Table 1.
Data items extracted from the selected studies
| Author(s)/ Year of Publication | Country | Study Type | Participants Sample | Psychopathology Assessment Methods | Key Findings |
|---|---|---|---|---|---|
| Mood disorders (n=12) | |||||
| Pope & Katz (1988) [53] | US | Cross-sectional | 41 bodybuilders and football players current or past AAS users | DSM-III-R criteria | 9 (22%) current AAS users displayed a full affective syndrome and 5 (12%) displayed psychotic symptoms. Another five (12%) developed major depression when they stopped taking AASs |
| Tennant et al. (1988) [66] | US | Case report | One bodybuilder AAS user | Semi-structured interview | The AAS user stated that he was “addicted” to AASs and could not stop to take them without experiencing severe withdrawal symptoms, including depression, disabling fatigue, nausea, and dizziness. A diagnosis of AAS dependence is hypothesized |
| Brower et al. (1989) [63] | US | Case report | One weightlifter AAS-dependent user | DSM-III-R criteria | The AAS-dependent user manifested severe depression and aggression during AAS use |
| Brower et al. (1990) [64] | US | Cross-sectional | 8 weightlifters AAS-dependent user | DSM-III-R criteria | The AAS-dependent users often lamented depressive symptoms |
| Lindström et al. (1990) [65] | Sweden | Cross-sectional | 53 bodybuilders AAS users | Semi-structured interview | 27 (51%) AAS users reported unspecified mood disturbances |
| Perry et al. (1990) [55] | US | Cross-sectional | 20 weightlifters AAS users; 20 weightlifters AAS nonusers (controls) | Standardized Psychological Index; DSM-III-R criteria |
AAS users had significantly more somatic, depressive, anxiety, hostility, and paranoid symptoms when using AASs than when not using them (p<0.005). They also had significantly more depressive, anxiety, and hostility symptoms compared to AAS nonusers (p<0.005). However, no difference in the frequency of major psychiatric disorders was found between the two groups |
| Bahrke et al. (1992) [4] | US | Retrospective, controlled | 12 male weightlifters current AAS users; 14 male weightlifters past AAS users; 24 male weightlifters AAS nonusers (controls) | Semi-structured interview; physical and medical history questionnaire; Profile of Mood States Questionnaire; Buss-Durkee Hostility Inventory | AAS current users, past users, and nonusers showed no significant difference in the Profile of Moods scale and subscale scores |
| Pope & Katz (1994) [54] | US | Cross-sectional | 88 weightlifters AAS users; 68 weightlifters AAS nonusers (controls) | DSM-III-R criteria | 20 (23%) AAS users reported major mood disorders vs. only 4 (6%) of AAS nonusers (p<0.01). Moreover, AAS users displayed mood disorders during AAS exposure significantly more than in the absence of AAS exposure (p<0.001) |
| Malone et al. (1995) [58] | US | Retrospective, controlled | 164 weightlifters and bodybuilders, either current AAS users, or past AAS users, or AAS nonusers | DSM-III-R criteria | Past AAS users had a higher incidence of psychiatric diagnosis than current users and nonusers. About 10% of current AAS users had hypomania. Depression occurred when AAS were stopped in about 10% of weightlifters and bodybuilders. Present psychoactive substance abuse or dependence was relatively low across all user categories. AAS dependence was found in 12.9% of current AAS users and in 15.2% of past AAS users |
| Mood disorders (n=12) | |||||
| Gruber & Pope (2000) [59] | US | Retrospective, controlled | 25 female athletes current or past AAS users; 50 female athletes AAS nonusers (controls) | DSM-IV criteria | 14 (56%) AAS users reported hypomanic symptoms during AAS use and 10 (40%) reported depressive symptoms during AAS withdrawal, but none met full DSM-IV criteria for a hypomanic or major depressive episode. Both AAS users and nonusers frequently reported muscle dysmorphia |
| Perry et al. (2003) [57] | US | Retrospective, controlled | 10 male weightlifters AAS users; 18 male weightlifters AAS nonusers (controls) | Hamilton Depression Rating Scale; Hamilton Anxiety Scale; Mania Rating Scale; Buss-Durkee Hostility Inventory; Point Subtraction Aggression Paradigm; Personality Disorder Questionnaire | AAS users reported more affective – i.e., depressive and manic – symptoms than AAS nonusers |
| Papazisis et al. (2007) [67] | Greece | Case report | One bodybuilder/martial artist AAS user | Semi-structured interview | The AAS user, with a prior history of psychotic depression, was hospitalized for a manic episode and was diagnosed with an AAS-induced mood disorder with manic features |
| Ip et al. (2012) [86] | US | Cross-sectional | 112 male fitness amateurs, bodybuilders and weightlifters AAS-dependent users; 367 male fitness amateurs, bodybuilders and weightlifters AAS-nondependent users (controls) | DSM-IV-TR criteria | AAS-dependent users were more likely to have a diagnosis of a major depressive disorder (15.2% vs. 7.4%, p=0.012) than AAS-nondependent users |
| Lindqvist et al. (2013) [56] | Sweden | Retrospective, controlled | 136 AAS user male former élite athletes in power sports vs. 547 nonuser male former elite athletes in power sports | 30-year follow-back | AAS users sought significantly more often than nonusers professional help for depression (13% vs. 5%; p<0.001), anxiety (13% vs. 6%; p<0.01), melancholy (13% vs. 4%; p<0.001), and worry for mental health (8% vs. 3%; χ2=6.77; p<0.01) |
| Suicide (n=7) | |||||
| Brower et al. (1989) [63] | US | Case report | One weightlifter AAS-dependent user with suicidal ideation | DSM-III-R criteria | The AAS-dependent user manifested severe depression. He had no personal or family history of depression or suicidal tendencies |
| Thiblin et al. (1999) [74] | Sweden | Case series | 8 male athletes AAS-users deceased by suicide | Medico-legal examination; systematic interview with survivors (i.e., family members, friends) |
5 (62.5%) suicides were committed during current AAS use and 2 (25%) following two and six months of AAS withdrawal, respectively. In one case (12.5%) it was unclear whether the suicide was committed during current use or after recent discontinuation |
| Suicide (n=7) | |||||
| Pärssinen et al. (2000) [76] | Finland | Prospective, controlled | 62 male elite weightlifters suspected AAS users; 1094 population controls | 12-year follow-up | A 4.6 times higher mortality rate (95% CI 2.04-10.45; p=0.000) was found in the athletes compared to the general population. The main causes of death were suicide (5%) and myocardial infarction (5%) |
| Thiblin et al. (2000) [75] | Sweden | Retrospective | 25 deceased male athletes current AAS users; 9 deceased male athletes past AAS users | Medico-legal examination | A high proportion (59%) of AAS users died by violent death, i.e., suicide (n=11, 32%) or homicide (n=9, 27%). Suicide was related to impulsive, aggressive behavior characterized by violent rages and mood swings and associated with AAS use |
| Petersson et al. (2006) [77] | Sweden | Retrospective, controlled | 52 deceased athletes AAS users; 68 deceased amphetamine and/or heroin users negative for AAS; 329 deceased AAS and amphetamine and/or heroin nonusers | Medico-legal examination | 44% percent of AAS users died by violent death, i.e., homicide (n=12, 23%) or suicide (n=11, 21%), compared to 7% of amphetamine and/or heroin users. No significant difference between AAS users and AAS and amphetamine and/or heroin nonusers was found, as the proportion of violent death in the latter group was 38% |
| Papazisis et al. (2007) [67] | Greece | Case report | One bodybuilder/martial artist AAS user | Semi-structured interview | The AAS user, with a prior history of psychotic depression, committed suicide after a brief hospitalization for a manic episode, during which he was diagnosed with an AAS-induced mood disorder with manic features |
| Lindqvist et al. (2014) [78] | Sweden | Retrospective, controlled | 181 male elite athletes in power sports suspected AAS users; population controls | 30-year follow-up | No significant increased mortality rate was found in the athletes compared to the general population, but in the age interval of 40-50 years. there was a slightly increased mortality (3.0 vs. 2.2). The main causes of death were cardiovascular disease (n=66, 36%), tumors (n=37, 20%), and suicide (n=21, 11%). A 1.74 times higher mortality rate from suicide (95% CI 1.08-2.66, p=0.025) was noticed in the observed dead athletes when compared to the general population |
| Darke et al. (2014) [79] | Australia | Case series | 24 deceased male bodybuilders, fitness trainers, and bodyguards AAS users | Medico-legal examination | 15 (62.5%) AAS users died from accidental drug toxicity, 4 (16.7%) from suicide by gunshot or hanging, and 3 (12.5%) form homicide |
| Anxiety (n=3) | |||||
| Pope & Katz (1988) [53] | US | Cross-sectional | 41 bodybuilders and football players current or past AAS users | DSM-III-R criteria | 9 (22%) AAS users displayed a full affective syndrome and 5 (12%) displayed psychotic symptoms |
| Ip et al. (2012) [86] | US | Cross-sectional | 112 male fitness amateurs, bodybuilders and weightlifters AAS-dependent users; 367 male fitness amateurs, bodybuilders and weightlifters AAS-nondependent users (controls) | DSM-IV-TR criteria | AAS-dependent users were more likely to report an anxiety disorder diagnosis of (16.1 vs. 8.4%, p=0.02) than AAS-nondependent users |
| Anxiety (n=3) | |||||
| Ip et al. (2014) [60] | US | Cross-sectional | 67 male AAS users and 76 male AAS nonusers recruited from fitness, weightlifting, bodybuilding, and steroid websites |
Semi-structured interview | 8 (12%) AAS users reported an anxiety disorder diagnosis in comparison with only 2 (2.6%) AAS nonusers, showing a significant difference (p=0.046) |
| Somatoform and eating disorders (n=8) | |||||
| Pope and Katz (1994) [54] | US | Cross-sectional | 88 male weightlifters AAS users; 68 male weightlifters AAS nonusers (controls) | DSM-III-R criteria | 16 (18.2%) AAS users reported a history of muscle dysmorphia vs. 0 (0%) of AAS nonusers |
| Blouin & Goldfield (1995) [105] | Canada | Cross-sectional | 139 male bodybuilders, runners, and martial artists | Eating Disorder Inventory; Beck Depression Inventory; Rosenberg Self-Esteem Scale; Anabolic Steroid Questionnaire; Drive for Bulk Scale; three Participation Questionnaires designed for bodybuilding, running, and martial arts |
Bodybuilders reported the greatest use of AASs and the most liberal attitudes towards AAS use. AAS users reported that the main reason for taking them was to improve looks |
| Schwerin et al. (1996) [106] | US | Cross-sectional | 35 male bodybuilders AAS users; 50 male bodybuilders AAS nonusers; 50 athletically active male exercisers AAS nonusers; 50 male nonexercisers AAS nonusers |
Body Dissatisfaction Index; Upper Body Strength Scale; Social Physique Anxiety Scale; Brief-Fear Of Negative Evaluation | AAS-users had significantly lower levels of social physique anxiety, significantly higher upper body strength ratings, and higher – but not reaching statistical significance – body dissatisfaction than AAS nonusers |
| Goldfield et al. (2006) [108] | Canada | Cross-sectional | 27 competitive male bodybuilders; 25 recreational male bodybuilders; 22 men with bulimia nervosa | Semi-structured interview | Competitive bodybuilders reported higher rates of AAS use compared to recreational bodybuilders |
| Kanayama et al. (2003) [107] | US | Cross-sectional | 48 male weightlifters current or past AAS users; 41 weightlifters AAS nonusers (controls) | Rosenberg Self-Esteem Scale; Eating Disorders Inventory; Male Role Attitudes Scale | AAS users showed few differences from AAS nonusers on most measures, but they showed greater symptoms of muscle dysmorphia. AAS experimenters were largely indistinguishable from nonusers, whereas heavy AAS users showed significant differences from nonusers on many measures, including marked symptoms of muscle dysmorphia and stronger endorsement of conventional male roles. An association between both body image concerns and narrow stereotypic views of masculinity and AAS use was found |
| Somatoform and eating disorders (n=8) | |||||
| Cafri et al. (2008) [110] | US | Cross-sectional | 15 male weightlifters with current muscle dysmorphia; 8 male weightlifters with past muscle dysmorphia; 28 male weightlifters with no history of muscle dysmorphia (controls) | Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I); Muscle Appearance Satisfaction Scale; Muscle Dysmorphic Disorder Inventory-Functional Impairment Subscale; Body Dysmorphic Disorder Diagnostic Module; Body Dysmorphic Disorder modification of the Yale-Brown Obsessive-Compulsive Scale; Muscle Dysmorphia Symptom Questionnaire | No significant differences in AAS use, abuse or dependence were found among the three groups |
| Goldfield (2009) [109] | Canada | Cross-sectional | 20 female competitive bodybuilders; 25 female recreational weighttrainers (controls) | Beck Depression Inventory; Eating Disorder Inventory; DSM-III-R Diagnostic Interview Schedule; Bodybuilding Questionnaire; Anabolic Steroid Questionnaire; Drive for Bulk Scale |
8 (40%) competitive bodybuilders reported AAS use compared to 0 (0%) recreational weighttrainers |
| Walker et al. (2009) [111] | US | Cross-sectional | 550 male college athletes | Male Body Checking Questionnaire; Muscle Dysmorphic Disorder Inventory; Beck Depression Inventory-II; Positive and Negative Affect Schedule; Eating Disorder Examination Questionnaire; Questionnaire on Appearance- and Performance-Enhancing Drugs (APEDs) | 471 (85.8%) college athletes reported to be APED (appearance- and performance-enhancing drugs) nonusers, 78 (14.2%) reported to be current or, for the majority, past APED users. Among APED users, 2 (2.9%) took AAS. Body checking was the best predictor of APED use after weight and shape concerns, muscle dysmorphia, depression, and positive and negative affect were included in the logistic regression analysis. Body checking uniquely accounted for the largest amount of variance in the Muscle Dysmorphic Disorder Inventory scores (16%) |
| Behavioral disorders (n=9) | |||||
| Conacher & Workman (1989) [112] | Canada | Case report | One bodybuilder AAS users |
Semi-structured interview; psychiatric and criminal history recollection | The AAS user murdered his wife after three months of taking AASs, which caused significant personality changes, including irritability, quarreling, and sleeplessness |
| Choy et al. (1990) [116] | UK | Prospective, controlled | 3 male strength athletes AAS users; 3 male strength athletes AAS nonusers (controls) | Several months follow-up; Profile of Mood States Questionnaire; Buss-Durkee Hostility Inventory; Rosenweig Picture Frustration Test | AAS users were tested on four occasions: two on-drug periods and two off-drug periods; nonusers were tested in equivalent periods. Self-rated aggression increased significantly in AAS users during their on-drug periods, especially when using multiple AASs |
| Behavioral disorders (n=9) | |||||
| Lefavi et al. (1990) [115] | France | Cross-sectional | 14 male bodybuilders current AAS users; 13 male bodybuilders past AAS users; 18 male bodybuilders AAS nonusers (controls) | Psychological Profile Questionnaire | AAS users had more frequent, more intense, and lengthier episodes of anger, with some of them reporting instances of violence and lack of control. No dose-response or duration-response relationships were found and no significant difference was detected in the ways that AAS users expressed their anger in comparison with nonusers |
| Brower et al. (1991) [117] | US | Cross-sectional | 49 male weightlifters current AAS users | Anonymous, self-administered questionnaire on AAS use; DSM-III-R criteria | 46 (94%) AAS users met at least one DSM-III-R criteria for AAS dependence, 28 (57%) met three or more criteria, consistent with a diagnosis of AAS dependence. AAS-dependent users (n=28, 38%) could be distinguished from nondependent ones (n=21, 28%) by their use of larger doses, more cycles of use, and more aggressive symptoms |
| Bahrke et al. (1992) [4] | US | Retrospective, controlled | 12 male weightlifters current AAS users; 14 male weightlifters past AAS users; 24 male weightlifters AAS nonusers (controls) | Semi-structured interview; physical and medical history questionnaire; Profile of Mood States Questionnaire; Buss-Durkee Hostility Inventory | Current and past AAS users reported the following changes associated with AAS use: increases in aggression and irritability; changes in insomnia, muscle size, muscle strength; faster recovery from workouts and injuries; changes in libido. Current and past users and nonusers showed no significant difference in the Buss-Durkee Hostility Inventory scale and subscale scores |
| Choy & Pope (1994) [119] | UK | Retrospective, controlled | 23 strength athletes AAS users; 14 strength athletes AAS nonusers (controls) | Semi-structured interview; Dyadic Adjustment Scale; Conflict Tactics Scales | AAS users reported significantly more fights, verbal aggression, and violence towards their wives and girlfriends when using AAS than when not using them and in comparison to AAS nonusers |
| Stanley & Ward (1994) [118] | UK | Case report | One bodybuilder AAS abuser | Semi-structured interview | The bodybuilder with AAS abuse manifested psychiatric symptoms and a violent outburst associated with AAS consumption |
| Bond et al. (1995) [120] | UK | Cross-sectional | 16 male strength athletes current AAS users; 16 male strength athletes past AAS users; 14 male strength athletes AAS nonusers (controls) | Aggression Rating Scale; modified Stroop Color Word Conflict Task |
Current AAS users rated themselves more negatively than past users (p<0.10) and took longer than past users and nonusers to name the colors of all word sets of the Stroop test, but there were no significant differences between word sets. Therefore, attentional bias did not differ between groups, but current AAS use produced subtle mood changes and slowed performance compared to past AAS users and nonusers |
| Perry et al. (2003) [57] | US | Cross-sectional | 10 weightlifters AAS users; 18 weightlifters AAS nonusers (controls) | DSM-IV criteria; Mania Rating Scale; Hamilton Depression Rating Scale; Buss-Durkee Hostility Inventory; Point Subtraction Aggression Paradigm; Personality Disorder Questionnaire | AAS users showed increased aggression compared to AAS nonusers, which was related to higher testosterone plasmatic levels (p<0001). However, AAS users were also characterized by higher scores of DSM-IV histrionic (p=0.035), borderline (p=0.016), and antisocial (p=0.000) personality disorders, which may have acted as confounding factors |
| Psychosis (n=3) | |||||
| Annitto et al. (1980) [125] | US | Case report | One male athlete AAS user | Semi-structured interview | The AAS user developed an acute schizophreniform illness during AAS use |
| Pope & Katz (1988) [53] | US | Cross-sectional | 41 bodybuilders and football players current or past AAS users | DSM-III-R criteria | 9 (22%) AAS users displayed a full affective syndrome and 5 (12%) displayed psychotic symptoms |
| Teuber et al. (2003) [126] | Germany | Case report | One male athlete AAS user |
Semi-structured interview | The AAS user, eight weeks after an intramuscular injection of nandrolone, developed anxiety and psychotic symptoms |