Steroid-Induced Psychosis: Emergency Recognition & Management Guide

• By Ian Roddick
• 26 Oct, 2025
• 8 Comments

When a patient on high‑dose steroids suddenly starts hearing voices or believing bizarre things, the clock starts ticking. Steroid‑Induced Psychosis is a medication‑induced psychotic disorder that appears after exposure to corticosteroids. Rapid identification can mean the difference between a short, treatable episode and a dangerous crisis. Below you’ll find the step‑by‑step approach that emergency clinicians use to spot, assess, and calm these patients before they harm themselves or others.

Why Steroids Can Flip the Mind

Corticosteroids mimic the body’s natural cortisol, but they jam the hypothalamo‑pituitary‑adrenal (HPA) axis. By flooding glucocorticoid receptors and suppressing mineralocorticoid activity, they create an imbalance that messes with mood, cognition, and perception. The exact neurobiology is still a research focus, yet clinical data show a clear dose‑response curve: patients receiving >40 mg/day of prednisone develop psychiatric symptoms 4.6 % of the time, climbing to 18.4 % when the dose exceeds 80 mg/day.

Job 1 - Spot the Early Red Flags

In the first five days after starting a steroid, watch for:

• Confusion or “brain fog” that seems out of proportion to the illness.
• Restlessness, agitation, or inexplicable irritability.
• Rapid mood swings - euphoria that flips to despair in minutes.
• Early auditory hallucinations (hearing whispers or comments).

If any of these pop up, ask the patient when the steroid was started and at what dose. The timeline often aligns perfectly with the onset of symptoms.

Job 2 - Run a Focused Emergency Assessment

The goal is twofold: keep everyone safe and rule out medical mimics. A structured 4‑step protocol works well:

1. Safety first: Use verbal de‑escalation, a calm tone, and a low‑stimulus environment. If agitation escalates, have IM olanzapine (5‑10 mg) or IM haloperidol (2‑5 mg) ready.
2. Confirm steroid exposure: Document drug name, dose, route, and initiation date.
3. Exclude other causes: Check glucose, electrolytes, calcium, thyroid panel, toxicology screen, and consider infection or head injury.
4. Start treatment: Taper the steroid (if possible) and begin a low‑dose antipsychotic.

The DSM‑5 criteria for substance/medication‑induced psychotic disorder require that the psychosis cannot be better explained by a primary psychiatric disorder, delirium, or another medical condition. In practice, that means a quick labs panel and a brief neuro exam are non‑negotiable.

Job 3 - Adjust the Steroid Dose Wisely

When the psychosis is linked to steroids, the most effective move is to lower the dose. Evidence shows that dropping prednisone below 40 mg/day (or dexamethasone below 6 mg/day) leads to symptom resolution in over 90 % of cases. Tapering must be gradual enough to avoid adrenal insufficiency, especially if the patient has been on steroids for weeks.

Typical taper:

• Day 1‑3: Reduce by 20 % of the current dose.
• Day 4‑7: Another 20 % cut if no rebound inflammation.
• After day 7: Switch to the lowest effective dose for the underlying disease, then continue a slow taper over 2‑4 weeks.

If the underlying condition (e.g., severe asthma flare) demands high‑dose steroids, you’ll need to control the psychosis pharmacologically while keeping the steroid level as low as clinically possible.

Job 4 - Choose the Right Antipsychotic

There is no FDA‑approved drug specifically for steroid‑induced psychosis, but several agents have solid real‑world data:

Start low, go slow. For most ED presentations, a single dose of oral olanzapine 5 mg plus a short‑acting benzodiazepine (lorazepam 1 mg) provides rapid calm without heavy sedation.

Job 5 - Coordinate Multidisciplinary Follow‑Up

Once the acute episode is under control, the patient needs a clear plan:

• Referral to liaison psychiatry for ongoing antipsychotic management.
• Education for the primary team on steroid‑related risks.
• Patient/family counseling about warning signs and when to call back.
• Document the episode in the electronic health record using the DSM‑5 code for medication‑induced psychotic disorder.

Studies show that when these steps are followed, long‑term psychiatric sequelae drop dramatically-most patients return to baseline within weeks.

Key Takeaways

• Steroid‑induced psychosis often appears within the first five days of high‑dose corticosteroid therapy.
• Early signs are confusion, agitation, and mood swings-treat them as red flags.
• Safety first: de‑escalate, then use low‑dose antipsychotics (olanzapine, risperidone, haloperidol).
• Lower the steroid dose below 40 mg prednisone (or equivalent) whenever possible.
• Arrange psychiatry follow‑up and educate the patient on warning signs.

Mini‑FAQ

Being alert to the psychiatric side effects of steroids saves lives and prevents unnecessary suffering. The next time you see a patient on prednisone who suddenly sounds confused or terrified, remember the quick four‑step protocol above-you’ll be ready to act before the situation spirals.