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

When someone starts taking high-dose steroids for asthma, lupus, or a flare-up of rheumatoid arthritis, they usually expect relief from swelling and pain. But in some cases, they might suddenly become confused, paranoid, or even hear voices. This isn’t a sign of weakness or a personal failing-it’s steroid-induced psychosis, a serious but treatable side effect that emergency teams need to spot fast.

What Exactly Is Steroid-Induced Psychosis?

Steroid-induced psychosis is a recognized medical condition listed in the DSM-5 as a substance/medication-induced psychotic disorder. It happens when corticosteroids-like prednisone, dexamethasone, or methylprednisolone-trigger delusions, hallucinations, or extreme mood swings that aren’t caused by another mental illness, drug use, or a physical brain problem.

It’s not rare. Studies show between 2% and 60% of people on high-dose steroids develop some kind of psychiatric symptom. The real danger zone? People taking more than 80 mg of prednisone per day. In one large study, nearly 1 in 5 patients on that dose developed clear psychotic symptoms. Even at 40 mg/day, over 4% of patients had noticeable changes in thinking or behavior.

These symptoms don’t show up after weeks. They usually hit within the first 2 to 5 days of starting the medication-or sometimes right after a dose increase. That’s why it’s so easy to miss. A patient might be admitted for pneumonia, get a high-dose steroid shot, and then suddenly start yelling about being watched by the government. Doctors might assume it’s delirium from infection, or worse, dismiss it as ‘just being dramatic.’ But if you don’t recognize it for what it is, you risk serious harm.

How Do You Spot It Early?

Waiting for full-blown hallucinations means you’ve already waited too long. The earliest signs are subtle but consistent:

• Confusion or trouble following simple conversations
• Unexplained agitation or restlessness
• Sudden mood swings-like going from calm to angry in minutes
• Difficulty sleeping, even when the body is exhausted
• Repeating the same thoughts or fears, even when told they’re not true

These aren’t just ‘bad days.’ They’re neurological reactions. Corticosteroids flood the brain with synthetic cortisol, which disrupts the balance between two key receptor systems: glucocorticoid and mineralocorticoid. This imbalance affects areas of the brain tied to emotion, memory, and perception-similar to what happens in Cushing’s syndrome or severe stress.

Research shows that mania (elevated mood, grandiosity, impulsivity) is more common in people on short-term, high-dose steroids. Depression, on the other hand, tends to appear after weeks or months of use. Psychosis-delusions and hallucinations-is less frequent than mood swings, but it’s the most dangerous because it increases the risk of violence, self-harm, or suicide.

What Else Could It Be? Ruling Out Mimics

Before you label it steroid-induced psychosis, you have to rule out everything else. Many medical conditions look exactly like psychosis:

• High blood sugar from steroid-induced diabetes
• Low sodium or potassium from electrolyte shifts
• Brain infections like meningitis or encephalitis
• Drug interactions (especially with antidepressants or opioids)
• Alcohol or benzodiazepine withdrawal
• Underlying bipolar disorder or schizophrenia triggered by stress

That’s why every emergency evaluation needs the same basic checks:

1. Ask: When did the steroids start? What’s the dose? Has it changed?
2. Check: Blood glucose, electrolytes, kidney and liver function
3. Test: Urine drug screen, CBC, CRP, TSH, vitamin B12
4. Assess: Neurological exam-any tremors, weakness, or abnormal reflexes?

If the patient has a fever, neck stiffness, or altered consciousness, a lumbar puncture might be needed. If glucose is over 250 mg/dL, that could be the main driver of confusion. You can’t treat steroid psychosis until you’ve ruled out these mimics.

Emergency Treatment: Safety First, Then Medication

The first rule in any emergency psychosis: Do no harm. Physical restraints should be a last resort. They increase fear, raise cortisol further, and can cause injury. Instead, use calm verbal de-escalation. Lower lights, reduce noise, have one trusted person speak slowly and clearly.

If the patient is violent or poses a danger, sedation is needed. But here’s where most ER teams get it wrong-they reach for high doses of antipsychotics meant for schizophrenia. That’s dangerous.

For steroid-induced psychosis, lower doses work better and are safer:

• Olanzapine: 2.5-10 mg orally (not 20-30 mg)
• Risperidone: 1-2 mg orally or IM
• Haloperidol: 0.5-1 mg orally, or 2-5 mg IM (always give with diphenhydramine to prevent muscle spasms)
• Lorazepam: 1-2 mg IM if there’s severe anxiety or agitation

Studies show these doses resolve symptoms in 2-7 days. Higher doses don’t speed things up-they just cause more side effects like sedation, low blood pressure, or abnormal movements.

For patients who refuse pills, disintegrating tablets or IM injections are the best options. Avoid long-acting injectables like fluphenazine-they’re overkill and risky in this setting.

The Real Fix: Tapering the Steroids

Medication alone won’t cure this. The root cause is the steroid. The single most effective treatment? Reducing the dose.

Research shows that 92% of patients recover fully when their steroid dose is lowered to under 40 mg of prednisone per day-or the lowest possible dose needed for their underlying condition. That’s not a suggestion. It’s the standard of care.

But you can’t just stop steroids cold. Abrupt withdrawal can trigger adrenal crisis-low blood pressure, vomiting, shock, even death. The goal is to taper slowly while monitoring for both psychiatric symptoms and physical stability.

For example:

• If someone is on 120 mg prednisone daily, drop to 60 mg in 24-48 hours
• Then reduce by 10-20 mg every 2-3 days until under 40 mg
• Once stable, continue tapering under specialist supervision

If the patient needs the steroid for a life-threatening condition-like a severe flare of vasculitis or organ transplant rejection-then you manage the psychosis with antipsychotics while keeping the steroid dose as low as possible. That’s where collaboration with rheumatology or immunology is critical.

What About Lithium or Antidepressants?

Lithium can help prevent steroid-induced mania, especially in people with a history of bipolar disorder. But it’s not a first-line choice. It takes weeks to work, requires blood tests, and can cause kidney or thyroid damage. Only use it if antipsychotics fail and the patient is at high risk for mania.

Antidepressants like SSRIs? Sometimes used for steroid-induced depression, but they don’t help psychosis. Antiseizure drugs like valproate or carbamazepine? There’s weak evidence. They’re not recommended unless there’s a clear seizure risk or bipolar component.

The bottom line: Stick to low-dose antipsychotics and steroid tapering. Everything else is a backup plan.

Why Do So Many ER Doctors Get It Wrong?

A 2022 survey of 127 emergency physicians found that while 89% knew steroids could cause psychosis, only 43% consistently tapered the dose. Over 60% gave antipsychotics at doses meant for schizophrenia-sometimes 20-30 mg of olanzapine. That’s more than double what’s needed. It’s like using a sledgehammer to fix a loose screw.

Why? Lack of training. Most ER staff learn psychosis from schizophrenia cases, not medication-induced cases. They don’t realize steroid psychosis responds better to gentler treatment. The American College of Emergency Physicians updated its guidelines in 2023 to say: Use 50-75% less antipsychotic than you would for primary psychosis. But few ERs have protocols to enforce this.

What’s missing? Simple checklists. A one-page form asking: Did the patient start or increase steroids in the last 5 days? Are they confused or agitated? What’s their glucose and sodium? That’s all it takes to catch it early.

What’s Next? Better Tools Coming

The National Institutes of Health is running a study tracking 500 patients on high-dose steroids to find genetic or blood markers that predict who’s at risk. Early results suggest certain gene variants may make people more sensitive to cortisol’s effects on the brain.

By mid-2025, the American Psychiatric Association will release a clinical decision tool that helps doctors calculate risk based on steroid dose, age, past mental health history, and early symptoms. It’ll flag high-risk patients before psychosis even starts.

Until then, the best tool is awareness. If you’re prescribing or giving steroids, watch for the first signs. If you’re in the ER and someone looks ‘off’ after a steroid shot, don’t assume it’s ‘just anxiety.’ Ask the right questions. Order the right tests. Taper the steroid. Give the right dose of antipsychotic. You can save someone from weeks of suffering-and maybe even their life.