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

When someone starts taking high-dose steroids for an autoimmune flare, a severe infection, or after an organ transplant, most people expect side effects like weight gain, insomnia, or a spike in blood sugar. But few anticipate something far more dangerous: steroid-induced psychosis. It doesn’t happen often-but when it does, it hits fast, hard, and can turn a medical recovery into a crisis.

What Exactly Is Steroid-Induced Psychosis?

Steroid-induced psychosis isn’t a mental illness you’re born with. It’s a reaction-triggered by corticosteroids like prednisone, dexamethasone, or methylprednisolone. The DSM-5 classifies it as a substance-induced psychotic disorder. That means: hallucinations, delusions, or severe disorganized thinking appear shortly after starting the drug, and they can’t be explained by schizophrenia, bipolar disorder, or another medical condition.

It’s not rare. Studies show 6% of people on high-dose steroids develop severe psychiatric symptoms. At doses over 80 mg of prednisone per day, that number jumps to nearly 1 in 5. The Boston Collaborative Drug Surveillance Program found that in 1972, patients on more than 80 mg/day had an 18.4% chance of developing psychosis. Even today, with better monitoring, those numbers haven’t dropped much.

And it doesn’t take long. Symptoms often show up within 2 to 5 days of starting the steroid. That’s why emergency teams need to ask one simple question early: “When did they start this steroid?” If the answer is within the last week, psychosis must be on the radar.

How Does It Present?

Steroid-induced psychosis doesn’t look like classic schizophrenia. It often starts subtly-then escalates quickly.

• Early signs: confusion, restlessness, irritability, trouble sleeping, or feeling “off”
• Progressing to: hearing voices, believing things that aren’t true (like being watched or poisoned), extreme mood swings
• Severe cases: mania (euphoria, grandiosity, reckless behavior), aggression, or suicidal thoughts

One study of 79 cases found that 40% had depression, 28% had mania, and 14% had full-blown psychosis. But here’s the catch: people on short-term steroids (like for a flare-up) are more likely to become manic. Those on long-term therapy (like for lupus or MS) tend to develop depression.

It’s easy to miss. A patient might be labeled “noncompliant” or “hysterical.” But if they’ve just started high-dose steroids, their brain chemistry has changed. Glucocorticoids flood the brain, overstimulating receptors, disrupting the HPA axis-the system that controls stress and mood. The same imbalance happens in Cushing’s disease. That’s why steroid psychosis can feel like a neurological emergency, not just a psychiatric one.

What Else Could It Be?

Before you diagnose steroid-induced psychosis, you must rule out everything else.

Many medical conditions mimic psychosis:

• High blood sugar (hyperglycemia) or low sodium (hyponatremia)
• Brain infections like meningitis or encephalitis
• Drug interactions (especially with antibiotics or antivirals)
• Withdrawal from alcohol or benzodiazepines
• Undiagnosed epilepsy or brain tumors

Emergency departments need a checklist: blood sugar, electrolytes, liver and kidney function, infection markers (CRP, WBC), and a urine drug screen. A head CT isn’t always needed-but if the patient has headaches, seizures, or focal neurological signs, it’s essential.

And don’t forget: steroids can cause delirium, especially in older adults. Delirium is confused, fluctuating, and often tied to infection or dehydration. Psychosis is more fixed in its delusions and hallucinations. Distinguishing them saves lives.

Emergency Management: What to Do Right Now

If someone is actively psychotic, agitated, or dangerous-your first job is safety.

Step 1: De-escalate

Don’t rush to restrain. Use calm voice, clear space, reduce noise. Offer water. Let them sit. Many patients respond to simple human connection. If they’re screaming, pacing, or threatening harm, don’t argue. Just say, “I’m here to help.”

Step 2: Medication

Antipsychotics are the go-to-but not the ones you’d use for schizophrenia. Doses need to be lower.

• Oral olanzapine: 2.5-20 mg/day (start low)
• Oral risperidone: 1-4 mg/day
• Oral haloperidol: 0.5-1 mg/day

For noncompliant or violent patients, use intramuscular (IM) options:

• IM olanzapine: 10 mg
• IM haloperidol: 2-5 mg (always give with benztropine or diphenhydramine to prevent stiffness or tremors)
• IM lorazepam: 1-2 mg if there’s severe anxiety or agitation

Never use high-dose antipsychotics (like 20-30 mg olanzapine). That’s for acute schizophrenia, not steroid psychosis. Overmedicating increases sedation, low blood pressure, and movement disorders-making recovery harder.

Step 3: Taper the Steroid

This is the most effective treatment. 92% of patients improve once the steroid dose drops below 40 mg prednisone/day-or even lower. But you can’t just stop it cold.

Patients on steroids for asthma, rheumatoid arthritis, or after transplant can go into adrenal crisis if you reduce too fast. Work with the prescribing doctor. Aim for the lowest effective dose. Sometimes, switching from prednisone to dexamethasone (which has less psychiatric risk) helps.

If the steroid can’t be reduced (e.g., transplant rejection), then antipsychotics become the long-term solution. Olanzapine and risperidone usually clear symptoms in 1-3 weeks.

What About Lithium or Antidepressants?

Lithium is proven to prevent steroid-induced mania-but it’s risky. It needs blood tests, can cause kidney or thyroid problems, and interacts with many drugs. Only use it if antipsychotics fail, and only with psychiatric consultation.

Antidepressants like SSRIs may help if depression dominates. Antiseizure drugs like valproate or carbamazepine are sometimes used off-label, but evidence is weak. Stick to what works: antipsychotics + taper.

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 tapered the dose. Over 60% gave too-high antipsychotic doses because they were scared of “not doing enough.”

That’s the real problem: fear. Fear of missing a diagnosis. Fear of violence. Fear of being sued. So they over-treat.

But the truth? Steroid psychosis is one of the most treatable forms of psychosis-if caught early. It’s not permanent. It’s reversible. You don’t need to hospitalize everyone. You don’t need to use high-dose meds. You just need to think differently.

What’s Changing in 2025?

There’s new hope. The NIH is tracking 500 patients on high-dose steroids to find genetic markers that predict who’s at risk. Early data suggests certain variations in the glucocorticoid receptor gene increase vulnerability.

Also, the American Psychiatric Association is rolling out a clinical decision tool in mid-2025. It’ll ask: What’s the dose? How long have they been on it? Any prior mental health history? Any recent infection? Then it’ll flag risk level and suggest actions-taper? Antipsychotic? Lab tests?

For now, the best tool is still the one you already have: awareness. Ask the question. Check the timeline. Rule out the mimics. Start low with meds. Taper the steroid. Watch closely.

Final Thought: It’s Not Just a Mental Health Issue

Steroid-induced psychosis blurs the line between neurology, psychiatry, and internal medicine. It’s not a “psych patient.” It’s a patient with a drug reaction. A medical emergency. A treatable condition.

If you’re prescribing steroids-especially above 40 mg/day-talk to your patient. Warn them: “Some people feel unusually anxious, confused, or see things that aren’t there. If that happens, call us immediately.”

If you’re in the ER-don’t assume it’s schizophrenia. Don’t assume it’s drug abuse. Don’t wait for the psychiatrist. Act now. Taper. Medicate low. Monitor. Save a life.