Steroid-induced psychosis

Abstract

CASE A retired teacher, aged 74 years, with a history of treated hypothyroidism and no psychiatric history, presented to our service after urgent referral from her rheumatologist. She had been diagnosed with giant cell arteritis one month before our involvement and had been taking prednisolone 50 mg daily since diagnosis. On initial review in a community clinic, she presented with irritable affect, insomnia, persecutory delusions and delusions of reference, auditory hallucinations and impaired insight. An initial diagnosis of steroid-induced psychosis was made and olanzapine 2.5 mg daily was commenced. Inadequate adherence to the antipsychotic regimen and deteriorating mental state resulted in hospital admission and an increase in olanzapine to 5 mg daily. Tocilizumab was prescribed weekly as the prednisolone dose reduction was expedited. Over the subsequent week, the patient refused all medications and the Mental Health Act1 was used to compel treatment given the risk of serious psychiatric deterioration and permanent visual loss. After recommencing treatment, the patient made a full recovery from her psychotic symptoms and suffered no permanent sequelae from giant cell arteritis. Following discharge from hospital, olanzapine was continued for two weeks before tapering and cessation, with sustained remission from psychotic symptoms 12 months later.