What should I ask patients before prescribing finasteride or dutasteride, and how should I monitor them for depression, suicidal ideation, or persistent sexual side effects?

For an adult male being considered for finasteride 1 mg (alopecia), finasteride 5 mg (BPH), or dutasteride 0.5 mg (BPH):

What to ask before prescribing

Ask and document:

1. Personal history of depression or suicidal ideation/self-harm

   • “Have you ever had depression, low mood, suicidal thoughts, self-harm, or a suicide attempt?”
   • “Any current mental health follow-up or treatment?”
   • MHRA specifically advises checking the medical record and asking about prior depression/suicidal ideation before prescribing finasteride. [1]

2. Current mood symptoms

   • “Any current low mood, anxiety, loss of interest, sleep change, irritability, or reduced coping?”
   • “Any recent major stressors?”

3. Baseline sexual function

   • “Any current problems with libido, erections, ejaculation, orgasm, or semen volume?”
   • “Any pre-existing sexual dysfunction that could make attribution difficult later?”
   • This is important because sexual adverse effects are common enough to be clinically relevant, and both finasteride and dutasteride SPCs describe libido/erection/ejaculatory effects. [2][3][4]

4. Fertility / pregnancy exposure issues

   • “Are you trying to conceive?”
   • “Is your partner pregnant or could she become pregnant?”
   • This matters because both agents can affect semen parameters and the product information advises avoiding exposure of a pregnant partner to semen; finasteride/dutasteride are contraindicated in women and children, and crushed/broken capsules/tablets should not be handled by women who are or may be pregnant. [2][3][4]

5. Counselling understanding

   • Ensure the patient has read the PIL/patient card and understands what to do if symptoms occur. MHRA highlights this specifically for finasteride. [1]

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How to monitor

Core principle

There is no fixed formal monitoring schedule in the MHRA advice/SPCs, but they consistently say to monitor patients regularly for psychiatric and sexual adverse effects. [1][2][3][4]

Practical approach

At each review (and after any dose/indication change), ask the same focused questions:

• Mood / suicidality
  • “Any new low mood, anxiety, agitation, hopelessness, or suicidal thoughts?”
  • “Any change noticed by partner/family/friends?”
• Sexual function
  • “Any change in libido, erectile function, ejaculation, orgasm, or semen volume?”
  • “If you’ve stopped the drug, have these symptoms resolved, improved, or persisted?”

Useful clinic practice

• Use a brief structured screen and document baseline vs follow-up.
• Consider a simple validated mood tool such as PHQ-9 if you want an objective baseline/follow-up, but the key requirement from MHRA is direct questioning and regular review rather than a specific instrument. [1]
• Encourage the patient to tell their partner/family that mood changes can occur and may be noticed by others first. MHRA explicitly notes patients may not notice some mood/behaviour changes themselves. [1]

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What to do if symptoms develop

Depression / suicidal ideation

• Finasteride 1 mg: stop immediately and contact clinician as soon as possible. [1][2]
• Finasteride 5 mg or dutasteride: contact prescriber urgently/as soon as possible; the SPCs/MHRA do not phrase this as “self-stop immediately” in the same way, but in practice I would hold the drug pending review if mood symptoms are concerning, especially if suicidal ideation is present. [1][3][4]
• If there is current suicidal intent, plan, or inability to keep safe: same-day emergency mental health assessment / emergency services.

Persistent sexual side effects

• Ask explicitly whether sexual dysfunction resolved after stopping.
• Finasteride SPCs state that sexual dysfunction may continue after discontinuation; dutasteride SPC states sexual adverse effects may persist after treatment discontinuation and the role of dutasteride is unknown. [2][3][4]
• If persistent:
  • document onset, duration, and severity,
  • exclude other causes/medicines,
  • consider alternative management,
  • report as a Yellow Card if suspected. [1][2][3][5]

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A concise script you could use

> “These medicines can sometimes affect mood and sexual function. Before we start, I want to check whether you’ve ever had depression or suicidal thoughts, and whether you have any sexual problems already. Once you’re on treatment, please tell us promptly about any low mood, suicidal thoughts, reduced libido, erection or ejaculation problems, and let your partner/family know to look out for mood changes too.”