Several months ago, I made an important change in my clinical practice. I started screening more closely for sexual side effects related to antidepressant use. While I’d always warned patients about the possibility of such effects, I’d mostly counted on them to approach me with any issues.
I was greatly surprised by the results of this simple change. Not only was it happening much more frequently than I would have imagined, it was a topic many of my patients felt uncomfortable bringing up themselves. I was reassured reading that physicians consistently underestimate the prevalence of sexual side effects among their patients (Montejo AL et al, J Clin Psychiatry 2001;62(Suppl 3):10–21).
Early studies involving Serotonin Reuptake Inhibitors (SRIs) failed to show significant sexual side effect profiles. Many hypothesize this may have been due to drastic under-reporting from patients. Especially considering that more recent studies show up to 72 percent of people on SRIs experience sexual side effects (Montejo ibid).
While we don’t fully understand the mechanism, current theory links this to serotonin playing an inhibitory role in sexual function; while dopamine may actually stimulate it. It reasons then, that medications effecting serotonin selectively would have higher rates of sexual side effects than nonselective antidepressants such as Remeron (mirtazapine) or Serzone (nefazodone).
Common Sexual Side Effects of Antidepressants
While it’s hard to predict which side effect will result from any given SRI, the most common sexual dysfunctions reported among men and women include:
- Diminished interest in sex
- Decreased arousal (in men this may be difficulty maintaining an erection, versus women, who may notice more vaginal dryness)
- Difficulty climaxing (delayed or absent orgasm)
Any one of these has high potential to worsen a patient’s self esteem, decrease their quality of life, and worsen relationships that may already be strained by their mood disorder.
Which Antidepressants Cause the Most or Least Sexual Side Effects?
When looking more closely at the SRIs, it appears Prozac (fluoxetine), Zoloft (sertraline), and Luvox (fluvoxamine) may have slightly lower rates of sexual dysfunction. In spite of this, more than half the patients on these medications will still be affected.
Conversely, Paxil (paroxetine), Celexa (citalopram), and Effexor (venlafaxine) have the highest rates; inducing sexual side effects in as many as 72 percent (Montejo ibid).
How to Treat Sexual Side Effects
With numbers this high, how do we go about lessening these effects? For years, the standard approach for treating SRI-induced sexual dysfunction included waiting for spontaneous resolution, decreasing the dose, using drug holidays (for planned sexual activity), or switching to an alternative (Kinzl JF, Neuropsychiatr 2009;23(2):134–138).
Sadly, spontaneous resolution is rare, and the other approaches have their limitations. For example, if symptoms are severe, it can be hard to justify decreasing the dose or taking a drug holiday when this could lead to symptom decompensation. Similarly, switching agents carries the risk of new side effects or a less robust treatment response.
Fortunately, clinicians are finding alternative ways to combat the sexual side effects of SRI use. These may be particularly helpful for patients whose depression is adequately responding to SRI treatment. Unfortunately, many of these recommendations are based on case reports and need more thorough research to support their use.
Some options, like BuSpar (buspirone) and Periactin (cyproheptadine), are thought to work by decreasing serotonin which, in turn, may lead to fewer problems with arousal and orgasm (Norden MJ, Depression 1994;2(2):109–112; Ashton AK et al, J Sex Marital Ther 1997;23(3):165–175).
Alternatively, you could add a medication to stimulate dopamine, such as Wellbutrin (buproprion), Symmetrel (amantadine), or stimulants, which seem to counter the sexual side effects of SRIs (Ashton ibid; Ashton AK et al, J Clin Psychiatry 1998;59: 112–115; Bartlik BD et al, J Sex Marital Ther 1995;21:264–271).
Yohimbine is a natural supplement made from the bark of the Corynanthe yohimbi tree. It’s long been regarded as having aphrodisiac properties that may increase arousal and erectile function (Morales A, Int J Impot Res 2000;Mar 12(Suppl 1):70–74).
As mentioned above, nefazodone and mirtazepine are two antidepressants with significantly lower rates of sexual dysfunction. There’s some research into whether they could be added to a patient’s medication regimen in hopes of reducing sexual dysfunction (Labbate LA et al, J Clin Psychiatry 2003;64(Suppl 10):11–19; Reynolds RD, J Clin Psychiatry 1997;58:89).
And last, but not least, some clinicians will use medications like Viagra (sildenafil) or Cialis (tadalafil), in both men and women alike, attempting to lessen sexual side effects through alternate pathways than many of the above options.
The options for treating sexual side effects of antidepressants are plentiful. What’s lacking is more robust screening to identify patients suffering from such effects. While sexual dysfunction may not be as worrisome as other potential side effects, they still play a significant role in our patient’s quality of life and willingness to stay on a medication. Habitually screening and openly discussing sexual side effects may go a long way in helping our patients achieve remission.
Photo courtesy of Chad Rogers on flickr