Guest: Dr. Lucinda Whitney

When corticosteroid risks come up, most clinicians immediately think about osteoporosis, hyperglycemia, infection risk, or adrenal suppression. But what about the organ sitting between the ears? In this episode of the JDD Podcast’s Corticosteroid Stewardship Series, host Dr. Adam Friedman welcomes Lucinda Whitney, DNP, APRN, PMHNP-BC, Clinical Assistant Professor and PMHNP Program Coordinator at the University of Kansas School of Nursing, for a conversation that shines a much-needed spotlight on one of corticosteroids’ most overlooked toxicities: their effects on mental health.

From subtle insomnia, irritability, and anxiety to mania, depression, and psychosis, psychiatric complications remain one of the least anticipated and, unfortunately, least discussed consequences of systemic corticosteroid therapy. Together, Dr. Friedman and Dr. Whitney explore why these effects continue to fly under the radar, why the seemingly harmless “steroid burst” deserves a second look, and how cumulative exposure can quietly reshape a patient’s psychiatric risk profile over time. The discussion moves beyond identifying complications to providing practical strategies clinicians can implement immediately: incorporating routine mental health screening before prescribing, recognizing early warning signs, counseling patients and families without creating unnecessary alarm, and building interdisciplinary partnerships that make corticosteroid stewardship a true team sport. Tune in for an evidence based, clinically practical conversation that reminds us that good corticosteroid stewardship means treating the whole patient, not just the inflammation.

Timestamp: 01.37 

Dr. Adam Friedman: Welcome Dr. Lucinda Whitney to the podcast.

Dr. Lucinda Whitney: Thank you, Adam. I’m happy to be here. I appreciate the invitation.

Dr. Adam Friedman: I’m really excited you’re here because I think we’re going to hit on something that may not necessarily take center stage when we’re talking to patients about the wide array of chronic or even acute inflammatory diseases, but chronic would be a top billing. That would be the psychiatric or psychological complications when it comes to one of our historical and continuing workhorses in topically or even systemically managing inflammation, corticosteroids. They are one of the most commonly prescribed drug classes across medicine. Yet, the psychiatric implications are under-discussed. Maybe it stems from gaps in education from the med school or even residency level. Why do you think mental health effects remain such a blind spot in the everyday prescribing culture overall?

Clinical Blind Spots 

Timestamp: 02.40 

Dr. Lucinda Whitney: I think that’s a great question. It’s because most clinicians are treating what’s right in front of them. If you’re seeing somebody with severe skin disease, the immediate goal is probably to get that patient’s inflammation under control. Psychiatric effects can also be very easy to miss because they often start with symptoms that don’t seem so dramatic. Maybe somebody’s having a little harder time getting to sleep or they’re a little more irritable, anxious, or keyed up. By the time somebody develops a more serious presentation like mania or psychosis, the connection to the steroid might not be quite so obvious.

Dr. Adam Friedman: As a species, we love temporal associations for both good and bad. To your point, that delay may mean you do not necessarily connect the dots. When we talk about stewardship, I think most practitioners jump to bone loss, glucose dysregulation, infection risk, and biologically concerning things like adrenal insufficiency and HPA suppression. Why should psychiatric complications deserve equal billing to things like bone loss or glucose regulation?

Dr. Lucinda Whitney: Right.

Dr. Adam Friedman: Why, again, maybe the same kind of theme, why does psychiatric complications not necessarily, or rather, why should they deserve equal billing to things like bone loss or glucose regulation?

Dr. Lucinda Whitney: Because the psychiatric complications that a patient can experience can significantly impact their level of functioning, their relationships, their quality of life, and even potentially their safety if we think about the sudden onset of suicidal ideation. If a patient suddenly can’t sleep or they’re developing psychotic symptoms, those consequences are really significant. That’s what levels it up as being as important to the conversation as glucose dysregulation in terms of the risk-benefit conversation.

The Journey to Stewardship 

Timestamp: 04.45 

Dr. Adam Friedman: Let’s focus on how you got involved as a psychiatric mental health nurse practitioner. How did you become interested in corticosteroid stewardship? Was there a particular patient experience or a clinical pattern?

Dr. Lucinda Whitney: As a psych NP, I’m really interested in anything that could impact my patient’s stability and their well-being. Corticosteroids are widely prescribed and they’re often not thought about in terms of how they can impact a person’s mental status. I’ve worked across the continuum of care from acute care to psychiatric urgent care. In urgent care, I see more patients coming in who have had an exacerbation of their psychiatric symptoms. Initially, they may think their medications aren’t working, but when I ask about their medical history, I notice more patients are getting steroids. It seems steroids are being used more for chronic pain conditions and inflammatory disorders than before. I polled some of my colleagues in emergency medicine and primary care, and they confirmed they seem to be prescribing more steroids than they did before.

Dr. Adam Friedman: That’s a problem. That’s the start of a nice research paper to share that information and have documentation. When you mentioned urgent care, the first thing I thought of is that short bursts of steroids are a common favorite in the emergency medicine setting. There’s a perception that a short course, like the Medrol dose pack, is safe because it’s only a handful of days. Is that assumption remotely true from a psychiatric perspective?

Dr. Lucinda Whitney: No, that’s a big misconception. While it is true that most patients tolerate short courses reasonably well, psychiatric symptoms can occur within the first couple of days or first one to two weeks. The literature suggests about 40% of patients will experience symptoms in the first week. We can’t assume there’s no psychiatric risk even with these short-term prescriptions.

Dr. Adam Friedman: Are there particular patient populations that have a higher risk for these consequences from corticosteroids?

Dr. Lucinda Whitney: I think a lot about patients who have mood disorders or psychotic disorders. Patients can become more depressed, but we worry about those with bipolar spectrum disorder, anxiety disorders, or a history of suicidality. We should also ask patients if they have ever had psychiatric symptom reactions to steroids.

Dr. Adam Friedman: We ask about allergy history; shouldn’t we also ask if individuals have had bad reactions in the past? That would be a great part of quality assurance and documentation.

Symptoms and Manifestations 

Timestamp: 09.25 

Dr. Adam Friedman: What are the most common psychiatric manifestations with steroid use, and which ones are most commonly missed?

Dr. Lucinda Whitney: People worry about psychosis, but the most common symptoms are often insomnia, feeling keyed up, irritability, or mood changes. These effects occur on a spectrum. Many patients have milder symptoms they never report before they escalate into an emergency.

Dr. Adam Friedman: Is there a reproducible timeframe for these consequences? Is the timing consistent?

Dr. Lucinda Whitney: It is a spectrum. Symptoms start to emerge in the first couple of days. For patients on chronic steroids, dose escalation or tapering can trigger psychotic symptoms. It can occur early on and in prolonged treatment. I read a case report where an older adult had a simple knee injection and developed psychotic symptoms.

Dr. Adam Friedman: That highlights that topicals and injections have systemic consequences. Any steroid could theoretically cause these issues.

Integration into Clinical Practice

Timestamp: 12.37

Dr. Adam Friedman: How can dermatologists better prepare for this? Are there useful questions we can integrate to suss out who might be at higher risk? We often silo ourselves into topicals and orals, but there is a cumulative burden from all delivery methods.

Dr. Lucinda Whitney: I would ask about personal and family history of mental illness. Rather than just asking for a diagnosis, ask about symptoms like depression, anxiety, or difficulty with sleep. It is also important to ask about previous psychiatric reactions to steroids, changes in appetite, mood, or any substance use that might play a role.

Dr. Adam Friedman: I like the appetite piece. That’s an easy one for us to ask. Steroid phobia is real, but I haven’t encountered patients bringing up psychiatric complications. How do you educate them without scaring them off when they actually need the medication?

Dr. Lucinda Whitney: Most patients don’t know because they weren’t told. I try to normalize the conversation. I say that like all medications, steroids have potential side effects, and while most people do fine, I want you to know what to watch for. I outline symptoms like poor sleep, anxiety, or irritability, and ask them or their family members to call early so we can make adjustments before problems develop.

Dr. Adam Friedman: Making it collaborative improves engagement and adherence. Are there stewardship guidelines within psychiatry for the meaningful use of steroids?

Dr. Lucinda Whitney: Not really. Clinicians are aware of side effects, but there isn’t a consistent approach to discussing risk or monitoring symptoms. This is an opportunity to enhance awareness and develop a consistent approach to improve patient outcomes.

Dr. Adam Friedman: If you were the Corticosteroid Stewardship Czar, what would your best practice model look like?

Dr. Lucinda Whitney: Stewardship doesn’t mean avoiding steroids when medically necessary; it means being thoughtful. A best practice model would include discussing psychiatric risks, identifying vulnerable patients, educating families on symptoms to report, and having a plan for who to contact if problems arise. Early recognition is key to preventing severe outcomes.

Dr. Adam Friedman: How can we better collaborate with psychiatry when it comes to prescribing and monitoring?

Dr. Lucinda Whitney: It starts with recognizing we all have a role. If a patient is started on a steroid, they might not see the prescriber for a month, but they might see primary care or psychiatry reporting changes. It is my responsibility to communicate with the prescriber so we have shared responsibility. The most effective approach is open communication and reaching out to one another.

Dr. Adam Friedman: Communication is essential. In an academic center, we have a shared EMR, but there are challenges in the community. It takes time, but it is time worth spending because of the possible complications.

Conclusion and Key Takeaways
Timestamp: 23:33

Dr. Adam Friedman: What is the biggest misconception clinicians still have about corticosteroids and mental health?

Dr. Lucinda Whitney: The biggest misconception is that psychiatric symptoms will always look like psychosis. Psychosis is dramatic and obvious, but many patients experience more subtle symptoms like anxiety and insomnia, which are often overlooked. These are early clues that something more serious could be developing.

Dr. Adam Friedman: Chronic inflammatory diseases impact sleep and mood, so sussing out whether it is the disease or a side effect is challenging. What is the single most important takeaway you want them to remember when they next reach for a steroid prescription?

Dr. Lucinda Whitney: I have three. Ask about a person’s mental health risk factors, educate the patient and family on what to watch for, and encourage early reporting so we can intervene while symptoms are manageable and prevent a mental health crisis.

Dr. Adam Friedman: Thank you so much for being here, Lucinda. This was extremely insightful. Please keep up the incredible work you’re doing. Thank you to everyone who tuned in to this episode of the JDD Podcast Corticosteroid Stewardship Series.