Mood and Behavioral Changes from Corticosteroids: What You Need to Know About Psychosis Risk

When you take corticosteroids for asthma, rheumatoid arthritis, or a flare-up of lupus, you’re counting on relief. But what if the very drug that calms your inflammation starts messing with your mind? It’s not rare. It’s not rare at all. Up to 18% of people on high-dose steroids develop serious mood or behavioral changes - including psychosis. And most doctors don’t see it coming.

It Starts with a Feeling You Can’t Explain

You might notice it first as trouble sleeping. Or sudden anger over small things. Maybe you feel unusually happy, almost giddy, even when nothing good is happening. These aren’t just "bad days." They’re early signs of corticosteroid-induced psychiatric effects. Studies show that 42% of patients on these drugs get insomnia. Nearly 39% experience mood swings. And 27% feel euphoria - a false, intense high that doesn’t match their situation.

These changes don’t wait weeks to show up. They often appear within the first three to four days after starting treatment. For many, it’s the first week. If you’re on 80 mg of prednisone or more, your risk jumps to nearly one in five. Even at lower doses - say, 40 mg - about 1 in 7 people will notice something off. And it’s not just about feeling "off." Some people develop full-blown psychosis: hearing voices, believing things that aren’t true, acting out of character in ways that scare family members.

Who’s Most at Risk?

Not everyone reacts the same way. Certain people are far more likely to develop these problems. Women are at higher risk than men - for reasons still not fully understood. People over 65 are more vulnerable, partly because their brains are more sensitive to hormonal shifts. And if you’ve had depression, bipolar disorder, or a previous psychotic episode, your chances of a steroid-triggered flare-up go up dramatically.

It’s not just about the dose. It’s about duration too. Long-term users - like those taking steroids for years to manage chronic autoimmune disease - face a cumulative risk. Even after stopping, symptoms can linger. There are documented cases where psychosis or mania didn’t fade for weeks or months after the last pill. That’s not a myth. It’s in the medical literature.

Why Does This Happen?

We don’t have a full answer, but we know enough to be worried. Corticosteroids flood your body with synthetic versions of cortisol - a hormone your adrenal glands normally make. When you take too much, your brain gets confused. The hypothalamus-pituitary-adrenal (HPA) axis shuts down. Your hippocampus, the part of your brain responsible for memory and emotional regulation, starts to shrink slightly. Dopamine levels spike. In animal studies, high doses of steroids trigger a surge in tyrosine hydroxylase, the enzyme that makes dopamine. Too much dopamine? That’s a known pathway to psychosis.

It’s not just one mechanism. It’s a mix. Memory problems are common - people forget names, lose track of conversations, struggle to recall recent events. That’s not just aging. That’s steroid-induced cognitive fog. And it’s reversible, but only if caught early.

What Does Psychosis Look Like?

Psychosis isn’t always dramatic. It doesn’t always mean screaming at imaginary people. Sometimes, it’s subtle: a patient who suddenly insists their family is poisoning them. Someone who believes they’re being watched by government agents. Or a person who talks in circles, jumps from topic to topic, and can’t follow a simple conversation. In some cases, it’s pure mania - racing thoughts, reckless spending, no need for sleep for days.

One study found that 23.5% of cases showed psychotic symptoms only - no mood swings, no depression. Another 11.8% showed mania alone. That means doctors can’t just look for depression. They have to screen for everything. And most don’t.

How Do You Know It’s the Steroids?

This is the hard part. Steroid-induced psychosis is a diagnosis of exclusion. That means your doctor has to rule out everything else first. Infections? Brain tumors? Drug interactions? Alcohol withdrawal? Metabolic imbalances like low sodium or high ammonia? All of those can mimic psychosis. If you’re on steroids and suddenly act strangely, your doctor should order blood tests, maybe a brain scan, and check for other causes before concluding it’s the medication.

But here’s the problem: most primary care doctors aren’t trained to suspect this. They see a patient with high blood pressure and irritability and assume it’s stress. Or they blame the underlying illness. A rheumatologist might think the joint pain is making the patient grumpy. A pulmonologist might chalk up confusion to low oxygen. It’s not their fault - it’s a systemic blind spot.

What Should You Do If You Notice Changes?

If you or someone you care about is on steroids and starts acting differently - especially within the first week - speak up. Tell your doctor. Don’t wait. Don’t assume it’s "just the illness." Document the changes: when they started, what exactly changed, how long it lasted, whether it got worse or better.

The first step? Reduce the dose. If you’re on 80 mg of prednisone, dropping to 40 mg or below often brings symptoms back to normal. In fact, 92% of patients improve significantly once the dose is lowered. But you can’t just stop cold. Tapering must be done under medical supervision. Abrupt withdrawal can cause adrenal crisis - a life-threatening drop in cortisol.

If you can’t reduce the steroid - maybe your condition is too severe - then antipsychotics may be needed. Haloperidol, risperidone, or olanzapine are commonly used off-label. Doses are low - often just 1 to 2 mg of risperidone per day. Symptoms usually start to lift within days. Lithium has been used to prevent mania, but it’s risky. It can damage kidneys and thyroid. Only a psychiatrist should manage that.

What About Long-Term Use?

If you’re on steroids for months or years - like many people with COPD, Crohn’s, or lupus - you need a different plan. Regular mental health check-ins should be part of your care. Not every six months. Every month. Ask your doctor to screen for mood changes during every visit. Use a simple tool: "Have you felt unusually happy, irritable, or anxious lately? Have you had trouble sleeping or felt like people are watching you?"

Pharmacists play a key role too. When you pick up your prescription, ask: "Could this affect my mood?" Most won’t say anything unless you ask. But if you’re over 65, female, or have a history of mental illness, they should flag it.

The Bigger Picture

About 10 million new steroid prescriptions are written in the U.S. every year. That’s millions of people at risk. And yet, there’s no FDA-approved drug to treat steroid-induced psychosis. No standardized screening tool. No official guidelines telling doctors when to worry. It’s all left to individual judgment.

That’s changing slowly. Researchers are pushing for "clinimetric" tools - simple, quick questionnaires doctors can use in 30 seconds during a check-up. They’re also looking for biomarkers - blood tests or brain scans that could predict who’s likely to react badly. Until then, awareness is your best defense.

What You Can Do Today

• If you’re starting steroids, ask your doctor: "What are the mental side effects?"
• Keep a mood journal for the first two weeks: note sleep, energy, irritability, unusual thoughts.
• Tell a family member to watch for changes. They’ll notice before you do.
• Never stop steroids abruptly. Always taper with medical help.
• If you feel detached, paranoid, or hear voices - call your doctor immediately.

These drugs save lives. But they don’t come without cost. The more we understand the mental risks, the better we can protect people who need them most.