Mood and Behavioral Changes from Corticosteroids: Understanding the Psychosis Risk

When you take corticosteroids for asthma, rheumatoid arthritis, or another inflammatory condition, you’re likely focused on relief - less pain, easier breathing, reduced swelling. But what you might not realize is that these powerful drugs can also change how you think, feel, and behave. For some people, the side effects go beyond weight gain or trouble sleeping. They can trigger psychosis, severe mood swings, hallucinations, or deep depression - sometimes within just a few days of starting treatment.

How Common Are Psychiatric Side Effects from Steroids?

It’s not rare. About 5% to 18% of people taking systemic corticosteroids like prednisone experience noticeable psychiatric symptoms. That’s one in five patients. At lower doses - under 40 mg of prednisone per day - the risk is around 1.3%. But once you hit 80 mg or more, that number jumps to nearly 1 in 5. And with roughly 10 million new oral steroid prescriptions written in the U.S. every year, we’re talking about tens of thousands of people each year who may face sudden, unexplained changes in their mental state.

These aren’t just "feeling a bit irritable" moments. These are real, measurable psychiatric events. Some patients become euphoric, overly confident, or reckless. Others spiral into deep depression or panic. A smaller but significant group develops full-blown psychosis - hearing voices, believing things that aren’t true, or acting in ways that don’t make sense to others.

When Do Symptoms Start - and How Long Do They Last?

Symptoms usually show up within the first week. Most patients report changes between day three and day four after starting treatment. But they can also appear weeks later, or even after the steroid is stopped. That last part is critical: many assume that once the drug is out of their system, the mental side effects vanish too. But that’s not always true. Case reports show psychosis and mania can linger for weeks or months after discontinuation.

Memory problems are another hidden issue. People often report trouble remembering names, appointments, or even recent conversations. This isn’t just "getting older" - it’s a direct effect on the hippocampus, the brain’s memory center. Studies show corticosteroids interfere with how neurons communicate there, leading to deficits in verbal and declarative memory.

Who’s Most at Risk?

Not everyone who takes steroids gets psychiatric side effects. But certain factors raise the risk significantly:

• High doses - Anything over 40 mg of prednisone per day is a red flag.
• Older adults - People over 65 are more vulnerable, partly because their brains are more sensitive to hormonal changes.
• Women - Multiple studies show women are more likely than men to develop mood or psychotic symptoms on steroids.
• History of mental illness - Especially bipolar disorder. Steroids can trigger mania or psychosis in people who’ve never had symptoms before.
• Prolonged use - Taking steroids for weeks or months increases risk more than a short course.

If you’ve had depression, anxiety, or mania in the past, your doctor should know. Even if you think it’s "in the past," your brain may still be more reactive to steroid-induced changes.

What Do the Symptoms Actually Look Like?

It’s not just "psychosis" or "depression." The spectrum is wide:

• Euphoria - Feeling unusually happy, invincible, or overly energetic. This can lead to risky spending, reckless driving, or impulsive decisions.
• Insomnia - Not just trouble falling asleep, but complete disruption of sleep cycles, leading to exhaustion and confusion.
• Mood swings - Rapid shifts from crying to laughing, anger to calm, within hours.
• Personality changes - A quiet person becomes aggressive. A patient person becomes easily provoked.
• Severe depression - Not just sadness. Hopelessness, suicidal thoughts, loss of interest in everything.
• Psychosis - Delusions (false beliefs), hallucinations (seeing or hearing things that aren’t there), disorganized speech, or catatonia.

Some people have only manic symptoms. Others have only psychotic symptoms. And many have a mix. This variability makes it harder for doctors to spot - especially if they’re focused on the original medical condition.

Why Does This Happen?

We don’t have a full answer yet, but here’s what we know:

• Corticosteroids suppress your body’s natural cortisol production, throwing off the HPA axis - the system that regulates stress, sleep, and mood.
• They increase dopamine activity in the brain. Too much dopamine is linked to psychosis, similar to what’s seen in schizophrenia.
• They reduce activity in the hippocampus, which affects memory and emotional regulation.
• They may alter how serotonin and other neurotransmitters function.

It’s not one single cause. It’s a mix of hormonal disruption, brain chemistry changes, and individual vulnerability. That’s why two people on the same dose can have completely different reactions.

What Should You Do If You Notice Changes?

If you or someone you care about starts acting strangely after beginning steroids - especially if it’s sudden - don’t wait. Don’t assume it’s "just stress" or "the illness talking."

Call your doctor immediately. Tell them exactly what you’ve noticed: "I’ve been hearing voices," or "I can’t sleep for days," or "I feel like I’m on top of the world but I’m scared." Write it down beforehand if you can. These symptoms are often dismissed as "behavioral" or "emotional" - but they’re medical.

Emergency signs: Suicidal thoughts, violent behavior, severe confusion, or hallucinations. Go to the ER. Don’t wait for a doctor’s appointment.

How Are These Symptoms Treated?

There are no FDA-approved drugs specifically for steroid-induced psychosis. That means doctors use what works based on experience:

• Tapering the steroid - The most effective step. Reducing the dose below 40 mg/day (or switching to a lower equivalent like 6 mg of dexamethasone) resolves symptoms in 92% of cases.
• Antipsychotics - Low doses of haloperidol, risperidone, or olanzapine can calm psychosis within days. These are used off-label but are well-documented in case studies.
• Lithium - Sometimes used to prevent mania, but it’s risky. Requires blood tests and careful monitoring. Not a first choice.

Stopping steroids isn’t always possible - if you have a life-threatening condition like severe asthma or lupus, your doctor may need to keep you on them. In those cases, antipsychotics become essential.

Psychiatry consultation is often needed. This isn’t a "just see your GP" situation. You need someone who understands the interaction between neurochemistry and medication.

What Doctors Often Miss

Many clinicians don’t connect psychiatric symptoms to steroids. Why?

• They assume the patient is "stressed" by their illness.
• They don’t ask about mood changes during routine visits.
• They don’t know the timeline - thinking symptoms take weeks to appear, when they often start in days.
• They don’t realize symptoms can persist after stopping the drug.

Pharmacists are often the first to notice. They see the prescriptions, know the dosages, and hear patients say things like, "I’ve never been this angry before." But unless they’re trained to speak up, it falls through the cracks.

Multiple guidelines recommend that primary care providers, pulmonologists, rheumatologists, and psychiatrists talk to each other when a patient is on high-dose steroids. But in practice, that rarely happens.

What You Can Do to Protect Yourself

• Ask your doctor: "What are the mental side effects of this steroid?" Don’t assume they’ll tell you unless you ask.
• Keep a daily journal: Note your mood, sleep, energy, and any strange thoughts. This helps doctors spot patterns.
• Inform a family member or close friend. Ask them to watch for changes you might not notice yourself.
• Don’t stop steroids suddenly. Tapering must be done under medical supervision.
• Get a baseline mental health check before starting long-term steroid therapy, especially if you have any past psychiatric history.

These aren’t just "side effects" - they’re serious medical events that can impact your safety, relationships, and recovery. Recognizing them early saves lives.

Where Do We Go From Here?

Despite being documented since the 1940s, we still lack standardized tools to detect these changes early. There’s no simple screening test. No blood marker. No quick questionnaire doctors routinely use.

Researchers are pushing for "clinimetric methods" - better ways to measure symptom severity in real time. Some are exploring genetic markers to predict who’s most vulnerable. Others are studying whether certain antidepressants or anti-inflammatory drugs might prevent these effects.

For now, awareness is the best defense. If you’re on steroids, know the signs. If you’re caring for someone on steroids, pay attention. And if something feels off - trust your gut. It might be the drug, not the person.

This isn’t about fear. It’s about being informed. Corticosteroids save lives. But they can also change them - sometimes in ways no one expects. Knowing the risks doesn’t mean avoiding treatment. It means getting the right care, at the right time, with the right support.