Depression: Prostate cancer diagnosis? Or could it be prostate-shrinking meds?

By Howard Wolinsky

Finasteride (Propecia or Proscar) and dutasteride (Avodart) are well-known to active surveillors with enlarged prostates who take these meds to shrink their glands to decrease their frequent post-midnight bathroom runs.

Enlarged prostates and prostate cancer are separate conditions that sometimes co-exist.

A new study appearing in in the Dec. 22 issue of JAMA suggests these drugs, known as 5α-Reductase Inhibitors (5-ARIs), might be linked with an increased risk for depression.

But the Swedish-Japanese team found no association between these meds and suicide or dementia.  {Don’t be fooled by the study’s title.]

They concluded: “There was no association between 5-ARIs and suicide, but both finasteride and dutasteride were associated with an increased risk for depression.” 

Researchers warn clinicians: “Both finasteride and dutasteride were similarly associated with depression with a constant risk over time, while neither drug was associated with suicide. Prescribing clinicians and potential users should be aware of the possible risks for depression associated with 5-ARI use.”

Researchers studied a registry of 2.3 million Swedish men aged 50-90. 79 227 (3.5%) of them started 5-ARI treatment between January 1, 2005, and December 31, 2018. Most took finasteride.

The statistically significant associations between 5-ARIs and depression are consistent with prior evidence and seem to emphasize the role of 5-ARIs in mood regulation, they said.

Why would this happen?

The researchers said that “a hypothesized mechanism to explain 5-ARI–induced depression and adverse cognitive outcomes is a decrease in the synthesis of neurosteroids and neuroactive steroids caused by the inhibition of 5-AR when taking 5-ARIs, owing to the important role that neurosteroids and neuroactive steroids play in neuroprotection, memory, and mood. However, many of the studies that investigated the association of 5-ARIs with dementia and depression had methodological shortcomings …”

Brian Helfand, MD, PhD, chief of the Division of Urology at NorthShore University HealthSystem outside Chicago, told me: “I think there is a risk to any medication. In fact, even antidepressants can initially increase the risk of depression and suicide.

“I think that it is hard to control for a lot of factors that may also contribute to this risk (e.g. obesity, baseline anxiety/depression). In fact, many men with LUTS (lower urinary tract symptoms) have severe anxiety and depression. These are most likely the patients who use finasteride. However, now our responsibility to inform [patients] that this may be a risk.”

Urologic oncologist Christopher Filson, MD, of Emory University School of Medicine in Atlanta, provided some context in the Twitter-verse: “Basically in 2,500 men taking finasteride, 1 extra case of depression can be attributed to finasteride.” He still urges counseling anyway.

So odds are good you won’t get depressed from taking the meds, but be aware

My hunch is that being diagnosed with prostate cancer is more likely to cause depression and anxiety than taking prostate shrinkers.

This report isn’t totally new news. Research has been accumulating. And reports are mixed. Some show that these meds reduce prostate cancer deaths. Take your pick.

Back in 2013, a Mayo Clinic-Tulane University team reported in the inaugural issue of Sexual Medicine Reviews that their comprehensive review revealed potential depression and anxiety were associated with taking 5-ARIs.

Nguyen, who appears in the tweet above, of the Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital in Boston, was lead on a study in JAMA last year that showed risks in young patients who take finasteride for male pattern baldness: “This study’s findings suggest that the risk of suicidality, depression, and anxiety should be considered when prescribing finasteride to younger patients with alopecia who may be more vulnerable to the drug’s adverse effects.”

He urges that urologists and primary care doctors counsel patients about these risks.

Note this article by Thai researchers that appeared a year ago in Biomedicine & Pharmacotherapy. They delved into the potential mechanisms for depression in former 5-ARI users.

They said: “Several clinical studies have indicated that former 5-ARIs users had a higher incidence of depressive symptoms and neuropsychiatric side effects than non-users. However, the underlying mechanisms involved in the depression in former 5-ARIs patients, a condition known as ‘post-finasteride syndrome (PFS)’, are not thoroughly understood.”

Side effects are not uncommon with 5-ARIs, just like any other drug. But notably, depression and anxiety don’t seem yet to have made the list of adverse effects.

Check out the Mayo Clinic for adverse effects from dutasteride and finasteride.

The headache remedy Excedrin used to ask in their ads: Why trade a headache for an upset stomach? A knock on the competition.

In the case of patients on AS who take prostate-shrinking 5-ARIs: Are you trading your libido to save you from those frustrating wake-ups to pee? Just asking.

Here’s part of Mayo's list of adverse effects of finasteride:

More common

1. Decreased interest in sexual intercourse

2. inability to have or keep an erection

3. loss in sexual ability, desire, drive, or performance

Will urologists take the new study seriously?

As it is, we know major medical groups—not including the American Urological Association or the American Society of Radiation Oncology—urge that all cancer patients be screened for emotional distress, I don’t know a single AS patient who was aware of being screened. for depression or anxiety.

Rockville, Maryland-based urologist Rachel Rubin warns her colleagues in a Tweet to “believe patients” if they complain about emotional distress.

Advice to be aware of emotional distress holds true for prostate patients in general. Independent of these meds, many of us experience emotional distress just from a cancer diagnosis, even one for wimpy low-risk “cancer.” The act of surveilling prostate cancer—rather than treating it initially—can trigger anxiety and depression.

I know patients who are very comfortable on finasteride and plan to take it for the rest of their lives.

I  took finasteride myself for a short time in 2012. Back then, some doctors suggested that these meds could help slow down prostate cancer or prevent deaths. I didn’t stick around long enough to find out.

I had a wild ride with finasteride. Not a good one. I rarely have adverse effects from meds.

I experienced extreme fatigue, malaise, and dizziness when I was on finasteride. I got off it because it made it difficult to put in a workday. I could barely tolerated an hour-long commute. I felt like I needed to be strapped into my office chair at Northwestern’s storied Medill School of Journalism and my seat on the Metra Electric train.

(Inexplicably, I remembered I still have an unused bottle of finasteride. A trophy from my personal “War” on Prostate Cancer.)

If you’re feeling symptoms of distress, please seek help. Whether you’re on 5-ARIs or not.

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How do 5-ARIs work?

5-ARIs, which also are taken by patients to treat male-pattern baldness, block the action of an enzyme called 5-alpha-reductase, which converts testosterone (T)  to dihydrotestosterone (DHT).

DHT causes the prostate to grow. As finasteride blocks the enzyme 5α-Reductase, less DHT is produced.

Growth of the prostate slows and your PSA (prostate-specific antigen) blood level drops. It works very well. When you take it, your doctor has to double your number to get an accurate reading.—Howard Wolinsky

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Join AnCan webinar with Dr. Mark Scholz, repeller of prostate snatcher invasions

By Howard Wolinsky

Dr. Mark C. Scholz, co-author of the groundbreaking 2010 book, “The Invasion of The Prostate Snatchers,” will be speaking at 8-9:30 p.m. Eastern on Jan. 30 at an AnCan webinar.

Scholz’s program is entitled "Invasion of the Prostate Snatchers: 13 years later. An evening with Dr. Mark Scholz." To register, click here.

He and co-author Ralph Blum blew the lid off the prostate cancer-industrial complex in 2010 when they exposed overuse and overdiagnosis of inpatients who didn’t need to be treated and could be followed with active surveillance.

Everyone is welcome to the free webinar, which will be open to patients ranging from those with low-risk cancer to those with advanced prostate cancer.

(Dr. Mark Scholz: Fighting the prostate invaders since 2010.)

Spoiler alert: Things are better now, but the invaders still are snatching and nuking large numbers of prostates unnecessarily.

A new edition of Invasion was issued in August 2021. Worth the read.

I recently reviewed the book:

Must-read for potential active surveillors: New edition of ‘The Invasion of the Prostate Snatchers’

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Tick-Tock

Meanwhile, mPulse Mobile, is working in conjunction with a major health organization, to develop the first smartphone app for active surveillance. If you want to participate, contact Anjali Logue at Anjali.logue@mpulsemobile.com  They’re paying $1,000 if you are selected to be interviewed. The video will be incorporated into the app.

(Disclosure: TheActiveSurveillor is a consultant on this project.)

Breaking Xmas gift from Congress

This just in on Xmas Eve from Ali Manson at ZERO--The End of Prostate Cancer.

We have scored a major victory for prostate cancer patients today!

Congress has passed the end-of-year package that not only contained increased prostate cancer funding, but also our Veterans Prostate Cancer Treatment and Research Act! This bill creates a clinical pathway for prostate cancer within the Veterans Health Administration, standardizing and improving care for our Veterans with the disease.

The bill now goes to the President's desk for his signature, which we expect to happen very soon.

Thank you to everyone who called or emailed their legislators, this victory would not have been possible without you!

Thank you again for all your support and happy holidays,