Is my finasteride causing my depression?
Depression in Finasteride Users: Full Evaluation is the Only Way
I’ve selected this question below for this week’s question of the week. It allows us to review the concept of depression in finasteride users and medication induced depression in general.
Question
I am a 42 year old male. I have been on finasteride for some time. I’m recently not feeling so great and my doctor wonders if I have depression from my finasteride pill. My health has not been good and I have high blood pressure and high cholesterol and take medications for these issues. I also have neuropathy and use gabapentin. I use Losec for stomach acid most days of the week.
Is stopping finasteride the right thing to do?
Answer
Thanks for the great question. I would need to know a lot more information about your story including your life from birth until now and review all your blood tests and review all your scalp photos to really get a good sense if stopping finasteride is the right thing to do or not.
If finasteride is related to your potential diagnosis of depression, then stopping it might make sense. You will loose hair if you stop.
If finasteride is NOT related to your potential diagnosis of depression, then stopping it might NOT make sense.
So a key point for you and your doctors to figure out is “how likely is it that finasteride is causing your depression?”
Let’s review some important points about depression and then we’ll come back to your question. It might seem like your question is simple … but it’s actually super complex.
Depression in the General Population
Depression is common in the population. This makes understanding depression and risks factors for depression absolutely essential. About 9 % of women and 5 % of men have depression. Depression and anxiety go together and about 50 % of those diagnosed with depression also have anxiety.
Data from the US National Health Interview Survey confirms just how common depression actually is. In 2019, surveyed people in the general public were asked about depressive symptoms in the prior 2 weeks. 2.8% of adults reported severe symptoms of depression, 4.2% reported moderate symptoms, and 11.5% reported mild symptoms The percentage of adults who experienced any symptoms of depression was highest among those aged 18–29 (21.0%), followed by those aged 45–64 (18.4%) and 65 and over (18.4%), and lastly, by those aged 30–44 (16.8%). Surveyed female respondents were more likely than male respondents to experience mild, moderate, or severe symptoms of depression.
How is the diagnosis of depression made?
The diagnosis of depression must be made by a practitioner who understands how to make the diagnosis. Making a diagnosis of depression is more than just recognizing a patient is sad. There are several depressive disorders that a specialist can make. A fully history and physical examination is needed and blood tests are needed as well to rule out other medical conditions that can cause depression. Blood tests for CBC, TSH, ferritin, AM cortisol, VDRL/RPR, vitamin B12, zinc, CRP, 25 hydroxy-vitamin D, testosterone, free testosterone, magnesium, folate, zinc, glucose, hemoglobin A1c should all be carefully considered in any patient with depression. For women, consideration should be given also to estradiol testing if the patient is not using hormone related medications. Testing for a celiac panel and ANA may be warranted if the history and physical examination show these tests are also warranted.
The DSM 5 Criteria for Depression
The DSM-5 outlines the criteria to make a diagnosis of depression. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines a major depressive episode as at least two weeks of a depressed mood or loss of interest or pleasure in almost all activities, as well as at least five other symptoms, such as:
Depressed mood most of the day, nearly every day.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
Diminished ability to think or concentrate, or indecisiveness, nearly every day.
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition.
What are practical ways to “screen” and “diagnose” for depression?
To “screen” for depression, physicians often use the two question PHQ2 first. This simple questionnaire asks 1) whether or not the patient has had little interest or pleasure in doing things and 2) whether the patient has been feeling down, depressed or hopeless. If the patient scores 3 or more, it’s considered a positive screen. From there, the physician moves on to using the PHQ 9 (Patient Health Questionnaire 9). The PHQ9 helps the physician determine if the patient meets the criteria for a depressive disorder and then to evaluate the severity of the disorder. In terms of depression severity, a score of 0-4 indicates no depression, a score of 5-9 indicates mild depression, a score of 10-14 indicates moderate depression, a score of 15-19 is moderately severe depression and a score of 20-27 is severe.
What is drug induced depression (DID)?
It’s clear that some medications can cause depression. With your story and the medications you’ve listed, it will be important to evaluate if any of your other medications could be affecting your mood
Depression caused by medications is known as drug induced depression or substance induced depression. Linking the use of a drug to new onset depression can be challenging and requires expertise. It’s far more complicated than simply looking at a list of drugs that can cause depression and finding that the patient is using one of those drugs. One needs to figure out how likely it is that the drug is causing depression. Many people take medications that potentially could cause depression but the patient never ends up having depression.
A 2018 study in the Journal of the American Medical Association showed that up to 37 % of the public is on medications that can potentially cause depression. I have a handout that I often given physicians that train with me. It shows the most common drugs that are implicated in depression.
Drugs Reported to Cause Depression in A Subset of Users
Definitively linking a medication to depression requires good science. Often it’s not possible to definitively link it only to give an estimate of the likelihood. One needs to start with a good history, conduct a thorough physical examination and order blood tests to rule out conditions that cause depression.
Thereafter, one can use objective scales like the Naranjo Score to get a better sense of whether a drug might be connected to the depression. We’ll review this again in just a moment.
In your case, Losec and gabapentin are potential triggers of depression. If you started these recently and developed depression recently it’s more likely these are a trigger than if you started finasteride 15 years ago. Also, if you just lost your job, got divorced or had a death in the family, it could be that medications are not related at all. Please be sure to review your entire story with your doctors.
Finasteride induced depression (FID)
With this important information behind us, we can return to your excellent question about finasteride.
There is clear evidence that finasteride can cause mood changes in some patients. It has been better studied in males than females given that finasteride is FDA approved for males and not formally approved for use in females. Studies suggest that finasteride may cause depression in 1-2 % of users. Suicidality is increased as well. Those interested may wish to review our prior discussion
For most men, finasteride does not trigger depression. I don’t know your story so I can’t say whether there is any potential link of not. Only you and your doctor can work through this and the Naranjo Risk Scale Can help you.
The Naranjo Scale for Finasteride: Questions that You and Your Doctor Need to Work Through
Let’s walk through the kind of thinking that is needed as you think about the likelihood finasteride caused your depression:
1. Are there previous conclusive reports on this reaction with finasteride?
Yes there is so go ahead and score 1 point
2. Did the adverse events appear after the finasteride was given?
Yes (+2) No (-1) Do not know or not done (0)
You’ll need to figure this out.
3. Did the adverse reaction improve when finasteride was discontinued ?
Yes (+1) No (0) Do not know or not done (0)
You and your doctor can decide if stopping finasteride is reasonable for a period of time or switching to topical is reasonable.
4. Did the adverse reaction appear when finasteride was readministered?
Yes (+2) No (-1) Do not know or not done (0)
You and your doctor can figure out if a rechallenge is going to be appropriate. By rechallenge, I mean giving back the drug after a period of time.
5. Are there alternative causes that could have caused the reaction?
Yes (-1) No (+2) Do not know or not done (0)
In your case that answer is yes so you subtract one point. You have gabapentin as a cause and Losec and maybe there are other causes too. You and your doctor can work through all those .
6. Did the reaction reappear when a placebo was given?
Yes (-1) No (+1) Do not know or not done (0)
This is rarely done - so most score zero.
7. Was the finasteride detected in any body fluid in toxic concentrations?
Yes (+1) No (0) Do not know or not done (0)
This is rarely done - so most score zero.
8. Was the reaction more severe when the finasteride dose was increased, or less severe when the finasteride dose was decreased?
Yes (+1) No (0) Do not know or not done (0)
You and your doctor can determine if cutting the dose in 1/2 make sense and see how you feel.
9. Did the patient have a similar reaction to the same or similar 5 alpha reductase blocking drugs in any previous exposure?
Yes (+1) No (0) Do not know or not done (0)
This is rarely done - so most score zero. If you used dutasteride in the past and had depression, you’d score 1 point.
10. Was the adverse event confirmed by any objective evidence?
Yes (+1) No (0) Do not know or not done (0)
This is generally scored 1 point.
Determining the Naranjo Score for Finasteride Users
Scores can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'
Right now, you are probably somewhere between 1 and 4. There are things that you are your doctor can try that can help better define the liklihood that finasteride is related to your depression.
Conclusion
If you are not feeling yourself, you really need expertise advice from a physician knowledgable about depression and mood disorders and how the various drugs you are on affect mood. This is not something that I’ll be able to fully answer here.
Stopping a medication may or may not be the right answer - but this needs to be taken on a case by case basis. Immediately stopping a medication that is essential for your health is not going to be a good idea and could in fact cause harm. For example, if you’re on gabapentin and you think it’s contributing to depression, you need to speak with your doctor rather than just stop on your own. A referral to a neurologist may even be advised. Similarly, if you think Losec is the cause, stopping this may or may not be the right strategy. You can imagine a situation where your acid gets worse and you get a serious life threatening ulcer. You need a solid plan and switching medications or lowering medications might be the right plan.
When it comes to finasteride, there are options to stop or lower the dose or switch to topical finasteride. You might find this video segment helpful if thinking about topical finasteride. Again, if there is no good evidence that finasteride is the culprit, stopping it might not be the right plan.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. DSM-5. Washington, DC: Author.
Qato DM, Ozenberger K, Olfson M. Prevalence of prescription medications with depression as a potential adverse effect among adults in the United States. JAMA. 2018;319(22):2289-2298. doi:10.1001/jama.2018.6741
Pompili et al. Risk of Depression Associated With Finasteride Treatment. J Clin Psychopharmacol 2021 May-Jun 01;41(3):304-309.
Rogers D and Pies. General Medical Drugs Associated with Depression. Psychiatry (Edgmont). 2008 Dec; 5(12): 28–41.