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 - not a mental health crisis. But for some people, these powerful anti-inflammatory drugs can trigger sudden mood swings, paranoia, hallucinations, or even full-blown psychosis. It’s not rare. It’s not just "being moody." And it’s often missed by doctors and patients alike.

How Common Are Psychiatric Side Effects from Steroids?

About 1 in 5 people taking high-dose corticosteroids like prednisone will experience noticeable mood or behavioral changes. At doses under 40 mg per day, the risk is around 1.3%. But jump to 80 mg or more - a common starting dose for severe autoimmune flares - and that risk climbs to nearly 18%. With roughly 10 million new oral steroid prescriptions written each year in the U.S. alone, this isn’t a fringe issue. It’s a quiet epidemic.

Most people don’t realize steroids can affect the brain. They expect nausea, weight gain, or trouble sleeping. But psychosis? That’s not on the list most patients are given. Yet it happens. And when it does, it can turn a short treatment into a months-long recovery.

What Do These Changes Look Like?

Symptoms don’t always come with a siren. Sometimes, it starts small: you can’t sleep, you’re unusually irritable, or you feel "not like yourself." Then it escalates.

• Euphoria: Feeling overly happy, invincible, or reckless - even when things are going wrong.
• Insomnia: Not just trouble falling asleep, but being wide awake for days with racing thoughts.
• Mood swings: Going from calm to furious in minutes, or crying for no clear reason.
• Personality shifts: A usually kind person becomes suspicious, hostile, or withdrawn.
• Depression: Deep, hopeless sadness that doesn’t lift, even when physical symptoms improve.
• Psychosis: Hearing voices, believing things that aren’t true (delusions), or acting in ways that don’t make sense to others.

These aren’t just "side effects." They’re brain changes. Studies show that verbal memory, attention, and decision-making can dip within days of starting steroids. One patient described it as "a fog that made me forget my own name."

Who’s Most at Risk?

It’s not random. Certain people are far more likely to develop these reactions.

• Women: Multiple studies show women are more vulnerable than men, especially those over 50.
• Older adults: People over 65 have a higher risk, partly because their brains are more sensitive to hormonal shifts.
• Those with a history of mental illness: If you’ve had depression, bipolar disorder, or psychosis before, steroids can trigger a relapse - even years later.
• High-dose users: Anything over 40 mg of prednisone daily is a red zone. Even short courses of 60-80 mg can cause problems.
• People on long-term therapy: The longer you’re on steroids, the higher the chance your brain adapts in unhealthy ways.

And here’s the twist: you don’t need to be on steroids for weeks. Symptoms can hit as early as day two or three. Some patients develop psychosis within 72 hours of starting treatment.

Why Does This Happen?

No one fully understands why steroids mess with the brain - but we know enough to be alarmed.

One theory points to the hippocampus, the part of the brain that handles memory and emotion. Steroids reduce activity there, which can lead to confusion and memory loss. Another theory focuses on dopamine, the brain’s reward chemical. Animal studies show steroids spike dopamine levels - enough to trigger hallucinations and mania.

There’s also the HPA axis - your body’s stress-response system. Steroids suppress it, which sounds good (less inflammation) but throws your whole hormonal balance off. That imbalance can trigger anxiety, depression, and even panic attacks.

And here’s the scary part: symptoms don’t always vanish when you stop the drug. In some cases, psychosis or mania lasts for weeks - or even months - after the last pill. That means the damage isn’t always reversible right away.

What Should You Do If You Notice Changes?

If you or someone you care about is on steroids and starts acting strangely - don’t wait. Don’t assume it’s "just stress."

1. Call your doctor immediately. Mention the exact symptoms: "I’m hearing voices," or "I can’t sleep and I feel like I’m losing my mind."
2. Don’t stop steroids on your own. Stopping suddenly can cause adrenal crisis - a life-threatening drop in cortisol. But don’t keep taking them if you’re psychotic.
3. Ask about tapering. Reducing the dose to under 40 mg/day resolves symptoms in 92% of cases. Sometimes, just cutting the dose in half is enough.
4. Request a psychiatric consult. A psychiatrist can help distinguish steroid-induced psychosis from other conditions like schizophrenia or bipolar disorder.
5. Get blood tests. Rule out infections, liver or kidney problems, or electrolyte imbalances - they can mimic psychiatric symptoms.

There’s no FDA-approved drug for steroid-induced psychosis. But doctors use low-dose antipsychotics like olanzapine (5-10 mg/day) or risperidone (1-2 mg/day) to calm symptoms. These often work within days. Lithium is sometimes used for mania, but it’s risky - especially in older adults.

What Doctors Often Miss

Many physicians focus only on the physical reason for prescribing steroids - asthma, arthritis, colitis - and overlook the mental side effects. They assume patients will report symptoms. They assume they’ll recognize them.

They’re wrong.

Patients often feel ashamed. They think they’re "going crazy." Family members think it’s "just moodiness." Nurses might chalk it up to "hospital delirium." And by the time someone sees a psychiatrist, the person may already be in crisis - hospitalized, confused, or dangerous to themselves or others.

There’s no standard screening tool. No checklist. No routine question like, "Have you felt unusually elated or paranoid since starting your steroid?" That gap costs lives.

What You Can Do Now

If you’re prescribed steroids:

• Ask your doctor: "What are the mental side effects? What should I watch for?"
• Ask: "Is there a lower dose I can start with?"
• Ask: "Should I tell my pharmacist or family to call you if they notice changes?"
• Keep a daily mood log: Note sleep, energy, irritability, thoughts. Bring it to your next appointment.
• Don’t hide symptoms. Even if you think it’s "not that bad," it might be the first sign of something serious.

If you’re caring for someone on steroids:

• Watch for sudden changes in behavior - especially after a dose increase.
• Don’t dismiss agitation or confusion as "just being tired."
• If they’re talking about things that aren’t real, or seem terrified for no reason - get help now.

The Bigger Picture

Corticosteroids are miracle drugs. They save lives. But they’re not harmless. We’ve been using them for over 70 years, yet we still don’t have a reliable way to predict who will develop psychosis. We don’t have a standard screening protocol. We don’t have a drug approved specifically for this.

It’s a gap in medicine - and it’s dangerous.

Every time a patient is prescribed prednisone, they should be given a clear warning: "This can change your mind. Watch for it. Tell someone if it happens."

Until that changes, awareness is your best protection.