Q:  Injected Steroids & Bipolar Disorder

Dear Dr. Phelps,
My question is regarding your new book, page 88 on steroids.  (A wonderful, much-needed book!)  You mention the steroids to be concerned about are the oral versions and even a bring up inhaled steroids.  What about injections?  The first time I had an steroid injection for calcium deposits in a joint (at 30), I missed two to three periods and felt like I was losing my mind.  I was seriously agitated and "felt" ready to leave my husband.  It was frightening.  Years later I thought I could handle a lower dose injection, but still had mood reactions.  I have a history of major depression.  Can such a reaction to steroid injections be a sign of Bipolar illness?  I have never received a solid answer as my doctor at the time said he'd never had anyone respond the way I did.  It made me feel even more crazy.  Any thoughts?


Dear Marci --
Thanks for the nice book plug there. As for injected steroids, I just looked again and still find no articles directly addressing this topic (steroid injection mania, or steroid injection bipolar). However, if we think inhaled steroids might have an effect, then surely an injection would be likely to leak into the bloodstream and have a potential effect. Indeed, I had one patient whose severe mania began after a spinal injection of steroids for back pain (although that has a pretty direct route to the brain, if they got the stuff into the fluid inside the spinal cord itself (not where they'd be aiming, but could have landed there). 

Here's an example of a case of a fellow without prior signs of bipolar disorder who became frankly manic after steroids. There are many such cases, but in case you needed to see one where there was no bipolar disorder until after the steroids, try this. His steroids were very high doses and very direct, compared to your injections, however. 

But, the bottom line: does having a manic-like reaction after a steroid injection, when you only had depressive episodes prior to that, mean you have "bipolar disorder"? No. It just means you have some such susceptibility if you get steroids. Does that mean you have susceptibility to bipolar disorder even without steroids? I don't have enough experience with following people over time who had one or two such reactions to steroids but no bipolar disorder prior, to answer that question, nor have I seen such a series of cases reported, so I think that remains an open question.  Perhaps it is like having a hypomanic reaction to an antidepressant, with no prior bipolar signs: at least it means "watch out if you ever have to use an antidepressant again" and maybe even similar to the idea "if you do ever have to use an antidepressant again, have a mood stabilizer on board first" (or use one of the 9 antidepressant modalities that aren't antidepressants instead).  I certainly wouldn't want to imply or tell you that  you "have bipolar", or anything close to such a summary conclusion; all I can do is give you ideas and make you think.  I hope that's what you were after. Thanks for your interesting question. 

Dr. Phelps


Published June, 2006