Sexual dysfunction, antidepressant-induced

After more than a decade of use, bupropion (24) is considered a safe and effective antidepressant, suitable for use as first-line treatment. In addition, it is approved for smoking cessation and seasonal affective disorder. It is also prescribed off-label to treat the sexual dysfunction induced by SSRIs. Bupropion is often referred to as an atypical antidepressant and has much lower affinity for the monoamine transporters compared with other monoamine reuptake inhibitors. The mechanism of action of bupropion is still uncertain but may be related to inhibition of dopamine and norepinephrine reuptake transporters as a result of active metabolites [71,72]. In a recently reported clinical trial, bupropion extended release (XL) had a sexual tolerability profile significantly better than that of escitalopram with similar re-... 

Cohen AJ, Bartlik B. (1998). Ginkgo biloba for antidepressant-induced sexual dysfunction. J Sex Marital Ther. 124(2) 139-43. 

Take a Medication Holiday. Some side effects are not a problem on a daily basis nonetheless, they can be qnite distnrbing. The best examples are sexual side effects of some antidepressants or the possible effects of stimulants upon the growth of children with ADHD. One approach has been to skip taking the medication for a brief period of time. For example, those with antidepressant-induced sexual dysfunction have sometimes circnmvented this problem by skipping a single day s dose when they plan to have sex. In a similar fashion, parents concerned with the effects of stimulants on their child s growth may have their child skip doses on the week-... 

Fava M, Rankin MA, Alpert JE, et al An open trial of oral sildenafil in antidepressant-induced sexual dysfunction. Psychother Psychosom 67 328-331, 1998... 

Ginkgo 1 2 151 million (36), 395.68 million (7) Age-related macular degeneration treatment, age-related memory impairment, altitude Antidepressant-induced sexual dysfunction, seasonal affective disorder, tinnitus... 

Sedation is uncommon and instead many patients will find that these drugs may impair sleep, which is why the dose is best taken in the morning. There is also little effect on psychomotor function. Occasional patients have a small reduction in heart rate but otherwise effects on the cardiovascular system are rare. Epileptic convulsions can occur but are rare and much less common than with tricyclic antidepressants. There is some evidence for potentiation of electroconvulsive therapy (ECT)-induced seizures. Sexual dysfunction is reported, principally delayed ejaculation and anorgasmia. 

In their review of 12 reported cases, Barnhart et al. (2004) found three cases associated with fluvoxamine, seven with fluoxetine, and two with paroxetine. The apathy states improved or resolved with dose reduction or discontinuation. The authors believed that the syndrome frequently goes undetected despite its significant clinical impact. Opbroek et al. (2002) reported that 80% of patients with SSRI-induced sexual dysfunction reported suffering from treatment-emergent emotional blunting. This is consistent with my clinical observations that so-called sexual dysfunction in patients receiving antidepressants often involves a more generalized loss of interest in both sex and loved ones. 

These data suggest that antidepressant-induced sexual dysfunction is more likely to be associated with agents that greatly potentiate 5HT neurotransmission. This notion is supported by the results of a 6-week doubleblind study of 24 men with premature ejaculation, in which paroxetine (20 mg/day) increased latency to ejaculation six-fold while mirtazapine (30 mg/day) had minimal effect (4). In a randomized, 8-week, double-blind, placebo-controlled study in 450 patients with major depression, fluoxetine (20 -0 mg/day) significantly impaired sexual function, while the noradrenaline re-uptake inhibitor reboxetine had no effect (5). 

In a double-blind, placebo-controlled study in 90 patients with sexual dysfunction who were taking a variety of 5HT re-uptake inhibitor antidepressants, sildenafil (50-100 mg) produced improvement in all aspects of the sexual response in 54% of antidepressant-treated patients compared with a placebo response rate of 4.4% (NNT = 2) (6). This suggests that sildenafil is an effective treatment for antidepressant-induced sexual dysfunction. 

TABLE 3.11. Types of Sexual Dysfunction Induced by Antidepressant Medications... 

B Sexual dysfunction is generally believed to be a dose-dependent side effect with SSRIs and may be relieved or prevented with lower doses. Although RH may run the risk of relapse at a lower dose, many patients will achieve a therapeutic response at lower doses. If this approach is unsuccessful, bupropion is an excellent antidote and may also provide additional antidepressant effects (i.e., augmentation). Sildenafil has actually been found to reverse SSRI-induced sexual dysfunction but is an expensive alternative with potential cardiovascular complications that should only be considered after other measures fail. 

Kang BJ, Lee SJ, Kim MD, Cho MJ. A placebo-controlled, double-blind trial of Ginkgo biloba for antidepressant-induced sexual dysfunction. Hum Psychopharmacol Clin Exp 2002 17 279-284. 

Most prominent among the psychotropics that enhance serotonergic transmission are the selective serotonin reuptake inhibitors (SSRIs), which may induce sexual dysfunction in as many as 50-75% of patients, in part by activation of central 5-HT2 receptors. Antidepressants that antagonize the 5-HT2 receptor, such as mirtazapine and trazodone, cause fewer sexual side-effects compared with the SSRIs. Stimulation of the 5-HTia receptor facilitates sexual functioning, while activation of the 5-HTib,id and 5-HTic receptors inhibits... 

A. J. Cohen and B. Bartlik, Ginkgo Biloba for Antidepressant-Induced Sexual Dysfunction. Journal of Sex and Marital Therapy 24, no. 2 (1998) 139-144. 

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