Secondary mania related to steroid use

Corticosteroids are commonly used for treating various diseases. It is known that there are many steroid-related psychiatric disorders. Mania, depression, psychotic disorders and delirium are the most common psychiatric side effect of steroids. It is suggested that short-term use of high dose steroids causes mania whereas long-term use of low dose steroids causes depression. In this report, we present a case of a patient, who had manic episode following high dose methylprednisolone used for Addison’s disease. A 36-year-old woman with irritability, hostility, increased talkativeness, sleepless, increased in religious activities, persecution and grandiose delusions were hospitalized in our in-patient clinic. She was presented to an internal medicine clinic with complaints of fatigue, loss of appetite, nausea, weight loss and darkening of the skin and was hospitalized one week ago. Addisonian crisis was prediagnosed, as her plasma cortisol level was 9.35 mcg/dl and ACTH level was above 1250 pg/ml. She received methylprednisolone 80 mg/day for two days and prednisolone 20 mg/day for the following three days. She was discharged with a treatment regimen of prednisolone 20 mg per day after her biochemical parameters were normalized and her symptoms disappeared. Two days after her discharge, she experienced irritability, hostility, increased speech and insomnia and was hospitalized in our clinic. The patient without any previous psychiatric diagnosis and no history of psychiatric illness in the family was considered as steroid-related mania. The dose of was decreased prednisolone to 7.5 mg/day by internal medicine specialist. As she rejected to take oral medications, we added haloperidol 10 mg per day to her treatment regimen. The severity of irritability and hostility symptoms decreased; as such, haloperidol treatment was tapered to 5 mg/day three days after her hospitalization. She decided to take oral medications; for this reason, her treatment was changed to olanzapine 5 mg/day in the fifth day. She was discharged two weeks later and in the examination, which was done 15 days after her discharge, she had no psychiatric complaints. Previous studies showed that psychiatric side effects of corticosteroids were related to dose and duration of the medication. The use of 80 mg methylprednisolone followed by manic symptoms within a week in our case is consistent with previous studies. Four criteria are required for the diagnosis secondary mania: A close temporal relationship between mania and medication use, late onset, absence of family history and no previous history of a psychiatric disorder. Our case meets all these criteria and this supports the claim that manic episode was related to corticosteroids. It was reported that olanzapine is effective in steroid-related manic episodes. In our case, olanzapine rapidly decreased the manic symptoms and remained effective during follow-up. Corticosteroids that are used for various diseases may cause medical and psychiatric side effects. Therefore, medical side effects as well as psychiatric side effects of corticosteroids should be explored carefully.