Evidence-Based Reviews

Corticosteroid-induced mania: Prepare for the unpredictable

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

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Treating other psychiatric symptoms. Case reports support electroconvulsive therapy,^2,15 fluoxetine,¹⁸ amitriptyline,¹² lamotrigine,¹⁹ or lithium^20,21 for steroid-induced depression, and haloperidol²² or risperidone²³ for steroid-induced psychosis.

In four cases,⁶ tricyclic antidepressants appeared to worsen corticosteroids’ psychiatric side effects. These case patients might have had steroid-induced delirium instead of mood disorders or psychosis, however, and the tricyclics’ anticholinergic effects could have worsened the delirium.⁹

Preventing steroid-induced symptoms

Although clear guidelines on when to start preventive treatments do not exist, potential candidates for pretreatment with lithium or other agents include patients who:

have developed psychiatric symptoms multiple times after repeated corticosteroid use
are at high risk if psychiatric side effects occur.

Lithium. Prophylactic lithium was given to 27 patients with multiple sclerosis and taking corticosteroids for acute exacerbations. None developed psychiatric symptoms.²⁴ At the same clinic, 6 of 44 patients with multiple sclerosis or retrobulbar neuritis developed psychiatric side effects after using corticosteroids without lithium.

Be cautious when using prophylactic lithium because some conditions treated with corticosteroids—such as systemic lupus erythematosus—can impair renal function.²⁰ Corticosteroids also can affect sodium balance and increase the risk of lithium intoxication.²⁵

Check renal function before and during lithium titration, and initiate corticosteroid therapy when lithium is at effective blood levels (0.8 to 1.2 mEq/L). Monitor lithium levels and renal function frequently during steroid treatment.

Other mood stabilizers. Two case reports describe patients who repeatedly developed manic symptoms after multiple corticosteroid doses. Carbamazepine, 600 mg qd,¹⁶ and gabapentin, 300 mg tid,²⁶ prevented manic symptoms after additional corticosteroid pulses.

Related resources

Brown ES, Chandler PA. Mood and cognitive changes during systemic corticosteroid therapy. Prim Care Companion J Clin Psychiatry 2001;3(1):17-21. www.psychiatrist.com/pcc/abstracts/pcc030103.htm.
Merrill W. Case 35-1998: use of lithium to prevent corticosteroid-induced mania. N Engl J Med 1999;340:1123.

Drug brand names

Amitriptyline • Elavil
Carbamazepine • Tegretol
Fluoxetine • Prozac
Gabapentin • Neurontin
Haloperidol • Haldol
Lamotrigine • Lamictal
Lithium • Eskalith, others
Olanzapine • Zyprexa
Quetiapine • Seroquel
Risperidone • Risperdal