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REVIEW

FARID TALIH, MD OMAR FATTAL, MD DONALD MALONE, JR, MD Department of Psychiatry and Department of Psychiatry, Head, Section of Mood and , Psychology, and Sleep Disorders Lutheran Hospital, Cleveland Department of Psychiatry and Psychology, Center, Cleveland Clinic Cleveland Clinic

Anabolic abuse: Psychiatric and physical costs

■ ABSTRACT NABOLIC-ANDROGENIC STEROID ABUSE is no A longer confined to professional athletes; it The psychiatric effects of anabolic-androgenic (ie, is now on the rise in the general population, even and its derivatives) have been less well among adolescents. Physicians should be aware studied than their physical effects but are reported to of its in order to address include , mania, psychosis, and . adverse effects and provide treatment. Dependence can also occur, with withdrawal involving This paper briefly discusses the physical psychiatric and physical symptoms. Adverse effects of effects of anabolic-androgenic steroids and how steroid abuse should be managed by discontinuing the to recognize possible abuse in patients. We then drugs—by tapering if necessary—and by treating the detail the literature regarding psychiatric effects. symptoms. ■ STEROID ABUSE IS NOT NEW ■ KEY POINTS Steroid use has gained widespread public Steroid abusers typically take doses 10 to 100 times attention in recent years, owing to news of higher than physiologic doses, in cycles lasting 6 to 14 abuse by high-profile athletes in professional weeks, consisting of daily oral doses plus weekly or and Olympic sports.1,2 Hundreds of thousands monthly intramuscular injections. of Americans are estimated to be abusing these drugs, mostly in secret. Incidents of vio- lent, aggressive, and even homicidal behavior Anabolic-androgenic steroids can affect nearly every have added notoriety to this topic.3 organ system. , , abnormalities, Athletes have used performance-enhanc- abnormal function tests, and changes are ing substances since the time of ancient among the manifestations of steroid abuse. Greece. There are anecdotal reports from the 1940s of steroids being given to German sol- Treatment of psychiatric effects starts with stopping the diers to increase aggressiveness.4 In the 1950s, steroids. It is reasonable to substitute testosterone the first reports emerged of steroid abuse by ath- enanthate (Andro-Estro) and gradually taper the dose. letes, who used them to increase muscle mass, strength, and competitiveness.2,5,6 Anabolic- The short-term use of antipsychotic may help androgenic steroids were banned by the 4,6,7 treat steroid-induced mania and psychosis. International Olympic Committee in 1975. may help control panic or anxiety in the In 1991, the US Congress made anabolic- androgenic steroids schedule III substances. short term. Selective serotonin reuptake inhibitors or The US Drug Enforcement Agency controls tricyclic should be used if long-term and monitors their use.1,5 treatment is needed. ■ WHO IS ABUSING STEROIDS? Depression sometimes occurs when use is stopped. (Prozac) can be used in this situation. Professional athletes in almost every major

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T ABLE 1 genic steroids at 1.7% in eighth graders, 2% in 10 Commonly abused anabolic- tenth graders, and 2.6% in twelfth graders, which is significantly more than in 1990. androgenic steroids Risk factors for using anabolic-androgenic Oral preparations steroids are poorly understood but include (Halotestin) poor relationships with fathers, a history of (Proviron) conduct disorders, a history of substance Methandienone (Dianabol) abuse, and poor body image.11 Race, educa- (Virilon) tion level, and income do not appear to be sig- (Cheque) nificant factors. Among adolescents, boys are (Anavar, Oxandrin) (Anadrol) more prone to abuse steroids than are girls, (Winstrol) and participation in organized sports and knowing someone who uses anabolic steroids Intramuscular preparations are predictors of future use.12 undecylenate (Equipoise) Methenolone enanthate (Primobolan) In 1990, the illicit steroid market was esti- decanoate (Deca Durabolin) mated to be $400 million. Steroid cycles, typi- Nandrolone phenpropionate (Durabolin) cally lasting 6 to 14 weeks, can cost hundreds of (Depotest) dollars. A cycle consists of daily oral doses plus (Andro-Estro) weekly or monthly intramuscular depot injec- (Testex) tions. Some users take multiple cycles per year.2,5 acetate (Finajet) DATA FROM KNOPP WD, WANG TW, BACH BR JR. ERGOGENIC ■ WHAT ARE ANABOLIC- DRUGS IN SPORTS. CLIN SPORTS MED 1997; 16:375–392; PERRY PJ, KUTSCHER EC, LUND BC, YATES WR, HOLMAN TL, DEMERS L. ANDROGENIC STEROIDS? MEASURES OF AGGRESSION AND MOOD CHANGES IN MALE WEIGHTLIFTERS WITH AND WITHOUT ANDROGENIC USE. J FORENSIC SCI 2003; 48:646–651; AND MALONE People have known for centuries that castrat- DA JR, DIMEFF RJ, LOMBARDO JA, SAMPLE RH. PSYCHIATRIC EFFECTS AND PSYCHOACTIVE SUBSTANCE USE IN ANABOLIC- ing animals leads to tameness, loss of male ANDROGENIC STEROID USERS. CLIN J SPORT MED 1995; 5:25–31 characteristics, and infertility. In 1849, it was Risk factors discovered that the human testes provide hor- for steroid use: mones that affect the body. Human testos- sport are involved in allegations of anabolic- terone was first isolated in 1935.13 poor androgenic steroid use. The current media Testosterone, a four-ring cyclic compound relationships exposure might reflect an increased preva- composed of 19 carbon atoms, is produced in lence and penetration of steroid use in sports the body from .1,14 In males, the with fathers, culture. testes are the major site of testosterone pro- conduct Many cultural factors may enhance duction, and the adrenal glands are a minor disorders, steroid abuse: increased competitiveness, con- site. In , testosterone is produced in cerns about body image, and advances in bio- the adrenal glands and the .14 substance chemical technology. Younger people are also Normal total plasma testosterone levels in abuse, poor affected by such trends because of the highly males are in the range of 300 to 1,000 ng/dL.14 competitive nature of high school and colle- Most is bound by -binding pro- body image giate sports. The enhanced performance that tein and is inactive; free testosterone, the steroids provide may be the deciding factor in active form, makes up only 2% to 3% of circu- securing an athletic scholarship or acceptance lating testosterone. Testosterone is metabo- into professional sports. lized into , which is 10 Limited data are available on the preva- times more potent than testosterone, and lence of anabolic steroid use in adults, but esti- , which has feminizing effects.15 mates are in the hundreds of thousands.8 Most After its discovery, testosterone was found users are men involved in weightlifting, body- to be inactive when taken orally and rapidly building, and professional sports, but use inactivated by the liver when injected. among women and adolescents is also on the Synthetic derivatives, made by modifying the rise.9 The 2005 Monitoring the Future study testosterone molecule, have enhanced bio- estimated the lifetime use of anabolic-andro- availability and activity. Currently available

342 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 5 MAY 2007 anabolic-androgenic steroids (TABLE 1) are controls. Over a 12-year period, 8 (12.9%) of active when taken either orally or as an intra- the weightlifters died vs 34 (3.1%) of the con- muscular depot , depending on the trols (P = .0002). The causes of death in the position and type of the biochemical alter- weightlifters were suicide (3 subjects), acute ation.14 Some of these agents are designed to myocardial infarction (3), hepatic coma (1), have minimal side effects, and others (not list- and non-Hodgkin lymphoma (1). ed in TABLE 1) are designed to avoid detection Vascular effects. Reported severe adverse in antidoping tests.16 effects of anabolic-androgenic steroid use Medical uses for testosterone include include cerebral venous sinus thrombosis, treatment of some anemias, muscle dystro- ischemic cerebral ,22,23 and cardiovascu- phies, wasting related to human immunodefi- lar events in the absence of risk factors.24,25 ciency virus infection, and male hypogo- Two cases of limb-threatening arterial throm- nadism.1,14,15 bosis were reported with the use of Nearly every in the human body has (Danocrine), an steroid-like receptors for steroids, so that every organ sys- compound with weak anabolic properties.26 tem is susceptible to the effects of these mole- Cardiovascular toxicity may occur via cules.2 Giving physiologic amounts of testos- atherogenic, thrombotic, or vasospastic mech- terone has no net effect on plasma levels anisms or through direct myocardial because inhibition shuts down injury.27–29 endogenous production. Users of anabolic Hepatic effects. Toxic hepatitis and life- steroids take 10 to 100 times the physiologic threatening hepatocellular adenomas have dose to override feedback inhibition.15 been reported.30,31 Infections from injecting steroids are a ■ ADVERSE PHYSICAL EFFECTS serious problem, although no cross-sectional or prospective studies exist that document the Testosterone and its derivatives can have risk. Rich et al32 reviewed the literature from adverse effects on the cardiovascular, meta- 1966 to 1998 and found three cases of human bolic, reproductive, endocrine, dermatologic, immunodeficiency virus infection, one case of Cardiac and hepatic systems.2,9,14,17–19 Coronary artery hepatitis B infection, one case of hepatitis C toxicity may be disease is of the most concern. infection, eight abscesses, and one case of fun- O’Sullivan et al20 conducted a communi- gal endophthalmitis. atherosclerotic, ty-based study of 27 past users of anabolic- Orthopedic complications, mostly ten- thrombotic, or androgenic steroids, 14 current users, and 17 don ruptures, have been reported.26,33–36 potential users (who served as controls) Sexual changes. Gynecomastia can occur vasospastic, attending a medical clinic established specifi- in men but may be reversible. Many mas- or a direct cally to examine steroid use. The most com- culinizing changes in women tend to be irre- effect mon adverse effects were changes in , versible.1,14,15 changes in mood, reduced testicular volume, and acne. Twenty-nine percent of the present ■ RECOGNIZING STEROID ABUSE users had hypertension, as did 37% of past users—but only 8% percent of potential users. Physicians should be alert to the signs and After learning of the results of the study, only symptoms of steroid abuse and should consid- 11 participants (19%) reported that they er the problem in patients at high risk. Early would not use anabolic steroids in the future. recognition and intervention may prevent Increased risk of , death. Some adverse and potentially irreversible conse- reports have found that anabolic steroid use quences. can have more serious effects, including an Clues to possible anabolic-androgenic increased risk of cancer and of death.18 steroid abuse are listed in TABLE 2.37 New-onset Parssinen et al21 studied 62 professional acne on the back and chest, temporal hair weightlifters in Finland who were strongly sus- loss, and alopecia are common signs. Subtle pected of using anabolic-androgenic steroids personality or mood changes are sometimes and compared them with 1,094 population the only manifestation.

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TABLE 2 Psychiatric effects of steroids are hard to study Clues to anabolic-androgenic steroid use The psychiatric effects of anabolic-androgenic

SYSTEM AFFECTED SIGN OR SYMPTOM steroids are hard to study, for several reasons. Many of the available studies were, by neces- Cardiovascular Cardiac disease in absence of risk factors sity, observational. But because the substances Thrombotic events in absence of risk factors are illicit, users have no way to verify their exact nature or amounts taken.1,2,39 Moreover, Dermatologic Alopecia Male pattern baldness in women many steroid users concomitantly take a mul- Needle marks on buttocks and thighs titude of other performance-enhancing drugs New-onset acne affecting the chest and back and dietary supplements that also may have psychiatric effects (TABLE 3).40,41 Endocrine intolerance Prospective studies are hard to carry out Lipid abnormalities because of the ethical issues inherent in test- Hepatic Abnormal liver function tests ing a potentially dangerous substance. Because Hepatic masses many users belong to a subculture of body- Jaundice builders, weightlifters, or elite athletes, study Infectious Deep abscesses in the thighs or buttocks results are hard to extrapolate to the general Human immunodeficiency virus infection public.42 Most studies to date have evaluated or hepatitis dosages lower than most users report tak- ing.15,42,43 Further, users of anabolic-andro- Musculoskeletal Rapid and pronounced Tendon injury genic steroids tend to use them for prolonged and repeated cycles over many years, which is Neurologic in absence of risk factors hard to recreate in clinical trials. Unexplained syncope More studies are needed on a larger scale Psychiatric Irritability, hostility with dosing that is compatible with the supra- Mood changes (mania or depression) physiologic dosages used in the community. Personality changes Psychosis Are steroid users psychologically Reproductive atrophy in women dysfunctional to begin with? Clitoromegaly In addition, pre-existing personality traits that Gynecomastia in men might predispose people to use steroids may Testicular volume decrease significantly confound assessing any psychi- in women with voice changes atric effects of drug use.44–47 Suspected risk factors for men include antisocial personality traits, low self-esteem, and poor body image (body dysmorphia).11,48 Porcerelli and Sandler49 found that ■ PSYCHIATRIC SIDE EFFECTS weightlifters and bodybuilders who used ana- ARE LESS WELL UNDERSTOOD bolic steroids had significantly higher scores on dimensions of pathologic narcissism and Psychiatric effects of anabolic-androgenic lower scores on ratings of empathy. Another steroid use are not as well understood as the study found that up to 50% of steroid users had physiologic effects.19 worked as bouncers and described themselves Steroids act on the central as aggressive regardless of their drug use.47 in several ways: they can affect the by releasing endogenous opiate or by ■ MOOD EFFECTS converting into derivatives and acti- vating secondary messenger systems. Electro- Uncontrolled, observational trials in the encephalographic changes are similar to those 1930s and 1940s found that men with refrac- seen with amphetamines and tricyclic antide- tory depression responded favorably to testos- pressants.14,38 terone treatment.15 However, randomized,

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TABLE 3 In controlled studies, high dosages led to mood changes in some users Other drugs that Studies with supraphysiologic doses of anabol- steroid abusers often use ic-androgenic steroids found minimal or no

SUBSTANCE EFFECT changes in mood in most users, but a minori- ty of users had significant mood changes. Amino acids (various) Anabolic Pope et al,53 in a randomized, placebo-con- Clenbuterol (Ventipulmin, equine) Weight control trolled crossover trial, gave injections of testos- Danazol (Danocrine) Antigonadotropin terone cypionate (Depotest) to 56 men, gradu- () Anabolic ally increasing the dosage to 600 mg/week. Diuretics (various) Weight control Most of the men showed no significant manic Ephedrine/pseudoephedrine (Sudafed) Weight control symptoms, but 6 (12%) had mild hypomania (Humatrope) Anabolic Human chorionic (Ovidrel) Anabolic and 2 (4%) had marked hypomania. 54 (various) Anabolic Su et al, in a placebo-controlled, crossover (Synthroid) Weight control prospective trial, gave oral methyltestosterone Nalbuphine hydrochloride (Nubain) Pain control (Virilon) 40 or 240 mg/day to 20 normal men. (Nolvadex) Antifeminizing Those on the high dose had increased positive DATA FROM PERRY PJ, KUTSCHER EC, LUND BC, YATES WR, HOLMAN TL, DEMERS L. mood changes (euphoria, increased energy, and MEASURES OF AGGRESSION AND MOOD CHANGES IN MALE WEIGHTLIFTERS ) as well as negative mood changes WITH AND WITHOUT ANDROGENIC ANABOLIC STEROID USE. J FORENSIC SCI 2003; 48:646–651; AND POPE HG JR, KATZ DL. PSYCHIATRIC AND MEDICAL EFFECTS OF ANABOLIC-ANDROGENIC (irritability, violent feelings, hostility, and dis- STEROID USE. A CONTROLLED STUDY OF 160 ATHLETES. ARCH GEN PSYCHIATRY 1994; 51:375–382. tractibility). One developed mania at the high dosage, and another developed hypomania. Kouri et al,55 in a randomized, placebo- placebo-controlled studies conducted in the controlled crossover study, gave gradually 1980s were equivocal.50,51 increasing doses of testosterone cypionate (150 mg/week for 2 weeks, 300 mg/week for 2 Observational studies show hypomania, weeks, 600 mg/week for 2 weeks) or placebo mania, and depression to 8 normal male volunteers. Higher dosages Malone et al45 retrospectively studied 164 of testosterone were associated with manic weightlifters and bodybuilders who used ana- symptoms. bolic-androgenic steroids and found that about 10% had hypomania. Depression occurred Physiologic doses when steroids were stopped in about 10%. have minimal mood effects Pope and Katz52 interviewed 41 body- Studies of the effects of low or near-physiolog- builders and football players taking anabolic- ic doses of anabolic-androgenic steroids found androgenic steroids and found that 9 dis- minimal effects on mood. played full affective syndromes and 5 showed Pope et al56 randomized 23 men with psychotic symptoms. refractory depression to treatment with testos- In a later study, Pope and Katz39 compared terone or placebo. Treated 88 athletes who were using anabolic-andro- patients had improved depressive symptoms genic steroids with 68 nonusers and found compared with controls. No negative side that 23% of the steroid users reported major effects were found. mood symptoms (including mania, hypoma- Seidman et al,57 in a randomized, double- nia, and depression) vs only 6% of the blind trial, gave testosterone enanthate nonusers, and several users reported aggressive (Andro-Estro) 200 mg per week or placebo to thoughts. The higher the steroid dosage, the 30 hypogonadal men with major depression. more severe the psychiatric symptoms. Treated patients had marginal but statistically Perry et al44 conducted a similar study of significantly improved sexual function com- weightlifters and found more symptoms of pared with controls but no other mood effects. depression and mania among users of anabol- O’Connor et al58 gave either testosterone ic-androgenic steroids, although formal diag- enanthate 200 mg per week intramuscularly noses were not made. or placebo to 8 hypogonadal and 30 eugo-

346 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 5 MAY 2007 nadal men and found no significant mood Kouri et al,55 in the study in 8 volunteers change in the eugonadal men but significant summarized above, found significantly higher mood improvement from baseline in the aggressive response scores with testosterone hypogonadal men. cypionate use, but the authors did not report Mania has been reported with use of the whether a dose-response effect was seen. testosterone patch (Testoderm).59 Tricker et al64 randomized 43 eugonadal men to receive either supraphysiologic doses ■ AGGRESSION of testosterone enanthate (600 mg/week) or placebo and found no increase in angry behav- Studies in mice have found aggressive behav- ior. ior correlating with increasing dosages and duration of anabolic-androgenic steroid treat- Physiologic doses ment, culminating in females killing their off- do not enhance aggression spring.60 Studies of men taking physiologic doses of anabolic-androgenic steroids found no Observational studies were equivocal changes in aggressive behavior. Observational studies of aggressive behavior O’Connor42 randomized 28 eugonadal changes in people taking steroids have been men to receive equivocal. (Andriol; mostly used in research, but Midgley et al47 compared measures of uncommon in illicit use) or placebo and found aggression in 50 users of anabolic-androgenic no increase in aggressive behavior. steroids and 40 nonusers and found that the In another study, O’Connor et al58 ran- only significant difference was that steroid domized a group of eugonadal and hypogo- users tended to be less in control of aggressive nadal men to receive either testosterone enan- feelings. Although 60% of users had higher thate or placebo and found no increase in levels of irritability and bad temper, no signif- aggression or impulsivity. The hypogonadal icant difference in physical violence was men improved in self-reported symptoms of found. tension and anger. Up to half Malone et al45 performed psychological Ellingrod et al65 gave testosterone cypi- of steroid tests on 164 anabolic-androgenic steroid users onate 100 mg per week (a physiologic dosage) and nonusers and did not find a significant dif- and 250 and 500 mg per week (supraphysio- abusers ference in measures of hostility and aggression. logic dosages) to six normal volunteers and develop Perry et al44 compared 10 weightlifters detected no increased aggressiveness during who used anabolic steroids and 18 who did not simulated driving. physical or and found significantly elevated measures of psychological aggression in those with supraphysiologic lev- Serum testosterone level dependence els of testosterone. correlates with aggressiveness Pope et al61 interviewed 133 consecutive Salvadora et al66 analyzed videotapes of 28 male convicts and found two cases of apparent judo competitors during fights and found that steroid-induced crimes. aggressiveness correlated with higher serum Other small studies showed increased verbal testosterone levels. aggression in users of anabolic-androgenic Orengo et al67 measured hormone lev- steroids and no increased attention to aggressive els in 50 elderly men with and environmental cues (ie, no increased paranoia; found that plasma free testosterone levels the subjects did not misinterpret the behaviors were positively associated with aggressive- of others as hostile or aggressive).62,63 ness.

Controlled studies: ■ ADDICTION AND ABUSE Also equivocal for aggression OF OTHER SUBSTANCES Placebo-controlled studies using supraphysio- logic doses of anabolic-androgenic steroids An estimated 14% to 57% of anabolic-andro- have also been equivocal. genic steroid users develop dependence. How

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addiction develops is unknown, but psycho- as teenagers or adults, and most started or logical dependence is believed to play a large increased their weightlifting activities as a role.14 defense strategy. Seven of the 10 rape victims Different substance abuse patterns exist in used anabolic steroids.70 different populations that use anabolic-andro- genic steroids. ■ EFFECTS IN CHILDREN Kanayama et al11 found that steroid-using weightlifters almost always previously tried A few studies have examined the behavioral other illicit substances. On the other hand, effects of anabolic-androgenic steroids in chil- others found that elite athletes, weightlifters, dren. and bodybuilders rarely abuse illicit drugs, Finkelstein et al,71 in a double-blind, reflecting their interest in optimizing their placebo-controlled, crossover trial, gave injec- physique and performance.14,45 tions of testosterone in increasing doses to 35 Adolescents who abuse steroids are more boys and oral doses of conjugated to likely to smoke and use other illicit substances 14 girls with delayed . Both treatment than are older users.12 Steroid abuse in adoles- groups had more physical aggressive behavior cents is especially worrisome because of the and aggressive impulses than those receiving danger of further illicit drug experimentation. placebo. Results of the Monitoring the Future study A study by van Goozen et al72 compared reinforce these concerns.10 plasma levels of in 15 boys with Unfortunately, even substance abuse conduct disorders and in 25 normal controls. treatment centers frequently overlook the use The boys with conduct disorders had signifi- of anabolic-androgenic steroids and other sub- cantly higher levels of dehydroepiandros- stances that athletes tend to use. terone , marginally significantly higher A study of 200 men admitted to substance levels of , and no differences abuse treatment centers found that 13% had a in testosterone levels. history of anabolic-androgenic steroid use. Steroid Despite being common, steroid use was often ■ TREATING PSYCHIATRIC EFFECTS abusers rarely unrecognized by the physician. In this study, OF STEROID USE 25% of opiate users admitted to earlier steroid seek help, and use.6 Little information is available about treating many regard Wines et al68 reported on anabolic-andro- the psychiatric effects of anabolic-androgenic genic steroid users who were dependent on steroids. Steroid abusers rarely seek help, and the psychiatric the opiate analgesic nalbuphine hydrochlo- many regard the psychiatric effects as benefi- effects as ride. Anecdotal reports from users describe cial, especially for athletes in certain sports. beneficial the analgesic’s widespread abuse in gymnasi- Illicit use is compounded by mistrust of doc- ums for treating pain from excessive training. tors, a perception that medical people lack knowledge about these drugs, and fear of stig- ■ EFFECTS IN WOMEN ma or negative consequences that may result from drug use being exposed. Few studies have evaluated the effects of ana- Malone and Dimeff73 reported that four bolic-androgenic steroids in women. men who had used anabolic-androgenic Gruber et al69 evaluated 75 body- steroids in high doses over a long time and builders and weightlifters and found that 33% who developed severe depression when they reported current or past anabolic-androgenic stopped the drugs responded to treatment steroid use. Among steroid users, 56% report- with fluoxetine (Prozac). ed hypomanic symptoms during use, and 40% Rashid74 described a patient who had reported depression when the steroids were been diagnosed with bipolar disorder and discontinued. Some users developed a body antisocial personality disorder who was secret- image distortion similar to “reverse anorexia,” ly abusing anabolic-androgenic steroids. He in which they felt they were too small. significantly improved when the steroids were Ten of the 75 weightlifters had been raped stopped. Providing the patient with literature

350 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 5 MAY 2007 about the negative physiologic and psychiatric pressants should be used.76 Psychotherapeutic effects of testosterone was helpful. interventions to encourage and maintain absti- The first step in treating psychiatric effects nence are essential.74,75 of anabolic-androgenic steroids is to get the To withdraw steroids, it is reasonable to patient to stop using steroids and to address any taper off high doses by substituting testos- psychiatric or physical symptoms.75 A short terone enanthate in gradually decreasing course of an antipsychotic can help doses. Clonidine (Catapres) may help in treat- treat mania and psychosis. In severe cases, hos- ing withdrawal, as some researchers postulate pitalization is needed. For panic or anxiety an opiate-like withdrawal mechanism.76 symptoms, the short-term use of benzodi- Information about the physical and psychi- azepines is usually enough to control symptoms. atric dangers of anabolic-androgenic steroids If long-term treatment is needed, selective sero- should be made more readily available for the gen- tonin reuptake inhibitors or tricyclic antide- eral population and especially for adolescents. ■

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Testosterone replace- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; ment therapy for hypogonadal men with major depressive dis- e-mail [email protected].

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