The Mental Health Risks of Glucocorticoids

I ran across this review of the psychiatric adverse effects of glucocorticoids, medications like Prednisone [1]. Glucocorticoids have a variety of indications, and a lot of them are for inflammatory conditions, such as systemic lupus erythematosus. They are extremely effective agents when used for the conditions for which they are indicated. However, they also have a wide variety of psychiatric side effects and I’ve seen many of them in the general hospital and on our Medical-Psychiatry Unit. What’s new, at least to me, in the paper by Fardet and colleagues, is the association between exposure to glucocorticoids and higher risk for psychiatric adverse events in those with previous neuropsychiatric illness. Most of us know that they’re dose-related but most reviews have not emphasized the higher risk in those with previously diagnosed psychiatric illness as much as this one.

1. Fardet, L., I. Petersen, et al. (2012). “Suicidal behavior and severe neuropsychiatric disorders following glucocorticoid therapy in primary care.” Am J Psychiatry 169(5): 491-497.

OBJECTIVE: The incidence and the risk of suicidal behaviors and severe neuropsychiatric disorders in people treated with systemic glucocorticoids are poorly known. The authors assessed the incidence rates of depression, mania, delirium, panic disorder, and suicidal behaviors in patients treated with glucocorticoids in primary care settings and the risk factors for developing these outcomes. METHOD: Data were obtained for all adult patients registered between 1990 and 2008 at U.K. general practices contributing to The Health Improvement Network (THIN) primary care database. The incidence rates for the outcomes of interest were assessed in patients who received prescriptions for oral glucocorticoids and compared with those in patients who did not receive such prescriptions. The predictors of these outcomes in exposed patients were ascertained using Cox proportional hazards models. RESULTS: Overall, 786,868 courses of oral glucocorticoids were prescribed for 372,696 patients. The authors identified 109 incident cases of suicide or suicide attempt and 10,220 incident cases of severe neuropsychiatric disorders in these patients. The incidence of any of these outcomes was 22.2 per 100 person-years at risk for first-course treatments. Compared to people with the same underlying medical disease who were not treated with glucocorticoids, the hazard ratio for suicide or suicide attempt in exposed patients was 6.89 (95% CI=4.52-10.50); for depression, 1.83 (95% CI=1.72-1.94); for mania, 4.35 (95% CI=3.67-5.16); for delirium, confusion, or disorientation, 5.14 (95% CI=4.54-5.82); and for panic disorder, 1.45 (95% CI=1.15-1.85). Older men were at higher risk of delirium/confusion/disorientation and mania, while younger patients were at higher risk of suicide or suicide attempt. Patients with a previous history of neuropsychiatric disorders and those treated with higher dosages of glucocorticoids were at greater risk of neuropsychiatric outcomes. CONCLUSIONS: Glucocorticoids increase the risk of suicidal behavior and neuropsychiatric disorders. Educating patients and their families about these adverse events and increasing primary care physicians’ awareness about their occurrence should facilitate early monitoring.

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