A Case of Oral Budesonide–Induced Psychosis

Psychiatric side effects from systemic corticosteroids are relatively common, with severe reactions affecting approximately 6% of patients on agents such as prednisone and dexamethasone.¹ Most cases involve mood disorders, with around one-sixth featuring psychosis or delirium.² Risk factors include higher doses, female sex, and older age.^1,2 Prior psychiatric history, including prior steroid-induced symptoms, does not increase risk. Psychosis most commonly occurs 1–2 weeks after steroid initiation. Budesonide is a steroid with low systemic activity and decreased adverse effects, owing to high first-pass metabolism.³ Severe psychiatric side effects such as psychosis associated with oral budesonide are scarce in the literature.³ A February 2026 PubMed search using the terms “budesonide” AND (“psychosis” OR “mania” OR “psychiatric”) identified no published reports of oral budesonide-induced psychosis. We present a patient who developed psychosis 1 week after beginning oral budesonide, which resolved with steroid taper.

Case Report

A 66-year-old woman with no psychiatric history presented to the emergency department with several weeks of paranoid delusions regarding her finances, worsening isolation, uncontrollable anxiety, insomnia, and diminished oral intake. Information obtained confirmed no recent financial stressors and a rapid psychological decline. There was no reported substance or alcohol use. The patient had an unremarkable medical workup including head computed tomography and laboratory studies. The patient was diagnosed with psychosis with persistent, fixed delusions and generalized anxiety disorder (GAD) and was psychiatrically hospitalized for further management.

At admission, the patient was visibly anxious, hyperkinetic, and perseverating on financial concerns and other worries that shifted frequently. She demonstrated an illogical and nonlinear thought process that derailed frequently. She had an inability to focus on or understand treatment or the rationale for hospitalization and often appeared to be internally preoccupied. Despite this, there were no reported perceptual disturbances.

The patient had recently started a new medication, budesonide 9 mg extended release daily, for microscopic colitis. Four years prior, she took budesonide 3 mg with no issues. It was ultimately confirmed that the symptoms began approximately 1 week following budesonide initiation, leading to a presumptive diagnosis of steroid-induced psychosis.

Given her presentation, antipsychotic medications were avoided in favor of a steroid taper (6 mg for 7 days, 3 mg for 7 days). During the taper, the patient’s symptoms began to improve, with a reduction in anxiety and a more logical thought process. Ultimately, she demonstrated insight regarding the prior delusions and returned to her premorbid psychological state. Given her GAD diagnosis, she was started on sertraline 25 mg during hospitalization. She was discharged to outpatient follow-up.

Discussion

Given the patient’s lack of psychiatric history, lack of substance use, timing of symptoms, and improvement with a steroid taper, the presentation was attributed to budesonide-induced psychosis. GAD does not typically produce psychotic features. The history was inconsistent with major depressive disorder, which may present with psychosis.

This case presentation suggests that oral budesonide can cause psychosis, despite low systemic activity. In contrast, a recent meta-analysis of microscopic colitis studies, which found no significant difference in adverse event frequency between budesonide and placebo, including no psychiatric side effects.³ US Food and Drug Administration labeling data for budesonide extended release supports those findings, reporting comparable rates of psychiatric symptoms between treatment and placebo groups.⁴ Assuming our attribution of the presentation to budesonide is correct, it represents a rare adverse effect.

This case supports the dose dependence of steroid-induced psychosis.¹ The patient was asymptomatic on low-dose budesonide but quickly became symptomatic on standard-dose budesonide. As prior steroid-induced psychosis does not increase risk for future episodes, the patient’s gastroenterologist might retrial the medication, gradually increasing the dose to monitor for adverse effects. For patients on oral budesonide with new-onset psychiatric symptoms, steroid-induced psychosis should be considered.

Article Information

Published Online: October 29, 2026. https://doi.org/10.4088/PCC.26cr04283
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(5):26cr04283
Submitted: May 22, 2026; accepted July 29, 2026.
To Cite: Phelan CL, Sablaban IM. A case of oral budesonide–induced psychosis. Prim Care Companion CNS Disord 2026;28(5):26cr04283.
Author Affiliations: Oakland University William Beaumont School of Medicine, Rochester, Michigan (Phelan, Sablaban).
Corresponding Author: Conrad L. Phelan, BA, Oakland University William Beaumont School of Medicine, 586 Pioneer Drive, Rochester, MI 48309 ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.
ORCID: Conrad L. Phelan: https://doi.org/0000-0003-0260-9154