Evidence-Based Reviews

Corticosteroid-induced mania: Prepare for the unpredictable

Current Psychiatry. 2006 June;5(6):43-50

References

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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).

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)

Age and gender. Patient age appears unrelated to development of psychiatric symptoms after corticosteroid use.² One study suggested women are twice as likely as men to develop psychiatric symptoms (77 versus 38 cases in 115 patients),³ but many illnesses that require corticosteroid treatment occur more frequently in women. Other researchers found a slight female predominance (58% versus 42% of cases) when they excluded patients with systemic lupus erythematosus and rheumatoid arthritis, which are more common in women than in men.²

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.

Psychiatric history. Past psychiatric illness does not seem to be a risk factor for psychiatric side effects of corticosteroids,⁹ although patients with a history of posttraumatic stress disorder are more likely to suffer depression while taking corticosteroids.¹⁰

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

Bipolar trigger?

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

Continue to: ... case reports are inconclusive...