66-Year-Old Patient Develops Delusions After Resuming Common Steroid at Higher Dose

A 66-year-old woman with no prior history of mental illness was admitted to a psychiatric unit after developing severe paranoia, anxiety, and insomnia shortly after resuming a steroid medication for microscopic colitis—a drug she had safely taken four years earlier at a lower dose.

The case study, authored by Dr. Conrad Phelan and Dr. Ibrahim Sablaban of the Oakland University William Beaumont School of Medicine, was published October 29 in The Primary Care Companion for CNS Disorders.

The patient was receiving treatment for microscopic colitis, an inflammatory bowel condition characterized by chronic, watery diarrhea. Because intestinal inflammation from microscopic colitis is typically invisible during a standard colonoscopy, diagnosis relies on microscopic tissue biopsy analysis. To manage the flare-up, clinicians prescribed budesonide at a standard dose of 9 mg daily.

Roughly one week after starting the medication, the patient began experiencing persecutory delusions focused on financial matters, accompanied by severe anxiety, sleep deprivation, social withdrawal, and reduced food intake. The symptoms persisted for several weeks.

Psychiatric Symptoms Emerged After Tripling Previous Dose

A comprehensive medical evaluation—including brain CT imaging and diagnostic blood panels—ruled out organic or metabolic causes for her psychiatric presentation.

Upon reviewing her pharmacological history, medical staff identified a key variable: four years prior, the patient had successfully taken budesonide at a dose of 3 mg daily without adverse effects. The onset of psychiatric symptoms coincided with taking 9 mg daily—triple her previous dosage.

Budesonide is an orally administered corticosteroid designed to target inflammation in the gastrointestinal tract. Because the liver rapidly metabolizes most of the drug absorbed into the bloodstream, budesonide exhibits lower systemic bioavailability compared to conventional systemic steroids like prednisone. Nevertheless, systemic corticosteroid effects, including rare psychiatric adverse events such as psychosis and mania, can still occur.

While steroid-induced psychiatric side effects are known to be dose-dependent, the authors noted that 9 mg daily remains the standard initial dose for active microscopic colitis.

Rapid Recovery Following Steroid Taper

To address the adverse reaction, the medical team systematically tapered the budesonide dosage to 6 mg daily for seven days, followed by 3 mg daily for an additional seven days.

As the dose was reduced, her anxiety and paranoid delusions gradually resolved, and she regained full insight into her condition. The patient did not require antipsychotic medication, though she was started on the antidepressant sertraline to manage underlying anxiety. She subsequently returned to her baseline psychiatric state and was discharged.

Although the timeline of onset and resolution strongly suggested a drug-induced effect, the authors cautioned that a single-patient case report cannot definitively establish direct causality or isolate dose variance as the sole factor.

The case underscores that unexpected adverse reactions can manifest even with medications patients have previously tolerated well. Clinicians emphasize that patients experiencing sudden onset insomnia, severe anxiety, or mood changes after initiating steroid therapy should immediately contact their healthcare providers, and should never alter or stop their prescribed dosage independently.