A 39-year-old woman recently diagnosed with systemic lupus erythematosis comes to the office for follow-up accompanied by her husband. The husband says, "I can understand that she's been depressed about having lupus, but for the past week she seems really upset even though her pain is better. She keeps picking fights with me, gets angry, and yells at me. A few minutes later she calms down and starts bawling her eyes out." The patient states "I'm not myself" and reports that for the past week her mood has been "up and down, but mostly depressed." She is able to sleep only 5 hours each night. During the day her energy and motivation are low and she spends most of the time lying on the couch. Her appetite, which was low before, has declined further. Medications include hydroxychloroquine, ibuprofen, and multivitamins. Two weeks ago she began taking prednisone 40 mg daily due to a flare-up with worsening joint pain and fatigue. The patient does not use alcohol or illicit drugs. She has no psychiatric history. There is a family history of bipolar disorder. Temperature is 36.7 C (98 F), blood pressure is 126/80 mm Hg, pulse is 82/min, and respirations are 16/min. Physical examination is unchanged from her last visit. On mental status examination, the patient's mood is "down" and her affect is mildly reactive. Her speech is not pressured and she has no flight of ideas, hallucinations, or delusions. Laboratory results indicate no renal insufficiency or cytopenias, and there is no evidence of nephritis. Which of the following is the most appropriate next step in management of this patient?

Question

A 39-year-old woman recently diagnosed with systemic lupus erythematosis comes to the office for follow-up accompanied by her husband.  The husband says, "I can understand that she's been depressed about having lupus, but for the past week she seems really upset even though her pain is better.  She keeps picking fights with me, gets angry, and yells at me.  A few minutes later she calms down and starts bawling her eyes out."  The patient states "I'm not myself" and reports that for the past week her mood has been "up and down, but mostly depressed."  She is able to sleep only 5 hours each night.  During the day her energy and motivation are low and she spends most of the time lying on the couch.  Her appetite, which was low before, has declined further.  Medications include hydroxychloroquine, ibuprofen, and multivitamins.  Two weeks ago she began taking prednisone 40 mg daily due to a flare-up with worsening joint pain and fatigue.  The patient does not use alcohol or illicit drugs.  She has no psychiatric history.  There is a family history of bipolar disorder.  Temperature is 36.7 C (98 F), blood pressure is 126/80 mm Hg, pulse is 82/min, and respirations are 16/min.  Physical examination is unchanged from her last visit.  On mental status examination, the patient's mood is "down" and her affect is mildly reactive.  Her speech is not pressured and she has no flight of ideas, hallucinations, or delusions.  Laboratory results indicate no renal insufficiency or cytopenias, and there is no evidence of nephritis.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's new onset of mood symptoms is most likely due to corticosteroid use. High doses of prednisone (>40 mg/day), often given for allergic, inflammatory, or autoimmune conditions (such as systemic lupus erythematosis), may cause psychiatric symptoms in a dose-dependent fashion, with or without any history of underlying psychiatric disorders. Longer duration of use can increase the risk; however, psychiatric symptoms secondary to corticosteroids may begin at any time during the course of treatment. Corticosteroid-induced psychiatric symptoms are more common in women than in men. In addition to mood symptoms, psychosis and anxiety can also occur. Other neuropsychiatric symptoms seen in patients taking glucocorticoids include sleep disturbances, restlessness, and memory loss. Whenever possible, the first step in the treatment of corticosteroid-induced psychiatric symptoms is dose reduction (or discontinuation if appropriate) of the offending medication. Once the corticosteroid has been reduced, then psychiatric symptoms can be treated if they persist (Choices A, B, and C). (Choice D) This patient's depressive symptoms are likely medication-induced, and the most appropriate next step is reducing the dose of prednisone. Cognitive behavioral psychotherapy could be considered at a later point if the patient's depressive symptoms persist and/or if she needs assistance coping with her diagnosis. Educational objective: Psychiatric symptoms are commonly seen in patients taking corticosteroids and can include mood changes, psychosis, and anxiety. The symptoms occur more commonly in patients taking high doses for prolonged periods, but they can occur at any time. The first step in treatment is dose reduction of the offending corticosteroid. References: Psychiatric adverse effects of corticosteroids. (http://www.ncbi.nlm.nih.gov/pubmed/17036562) Psychiatric complications of treatment with corticosteroids: review with case report. (http://www.ncbi.nlm.nih.gov/pubmed/22003987) The diagnosis and clinical management of the neuropsychiatric manifestations of lupus. (http://www.ncbi.nlm.nih.gov/pubmed/27427403)

A 39-Year-Old Woman Recently Diagnosed with Systemic Lupus Erythematosis Comes