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Prophylaxis of Steroid-Induced Psychiatric Syndromes
Letters
of 19 depressed subjects selected from psychology classes who had a mean BDI score of 14.21 and who were not engaged in any exercise activity for a period of 10 weeks. At the end of the 100week period, we assessed changes in depressive symptoms and the subjects' reactions to their classes. Our results showed declines in mean BDI scores of approximately five points for subjects enrolled in aerobic dancing and four points for those enrolled in racquetball classes. The subjects who did not exercise had a decline in the mean BDI score of only one point The decline in depressive symptoms shown by subjects in the exercise classes was significantly greater than that shown by the subjects who did not exercise (F=56.78, df=I,47,p<.OOI). This result was consistent with reports that exercise is an effective treabnent for depression. Of particular interest was the finding that aerobic dancing was slightly, but significantly, more effective in reducing symptoms of depression than racquetball (F=6.36, d.f=I,46, p<.02). Because these two activities differ in several regards, including self-selection for the activities, it is difficult to offer a theoretical account for the results. Interestingly, when we assessed the subjects' reactions to the exercise programs, we did not find differences in terms of the psychosocial impact of the activities. We have hypothesized that aerobic dancing may be more beneficial because it is an aerobic activity, while racquetball is not. However, because we did not measure the aerobic effects directly, our hypothesis requires further study to determine if aerobic exercise is more effective than nonaerobic exercise in reducing symptoms of depression. George P. Pappas, Ph.D. Sanford Golin, Ph.D. Donald L. Meyer, Ph.D. Department of Psychology University of Pittsburgh Pittsburgh, Pennsylvania References I. McCann LI, Holmes OS: Influence of aerobic exercise on depression.] Pers Soc Psychol46:1 142-1 147, 1984 2. Folkins CH, Sirne WE: Physical fitness training and menVOLUME31'NUMBERI'~NTERl~
tal health. American Psychologist 36:37>-.389, 1981 3. Beck AT: Depression: Clinical, Experimental. and Theoretical Aspects. New York, Harper & Row, 1967
Note: A full report of this study may be obtainedfromDr. Golin,DepartmentofPsychology. University of Pittsburgh, Pinsburgh, PA 15260.
Prophylaxis ofSteroid-Induced Psychiatric Syndromes SIR: Psychiatric syndromes associated with steroids have been reported in an average of 5% and as many as 50% of patients undergoing steroid therapy. I Lithium therapy has been used to attempt to prevent psychosis associated with steroids. 2 We describe a patient in whom steroid-induced psychosis and a mood disorder may have been prevented through combined treabnent with haloperidol, lithium, and protriptyline.
Case Report A 34-year-old woman with a 15-year history of ulcerative colitis presented with edema in the lower extremities, a generalized maculopapular rash, and decreased urinary output. She had been discharged three days earlier following a successful S-pouch procedure and a proctectomy. An extensive workup, including a renal biopsy, revealed nonspecific, generalized vasculitis with renal artery involvement. Worsening renal function made her need for steroid therapy apparent. However, on two previous occasions within the last four years the patient had brief
psychotic states in response to steroid treatment, which were followed by a persistent melancholic depression. Her depression had required inpatient treatment, electroconvulsive therapy, and subsequent protriptyline maintenance therapy. She was treated prophylactically with lithium citrate to serum levels ranging from 0.6 mg/dl to 0.8 mg/dl and haloperidol. She was subsequently (within three days) treated with oral prednisone. During the seven days following this treatment, her renal indices gradually normalized, and steroid treatment was continued for six weeks after discharge. Halo113
Letters
peridol was discontinued prior to discharge. She continued to take lithium carbonate to maintain a serum level of 0.6 mg/dl and maintenance doses of protriptyline. No evidence of psychosis or depression was apparent at follow-up four and eight weeks after discharge. Lithium and protriptyline were discontinued gradually after termination of steroid therapy.
Discussion
, l
The incidence of psychiatric syndromes associated with steroid treatment has been reported to be 40% for depressive syndromes, 31 % for manic syndromes, II % for manic depressive syndromes, and 16% for acute psychotic reactions.I.3·4 Increased risk factors for steroid-induced psychiatric syndromes are being female. the presence of systemic lupus erythematosus, and the use of high prednisone-equivalent doses.' Goggans et aI. 2 reported that treatment with lithium possibly served a prophylactic role in preventing steroid-induced psychosis in a patient with severe chronic obstructive pulmonary disease who required high-dose steroid therapy. Moreover, a retrospective study by Falk5 suggested that lithium could prevent psychosis induced by adrenocorticotropic hormone (ACTH). Depending on the clinical picture, various measures have been used to treat steroid-induced psychiatric syndromes. Tricyclic antidepressants do not seem to be useful for the treatment of depression associated with steroid treatment6 ; however, we are not aware of any studies evaluating their use as prophylactic measures. In our patient, we used haloperidol and lithium to prevent acute psychosis, and lithium and protriptyline were continued for prophylaxis against a long-term depressive state. We chose protriptyline because the patient had previously responded to it during a relapse of depression. This case report demonstrates the need for an individualized approach to the treatment and management of steroid-induced psychiatric syndromes. A variety of therapeutic and prophylactic measures need to be considered. Farid Sabet-Sharghi. M.D. Jeffery C. Hutzler, M.D. The Cleveland Clinic Foundation Cleveland. Ohio 114
Referenc:es I. Cordess C. Folslein M. Drachman 0: Psychiatric effects of altemale-day steroid therapy. Br J Psychiatry 138:504506.1981 2. Goggans FC. Weisberg U. Koran LM: Lithium prophylaxis of prednisone psychosis: a case repon. J Clin Psychiatry 44: 111-112. 1983 3. Hall RC. Dopkin MC: Tricyclic exacerbation of steroid psychosis. J Nerv Ment Dis 166:738-742. 1978 4. Lewis DA. Smith RE: Steroid-induced psychiatric syndromes. J Affective Dis 5:319-332.1983 5. Falk WE: Steroid psychosis: diagnosis and treatment. in Mansheric TC (cd). Psychiatric Medicine Update. New York. Elsevier. 1981 6. Ling MH. Perry Pl. Tsuang MT: Side effects of conicosteroid therapy: psychiatry aspects. Arch Gen Psychiatry 38:471-477.1981
OfMurmurs and Mania SIR: As the students huddle around the patient on the medical ward, they listen with awe as a cardiologist describes a subtle murmur that none of them had heard. "A IVNI murmur can be diagnosed by any beginner," the cardiologist says, "but a INI murmur like this takes years of experience to pick up." Humbled by how much they still have to learn, the students leave, anxious to improve their clinical skills. No one doubts the existence of the murmur. Meanwhile, on the psychiatry ward, the students listen with skepticism as a psychiatrist demonstrates the subtle finding of psychosis that none of them observed. "Gross psychosis can be diagnosed by any beginner," the psychiatrist says, "but a subtle lack of reality testing like this takes years of experience to pick up." Angered by their certainty that the psychiatrist has just put a stigmatizing label on a patient they are sure is mentally normal, the students leave, wondering how a physician with so many years of training could dream up clinical findings they are sure do not exist. What accounts for the striking contrast between these two common scenarios in medical education? Could it be that physical findings are assumed to involve more subtlety than psychiatric fmdings? The medical students in these two PSYCHOSOMATICS
of 19 depressed subjects selected from psychology classes who had a mean BDI score of 14.21 and who were not engaged in any exercise activity for a period of 10 weeks. At the end of the 100week period, we assessed changes in depressive symptoms and the subjects' reactions to their classes. Our results showed declines in mean BDI scores of approximately five points for subjects enrolled in aerobic dancing and four points for those enrolled in racquetball classes. The subjects who did not exercise had a decline in the mean BDI score of only one point The decline in depressive symptoms shown by subjects in the exercise classes was significantly greater than that shown by the subjects who did not exercise (F=56.78, df=I,47,p<.OOI). This result was consistent with reports that exercise is an effective treabnent for depression. Of particular interest was the finding that aerobic dancing was slightly, but significantly, more effective in reducing symptoms of depression than racquetball (F=6.36, d.f=I,46, p<.02). Because these two activities differ in several regards, including self-selection for the activities, it is difficult to offer a theoretical account for the results. Interestingly, when we assessed the subjects' reactions to the exercise programs, we did not find differences in terms of the psychosocial impact of the activities. We have hypothesized that aerobic dancing may be more beneficial because it is an aerobic activity, while racquetball is not. However, because we did not measure the aerobic effects directly, our hypothesis requires further study to determine if aerobic exercise is more effective than nonaerobic exercise in reducing symptoms of depression. George P. Pappas, Ph.D. Sanford Golin, Ph.D. Donald L. Meyer, Ph.D. Department of Psychology University of Pittsburgh Pittsburgh, Pennsylvania References I. McCann LI, Holmes OS: Influence of aerobic exercise on depression.] Pers Soc Psychol46:1 142-1 147, 1984 2. Folkins CH, Sirne WE: Physical fitness training and menVOLUME31'NUMBERI'~NTERl~
tal health. American Psychologist 36:37>-.389, 1981 3. Beck AT: Depression: Clinical, Experimental. and Theoretical Aspects. New York, Harper & Row, 1967
Note: A full report of this study may be obtainedfromDr. Golin,DepartmentofPsychology. University of Pittsburgh, Pinsburgh, PA 15260.
Prophylaxis ofSteroid-Induced Psychiatric Syndromes SIR: Psychiatric syndromes associated with steroids have been reported in an average of 5% and as many as 50% of patients undergoing steroid therapy. I Lithium therapy has been used to attempt to prevent psychosis associated with steroids. 2 We describe a patient in whom steroid-induced psychosis and a mood disorder may have been prevented through combined treabnent with haloperidol, lithium, and protriptyline.
Case Report A 34-year-old woman with a 15-year history of ulcerative colitis presented with edema in the lower extremities, a generalized maculopapular rash, and decreased urinary output. She had been discharged three days earlier following a successful S-pouch procedure and a proctectomy. An extensive workup, including a renal biopsy, revealed nonspecific, generalized vasculitis with renal artery involvement. Worsening renal function made her need for steroid therapy apparent. However, on two previous occasions within the last four years the patient had brief
psychotic states in response to steroid treatment, which were followed by a persistent melancholic depression. Her depression had required inpatient treatment, electroconvulsive therapy, and subsequent protriptyline maintenance therapy. She was treated prophylactically with lithium citrate to serum levels ranging from 0.6 mg/dl to 0.8 mg/dl and haloperidol. She was subsequently (within three days) treated with oral prednisone. During the seven days following this treatment, her renal indices gradually normalized, and steroid treatment was continued for six weeks after discharge. Halo113
Letters
peridol was discontinued prior to discharge. She continued to take lithium carbonate to maintain a serum level of 0.6 mg/dl and maintenance doses of protriptyline. No evidence of psychosis or depression was apparent at follow-up four and eight weeks after discharge. Lithium and protriptyline were discontinued gradually after termination of steroid therapy.
Discussion
, l
The incidence of psychiatric syndromes associated with steroid treatment has been reported to be 40% for depressive syndromes, 31 % for manic syndromes, II % for manic depressive syndromes, and 16% for acute psychotic reactions.I.3·4 Increased risk factors for steroid-induced psychiatric syndromes are being female. the presence of systemic lupus erythematosus, and the use of high prednisone-equivalent doses.' Goggans et aI. 2 reported that treatment with lithium possibly served a prophylactic role in preventing steroid-induced psychosis in a patient with severe chronic obstructive pulmonary disease who required high-dose steroid therapy. Moreover, a retrospective study by Falk5 suggested that lithium could prevent psychosis induced by adrenocorticotropic hormone (ACTH). Depending on the clinical picture, various measures have been used to treat steroid-induced psychiatric syndromes. Tricyclic antidepressants do not seem to be useful for the treatment of depression associated with steroid treatment6 ; however, we are not aware of any studies evaluating their use as prophylactic measures. In our patient, we used haloperidol and lithium to prevent acute psychosis, and lithium and protriptyline were continued for prophylaxis against a long-term depressive state. We chose protriptyline because the patient had previously responded to it during a relapse of depression. This case report demonstrates the need for an individualized approach to the treatment and management of steroid-induced psychiatric syndromes. A variety of therapeutic and prophylactic measures need to be considered. Farid Sabet-Sharghi. M.D. Jeffery C. Hutzler, M.D. The Cleveland Clinic Foundation Cleveland. Ohio 114
Referenc:es I. Cordess C. Folslein M. Drachman 0: Psychiatric effects of altemale-day steroid therapy. Br J Psychiatry 138:504506.1981 2. Goggans FC. Weisberg U. Koran LM: Lithium prophylaxis of prednisone psychosis: a case repon. J Clin Psychiatry 44: 111-112. 1983 3. Hall RC. Dopkin MC: Tricyclic exacerbation of steroid psychosis. J Nerv Ment Dis 166:738-742. 1978 4. Lewis DA. Smith RE: Steroid-induced psychiatric syndromes. J Affective Dis 5:319-332.1983 5. Falk WE: Steroid psychosis: diagnosis and treatment. in Mansheric TC (cd). Psychiatric Medicine Update. New York. Elsevier. 1981 6. Ling MH. Perry Pl. Tsuang MT: Side effects of conicosteroid therapy: psychiatry aspects. Arch Gen Psychiatry 38:471-477.1981
OfMurmurs and Mania SIR: As the students huddle around the patient on the medical ward, they listen with awe as a cardiologist describes a subtle murmur that none of them had heard. "A IVNI murmur can be diagnosed by any beginner," the cardiologist says, "but a INI murmur like this takes years of experience to pick up." Humbled by how much they still have to learn, the students leave, anxious to improve their clinical skills. No one doubts the existence of the murmur. Meanwhile, on the psychiatry ward, the students listen with skepticism as a psychiatrist demonstrates the subtle finding of psychosis that none of them observed. "Gross psychosis can be diagnosed by any beginner," the psychiatrist says, "but a subtle lack of reality testing like this takes years of experience to pick up." Angered by their certainty that the psychiatrist has just put a stigmatizing label on a patient they are sure is mentally normal, the students leave, wondering how a physician with so many years of training could dream up clinical findings they are sure do not exist. What accounts for the striking contrast between these two common scenarios in medical education? Could it be that physical findings are assumed to involve more subtlety than psychiatric fmdings? The medical students in these two PSYCHOSOMATICS