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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 157-160

A case report: Steroid-induced mania in the context of COVID-19: The compounding impact of treatment on mental health


1 Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, West Virginia, USA
2 Department of Radiation Oncology, West Virginia University School of Medicine, Morgantown, West Virginia, USA

Date of Submission07-Mar-2021
Date of Acceptance28-Apr-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Wanhong Zheng
Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, West Virginia
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_17_21

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  Abstract 

The coronavirus disease 19 (COVID-19) pandemic has negatively affected people's day-to-day lives, especially those with mental illness. We present a case of a manic episode with psychotic features induced by dexamethasone administered as part of COVID-19 treatment. The patient had underlying depression, anxiety, and posttraumatic stress disorder, but was stable before contracting COVID-19. The implications of quarantine and social stress on mood stability are also discussed. We call for better patient education on the risks of steroid-induced mania and psychosis as well as increased attention to mental illness screening and treatment during this unprecedented pandemic time.

Keywords: Coronavirus disease 19, dexamethasone, mania, psychosis


How to cite this article:
Perez JM, Murdock S, Singh S, Zheng W. A case report: Steroid-induced mania in the context of COVID-19: The compounding impact of treatment on mental health. Heart Mind 2021;5:157-60

How to cite this URL:
Perez JM, Murdock S, Singh S, Zheng W. A case report: Steroid-induced mania in the context of COVID-19: The compounding impact of treatment on mental health. Heart Mind [serial online] 2021 [cited 2022 Jun 25];5:157-60. Available from: http://www.heartmindjournal.org/text.asp?2021/5/4/157/331561




  Introduction Top


In December 2019, the first case of coronavirus disease 19 (COVID-19) was diagnosed in Wuhan China.[1] In the intervening months, the deadly virus has swept the globe and led to unprecedented changes in the daily lives of populations across the globe. In addition to the infectious disease component of the virus, fear of the virus and the need for social isolation have created a mental toll and led to increased psychological and emotional distress in patients and healthcare providers.[2] This has been supported by preliminary studies demonstrating increases in depression, anxiety, substance abuse, and loneliness, along with a rise in domestic violence and child abuse over the past year.[3] There is also a projected rise in suicidal behaviors attributed largely to the virus's economic impacts.[4]

An underappreciated effect of COVID-19 is the adverse consequence that stems from treating the infection itself. Glucocorticoids are an integral component of standard-of-care treatment for moderate-to-severe cases of COVID-19 infection and their use leads to reduced mortality in patients requiring respiratory support.[5] Unfortunately, neuropsychiatric symptoms are important known adverse effects of steroid treatment. The often reported symptoms include emotional lability, hypomania, mania, depression, psychosis, delirium, confusion, or disorientation.[6],[7] Steroid-induced psychosis is more common in women and is surprisingly not associated with a history of underlying psychiatric conditions. The risk is dose-dependent, usually occurring in patients taking >20 mg/day of prednisone (equivalent to 3 mg dexamethasone), with an incidence of 5% for those treated with doses ≥40 mg (equivalent to 6 mg dexamethasone). The risk is further increased with longer courses of therapy. Psychiatric symptoms usually begin in the first 5 days following initiation of therapy but may start at any time during the course of treatment.[8] Typical presenting symptoms do not vary from that of primary psychiatric illnesses and include emotional lability, distractibility, pressured speech, and auditory or visual hallucinations. These symptoms typically resolve within 1–2 weeks following steroid dose reduction or cessation. However, approximately 10% of patients have persistent symptoms requiring additional treatment with antipsychotics. Several reports describe successful treatment of persistent steroid-induced psychosis with various antipsychotics and mood stabilizers, including haloperidol, lithium, quetiapine, olanzapine, and clonazepam. The use of antipsychotics typically results in complete resolution of symptoms within 2 weeks,[9],[10] although the resolution of mania may take up to 6 weeks.[11] Here, we report a case of prolonged steroid-induced psychosis developing after glucocorticoid treatment for moderately severe COVID-19 pneumonia.


  Case Report Top


A 39-year-old male with a history of depression, anxiety, posttraumatic stress disorder but no prior history of psychosis presented to an outpatient family medicine clinic with progressive shortness of breath and coughing fits for 7 days. He has a medical history of childhood asthma, obstructive sleep apnea, and is a current smoker. COVID-19 infection was suspected then confirmed using Abbott RealTime severe acute respiratory syndrome coronavirus 2 real-time reverse transcription-polymerase chain reaction test. Chest X-ray at that time showed peripheral opacification consistent with the diagnosis of COVID-19-related pneumonia. He was sent home with a prescription for Augmentin and was asked to self-quarantine. At that time, he had no oxygen requirement.

Three days later, the patient presented to the emergency department (ED) for worsening shortness of breath, cough, fever, and chills. Review of systems was positive for sweating, diarrhea, anosmia, and loss of taste. Chest X-ray demonstrated bilateral diffuse pulmonary infiltrate consistent with worsening COVID-19 associated pneumonia. The patient was admitted for respiratory compromise. He was started on 3 L oxygen through nasal cannula plus dexamethasone 6 mg IV daily. The next day, his oxygen saturations decreased to 92% prompting increased oxygen supplementation to 5 L setting. The duration of his symptoms placed him 1 day out of the 10-day window for remdesivir, but he was able to receive convalescent plasma on day 2 and day 5. The patient was hospitalized for a total of 9 days during which time he received dexamethasone 6 mg IV daily. He was discharged home on dexamethasone 6 mg oral daily for 2 days, albuterol 2 puffs every 4 hours as needed, guaifenesin 200 mg every 4 hours as needed, duloxetine 30 mg, and gabapentin 600 mg daily.

Two days after discharge, he followed up with his primary care physician. His follow-up visit was noted to be normal with no mention of mania or psychosis. He did express concern for insomnia but this was attributed to his steroid taper.

Two days later, the patient presented to ED with insomnia, grandiose thoughts, and religious delusions. The urine drug screen was negative. Complete blood count and basic metabolic panel were within normal limits. He was treated in the ED for acute mania with lorazepam and olanzapine. Psychiatry was consulted. After psych evaluation, it was recommended that the patient be discharged home to the care of his family on a short course of olanzapine 5 mg daily for presumed steroid-induced mania. He was discharged and scheduled for outpatient follow-up with psychiatry. Unfortunately, the patient had trouble obtaining the prescription and never started his discharge medications.

The very next day, he was brought to the ED by authorities due to manic and bizarre behaviors at a local retail store. He was noted to have elevated mood, pressured speech, and increased irritability. Again, his urine drug screen was negative. His mania featured a belief that he was deciphering codes all around him as part of a mission from God to save veterans. In the day prior to this presentation, he had sent “hundreds of” text messages and E-mails to various contacts about unrealistic business ventures to achieve his mission. This time, he was provided psychiatric hospitalization for acute mania and psychosis. He was started on olanzapine 10 mg daily and valproate. His home Cymbalta was discontinued to avoid serotonergic contribution to mania; gabapentin was also discontinued in lieu of new medications and possible interactions such as oversedation.

After 6 days of hospitalization, he was discharged home with olanzapine 10 mg and valproate 1000 mg. One week later, the patient presented again to the ED with complaints of only sleeping 2–3 h each night but was noted to be much more calm and cooperative than prior presentations. He spent one night in the psychiatric hospital before being discharged home with only a slight increase in his olanzapine to 5 mg qam and 10 mg qpm.

At 1-month follow-up, the patient reported improved sleep, getting at least 5 h each night, improved mood, and no evidence of manic behavior. At 2-month follow-up, the patient requested de-escalation of his medications due to over-sedation and lack of manic symptoms. His olanzapine and valproate were gradually tapered with close monitoring and the patient had no further psychotic episodes. At 3-month follow-up, the patient reported complete resolution of symptoms, paranoia, hallucinations, insomnia, or manic symptoms.

Differential diagnosis

The major psychiatric symptoms of this patient are mania and psychosis. The most relevant differential diagnoses included substance-induced psychosis, bipolar I manic episode with psychosis and schizoaffective disorder bipolar type. Substance-induced psychosis was supported by recent high-dose steroid therapy. His home dosage of gabapentin and Cymbalta had been long-standing and were deemed low risk of triggering mania with no underlying history of bipolar disorder. History and negative urine drug screen helped rule out illicit substance-induced mania. Although bipolar mania could not be ruled out, the patient had no prior history of manic episodes and a late first episode at the age of 39 years would be considered atypical. Finally, as this is the first time this patient experienced psychotic symptoms with concurrent mood changes, there was no evidence of a period of at least 2 weeks of psychosis without a mood component to make a schizoaffective disorder diagnosis.


  Discussion Top


There are a variety of ways the pandemic has likely affected mental health. In this report, we presented a case of psychotic mania that was triggered by COVID-19 treatment medicine dexamethasone. Even though other factors such as quarantine for treatment, loneliness, and fear of death could have contributed to this patient's psychiatric presentation, the characteristic and onset of symptoms correlated well with his iatrogenic high dose of steroid use. Even if manic episodes are most commonly associated with bipolar I disorder, mania is a well-documented but unpredictable adverse effect of corticosteroid treatment. While most of the mental health attention is focused on skills to help cope with stress during COVID-19, we reported a serious psychiatric condition that is associated with COVID-19 treatment, in hopes of increasing awareness and screening of mental health problems during general hospital treatment time.

Mania is a common symptom of bipolar disorder. Epidemiological studies suggest that there is a 1% lifetime prevalence of bipolar I in the general population, with a higher incidence among first-degree relatives. The annual incidence of first-episode bipolar mania is around 5/100,000 of the population with the peak age of incidence between 21 and 25 years.[12] In contrast, epidemiological studies for substance or medication-induced mania or bipolar disorder are limited. A review of 29 studies examining the clinical efficacy of corticosteroids reported that treatment-induced psychiatric side effects and disturbances occur at a mean incidence of 5.7%.[13] Another source reveals an incidence ranging from 5% to 18%, with the primary risk factor being higher doses of steroids.[14]

In order for a diagnosis of substance-induced mania to be made, certain criteria must be met. Besides a disturbance in mood that is prominent, persistent, and characterized by elevated or irritable mood, with or without depressed mood, there must be evidence that the symptoms emerged during or soon after the substance use, withdrawal, or treatment with medication. The substance or medication must also be capable of producing the symptoms. The exclusion criteria are that the psychiatric disturbance should not be better explained by bipolar or a disorder related to bipolar; and the psychiatric disturbance does not occur only within the course of a delirious episode. Finally, the disturbance must be severe enough to cause profound stress or disablement in occupation, social, or other functioning in daily living.[15] The patient in this case report clearly met the diagnostic criteria.

This case exemplified that the adverse effects of corticosteroids as a component of COVID-19 treatment may compound the problem of deteriorating mental health in the setting of pandemic-associated stressors and potential psychiatric sequelae of the virus itself. Recent case reports have even described acute-onset psychosis and mania as rare presenting features of COVID-19 infection.[16] Additionally, with the emergence of COVID-19 our society was introduced to many novel mental health stressors. The rapid spread and morbidity of viral infection have forced us into self-isolation where we are left alone to reflect with trepidation on the resultant loneliness, financial insecurities, and longing for normalcy. A study conducted by McGinty et al. found that symptoms of psychological distress in US adults had increased during the COVID-19 pandemic compared to 2 years earlier.[17] These findings indicate that stressors associated with the pandemic alone may contribute to the onset of psychiatric syndromes and disturbances.

It is anticipated that there are and will be significant upticks in depression, anxiety, and isolation leading to loneliness, substance abuse, and other psychiatric disturbances secondary to the COVID-19 pandemic.[18] As the COVID-19 pandemic reaches its peak, so does the psychological distress that it accompanies, emphasizing the need for effective mental illness screening, treatment, and monitoring, as well as posttreatment surveillance for neuropsychiatric effects of treatments received, namely, steroid use.


  Conclusion Top


Neuropsychiatric effects of COVID-19 treatment may be long-lasting, with a large impact on patients and their families. They also likely represent an underreported phenomenon since they can occur many days after treatment is initiated. They may come at a great cost including interpersonal strain, employment jeopardization, and even prolonged psychiatric hospitalization. Current NIH guidelines discuss neuropsychiatric effects of COVID-19 but make no mention of how the treatment itself may contribute to these effects.[19] This case report highlights the importance of mental health evaluation during and after COVID-19 treatment. It is particularly important to warn patients of the possible neuropsychiatric effects associated with these medications so that they may monitor for signs and symptoms and seek appropriate care should they occur. Psychoeducation is also critical so that patients and families can anticipate behavioral changes that are known to occur after receiving steroid therapy.

Declaration of ethical approval and patient consent

We've obtained a Flexibility Review Model case from West Virginia University IRB office, which has been approved on 10/20/2021. The WVU Protocol #: 2110443557.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
2.
Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry 2007;52:233-40.  Back to cited text no. 2
    
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Mental Health UK. Managing your Mental Health during the Coronavirus Outbreak. Available from: https://mentalhealth-uk.org/help-and-information/covid-19-and-your-mental-health/. [Last accessed on 2021 Jan 30].  Back to cited text no. 3
    
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Devitt P. Can we expect an increased suicide rate due to Covid-19? Ir J Psychol Med 2020;37:264-8.  Back to cited text no. 4
    
5.
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med 2021;384:693-704.  Back to cited text no. 5
    
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Brown ES, Chandler PA. Mood and cognitive changes during systemic corticosteroid therapy. Prim Care Companion J Clin Psychiatry 2001;3:17-21.  Back to cited text no. 6
    
7.
Fardet L, Petersen I, Nazareth I. Suicidal behavior and severe neuropsychiatric disorders following glucocorticoid therapy in primary care. Am J Psychiatry 2012;169:491-7.  Back to cited text no. 7
    
8.
Wolkowitz OM, Rubinow D, Doran AR, Breier A, Berrettini WH, Kling MA, et al. Prednisone effects on neurochemistry and behavior. Preliminary findings. Arch Gen Psychiatry 1990;47:963-8.  Back to cited text no. 8
    
9.
Da Silva JA, Jacobs JW, Kirwan JR, Boers M, Saag KG, Inês LB, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: Published evidence and prospective trial data. Ann Rheum Dis 2006;65:285-93.  Back to cited text no. 9
    
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Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric complications of glucocorticoid use: Steroid psychosis revisited. Psychosomatics 2012;53:103-15.  Back to cited text no. 10
    
11.
Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc 2006;81:1361-7.  Back to cited text no. 11
    
12.
Rowland TA, Marwaha S. Epidemiology and risk factors for bipolar disorder. Ther Adv Psychopharmacol 2018;8:251-69.  Back to cited text no. 12
    
13.
Lewis DA, Smith RE. Steroid-induced psychiatric syndromes. A report of 14 cases and a review of the literature. J Affect Disord 1983;5:319-32.  Back to cited text no. 13
    
14.
Zagaria MA. Systemic corticosteroid-associated psychiatric adverse effects. US Pharm 2016;41:16-8.  Back to cited text no. 14
    
15.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.  Back to cited text no. 15
    
16.
Noone R, Cabassa JA, Gardner L, Schwartz B, Alpert JE, Gabbay V. Letter to the Editor: New onset psychosis and mania following COVID-19 infection. J Psychiatr Res 2020;130:177-9.  Back to cited text no. 16
    
17.
McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US Adults in 2018 and April 2020. JAMA 2020;324:93-4.  Back to cited text no. 17
    
18.
Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Intern Med 2020;180:817-8.  Back to cited text no. 18
    
19.
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available from: https://www.covid19treatmentguidelines.nih.gov/. [Last accessed on 2021 Jan 30].  Back to cited text no. 19
    




 

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