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