Published: 5 March 2015

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Sexual Dysfunction Associated with Antidepressants and Antipsychotics

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Prescriber Update 36(1): 5-7
March 2015

The Centre for Adverse Reactions Monitoring (CARM) continues to receive reports of sexual dysfunction associated with the use of antidepressants and antipsychotics. Since 1965, the most frequently reported medicines have been fluoxetine (17 reports), citalopram (12), paroxetine (7), venlafaxine (5), risperidone (12) and clozapine (7).

Disorders of sexual functioning can be classified into four categories.

• Sexual desire disorders, including partial or total lack of libido.
• Sexual arousal disorders including erectile dysfunction and lack of vaginal lubrication.
• Orgasm disorders, including premature, delayed or absent orgasm (anorgasmia); also failure of ejaculation.
• Sexual pain disorders including dyspareunia and vaginismus.¹

Sexual dysfunction in depression

Recent reviews indicate that the prevalence of sexual dysfunction in major depression may be up to 70% of patients. Most often this takes the form of lack of libido. Sexual desire tends to improve with treatment of depression; however, successful antidepressant treatment often causes other detrimental effects on sexual function.¹

Reported rates of sexual dysfunction associated with antidepressants in clinical studies vary by assessment method. Studies using specific instruments (questionnaires) to assess sexual dysfunction identify more cases than those relying on spontaneous reporting (both in clinical trials and to pharmacovigilance agencies such as CARM).² Many patients do not volunteer to discuss problems with sexual function with their prescriber and may simply stop taking the medicine without mentioning it.

Antidepressant-associated sexual dysfunction may also result from inadequate treatment of depression, comorbid alcohol abuse, comorbid physical illness, relationship problems, or a combination of these factors.¹

Results of a meta-analysis found that up to 80% of patients reported sexual dysfunction that emerged with anti-depressant treatment.² The meta-analysis showed that the medicines with the greatest risk included: sertraline, venlafaxine, citalopram and paroxetine. No difference from placebo was found for bupropion, moclobemide and mirtazapine. Other antidepressants such as escitalopram and imipramine had an intermediate effect.

Men taking an antidepressant tended to have higher rates of desire and orgasm dysfunction whereas women had greater arousal dysfunction.² Sexual dysfunction associated with antidepressants may also be dose-dependent.¹

Management of sexual dysfunction during treatment with antidepressants can be difficult, in part due to often multifactorial aetiology (see above). Therefore, prior to treatment, it is important to ascertain existing sexual dysfunction and the likely cause. The possibility of treatment-emergent sexual dysfunction should be discussed and the importance of sexual function to the patient should be taken into consideration when choosing an antidepressant.³

Patients are often hesitant to discuss sexual dysfunction with their doctor. Patients taking antidepressants should be sensitively questioned regarding sexual dysfunction. Doctors may be surprised by how willing (and sometimes relieved) patients are to discuss sexual function once the issue has been broached. Close monitoring helps to optimise quality of life and support treatment adherence. It is also important to provide reassurance that the problem is common and usually manageable.
There are several options for patients experiencing problems (Table 1).

Table 1. Options for patients experiencing sexual dysfunction associated with antidepressants

Option	Caveats
Reduce dose	May increase risk of relapse1, 4
Drug holidays	May jeopardise compliance with treatment Does not allow for spontaneity1 Withdrawal symptoms may be experienced in patients using antidepressants with short half-lives4
Switch antidepressant	May increase risk of relapse May result in different side effects
Continuing treatment ('wait and see')	Relatively few patients experience resolution of symptoms; this may take several months
Addition of an reversal agent (eg, phosphodiesterase inhibitor)	Additional side effects are possible

Antidepressant associated sexual dysfunction is generally reversible on discontinuation of treatment.

Sexual dysfunction in schizophrenia

Rates of sexual dysfunction are higher in patients with schizophrenia than the general population or patients with other psychiatric disorders.^5,6 There is a correlation between the severity of psychotic symptoms and the reported severity of sexual dysfunction.

Sexual dysfunction is rated as one of the most distressing side effects of antipsychotics and a major cause of poor quality of life. Sexual dysfunction is associated with a negative attitude towards therapy and, as with antidepressants, often results in non-adherence to treatment.⁵

Risperidone, haloperidol and olanzapine have been reported to be associated with the greatest risk of sexual dysfunction. These medicines are most often associated with erectile and ejaculatory dysfunction in men, menstrual irregularities, amenorrhea and decreased vaginal lubrication in women, as well as more general effects impairing libido and orgasm. ^5,6

Clozapine is associated with generally low rates of sexual dysfunction, except for erectile and ejaculatory problems. Quetiaptine has been reported to have a lower impact on sexual function in terms of number of patients affected and the severity of the dysfunction.⁷ Aripiprazole appears to be associated with the lowest risk of sexual dysfunction, based on current evidence. More research is needed in this area.⁶

Other factors contributing to sexual dysfunction include the disease itself, psychosocial factors (including performance anxiety), comorbid diseases (especially cardiovascular) and concomitant medication.⁷

There is limited information on the management of sexual dysfunction in patients taking antipsychotics. Active discussion of the risks of sexual dysfunction prior to and on treatment is recommended to help support patient adherence to treatment. Potential strategies to help manage sexual dysfunction are outlined in Table 2.

Table 2. Options for patients experiencing sexual dysfunction associated with antipsychotics ⁷

Option	Caveats
Reduce dose	May increase risk of relapse
Switch antipsychotic	May increase risk of relapse May result in different side effects
Augmentation of treatment	Aripiprazole has been recommended
Addition of an reversal agent (eg, dopamine agonist)	May aggravate psychosis Additional side effects are possible

References

1. Schweitzer I, Maguire K, Ng Chee 2009 'Sexual side-effects of contemporary antidepressants: review' Australian and New Zealand Journal of Psychiatry 43: 795-808.
2. Serretti A, Chiesa A 2009 'Treatment-emergent sexual dysfunction related to antidepressants a meta-analysis' Journal of Clinical Psychopharmacology 29: 259-266.
3. Kennedy SH, Rizvi S 2009 'Sexual dysfunction, depression and the impact of antidepressants' Journal of Clinical Psychopharmacology 29: 157-164.
4. Clayton AH Croft HA, Handiwala L 2014 'Antidepressants and sexual dysfunction: mechanisms and clinical implications' Postgraduate Medicine 126:91-99.
5. Bella AJ, Shamloul R 2013 'Psychotropics and sexual dysfunction' Central European Journal of Urology 66: 466-471.
6. Serretti A, Chiesa A 2011 'Sexual side effects of pharmacological treatment of psychiatric diseases' Clinical Pharmacology and Therapeutics 89: 142-147.
7. De Hert M, Detraux J, Peuskens J 2014 'Second-generation and newly approved antipsychotics, serum prolactin levels and sexual dysfunctions: a critical literature review' Expert Opinion in Drug Safety 13: 605-624.