Topical steroid‐induced mood disorder responding to lithium

Abstract

A 79-year-old female presented to the mental health crisis team in 2019 with a three-week history of mood f luctuations. This was preceded by use of corticosteroid cream for widespread discoid eczema, prescribed by her GP. Her family reported that one week into using the prescribed h y d r o c o r t i s o n e c r e a m , s h e became agitated, and was having ‘severe mood swings’ that worsened with continued use of the cream. She had episodes of elevated or irritable mood, increased energy, decreased sleep, racing thoughts and disinhibition. In addition she was reported to have been overfamiliar with friends and was pressured in speech. However, she also had periods of depressed mood, which were associated with tearfulness, reduced appetite, poor concentration, loss of interest, and fleeting suicidal ideation although with no plan or intent. Despite discontinuation of the topical steroid, her symptoms continued. In her past history, the patient had a similar presentation in 2008 when she presented with a similar episode of steroid-induced mixed affective state after she was commenced on oral corticosteroids for polymyalgia rheumatica. She was admitted to hospital for about three months in 2008, following trials of various medications like venlafaxine, risperidone and quetiapine with no improvement. Her mental health was eventually optimised and improved on lithium, which she remained on for 18 months but had to be weaned off due to tremors. She was eventually discharged from the mental health service after a period of follow-up during which she was not on any psychotropic medicat i o n a n d h e r m e n t a l s t a t e remained stable. The patient’s past medical history was not significant apart from a history of polymyalgia rheumatica. Her medications on presentation were aspirin 75mg daily, atorvastatin 20mg daily, lercanidipine 10mg daily, nebivolol 5mg daily and perindopril 6mg daily. Routine laboratory investigations were all within normal limits. Her ECG was also normal. Her family were rather keen for her to be promptly commenced on lithium because she benefitted from the medication in the past and they were concerned about the risk of a further decline that could eventually require hospital admission, which they were very much against. She was commenced on lithium carbonate. She responded favourably to the treatment, similar to how she had done in 2008. Her mental state improved and she reported no significant side-effects. She was eventually discharged from the mental health crisis team to a community mental health team for follow-up. At the time of discharge, she had a lithium level of 0.6mmol/L on a dose of l i thium carbonate 200mg nocte.