Steroid-induced psychosis treated with valproic acid and risperidone in a patient with systemic lupus erythematosus.

Sir: We report a case in which steroid-induced psychosis was eliminated with combined therapy with valproic acid and risperidone in a patient with systemic lupus erythematosus (SLE). Case report. Ms. A, a 46-year-old woman, had had a diagnosis of SLE for 20 years. She had been treated with prednisolone from a minimum of 7.5 mg to a maximum of 30 mg daily. Her SLE symptoms had been controlled with prednisolone, 12.5 mg daily, for 5 years. For the last 15 years, she had taken triazolam, 7.5 mg daily, or flunitrazepam, 2 mg daily, for insomnia. She had not experienced episodes of depression, mania, or psychosis. In December 2002, approximately 2 months before her admission to our hospital, her prednisolone dosage was increased to 40 mg daily owing to exacerbation of erythema. After 1 month at this dosage, she had a hypomanic episode (DSM-IV criteria), with symptoms including being more talkative than usual and hyperactivity; thus, prednisolone was tapered to 30 mg daily. Valproic acid was initiated at 600 mg daily, but her symptoms of hypomania progressively worsened during the next month. Owing to her manic episode and psychomotor excitement, she was admitted to our hospital in February 2003. The results of a physical examination and laboratory tests (including cerebrospinal fluid studies and computed tomography) did not point to a specific physical etiology of her mental symptoms. She was diagnosed as having steroid-induced psychosis (DSM-IV criteria). She was treated with 20 mg of IV haloperidol and 30 mg of IV prednisolone daily because administration of oral medication was not possible due to her psy-chomotor excitement. After 1 week, she was switched from IV haloperidol to risperidone, 4 mg daily, and her dosage of val-proic acid was increased to 800 mg daily. For the next week, her symptoms were relieved. She was discharged after 2 additional weeks. The daily dose of prednisolone had been tapered to 22.5 mg by the time of discharge. For the next month, she did not have psychotic symptoms; therefore, risperidone was discontinued. Valproic acid, 800 mg daily, alone has controlled her mental status since discharge. This patient developed psychotic symptoms after high-dose prednisolone treatment during an exacerbation of SLE. These symptoms seemed to be caused by steroid-induced psychosis or psychosis attributable to SLE rather than by endogenous psychosis. It is often difficult to differentiate steroid-induced psychosis from SLE psychosis. In the present case, our patient's diagnosis of steroid-induced psychosis was based on medical findings and the temporal relationship between disease progression, treatment, and symptom onset. Lithium has been used successfully to both manage and prevent glucocorticoid-associated affective disorder.1 The efficacy of valproate as a prophylaxis against steroid-induced psychosis has been documented.2 Steroid-induced psychosis has been successfully treated with typical antipsychotics3 or risperidone.4,5 In this case, combined therapy with valproic acid and risper-idone was effective. Considering the risk of lupus nephritis, treatment with valproic acid as a mood stabilizer was more reasonable than that with lithium. Given the potential for complications with SLE or steroid-induced glucose abnormalities, selection of risperidone as the antipsychotic used was reasonable. Combined therapy with valproic acid and risperidone was effective in this case of steroid-induced psychosis in SLE.