Abstract
Reiji Yoshimura, Nobuhisa Ueda, Jun Nakamura, University of Occupational and Environmental Health, Fukuoka, Japan:
Steroids are a very common class of prescription drugs known to produce psychiatric syndromes. The incidence of steroid-induced psychiatric syndromes averages 5.7%%, with a maximum incidence of 50%% [1]. Ling et al. [2] reported that 40%% of patients with a steroid-induced psychiatric syndrome manifested a depressive state. As for the treatment of steroid-induced depression, paradoxically, tricyclic antidepressants have been reported to worsen the depressive symptoms [3]. In the present study, we demonstrated two case reports of steroidinduced depression which responded successfully to treatment with fluvoxamine, a SSRI.
Case 1; A 50-year-old female patient, who had no personal or family history of psychiatric disorders, was suffering from interstitial pneumonia and had been treated with 80 mg/day of prednisolone. Two weeks after the start of the prednisolone treatment, she fell into a depressive state characterised by insomnia, appetite loss, depressed mood, agitation anxiety, self-blame, and suicidal idea. Her score on the 17-item Hamilton Depression Rating Scale (Ham-D) was 30. She was started on 50 mg/day of fluvoxamine. One week after she started taking fluvoxamine, her depressive symptoms rapidly and dramatically improved, the Ham-D decreased to eight, and the plasma concentration of fluvoxamine at 50 mg/day with 80 mg/day of prednisolone was 87 ng/ml. The dosage of prednisolone was decreased from 80 mg/day to 40 mg/day, and the fluvoxamine was also decreased to 25 mg/day. Consequently, her depressive symptoms were aggravated. The dosage of fluvoxamine was increased to 50 mg/day again, and she improved within a week. After the prednisolone was tapered off, 50 mg/day of fluvoxamine was continued for 2 weeks and then tapered off, however, her depressive state did not relapse. The plasma concentration of fluvoxamine at 50 mg/day without prednisolone was 48 ng/ml.
Case 2; A 70-year-old male patient, who had a stable family situation and no history of psychiatric illness, was suffering from interstitial pneumonia and had been started on 100 mg/day of prednisolone. A week after fluvoxamine was administered, he revealed depressive symptoms such as insomnia, depressed mood, anxiety, psychomotor retardation, hopelessness, suicidal idea, etc. His Ham-D score was 25. He was treated with 50 mg/day of fluvoxamine. His depressive symptoms gradually improved, and the Ham-D was 10 and 5 after 2 and 4 weeks, respectively, after fluvoxamine was started. The plasma concentration of fluvoxamine at 50 mg/day with 100 mg/day of prednisolone was 43 ng/ml. After prednisolone was tapered off, 50 mg/day of fluvoxamine was continued for 4 weeks and tapered off without the patient relapsing into a depressive state. The plasma concentration of fluvoxamine at 50 mg/day without prednisolone was 20 ng/ml.
The time of onset of depressive symptoms, the relation of the prednisolone dosage to the severity of the depressive symptoms, and the absence of a history of psychiatric disorder suggest that the patient's depressive state was secondary to the use of prednisolone. In the present study, we demonstrated that treatment with a low dosage of fluvoxamine was effective for treating prednisoloneinduced depression. Since both steroids and fluvoxamine are metabolized by cytochrome P450 3A isoforms. [4], [5], prednisolone might increase plasma levels of fluvoxamine. In the present study, the plasma fluvoxamine level decreased from 87 ng/ml to 48 ng/ml in the first case and from 43 to 20 ng/ml in the second case, respectively, with or without prednisolone. The results of the present study confirm the speculation that prednisolone increases plasma fluvoxamine levels. In conclusion, fluvoxamine could be one of the candidates for treatment of steroidinduced depression.