Analytical review of depression and suicidality from finasteride
psychiatrist.com
psychiatrist.com
The "dedication" at the top should clue readers into what is going on -- it's not even trying particularly hard to look legitimate -- but alas.
Edit: this line, in particular, made me laugh. It is one of the more egregious examples of "pretending to do statistics" that I have seen recently:
> Table 1 summarizes the studies in the last decade examining a potential link between neuropsychiatric reactions and finasteride exposure. When prescribed mainly for AGA, all reports suggest that finasteride can cause depression, anxiety, suicide ideation, and suicides. Assuming a null hypothesis (finasteride does not affect mood) and a 50% chance of 1 result against this hypothesis, the probability of getting all 8 studies concluding against the null hypothesis by chance is 0.58 = 0.0039.
Maybe they are, maybe they aren't. Proof is required.
Now, I'm not going to argue that there can't be rare side effects that are only discovered with time. I'm also not going to claim that the original trials were perfect, or that research into the question isn't justified. But you're trying to assert that they didn't test for safety, and that's just factually incorrect.
Whether those harms outweigh the benefits overall remains to be seen and likely will never be known unless it's really really bad, which is likely not the case here.
I'd agree more research is probably justified, but there's likely little profit in it for anyone.
There have been over 30 randomized controlled trials of this drug, and the author picked only eight papers, none of which were randomized, none of which were controlled, and all of which were based on mining self-reported data from patient databases.
Come now.
There is no current listing for suicide, suicidal ideation, etc.
[1] https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/02...
[2] "Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure"
The difference here is that this article is someone with an axe to grind (again, see the "dedication", which is never done in a legitimate review; and the clownish application of statistics, which is so completely absurd that it implies incompetence, malice or both). I have no faith that this writer made a legitimate attempt to impartially weigh the evidence on this question.
Want to debate javascript frameworks and linux distros? sure, there’s great knowledge here.
This is not the case for most topics outside of software.
If you followed the health advice here you’d be living in a shed in Antarctica to avoid microplastics, taking shrooms for your mental health and rejecting all pharmaceuticals when you get an infection.
Five years ago, I was diagnosed with CKD (3A), so I stopped taking Finasteride, which was the only prescription drug I was taking. I cannot claim any causal relationship, but I have been happier for these past five years. Of course, it could be because I'm now retired and financially secure. My hair seems to be thinning again, but it's still there.
> It is difficult to imagine what data could justify hiding in a drug safety review.
I've been sceptical of any direct relationship between "post-finasteride syndrome" and sexual function, but I've never doubted the direct effect on mental health of suppressing dihydrotestosterone in cis men. (Even if the pharmacological effects end shortly after cessation, which I suspect, a sudden and unexplained strong feeling of constant wrongness can be traumatic.) The part I find interesting is that most men seem to be just fine with taking finasteride, even orally.
We have a lot of data about trans women taking finasteride as part of HRT and depression, and the clear correlation runs in the exact opposite direction from what this article is talking about.
> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
>> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
Judging from this and your other comments in the thread, I'm assuming you're not an endocrinologist.
You're pulling quotes from tertiary sources that at first glance seem to support the argument you're making, but you're missing the broader context, which is that pharmacokinetics and our endocrine systems are way more complicated than you're giving them credit for. It's not as simple as "drug A makes X go down, and X does Y, so A decreases Y".
It would make a lot of people's jobs much easier if that were the case, but the clinical reality is actually much more complicated.
"Drug A makes X go down, and X does Y, so A decreases Y" is a good description of the operation of finasteride and dutasteride (if we disregard the unexplained differences between the effects of the two drugs (we'd naïvely expect one to be strictly "better" than the other, but this is not the case)) on everything except the brain. Everything else responds as you'd expect a priori from modelling hysteresis with pencil and paper. But there's a lot we don't understand about the brain.
a sudden hormonal change can absolutely cause changes to mood and libido, but with finasteride these seem to be rare and generally mild. i would expect them to lessen or even disappear after some time of continued treatment. i wonder how often finasteride is discontinued before the body even has a chance to adjust to the new hormone levels. the claims that the side effects persist after discontinuation are particularly dubious, and they remind me of castration anxiety.
Sure but that's besides the point. I was responding to - and refuting - the claom:
> Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship would exist here.
There's no reason to believe that the effects of hormones on depression in trans people are predictive of hormones taken by cis people in completely different doses for different reasons, but it's especially fallacious to assume that it's not only predictive, but predictive of the the exact opposite effect.
This is a really weird argument because it gets so many basic facts wrong. The most fundamental of which is the idea that taking finasteride means lower testosterone levels - it doesn't!
And I'm not even going into the issues with all the other confounding variables at play here, such as the motivations and dosing schedules for HRT being substantially different from other uses of finasteride.
I really don't know why you're bringing up data about HRT for transgender people that's nearly a century old in an article that's not about HRT, when we have plenty of data that's not only far more recent but far more germane to the topic at hand.
I'm bringing up trans HRT in the 1930s (got the decade wrong, sorry!) because the Nobel Prize for the synthesis of testosterone was awarded in 1939. That discovery was made at the start of our understanding of what happens when you muck around with sex steroids: "what effect does this have on mental health?" has always been a question that people have considered, and I was frankly shocked by the article's claim that it hadn't been properly considered in the US.
Of course, others have pointed out that this article is more of a hit piece than a scientific work, so it appears my surprise was justified.
I think many men would also (naively) be happy to risk depression when confronted with impending hair loss. Ironically, maybe more happy chemicals are what's actually needed so we can feel like losing our hair is not the end of the world.
Without getting personal, finasteride didn't worsen my situation.
I have never had any other drugs/supplements/etc impact me like this. I'm kind of the 'feel no pain, don't pay attention to my body' type as well, so it was outside my comprehension this product could do this.
People REALLY need to be warned better if they are going to push this on so many ads, and the process is setup in a way you don't really get the risk brought to your attention. Between these risks and the huge testosterone drop when taking it I don't understand how there is a market for this.
Let me put this way: Assuming you only get 1 life on this earth, 1 body, one chance. You get certain bodily functions that basically work the same way from puberty into your older age assuming no other harm or accident. You are in mid adulthood you try a drug for a few months. you quit that drug because weird symptoms develop. shortly after stopping those symptoms magnify and then persist. you can classify the persistence in two categories (1) persistent irrevisble, my body worked this X or Y way in this or that category my entire life now it doesnt and hasnt for years. (2) slowly reversing with random waves of lingering symptoms. there is a small % of people that will get permanent issues from ssri similarly and for finasteride its a small % that get totally messed up. and i tried straterra (an ssri) once and had side effect that made me quit. read worse cases than mine but there is a subjectively persistent pushback that its all a delusional mental problem but if i knew you and talked to you in a secure setting and i can assure you this drug is exceptionally dangerous to a small % of people that try it and seems like we have no science and or data to tell who is at risk anywhere close reasonable safety.
If you would be willing to contact me privately about this, there are various ways for you to do so.
This might compound with the findings described in "Alcohol and Placebo: The Role of Expectations and Social Influence" (2020) https://doi.org/10.1007/s11469-020-00321-0:
> We suggest that expectations of inebriation formed by socialization and experiences can explain most of the behavioural changes following alcohol consumption.
If you can find someone who experienced these effects from taking finasteride, which persisted when they stopped taking it, despite them not ever really minding the symptoms at all, then that'd be evidence that my "it's trauma-related" theory is wrong. But all I'm aware of is people getting really distressed about normal/known side-effects of finasteride, and then afterwards they report a slew of other symptoms that are associated with PTSD.
We don't know which direction the arrow of causality points, and I'm not sure how to establish that.
Why? The topical product is cheap and available and effective. Why choose to take a pill rather than directly target the affected area?
I assume it still blocks enough hormones to cause mood shifts or other effects?
> I assume it still blocks enough hormones to cause mood shifts or other effects?
Endocrinology is a lot more complicated than you're giving it credit for. DHT blockers don't necessarily lower testosterone levels; they can actually increase it (although even then, the mechanism isn't as direct as you might think).
It's neither established nor a given that any side effects of finasteride have anything to do with effects on testosterone or hormone levels at all. A lot of people make that assumption, and there's reason to suspect there's truth to that hypothesis, but it's completely possible it's an unknown side effect of the drug, and there hasn't been enough study into the mechanism to understand it (in part because the side effects are relatively rare and weakly established).
As for DHT, that hormone doesn’t appear to have much significance for adult males. It’s critically important in puberty, though!
I know you probably didn't mean it this way, but Finasteride started as a treatment for prostate enlargement, and is still used for that.
I have several anecdotes from my own life. When I was ~18 the doctor proposed to give me jaw surgery to fix my overbite by extending my lower jaw. I asked him what the reasons for this were and he said it was mainly cosmetic. I thought this was not a good enough reason for surgery - which while often safe does also often have harmful side effects - I now know way too many people who had surgery complications that often took a long time for them to become aware of. I think I feel better about myself now for having made that choice than I imagine I would if I had a better jaw line.
It's true that some people are going to have a story where they see the cosmetic medical intervention as having been beneficial for their mental wellbeing. I'd still suggest that in many such cases there might have been other ways to get a better outcome. It's for each of us to decide.
Still, burden of proof of the safety of a drug should be on the company profiting from it.
I can tell you tho I would never consider it just so superficial. A lot of unconscious behavior happens based on facial symmetry that is hard wired into us. Malloclusions can effect breathing especially at night (some problems that will only surface later in life when options to fix limited by your age), the way other parts of your face look such as the nose, oral health, long term root problems, uneven wear etc etc
I had a doctor that just shrugged his shoulders and said the same thing to me. I wish id had a doctor that pressed me a little to really think about the long term picture when I had the chance.
If theres already problems like pain etc then obviously the justification is more than cosmetic.
I dont know if you are still young enough I would reconsider. I think in general overbites are still more bearable than under.
Another related anecdote from my own life, I had sleep apnea from when I was a teenager. Another doctor also proposed surgery to fix my nose for that, but somehow I'd become skeptical of doctors wanting to do surgery (probably I'd heard too many stories of something going wrong.) Anyway, a year ago I fixed my sleep apnea using a nose dilator and mouth tape at night for a month. I still have overbite but mostly breathe through my nose now.
Again, not saying that surgery or intervention is always bad, but this was an even more extreme case where they wanted to do surgery to fix something that could be fixed in a much more natural and much easier and extremely cheap way, but the natural way was never mentioned by a doctor, I only heard about it from a friend 15+ years later. And it just worked, and for the past year I've not had sleep apnea - I sleep better, don't snore anymore, and can breathe enough through my nose now while exercising etc. i.e. the nose must have been able to reshape itself with the help of the dilator and necessity (because the mouth was taped). I still have overbite but I'm not sure it's really a problem especially compared with the risks of surgery.
Since there is a known central activity, it also raises the question -- in fact the article explicitly mentions it -- of whether a brain-sparing analogue of finasteride might not show the same side effects.
The apparent connection to "masculinity" or "feminization" may be a red herring. Excessive concern about "sex" effects in biological systems kind of reminds me of the alchemical theory of the four elements. It's not a great way to analyze the complicated effects of medicines.
Additionally, topical is not FDA approved. While not necessary for research it adds typically unwanted complications to studies.
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Results: Compared with the controls, an increased risk of suicide attempts was observed in patients with AA, with an adjusted hazard ratio of 6.28 (95% confidence interval, 4.47-8.81). Suicide risk remained significantly elevated in AA patients when stratified by underlying psychiatric disorders. The mean age of initial suicidal behaviors was also lower in patients with AA.
Conclusions: Patients with AA had a significantly higher incidence of suicidal attempts than controls, regardless of concurrent psychiatric illness. Further studies are needed to elucidate the pathophysiology of the association between AA and suicidality. In addition, dermatologists should be aware of the increased suicidality of patients with AA.
https://pubmed.ncbi.nlm.nih.gov/36921592/
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Not enough time to size these in comparable numbers to this study, but would be really interesting.
Is it a net positive (reduced risk) over just going bald?
I still think it applies though; the psychological effect of being bald probably doesn't care much about the underlying cause.
There's also the fact that Alopecia Areata is actually more common in women, which I imagine exaggerates the distress compared to the more run of the mill MPB.
I realize you didn't mean to use a study on Alopecia Areata, but the difference in degree could be quite large.
I also wonder whether there's some degree of placebo going on. Patients know finasteride is anti-androgenic; perhaps when they inevitably experience some symptoms associated with hypogonadism they assume the worst and lament the choice between having hair and feeling youthful. This would also explain why many who get off finasteride don't notice their symptoms improve.
Personal bias: I've taken finasteride for years with no side effects.
Many people supposed that it’s just the acne making people depressed because it’s a nice plausible explanation, but it’s verifiably wrong.
If anything finasteride has improved my mental health. I've taken it for ~7 years with no negative side effects, and I'm certain it's the only reason I still have hair
I have been on it for 5 years but I didn't read stuff online about it before though so I didn't end up noceboing myself.
it's worth noting that candidates for finasteride treatment are already likely to be older and dealing with comorbidities like depression and anxiety, which makes it harder to say for sure if it's the drug in a lot of cases, but they do seem slightly higher than placebo. it is not surprising that a sudden change in hormone levels would cause a noticeable change in mood or sexual function, but there is usually improvement with continued treatment as levels stabilize.
for persistent effects, really there isn't a lot of reliable data to go on, and no plausible mechanism of action. we have a handful of anecdotal reports and some armchair hypotheses.
i'm happy to be proven wrong, and lots of drugs are indeed implicated in serious and lasting side effects, but in the case of finasteride i'm not convinced.
"after hormone levels return to baseline, there's no more pharmaceutical effect" Maybe no longer directly, but with one level of indirection there certainly _could_ be.
"no plausible mechanism of action" - I haven't looked into it to understand the mechanism of action for side effects from finasteride, but certainly if it can cause side effects during use, those could impact the body in a way that causes effects that persist past when usage stops.
Same with almost anything harmful that we do to our body - ideally the damage or effect is healed and we return to baseline, but very often we don't.
There could also be an effect where someone tried it, it didn't work as well as they wanted or it caused a side effect, and this was psychologically difficult to deal with and helped lead to depression and anxiety without that being directly chemically caused by the drug. And it would be fair to argue that that's not the drug's fault.
now it makes me feel a little anxious. it also gives me silent reflux feeling, which that i think already was there before as ive gotten older.
in short - before trying alcohol always made feel the same way - since trying that drug ive literally never felt that way from alcohol ever again. i never was much of a drinker only in college and a few years after. but even if you have wine at a guests house at dinner you can feel its effects quickly. thats just been completely gone ever since.
otherwise see my other comment https://news.ycombinator.com/item?id=45502828
The way the 'male products' company promotes and manages this drug might as well be OTC. It is basically set and forget on their side with zero discussion/follow up about the risks.
It seems clear to me that anything which has depression as a side effect has an increased risk of suicide as well and the only remaining truth to find is the degree.
The executives and scientists should both be prosecuted.
My whole family on both sides is bald bald. Without it I would have been bald bald in my early 20s.
I knew there were risks of hormone disruption/mood swings/etc but I still prefer it over being bald. I took a calculated risk and I'm thankful that the drug exists. Please don't prosecute the people that gave me the only real, working treatment for my baldness.
Dutasteride is not a stronger version of finasteride. It's a more effective DHT blocker, but it works differently.
The side effects are also different and not easy to predict. Some people have terrible side effects from finasteride and none from dutasteride. Some people have the opposite. And some people can tolerate either one. We don't have a way at the moment to reliably predict which one will work better or be better tolerated for a given individual.
Anyway, I'm glad it has worked for you, and I also would not want to prosecute people who've created a medication that's one of the most effective and well-tolerated around.
Idk about you, but i know 10s of different friends who also went through hairloss and were struggling to stop it, who went through severe depression, loss of confidence, suicidal tendencies in extreme cases.
Just because you saw a study that X drug causes side effects/harms in 1-0.1% of patients, doesnt mean the med should be taken off sale especially for a drug as important as finasteride.
It’s easy for someone to say it’s just a cosmetic drug until they go through the full extent of social, mental, and even physical damage, hairloss at a young age causes.
I and almost everyone who takes finasteride take it knowing the risk of a whole range of side effects , often far more severe then just increasing risk of depression. like risk of reduction in fertility, libido in some patients often struggling with obesity.
Obesity creates a whole range of problems too, should we start prosecuting creators of tasty food too ? , fin 1mg is one of the most impactful drugs sold globally both under brand names and generic cheap drugs (i take a generic one) that is life changing for almost a quarter or more of men depending on the country who face male pattern baldness and its related issues.
More studies certainly should be done in link of depression and suicide in some patient cases, but bringing out the pitchfork like luddites and asking to prosecute executives and scientists for a non-opiod, non-addictive, drug that’s been used safely for decades across generations, and saved families thousands of dollars (including mine) in snake oil salesman products that claim to treat hairloss but dont. They should get awards, not pitchforks.
I have receding hairline and I am not touching fin with a 10-foot pole. It's basically chemical castration.
Calling it chemical castration is plain wrong
For what? Many drugs have depression as a possible side effect, but that doesn’t mean they should be pulled from the market and executives prosecuted for simply the possibility of depression.
Negative reactions to drugs are always a possibility. Weighing the risks and tradeoffs and monitoring patients is important. This is why drugs like this are not OTC.
If there was some indication that the pharmaceutical company knew of and concealed evidence that finasteride caused depression/suicidality, then there could be grounds for criminal prosecution. But a non-consensus view in hindsight that a drug might increase depression looks more like a losing civil liability claim.