What to Do When Patients on Antidepressants Report Sexual Dysfunction
Abstract
Studies suggest that patients who take selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors may be more likely to experience sexual side effects than those taking other antidepressants.
Although antidepressants can help to decrease depressive symptoms in people with depression, for some patients these medications can also lead to decreased interest in or pleasure from sex.
Anita Clayton, M.D., and Stephen Levine, M.D., believe that psychiatrists should assess how important sex is to patients with depression when prescribing antidepressants.
According to Anita Clayton, M.D., an expert in female sexual disorders, approximately two-thirds of people with depression have some type of sexual dysfunction. Additionally, between 30 and 75 percent of patients who take selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) experience sexual side effects. These effects include a reduced sex drive, challenges becoming sexually aroused, and a decreased ability to orgasm, she told Psychiatric News.
In 2002, Clayton and colleagues published a study in the Journal of Clinical Psychiatry that included information on sexual side effects of nearly 6,300 people taking antidepressant monotherapy in a primary care setting. The analysis showed that sexual dysfunction was prevalent in an average of 40 percent of patients who took the SSRIs fluoxetine, paroxetine, sertraline, or citalopram, or the SNRIs venlafaxine or mirtazapine. In the same study, the researchers found that patients who took the atypical antidepressant bupropion had the lowest reports of sexual side effects, at a prevalence rate of 22 percent.
A pharmaceutical-sponsored study showed that relatively fewer sexual side effects were associated with vortioxetine. In a review of the literature, there is the suggestion that vilazodone may cause fewer sexual side effects. In a meta-analysis of pharmaceutical-sponsored, short-term studies of the transdermal formulation of a monoamine oxidase inhibitor, there were indications that this formulation may cause fewer sexual side effects.
“It seems as though drugs that mainly target serotonergic activity inhibit sexual function, while dopaminergic activity [which is increased by bupropion] seems to be excitatory for sexual function,” said Clayton, who is the David C. Wilson Professor and chair of psychiatry and neurobehavioral sciences at the University of Virginia Health. However, because most clinical trials compare the side effects of medication with those of placebo, Clayton said it is difficult to know how each stacks up when it comes to changes in sexual function.
What’s Driving Sexual Dysfunction in Your Patient?
Because a variety of factors can lead to sexual dysfunction in people, Stephen Levine, M.D., a clinical professor of psychiatry at Case Western Reserve University School of Medicine and co-director of the Center for Marital and Sexual Health in Cleveland, said there are several questions clinicians should ask to determine whether or not the antidepressant is to blame:
What was the state of the patient’s sexual functioning—either with an intimate partner or in solitude—before the onset of the psychiatric disturbance?
What was the effect of depression on the patient’s sexual function?
What was the impact of the antidepressant on the sexual function?
What is the patient’s state of sexual functioning when depressive symptoms have improved after antidepressant treatment?
“There is wisdom in understanding these questions,” said Levine, the author of the Handbook of Clinical Sexuality for Mental Health Professionals. “Depending on the circumstances, the same drug that causes sexual side effects in one patient may be the same drug to enhance sexual function in another.”
Options to Restore Libido and Sexual Engagement in Patients
Clayton emphasized that it is important for clinicians to talk with patients about the potential sexual side effects of medications and assess the importance of sex in the person’s life before prescribing antidepressants.
“Although sexual dysfunction is a common problem, we do have options for people who do not want to experience or are experiencing sexual impairment associated with antidepressant medications,” Clayton said.
Some of these options include waiting four to six months to see whether the dysfunction subsides, which occurs in 5 percent to 10 percent of patients; switching to another antidepressant; or, if the patient shows improvement in depressive symptoms while on current antidepressive therapy, using an add-on medication such as a PDE-5 inhibitors (for both men and women) or another antidepressant, such as bupropion, to counterbalance sexual impairments. ■
