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Risk of early psychiatric side-effects is one of several important safety issues for healthcare professionals to discuss with patients and carers, who should seek urgent medical advice in the event of any worrying symptoms.
Article date: September 2007
Corticosteroids are used in varying doses to treat a wide range of diseases. Psychiatric side-effects can occur with all systemic steroids. A recent case report of the suicide of a 16-year-old has highlighted the need to consider these common reactions and warn patients and their carers about the risks.
Types of reaction
A wide range of psychiatric reactions have been reported in association with corticosteroids, including: affective disorders (eg, irritable, euphoric, depressed, and labile mood, and suicidal thoughts); psychotic reactions (eg, mania, delusions, hallucinations, and aggravation of schizophrenia); behavioural disturbances; irritability; anxiety; sleep disturbances; and cognitive dysfunction (including confusion and amnesia).
Onset, severity, frequency, and risk factors
Psychiatric symptoms typically emerge a few days or weeks after the start of treatment. Risks may be higher with high doses compared with low doses, although there is no clear relation between dose and type, severity, or duration of reactions. Most patients recover from these reactions after dose reduction or withdrawal, although specific treatment might be necessary.
Reactions can occur in adults and children. In adults, the frequency of severe psychiatric reactions might be as high as 5–6%.(Lewis DA, Smith RE. J Affect Disord 1983; 5: 319–32) Psychiatric side-effects have also been reported on withdrawal of corticosteroids. Patients with previous history or close family history of severe affective disorders (especially steroid psychosis) should be treated with particular care; however, there is no firm evidence of an increased risk in these patients compared with others.
Important information for patients and carers
- All patients (or their carers) should be informed of the important benefits of steroid treatment, and should be warned of the most important safety issues associated with acute and chronic use (see box below)
- All patients (or their carers) who receive systemic steroids should receive a Patient Information Leaflet
- All patients should seek urgent medical advice in the event of worrying symptoms (eg, suicidal thoughts) or illness while taking systemic steroids
- Patients who take systemic steroids for more than 3 weeks or high-dose inhaled steroids should not stop treatment abruptly, and should be given a steroid card by their doctor or pharmacist (Current Problems in Pharmacovigilance 1998; 24: 5–7, (Current Problems in Pharmacovigilance: Volume 24 (Pages 5-10) May 1998),(Current Problems in Pharmacovigilance 2006; 31: 5, Current Problems in Pharmacovigilance: Volume 31 (pages 1-12) May 2006)
A list of questions and answers for patients on the safety of corticosteroids is available on the MHRA website.
Key safety issues to discuss with patients given systemic steroids and their carers
Endocrine: adrenal suppression, Cushing’s syndrome
Eye: cataracts, glaucoma, and papilloedema
Gastrointestinal: ulceration, pancreatitis, candidiasis
Immune: increased susceptibility to infections—especially chickenpox
Musculoskeletal: myopathy, osteoporosis, fractures, growth suppression
Neurological: aggravation of epilepsy
Psychiatric: psychosis; affective (eg, risk of suicide), behavioural, and cognitive disorders
Article citation: Drug Safety Update September 2007, vol 1 issue 2: 9.
Steroid medicines - Q&A for patients
Therapeutic area: Anaesthesia and intensive care Cancer Dentistry Dermatology Ear, nose and throat Endocrinology, diabetology and metabolism GI, hepatology and pancreatic disorders Haematology Immunosuppression and transplantation Infectious disease