REVIEW FARID TALIH, MD OMAR FATTAL, MD DONALD MALONE, JR, MD Department of Psychiatry and Department of Psychiatry, Head, Section of Mood and Anxiety, Psychology, and Sleep Disorders Lutheran Hospital, Cleveland Department of Psychiatry and Psychology, Center, Cleveland Clinic Cleveland Clinic Anabolic steroid 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 steroids (ie, is now on the rise in the general population, even testosterone and its derivatives) have been less well among adolescents. Physicians should be aware studied than their physical effects but are reported to of its signs and symptoms in order to address include depression, mania, psychosis, and aggression. 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. Gynecomastia, acne, lipid abnormalities, Athletes have used performance-enhanc- abnormal liver function tests, and personality 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 medications may help androgenic steroids were banned by the 4,6,7 treat steroid-induced mania and psychosis. International Olympic Committee in 1975. Benzodiazepines 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 antidepressants 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. Fluoxetine (Prozac) can be used in this situation. Professional athletes in almost every major CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 • NUMBER 5 MAY 2007 341 Downloaded from www.ccjm.org on September 27, 2021. For personal use only. All other uses require permission. ANABOLIC STEROIDS TALIH AND COLLEAGUES 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 Fluoxymesterone (Halotestin) poor relationships with fathers, a history of Mesterolone (Proviron) conduct disorders, a history of substance Methandienone (Dianabol) abuse, and poor body image.11 Race, educa- Methyltestosterone (Virilon) tion level, and income do not appear to be sig- Mibolerone (Cheque) nificant factors. Among adolescents, boys are Oxandrolone (Anavar, Oxandrin) Oxymetholone (Anadrol) more prone to abuse steroids than are girls, Stanozolol (Winstrol) and participation in organized sports and knowing someone who uses anabolic steroids Intramuscular preparations are predictors of future use.12 Boldenone undecylenate (Equipoise) Methenolone enanthate (Primobolan) In 1990, the illicit steroid market was esti- Nandrolone decanoate (Deca Durabolin) mated to be $400 million. Steroid cycles, typi- Nandrolone phenpropionate (Durabolin) cally lasting 6 to 14 weeks, can cost hundreds of Testosterone cypionate (Depotest) dollars. A cycle consists of daily oral doses plus Testosterone enanthate (Andro-Estro) weekly or monthly intramuscular depot injec- Testosterone propionate (Testex) tions. Some users take multiple cycles per year.2,5 Trenbolone 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 ANABOLIC STEROID 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 cholesterol.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 females, testosterone is produced in cerns about body image, and advances in bio- the adrenal glands and the ovaries.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 sex hormone-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 dihydrotestosterone, 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- estradiol, 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 Downloaded from www.ccjm.org on September 27, 2021. For personal use only. All other uses require permission. 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 injection, 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 stroke,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 danazol Nearly every cell in the human body has (Danocrine), an antigonadotropin 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 feedback inhibition shuts down injury.27–29