Academic journal article Perspectives in Psychiatric Care

Mechanisms and Treatments of SSRI-Induced Sexual Dysfunction. (Biological Perspectives)

Academic journal article Perspectives in Psychiatric Care

Mechanisms and Treatments of SSRI-Induced Sexual Dysfunction. (Biological Perspectives)

Article excerpt

Individuals treated for depression frequently experience sexual dysfunction as a side effect. This specific side effect commonly presents when depressed people take selective serotonin reuptake inhibitors (SSRIs). Although other antidepressants also cause sexual dysfunction, the clinical dominance of SSRIs dictates their review.

Sexual dysfunction, defined as reduction in desire (i.e., libido), arousal (i.e., vaginal lubrication, erection), and/or release (i.e., orgasm, ejaculation), occurs in 30% to 50% or more of those treated with SSRIs (Clayton, McGarvey, Abouesh, & Pinkerton, 2001; Woodrum & Brown, 1998). Patients taking SSRIs may experience one or all of these sexual disruptions. Because sexual dysfunction leads to noncompliance, nurses need to understand both underlying mechanisms and appropriate treatments. Unfortunately, both depression and its pharmacologic treatment cause sexual dysfunction, making etiology less clear. Ferguson (2001) notes, however, that 70% (n = 6,000) of these patients (treated and untreated) report a continued interest in sexual activity. Hence, it behooves the practitioner to attempt to determine whether these symptoms are a product of treatment, a vestige of nonameliorated depression, or related to some other drug or condition. Table 1 lists common medications, and Table 2 lists common conditions associated with sexual dysfunction.

Sexual dysfunction related to SSRIs, although far from rare, remains highly unrecognized. Comparing statistics from the Physician's Desk Reference (PDR) (2002) to a number of studies supports this assertion. The PDR indicates 2% to 16% of patients taking SSRIs experience sexual dysfunction, while other sources suggest rates of 50%, 70%, or even 90% (Clayton et al., 2001; Ferguson, 2001; Hirschfeld, 1999; Keltner & Folks, 2001). One explanation for disparities between classic references such as the PDR and other sources centers on the tendency of clients to not volunteer information of such a sensitive nature. However, when directly queried about such matters, there is a sharp increase in reports of sexual dysfunction.

Mechanisms of SSRI-Induced Sexual Dysfunction

How SSRIs Increase Serotonin

As their name suggests, SSRIs block the reuptake of serotonin; the process of achieving increased synaptic serotonin availability, however, is complex. A cascade of events must occur. Stahl (1998), Rosenbaum (2001), and others carefully outline the multistep process.

SSRIs block the reuptake of serotonin and do so immediately. Although they are often taught that the increase occurs at the synapse, nurses should understand that at least initially, the increase in serotonin occurs primarily in the somatodendritic area (i.e., area of the cell body and dendrites). As serotonin increases in the somatodendritic area, autoreceptors located there begin to desensitize--remember that autoreceptors, when stimulated, signal the cell to slow serotonin synthesis. As autoreceptors desensitize they become "immune" to serotonin and turn off nature's negative feedback system. Hence, serotonin no longer inhibits neuronal activity, so neuronal activity increases, releasing more serotonin at the axonal terminal. Increase in synaptic serotonin is dependent on the foregoing steps, and takes 2 to 4 weeks. Stahl (1998) suggests this may provide an explanation for delayed occurrence of an antidepressant effect.

How SSRIs Cause Sexual Dysfunction

While this discussion provides a better understanding of how SSRIs increase serotonin, it still does not hint at the mechanisms by which these drugs cause sexual dysfunction (i.e., decreased desire, arousal, and/or release). A simple axiom illuminates our understanding of SSRI-induced sexual dysfunction--serotonin tends to diminish sexual function, while dopamine tends to enhance sexual function. Drugs that enhance serotonin or block dopamine tend to decrease sexual activity; drugs that increase dopamine or block specific serotonin receptors tend to enhance sexual activity (Montejo-Gonzalez et al. …

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