What are the mental health side effects of finasteride (BPH/androgenetic alopecia medication)?

Mental Health Side Effects of Finasteride

Finasteride is associated with significant mental health side effects including depression, anxiety, and suicidality, particularly in younger men using it for androgenetic alopecia, with evidence suggesting these effects may persist even after discontinuation of the medication. 1

Sexual and Mental Health Side Effects

Established Side Effects

• Sexual dysfunction is the most well-documented adverse effect of finasteride, including:
  • Erectile dysfunction (2-4% higher than placebo) 2
  • Decreased libido (statistically significant increase) 2
  • Decreased ejaculate volume 2
  • Gynecomastia 2

Mental Health Side Effects

• Depression:

  • Finasteride can significantly increase depression scores 3
  • Higher rates of depression in androgenetic alopecia patients (0.5% vs. 0.4% in controls, p=0.007) 4
  • Nearly 50% of men in some studies reported clinically significant depression 5

• Anxiety:

  • Higher rates in androgenetic alopecia patients (0.6% vs. 0.4% in controls, p=0.04) 4
  • Finasteride identified as a risk factor for anxiety (OR 1.449, p=0.002) 4

• Suicidality:

  • Significant disproportionality signal for suicidality (Reporting Odds Ratio 1.63) 6
  • Stronger signal in younger patients (ROR 3.47) and those using for alopecia (ROR 2.06) 6
  • Recent data shows concerning upward trend in suicidality reports, peaking in 2022-2024 7

Risk Factors for Mental Health Side Effects

• Age: Younger patients (<45 years) show stronger signals for adverse mental health effects 6
• Indication: Higher risk in those using finasteride for androgenetic alopecia versus BPH 4, 6
• Pre-existing conditions:
  • History of depression or other psychiatric diagnoses 5
  • Family history of mental health disorders 5

Persistence of Side Effects

• The American Urological Association acknowledges post-finasteride syndrome (PFS), a constellation of symptoms that may persist after discontinuation 1
• Sexual dysfunction associated with finasteride may decrease over time but can remain statistically significant even with continued treatment 2
• The FDA has added warnings about potential persistent sexual side effects 1

Clinical Implications and Management

Patient Screening and Monitoring

• Screen for psychiatric history before initiating finasteride 5
• Regular assessment of mental health during treatment 1
• Consider alternatives for patients with pre-existing mental health conditions 1

Patient Counseling

• Discuss potential for persistent sexual and psychological side effects before starting therapy 1
• Inform patients about the risk of depression, anxiety, and suicidality, particularly in younger men using for hair loss 6, 7
• Advise discontinuation at first sign of mental health problems 1

Important Caveats

• Reporting bias may influence adverse event data, particularly after 2012 when public awareness increased 6
• The absolute incidence of psychiatric side effects remains relatively low (1-2.3% in population studies) 4
• Risk-benefit assessment differs between BPH and androgenetic alopecia indications 4, 6

While finasteride is effective for its intended uses, clinicians must carefully weigh the risk-benefit ratio, particularly in younger patients seeking treatment for hair loss, and maintain vigilance for emerging mental health symptoms throughout treatment.