Presentation on theme: "Anti-libidinal medication"— Presentation transcript:
1Anti-libidinal medication Dr Prathima ApurvaST5 Forensic psychiatryNov 2013
2Overview Context What is anti-libidinal medication? Why might we need it in managing sex offenders?How does it work?Availability in Scotland.Some legal and ethical issues
3Sex offenders with ID Static variables 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
4Low treatment motivation, erratic attendance and unexplained break from routine, deterioration in family attitudes.Unplanned discharge
5Dynamic variables Social effective functioning Distorted attitudes and beliefsSelf management and self regulationSexual preference and sexual drive
6Social effective functioning 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.
7Distorted cognitions and beliefs Counterfeit devianceWhilst assessing to be cautious about processes such as suppression, social desirability and lying.
8Self management and self regulation Deficits in self regulation and ability to engage in appropriate problem solving strategies and impulse control.
9Sexual preference and sexual drive Interest rather than accessibilityPaedophilia
10What is antilibidinal medication 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.Therefore a reduction in testosterone = a reduction in a man’s libido and desire to engage in sexual activity.
11Why?It not to completely suppress sexual drive and create an asexual individual.To selectively suppress deviant sexual urges and fantasies.
12Hormones and neuro-transmitters involved in sexual response Dehydroepiandrosterone (DHEA)OxytocinPhenylethylamine (PEA)OestrogenTestosteroneProgesteroneProlactinVasopressinDopamineSerotoninAcetylcholineDESIRE (LIBIDO)AROUSALORGASM
14Cyproterone acetate LICENSED FOR MALE HYPERSEXUALITY MODE OF ACTIONBlocks testosterone receptorsAlso decreases GnRH and LH secretionDOSE50 – 200 mg orally300 – 600 mg fortnightly intramuscular depot (named patient basis)COST£300 – 400 per year
15Cyproterone acetate ADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight gain, cardiovascular)gynaecomastiaosteoporosiscarbohydrate metabolism, other endocrineCAUTIONS / CONTRA-INDICATIONSunder 18 (or incomplete growth)liver diseasemalignancy (except prostate)cardiovascular diseasesevere diabetessevere chronic depressionmetabolic bone disease
16Leuprorelin NOT LICENSED MODE OF ACTIONGnRH agonist: exhausts LH and FSHDOSE3.75 mg 4 weekly titrate between every 2 weeks and every 8 weeksor 22.5mg every 3 monthsCOST3.75mg = £ = £1630 annually
17Triptorelin SALVACYL LICENSED FOR SEVERE SEXUAL DEVIANCE MODE OF ACTIONGnRH agonist: exhausts LH and FSHDOSE3.75mg – 7.5 mg every 4 weeks11.5mg every 3 monthsCOST3.75mg = £ = £1366 annually
18Goserelin NOT LICENSED MODE OF ACTIONGnRH agonist: exhausts LH and FSHDOSE3.6mg every 4 weekslong acting 10.8mg every 12 weeksCOST3.6mg = £ = £1590 annually10.8 mg = £ = £1559 annually
19GnRH agonists ADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight gain, cardiovascular)gynaecomastiaosteoporosiscarbohydrate metabolism, other endocrineBUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATEinitial increase in testosterone – not need flutamideCAUTIONS / CONTRA-INDICATIONSunder 18 (or incomplete growth)malignancy (except prostate)cardiovascular diseasesevere diabetessevere chronic depressionmetabolic bone disease
20GnRH agonists STUDIES Case studies and case series 118 patients in systematic review (Briken et al., 2003)Very low re-offendingBetter outcome for those previously on MPA or CASexual urges and fantasies may disappearFrequency of masturbation reduced drasticallySide-effects less problematic
21SSRIs NOT LICENSED MODE OF ACTION Potentiate serotonin activity by decreasing re-uptake from synapseDOSEfluoxetine:20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4 weekssertraline:50mg, 100mg, 150mgCOST£ annually
22SSRIs ADVERSE EFFECTS nausea agitation, restlessness insomnia sexual dysfunction (decreased libido; delayed ejaculation)too much coffee feelingraised prolactinCAUTIONS / CONTRA-INDICATIONSmaniaepilepsy (poorly controlled)history of bleeding disordershypersensitivityakathisia
23SSRIsSTUDIESover 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 arousaloften without negative effects on normal sexual behaviorsystematic review (Adi et al., 2002)very few trials of reasonable methodological qualityoutcomes positiveuse of SSRI medication in sex offenders warranted
24SSRIs HOW DO THEY WORK? May have effect through: Impulsivity Mood Obsessive-compulsiveDecreased deviant fantasizingAttachment
26Voluntary or Mandatory Mandatory in many USA statesIf Voluntary – issues with consentVoluntary more like to work?Most psychiatrist feel treatment should be voluntary.If capacity is an issue then AWI and DMP opinion.