Lithium and sexual dysfunction: an under-researched area

Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors

INTRODUCTION

In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly.

METHODS

Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches.

RESULTS

Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty.

CONCLUSIONS

The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.

Sexual dysfunction in bipolar depression: Gender differences

Objective

To find sexual dysfunction in acute-phase bipolar depression patients and subsequently characterize the gender-wise differences in sexual functioning.

Materials and Methods

A cross-sectional, descriptive, observational, purposeful, and hospital-based study was done with 45 patients (age range: 18-59 years) with moderate to severe acute phase bipolar depression (HAM-D scores >18). The domain-wise (Pleasure, Desire/Frequency Desire/Interest, Arousal/Excitement, and Orgasm/Completion) sexual functioning was assessed by the Change in Sexual Functioning Questionnaire (CSFQ-14) (≤41 for females, ≤47 for males as a cut-off for dysfunction). This study is registered in the CTRI (Clinical Trials Registry India, Number: CTRI-2021-07-035182).

Results

The prevalence of sexual dysfunction was 91% of bipolar disorder patients with more male participants (53.3%) compared to females (46.7%). The mean HAM-D score for the study sample was 27.93 ± 8.035. The female gender had more dysfunctional scores in desire/frequency (t = 2.229, P = 0.031), desire/interest (t = 2.448, P = 0.019), orgasm/completion (t = 2.974, P = 0.005), and overall total CSFQ (t = 2.946, P = 0.005). The odds of sexual dysfunction were significant given a one-unit increase in suicidal ideation in the index episode (adjusted OR = 1.222, 95% CI: 1.004-1.488, P = .049).

Conclusion

Acute-phase bipolar patients have very high sexual dysfunction rates. Females have both global and specific sexual response cycle deficits in comparison to acute phase bipolar depressed males. Future trials shall amuse neurobiology grounded, more individualistic sexual rehabilitation-based interventional paradigms, and longitudinal research models in acute phase bipolar depression.

Effects of lithium on aggression in Drosophila

Lithium is a common medication used to treat mania and bipolar disorder, but the mechanisms by which lithium stabilizes mood and modifies aggression are still not fully understood. Here we found that acute but not chronic lithium significantly suppresses aggression without affecting locomotion in Drosophila melanogaster. Male flies treated with acute lithium are also less competitive than control males in establishing dominance. We also provided evidence that glycogen synthase kinase-3 (GSK-3), a well-known target of lithium, plays an important role in the anti-aggressive effect of lithium in Drosophila. Our genetic data showed that acute knockdown of GSK-3 in neurons can mimic the inhibitory effect of acute lithium on aggression, while specific overexpression of GSK-3 in a subset of P1 neurons profoundly promotes aggression which can be partially rescued by acute lithium application. Thus, these findings revealed the inhibitory effect of lithium on aggression in Drosophila and laid a groundwork for using Drosophila as a powerful model to investigate the mechanisms by which lithium reduces aggression.

Premature Ejaculation after Lithium Treatment in a Patient with Bipolar Disorder

Lithium has proven its efficacy in treating bipolar disorder. Severe side effects caused by lithium, including renal and endocrine outcomes, have already been amply documented. The impact of lithium on sexual function, however, is less well known. A 33-year-old man, with no past medical history, diagnosed with bipolar disorder, developed premature ejaculation after short-term use of lithium. The dose of lithium was reduced, leading to a rapid clinical resolution. Retrospectively, lithium-induced premature ejaculation was deemed the most likely diagnosis. Premature ejaculation is a rare side effect of lithium. Changing the time of medication administration and lowering dose could be considered as alternatives. Given lithium's pharmacological profile, it is likely that the pathophysiologic mechanism behind premature ejaculation is altered levels or altered serotonin receptor sensitivity in the ejaculatory modulating centers of the central nervous system. Given the reluctance to spontaneously report sexual adverse effects, clinicians should be aware of this possible side effect.

Long-Term Lithium Therapy: Side Effects and Interactions

Lithium remains the drug of first choice for prophylactic treatment of bipolar disorder, preventing the recurrences of manic and depressive episodes. The longitudinal experiences with lithium administration greatly exceed those with other mood stabilizers. Among the adverse side effects of lithium, renal, gastrointestinal, neurological, thyroid, metabolic, cognitive, dermatological, cardiologic, and sexual are listed. Probably, the most important negative effect of lithium, occurring mostly after 10-20 years of its administration, is interstitial nephropathy. Beneficial side-effects of long-term lithium therapy also occur such as anti-suicidal, antiviral, and anti-dementia ones. Pharmacokinetic and pharmacodynamic interactions of lithium, mostly those with other drugs, may have an impact on the success of long-term lithium treatment. This paper makes the narrative updated review of lithium-induced side-effects and interactions that may influence its prophylactic effect in bipolar disorder. Their description, mechanisms, and management strategies are provided. The papers appearing in recent years focused mainly on the long-term lithium treatment are reviewed in detail, including recent research performed at Department of Psychiatry, Poznan University of Medical Sciences, Poland. Their own observations on ultra-long lithium treatment of patients with bipolar disorder are also presented. The review can help psychiatrists to perform a successful lithium prophylaxis in bipolar patients.

Affective temperaments and sexual functioning in euthymic patients with bipolar disorder

Sexual functioning in bipolar disorder (BD) is dependent on multiple clinical and demographic determinants that can eventually lead to sexual dysfunction. However, the contribution of affective temperaments remains unstudied in this population. In this cross-sectional multicentric work, we studied the impact of temperament traits on sexual functioning in 100 euthymic BD outpatients treated only with mood stabilizers with or without benzodiazepines. Temperament was evaluated using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego - Autoquestionnaire (TEMPS-A) and sexual functioning with the Changes on Sexual Functioning Questionnaire (CSFQ-14). The effect of temperament on sexual functioning was analyzed using Bayesian ordinal regression models, which included age, gender, BD type, dominant polarity, metabolic syndrome, marital status, and affective symptomatology. Our results showed that hyperthymic traits predicted a significantly higher CSFQ-14 score for global sexual functioning (OR = 1.222; 95% CI [1.073, 1.431]), desire (OR = 1.164; 95% CI [1.025, 1.357]), arousal (OR = 1.278; 95% CI: [1.083, 1.551]), and orgasm (OR = 1.182; 95% CI [1.037, 1.365]). We did not find a significant contribution for other types of temperaments. Better sexual functioning was also associated with a better quality of life. Our findings highlight the importance of temperament traits in sexual functioning in euthymic BD, which may have implications in sexual dysfunction prevention.

Posttraumatic stress disorder and the risk of erectile dysfunction: a nationwide cohort study in Taiwan : PTSD and erectile dysfunction

BACKGROUND

This study aimed to investigate the association between posttraumatic stress disorder and the risk of developing erectile dysfunction.

METHODS

In this population-based retrospective cohort study, we used Taiwan's National Health Insurance Research Database to analyze patients who were newly diagnosed with posttraumatic stress disorder (PTSD) between 2000 and 2013, with a 1:3 ratio by age and index year matched with patients in a non-PTSD comparison group, for the risk of erectile dysfunction.

RESULTS

In total, 5 out of 1079 patients in the PTSD group developed erectile dysfunction, and 3 out of 3237 patients in the non-PTSD group (47.58 vs. 9.03 per 100,000 per person-year) developed erectile dysfunction. The Kaplan-Meier analysis showed that the PTSD cohort had a significantly higher risk of erectile dysfunction (log-rank, p < 0.001). The Cox regression analysis revealed that the study subjects were more likely to develop an injury (hazard ratio: 12.898, 95% confidence intervals = 2.453-67.811, p = 0.003) after adjusting for age, monthly income, urbanization level, geographic region, and comorbidities. Psychotropic medications used by the patients with PTSD were not associated with the risk of erectile dysfunction.

CONCLUSIONS

Patients who suffered from PTSD had a higher risk of developing erectile dysfunction.

Sexual Dysfunction in Patients With Chronic Gastrointestinal and Liver Diseases: A neglected Issue

INTRODUCTION

Normal sexual activity is an important determinant of quality of life. Unfortunately, several chronic health disorders are associated with an impaired sexual function.

OBJECTIVE

To provide coverage of the current literature on prevalence and pathophysiology of sexual dysfunction in patients with gastrointestinal and liver disorders METHODS: A Comprehensive review of the literature on the prevalence of sexual dysfunction in chronic gastrointestinal and liver disorders, assessing the underlying mechanism (s) was performed.

RESULTS

Many gastrointestinal disorders, either functional or organic, are associated with some degree of sexual dysfunction. The main pathogenic mechanisms are: (i) the disease itself causing fatigue, anxiety or depression with a potential alteration of self-esteem; (ii) worry of transmitting a potential infectious agent through sexual activity; (iii) alteration of the endocrine mechanisms which are necessary for normal sexual functioning; (iv) chronic pro- inflammatory conditions which may cause endothelial dysfunction and abnormal vascular responses; (v) iatrogenic.

CONCLUSION

Based on this review, a thorough evaluation of sexual function through validated questionnaires and/or psychological interviews with patients with chronic gastrointestinal disorders should be part of the clinical assessment in order to timely diagnose and possibly treat sexual dysfunction in this clinical setting. L Romano, L Granata, F Fusco, et al. Sexual Dysfunction in Patients With Chronic Gastrointestinal and Liver Diseases: A neglected Issue. Sex Med Rev 2021;XX:XXX-XXX.

Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder

BACKGROUND

In addition to factors intrinsic to bipolar disorder (BD), sexual functioning (SF) can be affected by extrinsic causes, such as psychotropic drugs. However, the effect of mood stabilizers on SF and quality of life (QoL) is an underexplored research area.

AIM

To analyze SF in BD outpatients in euthymia for at least 6 months treated only with mood stabilizers and the association between SF and QoL.

METHODS

A multicenter cross-sectional study was conducted in 114 BD outpatients treated with (i) lithium alone (L group); (ii) anticonvulsants alone (valproate or lamotrigine; A group); (iii) lithium plus anticonvulsants (L+A group); or (iv) lithium plus benzodiazepines (L+B group). The Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14) was used. Statistical analyses were performed to compare CSFQ-14 scores among the pharmacological groups. An adaptive lasso was used to identify potential confounding variables, and linear regression models were used to study the association of the CSFQ-14 with QoL.

MAIN OUTCOME MEASURES

Self-reports on phases of the sexual response cycle (ie, desire, arousal, and orgasm) and QoL were assessed.

RESULTS

The A group had better total SF scores than the L group and the L+B group. Relative to the A group, the L and L+B groups had worse sexual desire; the L group had worse sexual arousal; and the L+A group and the L+B group had worse sexual orgasm. Regarding sociodemographic factors, being female and older age were associated with worse total SF and all subscale scores. Among all subscales scores, higher sexual arousal scores were associated with better QoL.

CLINICAL IMPLICATIONS

Potential modified extrinsic factors such as psychotropic medication that can affect SF can be addressed and adjusted to lessen side effects on SF.

STRENGTHS & LIMITATIONS

Sample of patients with euthymic BD in treatment with mood stabilizers and no antipsychotics or antidepressants, substance use as an exclusion criterion, and use of a validated, gender-specific scale to evaluate SF. Major limitations were cross-sectional design, sample size, and lack of information about stability of relationship with partner.

CONCLUSIONS

Lithium in monotherapy or in combination with benzodiazepines is related to worse total SF and worse sexual desire than anticonvulsants in monotherapy. While the addition of benzodiazepines or anticonvulsants to lithium negatively affects sexual orgasm, sexual arousal (which plays a significant role in QoL) improves when benzodiazepines are added to lithium. Anticonvulsants in monotherapy have the least negative effects on SF in patients with BD. García-Blanco A, García-Portilla MP, Fuente-Tomás L de la, et al. Sexual Dysfunction and Mood Stabilizers in Long-Term Stable Patients With Bipolar Disorder. J Sex Med 2020;17:930-940.

Relationship between suicide mortality and lithium in drinking water: A systematic review and meta-analysis

BACKGROUND

Lithium at therapeutic doses has protective effects against suicide in clinical practice. This meta-analysis aimed to investigate the relationship between lithium concentration in drinking water and suicide mortality in the general population.

METHODS

A systematic search was conducted in Web of Knowledge, PubMed, ScienceDirect, and Scopus to find papers reporting the crude relationship between drinking water lithium and suicide incidence in the general population until June 2019. The pooled effect measure was expressed as odds ratio (OR) and 95% confidence interval (CI) using the random-effects model.

RESULTS

We retrieved 308 English original articles, of which 13 ecologic studies with a total sample size of 939 regions and one cohort study with a sample size of 3,740,113 people were eligible for the meta-analysis. A significant relationship was found between the lithium concentration in drinking water and reduced suicide mortality (OR= 0.42; 95% CI: 0.27-0.67; p-value <0.01). Ten studies reported gender-specific responses to lithium, with the pooled estimates as follows: OR= 0.54; 95% CI: 0.35-0.84; p-value <0.01 for men, OR= 0.70; 95% CI: 0.48-1.01; p-value =0.057 for women, and OR= 0.63; 95% CI: 0.47-0.83; p-value <0.01 for total.

LIMITATIONS

The study was limited to the assessment of the crude relationship between lithium exposure and suicide rate without considering the role of confounders.

CONCLUSIONS

Lithium in drinking water is dose-dependently associated with reduced suicide mortality at least in ecological studies. However, we need well-designed clinical trials to confirm the protective effect of drinking water lithium intake against suicide.

Lithium - Pharmacological and Toxicological Aspects: The Current State of the Art

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Lithium is the smallest monovalent cation with many different biological effects. Although lithium is present in the pharmacotherapy of psychiatric illnesses for decades, its precise mechanism of action is still not clarified. Today lithium represents first-line therapy for bipolar disorders (because it possesses both antimanic and antidepressant properties) and the adjunctive treatment for major depression (due to its antisuicidal effects). Beside, lithium showed some protective effects in neurological diseases including acute neural injury, chronic degenerative conditions, Alzheimer's disease as well as in treating leucopenia, hepatitis and some renal diseases. Recent evidence suggested that lithium also possesses some anticancer properties due to its inhibition of Glycogen Synthase Kinase 3 beta (GSK3β) which is included in the regulation of a lot of important cellular processes such as: glycogen metabolism, inflammation, immunomodulation, apoptosis, tissue injury, regeneration etc.

:

Although recent evidence suggested a potential utility of lithium in different conditions, its broader use in clinical practice still trails. The reason for this is a narrow therapeutic index of lithium, numerous toxic effects in various organ systems and some clinically relevant interactions with other drugs. Additionally, it is necessary to perform more preclinical as well as clinical studies in order to a precise therapeutic range of lithium, as well as its detailed mechanism of action. The aim of this review is to summarize the current knowledge concerning the pharmacological and toxicological effects of lithium.

The capacity to consent to sex in mental health inpatient units

OBJECTIVE

Discussions of capacity to consent in mental health care usually revolve around capacity to consent to treatment. This paper instead explores the issue of capacity to consent to sexual activity in a mental health inpatient setting as a way of exploring capacity from a different perspective. This is not a purely theoretical exercise, with both consensual sexual activity and sexual assault commonplace in mental health inpatient units, current policy and practice approaches are clearly not working and require re-examination.

METHODS

Four key frameworks are explored: human rights law, mental health law, the criminal law and the law of tort governing the duty of care. These frameworks are explored by highlighting relevant case law and statutes and considering their potential application in practice. This is undertaken using the state of Victoria, Australia, as a case study.

RESULTS

The four frameworks are shown to be consistent with each other but inconsistent with contemporary policy. All four legal frameworks explored require clinicians to take a case-by-case assessment to ensure that a person's right to make their own decisions is preserved 'unless the contrary is demonstrably justified' or where it is 'legally demanded'. While Victorian inpatient units attempt to enforce a blanket ban on consensual sexual activity in inpatient settings, this ban may be without legal basis and may be in breach of both human rights and mental health law.

CONCLUSION

In policing the lawful bodily interactions of their patients and pushing sexual activity out of sight, clinicians may be breaching their duty of care to provide sexual health support and risk creating an environment in which the therapeutic relationship will be sacrificed to the enforcement of institutional policy. Clinicians and policymakers must understand the relevant legal frameworks to ensure that they are acting ethically and lawfully.

Efficacy and safety of combination of tadalafil and aspirin versus tadalafil or aspirin alone in patients with vascular erectile dysfunction: a comparative randomized prospective study

PURPOSE

We aimed to investigate the efficacy and safety of tadalafil, aspirin, and tadalafil + aspirin combination therapy in vascular erectile dysfunction (VED).

METHODS

A total of 336 patients were randomly divided into four groups (group 1, aspirin 100 mg/day, 126 patients; group 2, tadalafil 5 mg/day, 72 patients; group 3, tadalafil 5 mg + aspirin 100 mg, 72 patients; group 4, placebo, 66 patients). In all groups, the changes from baseline to end point in erectile function scores on the International Index of Erectile Function (IIEF-EF) and the number of patients who answered "yes" to questions 2 and 3 of the sexual encounter profile(SEP) were compared statistically.

RESULTS

The changes in IIEF-EF scores after treatment were 7.2 ± 4.4, 7.3 ± 4.3, 7.5 ± 4.4, and 2.0 ± 4.6 for group 1 (p < 0.0001), group 2 (p < 0.0001), group 3 (p < 0.0001), and group 4 (p = 0.0204), respectively. The change in SEP-2 ratios after treatment were 36.6%, 36.9%, 41.7%, and 9.4% for group 1 (p < 0.0001), group 2 (p < 0.0001), group 3 (p < 0.0001), and group 4 (p = 0.2925), respectively. The change in SEP-3 ratios after treatment was 46.6%, 49.2%, 53.7%, and 12.5% for group 1 (p < 0.0001), group 2 (p < 0.0001), group 3 (p < 0.0001), and group 4 (p = 0.1456), respectively. In group 2, both the number of patients who reported side effects (p < 0.0001) and stopped using the drug due to side effects (p < 0.05) were significantly higher than the control and others groups.

CONCLUSIONS

Successful results were obtained by tadalafil and aspirin monotherapy and tadalafil + aspirin combination therapy in patients with VED. However, the least side effect was observed in the tadalafil + aspirin group. Aspirin can be used alone in the treatment of patients with VED, or combined with tadalafil to reduce side effects and increase success.

The impact of severe mental disorders and psychotropic medications on sexual health and its implications for clinical management

Sexual dysfunction often accompanies severe psychiatric illness and can be due to both the mental disorder itself and the use of psychotropic treatments. Many sexual symptoms resolve as the mental state improves, but treatment-related sexual adverse events tend to persist over time, and are unfortunately under-recognized by clinicians and scarcely investigated in clinical trials. Treatment-emergent sexual dysfunction adversely affects quality of life and may contribute to reduce treatment adherence. There are important differences between the various compounds in the incidence of adverse sexual effects, associated with differences in mechanisms of action. Antidepressants with a predominantly serotonergic activity, antipsychotics likely to induce hyperprolactinaemia, and mood stabilizers with hormonal effects are often linked to moderate or severe sexual dysfunction, including decreased libido, delayed orgasm, anorgasmia, and sexual arousal difficulties. Severe mental disorders can interfere with sexual function and satisfaction, while patients wish to preserve a previously satisfactory sexual activity. In many patients, a lack of intimate relationships and chronic deterioration in mental and physical health can be accompanied by either a poor sexual life or a more frequent risky sexual behaviour than in the general population. Here we describe the influence of psychosis and antipsychotic medications, of depression and antidepressant drugs, and of bipolar disorder and mood stabilizers on sexual health, and the optimal management of patients with severe psychiatric illness and sexual dysfunction.

Antiplatelet (aspirin) therapy as a new option in the treatment of vasculogenic erectile dysfunction: a prospective randomized double-blind placebo-controlled study

PURPOSE

To investigate the efficiency of antiplatelet (aspirin) therapy in vasculogenic erectile dysfunction (VED) patients with a high mean platelet volume.

METHODS

A total of 184 patients diagnosed with VED between the ages of 18 and 76 were randomly divided into two groups and treated for 6 weeks [group 1: 120 patients (mean age 48.3), aspirin 100 mg/day; group 2: 64 patients (mean age 47.7), placebo 100 mg/day]. The changes from baseline to end point in erectile function scores on the International Index of Erectile Function (IIEF-EF) and the number of patients who answered "yes" to questions 2 and 3 of the sexual encounter profile (SEP) were compared statistically.

RESULTS

The mean baseline IIEF-EF scores in groups 1 and 2 were 14.1 ± 4.9 and 14.3 ± 5.2, respectively (p = 0.7966), the number of patients who answered "yes" to SEP-2 was 62 (51.6%) in group 1 and 32 (50%) in group 2 (p = 0.8366), and the number of patients who answered "yes" to SEP-3 was 38 (31.6%) in group 1 and 20 (31.2%) in group 2 (p = 0.9557). In the aspirin group, the changes from baseline to end point in the IIEF-EF, SEP-2, and SEP-3 scores were 7.2, 36.6, and 46.6%, respectively. In the placebo group, these changes were 2.0, 9.4, and 12.5%, respectively. When compared with the placebo group, aspirin-treated subjects showed a significant improvement in all three efficacy measures (p < 0.0001).

CONCLUSIONS

100 mg of aspirin administered once a day significantly improved EF in men with VED.

A Place for Sexual Dysfunctions in an Empirical Taxonomy of Psychopathology

Sexual dysfunctions commonly co-occur with various depressive and anxiety disorders. An emerging framework for understanding the classification of mental disorders suggests that such comorbidity is a manifestation of underlying dimensions of psychopathology (or "spectra"). In this review, we synthesize the evidence that sexual dysfunctions should be included in the empirical taxonomy of psychopathology as part of the internalizing spectrum, which accounts for comorbidity among the depressive and anxiety disorders. The review has four parts. Part 1 summarizes the empirical basis and utility of the empirical taxonomy of psychopathology. Part 2 reviews the prima facie evidence for the hypothesis that sexual dysfunctions are part of the internalizing spectrum (i.e., high rates of comorbidity; shared cognitive, affective, and temperament characteristics; common neural substrates and biomarkers; shared course and treatment response; and the lack of causal relationships between them). Part 3 critically analyzes and integrates the results of the eight studies that have addressed this hypothesis. Finally, Part 4 examines the implications of reconceptualizing sexual dysfunctions as part of the internalizing spectrum, and explores avenues for future research.

Lithium side effects and toxicity: prevalence and management strategies

Despite its virtually universal acceptance as the gold standard in treating bipolar disorder, prescription rates for lithium have been decreasing recently. Although this observation is multifactorial, one obvious potential contributor is the side effect and toxicity burden associated with lithium. Additionally, side effect concerns assuredly play some role in lithium nonadherence. This paper summarizes the knowledge base on side effects and toxicity and suggests optimal management of these problems. Thirst and excessive urination, nausea and diarrhea and tremor are rather common side effects that are typically no more than annoying even though they are rather prevalent. A simple set of management strategies that involve the timing of the lithium dose, minimizing lithium levels within the therapeutic range and, in some situations, the prescription of side effect antidotes will minimize the side effect burden for patients. In contrast, weight gain and cognitive impairment from lithium tend to be more distressing to patients, more difficult to manage and more likely to be associated with lithium nonadherence. Lithium has adverse effects on the kidneys, thyroid gland and parathyroid glands, necessitating monitoring of these organ functions through periodic blood tests. In most cases, lithium-associated renal effects are relatively mild. A small but measurable percentage of lithium-treated patients will show progressive renal impairment. Infrequently, lithium will need to be discontinued because of the progressive renal insufficiency. Lithium-induced hypothyroidism is relatively common but easily diagnosed and treated. Hyperparathyroidism from lithium is a relatively more recently recognized phenomenon.

Sexual Dysfunction Due to Psychotropic Medications

Sexual functioning is important to assess in patients with psychiatric illness as both the condition and associated treatment may contribute to sexual dysfunction (SD). Antidepressant medications, mood stabilizers, antipsychotics, and antianxiety agents may be associated with SD related to drug mechanism of action. Sexual adverse effects may be related to genetic risk factors, impact on neurotransmitters and hormones, and psychological elements. Effective strategies to manage medication-induced sexual dysfunction are initial choice of a drug unlikely to cause SD, switching to a different medication, and adding an antidote to reverse SD. Appropriate interventions should be determined on a clinical case-by-case basis.

Psychotropic induced sexual dysfunction for people with a dual diagnosis

Purpose

– The purpose of this paper is: first, to consider the reported problems in sexual function caused by psychotropic medication. Second, the complex undertaking of completing an assessment of sexual functioning. Third, the role of the pharmaceutical industry is explored. Finally, implications for future research and practice are suggested.

Design/methodology/approach

– As a commentary this paper draws on the available literature to synthesise what is already known about the relationship between psychoactive substances and sexual functioning.

Findings

– The limited literature and lack of research attention given to psychotropic induced sexual dysfunction limits our collective understanding of how many people are affected and in what way.

Research limitations/implications

– A greater focus on psychotropic induced sexual dysfunction is needed for people with a dual diagnosis. There has been an over reliance on single case studies and self-reporting. Large scale epidemiological investigation would help understand the extent and nature of the problem more fully. The demographic shift particularly in relation to an ageing population should be considered as psychotropic substances effect individuals in different ways as they grow older.

Practical implications

– There is scope for workers to engage more fully in a conversation with clients about their experience of using psychotropic substances and how this has impacted their sexual functioning. The literature suggests that clients want to talk about this issue but staff are unwilling or unable to discuss the topic.

Originality/value

– To the authors’ knowledge this is the first paper that draws on the available literature to explore the known and likely implications of psychotropic induced sexual dysfunction for this client group.

Impact of Antidepressant Drugs on Sexual Function and Satisfaction

Pleasurable sexual activity is important in many human relationships and can provide a sense of physical, emotional and social well-being. Depressive symptoms and depressive illness are associated with impairments in sexual function and sexual dissatisfaction in untreated and treated patients. Most currently available antidepressant drugs are associated with development or worsening of sexual dysfunction in a substantial proportion of patients. Sexual difficulties during antidepressant treatment often resolve as depression lifts, but can persist over long periods, reducing self-esteem and affecting mood and relationships adversely. Sexual difficulties during antidepressant treatment typically have many possible causes but the incidence and nature of dysfunction varies between drugs. Many interventions can be considered when managing sexual dysfunction associated with antidepressants but no approach is 'ideal'. Because treatment-emergent sexual difficulties are less frequent with certain drugs, presumably related to differences in pharmacological properties, and since current interventions are suboptimal, a lower incidence of sexual dysfunction is a relevant tolerability target when developing novel antidepressants.

Management of adverse effects of mood stabilizers

Mood stabilizers such as lithium and anticonvulsants are still standard-of-care for the acute and long-term treatment of bipolar disorder (BD). This systematic review aimed to assess the prevalence of their adverse effects (AEs) and to provide recommendations on their clinical management. We performed a systematic research for studies reporting the prevalence of AEs with lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. Management recommendations were then developed. Mood stabilizers have different tolerability profiles and are eventually associated to cognitive, dermatological, endocrine, gastrointestinal, immunological, metabolic, nephrogenic, neurologic, sexual, and teratogenic AEs. Most of those can be transient or dose-related and can be managed by optimizing drug doses to the lowest effective dose. Some rare AEs can be serious and potentially lethal, and require abrupt discontinuation of medication. Integrated medical attention is warranted for complex somatic AEs. Functional remediation and psychoeducation may help to promote awareness on BD and better medication management.