Dear Editor, The manifold uses of steroids in medical therapy are well-established. It is routinely prescribed for inflammatory, allergic, autoimmune, and neoplastic disorders. Psychiatric symptoms induced by steroid therapy are common and include depression, anxiety, mania, psychosis, and dementia. Manic and hypomanic symptoms are the most common.1 Psychiatric symptoms may appear at any point during steroid therapy, from soon after starting therapy, during therapy, and even after the stoppage of therapy. Dosage of steroids is directly linked to the occurrence of Psychiatric symptoms, and the symptoms usually resolve with dosage reduction or cessation of corticosteroids. In severe cases or situations in that the dose cannot be reduced, mood stabilizers or antipsychotics are required.2 We present a case of steroid-induced mania treated with Quetiapine. A 46-year-old female patient was brought to the psychiatry OPD by her husband with complaints of reduced sleep, aggressive behavior, and excessive talkativeness for the last 10 days. She used to speak continuously without getting tired, used to get angry over trivial issues, and she scolded her family members with filthy words. She felt a decreased need for sleep. While doing household chores, before completing one task, she used to move to the next task. Fifteen days before this presentation, she had reported to the dermatology department with skin lesions on the face, scalp, and back for 5 months; after detailed investigations, including histopathological examination, she was diagnosed with pemphigus foliaceous and was started on oral prednisolone 20 mg/day. She started developing psychiatric symptoms within 1 week of taking prednisolone. For her psychiatric symptoms, she was put on olanzapine 7.5 mg by a psychiatrist before being brought to us. However, it was stopped since the patient developed tremors and rigidity. There was no past or family history of any psychiatric illness. Premorbid personality was well adjusted. The physical examination was unremarkable. On mental status examination, she had increased psychomotor activity. Speech rate and volume were increased. She was irritable. No delusions or hallucinations were elicited. She was oriented to time, place, and person. She was unable to pay attention and sustain concentration. Her insight was poor, and her personal and social judgment was impaired. The Young Mania Rating Scale (YMRS) score was 31. Investigations such as complete blood count, liver function tests, renal function tests, serum electrolytes, and thyroid function tests were within normal limits. Considering history, clinical presentation, and investigations, a diagnosis of steroid-induced mania was made. A dermatologist’s opinion was sought, and prednisolone was tapered off. The patient was started on Quetiapine 50 mg/day, which was up-titrated to 300 mg/day over several days. She was also started on lorazepam 4 mg/day, which was down-titrated to 2 mg/day. Over the next 1 week, her YMRS score reduced to seven, and a 60% improvement was reported. She was lost to follow-up after that. Although the pathophysiology of steroid-induced mania remains unclear, it is believed to be like that of Cushing’s illness and other hypothalamic-pituitary-adrenal (HPA) axis disorders. Glucocorticoid receptors are preferentially activated over mineralocorticoid receptors by exogenous steroids. Furthermore, exogenous steroids inhibit the adrenal glands’ natural production of cortisol and give the HPA axis negative feedback. As a result, glucocorticoid receptor stimulation is higher than mineralocorticoid receptor stimulation because less cortisol is available to activate mineralocorticoid receptors. This imbalance results in cognitive impairment and emotional disturbances.3 Dosages of 40 mg/d were reported to be related to psychiatric symptoms. Corticosteroid-induced psychiatric side effects are more common if the patient has the psychiatric disorder, drug use or abuse, female sex, and a family history of psychiatric disorder.4 The treatment of corticosteroid-induced hypomania, mania, and mixed mania with carbamazepine, lithium, valproate, haloperidol, risperidone, and olanzapine is well-established.5-9 However, the literature is limited concerning treating corticosteroid-induced mania with Quetiapine.4 Quetiapine is generally well tolerated and has a low incidence of extrapyramidal side effects (EPS).4 This patient was given Quetiapine due to its antimanic, mood-stabilizing properties, and sedative properties, with good results. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Authors’ contributions All authors contributed in conceptualizing, writing, and editing the paper. Data availability statement Data will be made available on reasonable request. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Garg et al. (Wed,) studied this question.