Suicidal ideation in patients undergoing treatment with 5α-reductase inhibitors

Background: There have been concerns raised by patients and regulatory agencies after the emerging of reports on men who had used finasteride and developed psychiatric adverse effects such as suicidal ideation. Objectives: Our aim was to critically review the literature on the risk of suicidal ideation and suicide during or after use of 5α-reductase inhibitors. Methods: In November 2023, we conducted a search of the PubMed database using the search equation ("5-alpha Reductase Inhibitors" [Pharmacological Action]) AND "Suicidal Ideation" [Mesh]. The available scientific publications were analyzed by the authors, collecting pertinent information on the association of testosterone 5- α reductase inhibitors and suicidal ideation. Results: In total, 12 publications were obtained and 8 were excluded (three were commentary articles, two had no full-text available, one was a letter to the editor, one was a meta-analysis, and one was a pharmacovigilance note). One additional publication was included after analyzing the references of the studies obtained. The analysis of the 5 original articles included revealed that there is no apparent difference in the presence of suicidal ideation when comparing different 5α-reductase inhibitors (finasteride and dutasteride) [1–5]. However, there seem to be contradictory results when comparing different doses of finasteride [2,4] and patients age or therapeutic indications (alopecia and benign prostatic hyperplasia) [4]. One of the studies also revealed that there is a greater risk of suicidal outcomes only in patients with a history of mood disorders, reinforcing the importance of psychiatric history as a confounding factor in the analysis of studies [3]. Conclusion: In sum, more studies are needed to understand suicidal ideation in patients undergoing treatment with 5α-reductase inhibitors, clarifying potential confounding covariates, to improve evidence-based clinical practice.