Association between mental health status and substance use risk taking behavior among young Egyptian athletes using anabolic androgenic steroids (AAS)

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Methods: Face-to-face surveys were conducted at fitness-related sites. Inclusion criteria were age ≥ 18 years and exercise frequency ≥ twice weekly. Depression, anxiety and stress scale (DASS-21) inventory was used for depression, anxiety and stress assessments. Eating disorder Screen for Primary care (ESP) was the questionnaire used to assess eating disorders. Substance use risk-taking behavior was assessed by direct questions. In a separate analysis, AAS users were compared to AAS-naïve individuals. Results: In total, 418 participants completed the questionnaire. Of these, 40.47% (136/336) of AAS users and 24.39% (20/82) of AAS non-users had a history of polysubstance use. AAS users had significantly higher odds of exhibiting depressive traits, anxiety traits and nearly twice the odds of engaging in substance use risk-taking behaviors, compared to AAS nonusers. Conclusions: This cross-sectional study underpins AAS being strongly associated with depression, anxiety and substance-use risk taking behavior disorders. These associations reported herein justifies further needed research to clarify if these associations arise before, in parallel to, or a secondary subsequence to the use of AAS. anabolic androgenic steroids depression anxiety stress eating disorders substance use risk behaviors Introduction Global reports showed that around 6% of males have used anabolic androgenic steroids (AAS), a synthetic derivative of male sex hormone (testosterone), marketed under different brands such as stanozolol, oxandrolone and methyltestosterone. AAS are usually used by athletes and body builders for better performance [ 1 , 2 ]. Physically active individuals also use AAS to increase their muscle mass and for better physical appearance and that 30% of the users developed AAS dependence when used for a long term [ 3 , 4 ]. This rate of dependence is significantly higher when compared to other illicit or prescribed drugs [ 4 , 5 ]. Additionally, studies reported AAS association with some serious health side effects like cardiovascular and metabolic complications, male gonads atrophy, baldness and infertility [ 6 ]. Researchers found that there is a strong association between AAS usage and concurrent use of other drugs and substances [ 6 – 8 ], along with exhibition of idiosyncratic negativity and psychological issues [ 9 – 13 ]. Further studies highlighted the psychological adverse effects reported with AAS usage such as mood disturbances, grandeur delusions, being invincible and depression [ 14 – 16 ]. These findings were further investigated, where researchers studied the effects of AAS usage on neurodegenerative disorders, anxiety and depression [ 17 , 18 ]. Moreover, the chronic use of AAS is connected to accelerated brain aging and disrupted normal neural forebrain functions, which in turn could increase anxiety and limit inhibitory control actions [ 19 – 25 ]. Moreover, increased depressive symptoms are commonly reported during the withdrawal period of AAS [ 25 , 26 ]. From a psychological perspective, seeking a better body image and satisfaction [ 27 – 29 ], somatoform and other eating disorders [ 29 – 32 ], and seeking greater muscular mass [ 33 ], was found to be strongly associated with increased levels of AAS usage [ 34 ]. The connection of AAS with the cognitive and behavioral features in its users highlights the possibility of considering AAS abuse under the spectra of eating disorders [ 35 , 36 ]. However, for AAS usage to be considered as a psychiatric disorder, its association with functional impairment and psychological distress needs to be further evaluated and measured [ 37 ]. This study is a cross-sectional study, which aimed for detecting the prevalence of psychological abnormalities (depression, anxiety, stress and eating disorders), in addition to assessing risk taking behavior (sharing needles and illicit drug abuse) among androgenic anabolic steroids users and non-users in young Egyptian recreational athletes. Methods Procedure and participants: The study followed and was approved by the British University in Egypt Ethical Committee on Activities involving Human Subjects and we conducted in reference to the Declaration of Helsinki principles. A large sample of 418 adult biologically male recreational athletes were anonymously recruited. Then the recruited individuals were asked about exercising habits, psychological states, risk-taking behaviors if any, and if there were any physical problems that the members might have experienced. The anonymous survey used to collect data took place within the period from January 2023 to June 2024. All participants provided informed consent before participating in the survey. Measures Demographic questions Participants provided their age (years), height (cm), weight (Kg), and level of education. Diet and exercise: Participants were asked about their exercising habits during the last month given the following options (every day, most days, and some days). Appearance and performance enhancing drugs: The anonymously recruited participants indicated if they have ever used topical, oral or injectable AAS (“yes, currently,” and “no, never considered taking” for each). Risk-taking behaviour: Each participant indicated if he had engaged in or experienced the following: reusing needles, sharing needles, using non-medically indicated stimulants (e.g. amphetamine or powdered cocaine), smoking marijuana, using depressants without prescription (such as Xanax, Valium and Barbiturates), and using opiates for non-medical purposes (for example morphine or heroin). Depression, anxiety and stress: we used DASS-21 for depression, anxiety and stress assessments. DASS-21 is a self-report questionnaire that consists of three sets to measure the emotional states of depression, anxiety and stress. Each scale includes 7 items that are divided into subscales within the same content. The first scale is the depression scale, and it is used to measure despairing, self-effacing, diminishing, apathy and anhedonia. The second scale is the anxiety scale, and it assesses skeletal muscle effects, physiological arousal, individual perspective of anxious effects and situational anxiety. The third and last scale is the stress scale, which assesses agitation, trouble relaxing, restlessness and being touchy or sensitive. The summation of relevant items scores was used for scale scoring for each of the three mentioned scales as described by was done by Lovibond et al. [38,39]. Eating Disorders: Eating disorder Screen for Primary care (ESP) was the questionnaire used to assess eating disorders. ESP questionnaire includes 5 simple questions, where a “no” answer to question 1 is classified as an abnormal response. While a “yes” answer to the rest of questions (2-5) is considered as an abnormal response. Statistical Analysis The study employed accidental sampling technique, with no set sample size or preceding power calculation. For our main analysis, we grouped participants who responded “yes, currently” or “yes, formerly” to having used AAS as AAS users (n=336). While for those who responded to be AAS nonusers (n=82). Psychological and behavioral characteristics were grouped into the five categories: depressive symptoms, anxiety symptoms, stress symptoms, eating disorders problems, and substance use risk-taking behavior. Logistic regression models were then used to examine the possible association between AAS and the traits of interest. Odd ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Moreover, age, race and education were included as basic demographic variables, while exercise frequency and BMI were included to account for variations in body building goals, dedication and success. Statistical analyses and data visualization were conducted using GraphPad Prism version 9.5.1 (GraphPad Software, San Diego, CA, USA). Results Participant characteristics are listed in Table 1 . Most participants were younger than 25 years old (86.6% of AAS users; 100% of AAS nonusers), had education beyond high school (88.1% of AAS users; 85.3% of AAS nonusers). The majority in each group exercised most days of the week (50% of AAS users; 43.9% of AAS nonusers). For AAS users 88.7% had BMI between 21–25, while 64.6% of AAS nonusers had BMI between 21 and 25. Tables 2 , 3 and 4 summarize traits of interest and specific substance use risk-taking behaviors by AAS use status; 40.47% (136/336) of AAS users and 24.39% (20/82) of AAS nonusers had a history of polysubstance use. AAS users had significantly higher odds of exhibiting depressive traits (OR = 92.29, 95% CI 35.94–237.0), significantly higher odds of exhibiting anxiety traits (OR = 21.20, 95% CI 9.703–46.30) and nearly twice the odds of engaging in substance use risk-taking behaviors (OR = 1.871, 95% CI 1.263–2.772), compared to AAS nonusers (Table 4 ). There was no significant difference between the two groups with respect to stress and eating disorders parameters. Table 1 Participants Characteristics. AAS User (n = 336) AAS Nonuser (n = 82) Age Younger than 25 (86.6) 291 (100) 82 25 or Older (13.4) 45 (0) 0 Level of Education High School or Less (11.9) 40 (14.7) 12 Greater than High School (88.1) 296 (85.3) 70 Exercise Frequency Every Day (23.2) 78 (15.8) 13 Most Days (50) 168 (43.9) 36 Some Days (27.8) 90 (28) 23 BMI > 20 (0.9) 3 (2.5) 2 21–25 (88.7) 298 (64.6) 53 > 25 (10.4) 35 (32.9) 27 Table 2 Traits of interest by AAS use status. AAS User (n = 336) AAS Nonuser (n = 82) Depressive Symptoms Normal (5) 17 (46.4) 38 Mild (1.5) 5 (11) 9 Moderate (1.8) 6 (20.7)17 Severe (5.6) 19 (13.4) 11 Extremely Severe (86) 289 (8.5) 7 Anxiety Symptoms Normal (3.9) 13 (32.9) 27 Mild (1.2) 4 (7.3) 6 Moderate (1.2) 4 (14.6) 12 Severe (1.5) 5 (15.8) 13 Extremely Severe (92.3) 310 (29.2) 24 Stress Symptoms Normal (6.25) 21 (50) 41 Mild (1.5) 5 (14.6) 12 Moderate (2.4) 8 (14.6) 12 Severe (9.8) 33 (20.7) 17 Extremely Severe (80.1) 269 (0) 0 Eating Disorder Yes (34.8) 117 (28.1) 23 No (65.2) 219 (71.9) 59 Table 3 Substance use risk-taking behaviors by AAS use status. AAS User (n = 336) AAS Nonuser (n = 82) Shared Needles Yes (8.6) 29 (1.2) 1 No (91.4) 307 (98.8) 81 Reused Needles Yes (16.4) 55 (11) 9 No (83.6) 281 (89) 73 Used Opiates (Morphine, Heroin) Yes (3.6) 12 (3.7) 3 No (96.4) 324 (96.3) 79 Used Depressants (Benzodiazepine (Xanax, Valium, etc.) Yes (14.6) 49 (4.9) 4 No (85.4) 287 (95.1) 78 Used Stimulants (Amphetamine, Cocaine) Yes (2.4) 8 (6.3) 6 No (97.6) 328 (92.7) 76 Used THC products Yes (14.9) 50 (4.9) 4 No (85.1) 286 (95.1) 78 History of Polysubstance Use (3 + THC, stimulants, depressants, and opiates) Yes (5.1) 17 (3.7) 3 No (94.9) 319 (96.3) 79 Table 4 Associations of AAS Use/Non-Use with Traits of Interest. Results with significant difference are bolded. Variable AAS users compared to AAS nonusers OR (95% CI, P value) Depression 92.29 (35.94 to 237.0, P < 0.0001) * Anxiety 21.20 (9.703 to 46.30, P < 0.0001) * Stress 0.1510 (0.008970 to 2.543, P = 0.0893) Eating Disorders 1.370 (0.8053 to 2.332, P = 0.2965) Substance Use Risk-Taking Behavior 1.871 (1.263 to 2.772, P = 0.0020) * Discussion In this study we tried to examine the psychiatric adverse effects of using AAS on young male athletes. Notably, the findings of our study indicated that AAS usage was accompanied by high levels of anxiety, depression and substance use risk-taking behavior. Moreover, depression and anxiety symptoms were more prevalent in AAS users when compared with non-AAS users. AAS are used by physically active individuals and athletes for better physical appearance and performance enhancement, yet it is associated with many side effects [ 40 ]. Since, AAS are synthetic derivatives of the male sex hormone (testosterone), they can alter the hormonal equilibrium in the body, which results in common psychiatric adverse effects such as irritability, mood swings, anxiety and depression [ 41 ]. Moreover, alterations in the neurotransmitters of the brain, especially dopamine and serotonin were reported, which has an essential role in mood regulation and is strongly linked to anxiety and depression [ 42 ]. In addition, AAS discontinuation, especially in the initial withdrawal months, is usually accompanied by increased risk in experiencing major depressive episodes [ 43 ]. Here we report that, consistent with prior research, the AAS users displayed moderate to extremely severe depressive symptoms. Similarly, mild anxiety was detected in the AAS users’ group. The concurrent misuse of other substances is an additional factor that affects the mental health wellbeing of AAS users. A significant higher intake rate of illicit drugs (amphetamines, cannabis and antidepressants) was reported by AAS users when compared to AAS non-users [ 44 , 45 ]. In our face-to-face surveys reported in this study, we found AAS use was associated with higher odds of substance use risk-taking behavior. Importantly, this association was also present among participants with no history of polysubstance use. It is not an assured fact that AAS use has a direct relation with substance abuse behavior, thus longitudinal research would be of paramount importance to elaborate on such a relationship, and our study is one of many ways to link AAS use with substance use risk-taking behaviors [ 46 , 47 ]. Interestingly, multiple studies showed that some AAS users experimented or were regular users of other substances prior to using AAS [ 47 – 49 ]. Which might highlight a possibility of bi-directional relationship between AAS usage and substance misuse, yet further investigations are needed to understand the mechanism behind this correlation. In our study, we did not observe associations between using AAS and stress symptoms or eating disorders. Although, previous research identified various cognitive and psychological traits in AAS users including impulsiveness, depression and mania [ 50 ]. In fact, these traits are idiosyncratic in nature [ 51 , 52 ]. Most individuals use exercise as their first line in dealing with stress and emotional distress instead of reaching out to medical personnel. Thus, this might explain the prevalence of undiagnosed depression in our study population. Moreover, multiple studies confirmed that exercise withdrawal might cause mood-disturbances among physically active individuals, which could be worse in case of substance dependence [ 53 , 54 ]. Remarkably, there have been various studies in humans and animals highlighting the beneficial effect of exercising in reducing drug seeking behavior neurologically [ 55 , 56 ]. However, AAS users were found to frequently use other substances which align with prior studies [ 57 , 58 ]. Therefore, AAS users should be studied selectively due to significant comorbidities observed in this population. Declarations Ethics approval and consent to participate: The study protocol was reviewed and approved by the Research Ethics Committee at the British University in Egypt (BUE). All procedures involving human participants were conducted in accordance with institutional guidelines and the 2013 revision of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Consent for publication : Not applicable, as no identifiable data or images are included in the manuscript. Participants were anonymous and no personal information was collected. Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due to sensitivity and privacy considerations. The data are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests . Funding: self-funding. Authors' contributions: MS planned the study. MS was responsible for the ethics application, FA, MR and PE were part of the data collection procedure. MS conducted statistical analyses, wrote the draft of the paper, and was edited by both MS and NA. Results were discussed by all authors. All authors contributed to the article and approved the submitted version. Acknowledgements: Not applicable. References Sagoe, D., Molde, H., Andreassen, C. S., Torsheim, T. & Pallesen, S. The global epidemiology of anabolic-androgenic steroid use: A meta-analysis and meta-regression analysis. Ann. Epidemiol. 24, 383–398 (2014). Wenbo Z, Yan Z. 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Characteristics and Behaviors of Older Male Anabolic Steroid Users. J Pharm Pract. 2015 Oct;28(5):450-6. doi: 10.1177/0897190014527319. Epub 2014 Mar 18. PMID: 24643452. Mhillaj E, Morgese MG, Tucci P, Bove M, Schiavone S, Trabace L. Effects of anabolic-androgens on brain reward function. Front Neurosci. 2015 Aug 26;9:295. doi: 10.3389/fnins.2015.00295. PMID: 26379484; PMCID: PMC4549565. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6907286","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":478607901,"identity":"74f52c64-1844-491f-bd6e-6c66cae645d5","order_by":0,"name":"NourAllah Ahmed","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"NourAllah","middleName":"","lastName":"Ahmed","suffix":""},{"id":478607902,"identity":"05b86515-846e-4f64-8665-c303468e637d","order_by":1,"name":"Mohamed Ahmed","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Ahmed","suffix":""},{"id":478607905,"identity":"3ff817e8-3c4d-4d3b-a8ce-1a034af06d25","order_by":2,"name":"Joumana Abousharkh","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"Joumana","middleName":"","lastName":"Abousharkh","suffix":""},{"id":478607907,"identity":"f4e1a3c7-fe53-4222-ae0a-3ac8b5478512","order_by":3,"name":"Fady Aboelsaad","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"Fady","middleName":"","lastName":"Aboelsaad","suffix":""},{"id":478607908,"identity":"9dd58b2b-45a4-44f6-89ca-7a584fdc7dac","order_by":4,"name":"Mahmoud Radwan","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Radwan","suffix":""},{"id":478607909,"identity":"286cf295-7c76-4e95-bc48-dfb07a2f1825","order_by":5,"name":"Philip Eltarzy","email":"","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":false,"prefix":"","firstName":"Philip","middleName":"","lastName":"Eltarzy","suffix":""},{"id":478607910,"identity":"a9e4c13c-f804-48e1-9bd2-0f1c861fdba8","order_by":6,"name":"Moustafa Sayed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBACAwbmBjjnA0PFATBDAr8WRqgWNgbGGQxnSNbC2EaEFnP2xtbNPAzb5OTnNz9s+DnvTmI/A/PB2zwMNnYNOLRY9hxsAyq4bWxwjM2wsXfbs8SZDWzJ1jwMacm4tBjcSARrSdzAxmD+gHfb4cQNB3jMpHkYDifj9Mv9hxAt89vYPzb+nXM4cf8B/m9ALf9xa7nBCNHScIzHsJm3AWgLAw8bUMsBO5xaziS23ZxjAPJLTmGzzLFnxjMOsxlbzjFITsCp5fjhYzfeVNyWk28+vrHxTc0d2f725odAETt7XFpAgInHAJnLDDaKIbEBjxbGH9hE8doyCkbBKBgFIwoAADmHYCrC9R53AAAAAElFTkSuQmCC","orcid":"","institution":"The British University in Egypt (BUE)","correspondingAuthor":true,"prefix":"","firstName":"Moustafa","middleName":"","lastName":"Sayed","suffix":""}],"badges":[],"createdAt":"2025-06-16 16:09:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6907286/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6907286/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99796672,"identity":"0075fc43-0c20-4c5d-8e54-7365736857cc","added_by":"auto","created_at":"2026-01-08 13:43:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":938872,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6907286/v1/b1280d47-4d6f-41fa-8f4c-b28ed4bfb04e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between mental health status and substance use risk taking behavior among young Egyptian athletes using anabolic androgenic steroids (AAS)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobal reports showed that around 6% of males have used anabolic androgenic steroids (AAS), a synthetic derivative of male sex hormone (testosterone), marketed under different brands such as stanozolol, oxandrolone and methyltestosterone. AAS are usually used by athletes and body builders for better performance [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Physically active individuals also use AAS to increase their muscle mass and for better physical appearance and that 30% of the users developed AAS dependence when used for a long term [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This rate of dependence is significantly higher when compared to other illicit or prescribed drugs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, studies reported AAS association with some serious health side effects like cardiovascular and metabolic complications, male gonads atrophy, baldness and infertility [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearchers found that there is a strong association between AAS usage and concurrent use of other drugs and substances [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], along with exhibition of idiosyncratic negativity and psychological issues [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Further studies highlighted the psychological adverse effects reported with AAS usage such as mood disturbances, grandeur delusions, being invincible and depression [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These findings were further investigated, where researchers studied the effects of AAS usage on neurodegenerative disorders, anxiety and depression [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Moreover, the chronic use of AAS is connected to accelerated brain aging and disrupted normal neural forebrain functions, which in turn could increase anxiety and limit inhibitory control actions [\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Moreover, increased depressive symptoms are commonly reported during the withdrawal period of AAS [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a psychological perspective, seeking a better body image and satisfaction [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], somatoform and other eating disorders [\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and seeking greater muscular mass [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], was found to be strongly associated with increased levels of AAS usage [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The connection of AAS with the cognitive and behavioral features in its users highlights the possibility of considering AAS abuse under the spectra of eating disorders [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, for AAS usage to be considered as a psychiatric disorder, its association with functional impairment and psychological distress needs to be further evaluated and measured [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study is a cross-sectional study, which aimed for detecting the prevalence of psychological abnormalities (depression, anxiety, stress and eating disorders), in addition to assessing risk taking behavior (sharing needles and illicit drug abuse) among androgenic anabolic steroids users and non-users in young Egyptian recreational athletes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eProcedure and participants:\u003c/strong\u003e The study followed and was approved by the British University in Egypt Ethical Committee on Activities involving Human Subjects and we conducted in reference to the Declaration of Helsinki principles. A large sample of 418 adult biologically male recreational athletes were anonymously recruited. Then the recruited individuals were asked about exercising habits, psychological states, risk-taking behaviors if any, and if there were any physical problems that the members might have experienced. The anonymous survey used to collect data took place within the period from January 2023 to June 2024. All participants provided informed consent before participating in the survey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic questions\u003c/strong\u003e Participants provided their age (years), height (cm), weight (Kg), and level of education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiet and exercise:\u0026nbsp;\u003c/strong\u003eParticipants were asked about their exercising habits during the last month given the following options (every day, most days, and some days).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAppearance and performance enhancing drugs:\u0026nbsp;\u003c/strong\u003eThe anonymously recruited participants indicated if they have ever used topical, oral or injectable AAS (“yes, currently,” and “no, never considered taking” for each).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk-taking behaviour:\u0026nbsp;\u003c/strong\u003eEach participant indicated if he had engaged in or experienced the following: reusing needles, sharing needles, using non-medically indicated stimulants (e.g. amphetamine or powdered cocaine), smoking marijuana, using depressants without prescription (such as Xanax, Valium and Barbiturates), and using opiates for non-medical purposes (for example morphine or heroin).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepression, anxiety and stress:\u0026nbsp;\u003c/strong\u003ewe used DASS-21 for depression, anxiety and stress assessments. DASS-21 is a self-report questionnaire that consists of three sets to measure the emotional states of depression, anxiety and stress. Each scale includes 7 items that are divided into subscales within the same content. The first scale is the depression scale, and it is used to measure despairing, self-effacing, diminishing, apathy and anhedonia. The second scale is the anxiety scale, and it assesses skeletal muscle effects, physiological arousal, individual perspective of anxious effects and situational anxiety. The third and last scale is the stress scale, which assesses agitation, trouble relaxing, restlessness and being touchy or sensitive. The summation of relevant items scores was used for scale scoring for each of the three mentioned scales as described by was done by Lovibond et al. [38,39].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEating Disorders:\u0026nbsp;\u003c/strong\u003eEating disorder Screen for Primary care (ESP) was the questionnaire used to assess eating disorders. ESP questionnaire includes 5 simple questions, where a “no” answer to question 1 is classified as an abnormal response. While a “yes” answer to the rest of questions (2-5) is considered as an abnormal response.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study employed accidental sampling technique, with no set sample size or preceding power calculation. For our main analysis, we grouped participants who responded “yes, currently” or “yes, formerly” to having used AAS as AAS users (n=336). While for those who responded to be AAS nonusers (n=82). Psychological and behavioral characteristics were grouped into the five categories: depressive symptoms, anxiety symptoms, stress symptoms, eating disorders problems, and substance use risk-taking behavior. Logistic regression models were then used to examine the possible association between AAS and the traits of interest. Odd ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Moreover, age, race and education were included as basic demographic variables, while exercise frequency and BMI were included to account for variations in body building goals, dedication and success. Statistical analyses and data visualization were conducted using GraphPad Prism version 9.5.1 (GraphPad Software, San Diego, CA, USA).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant characteristics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most participants were younger than 25 years old (86.6% of AAS users; 100% of AAS nonusers), had education beyond high school (88.1% of AAS users; 85.3% of AAS nonusers). The majority in each group exercised most days of the week (50% of AAS users; 43.9% of AAS nonusers). For AAS users 88.7% had BMI between 21\u0026ndash;25, while 64.6% of AAS nonusers had BMI between 21 and 25. Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarize traits of interest and specific substance use risk-taking behaviors by AAS use status; 40.47% (136/336) of AAS users and 24.39% (20/82) of AAS nonusers had a history of polysubstance use.\u003c/p\u003e \u003cp\u003eAAS users had significantly higher odds of exhibiting depressive traits (OR\u0026thinsp;=\u0026thinsp;92.29, 95% CI 35.94\u0026ndash;237.0), significantly higher odds of exhibiting anxiety traits (OR\u0026thinsp;=\u0026thinsp;21.20, 95% CI 9.703\u0026ndash;46.30) and nearly twice the odds of engaging in substance use risk-taking behaviors (OR\u0026thinsp;=\u0026thinsp;1.871, 95% CI 1.263\u0026ndash;2.772), compared to AAS nonusers (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). There was no significant difference between the two groups with respect to stress and eating disorders parameters.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants Characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAS User (n\u0026thinsp;=\u0026thinsp;336)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAAS Nonuser (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYounger than 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(86.6) 291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(100) 82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25 or Older\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(13.4) 45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0) 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School or Less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(11.9) 40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.7) 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreater than High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(88.1) 296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(85.3) 70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExercise Frequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvery Day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(23.2) 78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.8) 13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost Days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(50) 168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(43.9) 36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome Days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(27.8) 90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(28) 23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0.9) 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2.5) 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(88.7) 298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(64.6) 53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(10.4) 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(32.9) 27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTraits of interest by AAS use status.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAS User (n\u0026thinsp;=\u0026thinsp;336)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAAS Nonuser (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive Symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(5) 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(46.4) 38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.5) 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(11) 9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.8) 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(20.7)17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(5.6) 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13.4) 11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(86) 289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.5) 7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety Symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(3.9) 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(32.9) 27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.2) 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(7.3) 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.2) 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.6) 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.5) 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.8) 13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(92.3) 310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(29.2) 24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStress Symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(6.25) 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(50) 41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1.5) 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.6) 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(2.4) 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.6) 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(9.8) 33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(20.7) 17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(80.1) 269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0) 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEating Disorder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(34.8) 117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(28.1) 23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(65.2) 219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(71.9) 59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubstance use risk-taking behaviors by AAS use status.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAS User (n\u0026thinsp;=\u0026thinsp;336)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAAS Nonuser (n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShared Needles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(8.6) 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.2) 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(91.4) 307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(98.8) 81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReused Needles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(16.4) 55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(11) 9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(83.6) 281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(89) 73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsed Opiates (Morphine, Heroin)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(3.6) 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.7) 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(96.4) 324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(96.3) 79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsed Depressants (Benzodiazepine (Xanax, Valium, etc.)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(14.6) 49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.9) 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(85.4) 287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(95.1) 78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsed Stimulants (Amphetamine, Cocaine)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(2.4) 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6.3) 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(97.6) 328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(92.7) 76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsed THC products\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(14.9) 50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4.9) 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(85.1) 286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(95.1) 78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of Polysubstance Use (3\u0026thinsp;+\u0026thinsp;THC, stimulants, depressants, and opiates)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(5.1) 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(3.7) 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e(94.9) 319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(96.3) 79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations of AAS Use/Non-Use with Traits of Interest. Results with significant difference are bolded.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAS users compared to AAS nonusers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOR (95% CI, P value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.29 (35.94 to 237.0, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) *\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e21.20 (9.703 to 46.30, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1510 (0.008970 to 2.543, P\u0026thinsp;=\u0026thinsp;0.0893)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEating Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.370 (0.8053 to 2.332, P\u0026thinsp;=\u0026thinsp;0.2965)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubstance Use Risk-Taking Behavior\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.871 (1.263 to 2.772, P\u0026thinsp;=\u0026thinsp;0.0020) *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we tried to examine the psychiatric adverse effects of using AAS on young male athletes. Notably, the findings of our study indicated that AAS usage was accompanied by high levels of anxiety, depression and substance use risk-taking behavior. Moreover, depression and anxiety symptoms were more prevalent in AAS users when compared with non-AAS users.\u003c/p\u003e \u003cp\u003eAAS are used by physically active individuals and athletes for better physical appearance and performance enhancement, yet it is associated with many side effects [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Since, AAS are synthetic derivatives of the male sex hormone (testosterone), they can alter the hormonal equilibrium in the body, which results in common psychiatric adverse effects such as irritability, mood swings, anxiety and depression [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Moreover, alterations in the neurotransmitters of the brain, especially dopamine and serotonin were reported, which has an essential role in mood regulation and is strongly linked to anxiety and depression [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In addition, AAS discontinuation, especially in the initial withdrawal months, is usually accompanied by increased risk in experiencing major depressive episodes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Here we report that, consistent with prior research, the AAS users displayed moderate to extremely severe depressive symptoms. Similarly, mild anxiety was detected in the AAS users\u0026rsquo; group.\u003c/p\u003e \u003cp\u003eThe concurrent misuse of other substances is an additional factor that affects the mental health wellbeing of AAS users. A significant higher intake rate of illicit drugs (amphetamines, cannabis and antidepressants) was reported by AAS users when compared to AAS non-users [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In our face-to-face surveys reported in this study, we found AAS use was associated with higher odds of substance use risk-taking behavior. Importantly, this association was also present among participants with no history of polysubstance use. It is not an assured fact that AAS use has a direct relation with substance abuse behavior, thus longitudinal research would be of paramount importance to elaborate on such a relationship, and our study is one of many ways to link AAS use with substance use risk-taking behaviors [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Interestingly, multiple studies showed that some AAS users experimented or were regular users of other substances prior to using AAS [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Which might highlight a possibility of bi-directional relationship between AAS usage and substance misuse, yet further investigations are needed to understand the mechanism behind this correlation.\u003c/p\u003e \u003cp\u003eIn our study, we did not observe associations between using AAS and stress symptoms or eating disorders. Although, previous research identified various cognitive and psychological traits in AAS users including impulsiveness, depression and mania [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In fact, these traits are idiosyncratic in nature [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost individuals use exercise as their first line in dealing with stress and emotional distress instead of reaching out to medical personnel. Thus, this might explain the prevalence of undiagnosed depression in our study population. Moreover, multiple studies confirmed that exercise withdrawal might cause mood-disturbances among physically active individuals, which could be worse in case of substance dependence [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRemarkably, there have been various studies in humans and animals highlighting the beneficial effect of exercising in reducing drug seeking behavior neurologically [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. However, AAS users were found to frequently use other substances which align with prior studies [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Therefore, AAS users should be studied selectively due to significant comorbidities observed in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study protocol was reviewed and approved by the Research Ethics Committee at the British University in Egypt (BUE). All procedures involving human participants were conducted in accordance with institutional guidelines and the 2013 revision of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eNot applicable, as no identifiable data or images are included in the manuscript. Participants were anonymous and no personal information was collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to sensitivity and privacy considerations. The data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eself-funding.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eMS planned the study. MS was responsible for the ethics application, FA, MR and PE were part of the data collection procedure. MS conducted statistical analyses, wrote the draft of the paper, and was edited by both MS and NA. \u0026nbsp;Results were discussed by all authors. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSagoe, D., Molde, H., Andreassen, C. S., Torsheim, T. \u0026amp; Pallesen, S. The global epidemiology of anabolic-androgenic steroid use: A meta-analysis and meta-regression analysis. Ann. Epidemiol. 24, 383\u0026ndash;398 (2014).\u003c/li\u003e\n\u003cli\u003eWenbo Z, Yan Z. The Uses of Anabolic Androgenic Steroids Among Athletes; Its Positive and Negative Aspects- A Literature Review. J Multidiscip Healthc. 2023 Dec 29;16:4293-4305. doi: 10.2147/JMDH.S439384. 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Adverse effects of anabolic-androgenic steroids: A literature review. Healthc. Basel 9, 97 (2021).\u003c/li\u003e\n\u003cli\u003eMelia, P., Pipe, A. \u0026amp; Greenberg, L. The use of anabolic-androgenic steroids by Canadian students. Clin. J. Sport Med. 6, 9\u0026ndash;14 (1996).\u003c/li\u003e\n\u003cli\u003eHartgens, F. \u0026amp; Kuipers, H. Effects of androgenic-anabolic steroids in athletes. Sports Med. 34, 513\u0026ndash;554 (2004).\u003c/li\u003e\n\u003cli\u003eLood, Y., Eklund, A., Garle, M. \u0026amp; Ahlner, J. Anabolic androgenic steroids in police cases in Sweden 1999\u0026ndash;2009. Forensic Sci. Int. 219, 199\u0026ndash;204 (2012).\u003c/li\u003e\n\u003cli\u003ePope, H. G., Jr., \u0026amp; Kanayama, G. (2012). Anabolic-androgenic steroids. In J. C. Verster, K. Brady, M. Galanter, \u0026amp; P. Conrod (Eds.), Drug abuse and addiction in medical illness: Causes, consequences and treatment (pp. 251\u0026ndash;264). 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PMID: 26379484; PMCID: PMC4549565. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"anabolic androgenic steroids, depression, anxiety, stress, eating disorders, substance use risk behaviors","lastPublishedDoi":"10.21203/rs.3.rs-6907286/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6907286/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e This paper aimed for exploring the prevalence of psychological abnormalities (depression, anxiety, stress and eating disorders), along with assessing risk-taking behavior (sharing needles and illicit drug abuse) among androgenic anabolic steroids (AAS) users and non-users in young Egyptian recreational athletes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Face-to-face surveys were conducted at fitness-related sites. Inclusion criteria were age ≥ 18 years and exercise frequency ≥ twice weekly. Depression, anxiety and stress scale (DASS-21) inventory was used for depression, anxiety and stress assessments. Eating disorder Screen for Primary care (ESP) was the questionnaire used to assess eating disorders. Substance use risk-taking behavior was assessed by direct questions. In a separate analysis, AAS users were compared to AAS-naïve individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In total, 418 participants completed the questionnaire. Of these, 40.47% (136/336) of AAS users and 24.39% (20/82) of AAS non-users had a history of polysubstance use. AAS users had significantly higher odds of exhibiting depressive traits, anxiety traits and nearly twice the odds of engaging in substance use risk-taking behaviors, compared to AAS nonusers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This cross-sectional study underpins AAS being strongly associated with depression, anxiety and substance-use risk taking behavior disorders. These associations reported herein justifies further needed research to clarify if these associations arise before, in parallel to, or a secondary subsequence to the use of AAS.\u003c/p\u003e","manuscriptTitle":"Association between mental health status and substance use risk taking behavior among young Egyptian athletes using anabolic androgenic steroids (AAS)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 05:45:43","doi":"10.21203/rs.3.rs-6907286/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3036ffb-bc14-4e6f-97d9-47dc41ac6b92","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-07T09:40:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 05:45:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6907286","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6907286","identity":"rs-6907286","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}