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Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 145-147

Steroids use in COVID-19 saves the lungs but can precipitate psychosis: A case series from a tertiary care center in Andhra Pradesh

Department of Psychiatry, Indlas VIMHANS Hospital, Vijayawada, Andhra Pradesh, India

Date of Submission17-Sep-2021
Date of Decision06-Oct-2021
Date of Acceptance11-Oct-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Aakanksha Brahmdeo Singh
Department of Psychiatry, Indlas VIMHANS Hospital, Vijayawada - 520 002, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_32_21

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Steroid-induced psychiatric adverse effects are not uncommon with an average incidence of 27.6%. The symptoms can range from mild anxiety to severe psychosis. An increase in the use of corticosteroids to treat severe acute respiratory syndrome-coronavirus-2 has been observed which resulted in more patients presenting with steroid psychosis. Herein, we report two case vignettes, presenting with steroid-induced psychosis after recovery from a recent infection of coronavirus disease-2019.

Keywords: Corticosteroids, COVID-19, SARS-COV-2, steroid induced, steroid-induced mania, steroid-induced psychosis

How to cite this article:
Singh AB, Goud SS, Indla V. Steroids use in COVID-19 saves the lungs but can precipitate psychosis: A case series from a tertiary care center in Andhra Pradesh. Telangana J Psychiatry 2021;7:145-7

How to cite this URL:
Singh AB, Goud SS, Indla V. Steroids use in COVID-19 saves the lungs but can precipitate psychosis: A case series from a tertiary care center in Andhra Pradesh. Telangana J Psychiatry [serial online] 2021 [cited 2022 Nov 28];7:145-7. Available from: https://tjpipstsb.org/text.asp?2021/7/2/145/335641

  Introduction Top

The first case of severe acute respiratory syndrome-coronavirus-2 (SARS-COV-2), also known as the coronavirus disease-2019 (COVID-19), was reported in Wuhan, China. High transmissibility has led to an occurrence of a worldwide pandemic. Up to two-thirds who are infected with COVID-19 infection may not have any noticeable symptoms. When they develop symptoms, it can present as mild flu to potentially fatal respiratory distress syndrome. Amid various medical treatments available, corticosteroids are being widely used due to their well-known potent anti-inflammatory and immunosuppressant properties. Steroid treatments are often associated with neuropsychiatric complications, which remain poorly understood and need further exploration.[1] Herein, we report two cases of steroid-induced psychosis, one presenting as manic psychosis and the second with polymorphic psychosis.

  Case Reports Top

Case 1

A 39-year-old female was referred to our hospital with complaints of acute onset of aggression toward family members, disinhibited behavior, decreased need for sleep, and restlessness for 5 days. The patient had no past or family history of psychiatric illness. One month ago, both patient and husband tested positive for the COVID-19 infection. Due to persistent fever, breathlessness, and fatigue, they consulted a physician over the phone. Blood investigations showed mild leukocytosis and elevated C-reactive protein levels (22.4 mg/l and normal <10 mg/l). On high-resolution computed tomography chest, COVID-19 reporting and data system high level of suspicion (CO-RADS V) was reported with computed tomography-severity of 11/25. She was treated with a course of methylprednisolone 48 mg (gradually tapered within 10 days), doxycycline, ivermectin, and multivitamins. The patient recovered well. After 20 days of recovery, the patient had developed psychological symptoms.

On mental state examination (MSE), the patient appeared distracted by the surrounding, she was singing devotional songs, and dancing to them. She was decked up with loud makeup and jewelry. Her speech was excessive with megalomaniac beliefs of “possessing holy powers of goddess Durga to cure people of their problems and wished to donate large sums of money to the poor.” Her mood was elated. She had poor insight and judgment. On admission, she was treated with oral haloperidol 10 mg twice a day, divalproex sodium 500 mg twice a day, nitrazepam 10 mg at bedtime for insomnia, and trihexyphenidyl 2 mg in the morning. She was discharged on the 10th day of admission after the complete resolution in her manic symptoms and advised to follow-up in 2 weeks. As the patient remained stable on follow-ups for the next 3 months, the family requested to stop the medications. Thus, the patient's medication was gradually tapered and stopped over these 3 months. The family was given psychoeducation about a relapse of symptoms and advised to consult immediately.

Case 2

A 34-year-old married woman was brought to our outpatient department by her husband. She complained of sudden onset of anger outbursts, incessant crying spells, suspiciousness, muttering to self, self-injurious behavior, and decreased sleep for 2 days. She was recently hospitalized due to the COVID-19 infection. The patient needed oxygen support due to breathlessness and dyspnea. She was treated with intravenous (IV) remdesivir, IV dexamethasone, and supportive care. She was discharged after 10 days with oral antibiotics, prednisolone 20 mg thrice a day for 5 days, then tapered to twice a day for the next 5 days, apixaban 2.5 mg, pantoprazole, and multivitamins.

Within 3 days of discharge, the patient manifested psychiatric symptoms. On MSE, the patient appeared fearful, staring in space with poor eye contact. She appeared aggressive with increased restlessness. She strongly held persecutory beliefs against her husband and denied any perceptual disturbances. Her mood was irritable. Insight was absent. There was no past or family history of psychiatric illness. Her blood investigations and neuroimaging of the brain were unremarkable. She was admitted as an inpatient with a diagnosis of medication-induced psychosis. We tapered and stopped prednisolone over 3 days. Simultaneously, risperidone 1 mg twice a day was added and incremented to 3 mg twice a day. Lorazepam 2 mg was added for sleep. The patient showed good recovery and was discharged after 7 days. Thereafter, the patient has been coming for regular follow-ups for the past 2 months and maintaining well.

  Discussion Top

Steroid-induced psychosis is classified under the subsection of substance or medication-induced psychosis in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[2]

The incidence of psychiatric symptoms with steroid use is estimated to vary from 13% to 62% with an average of 27.6%. The duration of treatment with steroids before the onset of psychiatric symptoms can range from 1 day to 54 days, the median being 11.5 days. About half of these patients show symptoms within 2 weeks of therapy. The incidence of depression reported is 40.5%, mania 27.8%, psychosis 13.9%, and delirium 10.1%.[3] Side effects can occur through any route of administration, for example, oral, IV, intraarticular injection, epidural, and topical. The development of psychiatric symptoms is dependent on the initial and total dosages (in prednisolone equivalents) administered.[4],[5] Gender-wise, female patients report a higher incidence of side effects due to a greater propensity to seek medical care or a higher prevalence of autoimmune disorders in women.[6] Past psychiatric illness or premorbid personality does not correlate with steroid psychosis.[3] Occurrence of a specific psychiatric disorder during corticosteroid therapy increases the risk of recurrence during the next treatment exposure.[5]

Various possible mechanisms are proposed to explain the development of neuropsychiatric complications with exogenous steroid use. The action of exogenous glucocorticoids on the hypothalamic–pituitary–adrenal axis produces cognitive impairment and emotional disturbances. They also inhibit the brain-derived neurotrophic factor, which is found in key brain regions such as the hippocampus and prefrontal cortex, resulting in depression and anxiety. The concentrations of serotonin receptors at the synaptic cleft are also affected, resulting in mood symptoms.[5] Behavioral changes can occur through direct effects on neuronal membranes, on which steroids have inhibitory and excitatory effects.[1]

Neither of the patients in this case series had past or family history of any psychiatric illness. Their symptom manifestations only began after treatment with steroids for COVID-19 infection. Both patients had scored “6” on Naranjo's adverse drug reaction probability scale, suggestive of the “probable role” of steroids in causing psychosis.[7]

Regarding treatment, a review of literature conducted by Lewis and Smith suggested that tapering of steroid dosages alone was found to be effective in more than 90% of cases and the use of neuroleptics, mood stabilizers, or electroconvulsive therapy (ECT) resulted in 100% improvement in symptoms.[3] Steroid-induced mania or mixed episodes respond to lithium, olanzapine, or phenytoin, depressive symptoms to selective serotonin reuptake inhibitors or lithium alone, and psychotic symptoms to antipsychotics. Steroid-induced psychotic depression is responsive to ECT. Patients with memory impairments can be treated with prophylactic administration of lamotrigine and memantine.[5]

  Conclusion Top

A short course of steroid therapy has proven efficacious in the management of COVID-19 patients. Physicians must be watchful and educate the family members about important adverse effects associated with steroid treatment. Although the occurrence of psychiatric illness is rare with steroids, it can impact the ongoing treatment and causes an enormous burden on the caregivers. Early identification and timely interventions have a very good prognosis in cases of steroid-induced psychosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric complications of glucocorticoid use: Steroid psychosis revisited. Psychosomatics 2012;53:103-15.  Back to cited text no. 1
Vahia VN. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian J Psychiatry 2013;55:220-3.  Back to cited text no. 2
[PUBMED]  [Full text]  
Lewis DA, Smith RE. Steroid-induced psychiatric syndromes. A report of 14 cases and a review of the literature. J Affect Disord 1983;5:319-32.  Back to cited text no. 3
Ciriaco M, Ventrice P, Russo G, Scicchitano M, Mazzitello G, Scicchitano F, et al. Corticosteroid-related central nervous system side effects. J Pharmacol Pharmacother 2013;4:S94-8.  Back to cited text no. 4
Judd LL, Schettler PJ, Brown ES, Wolkowitz OM, Sternberg EM, Bender BG, et al. Adverse consequences of glucocorticoid medication: Psychological, cognitive, and behavioral effects. Am J Psychiatry 2014;171:1045-51.  Back to cited text no. 5
Lu Y, Ann L, McCarron R. Steroid-induced psychiatric symptoms: What you need to know. Curr Psychiatry 2021;20:33-8.  Back to cited text no. 6
Naranjo CA, Busto U, Sellers EM,Sandor P,Ruiz I,Roberts EA, et al. Naranjo adverse drug reaction probability scale. Clin Pharmacol Ther 1981;30:239-45.  Back to cited text no. 7


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