Magazine article Clinical Psychiatry News

Treating Sexual Dysfunction: Antidepressant-Associated SD Tends to Be Dose Related, but a Dosage Reduction Can Prove Risky

Magazine article Clinical Psychiatry News

Treating Sexual Dysfunction: Antidepressant-Associated SD Tends to Be Dose Related, but a Dosage Reduction Can Prove Risky

Article excerpt

Sexual dysfunction is commonly encountered in psychiatric practice as both a symptom of major mental disorders and a consequence of their treatment.

In the last decade, considerable attention has been paid to the latter issue. This is a consequence, said Michael Gitlin, M.D., professor of clinical psychiatry at the University of California, Los Angeles, of the widening use of drugs--selective serotonin reuptake inhibitors (SSRIs) in particular, but antipsychotics as well--that have substantial sexual side effects.

In one study of 6,297 adult outpatients under treatment for depression, investigators found sexual dysfunction (SD) rates of 36%-43% among those receiving SSRI or venlafaxine monotherapy (J. Clin. Psychiatry 2002;63:357-66).

Research into treatment has not kept pace, however.

"The database is minimal, considering the size of the problem," Dr. Gitlin said. With the exception of one agent--sildenafil (Viagra)--there are no "antidote" strategies for which controlled data are at all robust, he said.

The effect of SD on treatment adherence is cause for concern. A survey of 51 severely mentally ill outpatients taking a variety of psychotropic drugs found that 42% of men and 15% of women admitted stopping medication at some point because of putative sexual side effects (J. Sex Marital Ther. 2003;29:289-96).

"When physicians prescribe SSRIs, by the third month, half of patients have stopped taking them," said H. George Nurnberg, M.D., professor and executive vice chair for clinical psychiatry programs at the University of New Mexico, Albuquerque. The persistence of SD takes a particular toll on efforts to maintain treatment long enough to achieve remission and forestall relapse, he said.

Management begins with the initial evaluation, said Anita L.H. Clayton, M.D., the David E. Wilson Professor and vice chair of the department of psychiatric medicine at the University of Virginia, Charlottesville. Sexual difficulties are a cardinal symptom of depression, and they are common in schizophrenia and anxiety disorders as well, so baseline data are invaluable in deducing whether later problems are indeed related to medication.

Considerable detail can be derived from a 2-minute series of questions, Dr. Gitlin suggested: "Ask the patient about his or her sex drive, whether erections or lubrication are adequate, if he or she can have orgasms, whether there have been recent changes."

Sexual function should be a point of inquiry during subsequent visits. "If you wait for the patient to spontaneously report problems, the rate is 5%-10%. If you systematically ask, it's 35%-40%," Dr. Nurnberg said of SSRI treatment.

A preemptive strategy deserves consideration for some patients, Dr. Clayton said. For a depressed woman with several risk factors (over 50 years old, married, not employed full time, cigarette smoker, history of antidepressant-induced SD, poor psychosexual adjustment) an agent with less apparent sexual liability, such as bupropion or mirtazapine, might be an option.

Whether to address treatment-emergent SD depends on its meaning to the patient. "Some view the impact as huge, while others feel they can manage it," she said.

When intervention is called for, general strategies should be considered first, Dr. Gitlin said.

Antidepressant-associated SD is generally dose related, but a dosage reduction risks reemergence of symptoms.

Switching from one SSRI to another is a "low risk, low gain" strategy because the chances of relapse and relief are comparably small. …

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