Finasteride-Induced Neuropsychiatric Reactions: No Room for Complacency

See letter by Tringali and Tringali and article by Brezis

To the Editor: We thank Drs Tringali for their comments.¹ They argue that our recent article² overstated the risks of finasteride. In our view, sustaining finasteride safety is misleading and poses a public health risk.

The evidence that finasteride can induce neuropsychiatric reactions is strong: Studies from multiple countries, using a variety of research designs, have confirmed many earlier clinical and experimental findings.² Bradford-Hill criteria for causality are met: temporality and reversibility (including rechallenge), consistency and replicability of results across studies, high statistical significance, and biological plausibility. The European Medicines Agency has recently acknowledged that finasteride can cause depression and suicidal thoughts.

Drs Tringali attribute depression in finasteride users to the androgenetic alopecia (AGA) itself. However, systematic reviews did not find that AGA causes depression.^3,4 By contrast, studies consistently found that finasteride can cause depression.² Drs Tringali cite an uncontrolled survey of alopecia areata, based on a biased sample of hospital referrals and showing depression predominantly in women.⁵ While AGA affects most men,⁴ alopecia areata is a rare condition with a lifetime incidence of 2%, making it more stigmatizing and thus likely associated with a higher risk of depression.

While not typically associated with depression, patients with AGA may experience body image concerns and low self-esteem,³ for which cognitive behavioral therapy, mindfulness-based stress reduction, supportive counseling, and structured coping strategies may help.⁶ If AGA is associated with emotional distress, this is an additional reason to avoid finasteride, which can worsen mood and increase the risk of suicide.⁷ Other nonpharmacologic treatments offer safer and potentially more effective alternatives,⁸ avoiding the risk of suicide.

The “rigorous, prospective research” proposed by Drs Tringali is nearly impossible, as it requires a study size of many millions to have the power to rule out an increase in suicides,² and it cannot be ensured that controls do not purchase finasteride online, which would lead to misclassification bias.

Experienced clinicians who prescribe finasteride often fail to recognize the issue⁹: Suicide is rare (about 1–2 in 10,000 over a decade, even assuming elevated risk), and few practitioners follow enough patients to encounter one. Depressive symptoms, conversely, are so common that it is difficult to attribute them to a drug rather than to a life event (eg, job or family crisis): Patients are unlikely to ascribe a worsening mood to a cosmetic medicine, and clinicians unaware of this risk overlook the connection.⁹ Only epidemiologic studies can identify the problem, and this is what was found with finasteride, with overwhelming consistency across studies.

Finasteride-induced depression results in billions of dollars in lost productivity globally each year.² These external costs, borne by third parties unable to mitigate them, constitute a market failure that should be addressed through regulatory intervention. Finasteride for hair loss would likely not receive approval today, and its marketing should now be suspended in accordance with the precautionary principle. In the meantime, physicians must warn patients about the drug’s serious side effects. Drs Tringali suggest “nuanced” patient monitoring, a term that remains undefined. They overlook that depression may persist after discontinuation of finasteride, that it may be resistant to treatment, and lead to suicide. For maximum patient safety, this risky medication should be avoided, and alternative therapies recommended.

Article Information

Published Online: December 17, 2025. https://doi.org/10.4088/JCP.25lr16181a
© 2025 Physicians Postgraduate Press, Inc.
J Clin Psychiatry 2026;87(1):25lr16181a
To Cite: Brezis M. Finasteride-induced neuropsychiatric reactions: no room for complacency. J Clin Psychiatry 2026;87(1):25lr16181a.
Author Affiliations: Braun School of Public Health and Faculty of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
Corresponding Author: Mayer Brezis, MD, MPH, Professor of Medicine (Emeritus) Hadassah Medical Center, Ein Kerem, POB 12000 Jerusalem, 91120, Israel ([email protected]).
Relevant Financial Relationships: None.
Funding/Support: None.