How do you treat steroid-induced agitation? A comprehensive approach

October 14, 2025 •

4 min read

According to case studies, psychiatric disturbances from corticosteroids are often dose-dependent, with risks potentially increasing at higher doses. Knowing how do you treat steroid-induced agitation is critical for safe patient care, as this serious side effect requires prompt and careful management.

Quick Summary

Treatment for steroid-induced agitation primarily involves tapering the corticosteroid dose under medical supervision. Adjunctive psychotropic medications, particularly atypical antipsychotics and mood stabilizers, are used for severe symptoms. Non-pharmacological interventions like de-escalation are also crucial.

Key Points

Steroid Taper is First Line: The primary strategy for treating steroid-induced agitation is the supervised and gradual reduction or discontinuation of the corticosteroid.
Psychotropic Medications for Severe Symptoms: When tapering is insufficient or symptoms are severe, adjunctive medications like atypical antipsychotics (olanzapine, risperidone) or mood stabilizers are used.
Non-Pharmacological De-escalation: Calming techniques, verbal de-escalation, and environmental modification are essential, especially for milder agitation or in hospital settings.
Antipsychotics are Often Preferred: Atypical antipsychotics are generally preferred over older generations due to a more favorable side effect profile and proven effectiveness in managing corticosteroid psychosis.
Benzodiazepines for Acute Episodes: Used for short-term control of severe agitation, anxiety, or insomnia, but should be used cautiously, especially in older adults.
Personalized Treatment is Key: Management requires a tailored approach considering the patient's overall health, severity of agitation, and risk factors.

The First and Most Important Step: Tapering Steroids

The cornerstone of managing steroid-induced agitation is addressing the root cause: the corticosteroid itself. Whenever clinically appropriate, reducing the dose or discontinuing the medication is the first-line and most effective treatment strategy. This process must be carefully managed by a healthcare provider to avoid withdrawal-related complications, such as adrenal insufficiency.

Safe Tapering: The physician will create a gradual tapering schedule to allow the body's natural adrenal function to resume. Abrupt cessation of long-term steroid therapy is dangerous and can cause severe withdrawal symptoms.
Symptom Resolution: Most patients experience significant improvement in agitation and other psychiatric symptoms within days to weeks of beginning the steroid taper. For some, reducing the dose may be enough to resolve the symptoms.

Non-Pharmacological Strategies for Managing Agitation

For mild-to-moderate agitation, or as an adjunct to medication in severe cases, several non-pharmacological techniques can help calm the patient and ensure safety. These strategies are especially useful in a hospital setting where environmental control is possible.

De-escalation: Verbal de-escalation involves using calm, respectful communication to help the patient regain control. Speaking in a low, soothing voice, validating the patient's feelings, and offering simple choices can be effective.
Environmental Adjustments: A quiet, low-stimulation environment can reduce anxiety and agitation. Limiting visitors, maintaining a consistent routine, and avoiding overstimulation from noise or bright lights can be beneficial.
Comfort and Basic Needs: Ensuring the patient's basic needs are met can prevent frustration and escalating agitation. Address needs like hunger, thirst, pain, and comfort.
Family Involvement: Including family members in the patient's care can increase their comfort and reduce agitation. They can provide familiar faces and aid in reality orientation.

Pharmacological Interventions for Persistent or Severe Agitation

When tapering steroids is not feasible due to the patient's underlying condition or when agitation is severe (e.g., involves psychosis, aggression), psychotropic medications may be necessary. These are typically used temporarily until the steroid dose can be safely lowered.

Atypical (Second-Generation) Antipsychotics

Often the first-line pharmacological treatment for severe agitation or psychosis caused by steroids. These medications target dopamine and serotonin receptors and have a lower risk of extrapyramidal side effects compared to older antipsychotics.

Olanzapine (Zyprexa): Several case reports show effectiveness. It is available in oral and fast-acting intramuscular (IM) formulations for rapid control of severe agitation.
Risperidone (Risperdal): Effective for various psychiatric symptoms, including hypomania, hallucinations, and agitation. Symptom improvement is typically seen within days to weeks.
Quetiapine (Seroquel): Case reports have shown effectiveness, particularly for manic symptoms. However, its use in the emergency setting is sometimes limited by a higher risk of orthostatic hypotension.

Mood Stabilizers

These may be considered, especially if the agitation presents with manic or hypomanic features.

Lithium: Can be used, but requires careful monitoring of blood levels and renal function, especially in patients with coexisting autoimmune illnesses.
Valproic Acid or Carbamazepine: May be used as alternatives for patients who do not tolerate atypical antipsychotics or lithium.

Benzodiazepines

These are useful as a short-term adjunct for acute agitation, anxiety, and insomnia.

Lorazepam: Often combined with an antipsychotic in a hospital setting for rapid calming.
Caution: Use in the elderly or for long durations should be avoided due to risks of over-sedation, confusion, and dependence. They treat the symptom, not the underlying steroid-induced psychosis.

Comparison of Pharmacological Options


Medication Class	Examples	Primary Use in Agitation	Considerations
Atypical Antipsychotics	Olanzapine, Risperidone, Quetiapine	First-line for severe agitation and psychosis	Lower risk of EPS. Monitor for metabolic side effects, weight gain.
Mood Stabilizers	Lithium, Valproic Acid	Adjunct for manic or mood-related agitation	Requires therapeutic drug monitoring (Lithium). Consider renal and liver function.
Benzodiazepines	Lorazepam, Diazepam, Clonazepam	Short-term relief for acute agitation, anxiety	Risk of over-sedation. Should be used cautiously, especially in elderly.

Special Considerations in Management

The approach to managing steroid-induced agitation can vary based on the patient's individual circumstances and care setting.

Elderly Patients: Older adults are more susceptible to the psychiatric side effects of steroids and are at a higher risk for delirium. Treatment should follow a cautious approach, with careful monitoring for adverse effects.
Hospital vs. Outpatient: In a hospital, rapid-acting intramuscular medications like olanzapine may be used for severe agitation. Outpatient management focuses more on steroid tapering and oral medications.
Differential Diagnosis: Agitation can have multiple causes. It is crucial to rule out other medical issues, such as infection, electrolyte imbalances, or hypoxia, before attributing agitation solely to the steroid.

Conclusion

Treating steroid-induced agitation requires a multi-pronged strategy that addresses the underlying cause while also managing acute symptoms. The cornerstone of treatment is a carefully supervised taper or discontinuation of the offending corticosteroid. For severe or persistent symptoms, adjunctive pharmacological agents, particularly low-dose atypical antipsychotics, may be needed temporarily. Concurrently, non-pharmacological interventions like de-escalation and creating a calm environment are vital for patient safety and comfort. Effective management necessitates close collaboration between the medical team, the patient, and their family, with continuous monitoring to ensure a favorable prognosis and complete recovery.

For more information on managing psychiatric emergencies, consult authoritative medical resources like those available on PubMed Central: https://pmc.ncbi.nlm.nih.gov/articles/PMC3298219/.

Frequently Asked Questions

Symptom resolution typically occurs within days to weeks of beginning a steroid dose reduction or discontinuation. For some, improvements can be seen within a few days, though a full recovery from psychiatric symptoms often happens within two weeks of starting treatment.

Severe steroid-induced agitation, especially if accompanied by psychosis, is often treated with atypical antipsychotics like olanzapine, risperidone, or quetiapine. Benzodiazepines like lorazepam may also be used in acute, inpatient settings for immediate calming.

No, you should never stop steroids abruptly, especially after long-term or high-dose therapy. This must be done under a doctor's supervision to prevent life-threatening adrenal insufficiency and other withdrawal symptoms.

While lifestyle and environmental changes can help, there are no proven natural remedies to treat severe steroid-induced agitation. Techniques like breathing exercises, relaxation, and reducing environmental stress can be supportive but do not replace medical management.

In a hospital, management includes non-pharmacological approaches like verbal de-escalation and providing a calm environment. For moderate-to-severe agitation, intramuscular atypical antipsychotics like olanzapine or intramuscular benzodiazepines like lorazepam may be used.

Mood stabilizers, such as lithium or valproic acid, may be used as adjuncts, particularly if the agitation presents with manic symptoms. They are typically reserved for specific cases where atypical antipsychotics are not tolerated or insufficient.

Before concluding agitation is steroid-induced, healthcare providers must rule out other potential causes, such as infection, hypoxia, metabolic issues, or other forms of delirium. This ensures the correct underlying cause is addressed.