Steroid-induced psychiatric disorders

Oral corticosteroid dosage and clinical presentation of psychiatric conditions after steroid use: A consultation-liaison psychiatry service's experience

Aim

Psychiatric disturbances are the major adverse effects of corticosteroids. There are no consistent conclusions regarding changes in steroid dosage and the incidence of psychiatric conditions, due in part to the lack of consistent evaluation criteria. The purpose of this research was to determine the incidence and dose‐dependency of psychiatric conditions as assessed by trained psychiatrists.

Methods

A retrospective chart review was conducted at a university hospital in Japan. We identified inpatients receiving oral prednisolone treatment, who were referred to the consultation‐liaison psychiatry team from April 2015 to March 2018. Patients were divided into high‐dose (≥0.5 mg/kg/day) and low‐dose (<0.5 mg/kg/day) groups. We investigated the associations between steroid dosage and incidence of psychiatric conditions.

Results

A total of 93 patients (35 in the high‐dose group, 58 in the low‐dose group) were included. Various psychiatric conditions, such as insomnia, delirium, depression, and psychosis, occurred during steroid therapy. The most common condition was insomnia (72%). We observed no significant differences in the patient background characteristics and the incidence of most psychiatric conditions between the high‐dose and low‐dose groups. However, there were more patients with delirium in the low‐dose group than in the high‐dose group.

Conclusions

Based on the accurate assessment of psychiatric conditions by psychiatrists, our analysis suggests that, among inpatients referred to a consultation‐liaison psychiatry team, the incidence of psychiatric conditions, with the exception of delirium, is independent of the dose of oral prednisolone.

We investigated the differences in psychiatric symptoms and clinical features according to the dose of oral prednisolone by conducting a retrospective chart review of the 93 patients referred to our consultation‐liaison psychiatry team. The results showed that psychiatric symptoms, except for delirium, were not dose‐related.

Myasthenia gravis, schizophrenia, and colorectal cancer in a patient: long-term follow-up with medication complexity

In a case of 46-year-old woman suffering from schizophrenia for over 20 years, she experienced frequent episodes of dyspnea and confirmed as superimposed with myasthenia gravis (MG). Throughout the seven-year follow-up period, after diagnosed as MG, she has been hospitalized 6 times and also diagnosed as colorectal cancer. Authors experienced various conditions associated with untoward effects of medication for myasthenia, schizophrenia, and colorectal cancer. Therefore, authors reported considerations for the pharmacotherapy of schizophrenia with myasthenia gravis.

[Homicide and acute cortico-induced psychosis: A case report]

BACKGROUND

Since their commercialization in 1950, the first psychiatric side effects of steroids have been reported. Today, steroids have become an important therapeutic tool in many diseases, but pharmacological mechanisms responsible for their side effects are still little known. The neuropsychiatric side effects concern 15% of patients while severe reactions occur in 5% of cases, mostly as acute psychotic episodes such as delusion. Serious forensic risks in this context are poorly documented and underestimated.

CASE REPORT

We report the case of a 77 year-old man, treated by methylprednisolone for chronic lymphoid leukemia. After two months of treatment, although stabilized for the neoplastic disease, he stabbed his wife to death with a knife. In the emergency unit, an acute delirious state, a disorganization syndrome, and confusion items such as amnesia, disorientation and symptomatology fluctuation were observed. Mr. M also presented with hyponatremia and infectious pneumonia. Steroids were stopped and his condition rapidly declined, he died one month later during the hospitalization.

DISCUSSION

This clinical case underlines the importance of the early detection of steroid psychosis and its management. Treatment should not be stopped brutally and a dose reducing strategy should be applied in combination with a mood stabilizer or antipsychotic treatment. Disease management strategies are insufficiently documented to be recommended. The extremely acute onset of the symptoms, a partial insight into delusions, a history of iatrogenic neuropsychiatry, the existence of somatic precipitating disorders and confusion factors should always alert the practitioner. The patient, and eventually his family circle, must be aware of the risks of adverse psychiatric effects of steroids for both ethical and forensic reasons, and must report them as early as possible to the clinician if they occur.

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.