Introduction: Long-term use of anabolic-androgenic steroids, synthetic derivatives of the male sex hormone testosterone, can be associated with mood destabilizing effects and psychotic behavior. Most studies investigating psychiatric complications of anabolic-androgenic steroids have used small samples, but a comprehensive assessment of the risk of developing mental health disorders after steroid use has not been performed at the population level.
Methods: To determine whether anabolic-androgenic steroid use is associated with major depressive disorder and suicide attempts, we conducted a retrospective cohort study using the TriNetX database, which includes electronic health record data on 70 million patients from 44 US healthcare organizations. We propensity-score matched cohorts of men aged 18-50 who either used anabolic-androgenic steroids (inclusive of testosterone) or did not by age, race, ethnicity, testicular hypofunction (E29.1), nicotine dependence (F17), or alcohol-related disorder (F10). Outcomes were diagnosis of major depressive disorder (F32-33) and suicide attempt (T14.91, X71-83, T36-65 and T71 intentional self-harm codes) following anabolic-androgenic steroid use within 5 years.
Results: We analyzed 65,616 men who used anabolic-androgenic steroids and 12,249,640 men who did not. Following propensity score matching, anabolic-androgenic steroid use was independently associated with both Major Depressive Disorder (OR 2.06, 95% CI 1.95-2.18, p<0.0001) and Suicide Attempt/Intentional Self-Harm (OR 1.40, 95% CI 1.17-1.69, p=0.0003). Strengths of the study include a large sample size and high strength of association along with the ability to assess chronology of diagnoses as outcomes. Limitations include potential for incorrect coding and inability to assess precise duration of steroid use and timing of discontinuation.
Conclusions: Anabolic-androgenic steroid use was independently associated with mental health comorbidities. Men who use steroids should be screened for and counseled about risks of depression and suicidality. Future studies are necessary to elucidate whether a dose-response association exists, whether withdrawal from anabolic-androgenic steroids worsens the risk, and if patient selection or preventative measures can mitigate the risk.