Poor sexual communication
SSRI side effects have forced us to broach the awkward topic of sex with our patients. Simply forcing the issue into the open often has unanticipated benefits. For example, a woman referred for panic disorder was asked about her sex life, in order to get a baseline history before starting Zoloft. She reported that she and her husband rarely had sex, because she thought he was uninterested. She agreed to bring him into her next psychopharm session, and it became clear that, in fact, her husband assumed that she was the uninterested party. Once better communication was established, their sex life improved, despite the fact that Zoloft caused decreased clitoral sensitivity.
Premature ejaculation affects up to 30% of males in the general population, so if you don’t ask about this, you’re missing many cases. Some will remember a 1998 study played up by Luvox reps (Solvay Pharmaceuticals) that compared SSRIs for the treatment of premature ejaculation (1). Paxil worked the best, while Luvox didn’t even beat placebo. This was supposed to be a selling point for Luvox, but it’s also a nice endorsement of Paxil’s utility for this condition. A more recent study (2) found that the combination of Paxil 20 mg and Viagra 25-100mg works excellently in the most treatment resistant cases of premature ejaculation.
Too much libido can be as bad as too little, although patients rarely seek treatment for the former. In one case, a married man presented with a chief complaint of cocaine addiction and mild depression. He very strongly associated his addiction with a parallel compulsion to engage prostitutes, from whom he would also obtain his drugs. On Effexor XR, not only did his depression lift, but his libido dipped, indirectly providing him with better control over his cocaine addiction.
Agitated depression in underweight elderly patients
A common clinical constellation is the underweight, elderly patient with ruminative depression and insomnia. Remeron 15-30 mg QHS almost always works well in such situations, because of its otherwise unwanted side effects of sedation and weight gain. Zyprexa, too, produces almost miraculous responses, at doses in the 2.5 mg QHS range. But beware that even very low doses of Zyprexa may ultimately cause excessive weight gain.
Irritable Bowel Syndrome
Low dose doxepin (Sinequan) is a favorite of many primary care physicians for symptomatic treatment of IBS, often in the the 25-50 mg QHS range. Its side effects of constipation and sedation are often perfect for such patients. Word on the street has it that Remeron works just as well.
If you have an anorexic patient with hypotension and comorbid depression, it would be pretty hard to argue against turning to Effexor XR as first-line. While at average doses it does not cause more hypertension than does placebo, at 300 mg and above, chances are pretty good that the norepinephrine reuptake inhibition will kick into high gear and help to bring up your patient’s too low blood pressure.
TCR VERDICT: Look for the Silver Lining!
1. Waldinger MD, Hengeveld MW, Zwinderman AH, et al. Effect of SSRI antidepressants on ejacuation. J Clin Psychopharm. 1998; 18(4):274-81.
2. Chen J, Mabjeesh NJ, Matzkin H, et al. Efficacy of sildenafil as adjuvant therapy to selective serotonin reuptake inhibitor in alleviating premature ejaculation. Urology. 2003; 61(1): 197-200.