Psychiatric Price of Steroid Abuse

February 1, 2006

Anabolic steroids have gone from an appropriate treatment for men with hypogonadism to an agent abused by athletes, bodybuilders, adolescents, and young adults. Use of steroids at levels 10 to 100 times those of therapeutic dosages can cause psychiatric symptoms, such as aggression, mania, depression, and psychosis. Steroid abusers often "stack" several steroids or "pyramid" agents through a 4- to 12-week cycle. Presenting complaints of steroid abusers include muscle spasms, dizziness, frequent urination, and menstrual abnormalities. Signs may include high blood pressure, needle marks, icteric eyes, muscle hypertrophy, and edema; testicular atrophy and gynecomastia in men; and hirsutism and atrophied breasts in women. Mood changes can occur within a week of first use, and body changes may occur after acute behavioral disturbances.

Trenton AJ, Currier GW. Behavioral manifestations of anabolic steroid use. CNS Drugs. 2005;19:571-695.

Summary

Anabolic steroids have gone from an appropriate treatment for men with hypogonadism to an agent abused by athletes, bodybuilders, adolescents, and young adults. Use of steroids at levels 10 to 100 times those of therapeutic dosages can cause psychiatric symptoms, such as aggression, mania, depression, and psychosis. Steroid abusers often "stack" several steroids or "pyramid" agents through a 4- to 12-week cycle. Presenting complaints of steroid abusers include muscle spasms, dizziness, frequent urination, and menstrual abnormalities. Signs may include high blood pressure, needle marks, icteric eyes, muscle hypertrophy, and edema; testicular atrophy and gynecomastia in men; and hirsutism and atrophied breasts in women. Mood changes can occur within a week of first use, and body changes may occur after acute behavioral disturbances.

Persons who discontinue steroid use may have withdrawal symptoms, such as fatigue, anorexia, headaches, muscle and joint pain, decreased libido, and depression. Some experience suicidal ideation in connection with withdrawal.

Acute therapy may be needed for agitation, mania, or psychosis with medications such as antipsychotic agents, benzodiazepines, or valproate. Use of NSAIDs and antidepressants may also be necessary in the withdrawal period. Human chorionic gonadotropin can aid in returning the hypothalamic-pituitary-gonadal axis to normal functioning.

Commentary

You hardly need to change television channels to be informed about the latest scandal involving anabolic steroids. This is certainly a "hot" topic. As this excellent review exemplifies, it is surprising (in light of the significance of and public interest in this topic) how little is known about steroid abuse and its psychiatric sequelae.

Many recurrent themes are well articulated in this review. Do steroids make persons prone to violence, or are already violent persons more likely to take these agents? A similar question could be asked regarding the possible relationship between steroid use and suicidality. With bipolar disorder (particularly bipolar depression) now a more frequent consideration, the relationship between mood disturbances and steroid abuse seems murkier than before. That said, the review overall upholds the impression that steroid abuse is bad for one's mental health and can produce a range of psychiatric manifestations.

Reflecting the dearth of information currently available, the article falls short on treatment recommendations beyond general principles of care for drug abusers. It seems intuitive that the motivations of persons abusing steroids might differ from those of persons who use illicit street drugs.

Peter F. Buckley, MD Professor and Chairman Department of Psychiatry Medical College of Georgia Augusta