Clinical and Research News
Psychiatrists Urged to Learn Signs of Steroid Use
Psychiatric News
Volume 43 Number 24 page 14-21

Don Hooton wants the world to know about his son, Taylor, a high school baseball player who committed suicide after using anabolic steroids to" bulk up" at the suggestion of his coach. Several episodes of rage persuaded Hooton that his son needed help, but it took six sessions with a psychiatrist for the boy to admit to steroid use.

Six weeks later, Taylor hanged himself during a period of acute depression.

Hooton now travels the country to alert athletes, coaches, and physicians about the dangers of steroids.

"Psychiatrists are seeing children today who are using steroids, but they won't recognize it unless they are trained," he told a group at the annual American Academy of Child and Adolescent Psychiatry (AACAP) meeting in Chicago in October. The psychiatrist who saw Hooton's son wasn't aware that a steroid screen was not included in the drug tests that the psychiatrist ordered for the boy, said Hooton.

Performance-enhancing drugs have migrated from the alpine peaks of the Tour de France down to the high school playing fields of Midwestern farm states and everywhere in between, Gary Gaffney, M.D., said at the meeting.

Teens are using drugs of all kinds not only to become the biggest, baddest player on the team but often just to look like one, said Gaffney, an associate professor of psychiatry at the University of Iowa's Carver College of Medicine.

"We think of drugs like steroids as used to improve athletic performance, but because they increase muscle mass and cause weight loss, they are also 'appearance-enhancing' drugs too, and that may be an even bigger motivation to use them in the U.S.," he said. While all evidence points to steroid use as a problem among adolescents, the scientific literature on the subject is sparse, said Gaffney.

Substances to improve athletic prowess have probably been used since the ancient Greeks invented athletics, but modern drug-development techniques have brought continuing waves of new chemical compounds sold legally or otherwise to boost strength, speed, power, endurance, quickness, oxygen capacity, alertness, or motivation, said Gaffney.

Anabolic steroids are the best known, but athletes and wannabees from high school to the Olympics also use stimulants, growth hormones, insulin, diuretics, painkillers, erythropoietin (EPO), vascular endothelial growth factor (VEGF), and anti-inflammatories of all kinds. Some are used to boost results in the gym or on the field, while others lessen side effects of those drugs or can hide them from drug testers. Users often "stack" the drugs, taking doses hundreds of times larger than therapeutic levels of several drug classes over a six-week cycle, then briefly going off the drugs.

Drugs are widely used in all professional sports, said Gaffney. More than 600 track athletes have been caught by anti-doping testing in the last 20 years. In the 1970s and 1980s, cyclists died from misuse of EPO, amphetamines, and other drugs.

The "arms race" among athletes and between athletes and sports regulators has only intensified over that time. "The East Germans doped adolescents without their knowledge, and many female athletes later bore disproportionate numbers of children with clubfeet or other skeletal deformities," he said.

Access to steroids and other drugs is simple, even for American high schoolers, added Thomas Hildebrandt, Psy.D., an assistant professor of psychiatry at Mt. Sinai School of Medicine in New York. Many begin by using over-the-counter nutritional supplements, attracted by dubious claims of health and strength. It's a short step from supplements to clandestine chemical muscle builders, he said.

"An estimated 12 to 15 percent of supplements contain illegal prohormones or anabolic steroids, although it isn't clear whether they were incorporated accidentally or deliberately," he said.

In a small study now under way, Hildebrandt said he found that 85 percent of steroid users also took nutritional supplements before adding steroids to their regimen. He sees both psychological and social mechanisms at work to draw new users into the orbit of these drugs.

Using the same protein powder as the alpha male body builder down at the gym is an entry into a social group that is probably using steroids too, he said. "Using supplements in that setting also changes attitudes toward safety and effectiveness of illegal performance-enhancing drugs."

(The veterinary supply chain is often another source of the drugs for rural users.)

The list of side effects of steroids is long, depressing, and familiar to physicians although apparently not well enough known to young athletes. Males can develop acne, early male pattern baldness, jaundice, gynecomastia, testicular atrophy, swelling of the kidneys or liver, and edema. Female users may exhibit genital hypertrophy, hirsutism, clitoral hypertrophy, high blood pressure, and, paradoxically, weight gain.

Performance-enhancing drugs also induce psychiatric symptoms such as mood instability, rage, insomnia, and symptoms of mania, ADHD, or anxiety.

Psychiatrists should be aware of behavioral or physical changes in high-risk populations like athletes or bodybuilders.

Withdrawal can be difficult and produces its own set of symptoms: mood lability, depression, anxiety, insomnia, anorexia, headache, decreased libido, muscle or joint pain, a craving for steroids, and suicidality.

Patients trying to withdraw from these drugs feel weaker and more vulnerable than when they were using, and so they need psychosocial support to persevere, said Gaffney. An endocrine consult may be needed to deal with hypothalamic-pituitary-gonadal dysfunction.

"Symptomatic treatment may call for neuroleptics to manage psychosis, mood stabilizers, or SSRIs, but there is almost no research in this area," he said.

Given the pressures to excel at every level of athletics, persuading young people to avoid these drugs isn't easy.

Every avenue of society pushes performance-enhancing drugs, said Hooton. Advertisers for cars and other power-associated products idealize" steroids" as a metaphor for strength or better performance. That diffuses the idea that they are dangerous, illegal drugs. Slugger Mark McGwire's admission to using androstenedione (a prohormone then unregulated in professional baseball) sparked a 10-fold increase in sales, he said." It's hard to argue that steroids are bad if all their heroes use them."

Adults who play important roles in the lives of children must take more responsibility, said Gaffney. "Behind the elite athletes are trainers, coaches, and physicians—our colleagues."

Gary Gaffney's blog "Steroid Nation" can be accessed at<http://grg51.typepad.com/steroid_nation>.

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