Steroid-Induced Psychosis: How to Recognize and Treat It in an Emergency

When someone starts a high-dose steroid treatment - say, for severe asthma, lupus, or a flare-up of rheumatoid arthritis - most people expect side effects like weight gain, trouble sleeping, or mood swings. But few realize that steroid-induced psychosis can strike suddenly, sometimes within just two or three days. It’s not rare. In fact, up to 6% of patients on high-dose steroids develop full-blown psychosis, and that number jumps to nearly 1 in 5 when the daily dose exceeds 80 mg of prednisone. This isn’t just anxiety or stress. It’s real, dangerous, and often mistaken for schizophrenia or bipolar disorder - until you look at the timeline.

What Exactly Is Steroid-Induced Psychosis?

Steroid-induced psychosis is officially recognized as a substance/medication-induced psychotic disorder in the DSM-5. That means the person must have clear psychotic symptoms - like hearing voices, believing things that aren’t true (delusions), or acting wildly out of character - that directly follow steroid use and can’t be explained by another illness, drug use, or a pre-existing mental health condition. It’s not just feeling “off.” It’s losing touch with reality.

These symptoms usually show up within the first five days of starting high-dose steroids. The higher the dose, the faster and more severe the reaction. One landmark study from the 1970s found that 4.6% of hospitalized patients on more than 40 mg of prednisone per day developed psychiatric symptoms. For those on over 80 mg? That number jumped to 18.4%. Even today, with better monitoring, those numbers haven’t dropped much. And the risk doesn’t just come from oral pills - injections and IV steroids carry the same danger.

How Does It Happen?

Steroids aren’t just anti-inflammatory drugs. They’re powerful hormones that mimic cortisol, your body’s natural stress hormone. When you flood your system with synthetic versions - like prednisone, dexamethasone, or methylprednisolone - you throw off your brain’s delicate chemical balance.

Your brain has two main receptors for cortisol: glucocorticoid and mineralocorticoid. Too much synthetic steroid overstimulates the glucocorticoid receptors, which affects mood, memory, and perception. At the same time, your adrenal glands shut down, thinking they don’t need to produce natural cortisol anymore. This imbalance is why people on long-term steroids often feel emotionally flat or depressed. But in some, especially those with a genetic vulnerability or a history of mood disorders, it flips into mania or psychosis.

It’s not fully understood why this happens in some and not others. But we do know it’s not random. People with a personal or family history of bipolar disorder, depression, or prior psychotic episodes are at higher risk. So are older adults and those with existing brain injuries or neurological conditions.

What Does It Look Like?

The symptoms don’t appear all at once. They build like a storm.

• Day 1-3: Restlessness, confusion, irritability, trouble sleeping. Patients might say they feel “on edge” or that everything feels “too loud.”
• Day 3-5: Clear signs of psychosis emerge - hallucinations (hearing whispers or seeing things that aren’t there), paranoid delusions (“the nurses are poisoning me”), or grandiosity (“I’m invincible, I don’t need to sleep”).
• Severe cases: Aggression, violent outbursts, suicidal thoughts, or catatonia. In rare cases, patients have harmed themselves or others before being recognized.

Interestingly, the type of symptom often depends on how long the steroids have been used. Short-term, high-dose courses (like for a flare-up) are more likely to trigger mania. Long-term use (months or years) tends to lead to depression or anxiety. But psychosis? That can happen at any point - and it’s the most urgent.

Emergency Recognition: Don’t Wait for Full Psychosis

Too many emergency rooms miss this. They see a patient yelling about invisible threats and assume it’s schizophrenia. They give high-dose antipsychotics - 20 mg of olanzapine, maybe even 30 mg - and wonder why the patient gets worse. That’s the wrong approach.

The key is timing. If someone on steroids develops sudden confusion, agitation, or odd behavior within five days of starting treatment, steroid-induced psychosis should be the first thought. Not the last.

Here’s what every ER team needs to check right away:

1. Medication history: What steroid? What dose? When did they start? Even a single 80 mg IV dose can trigger this.
2. Neurological exam: Is there tremor? Slurred speech? Abnormal reflexes? These could point to infection, stroke, or metabolic issues - not psychosis.
3. Blood tests: Check glucose (steroids spike blood sugar), sodium, potassium, calcium, and kidney/liver function. Low sodium or high glucose can mimic psychosis.
4. Drug screen: Rule out cocaine, meth, or even withdrawal from alcohol or benzodiazepines.

If all that checks out and the timeline matches - you’re looking at steroid-induced psychosis.

How to Treat It - Fast and Safe

There’s no magic pill. But there is a clear, proven path - and it starts with stopping the steroid, not just covering up the symptoms.

Step 1: Safety First

If the patient is agitated, violent, or at risk of harm, you need to calm them - fast. But don’t reach for high-dose antipsychotics. Studies show that typical first-episode psychosis doses (10-20 mg olanzapine) are too strong here. Instead:

• Use low-dose oral antipsychotics: Olanzapine 2.5-5 mg, risperidone 1-2 mg, or haloperidol 0.5-1 mg.
• If they won’t swallow pills, use IM olanzapine (5-10 mg) - not haloperidol alone. Haloperidol can cause severe muscle spasms (EPS), especially in older patients.
• Add lorazepam 1 mg if needed for acute anxiety or aggression. Benzodiazepines are safer than high-dose antipsychotics in this setting.
• Never use restraints unless there’s an immediate threat. Even then, keep them brief. Physical restraint increases trauma and can worsen psychosis.

Step 2: Taper the Steroid

This is where most hospitals fail. They’re scared to reduce the steroid because the patient needs it for their asthma, transplant, or autoimmune disease. But here’s the truth: 92% of patients fully recover once the steroid dose is cut below 40 mg/day of prednisone (or 6 mg dexamethasone).

You don’t need to stop it completely. Just reduce it. If the patient is on 120 mg prednisone, drop to 40 mg. If they’re on 80 mg, drop to 20 mg. The psychosis will usually lift within 3-7 days. If they’re on a long-term regimen, work with their specialist - taper too fast and you risk adrenal crisis.

Step 3: Supportive Care

Once the acute phase passes, some patients need ongoing support. For those with recurrent mania or depression, lithium can help prevent future episodes - but it’s risky. It requires blood monitoring and can damage kidneys or thyroid. SSRIs or mood stabilizers like valproate may be used, but evidence is weaker. The goal isn’t to add more drugs - it’s to get the steroid dose down to the minimum needed.

Why Do So Many Doctors Miss This?

A 2022 survey of 127 ER doctors found that while 89% knew steroids could cause psychosis, only 43% consistently followed the recommended tapering protocol. Why? Fear. Fear of worsening the underlying disease. Fear of backlash if the patient’s condition flares. Fear of looking “unskilled” if they reduce a powerful drug.

But here’s what they’re missing: untreated steroid psychosis is far more dangerous than a mild disease flare. A patient in psychosis can refuse care, stop eating, jump out of windows, or attack staff. A flare can be managed. A psychotic episode can be fatal.

Emergency departments need protocols. Not just guidelines - real, written, posted procedures. Train staff to ask: “When did they start steroids?” before asking about family history. Use checklists. Build alerts into electronic records.

What’s Coming Next?

Researchers are working on ways to predict who’s at risk. The NIH is tracking 500 patients on high-dose steroids, looking for genetic markers and blood biomarkers that might signal trouble before symptoms start. By 2025, the American Psychiatric Association plans to roll out a clinical decision tool that will tell doctors: “This patient has a 72% risk of psychosis. Consider lowering the dose.”

For now, the answer is simple: Know the dose. Know the timeline. Taper early. Don’t overmedicate. The psychosis will clear. The disease can be managed. But if you wait too long, you risk losing more than just a few days of treatment - you risk losing a person.