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Anti-libidinal medication Dr Prathima Apurva ST5 Forensic psychiatry Nov 2013.

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Presentation on theme: "Anti-libidinal medication Dr Prathima Apurva ST5 Forensic psychiatry Nov 2013."— Presentation transcript:

1 Anti-libidinal medication Dr Prathima Apurva ST5 Forensic psychiatry Nov 2013

2 Overview Context Context What is anti-libidinal medication? What is anti-libidinal medication? Why might we need it in managing sex offenders? Why might we need it in managing sex offenders? How does it work? How does it work? Availability in Scotland. Availability in Scotland. Some legal and ethical issues Some legal and ethical issues

3 Sex offenders with ID Static variables Anti social attitude, poor relationship with mother, low self esteem, lack of assertiveness, poor response to treatment, Anti social attitude, poor relationship with mother, low self esteem, lack of assertiveness, poor response to treatment, Offences involving physical violence, staff complacency, an attitude tolerant of sexual crimes Offences involving physical violence, staff complacency, an attitude tolerant of sexual crimes

4 Low treatment motivation, erratic attendance and unexplained break from routine, deterioration in family attitudes. Low treatment motivation, erratic attendance and unexplained break from routine, deterioration in family attitudes. Unplanned discharge Unplanned discharge

5 Dynamic variables Social effective functioning Social effective functioning Distorted attitudes and beliefs Distorted attitudes and beliefs Self management and self regulation Self management and self regulation Sexual preference and sexual drive Sexual preference and sexual drive

6 Social effective functioning This refers to the way in which the individual relates to the other people and includes aspects of negative affect. This refers to the way in which the individual relates to the other people and includes aspects of negative affect. Low self esteem and loneliness. Low self esteem and loneliness.

7 Distorted cognitions and beliefs Counterfeit deviance Counterfeit deviance Whilst assessing to be cautious about processes such as suppression, social desirability and lying. Whilst assessing to be cautious about processes such as suppression, social desirability and lying.

8 Self management and self regulation Deficits in self regulation and ability to engage in appropriate problem solving strategies and impulse control. Deficits in self regulation and ability to engage in appropriate problem solving strategies and impulse control.

9 Sexual preference and sexual drive Interest rather than accessibility Interest rather than accessibility Paedophilia Paedophilia

10 What is antilibidinal medication Primary effect is to either stop androgens from being produced or to prevent them from working altogether. Primary effect is to either stop androgens from being produced or to prevent them from working altogether. Testosterone is thought to influence sexual arousal and responsiveness. Testosterone is thought to influence sexual arousal and responsiveness. Therefore a reduction in testosterone = a reduction in a man’s libido and desire to engage in sexual activity. Therefore a reduction in testosterone = a reduction in a man’s libido and desire to engage in sexual activity.

11 Why? It not to completely suppress sexual drive and create an asexual individual. It not to completely suppress sexual drive and create an asexual individual. To selectively suppress deviant sexual urges and fantasies. To selectively suppress deviant sexual urges and fantasies.

12 Hormones and neuro-transmitters involved in sexual response Dehydroepiandrosterone (DHEA) Dehydroepiandrosterone (DHEA) Oxytocin Oxytocin Phenylethylamine (PEA) Phenylethylamine (PEA) Oestrogen Oestrogen Testosterone Testosterone Progesterone Progesterone Prolactin Prolactin Vasopressin Vasopressin Dopamine Dopamine Serotonin Serotonin Acetylcholine Acetylcholine 1. DESIRE (LIBIDO) 2. AROUSAL 3. ORGASM

13 Types of medication Anti-libidinal medications: Anti-libidinal medications: Medroxyprogesterone Acetate (MPA). Medroxyprogesterone Acetate (MPA). Cyproterone Acetate (CPA). Cyproterone Acetate (CPA). Long-acting Gonadotropin-releasing Hormones (GnRH) agonists. ( Leuprorelin, Triptorelin & Goserelin. Long-acting Gonadotropin-releasing Hormones (GnRH) agonists. ( Leuprorelin, Triptorelin & Goserelin. Psychotropic medication: Psychotropic medication: Selective Serotonin Reuptake Inhibitors (SSRIs) Selective Serotonin Reuptake Inhibitors (SSRIs)

14 Cyproterone acetate LICENSED FOR MALE HYPERSEXUALITY MODE OF ACTION Blocks testosterone receptors Also decreases GnRH and LH secretion DOSE 50 – 200 mg orally 300 – 600 mg fortnightly intramuscular depot (named patient basis) COST £300 – 400 per year

15 Cyproterone acetate ADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight gain, cardiovascular) menopausal symptoms (hot flushes, depression, weight gain, cardiovascular) gynaecomastia gynaecomastia osteoporosis osteoporosis carbohydrate metabolism, other endocrine carbohydrate metabolism, other endocrine CAUTIONS / CONTRA-INDICATIONS under 18 (or incomplete growth) under 18 (or incomplete growth) liver disease liver disease malignancy (except prostate) malignancy (except prostate) cardiovascular disease cardiovascular disease severe diabetes severe diabetes severe chronic depression severe chronic depression metabolic bone disease metabolic bone disease

16 Leuprorelin NOT LICENSED MODE OF ACTION GnRH agonist: exhausts LH and FSH DOSE 3.75 mg 4 weekly titrate between every 2 weeks and every 8 weeks 3.75 mg 4 weekly titrate between every 2 weeks and every 8 weeks or 22.5mg every 3 months or 22.5mg every 3 monthsCOST 3.75mg = £ = £1630 annually

17 Triptorelin SALVACYL LICENSED FOR SEVERE SEXUAL DEVIANCE MODE OF ACTION GnRH agonist: exhausts LH and FSH DOSE 3.75mg – 7.5 mg every 4 weeks 11.5mg every 3 months COST 3.75mg = £ = £1366 annually

18 Goserelin NOT LICENSED MODE OF ACTION GnRH agonist: exhausts LH and FSH DOSE 3.6mg every 4 weeks 3.6mg every 4 weeks long acting 10.8mg every 12 weeks long acting 10.8mg every 12 weeksCOST 3.6mg = £ = £1590 annually 3.6mg = £ = £1590 annually 10.8 mg = £ = £1559 annually 10.8 mg = £ = £1559 annually

19 GnRH agonists ADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight gain, cardiovascular) menopausal symptoms (hot flushes, depression, weight gain, cardiovascular) gynaecomastia gynaecomastia osteoporosis osteoporosis carbohydrate metabolism, other endocrine carbohydrate metabolism, other endocrine BUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATE BUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATE initial increase in testosterone – not need flutamide initial increase in testosterone – not need flutamide CAUTIONS / CONTRA-INDICATIONS under 18 (or incomplete growth) under 18 (or incomplete growth) malignancy (except prostate) malignancy (except prostate) cardiovascular disease cardiovascular disease severe diabetes severe diabetes severe chronic depression severe chronic depression metabolic bone disease metabolic bone disease

20 GnRH agonists STUDIES Case studies and case series Case studies and case series 118 patients in systematic review (Briken et al., 2003) 118 patients in systematic review (Briken et al., 2003) Very low re-offending Very low re-offending Better outcome for those previously on MPA or CA Better outcome for those previously on MPA or CA Sexual urges and fantasies may disappear Sexual urges and fantasies may disappear Frequency of masturbation reduced drastically Frequency of masturbation reduced drastically Side-effects less problematic Side-effects less problematic

21 SSRIs NOT LICENSED MODE OF ACTION Potentiate serotonin activity by decreasing re-uptake from synapse DOSE fluoxetine: fluoxetine: 20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4 weeks sertraline: sertraline: 50mg, 100mg, 150mg COST £ annually

22 SSRIs ADVERSE EFFECTS nausea nausea agitation, restlessness agitation, restlessness insomnia insomnia sexual dysfunction (decreased libido; delayed ejaculation) sexual dysfunction (decreased libido; delayed ejaculation) too much coffee feeling too much coffee feeling raised prolactin raised prolactin CAUTIONS / CONTRA-INDICATIONS mania mania epilepsy (poorly controlled) epilepsy (poorly controlled) history of bleeding disorders history of bleeding disorders hypersensitivity hypersensitivity akathisia akathisia

23 SSRIs STUDIES over 200 case reports and open studies reported in the literature (Kafka, 2003; Greenberg & Bradford, 1997) over 200 case reports and open studies reported in the literature (Kafka, 2003; Greenberg & Bradford, 1997) most report success in reducing the frequency and intensity of sexual fantasy, urges and arousal most report success in reducing the frequency and intensity of sexual fantasy, urges and arousal often without negative effects on normal sexual behavior often without negative effects on normal sexual behavior systematic review (Adi et al., 2002) systematic review (Adi et al., 2002) very few trials of reasonable methodological quality very few trials of reasonable methodological quality outcomes positive outcomes positive use of SSRI medication in sex offenders warranted use of SSRI medication in sex offenders warranted

24 SSRIs HOW DO THEY WORK? May have effect through: Impulsivity Impulsivity Mood Mood Obsessive-compulsive Obsessive-compulsive Decreased deviant fantasizing Decreased deviant fantasizing Attachment Attachment

25 Legal and Ethical issues

26 Voluntary or Mandatory Mandatory in many USA states Mandatory in many USA states If Voluntary – issues with consent If Voluntary – issues with consent Voluntary more like to work? Voluntary more like to work? Most psychiatrist feel treatment should be voluntary. Most psychiatrist feel treatment should be voluntary. If capacity is an issue then AWI and DMP opinion. If capacity is an issue then AWI and DMP opinion.

27 Treatment or Punishment Voluntary = treatment? Voluntary = treatment? Mandatory = punishment? Mandatory = punishment? Side effects Side effects Risk management tool? Risk management tool?

28 Concluding thoughts Pharmacotherapy can work. Pharmacotherapy can work. More guidance on legal and ethical concerns. More guidance on legal and ethical concerns. Advice from SOLS Advice from SOLS


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