Typicals vs atypicals
“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.
Corey Yilmaz, MD
Adult and child psychiatrist
The authors respond
Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al1 and a case report by Ahmad and Rasul2 report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al3 describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.
Andrew J. Muzyk, PharmD
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital
Shannon Holt, PharmD
Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
1. Wada K, Yamada N, Suzuki H, et al. Recurrent cases of corticosteroid-induced mood disorder: clinical characteristics and treatment. J Clin Psychiatry. 2000;61(4):261-267.
2. Ahmad M, Rasul FM. Steroid-induced psychosis treated with haloperidol in a patient with active chronic obstructive pulmonary disorder. Am J Emerg Med. 1999;17:735.-
3. Bloch M, Gur E, Shalev A. Chlorpromazine prophylaxis of steroid-induced psychosis. Gen Hosp Psychiatry. 1994;16:42-44.