Steroid-Induced Mental Status Changes

Steroid-induced mental status changes are very common in the CL setting. Here is some teaching info to give you a general overview.

We can discuss this during teaching tomorrow:

Source: Open-Evidence

Steroid-Induced Mental Status Changes

Which steroids can cause mental status changes? At what doses?

-Any systemic glucocorticoid can cause neuropsychiatric effects

–Common culprits

• Prednisone / Prednisolone
• Methylprednisolone
• Dexamethasone
• Hydrocortisone

Steroids are often discussed in prednisone equivalents.

Dose relationship (prednisone equivalents)

• <20 mg/day → low risk
• 20–40 mg/day → moderate risk
• >40 mg/day → clearly increased risk
• >60–80 mg/day → high risk
• Pulse steroids (e.g., IV methylprednisolone 1 g/day) → very high risk

***Neuropsychiatric effects can occur even at low doses, particularly in vulnerable patients.

What mental status changes can steroids cause?

• Hypomania/mood elevation (most common)
• Mania (11%)
• Anxiety (8%)

• Insomnia
• Irritability / emotional lability
• Depression (more common in long-term use – 22%)

• Psychosis (delusions > hallucinations; ~5–10%)
• Delirium (16%)
• Cognitive impairment (attention, working memory)

What is the treatment? What is most effective?

Most effective treatment:
***Reduce or discontinue the steroid, if medically feasible.

If steroids cannot be stopped, treat symptomatically:

Anxiety / agitation / insomnia

• Low-dose antipsychotic (often very effective)
  • Quetiapine 12.5–50 mg
  • Olanzapine 2.5–5 mg
• Adjuncts
  • Trazodone
  • Melatonin
  • Gabapentin
• Benzodiazepines: short-term and cautious use only

Mania or psychosis

• Antipsychotic = first-line
  (olanzapine, risperidone, quetiapine)

Controlled trials support lithium and phenytoin for prevention of mood symptoms

***Antipsychotics are generally more effective than benzodiazepines.

How long do symptoms last after stopping steroids?

• Anxiety / insomnia: days
• Mania / psychosis: typically 1–2 weeks
• Occasionally up to 3–4 weeks
• Symptoms may persist longer after prolonged high-dose exposure

Improvement often begins within 48–72 hours of dose reduction.

How to distinguish steroid-induced anxiety from primary anxiety?

• Clear onset after steroid initiation or dose increase
• Prominent insomnia
• Restlessness / activation rather than worry-based rumination
• Often accompanied by:
  • Irritability
  • Mood elevation
  • Pressured thoughts

Who is at higher risk?

• High-dose steroid exposure
• Prior steroid-induced psychiatric reaction
• History of mood disorder (especially bipolar disorder)
• Older age
• Female  

• Hepatic or renal dysfunction
• Hypoalbuminemia
• ICU or severe medical illness
• Sleep deprivation

Richa Vijayvargiya, MD

Psychiatry Service Director, UF Shands

Associate Program Director, UF Psychiatry Residency

Assistant Clinical Professor

UF Department of Psychiatry

Consultation-Liaison Division

rvijayvargiya@ufl.edu