ReviewLong-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: A looming public health concern?
Introduction
The anabolic–androgenic steroids (AAS) are a family of hormones that includes the natural male hormone testosterone, together with its many synthetic relatives (Pope and Brower, 2005), all of which exhibit both anabolic (“muscle building”) and androgenic (“masculinizing”) properties (Kopera, 1985, Sheffield-Moore and Urban, 2004). AAS should not be confused with other types of steroids such as corticosteroids (e.g., cortisone or prednisone), which have no anabolic effects and hence little abuse potential (Pope and Brower, 2005, Sheffield-Moore and Urban, 2004). When taken in supraphysiologic doses, AAS allow users to greatly increase muscle strength and athletic performance, often well beyond the limit attainable by natural means (Kouri et al., 1995). As a result, many elite competitive athletes have used AAS—and this phenomenon has recently generated much publicity, as evidenced by burgeoning media reports around the world (Ewing, 2008, Fainaru-Wada and Williams, 2006, Magnay, 2008, Swartz, 2007) and recent investigations by the United States Congress (110th United States Congress, 2005; Mitchell, 2007). The great majority of illicit AAS users, however, are not elite athletes; indeed many are not competitive athletes at all, but simply individuals who want to become more muscular (Buckley et al., 1988, Kanayama et al., 2001b, Parkinson and Evans, 2006).
This much larger population of ordinary AAS abusers started to grow in the late 1970s and early 1980s (as detailed below), but has remained less visible than most other populations of substance abusers, because AAS users rarely seek treatment (Pope and Brower, 2008), rarely come to the attention of physicians in general (Dawson, 2001, Kutscher et al., 2002), and frequently distrust physicians (Pope et al., 2004). Field studies of these illicit users show that they commonly take two or more AAS simultaneously (a practice known as “stacking”), often ingesting a total AAS dose equivalent to 600–1000 mg of testosterone per week, and sometimes even 3000–5000 mg per week (Fudala et al., 2003, Parkinson and Evans, 2006, Parrott et al., 1994, Pope and Katz, 1988, Pope and Katz, 1994, Wilson-Fearon and Parrott, 1999). These latter doses are 50–100 times greater than the natural weekly production of testosterone by the normal male testis (Reyes-Fuentes and Veldhuis, 1993). Illicit users typically take AAS in repeated courses, or “cycles,” each lasting several weeks to several months (Pope and Katz, 1988), sometimes adding up to several years of cumulative lifetime exposure (Kanayama et al., 2006, Kanayama et al., 2003b, Parkinson and Evans, 2006).
Over the last 20–30 years, illicit AAS use has grown into a widespread substance abuse problem in the United States (Buckley et al., 1988, Johnston et al., 2006, McCabe et al., 2007, Yesalis et al., 1993) and many other countries (Galduroz et al., 2005, Handelsman and Gupta, 1997, Melia et al., 1996, Nilsson et al., 2001, Pallesen et al., 2006, Rachon et al., 2006, Wanjek et al., 2007). Most individuals with current or past AAS use are young men (Brower, 2002, Kutscher et al., 2002, Pope and Brower, 2005), but some – especially those who first started AAS in the 1980s – are now reaching middle age. Although many of these older men no longer use AAS, accumulating evidence suggests that they may still be vulnerable to long-term psychiatric and medical effects from their former drug use. In this paper, we suggest that these effects may pose a growing public health concern, as large numbers of these men move into middle age and beyond. As a foundation for this discussion, we begin with a more detailed chronology of the AAS epidemic, illustrated in Fig. 1, and explained in the following paragraphs.
Section snippets
The evolution of the problem
Testosterone was first isolated in the 1930s (David et al., 1935, Wettstein, 1935); synthetic derivatives of testosterone quickly followed, and both testosterone and other AAS were widely applied for medical and psychiatric purposes by the end of the following decade (Altschule and Tillotson, 1948, Gribetz et al., 1955). It was not until the 1950s, however, that athletes began to discover that AAS could greatly increase their muscularity. AAS were apparently first used by the Russians at the
Cardiovascular effects
Supraphysiologic doses of AAS appear to produce a range of adverse cardiovascular effects, including hypertension (Kuipers et al., 1991, Lenders et al., 1988, Urhausen et al., 2004), cardiomyopathy (Ferenchick, 1991b, Stolt et al., 1999, Sullivan et al., 1999, Vogt et al., 2002), left ventricular hypertrophy (Payne et al., 2004, Urhausen et al., 2004), dyslipidemia (increased low-density lipoprotein and decreased high-density lipoprotein cholesterol, with potential acceleration of
The prevalence of adverse effects in long-term AAS users
Little is known about the lifetime prevalence of the various medical and psychiatric consequences of AAS use described above. It might be speculated that publication bias exaggerates the apparent magnitude of AAS-associated pathology, in that rare cases of cardiac or hepatic toxicity, or of psychiatric effects such as violence or suicide, find their way into published case reports, while the great majority of long-term illicit AAS users are healthy. Indeed, some authors have suggested that
Conclusions
Accumulating evidence suggests that long-term use of supraphysiologic doses of AAS may have adverse effects on a number of organ systems, leading to both medical and psychiatric pathology. Importantly, accumulating evidence suggests that some of these effects may persist long after last AAS exposure. However, the frequency and severity of AAS-induced morbidity and mortality is still poorly understood, largely because these effects may not declare themselves until users enter middle or old
Conflicts of interest
Dr. Pope has provided expert testimony in legal cases involving anabolic steroids on two occasions in the last 3 years. Doctors Kanayama and Hudson report no conflicts of interest.
Acknowledgements
This work was supported in part by NIDA grant DA016744 (Drs. Kanayama, Hudson, and Pope).
Funding. Funding for this study was provided by NIDA Grant DA016744; NIDA had no further role in the design or writing of this review or in the decision to submit the review for publication.
Contributors. Authors Kanayama and Pope performed the literature searches, analysis of studies, and initial drafting of the manuscript. Author Hudson critiqued the initial draft and contributed to all subsequent
References (192)
- et al.
Behavioural anxiolytic effects of low-dose anabolic androgenic steroid treatment in rats
Physiol. Behav.
(1999) - et al.
Pursuit of the muscular ideal: physical and psychological consequences and putative risk factors
Clin. Psychol. Rev.
(2005) - et al.
Multiple hepatic adenomas after long-term therapy with testosterone enanthate. Review of the literature
J. Hepatol.
(1985) - et al.
Behavioral and physiological responses to anabolic–androgenic steroids
Neurosci. Biobehav. Rev.
(2003) - et al.
Detrimental effects of anabolic steroids on human endothelial cells
Toxicol. Lett.
(2007) - et al.
Hepatic angiosarcoma associated with androgenic–anabolic steroids
Lancet
(1979) - et al.
Sudden anabolic steroid abuse-related death in athletes
Int. J. Cardiol.
(2007) - et al.
Elevated testosterone induces apoptosis in neuronal cells
J. Biol. Chem.
(2006) - et al.
Hepatic angiosarcoma associated with androgenic–anabolic steroids
Lancet
(1979) - et al.
Androgenic–anabolic steroid abuse and platelet aggregation: a pilot study in weight lifters
Am. J. Med. Sci.
(1992)
Anabolic/androgenic steroid abuse and thrombosis: is there a connection?
Med. Hypotheses
Association of steroid abuse with cardiomyopathy in athletes
Am. J. Med.
Myocardial infarction associated with anabolic steroid use in a previously healthy 37-year-old weight lifter
Am. Heart J.
Household survey on drug abuse in Brazil: study involving the 107 major cities of the country–2001
Addict. Behav.
Psychiatric complications of anabolic steroid abuse
Psychosomatics
Hepatotoxicity associated with dietary supplements containing anabolic steroids
Clin. Gastroenterol. Hepatol.
Anabolic steroid abuse among teenage girls: an illusory problem?
Drug Alcohol Depend.
Risk factors for anabolic–androgenic steroid use among weightlifters: a case-control study
Drug Alcohol Depend.
Aortic elastic properties in athletes using anabolic–androgenic steroids
Int. J. Cardiol.
Anabolic steroids and withdrawal depression: a case report
Can. J. Psychiatry
The use of testosterone in the treatment of depressions
New Engl. J. Med.
Anabolic-androgenic steroids as a gateway to opioid dependence
New Engl. J. Med.
Anabolic steroid-induced hepatic adenomas with spontaneous haemorrhage in a bodybuilder
Aust. N. Z. J. Surg.
Psychological moods and subjectively perceived behavioral and somatic changes accompanying anabolic–androgenic steroid use
Am. J. Sports Med.
Weight training. A potential confounding factor in examining the psychological and behavioural effects of anabolic–androgenic steroids
Sports Med. Auckland, NZ
Psychological and behavioural effects of endogenous testosterone and anabolic–androgenic steroids. An update
Sports Med. Auckland, NZ
The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men
New Engl. J. Med.
Reversible hypogonadism and azoospermia as a result of anabolic-androgenic steroid use in a bodybuilder with personality disorder. A case report
J. Sports Med. Phys. Fitness
Withdrawal from anabolic steroids
Curr. Ther. Endocrinol. Metabol.
Anabolic steroid abuse and dependence
Curr. Psychiatry Rep.
Anabolic–androgenic steroid dependence
J. Clin. Psychiatry
Anabolic androgenic steroids and suicide
Am. J. Psychiatry
Clinical assessment and urine testing for anabolic–androgenic steroid abuse and dependence
Am. J. Alcohol Drug Abuse
Evidence for physical and psychological dependence on anabolic androgenic steroids in eight weight lifters
Am. J. Psychiatry
Estimated prevalence of anabolic steroid use among male high school seniors
JAMA
Anabolic steroid effects on body composition in normal young men
J. Sports Med. Phys. Fitness
Violence toward women and illicit androgenic–anabolic steroid use
Ann. Clin. Psychiatry
Muscle dysmorphia: a new syndrome in weightlifters
Br. J. Sports Med.
Muscle dysmorphia in weightlifters
Br. J. Sports Med.
Dilated cardiomyopathy and acute liver injury associated with combined use of ephedra, gamma-hydroxybutyrate, and anabolic steroids
Pharmacotherapy
A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States
J. Int. Soc. Sports Nutr.
A preliminary investigation into the relationship between anabolic–androgenic steroid use and the symptoms of reverse anorexia in both current and ex-users
Psychopharmacology
Legal Muscle: Anabolics in America
Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: a Doppler myocardial and strain imaging analysis * COMMENTARY
Br. J. Sports Med.
Anabolic steroids, brain and behaviour
Irish Med. J.
Uber Krystallinisches mannliches Hormon Hoden (Testosteron), wirksamer als aus Harn oder aus Cholesterin Bereitetes Androsteron
Zeit. Physiol. Chem.
Drugs in sport—the role of the physician
J. Endocrinol.
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