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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 55-57

Methylprednisolone abuse: Report of two cases and review of literature


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_13_17

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  Abstract 


Steroids are known to have mood-elevating effects and are commonly used by quacks for various medical ailments. In this report, we present two cases, who were started on corticosteroids for somatic symptoms, who continued to abuse the steroids and became dependent on the same because of the mood-elevating effect and feeling of general well-being with these medications.

Keywords: Abuse, dependency, steroids


How to cite this article:
Mehra A, Grover S. Methylprednisolone abuse: Report of two cases and review of literature. J Geriatr Ment Health 2018;5:55-7

How to cite this URL:
Mehra A, Grover S. Methylprednisolone abuse: Report of two cases and review of literature. J Geriatr Ment Health [serial online] 2018 [cited 2018 Dec 18];5:55-7. Available from: http://www.jgmh.org/text.asp?2018/5/1/55/235360




  Introduction Top


Illicit anabolic-androgenic steroid use represents a growing worldwide public health problem.[1],[2] Clinical experience suggests that many individuals treated with corticosteroids become psychologically dependent on the same due to the euphoric side effects of these agents. The psychological dependency frequently interferes with the physician's efforts to withdraw the drug when the primary disease is under control and there is no need to continue these medications.[3]

However, overall, the phenomenon of corticosteroids abuse/dependency has less frequently described in the literature. In this report, we describe two cases who presented with psychological dependence on corticosteroids.


  Case Reports Top


Case report 1

A 68-year-old male presented with a problem of inability to discontinue the use of steroids. He had been using methylprednisolone for 25 years. He was initially prescribed oral methylprednisolone for a medical ailment. His medical problem resolved after 2–3 weeks, but he continued taking methylprednisolone as he liked the euphoric effect of the same. In addition, use of methylprednisolone was associated with increased appetite and general well-being. He would buy the same over the counter. Initially, he started taking methylprednisolone 1 mg/day orally, but gradually over the period of 10 years, he increased the quantity to 2 mg/day as the lower dose would not provide the desired euphoria, increased appetite, and general well-being. Over the years, he had made multiple failed attempts to discontinue methylprednisolone. Whenever he would discontinue the same for 2–14 days, he would experience generalized weakness, backache, muscular aches, lethargy, a sense of being ill, and irritability. These symptoms would subside with initiation of methylprednisolone. Over the years, he was advised by many physicians to stop using steroids and was explained negative consequences of use of steroids. Despite all these, he was not successful in controlling his use. Over the last 2 years, he started to remain distressed due to his inability to discontinue methylprednisolone. He was not able to achieve the desired level of effect even with 2 mg/day of methylprednisolone and this led to index consultation. A diagnosis of “mental and behavioral disorders due to multiple drug use and use of other psychoactive substances,” harmful use versus dependence syndrome was considered as per the International Classification of Diseases-10 was considered. He was managed with painkiller, calcium and multivitamins, and dose of methylprednisolone tapered off gradually over a period of 2 weeks. In addition, he was taken up for cognitive behavior therapy. He maintained steroid-free for 3 months and continued on psychological intervention.

Case report 2

A 65-year-old woman presented with continued use of methylprednisolone for the last 15 years. Exploration of history revealed that since the last 20s, she would have frequent somatic symptoms in the form of aches and pains, was investigated for the same multiple times, but would not be found to have any underlying organic pathology. These symptoms were associated with marked dysfunction in the functioning. For the first time, she was prescribed methylprednisolone by a registered medical practitioner for her somatic complaints. She liked the euphoric effect of the medication, felt relaxed, and found herself to be sleeping adequately while taking oral methylprednisolone. Over the years, initially, she would take methylprednisolone regularly for 2–3 weeks and then stop the same. Stoppage would be associated with a feeling of being sick, lethargic, and dull. Hence, she would resume the use of methylprednisolone. Since the last 10 years, she started taking it almost daily and she increased the amount of intake from 1 to 2 mg/day orally. She made multiple attempts to discontinue the same but failed. She attempted to reduce the dose on her own and was able to cut down the dose to 1 mg/day. Since the last 1 year, she had been taking 1 mg/day orally. Any attempt to reduce the dose below, this was associated with subjective anxiety, palpitation, difficulty in breathing, lethargy, difficulty in falling sleep, and intense physical discomfort. She was not able to control over the use of substance. A diagnosis of “mental and behavioral disorders due to multiple drug use and use of other psychoactive substances,” harmful use versus dependence syndrome was considered. In addition, a possibility of somatoform disorder (unspecified) was also considered as a diagnostic possibility. She was managed with gradual taper of methylprednisolone, along with use of tablet pregabalin 75 mg b.d, multivitamins, and calcium supplement. She was also started on cognitive behavior therapy. Over the period of 4 weeks, she was free from all medication and maintained well for the next 2 months. Later, she was lost to follow-up.

In both the cases, there was no history of any other substance use and features suggestive of any axis-I psychiatric disorder.


  Discussion Top


Corticosteroids are well known for their mood-elevating effect and existing literature suggests that people receiving steroids can experience adverse psychiatric side effects in the form of depression, mania, psychosis, delirium, and cognitive deficits.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] These effects can occur at any point of steroid therapy and occasional patients report these symptoms during the withdrawal phase. In terms of doses, higher doses of steroids have been shown to be associated with psychological side effects.[3],[15] Previous reports also suggest that patients who have psychological dependence on corticosteroids often experience irritability and depressed mood on withdrawal of steroids.[3] Both of our patients also exhibited the similar phenomenon. It is quite possible that the withdrawal of steroid in both of our patients often led to the psychological side effect in the form of depressive, anxiety, and somatic symptoms which possibly led to self-medication with steroids for long term. In addition, the female patient possibly had features suggestive of somatoform disorder, and use of steroids led to reduction in her somatic symptoms; hence, this led to continuation of steroids over long period. Both our patients also exhibited somatic symptoms in the form of lethargy and weakness on stopping steroids. These possibly suggest that these patients also had physical dependence on corticosteroids. Similar physical dependence has been reported with other steroids, especially anabolic steroids.[2]

Both our cases exemplify that medically ill patients who are prescribed steroid can abuse the same and at times become psychologically and physically dependent on the same. Hence, physicians who prescribe steroids to patients for various ailments should prescribe them judiciously, should explain the patients about the psychological adverse effects, and should stop these medications at the earliest. For psychiatrists, it is important to recognize that whenever a patient with medical illness presents with nonspecific depressive, anxiety, and somatic symptoms, they should carefully review the treatment history of steroid intake and before prescribing any psychotropics must rule out psychological adverse effects and possible dependence on steroids.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pope HG, Brower KJ. Anabolic-androgenic steroid-related disorders. In: Sadock B, Sadock V, editors. Comprehensive Textbook of Psychiatry. 9th ed., Philadelphia, PA: Lippincott Williams & Wilkins; 2009. p. 1419-31.  Back to cited text no. 1
    
2.
Kanayama G, Hudson JI, Pope HG Jr. Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: A looming public health concern? Drug Alcohol Depend 2008;98:1-12.  Back to cited text no. 2
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3.
Kimball CP. Psychological dependency on steroids? Ann Intern Med 1971;75:111-3.  Back to cited text no. 3
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4.
Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis 1959;9:260-77.  Back to cited text no. 4
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5.
Sawyer CH. Some endocrine aspects of forebrain inhibition. Brain Res 1967;6:48-59.  Back to cited text no. 5
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6.
Estrada de la Riva G. Psychic and somatic changes observed in allergic children after prolonged steroid therapy. South Med J 1958;51:865-8.  Back to cited text no. 6
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7.
Suess WM, Stump N, Chai H, Kalisker A. Mnemonic effects of asthma medication in children. J Asthma 1986;23:291-6.  Back to cited text no. 7
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8.
Medicines Health, Regulatory Authority (MHRA), Committee on Safety of Medicines (CSM). Drug Analysis Print. Prednisolone/Dexamethasone, CDROM. Ver. 4.1. London: 2008; p. 1-24.   Back to cited text no. 8
    
9.
Fricchione G, Ayyala M, Holmes VF. Steroid withdrawal psychiatric syndromes. Ann Clin Psychiatry 1989;1:99-108.  Back to cited text no. 9
    
10.
Bender BG, Lerner JA, Poland JE. Association between corticosteroids and psychologic change in hospitalized asthmatic children. Ann Allergy 1991;66:414-9.  Back to cited text no. 10
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11.
Drigan R, Spirito A, Gelber RD. Behavioral effects of corticosteroids in children with acute lymphoblastic leukemia. Med Pediatr Oncol 1992;20:13-21.  Back to cited text no. 11
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12.
Soliday E, Grey S, Lande MB. Behavioural effects of corticosteroids in steroid sensitive nephritic syndrome. Pediatrics 1999;104:e51.  Back to cited text no. 12
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13.
Klein-Gitelman MS, Pachman LM. Intravenous corticosteroids: Adverse reactions are more variable than expected in children. J Rheumatol 1998;25:1995-2003.  Back to cited text no. 13
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14.
Harris JC, Carel CA, Rosenberg LA, Joshi P, Leventhal BG. Intermittent high dose corticosteroid treatment in children with cancer: Behavioral and emotional consequences. J Am Acad Child Adolesc Psychiatry 1986;25:120-4.  Back to cited text no. 14
    
15.
Stuart FA, Segal TY, Keady S. Adverse psychological effects of corticosteroids in children and adolescents. Arch Dis Child 2005;90:500-6.  Back to cited text no. 15
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