Differential Diagnosis of Sexual Dysfunction
Depressed patients can manifest sexual dysfunction due to a variety of causes. Clinicians should consider all possible causes before attributing sexual dysfunction to a prescribed antidepressant (Table I).[1,2] Etiologies can be grouped into 3 categories: (1) part of the presenting psychiatric disorder; (2) comorbid physical or psychiatric disorders; and (3) drug-induced from medical treatments.
Psychiatric disorders themselves are associated with sexual dysfunction. Depression is assumed to be linked with alterations in sexual functioning, although the evidence for this assertion is less consistent than expected. Only a handful of experimental studies on sexuality in depressed individuals have been published, and all these have evaluated only men.[3,4,5,6,7,8,9] These studies show that diminished sexual satisfaction, as opposed to decreased sexual interest or erectile dysfunction, is the most consistent finding in depressed outpatient men. This complaint of decreased satisfaction is probably related to the diminished ability of many patients with depression to enjoy most pleasurable activities.
Sexual dysfunction can occur as a primary condition from either a medical disorder or from a poor relationship with the partner. Unfortunately, the rate of primary sexual dysfunction in a normative population is still in doubt, although the rate of DSM-IV hypoactive sexual desire is estimated at 20%.[10,11] Rates of decreased libido in earlier studies of depressed patients have been estimated as high as 77%.
Given the number of possible causes of sexual dysfunction, clinicians should ask about sexual function prior to prescribing antidepressants to any patient. A minimal set of screening questions should include the 3 major areas of sexual function: interest (or libido), arousal (erectile function in men, lubrication and feelings of arousal in women), and orgasm.
A number of medications besides psychotropics can cause sexual dysfunction, including some antihypertensives and muscle relaxants. Antidepressants cause sexual side effects in all 3 phases of the normal sexual response cycle, including decreased libido, erectile dysfunction (in men), and delayed time to orgasm or anorgasmia in men and women. In open case series of patients treated with SSRIs, orgasmic dysfunction is the most common sexual dysfunction, followed by decreased libido; arousal difficulties represent the least common form.
Painful ejaculation was reported in as many as 20% of men in 2 case series of men taking tricyclic antidepressants (TCAs).[14,15] As yet, this side effect has not been reported to occur in association with the newer antidepressants such as SSRIs, bupropion, nefazodone, and mirtazapine.
Paradoxically, antidepressants (especially those with serotonergic effects such as SSRIs, monoamine oxidase inhibitors [MAOIs], and trazodone) have also been reported, albeit infrequently, to cause occasional increased sexuality. Case reports describe enhanced libido, spontaneous orgasm without sexual stimulation, and spontaneous orgasm with yawning.[16,17,18,19,20]
Medscape Psychiatry & Mental Health eJournal. 1998;3(3) © 1998 Medscape
Cite this: Treatment of Antidepressant-Induced Sexual Dysfunction - Medscape - May 01, 1998.