Mood and Behavioral Changes from Corticosteroids: Understanding the Risk of Psychosis

When you're prescribed corticosteroids for asthma, rheumatoid arthritis, or another inflammatory condition, you're probably focused on how they'll help your physical symptoms. But there's another side to these powerful drugs-one that affects your mind. Corticosteroids can trigger serious mood swings, depression, mania, and even psychosis. These aren't rare side effects. They happen more often than most doctors admit, and they can turn your life upside down-even after you stop taking the medication.

What Exactly Happens When Corticosteroids Hit Your Brain?

Corticosteroids like prednisone, dexamethasone, and methylprednisolone aren't just anti-inflammatory drugs. They flood your body with synthetic versions of cortisol, a hormone your adrenal glands normally make. When you take them in high doses, your brain doesn't know the difference. And that's where trouble starts.

Studies show that these drugs interfere with multiple brain systems. One major target is the hippocampus, the area responsible for memory and emotional regulation. High doses can shrink this region over time, leading to confusion, forgetfulness, and emotional instability. Another pathway involves dopamine. Animal studies reveal corticosteroids boost dopamine production, which can trigger hallucinations and delusions-hallmarks of psychosis. This isn't just theory; it's been seen in real patients.

It's not just one mechanism. Corticosteroids also suppress your body's natural stress response system-the HPA axis. When this happens, your brain loses its ability to balance mood. The result? A chemical storm that can push someone with no prior mental health history into a full-blown psychotic episode.

How Common Are These Side Effects?

You might think this is rare. It's not. About 5% to 18% of people taking systemic corticosteroids experience some kind of psychiatric reaction. That means roughly 1 in 10 patients could be affected. The numbers climb sharply with dose:

• At doses under 40 mg of prednisone per day: 1.3% risk
• At 80 mg or more per day: 18.4% risk

That’s a 14-fold increase in risk. And here’s the kicker-10 million new oral corticosteroid prescriptions are written every year in the U.S. alone. Even if only 5% of those patients develop psychiatric symptoms, that’s 500,000 people annually who might suddenly feel like they’re losing their mind.

The symptoms aren't always dramatic. Many start with subtle signs: trouble sleeping, irritability, or feeling unusually upbeat. These are often dismissed as stress or aging. But they can escalate fast. Within days to weeks, someone might go from mild anxiety to full psychosis-believing they're being watched, hearing voices, or acting out in ways they never would before.

Who’s Most at Risk?

Not everyone reacts the same way. Certain people are far more vulnerable:

• Women are more likely than men to develop psychiatric side effects, though the exact reason isn't clear.
• People over 65 have less brain resilience and are more sensitive to hormonal shifts.
• Those with prior mental illness, especially bipolar disorder, are at highest risk. One study found that 11.8% of cases involved mania with no prior history-but in patients with bipolar, the flare-up is often severe and sudden.
• High-dose, long-term users are the most vulnerable. A 10-day course of 40 mg might be fine. A 3-month course of 80 mg? That’s a different story.

Even if you’ve taken corticosteroids before without issues, that doesn’t mean you’re safe next time. The risk isn’t just about dosage-it’s about your body’s current state, your age, and whether you’re under physical or emotional stress.

What Do the Symptoms Look Like?

These aren’t vague feelings. They’re specific, measurable changes:

• Euphoria (27.5% of cases): An unnatural, exaggerated sense of well-being that doesn’t match reality.
• Insomnia (42.3%): Not just trouble sleeping-complete inability to rest, even when exhausted.
• Mood swings (38.7%): Rapid shifts from crying to laughing to anger, often within minutes.
• Personality changes (29.1%): A once calm person becomes aggressive or paranoid.
• Severe depression (14.6%): Suicidal thoughts can emerge suddenly, even in people with no prior history.
• Psychosis (5-18%): Delusions, hallucinations, disorganized speech, or catatonia. This is the most dangerous and least recognized.

Some people experience mania alone. Others get psychosis without mania. In rare cases, symptoms appear only after stopping the drug. That’s critical: if you think you’re safe once you finish the course, you’re wrong. There are documented cases where psychosis lasted weeks or even months after the last pill.

Why Is This So Often Missed?

Doctors aren’t ignoring it. They’re often unaware. Most medical training focuses on physical side effects-weight gain, blood sugar spikes, bone loss. Psychiatric effects? They’re mentioned in a footnote. Pharmacists rarely screen for them. Family members don’t know what to look for.

When a 70-year-old woman on prednisone for COPD starts yelling at her grandchildren and claims the TV is spying on her, her doctor might think it’s dementia. Or depression. Or just old age. But it could be steroid-induced psychosis. And if no one connects the dots, she might be misdiagnosed, hospitalized, or even put on antipsychotics that don’t address the root cause.

Diagnosis is a process of elimination. As one study puts it: “Steroid-induced psychosis is more of a diagnosis of exclusion.” That means doctors must rule out infections, brain tumors, drug interactions, metabolic imbalances, and other neurological conditions before blaming the steroid. And many don’t have the time-or the training-to do that thoroughly.

What Should You Do If You Notice These Signs?

If you or someone you care about is on corticosteroids and starts acting strangely, don’t wait. Don’t assume it’s “just stress.” Here’s what to do:

1. Call the prescribing doctor immediately. Don’t wait for your next appointment. Say: “I’m seeing unusual mood or behavior changes since starting the steroid.”
2. Don’t stop the medication on your own. Suddenly quitting corticosteroids can trigger adrenal crisis-a life-threatening drop in cortisol. Tapering must be done under medical supervision.
3. Ask about lowering the dose. Studies show 92% of patients improve when the dose is reduced below 40 mg of prednisone per day. Sometimes cutting the dose in half is enough to reverse symptoms.
4. Request a psychiatric consult. If symptoms are severe, involve a psychiatrist. They know how to distinguish steroid-induced psychosis from other conditions and can recommend safe, off-label treatments.

There’s no FDA-approved drug for this. But in practice, low-dose antipsychotics like haloperidol, risperidone, or olanzapine often work. They’re not perfect, but they can calm symptoms within days. Lithium has been used to prevent mania, but it carries risks and requires blood monitoring. For most patients, the best treatment is reducing the steroid-not adding another drug.

What’s Missing From Current Care?

We’ve known about this for decades. The first reports date back to the 1940s. Yet today, there’s still no standardized screening tool. No checklist for pharmacists. No routine mental health check-ins for patients on long-term steroids.

Experts are calling for “clinimetric methods”-simple, quick assessments doctors can use during visits to catch early signs. Imagine a one-page form asking: “Have you had trouble sleeping? Felt unusually happy or irritable? Had strange thoughts?” That could save lives. But until that happens, the burden falls on patients and families.

And here’s the hardest truth: no pharmaceutical company is developing a solution. There’s no new drug, no warning label upgrade, no patient education campaign. It’s left to individual clinicians to recognize it-and too many still don’t.

What You Can Do Now

If you’re on corticosteroids:

• Keep a mood journal. Note sleep, energy, irritability, and unusual thoughts.
• Ask your doctor: “What psychiatric side effects should I watch for?”
• Tell a family member what to look for. They might notice changes before you do.
• Never ignore sudden confusion, paranoia, or extreme mood shifts. They’re not normal.

If you’re a caregiver for someone on steroids:

• Monitor for agitation, withdrawal, or strange behavior.
• Don’t assume it’s “just aging” or “stress.”
• Keep a log of when symptoms started relative to the steroid dose.
• Insist on a psychiatric evaluation if symptoms are severe.

Corticosteroids save lives. But they can also steal someone’s sense of self. The more we talk about this, the less likely it is that someone will suffer in silence-misdiagnosed, isolated, or worse.