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How to Prevent and Treat Antidepressant Induced Sexual Dysfunction | Sexual Side Effects

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Sexual dysfunction is a persistent change occurring in any of the stages of the sexual response cycle that causes distress to a patient.

Today i’ll be taking you through an important  topic a topic that many of our viewers have   and we’re going to cover antidepressant induced  sexual dysfunction i’m going to talk about   what are the phases of the sexual response cycle  how antidepressants affect that particular those   phases uh how to prevent antidepressant

Induced  sexual dysfunction and treatment so we have   created chapters so have a look in the description  section if you want to just go to one particular   well so without further ado let’s get started   the stages of the sexual response cycle which of  course causes a lot of distress to the patient   there are

Four stages of the sexual response cycle  pleasure desire arousal and orgasm and the arousal   is where the erection aspect comes in as well so  when we think about sexual dysfunction we know   that it is a known side effect associated with  certain antidepressants but at the same time it is   also associated with depression the

Illness itself  we know low libido erectile dysfunction can be a   very core uh feature of depression depression is  associated with a 50 to 70 percent increased risk   of sexual dysfunction while sexual dysfunction  itself increases the risk of depression by 130   200 percent so really really high odds of sexual  dysfunction

Resulting in depression in the general   population the prevalence of sexual dysfunction is  approximately forty three percent of women thirty   one percent of males the prevalence increases to  approximately sixty to eighty percent in anxiety   mood psychotic disorder so psychiatric illnesses  can be closely associated with

Sexual dysfunction   way now how do antidepressants cause sexual   dysfunction the main antidepressants that are  associated with sexual dysfunction are ssris   the selective serotonin reuptake inhibitors and  the snris the serotonin noradrenaline and reuptake   inhibitors and you might notice the common aspect 

Between these two is the s the serotonin component   increase serotonin levels because they actually   inhibit the serotonin transporter which is the  uh the protein that is that’s responsible for   the uptake of serotonin the presynaptic neuron so  however we’ve covered snri um psychopharmacology   have a listen to

Those now serotonin directly   reduces the sensation in the reproductive system  uh anatomical structures so diminishes erection   so really all phases it also inhibits nitric   of vessels including the vasculature of the  reproductive structures so it’s responsible   for that vasodilatation um allowing sufficient 

Blood supply to the sexual organs during the   sexual response cycle and that vasodilation is  of course very very important when it comes to   the whole process of the sexual response cycle  then we have a specific uh receptor the 5-ht-1   a receptor which we know that when that receptor  is activated it increases levels of

Dopamine and   way you can think about them as a pleasure   for erection libido drive sexual desire   therefore what happens is some antidepressants  do not have this 5ht1a agonist activity   and those ones have a higher incidence of sexual  dysfunction than those that have the 5-ht-1a   amongst the ssris mainly so

Therefore we find that  you see fluvoxamine so if an ssri is considered   fluvoxamine has a lower incidence why because it  actually has this 5-ht-1a agonistic activity but   we’ll talk about it because doses are relevant  when it comes to fluvoxamine so what are the   think about these agents women the most commonly  

Reported adverse sexual side effects are problems  with sexual desire and sexual arousal ssris 42 % of women report problems having an orgasm snris  it’s associated with delayed or absent orgasm so   orgasm seems to feature quite prominently women  when it comes to men with ssris there is delayed   ejaculation and interestingly this

Is ssris are  used as a treatment for premature ejaculation   but also associated with erectile dysfunction  the erectile dysfunction risk is higher with   paroxetine, citalopram and venlafaxine now when  venlafaxine at lower levels acts as an ssri at   higher levels becomes a snri and snris and male  again you get erectile

Dysfunction and abnormal   ejaculation now how is it assessed i find the pam-d approach really really helpful and this is um   something that professor anita clayton has talked  about we’ve covered this uh as well uh during the   in where i interviewed professor anita clayton  and she talks about firstly plan in advance to  

Talk about sexual dysfunction so even patience  is important to to actively proactively bring it   up but for doctors and health professionals it’s  important to ask about that second is ask if you   ask the question it gives patients the opportunity  to talk about it 70 of people wanted to talk   about it but if we don’t ask it’s

Not discussed  monitor monitor sexual side effects at each visit   then discuss the d component discuss the pros   and cons of different medications because there  are medications that are you can be used for   treatment or don’t have sexual dysfunction as a  side effect so pam d plan ask monitor and discuss   when we

Think about assessment it is very very  important in the clinical history to rule out   medical conditions because we know a number of  diabetes for example excessive substance use   alcohol use nerve dysfunction these aspects can  affect sexual function parkinson’s disease etc   surgical procedures current medications  

We know besides antidepressants other medications  like diuretics ace inhibitors anticholinergic   medications these medications can be associated  with sexual dysfunction substance use history   drugs alcohol etc psychiatric history because  we saw that there is a high correlation between   desire erectile dysfunction etc and

Then we   have menopause there is also something known as  hypoactive sexual desire disorder um somewhat   of present or not but we do have treatments   know addyi it’s called uh the new medication   but uh it’s it’s something to take into account  in uh women and of course the hormonal aspects   treatments that can

Be considered so an overall   a holistic view is important before jumping to the  rating scales can be used now some of these  are the arizona sexual experience scale   the pr sex dq so these are some of the scales that  can be used but clinical evaluation with a patient   at two aspects firstly prevention of sexual  

A risk benefit analysis is important discussion  of side effects and sexual dysfunction should be   with regards to this particular property are   agameltine bupropion and mirtazapine agar melatine  is essentially an agent that antagonizes the 5ht   2c receptor the 5 ht2c receptor is situated lower  down in the spinal cord and if

You activate that   receptor it can lead to sexual dysfunction and  that’s what ssris snris do agameltine actually   antagonizes that receptor so it actually can treat  sexual dysfunction and has a lower incidence of   someone has ssri induced sexual dysfunction   agomelatine whilst reducing the dose to the off   ssri

So that the person doesn’t relapse so these  are some of the strategies and i’ll talk about the   specific strategies in the next sort of slide but  agameltine is a useful agent it also has melatonin   promoting properties it’s a good antidepressant  overall um metabolically friendly so weight gain   is not a an issue emotional

Blunting isn’t an  issue sexual dysfunction isn’t an issue so it’s   a good antidepressant consider second bupropion  bupropion is one of the few agents as you can see   low treatment emergent sexual dysfunction   and can also improve sexual function it is an ndri  which means it increases noradrenaline dopamine  

Also antagonizes the 5ht2c receptor and therefore  can treat sexual dysfunction has a lower incidence   weight gain of increasing weight because of   its antihistaminergic property so therefore you  know this is something to discuss uh overall when   starting agents now these are the antidepressants  that have no significant

Effect this is based on   the reviews ago melatine despended vaccine as  well but it is an snri but in some cases it’s   considered to have a lower effect having said  that sexual dysfunction can occur moclobemide   which is a rima which is a reversible monoamine  oxidase inhibitor a and then we have trazodone  

Available in australia available in the u.s we  have vortioxetine which is again a multi-modal   antidepressant can be useful as well so these  newer antidepressants ago melatine vortioxetine   are worth consideration then we have the evidence  for duloxetine levomilnacipran mirtazapine is   inconclusive this is from another

Paper and if  ssris are to be considered consider fluvoxamine   because of that 5ht1a and it says it’s considered  to have the least incidence of sexual dysfunction   under doses of 100 milligrams per day but in some  cases higher doses are required in which case you   can still have this effect now when we’re thinking 

About treating it now someone presents to me with   sexual dysfunction we have the following options  first wait and watch because in the initial stages   the receptors may sensitize and this side effect  may go down that’s a possibility some cases that   doesn’t happen it persists then dose reduction  may be an option reduce

The dose whilst ensuring   they don’t relapse into the primary illness of  depression or anxiety that the medication has   drug holidays has been mentioned there as you   can see not an ideal strategy because it poses  withdrawal symptoms for patients so that’s sort   switching strategies can be considered now  

Switching strategies means that we are completely  stopping one and starting one another one so that   can pose with ssris and snri withdrawal symptoms  now we’ve covered antidepressant withdrawal   symptoms and tapering in another video um do have  a listen to that one so therefore augmentation may   be considered first so let’s

Say someone’s on an  ssri or an snri and we’re thinking dose reduction   hasn’t worked but any further dose reduction may  actually lead to a relapse so in that case what   one might do is to reduce the dose if they start  having symptoms of depression coming back then a   which does not have a risk of serotonin  syndrome

Because it does not increase serotonin   or add-on mertazapine or add-on bupropion now  this is specialist treatment it’s not to be   should be discussed with the doctor but these   can be combined whilst the other one goes down   might take them off it or they might stay on it   and that’s a discussion you have with

The doctor  but this is a strategy that can work quite well   and finally, augmentation can lead to a switch  because one might say my depression is treated   i don’t have sexual dysfunction can we stop the  other medication and that might be considered   are taken into account so i hope that this gives   you an idea

What we want to do is firstly make  sure that we are proactive in asking about it   sue discussing it with patients the side effects  of sexual dysfunction with antidepressants   third always a thorough medical history during  evaluation if they have sexual dysfunction we   try to prevent it as much as possible by choosing 

Agents that are friendly agamalatine murtazapine   my mind because they have a lower incidence of  not only sexual dysfunction but other side effects   as well merit has been being an exception for  weight sorry for weight gain so you’ve got these   switching or augmentation of course drug holidays  a little bit controversial

Because it can cause   harm in the form of withdrawal symptoms so i hope  that this gives you an overview of antidepressant   distressing side effect now i haven’t covered   it is an established entity it is a difficult  entity to treat bupropion has been talked about   there the true incidence is actually not known 

Um so again i’ve written more about this on   induce sexual dysfunction present a couple of  other things that i haven’t mentioned are also   uh in erectile dysfunction now often one things  about viagra so sildenafil tadalafil cialis uh you   know which is longer acting so one doesn’t have  to take it just half an hour before

The act one   can actually take it and it lasts for three days  or so so one doesn’t have to have that pressure   of timing now these can be used but they’re much  better when used for the erectile dysfunction so   again these are aspects to discuss with the with  the doctor and i mentioned phleban serene uh addy  

Uh in hyperactive um uh sexual desire disorder uh  particularly in women is something to um that that   is being talked about not much is known whether it  actually helps for ssri induced sexual dysfunction   later on, so thank you very much for watching and   supporting our channel i really really appreciate  um your input and

Uh really your time as well   so i hope to see you in another edition of hub 

Transcribed from video
How to Prevent and Treat Antidepressant Induced Sexual Dysfunction | Sexual Side Effects By Dr Sanil Rege’s Hub – Psychiatry Simplified