednisolone – an easily overlooked complication

Objective: The use of corticosteroids might be associated with the sequelae of psychiatric comorbidity – manic and depressive symptoms, psychosis, and cognitive impairment.

Case report: We report a case of the 35 years old man who presented seven months period of irritability, occasional low mood, and sleep disturbances without the concurrent hallucinations or delusions. The patient had a history of nephrotic syndrome and for this reason, required prednisolone. The corticosteroid induced irritability that has appeared three months after the treatment has started. The psychiatric examination showed neither the psychomotor retardation, manic or depressed mood, nor hallucinations and delusions. However, the level of irritability was undoubtedly increased.

Conclusions: Corticosteroids are drugs commonly used in many systemic diseases. During a psychiatric examination, a careful evaluation is necessary to distinguish the side effects of corticosteroids from the primary psychiatric disorders.

Bipolar Disorder as Comorbidity with Sjögren's Syndrome: What Can We Do?

Neuropsychiatric manifestations in Sjögren's syndrome are common and can occur not only during its course, but also at the onset of the disease. Depression and anxiety were the most frequently described symptoms. However, the association with bipolar disorder seems to be rare and not well documented. This case report presents a patient with bipolar disorder as comorbidity with Sjögren's syndrome, suggesting that bipolar disorder could be associated with this autoimmune disease, which could lead to delaying diagnosis and treatment. A better analysis of the clinical background should be done by psychiatrists so to help early diagnosis and adapting prescription. Corticosteroids indicated in Sjögren's syndrome should be prescribed with caution in bipolar disorder.

Risks and benefits of corticosteroids in arthritic diseases in the clinic

Glucocorticoids (GCs) constitute a first line treatment for many autoimmune and inflammatory diseases. Due to their potent anti-inflammatory and immunosuppressive actions, GCs are added frequently to disease modifying antirheumatic drugs (DMARDs) in various arthritic diseases, such as rheumatoid arthritis. However, their prolonged administration or administration at high doses is associated with adverse effects that may be (quality of) life-threatening, including osteoporosis, metabolic, gastrointestinal and cardiovascular side effects. In this review, we summarize the clinical and pharmacological effects of GCs in different arthritic diseases, while documenting the current research efforts towards the identification of novel and more efficient GCs with reduced side effects.

Risk of Psychiatric Disorders Following Primary Sjögren Syndrome: A Nationwide Population-based Retrospective Cohort Study

OBJECTIVE

Primary Sjögren syndrome (pSS) is a chronic autoimmune disease. A clear temporal causal relationship between pSS and psychiatric disorders has not been well established. We used a nationwide population-based retrospective cohort study to explore the relationship between pSS and the subsequent development of psychiatric disorders.

METHODS

We identified subjects who were newly diagnosed with pSS between January 1, 2000, and December 31, 2008, in the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed for patients without pSS. There were 2686 patients with pSS and 10,744 matched controls observed until diagnosed with psychiatric disorders or until death, withdrawal from the NHI system, or December 31, 2009. The Institutional Review Board of Taipei Veterans General Hospital approved this study (2012-12-013BC).

RESULTS

The adjusted HR of depressive disorder, anxiety disorder, and sleep disorder in subjects with pSS were significantly higher at 1.829, 1.856, and 1.967 than those of the controls during the followup. We found that pSS might increase the risk of subsequent newly diagnosed depressive disorder, anxiety disorder, and sleep disorder that may impair life quality.

CONCLUSION

Our findings highlight the need for psychiatric evaluation and intervention for patients with pSS.

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.

Corticosteroid-related central nervous system side effects

Corticosteroids have been used since the 50s as anti-inflammatory and immunosuppressive drugs for the treatment of several pathologies such as asthma, allergy, rheumatoid arthritis, and dermatological disorders. Corticosteroids have three principal mechanisms of action: 1) inhibit the synthesis of inflammatory proteins blocking NF-kB, 2) induce the expression of anti-inflammatory proteins by IkB and MAPK phosphatase I, and 3) inhibit 5-lipoxygenase and cyclooxygenase-2. The efficacy of glucocorticoids in alleviating inflammatory disorders results from the pleiotropic effects of the glucocorticoid receptors on multiple signaling pathways. However, they have adverse effects: Growth retardation in children, immunosuppression, hypertension, hyperglycemia, inhibition of wound repair, osteoporosis, metabolic disturbances, glaucoma, and cataracts. Less is known about psychiatric or side effects on central nervous system, as catatonia, decreased concentration, agitation, insomnia, and abnormal behaviors, which are also often underestimated in clinical practice. The aim of this review is to highlight the correlation between the administration of corticosteroids and CNS adverse effects, giving a useful guide for prescribers including a more careful assessment of risk factors and encourage the use of safer doses of this class of drugs.

Characterization of cognitive dysfunction in Sjögren's syndrome patients

Sjögren's syndrome is an autoimmune disorder primarily affecting women, with decreased saliva and tear production as the principal characteristic. Cognitive, neurological, and psychiatric disorders also are associated with Sjögren's. The present study addressed the hypothesis that patients with Sjögren's syndrome differ significantly from matched controls in the prevalence and impact of a number of neuropsychiatric abnormalities. Sjögren's patients and controls (n = 37 per group) underwent medical and psychiatric evaluation, demographic assessments, quality of life and symptom evaluation, and extensive testing of cognitive function and memory. Patients and controls were closely matched for age, gender distribution, verbal IQ, marital status, educational level, employment status, and current/past medical or psychiatric history. On most subjective self-ratings, Sjögren's patients reported greater fatigue, impaired physical functioning, feeling depressed, and autonomic symptomatology compared to controls. Impaired memory was described mainly as loss of thought continuity in the midst of a task or activity. However, the majority of objective measures of cognition, psychomotor function, and memory showed minimal differences between groups. Sjögren's patients rate themselves as impaired on multiple ratings of emotional, cognitive, and physical function, but objective measures of cognition reveal fewer substantive differences between patients and matched controls. Sjögren's patients perceive deteriorated physical function over time, but they achieve a level of functioning comparable to controls despite the burden of their illness.

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.

Effects of glucocorticoids on mood, memory, and the hippocampus. Treatment and preventive therapy

Corticosteroids, such as prednisone and dexamethasone, are commonly prescribed medications that suppress the immune system and decrease inflammation. Common side effects of long-term treatment with corticosteroids include weight gain, osteoporosis, and diabetes mellitus. This paper reviews the literature on psychiatric and cognitive changes during corticosteroid therapy and potential treatment options. Hypomania and mania are the most common mood changes during acute corticosteroid therapy, although depression has also been reported. However, depression is reported to be more common than mania during long-term treatment with corticosteroids. A decline in declarative and working memory is also reported during corticosteroid therapy. Corticosteroids are associated with changes in the temporal lobe, detected by structural, functional, and spectroscopic imaging. The mood and cognitive symptoms are dose dependent and frequently occur during the first few weeks of therapy. Other risk factors are not well characterized. Controlled trials suggest that lithium and phenytoin can prevent mood symptoms associated with corticosteroids. Lamotrigine and memantine also have been shown to reverse, at least partially, the declarative memory effects of corticosteroids. Uncontrolled trials suggest that antipsychotics, anti-seizure medications, and perhaps some antidepressants can also be useful for normalizing mood changes associated with corticosteroids. Thus, both the symptoms and treatment response are similar to those of bipolar disorder. Moreover, corticosteroid-induced mood and cognitive alterations have been shown to be reversible with dose reduction or discontinuation of treatment.

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 psychosis: a review

This review is built upon a time-framed perspective to unfold the growth of evidence and the shifting of focus from primary affective short-term reactions to later findings of cognitive deficits and possible permanent impairment linked to steroid treatment. An incidence related to dosage has been documented and delirium and withdrawal symptoms have been reported in later studies. A hypothesis of sensitization process with multiple course of steroids has been proposed with the reporting of recurrent cases. The issue of individual risk appears unsettled while management of psychiatric reactions to steroids has shifted toward prophylactic use of lithium.

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.

The psychiatric side effects of corticosteroids

LEARNING OBJECTIVES

Readers will learn the importance of psychiatric symptomatology with corticosteroid drug therapy, especially when combined with other medications.

DATA SOURCES

A brief history of corticosteroid use over the last five decades was complied utilizing MEDLINE and PSYCHOINFO as sources of information which include peer-reviewed research articles, case studies, and relevant reviews in English.

CONCLUSION

Corticosteroids are routinely prescribed for a variety of allergic and immunologic illnesses. Psychiatric side effects from corticosteroids include mania, depression and mood disturbances. Psychiatric symptoms usually occur within the first two weeks of corticosteroid therapy and seem to be dose related. Treatment with lithium or antipsychotics may be helpful. Physicians should carefully monitor patients for psychiatric and cognitive side effects of corticosteroid use.

Drug-induced depression. Incidence, avoidance and management

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), drug-induced depression may be classified as an Organic Mood Syndrome, Depressed Type. Unfortunately, the DSM-III-R diagnostic criteria are not sufficiently precise for application in research, and studies of drug-induced depression have rarely utilised these criteria. Research concerned with drug-induced depression is characterised by a number of methodological complications. These include differing definitions of depression, including depression defined as a symptom, a syndrome, or by diagnostic criteria for a specific mental disorder. In addition, patients undergoing pharmacological treatments for medical illnesses are typically exposed to considerable psychosocial stress due to the suffering and disability associated with illness. These psychosocial factors may in themselves precipitate episodes of depression. Due to these complicating factors, sophisticated study designs are required to confirm an aetiological role for medications as risk factors for depression. Unfortunately, adequate studies have rarely been conducted, and much of the literature consists of case reports and clinical observations. Consequently, clinicians are frequently required to make clinical judgements about the aetiology of patients' depressive symptoms in the absence of definitive scientific information about the role of drugs. Nevertheless, a knowledge of the relevant literature will assist clinicians in making reasoned judgements about the aetiology, prevention and management of these disorders.