M. Gahr, M. Kölle, E. Baumgarten
Oct 1, 2012
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Journal of clinical psychopharmacology
Abstract
To the Editors: Anabolic androgenic steroids (AASs) not only act on the skeletal muscles but also have various psychotropic effects. They have been associated with several major psychiatric symptoms and disorders such as violence, aggression, suicidal tendency, psychotic deterioration, cognitive impairment, depression, and mania. Among these, manic symptomswere considered to be the most frequent, as shown by a clinical trial with testosterone cypionate and a controlled study that analyzed a population of AAS-using athletes. The synthetic male sex hormone mesterolone has even been tested as an antidepressant in clinical studies in the 1980s. These studies, however, yielded inconsistent results. Here we report the development of a manic episode subsequent to oral intake of mesterolone in a previously mentally healthy person. The 38-year-old white patient was admitted to our psychiatric ward because of a maniform syndrome that was present for approximately 2 weeks. On admission, he demonstrated with disturbed contact behavior, logorrhea, incoherent thinking with flight of ideas, reduced attention and appetite, increase of impulse, euphoric mood, and reduced need to sleep. There were no overt psychotic phenomena in terms of megalomania or delusion. Physical examination was unremarkable (body weight, 96 kg; height, 178 cm; body mass index, 30.3 kg/m) apart from hypertrophic upper body musculature. Evidence for previous psychiatric disorders, especially history of an addictive disorder or abuse of psychotropic substances, was absent. Family history revealed major depressive disorder of the patient’s sister, mother, and aunt on the mother’s side. The patient was working as a car mechanic and had a stable partnership without children. On admission, routine blood examination including thyroid tests and urine drug screening (amphetamines, benzodiazepines, cannabinoids, cocaine, 3,4-methylenedioxymethamphetamine, opiates, tricyclic antidepressants) were unremarkable. Blood glucose levels as well as glycated hemoglobin (HbA1c) were within reference limits. Four days later, the patient suddenly reported to have used Proviron (mesterolone 25 mg/d) for muscle gain during the last 21 days before admission until the day of admission. He reported that he had been bodybuilding for more than 15 years and that he had never used any illicit substances, that is, from the group of AAS to enhance training effects before the use of mesterolone. As the initial urine samples were already discarded, urine was collected again (4 days after the last self-reported mesterolone intake) and analyzed for mesterolone metabolites (1>-methyl-androsterone, 1>-methyl5>-androstane-3>, 17A-diol), but as expected in view of the short window for drug detection, these substances could no longer be detected by means of gas chromatography combined with high-resolution mass spectroscopy and liquid chromatography combined with mass spectroscopy. In addition, pituitary hormones were measured normal. To rule out an underlying somatic disease affecting the central nervous system (eg, encephalitis), electroencephalogram, magnetic resonance imaging of the brain, and examination of the cerebrospinal fluid were performed without pathological findings. Hence, a diagnosis of (putative) mesterolone-induced mania (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 292.84, substance-induced mood disorder) was made. Initially, the patient was treated with olanzapine that was gradually increased up to 30 mg/d. Because of a remarkable increase in liver enzymes, olanzapine was discontinued, and amisulpride was administered. Because the patient developed parkinsonism under amisulpride at a dosage of 800 mg/d and the antimanic effect was still insufficient, we reduced amisulpride and administered lithium carbonate. Under treatment with lithium carbonate (lithium carbonate 1800mg/d) and amisulpride (400 mg/d), the patient developed complete remission within 2 months of in-patient treatment (Clinical Global Impression Y Improvement rating scale score = 1, ‘‘very much improved’’). At follow-up 6 months after discharge, the patient was still without psychopathological findings. Mesterolone (1-methyl-dihydrotestosterone) is a relatively weak androgen with only partial androgenicity. Thus, it is rarely used for oral testosterone replacement therapy in male patients with hypogonadism associated with androgen deficiency. Although its application in medicine is rather infrequent, mesterolone is still used in professional as well as in amateur sports to enhance training success, particularly regarding muscle hypertrophy, and thus, it can require medical treatment for the development of adverse effects, as in the case presented. To our Letters to the Editors Journal of Clinical Psychopharmacology & Volume 32, Number 5, October 2012