Evidence-Based Reviews

Corticosteroid-induced mania: Prepare for the unpredictable

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

References

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Although intriguing, these case reports are inconclusive. Because bipolar type I incidence in the general population is 1.5%,¹³ many persons with bipolar disorder undergo corticosteroid treatment. Nevertheless, these results—especially from the retrospective review¹²—suggest that corticosteroid use may contribute to the onset of bipolar I illness.

Symptomatic treatment

Corticosteroid-induced side effects are usually managed by tapering off the steroids and treating the psychiatric symptoms.^2,3 Simply tapering off the steroids—without additional treatments—led to recovery in 33 of 36 patients.² Stopping corticosteroids is not always possible or desirable, however, especially in many medically complicated cases seen by psychiatric consult services.

In a recent case, I was asked to see a man, age 69, on the oncology service who was receiving corticosteroids every 2 weeks as part of his chemotherapy. The patient was admitted to the hospital for acute mental status changes 2 days after his last corticosteroid dose. He had pressured speech, grandiosity, and had not slept in 2 days. We started risperidone, 1 mg bid, and most of his manic symptoms resolved within 2 days. His chemotherapy was continued without corticosteroids. If this had not been not possible, I would have recommended continuing risperidone prophylactically.

No double-blind, placebo-controlled studies have examined prevention or treatment of steroid-induced mania or other psychiatric symptoms. Uncontrolled trials and case reports suggest benefit from some symptomatic and preventive treatments (Table 2).

Table 2

Mood stabilizers with evidence of benefit in treating corticosteroid-induced mania

Indication	Medication	Dosage/blood level	Evidence
Preventing psychiatric effects in patients requiring long-term corticosteroids	Lithium	0.8 to 1.2 mEq/L	Prospective trial (27 with multiple sclerosis)²⁴
Preventing recurrence of manic symptoms in patients requiring additional steroid pulses	Carbamazepine	600 mg qd (to therapeutic range of 8 to 12 μg/mL)*	Case report¹⁶
	Gabapentin	300 mg tid	Case report²⁶
Treating steroid-induced manic symptoms	Olanzapine	Initially 2.5 mg/d, titrated to 20 mg/d	Open-label trial (12 patients)¹⁴
	Lithium	0.7 mEq/L	Case report¹⁵
	Quetiapine	25 mg qhs and 12.5 mg bid prn	Case report¹⁷
	Carbamazepine	600 mg qd (to therapeutic range of 8 to 12 μg/mL)*	Case reports^12,16
	Haloperidol	2 to 20 mg/d*	Case reports^12,16
Treating steroid-induced depressive symptoms	Fluoxetine	20 mg/d	Case report¹⁸
	Amitriptyline	30 mg/d (usual effective range is 50 to 300 mg/d)*	Case report¹²
	Lamotrigine	Up to 400 mg/d	Case report¹⁹
	Lithium	0.1 to 0.8 mEq/L	Case reports^20,21
Treating steroid-induced psychotic symptoms	Haloperidol	5 mg IV on day 1, then 2 mg po bid	Case report²²
Treating steroid-induced psychotic symptoms	Risperidone	1.5 mg/d	Case report²³
*Dosage not included in published report; recommendation based on experience or anecdotal information

Treating manic and mixed mood symptoms. Twelve outpatients with manic or mixed symptoms from corticosteroid use received olanzapine in a 5-week, open-label trial. Flexible dosing started at 2.5 mg/d and was increased as needed (maximum 20 mg/d). One patient dropped out for lack of efficacy. For the others, manic and mixed symptoms improved significantly, as indicated by scores on the Young Mania Rating Scale, Hamilton Rating Scale for Depression, and Brief Psychotic Rating Scale.¹⁴ Patient weight, blood glucose, and involuntary movements did not change significantly.

Evidence from case reports indicates that lithium,¹⁵ carbamazepine,^12,16 haloperidol,^12,16 or quetiapine¹⁷ also can successfully treat steroid-induced manic symptoms.

Continue to: Treating other psychiatric symptoms