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Although teen bodybuilders have been using steroids since at least the early 1960s, only a few cases suggesting a link between steroids and suicide have been reported in the medical literaturein the 1990s.3–10,36 Nevertheless, an investigation in Japan that followed 1,821 male and female twins raised concerns about the possible adverse effects of this therapy. This case series includes a large number of suicides (1,822 by proxy) who had received the combined administration of sertraline, bupropion (brand name Lipitor®), and anabolic steroids. These three medications significantly increased suicide ideation and attempts, and the risk of death was similar whether the participant used this combination or a single medication. Among the 1,822 participants, 16% were depressed and 39% also had drug or alcohol abuse problems. Three of four participants indicated that the combination of medication increased sexual function and that it was important to use their combined medication even if they did not think it would help them. Two additional cases were reported by another Japanese case study that included two individuals with untreated histories of depression.7,9 The authors reported that the use of the combination of antidepressants with anti-depressant medication did not increase suicidal ideation or frequency, but did cause increased suicidal attempt risk.10 A recent review found that the use of prescription anti-depressants was associated with a higher risk of suicide in male patients with history of depression with an increased number of suicides.10 Given the high frequency of antidepressant medication in Japan (over 80%)13 and the high incidence of suicide in that population,2 it is noteworthy that only 2 cases are reported, both of individuals with untreated histories of depression. This is consistent with other studies showing that antidepressant use increases psychiatric morbidity in older males in Japan.14,15 The authors of this case-case series pointed out that the prevalence of suicidal ideation (40%) was significantly higher in the twins with anabolics and sertraline compared with those with anti-depressants and the use of antidepressants. This increased suicide risk was even larger, from 1.2% to 3.8% (1.6% to 3.7%) among male subjects who received anabolics. The increased risk for suicidal ideation among the anabolics and sertraline group was associated with a higher number and higher severity of suicidal ideation than among the anti-depressant group (all P<0.05), as well as with greater use of the combination medication. Suicide is a serious public health problem worldwide, in part because of the prevalence of untreated or untreated depression. Despite extensive treatment and research, suicidal thinking and behavior Related Article: