1. Antidepressant-Induced Sexual Dysfunction
Flavio Guzman, MD

2. Overview Normal sexual response Depression and sexual dysfunction
Antidepressant-induced sexual dysfunction
Mechanisms involved
Agents with lower risk of SD
Management strategies

3. Normal sexual response: 4 phases
Resolution
Muscular relaxation, well being. Men: refractory period.
Orgasm
Peak of sexual pleasure, release of sexual tension, contraction of perineal muscles and reproductive organs
Excitement
Subjective sense of sexual pleasure, physiological changes
Desire
Fantasies and desire to have sexual activity
Baldwin, D., & Mayers, A. (2003). Sexual side-effects of antidepressant and antipsychotic drugs.  Advances in Psychiatric Treatment, 9(3),

4. Sexual dysfunction and depression
Resolution
Orgasm
Excitement
Desire
Comparative studies indicate higher levels of sexual dysfunction
Loss of sexual desire may be more common than disorders of arousal and orgasm
Baldwin, D., & Mayers, A. (2003). Sexual side-effects of antidepressant and antipsychotic drugs.  Advances in Psychiatric Treatment, 9(3),

5. Sexual dysfunction and depression
The Zurich study:
Prospective, cohort study
Young people: 591 subjects years old
Group
Non-depressed subjects
Depressed patients
Treated depressed patients
SD prevalence
26%
45%
62%
Baldwin, D., & Mayers, A. (2003). Sexual side-effects of antidepressant and antipsychotic drugs.  Advances in Psychiatric Treatment, 9(3),

6. Antidepressants and sexual dysfunction
Seen with TCAs, MAOIs, SNRIs, and SSRIs
Underestimated incidence: up to 70% of patients treated with SSRIs and SNRIs
More common with paroxetine
Frequent impairments: orgasm and ejaculatory
70%
AD-Induced Sexual Dysfunction
Treatment adherence
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):
Mago, Rajnish, Rajeev Mahajan, and Dileep Borra. "Antidepressant-Induced Sexual Dysfunction: an Updated Review." Current Sexual Health Reports(2014): 1-7.

7. Antidepressants and sexual dysfunction
Spontaneous reporting
Direct questioning

8. Antidepressants associated with lower incidence of SD
Bupropion
Studies show lower incidence of SD than:
Fluoxetine
Escitalopram
Mirtazapine
Spanish Working Group for the Study of Psychotropic-Related Sexual Dysfunction
Lower incidence than SSRIs (24% vs 58%) and SNRIs (24% vs 73%)
Nefazodone
Montejo et al
Lower incidence than SSRIs and SNRIs
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):
Mago, Rajnish, Rajeev Mahajan, and Dileep Borra. "Antidepressant-Induced Sexual Dysfunction: an Updated Review." Current Sexual Health Reports(2014): 1-7.

9. Antidepressants associated with lower incidence of SD
Vilazodone (unclear)
Laughren et al (FDA, 2011):“inconsistent” data from sexual clinical scales
Mago et al (2014): may have lower incidence, verification in prospective studies with ADISD as primary outcome measure needed.
Agomelatine
In healthy volunteers, SD associated with agomelatine use not greater than placebo
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):
Mago, Rajnish, Rajeev Mahajan, and Dileep Borra. "Antidepressant-Induced Sexual Dysfunction: an Updated Review." Current Sexual Health Reports(2014): 1-7.

10. Antidepressants and SD: potential mechanisms
Norepinephrine
Increases sexual arousal
Dopamine
Motivated behaviors (sexual)
Sexual arousal, penile erection
DA antagonists can reduce sexual performance
Serotonin (5-HT)
Can reduce sexual behavior
Suspension of vasocongestion
Decrease NO function
Baldwin, D., & Mayers, A. (2003). Sexual side-effects of antidepressant and antipsychotic drugs.  Advances in Psychiatric Treatment, 9(3),

11. Lowering the dose Wait and watch Switching Adding an antidote
Management
Lowering the dose
Wait and watch
Switching
Adding an antidote

12. Dose lowering Not systematically studied
Risk of depression relapse (monitor)
Most appropriate for patients on high AD doses
“Drug holiday”
Discontinuation symptoms
Patient might discontinue treatment
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):

13. Wait and watch Simplest strategy Spontaneous improvement:
Only in 5-10 % of patients
Can take 4 to 6 months
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):
Mago, Rajnish, Rajeev Mahajan, and Dileep Borra. "Antidepressant-Induced Sexual Dysfunction: an Updated Review." Current Sexual Health Reports(2014): 1-7.

14. Switching to a different antidepressant
Switch to an AD with lower incidence of sexual dysfunction: bupropion, mirtazapine, agomelatine and vilazodone
Monitor effectiveness and adverse effects of new AD
Clayton, A. H., H. A. Croft, and L. Handiwala. "Antidepressants and sexual dysfunction: mechanisms and clinical implications." Postgraduate medicine126.2 (2014):
Mago, Rajnish, Rajeev Mahajan, and Dileep Borra. "Antidepressant-Induced Sexual Dysfunction: an Updated Review." Current Sexual Health Reports(2014): 1-7.

15. Adding an antidote Bupropion Men only:
150 mg/day no more effective than placebo
150 mg twice daily: improve in sexual function
Men only:
PDE inhibitors: sildenafil, tadalafil
Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database of Systematic Reviews 2013, Issue 5.

16. Key Points AISD impacts treatment adherence
Difference between spontaneous reporting and direct questioning
AD with lower risk of SD: bupropion, mirtazapine, nefazodone, agomelatine, vilazodone (?)
Management strategies:
Dose reduction
Wait and watch
Switching
Adding a second drug