Deborah Brauser

October 20, 2014

BERLIN ― Long-term antidepressant use may be associated with significant "emotional blunting" in both male and female patients ― but in different ways, new research suggests.

Dr Donatella Marazziti

Using a newly developed Sex-Attachment-Love Test (SALT) questionnaire, the study of nearly 200 adults with mild or moderate depression showed that use of selective serotonin reuptake inhibitors (SSRIs) had a significantly negative impact on the feelings of love toward partners, especially in men.

Long-term use of tricyclic antidepressants (TCAs) was significantly associated with disturbed sexual function, particularly in women.

"I think these results are quite exciting. And the most striking finding was that men were more affected by emotional side effects than women," lead author Donatella Marazziti, MD, professor of psychiatry at the University of Pisa, Italy, told Medscape Medical News.

The investigators note that these are "the first observations of a dimorphic effect of SSRIs and TCAs in the two sexes."

The study was presented here at the 27th European College of Neuropsychopharmacology (ECNP) Congress.

First Systematic Study

"There have been observations of antidepressants leading to emotional blunting. However, this topic was never studied systematically," said Dr Marazziti.

"Given the paucity of information on this topic and the total absence of data in our country, the aim of the present study was to explore and compare the eventual changes of some components of a loving relationship during a long-term treatment of depression," the researchers note.

They created the 40-item SALT questionnaire specifically for this study. The questions were divided into three groups under the sex, attachment, or love domains and took approximately 15 minutes to answer.

A total of 192 outpatients (64% women; mean age, 41.2 years) from Italy were selected to participate. All had a diagnosis of mild or moderate depression, had been taking just one antidepressant for at least 6 months, and were involved in what they considered "a loving relationship" (mean length, 150 months) before they had started antidepressant treatment.

A total of 76 women and 33 men were taking an SSRI. The most commonly used was paroxetine (multiple brands), followed by escitalopram (Lexapro, Forest Laboratories, Inc), citalopram (Celexa, Forest Laboratories, Inc) and sertraline (Zoloft, Pfizer Inc). A total of 48 women and 35 men were taking a TCA, with the most commonly used being clomipramine (Anafranil, Mallinkrodt), followed by imipramine (multiple brands), amitriptyline (multiple brands), and trimipramine (Surmontil, Odyssey Pharmaceuticals, Inc).

In addition, 60% of the participants were married, 24% lived with a partner, and 15% lived alone. Also, 93% were heterosexual, and 7% were homosexual.

Results showed a significant "interaction effect of drug x gender" on the SALT domains of love (P = .037) and sex (P = .007).

The total score for the sex domain questions was significantly higher (signifying impairment) in the women taking TCAs compared with the men (35.70 vs 32.06; P = .019).

The total score on the love domain was significantly higher in the men taking SSRIs than in the women (25.71 vs 23.18, respectively; P = .036).

Emotional Differences

"SSRIs seem to provoke more alterations of some emotional features than TCAs in men, while women seem to be 'preserved' by this side effect," write the investigators, noting that this could be because emotions differ between the sexes.

"Women often feel things deeper. So the medications may be more tolerable to them. However, this is speculation," added Dr Marazziti.

When examining specific items from the SALT, the investigators found that, overall, patients taking SSRIs had significantly more "less than before" answers than those taking TCAs to several attachment statements, including the following: "I feel at ease in sharing with my partner thoughts and feelings" (P = .035), "I address my partner for advice or help" (P = .017), and "I rely on my partner easily" (P = .001); and to the love statement, "I wish the love I feel for my partner would last forever" (P = .038).

"In general, the patients felt less committed to and detached from the partner than before the beginning of the treatment," explain the researchers.

Men taking SSRIs had more answers of "less than before" to the attachment statement, "I address my partner for advice or help" (37.5% vs 15.8%, P = .006) and to the love statement, "I take care of my partner" (39.7% vs 16.7%, P = .001) than women taking these medications.

Women taking TCAs had more answers of "less than before" than men did for the majority of items asking about sexual life and performance. These included, "I am sexually attracted by my partner" (42.4% vs 19.4%, P = .038) and "I seek sexual intimacy with my partner" (57.6% vs 27.8%, P = .012).

Although men taking SSRIs often have decreased libido, the men taking SSRIs in this study reported pursuing sexual intimacy and having satisfactory experiences. However, the investigators point out that this could be due to the small sample size or cultural reasons.

"Italian men do not like to say that they have sexual problems, so there could be some bias there. We hope to broaden the sample in a replication study," said Dr Marazziti.

Overall, "our findings support the notion that [SSRIs] provoke remarkable emotional side effects," write the investigators.

"Perhaps a forum should be promoted in order to reconsider their most appropriate use and to what extent they should replace TCAs," they add.

Quality-of-Life Issue

"I think this is a very important topic," Hans-Ulrich Wittchen, PhD, from the Institute of Clinical Psychology and Psychotherapy at the Technical University of Dresden, Germany, commented to Medscape Medical News.

Dr Hans-Ulrich Wittchen

"This is one of the rare studies that tries to look in an innovative way at how to measure things that were not considered in the past, like love and sexual life. The trouble, though, is that it's explorative and doesn't really tell us anything because of the relatively small sample of patients," he said.

"Nevertheless, it seems to show that there's a whole range of complications that we never considered before that seriously affect the quality of life in our patients."

Dr Wittchen, who is also chair of the ECNP's External Review Board, was not involved with this research. He noted that past research has discussed sexual dysfunction resulting from the use of certain medications, but the current study's examination of emotional blunting and effects on love was "innovative."

"The way this is typically presented is as a side effect, without telling us about the structure behind it. This study goes far beyond that, and I think it is extremely important," he said. "Also, I was surprised to see the differences between the old and the new medications. It wasn't as big as I suspected."

He added that he hopes the investigators will now look at these issues in a larger sample size and for a longer duration. However, he pointed out that it is not too early for clinicians to start asking about these issues in their own patients.

"I think they must do that. There is no reason not to address love, sexual life, and emotions in the diagnostic work-up. It's a symptom that affects the diagnosis; so not addressing this is a very bad idea," said Dr Wittchen.

The study authors have disclosed no relevant financial relationships.

27th European College of Neuropsychopharmacology (ECNP) Congress. Abstract P.2.e.001. Presented October 19, 2014.

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