SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients

Sexual dysfunction and commonly used drugs in neurology

Sexual dysfunction is common in men and women with neurological diseases. Medications used in neurology can cause sexual dysfunction independently of the disease process and this may adversely affect patients' quality of life. This review focuses on medications commonly prescribed to neurological patients that may contribute to altered sexual function, and discusses how they may differ in men and women.

The association of depressive symptoms and female sexual functioning in the menopause transition: a cross-sectional study

OBJECTIVE

Sexual dysfunction is very common among middle-aged females. Several factors are considered to influence sexual functioning, including reproductive aging and associated physiological changes as well as life stressors, mental health, and other socioeconomic influences. The objectives of this study are to evaluate the effect of current depressive symptoms on sexual functioning during menopause and to further analyze whether socioeconomic status, age, and antidepressant usage impact this association.

METHODS

Perimenopausal and postmenopausal women aged 40 to 65 years seeking treatment from a specialized menopause clinic completed a self-report survey with the main outcome measure being the 19-item Female Sexual Function Index quantifying sexual dysfunction. We used the 10-item Center for Epidemiological Studies Depression Scale to estimate a major depressive episode. Statistical analyses were completed to assess the potential associations of socioeconomic factors, age, and antidepressant usage.

RESULTS

Of the 269 participants, 61.3% met criteria for a major depressive episode and 67.0% had low sexual function. As predicted, women currently experiencing depressive symptoms had a greater risk of low sexual function during perimenopause and postmenopause. Antidepressant usage, low household income, being postmenopausal, and age also predicted low sexual function.

CONCLUSIONS

Among perimenopausal and postmenopausal women, current depressive symptoms were associated with low sexual function. A biopsychosocial approach should be considered when exploring effective treatment strategies for sexual concerns among midlife women.

Treatment-emergent sexual dysfunctions due to antidepressants: A primer on assessment and management strategies

Antidepressants (ADs) are among the most commonly prescribed drugs worldwide. Persons with mental illness taking ADs commonly report sexual dysfunction (SD) related to treatment. A brief discussion on the neurobiology of sexual functioning and mechanism of treatment-emergent SD (TESD) was performed. The incidence of prevalence of TESD in various studies has been reviewed. TESD impacts patients as it frequently leads to nonadherence, while psychiatrists have challenges in proceeding forward with treatment in such patients. Assessment of patients with suspected TESD is described with a focus on practical tips for clinicians. Five strategies (watchful waiting, drug holiday, downward titration, switching, and add-on therapy) to manage TESD have been extensively discussed with evidence in the literature. Each strategy comes with its own bag of advantages and drawbacks, which have been pointed out for simplicity. A detailed discussion on individual pharmacological strategies is given, and options for non-pharmacological management that can be tried are enlisted. Common clinical case scenarios have been discussed to incorporate the implementation of this literature.

Psychedelics and sexual functioning: a mixed-methods study

Do psychedelics affect sexual functioning postacutely? Anecdotal and qualitative evidence suggests they do, but this has never been formally tested. While sexual functioning and satisfaction are generally regarded as an important aspect of human wellbeing, sexual dysfunction is a common symptom of mental health disorders. It is also a common side effect of selective serotonin reuptake inhibitors (SSRIs), a first line treatment for depression. The aim of the present paper was to investigate the post-acute effects of psychedelics on self-reported sexual functioning, combining data from two independent studies, one large and naturalistic and the other a smaller but controlled clinical trial. Naturalistic use of psychedelics was associated with improvements in several facets of sexual functioning and satisfaction, including improved pleasure and communication during sex, satisfaction with one's partner and physical appearance. Convergent results were found in a controlled trial of psilocybin therapy versus an SSRI, escitalopram, for depression. In this trial, patients treated with psilocybin reported positive changes in sexual functioning after treatment, while patients treated with escitalopram did not. Despite focusing on different populations and settings, this is the first research study to quantitively investigate the effects of psychedelics on sexual functioning. Results imply a potential positive effect on post-acute sexual functioning and highlight the need for more research on this.

Post-Finasteride Syndrome And Post-Ssri Sexual Dysfunction: Two Clinical Conditions Apparently Distant, But Very Close

Post-finasteride syndrome and post-SSRI sexual dysfunction, are two poorly explored clinical conditions in which men treated for androgenetic alopecia with finasteride or for depression with SSRI antidepressants show persistent side effects despite drug suspension (e.g., sexual dysfunction, psychological complaints, sleep disorders). Because of some similarities in the symptoms, common pathological mechanisms are proposed here. Indeed, as discussed, clinical studies and preclinical data obtained so far suggest an important role for brain modulators (i.e., neuroactive steroids), neurotransmitters (i.e., serotonin, and cathecolamines), and gut microbiota in the context of the gut-brain axis. In particular, the observed interconnections of these signals in these two clinical conditions may suggest similar etiopathogenetic mechanisms, such as the involvement of the enzyme converting norepinephrine into epinephrine (i.e., phenylethanolamine N-methyltransferase). However, despite the current efforts, more work is still needed to advance the understanding of these clinical conditions in terms of diagnostic markers and therapeutic strategies.

Safety and Efficacy of Drug Holidays for Women with Sexual Dysfunction Induced by Selective Serotonin Reuptake Inhibitors (SSRIs) Other than Fluoxetine: An Open-Label Randomized Clinical Trial

Selective serotonin reuptake inhibitors (SSRIs) are the cornerstone of psychopharmacology. However, they cause side effects such as sexual dysfunction, leading to the discontinuation of treatment. We aimed to investigate the efficacy and safety of drug holidays for women experiencing sexual dysfunction Induced by SSRIs other than fluoxetine. This study was an 8-week randomized, open-label, controlled trial including married women aged between 18 and 50 years who had experienced sexual dysfunction while undergoing treatment with SSRIs. The intervention group implemented drug holidays by not taking medications on Thursdays and Fridays, while the control group continued regular medication use. The female sexual function index (FSFI) and the 28-question general health questionnaire (GHQ-28) were administered to assess sexual function and mental health, respectively. A total of 50 participants completed the trial. The drug holidays' group showed significant improvements in arousal (p < 0.001), desire (p = 0.001), orgasm (p < 0.001), satisfaction (p < 0.001), lubrication (p = 0.021), and overall sexual health (p < 0.001). The between-group difference of pain was significant (p < 0.001), despite no significant within-group change. Mental health improved in both groups, despite no significant between-group difference. No major adverse effects were reported. Drug holidays did not introduce immediate safety concerns or significant adverse effects during the timeframe of eight weeks, suggesting that it may be a safe and effective strategy for managing SSRI-induced sexual dysfunction in women, alongside improving mental health. Further research is needed to reach a definitive conclusion.

The pathophysiology of Post SSRI Sexual Dysfunction - Lessons from a case study

BACKGROUND

Although Post-SSRI Sexual Dysfunction (PSSD) has finally been recognized by the European Medicines Agency as a medical condition that can outlast discontinuation of SSRI and SNRI antidepressants, this condition is still largely unknown by patients, doctors, and researchers, and hence, poorly understood, underdiagnosed, and undertreated.

OBJECTIVE

Becoming familiar with the symptomatology of PSSD and understanding the underlying mechanisms and treatment options.

METHOD

We applied a design thinking approach to innovation to 1) provide insights into the medical condition as well as the personal needs and pains of a targeted patient; and 2) generate ideas for new solutions from the perspective of this particular patient. These insights and ideas informed a literature search on the potential pathophysiological mechanisms that could underlie the patient's symptoms.

RESULTS

The 55-year-old male patient developed symptoms of low libido, delayed ejaculation, erectile dysfunction, 'brain zaps', overactive bladder and urinary inconsistency after discontinuation of the SNRI venlafaxine. In many of these symptoms a dysregulation in serotonergic activity has been implicated, with an important role of 5-HT_1A receptor downregulation and possible downstream effects on neurosteroid and oxytocin systems.

CONCLUSIONS

The clinical presentation and development of symptoms are suggestive of PSSD but need further clinical elaboration. Further knowledge of post-treatment changes in serotonergic - and possibly noradrenergic - mechanisms is required to improve our understanding of the clinical complaints and to inform appropriate treatment regimes.

Chronic escitalopram in healthy volunteers has specific effects on reinforcement sensitivity: a double-blind, placebo-controlled semi-randomised study

Several studies of the effects on cognition of selective serotonin reuptake inhibitors (SSRI), administered either acutely or sub-chronically in healthy volunteers, have found changes in learning and reinforcement outcomes. In contrast, to our knowledge, there have been no studies of chronic effects of escitalopram on cognition in healthy volunteers. This is important in view of its clinical use in major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). Consequently, we aimed to investigate the chronic effect of the SSRI, escitalopram, on measures of 'cold' cognition (including inhibition, cognitive flexibility, memory) and 'hot cognition' including decision-making and particularly reinforcement learning. The study, conducted at the University of Copenhagen between May 2020 and October 2021, used a double-blind placebo-controlled design with 66 healthy volunteers, semi-randomised to receive either 20 mg of escitalopram (n = 32) or placebo (n = 34), balanced for age, sex and intelligence quotient (IQ) for at least 21 days. Questionnaires, neuropsychological tests and serum escitalopram measures were taken. We analysed group differences on the cognitive measures using linear regression models as well as innovative hierarchical Bayesian modelling of the Probabilistic Reversal Learning (PRL) task. The novel and important finding was that escitalopram reduced reinforcement sensitivity compared to placebo on both the Sequential Model-Based/Model-Free task and the PRL task. We found no other significant group differences on 'cold' or 'hot' cognition. These findings demonstrate that serotonin reuptake inhibition is involved in reinforcement learning in healthy individuals. Lower reinforcement sensitivity in response to chronic SSRI administration may reflect the 'blunting' effect often reported by patients with MDD treated with SSRIs. Trial Registration: NCT04239339 .

Sexual function improves as depressive symptoms decrease during treatment with escitalopram: results of a naturalistic study of patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is closely associated with sexual dysfunction, which may worsen during treatment with selective serotonin reuptake inhibitors (SSRIs) due to the side effects of pharmacologic treatment.

AIM

To examine the association between sexual function and severity of MDD in drug-naïve patients as compared with healthy controls and how treatment with SSRIs affects sexual function over time in individuals with MDD. Interaction with gender and treatment response was examined.

METHODS

In 92 patients with MDD, we measured MDD severity with 6- and 17-item versions of the Hamilton Depression Rating Scale (HDRS6 and HDRS17) and the level of sexual function with the Changes in Sexual Functioning Questionnaire at baseline and 4, 8, and 12 weeks after initiating treatment with escitalopram. Baseline sexual function was compared with the sexual function of 73 healthy controls. Linear regression models were used to assess differences in sexual function between healthy controls and patients and change in sexual function from baseline to week 12. Linear mixed models were used to assess differences in change in sexual function between treatment response groups.

OUTCOMES

Outcomes included total scores on the HDRS6, HDRS17, and Changes in Sexual Functioning Questionnaire and changes in total scores from baseline to week 12.

RESULTS

Unmedicated patients with MDD reported impaired sexual function as compared with healthy controls. Level of sexual function was not associated with severity of MDD at baseline. Patients' sexual function improved significantly during treatment, which was coupled with amelioration of depressive symptoms. Treatment response groups (remitters, intermediate responders, nonresponders) did not predict change in sexual function. Gender had no effect on sexual dysfunction symptoms during treatment.

CLINICAL IMPLICATIONS

Major depression is a risk factor for sexual problems, and improvement in sexual function was coupled with amelioration of depressive symptoms.

STRENGTHS AND LIMITATIONS

Among its strengths, this was a naturalistic study reflecting real-world settings in clinical practice. It additionally included a baseline measurement of sexual function and MDD severity on drug-naïve patients prior to the initiation of treatment. Finally, the follow-up of 12 weeks extends beyond the acute phase of treatment in which previous research has observed a peak in sexual side effects. In terms of limitations, there was no placebo arm; thus, the study cannot attribute the effects on sexual function to treatment with antidepressants per se. Also, the patients were young, which may have served as a protective factor against sexual side effects.

CONCLUSION

Sexual dysfunction was strongly associated with MDD and improved in parallel with overall symptoms of depression across a standard 12-week treatment with SSRI antidepressants.

CLINICAL TRIAL REGISTRATION

NCT02869035 (https://clinicaltrials.gov/ct2/show/NCT02869035).

Sex Differences in Depression and Anxiety

Depression and anxiety disorders carry a tremendous worldwide burden and emerge as a significant cause of disability among western societies. Both disorders are known to disproportionally affect women, as they are twice more likely to be diagnosed and moreover, they are also prone to suffer from female-specific mood disorders. Importantly, the prevalence of these affective disorders has notably risen after the COVID pandemic, especially in women. In this chapter, we describe factors that are possibly contributing to the expression of such sex differences in depression and anxiety. For this, we overview the effect of transcriptomic and genetic factors, the immune system, neuroendocrine aspects, and cognition. Furthermore, we also provide evidence of sex differences in antidepressant response and their causes. Finally, we emphasize the importance to consider sex as a biological variable in preclinical and clinical research, which may facilitate the discovery and development of new and more efficacious antidepressant and anxiolytic pharmacotherapies for both women and men.

[Sexual dysfunction on the background of antidepressant therapy]

The review is devoted to the problem of sexual dysfunction caused by taking antidepressants. Sexual dysfunction is widespread, but it is not reported, and its impact on the quality of life and compliance of patients is underestimated. Partly because of its bidirectional association with depression, sexual dysfunction is difficult to diagnose. Possible mechanisms and risk factors associated with sexual dysfunction in patients with depression are considered. The data on the frequency of sexual dysfunction with the use of various antidepressants are given. Therapeutic strategies for sexual dysfunction associated with taking antidepressants are described. The advantages of agomelatin as an antidepressant associated with a low risk of sexual side effects are emphasized.

Sexual dysfunction and quality of life in female patients with major depression disorder

Background

Major depression can negatively affect different domains in patients’ psychosexual life. Many females with depression have sexual dysfunction which goes under diagnosed leading to reduced sexual and overall health quality of life. The aim of this study is to evaluate the risk of sexual dysfunction, sexual quality of life, and general health quality of life in a sample of Egyptian females diagnosed with major depression compared to a control group.

Results

The sample consisted of 100 participants recruited by convenience sampling, divided into a case group (50 female patients diagnosed with major depression enrolled from our institute’s outpatient clinic) and a control group (50 apparently healthy matched females enrolled from employees working in the university hospitals). Patients answered The Structured Clinical Interview for DSM-IV Axis I Disorders, the Female Sexual Function Index, the Sexual Quality Of Life-Female, and the WHO Quality of Life. Descriptive data analysis showed that all patients with major depression had a higher risk of sexual dysfunction compared to 36% in the control group, with higher rates of marital conflicts, unemployment, positive psychiatric family history and lower monthly income than those in controls. Correlation analysis showed a positive correlation between the sexual quality of life in the case group and the psychosexual feelings (emotional intimacy), self-worthlessness and the total score domains of the FSFI, and a positive correlation with psychosexual feelings, sexual relationship satisfaction, and self-worthlessness domains in the control group. Female sexual functioning scores were positively correlated with most of the WHO quality of life domains in the case group.

Conclusions

Female patients with major depression are distinctly prone to sexual dysfunction and marital problems that can lead to both defective sexual and overall health quality of life. This mandates thorough screening of the psychosocial risks of sexual dysfunction in patients with depression for early management and more satisfactory quality of life.

Sexual Desire in Women: Paradoxical and Nonlinear Associations with Anxiety and Depressed Mood

The aim of the present study was to expand previous findings regarding paradoxical effects of negative mood on sexual desire. This was done by considering the full range of depressed mood and anxiety symptoms and using methods that are unaffected by recall bias and that don't require participants to infer causal associations between their mood and sexual desire. A convenience sample of 213 university students completed daily questionnaires for approximately two months. Multilevel random-effects models were used to estimate average effects for the entire sample and to test for variability across participants in the associations between negative mood and sexual desire, controlling also for potential influences of the menstrual cycle. Previous findings showing that some women report decreased sexual desire and others increased sexual desire when depressed or anxious were confirmed. More importantly, for both depressed mood and anxiety, results demonstrated the presence of within-person paradoxical associations, whereby there were some women for whom both low and high levels of negative mood were associated with the same change (an increase or a decrease) in sexual desire. Related to these diverse response patterns, paradoxical associations between negative mood and sexual desire were also present at low levels of negative mood. The discussion underlines the importance of considering individual variability and multifactorial nonlinear models when studying sexual desire.

Plantain peels restore sexual performance, hormonal imbalance, and modulate nitric oxide production and key enzymes of penile function in paroxetine-sexually impaired male rats

This study focused on the effect of unripe (UPP) and ripe (RPP) plantain peels' extracts (200 and 400 mg/kg) on sexual behavior, hormonal profiles [testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH)], and enzymes [acetylcholinesterase (AChE), phosphodiesterase-5' (PDE-5), arginase, angiotensin-I converting enzyme (ACE), ecto-5'neucleotidase, and adenosine deaminase (ADA)] in paroxetine (PAR)-induced penile dysfunction rats. From the result, arginase, PDE-5', ACE, ecto-5'-nucleotidase ADA, and AChE activities, sexual activities, hormonal profile, and NO level were reduced, while thiobarbituric acid reactive species (TBARS) level increased (p < .05) relative to normal control rats. However, treatment with UPP and URP reduced the activities of these enzymes, decreased TBARS levels, and increased hormones, and penile NO levels in PAR-induced rats. Thus, the use of UPP and RPP could be channeled towards the improvement of sexual performance in erectile dysfunction (ED) disorder. PRACTICAL APPLICATIONS: Plantain fruits are a tropical staple food crop commonly consumed at various stages of ripeness and cooking methods. However, its peels are regarded as a waste product with reported cases of environmental menace. Interestingly, plantain peel is being used as a major raw material for industrial applications in the agro-based industries and in folklore for the treatment of many human ailments due to its rich phytochemicals such as polyphenols, carotenoids, alkaloids, etc., which have been reported. A prelude study has also indicated its usefulness in ED management, but further pharmacological investigations are needed to proffer information on its effect in ED management and its anti-androgenic activity in male Wistar rats. The information from this study could be of pharmaceutical importance in designing natural remedies capable of improving penile rigidity, hormone profiles, and alteration of enzymes linked with ED.

[Adverse effects of opioids, antidepressants and anticonvulsants on sex hormones : Often unnoticed but clinically relevant]

Androgen insufficiency under treatment with opioids, antidepressants and anticonvulsants in chronic pain diseases is a side effect with a high prevalence. It can lead to clinical metabolic alterations, adynamia, stress intolerance, anemia or osteoporosis and has a significant impact on the quality of life. Opioids, antidepressants and anticonvulsants affect the hypothalamic-pituitary-gonadal axis of sex hormones. A urologist, andrologist or endocrinologist should be involved in the treatment at an early stage. The recommendation of a differential therapeutic selection of certain substances is only indicative and does not meet evidential criteria. The indications for androgen substitution must be individualized and in consideration of the risk-benefit profile. Awareness of this side effect of an otherwise lege artis medicinal pain therapy must be sharpened and compulsory included in the differential diagnostic considerations.

Prevalence of Sexual Dysfunction in Women With Depression: Need for Psychosexual Health Promotion Approach

Introduction:

Depression-associated sexual dysfunction (SD) is a pervasive and ignorant problem among the general population. The antidepressant used to treat depression may further alter the sexual response cycle in one way or another. This study aims to assess the prevalence of SD in females with major depressive disorders and the effects of antidepressant therapy after 4 weeks of follow-ups.

Material and Methods:

In a prospective observational survey, 94 women diagnosed with depression and on antidepressant therapy were purposively enrolled. Female Sexual Functioning Index (FSFI) and Montgomery-Asberg Depression Rating Scale (MADRS) are administered at baseline and 4 weeks of treatment to measure sexual function and depression changes. Relevant descriptive and inferential statistics are applied to compute the results.

Results:

The mean age of the participants was 35.87 (±5.10) years. A total of 95.7% of participants showed SD at baseline assessment. There was a significant difference (31.87 vs 18.51, P < .001) in depression from baselines to 4 weeks after antidepressant therapy. Further, a significant negative correlation was reported between the MADRS scores and the scores of arousals (r = −0.396, P < .001), lubrication (r = −0.453, P < .001), orgasm (r = −0.342, P < .001), satisfaction (r = −0.407, P < .001), pain (r = −0.362, P < .001), and total domains of FSFI (r = −0.412, P < .001) after 4 weeks. Using cut-off scores of different areas, decreased sexual desire was reported in 97.9%, poor vaginal lubrication (100%), a problem with arousal (100%), reduced satisfaction (96.8%), reduced ability to achieve orgasm (100%), and pain during sexual intercourse in 100% of the participants.

Conclusions:

There is a high prevalence of SD in women with depression. There is a marked improvement in depression at the end of 4 weeks. However, sexual function status remains unchanged and indicates the need for time to improve, suggesting different study designs.

Gender Differences in Medication Adverse Effects Experienced by People Living With Chronic Pain

Objectives

Understanding gender differences in chronic pain (CP) outcome research is essential to optimal treatment delivery. This study explored the associations between gender identity, gender roles, and the number of non-life-threatening pain medication adverse effects reported as severe by people living with CP.

Methods

The analyses were conducted using the COPE Cohort, a dataset generated through a web-based recruitment of adults with CP. Participants were asked how they identified themselves (women, men, unknown, unspecified) and gender roles were measured using the Bem Sex-Role Inventory (subgroups were formed applying the median split method). Pain medication adverse effects were assessed using a standardized checklist (none/mild/moderate/severe). A zero-inflated Poisson model was used to assess gender identity, gender roles and their interaction as potential predictors of the number of pain medication adverse effects.

Results

A total of 1,343 participants reported using pain medications. Adjusting for potential confounders, both gender identity (men vs. women: ß = −0.32, p = 0.0024) and gender roles (androgynous vs. undifferentiated: ß = 0.26, p = 0.0030) were associated with the number of pain medication adverse effects reported as severe, and they interacted with each other. The stratified analysis by gender roles showed that women reported a greater number of severe adverse effects than men among those classified as masculine and androgynous.

Discussion

Although we are unable to confirm whether the associations can be explained by differences in the experience or in the reporting of effects, gender identity and gender roles should both be explored when studying pain medication adverse effects.

Pharmaceutical management of sexual dysfunction in men on antidepressant therapy

INTRODUCTION

Sexual dysfunction (SD) and depression have a bidirectional relationship. The rising prescription of antidepressants, especially those with a serotonergic effect, is associated with increased SD. Sexual dysfunction reduces compliance and increases risk of recurrence of depressive episodes. Various strategies have been studied to manage antidepressant-induced SD.

AREAS COVERED

This review covers the identification of symptoms of antidepressant-induced SD, prevalence of symptoms in association with commonly used antidepressants, and the main lines of management, with a focus on pharmacological strategies.

EXPERT OPINION

The management of antidepressant-induced SD aims to reduce the unwanted sexual adverse effects while maintaining an acceptable control of depressive symptoms. It should implicate a multidisciplinary approach and determination of baseline sexual function and SD risk factors. In spite of several methodological issues, antidepressants can be divided into low- and high-risk categories with regard to the possibility of developing SD. In patients interested in sexual activity, it is recommended to start with low-risk antidepressants. Otherwise, encourage the patient to wait for tolerance and then switch to low-risk. In selected cases, dose reduction or a drug holiday may be applied. The adjunctive use of a PDE5i can help in a significant number of patients. Randomized controlled trials are needed to set high-level evidence-based recommendations.

Drug-Induced Sexual Dysfunction: An Analysis of Reports to a National Pharmacovigilance Database

INTRODUCTION

Sexual dysfunction (SD) is a problem that can affect any phase of the sexual response cycle (such as sexual desire, arousal and orgasm) and individuals of any age. SD can be caused by physical reasons, such as medical conditions, alcoholism or drug abuse; psychological factors, such as stress and anxiety; and different medicines, such as selective serotonin reuptake inhibitors (SSRIs), and their associated adverse effects.

AIM

The aim of this study was to characterise drugs suspected to have caused SD adverse drug reactions (ADRs) in patients, by conducting a descriptive study based on pharmacovigilance reports.

METHODS

Reports submitted to the Netherlands Pharmacovigilance Centre Lareb from January 2003 to December 2019 were used to investigate drug-induced sexual disorders. Selected reports had at least one ADR reported in the Medical Dictionary for Regulatory Activities (MedDRA^®) System Organ Class (SOC) 'Reproductive system and breast disorders' and the SOC 'Psychiatric disorders' relating to sexual disorders and corrected for drug utilisation (expenditure) for the Dutch population.

RESULTS

A total of 2815 SD ADRs were reported in the observed period. Data were divided according to three variables: pharmacotherapeutic group, the drug itself, and sex. A total of 722 different SD/pharmacotherapeutic group pairs were observed. The pharmacotherapeutic groups with the highest frequency of SD reports were SSRIs (n = 488, 17.58%), other antidepressants (n = 172, 6.20%) and HMG-CoA reductase inhibitors (n = 149, 5.37%). Distinguishing ADRs by sex, men suffered more from erectile dysfunction, decreased libido and ejaculation disorders, while among women, libido disorders, dyspareunia and SD were the most common ADRs.

CONCLUSION

Different reactions and disproportionality of reactions were detected between the sexes. Antidepressants, antihypertensives, oral contraceptives, α-blockers, and anti-androgens were the pharmacotherapeutic groups with the highest number of SD reports and corresponding high odds ratios.

Sexual dysfunction with major depressive disorder and antidepressant treatments: impact, assessment, and management

INTRODUCTION

Sexual dysfunction (SD) is a symptom of depression in ≈70% of patients presenting with major depressive disorder (MDD). Antidepressant medications (AD) and adjunctive treatments may further contribute to SD and complicate evaluation and management.

AREAS COVERED

A systematic literature search of PubMed, Ovid MEDLINE and Cochrane databases for MDD, SD, classes of antidepressants, etc. was performed with a focus on 2014 to June 2021. SSRIs are associated with 70% treatment-emergent sexual dysfunction (TESD), SNRIs and tricyclics have rates of TESD of 40 - 45%, and antidepressant medications without SRI effects or with additional unique mechanisms of action have rates similar to placebo (<10%). Appropriate assessment at baseline and throughout treatment, consideration of patient preferences in prescribing, addressing modifiable factors (comorbid medical/psychiatric conditions, substances, relationship difficulties), and utilizing management strategies of switching to an AD with less SD, adding an antidote/adjunctive therapy or lowering the dose are discussed.

EXPERT OPINION

MDD and antidepressant treatment contribute to SD in a high percentage of patients. Treating to remission reduces SD as a symptom of depression. Frequent assessment and targeted management strategies may be effective in preventing or addressing SD. Secondary outcomes like impact on adherence, relationships and self-image should also be considered.

Sexual Dysfunction Among Patients With Chronic Kidney Disease

Sexual dysfunction (SD) in patients with chronic kidney disease is common and negatively impacts quality of life. SD is often under-appreciated because of overall low awareness. Diagnosis of SD is subjective, and manifestations can be different among men and women. Causes of SD are multifactorial, including psychological disorders, hormonal imbalances, vascular disorders, neurological disorders, and medication side effects. Non-specific approaches to improving sexual function include addressing underlying psychological disorders, promoting lifestyle modifications, optimizing dialysis care, and facilitating successful kidney transplantation, whereas treatment with phosphodiesterase type 5 inhibitor, hormone replacement, and mechanical devices can be offered to patients with specific indications.

A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM)

INTRODUCTION

Although erectile dysfunction (ED) involves an interaction between physiological and psychological pathways, the psychosocial aspects of ED have received considerably less attention so far.

AIM

To review the available evidence on the psychosocial aspects of ED in order to develop a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine (ESSM).

METHOD

A comprehensive, narrative review of the literature was performed.

MAIN OUTCOME MEASURES

Specific statements and recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria were provided.

RESULTS

A multidisciplinary treatment, in which medical treatment is combined with a psychological approach, is preferred over unimodal treatment. There is increasing evidence that psychological treatments of ED can improve medical treatments, the patient's adherence to treatment, and the quality of the sexual relationship. The main components of psychological treatment of ED involve cognitive and behavioral techniques aimed at reducing anxiety, challenging dysfunctional beliefs, increasing sexual stimulation, disrupting sexual avoidance, and increasing intimacy and communication skills in a relational context. When applicable and possible, it is strongly recommended to include the partner in the assessment and treatment of ED and to actively work on interpartner agreement and shared decision-making regarding possible treatment options. To ensure a better integration of the biopsychosocial model into clinical practice, developing concrete treatment protocols and training programs are desirable.

CONCLUSION

Because the psychosocial approach to ED has been underexposed so far, this position statement provides valuable information for clinicians treating ED. Psychological interventions on ED are based on existing theoretical models that are grounded in empirical evidence. However, the quality of available studies is low, which calls for further research. The sexual medicine field would benefit from pursuing more diversity, inclusivity, and integration when setting up treatments and evaluating their effect. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM). Sex Med 2021;9:100434.

Understanding genetic risk factors for common side effects of antidepressant medications

Background

Major depression is one of the most disabling health conditions internationally. In recent years, new generation antidepressant medicines have become very widely prescribed. While these medicines are efficacious, side effects are common and frequently result in discontinuation of treatment. Compared with specific pharmacological properties of the different medications, the relevance of individual vulnerability is understudied.

Methods

We used data from the Australian Genetics of Depression Study to gain insights into the aetiology and genetic risk factors to antidepressant side effects. To this end, we employed structural equation modelling, polygenic risk scoring and regressions.

Results

Here we show that participants reporting a specific side effect for one antidepressant are more likely to report the same side effect for other antidepressants, suggesting the presence of shared individual or pharmacological factors. Polygenic risk scores (PRS) for depression associated with side effects that overlapped with depressive symptoms, including suicidality and anxiety. Body Mass Index PRS are strongly associated with weight gain from all medications. PRS for headaches are associated with headaches from sertraline. Insomnia PRS show some evidence of predicting insomnia from amitriptyline and escitalopram.

Conclusions

Our results suggest a set of common factors underlying the risk for antidepressant side effects. These factors seem to be partly explained by genetic liability related to depression severity and the nature of the side effect. Future studies on the genetic aetiology of side effects will enable insights into their underlying mechanisms and the possibility of risk stratification and prophylaxis strategies.

Antidepressants are commonly prescribed medications, but adverse side effects are cause for treatment discontinuation. We analysed data from a large group of adults who have taken antidepressants to understand why some people experience specific side effects. Our results suggest that a person’s genetic characteristics play a role. For example, participants genetically predisposed to a higher body mass index were more likely to report weight gain from antidepressants. These results open up the possibility of predicting adverse side effects as we increase our knowledge on the genetics of related complex traits. Future studies can focus on performing large-scale genetic studies of antidepressant side effects to gain further insights into the mechanisms underlying antidepressant side effects and to identify genetic markers of side effects that could be used in the clinic.

Campos et al. study the genetic aetiology of antidepressant side effects. Using data from the Australian Genetics of Depression study, the authors show that polygenic risk scores for traits such as BMI, insomnia and headaches have a shared genetic basis with side effects to commonly used antidepressant drugs.

Use of Sertraline in Hemodialysis Patients

Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.

Medical therapies causing iatrogenic male infertility

Primum non nocere. As physicians, our goal is to treat illnesses and alleviate suffering; however, in doing so, we can generate new problems in a game of medical whack-a-mole. For some patients, certain consequences or side effects are tolerable, while others may believe they have no alternative. For a male patient with infertility, a thorough history is imperative to elucidate whether the patient has been or is currently being exposed to medications that will harm libido, spermatogenesis, ejaculation, or the hypothalamic-pituitary-testosterone axis. This article will review the most common medications causing iatrogenic male infertility as well as options to minimize or even reverse their impact.

Resolution of sexsomnia with paroxetine

None

Sexsomnia is a parasomnia consisting of sexual behavior during non-rapid eye movement sleep. To date, there have been 116 clinical cases of sexsomnia reported and most were treated with clonazepam. We present a case of an adult male with sexsomnia that started during his college days. He presented to us because of problems in his current marriage arising from sexual behavior during sleep. Polysomnography revealed no significant sleep-disordered breathing, electroencephalography abnormality, or abnormal movement during non-rapid eye movement and rapid eye movement (REM) sleep. Alcohol consumption was reported to worsen his sexsomnia. To avoid the neuro-depressant effects of benzodiazepines, paroxetine was administered and resulted in complete resolution of sexsomnia.

Prescribing practices in the treatment of depression among psychiatrists in Oman

OBJECTIVES

To examine the prescribing patterns of antidepressants among a sample of psychiatrists working in Oman and to compare these practices to the current evidence for prescribing specific antidepressant in particular clinical situations.

METHODS

This retrospective cross sectional study. Massachusetts General Hospital Psychopharmacology Questionnaire, a 10-item questionnaire listing factors that might have influenced the choice of antidepressant medication, was sent to 83 psychiatrists working in governmental health sectors in Oman. The study was done from March to July 2019.

RESULTS

A total number of 78 psychiatrists responded to the questionnaire. Of these, 44 of the psychiatrists (56.4%) believed that one type of antidepressant is more efficacious than others, while 74 psychiatrists (94.9%) indicated that selective serotonin reuptake inhibitors (SSRIs) were their first-line treatment preference. Mirtazapine was chosen as the most likely antidepressant to cause weight gain by two-thirds of the participants. For the treatment of anxious depression and depression with melancholic feature, SSRIs were the first choice of treatment for 64.1% and 7% of respondents, respectively. For depression with atypical features, 42.3% indicated that a monoamine oxidase inhibitor would be their first option.

CONCLUSION

There is a discrepancy between the current antidepressant prescribing practices in Oman and empirical antidepressant-prescribing evidence, and this finding is consistent with previous studies.

Prevalencia y factores asociados al deseo sexual hipoactivo en hombres del Quindío

Introducción El deseo sexual hipoactivo describe el bajo interés hacia la actividad sexual en general, caracterizando la escasa o nula motivación para tener relaciones eróticas, con disminución o ausencia de pensamientos o fantasías sexuales.

Objetivo Evaluar la prevalencia y factores asociados, al deseo sexual hipoactivo en hombres del Quindío, así como estimar las demás disfunciones sexuales.

Métodos Estudio observacional. La población estuvo constituida por 171 hombres que asistieron a consulta externa en una clínica universitaria de la ciudad de Armenia, Colombia, en el 2019. Se excluyeron los hombres menores de 18 años, residentes fuera del Quindío, situación psicopatológica o social que dificultara la comprensión del instrumento y los que no consintieron participar en el estudio. Se aplicó como instrumento el “Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ)”. Se evaluaron las características socio-demográficas, estilos de vida, salud sexual y reproductiva, antecedentes y comportamiento sexual. Se hizo análisis descriptivo.

Resultados La edad promedio fue de 41,79 ± 11,46 años (rango 18–81). La prevalencia de disfunciones sexuales en el grupo estudiado fue de 21,63%. La puntuación del MGH-SFQ fue de 14,61 ± 4,23 puntos (variación: 7,26 - 19,26). Se presentaron dificultades con el interés sexual (15,78%), excitación sexual (6,43%), orgasmo (8,77%), erección (21,63%) y satisfacción sexual global (12,28%). La mediana de disfunciones sexuales por hombre fue de 2, que se hizo presente en el 27,48% %. El análisis multivariado (regresión logística) mostró que los factores asociados al deseo sexual hipoactivo fueron testosterona baja (OR: 5,59; IC95% 1,82–18,37), ansiedad / depresión (OR: 5,53; IC95% 1,72–18,43), convivencia en pareja mayor a 10 años (OR: 5,19; IC95%: 2,71–11,71), ansiedad de desempeño (OR: 4,62; IC95% 1,95–10,56), incremento de la edad (OR: 3,42; IC95%: 1,26–9,36), cansancio / estrés (OR: 2,58; IC95%: 1,08–3,28), trastornos del sueño (OR: 1,89; IC95%: 1,35–2,58), conflictos de pareja (OR: 1,53; IC95%: 1,02–2,37) y antecedente de disfunciones sexuales (OR: 1,47; IC95%: 0,99–2,22); mientras que, el uso de juguetes sexuales (OR: 0,78; IC95%: 0,72–0,96; p = 0,021), consumo de vitamina D (2000 UI / diarias) (OR: 0,64; IC95%: 0,42–0,96) o de Inhibidores de fosfodiesterasa-5 (OR: 0,78; IC95%: 0,63–0,93) constituyeron factores protectores.

Conclusiones En el presente estudio, el 21,63% de los hombres presentaron disfunciones sexuales. Los trastornos de la erección (21,63%) y el interés sexual (15,78%), fueron los más afectados. La testosterona baja, ansiedad / depresión y convivencia en pareja mayor a 10 años, encabezan los principales factores asociados al deseo sexual hipoactivo. El hacer actividades juntos (OR: 0,44; IC95%: 0,34–0,68), el respeto a ser personas diferentes (OR: 0,53; IC95%: 0,41–0,71), mantener la armonía en la pareja (OR: 0,61; IC95%: 0,47–0,79) y la expresión de sentimientos a la pareja (OR: 0,68; IC95%: 0,46–0,95) constituyen una línea de protección para mejorar las estrategias de prevención de los trastornos sexuales en esa población.

Management Strategies for Antipsychotic-Related Sexual Dysfunction: A Clinical Approach

Antipsychotic medication can be often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) remains underestimated in clinical practice. However, psychotic patients consider sexual issues as important as first rank psychotic symptoms, and their disenchantment with TESD can lead to important patient distress and treatment drop-out. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antipsychotic with a low rate of TESD) to possible pharmacological interventions aimed at improving patients' tolerability when TESD is present. The suggested recommendations include the following: prescribing either aripiprazole or another dopaminergic agonist as a first option antipsychotic or switching to it whenever possible. Whenever this is not possible, adjunctive treatment with aripiprazole seems to also be beneficial for reducing TESD. Some antipsychotics, like olanzapine, quetiapine, or ziprasidone, have less impact on sexual function than others, so they are an optimal second choice. Finally, a variety of useful strategies (such as the addition of sildenafil) are also described where the previous ones cannot be applied, although they may not yield as optimal results.

I. Antidepressants and sexual behavior: Weekly ketamine injections increase sexual behavior initially in female and male rats

The present study characterized the effects of weekly ketamine injections on sexual behavior and anxiety in female and male rats, using a dosing protocol that mimics human therapeutic treatment for depression. In Experiment 1A, ketamine (10 mg/kg, i.p.) or saline was injected once per week for four consecutive weeks. The partner preference paradigm was used to measure sexual motivation 30 min after each weekly injection. Briefly, subjects were first given a 10-min test during which they could choose to spend time in the vicinity of a sexually receptive female stimulus or a sexually experienced male stimulus, however physical contact was restricted (no-contact). Immediately after, subjects were given unrestricted access to the stimulus animals (contact). After a washout period, subjects received four additional weekly injections of ketamine or saline, and then were tested for anxiety-like behavior on the elevated plus maze (EPM) after the last injection (Experiment 1B). For Experiment 2, similar procedures were used to test the effects of weekly ketamine injections on sexual motivation (Experiment 2A) and anxiety (Experiment 2B) in male subjects. In female subjects, ketamine increased sexual motivation as measured by greater time spent with the male stimulus, decreased likelihood of leaving after receiving mounts, and shorter return latencies after receiving intromissions, when compared to saline controls. In male subjects, ketamine shortened latency to first mount and first intromission, as well as increased time spent with the female stimulus. Very little anxiety was observed in either group (ketamine or saline) of female or male subjects when tested on the EPM. In conclusion, even after four weeks of ketamine exposure, sexual dysfunction did not emerge in either females or males. In contrast, ketamine increased sexual motivation in both females and males, with an initial robust response. However, as both groups gained sexual experience, the impact of ketamine diminished.

β-caryophyllene improves sexual performance via modulation of crucial enzymes relevant to erectile dysfunction in rats

This study sought to investigate the effect of β-caryophyllene (BCP) on sexual performance, crucial enzymes linked to erectile function as well as lipid peroxidation in the penile tissue of paroxetine (PD)-induced rats. Animals were randomly divided into ten groups of five animals each: normal control (NC), BCP (10 mg/kg), BCP (20 mg/kg), sildenafil citrate (SD) (20 mg/kg), BCP + SD (20 mg/kg), PD (20 mg/kg), PD + BCP (10 mg/kg), PD + BCP (20 mg/kg), PD + SD (20 mg/kg) and PD + BCP (20 mg/kg) + SD (20 mg/kg). Oral administration of 20 mg/kg body weight of PD for the first 7 days was done while treatment with BCP and SD were performed between 8 and 14 days prior to euthanasia. The sexual performance study revealed that PD caused erectile dysfuction. Elevated activities of phosphodiesterase-5' (PDE-5'), arginase, adenosine deaminase (ADA), acetylcholinesterase (AChE) and angiotensin-I converting enzyme (ACE) as well as lipid peroxidation level were observed in PD-induced rats when compared to the NC group. However, treatment with sildenafil and/ or β-Caryophyllene significantly reduced the activities of AChE, PDE-5', arginase, ADA, and ACE in penile tissues of PD-induced rats. In addition, co-administration of β-caryophyllene and sildenafil citrate showed better modulatory effects. Thus, β-caryophyllene could represent a potential nutraceutical in the management of erectile dysfunction.

Selective Serotonin Reuptake Inhibitor-Induced Sexual Dysfunction: Current Management Perspectives

Any type of sexual dysfunction is an important problem in half of the patients with depressive disorder. On the other hand, one to a quarter of people without any depressive disorder experience sexual dysfunction. Antidepressant agents can lead to all types of sexual side effects including arousal, libido, orgasm and ejaculation problems. Selective serotonin reuptake inhibitors (SSRIs) are a widely used class of drugs which are prescribed for the treatment of a variety of disorders, including major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, generalized anxiety disorder, and impulse control disorders. It has been reported that one in eight people have utilized one of the SSRIs in the past 10 years. Some studies reported up to 80% of SSRI-induced sexual side effects. Management of SSRI-induced sexual dysfunction seems to be complex and hard. In this paper, SSRI-induced sexual dysfunction and new perspectives in the management of this problem were reviewed.

Antidepressant-induced sexual dysfunction

Sexual dysfunction is a frequent, potentially distressing, adverse effect of antidepressants and a leading cause of medication non-adherence. Sexual function should be actively assessed at baseline, at regular intervals during treatment, and after treatment cessation. Trials comparing the risk of sexual dysfunction with individual antidepressants are inadequate, but it is reasonable to conclude that the risk is greatest with selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), less with tricyclic antidepressants (except clomipramine) and mirtazapine, and least with moclobemide, agomelatine, reboxetine and bupropion. Management of antidepressant-induced sexual dysfunction requires an individualised approach (eg, considering other causes, dose reduction, addition of medication to treat the adverse effect, switching to a different antidepressant). Post-SSRI sexual dysfunction has been recently identified as a potential, although rare, adverse effect of SSRIs and SNRIs. Consider the possibility of post-SSRI sexual dysfunction in patients in whom sexual dysfunction was absent before starting antidepressants but develops during or soon after antidepressant treatment and still persists after remission from depression and discontinuation of the drug.

Phosphodiesterases PDE2A and PDE10A both change mRNA expression in the human brain with age, but only PDE2A changes in a region-specific manner with psychiatric disease

Many studies implicate altered cyclic nucleotide signaling in the pathophysiology of major depressive disorder (MDD), bipolar disorder (BPD), and schizophrenia (SCZ). As such, we explored how phosphodiesterases 2A (PDE2A) and 10A (PDE10A)-enzymes that break down cyclic nucleotides-may be altered in brains of these patients. Using autoradiographic in situ hybridization on postmortem brain tissue from the Stanley Foundation Neuropathology Consortium, we measured expression of PDE2 and PDE10 mRNA in multiple brain regions implicated in psychiatric pathophysiology, including cingulate cortex, orbital frontal cortex (OFC), superior temporal gyrus, hippocampus, parahippocampal cortex, amygdala, and the striatum. We also assessed how PDE2A and PDE10A expression changes in these brain regions across development using the Allen Institute for Brain Science Brainspan database. Compared to controls, patients with SCZ, MDD and BPD all showed reduced PDE2A mRNA in the amygdala. In contrast, PDE2A expression changes in frontal cortical regions were only significant in patients with SCZ, while those in caudal entorhinal cortex, hippocampus, and the striatum were most pronounced in patients with BPD. PDE10A expression was only detected in striatum and did not differ by disease group; however, all groups showed significantly less PDE10A mRNA expression in ventral versus dorsal striatum. Across development, PDE2A mRNA increased in these brain regions; whereas, PDE10A mRNA expression decreased in all regions except striatum. Thus, PDE2A mRNA expression changes in both a disorder- and brain region-specific manner, potentially implicating PDE2A as a novel diagnostic and/or patient-selection biomarker or therapeutic target.

Sexuality and sexual dysfunctions in older people: a forgotten problem

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

Prevalence of antidepressant-induced sexual dysfunction among psychiatric outpatients attending a tertiary care hospital

Objectives:

To measure the prevalence of sexual dysfunction in psychiatric outpatients treated with fluoxetine, paroxetine, venlafaxine or mirtazapine.

Methods:

This is a retrospective cross-sectional study conducted in Sultan Qaboos University Hospital, Muscat, Oman. All patients above 18 years of age, attending psychiatric clinic and taking fluoxetine, paroxetiene, venlafaxine or mirtazapine for various indications were invited to participate in the study. A data collection sheet was designed to document the patients’ demographic features, psychiatric diagnosis, type, dose and duration of antidepressant treatment. Sexual side effects’ part of Toronto Side Effect Scale (TSES) was used to assess the presence of sexual dysfunction.

Results:

A total of 137 patients (Male: 51%, Female: 49%) were included in the study. The mean age for the participants was 38 years (range: 19-72 years). The number of patients for each antidepressant was as follows: paroxetine (52 patients), fluoxetine (36), mirtazapine (36 patients) and venlafaxine (17 patients). The average duration of the antidepressant use was 3.9 years. The overall prevalence of sexual dysfunction was 39%. Paroxetine was the most common antidepressant associated with sexual dysfunction especially for decreased libido (59.6%) and delayed ejaculation (34.4%). In contrary, mirtazapine was the lowest among antidepressants to cause sexual dysfunction.

Conclusion:

Sexual dysfunction is common among patients treated with antidepressants particularly selective serotonin reuptake inhibitors (SSRIs). Addressing this side effects early in treatment can improve compliance to treatment and prevent relapse.

A practical approach to assessing and managing sexual dysfunction in multiple sclerosis

Sexual dysfunction is common in both men and women with multiple sclerosis but is often under-reported and undertreated. Neurologists report that a major barrier to discussing sexual dysfunction with patients is their lack of knowledge. Here we review the common presentations of sexual dysfunction, discuss its causes in people with multiple sclerosis, and provide a practical approach for neurologists to assess and manage these problems.

Selective serotonin reuptake inhibitors and benzodiazepines in panic disorder: A meta-analysis of common side effects in acute treatment

BACKGROUND

Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.

AIM

The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.

METHODS

We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.

RESULTS

Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.

CONCLUSION

Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

An experimental test of the ovulatory homolog model of female orgasm

The ovulatory homolog model of female orgasm posits that the neuro-endocrine mechanisms underlying female orgasm evolved from and are homologous to the mechanisms mediating copulation-induced ovulation in some mammals. This model predicts that pharmacological agents that affect human orgasm, such as fluoxetine, should also affect ovulation in animals with copulation-induced ovulation, such as rabbits. We tested this prediction by treating rabbits with daily doses of fluoxetine for 2 wk and found that fluoxetine treatment reduces the number of ovulations postcopulation by 30%. In a second experiment we tested whether this result was mediated by an effect on the brain or via peripheral serotonin functions. We treated animals with fluoxetine and induced ovulation with a single injection of human chorionic gonadotropin. In this experiment ovulation rate was nominally reduced by only 8%, which is statistically not significant. We conclude that the effect of fluoxetine on copulation-induced ovulation rate supports the ovulatory homolog model of female orgasm, suggesting that female orgasm has very deep evolutionary roots among the early eutherian mammals.

Management Strategies for Antidepressant-Related Sexual Dysfunction: A Clinical Approach

Major depressive disorder is a serious mental disorder in which treatment with antidepressant medication is often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) has a low rate of spontaneous reports by patients, and this side effect therefore remains underestimated in clinical practice and in technical data sheets for antidepressants. Moreover, the issue of TESD is rarely routinely approached by clinicians in daily praxis. TESD is a determinant for tolerability, since this dysfunction often leads to a state of patient distress (or the distress of their partner) in the sexually active population, which is one of the most frequent reasons for lack of adherence and treatment drop-outs in antidepressant use. There is a delicate balance between prescribing an effective drug that improves depressive symptomatology and also has a minimum impact on sexuality. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antidepressant with a low rate of TESD) to possible pharmacological interventions aimed at improving patients’ tolerability when TESD is present. The suggested recommendations include the following: for low sexual desire, switching to a non-serotoninergic drug, lowering the dose, or associating bupropion or aripiprazole; for unwanted orgasm delayal or anorgasmia, dose reduction, “weekend holiday”, or switching to a non-serotoninergic drug or fluvoxamine; for erectile dysfunction, switching to a non-serotoninergic drug or the addition of an antidote such as phosphodiesterase 5 inhibitors (PD5-I); and for lubrication difficulties, switching to a non-serotoninergic drug, dose reduction, or using vaginal lubricants. A psychoeducational and psychotherapeutic approach should always be considered in cases with poorly tolerated sexual dysfunction.

Paroxetine, but not Vortioxetine, Impairs Sexual Functioning Compared With Placebo in Healthy Adults: A Randomized, Controlled Trial

INTRODUCTION

Sexual dysfunction is prevalent among patients with depression, but assessment of treatment-emergent sexual dysfunction (TESD), a common side effect of antidepressants, can be confounded by the treatment of depressive symptoms in some patients.

AIM

To evaluate sexual functioning in healthy volunteers administered vortioxetine compared with paroxetine, an antidepressant known to cause sexual dysfunction, and placebo.

METHODS

This phase 4, multicenter, randomized, double-blind, placebo-controlled, 4-arm, fixed-dose, head-to-head study compared sexual functioning in healthy volunteers administered vortioxetine (10 and 20 mg once daily [QD]), paroxetine (20 mg QD), or placebo for 5 weeks. Approximately equal numbers of men and women ages 18-40 years with normal sexual functioning (self-reported Changes in Sexual Functioning Questionnaire Short-Form [CSFQ-14] score > 47 for men; > 41 for women) were enrolled. Two modified full analysis sets adjusting for treatment non-compliance were prespecified.

MAIN OUTCOME MEASURE

The primary endpoint was change in CSFQ-14 total score for vortioxetine (10 and 20 mg) vs paroxetine after 5 weeks. Additional endpoints included CSFQ-14 change scores vs placebo, CSFQ-14 subscales, and patient global impression.

RESULTS

Of the 361 subjects enrolled (mean age, 28.4 years), approximately 57% were white, 34% black/African American, and 4% Asian. Vortioxetine 10 mg was associated with significantly less TESD than paroxetine (mean difference, +2.74 points; P = .009). Although vortioxetine 20 mg was associated with numerically less TESD than paroxetine (mean difference, +1.05 points), this difference did not reach statistical significance. Non-compliance appeared to influence results, particularly the paroxetine and vortioxetine 20 mg arms. Paroxetine, but not vortioxetine, was associated with statistically significantly more TESD vs placebo. Vortioxetine also had better outcomes than paroxetine in the 3 phases and 5 dimensions of sexual functioning measured by CSFQ-14.

CLINICAL IMPLICATIONS

These data establish that vortioxetine is associated with less TESD than paroxetine in healthy individuals, suggesting that vortioxetine may be a drug of choice in managing depressive disorders when sexual functioning is a concern.

STRENGTHS & LIMITATIONS

Conducting the study in healthy adults mitigated the risk of an underlying condition (eg, depression) confounding the results. Assay sensitivity was demonstrated by statistically significant TESD with paroxetine vs placebo. The single comparator, paroxetine, and short study duration limit the generalizability of these results.

CONCLUSION

Vortioxetine is associated with less TESD than paroxetine in healthy adults across all phases and dimensions of the sexual response cycle. Vortioxetine was not significantly different from placebo on sexual functioning; however, the difference was significant between paroxetine and placebo, validating study results. Jacobsen P, Zhong W, Nomikos G, et al. Paroxetine, but not Vortioxetine, Impairs Sexual Functioning Compared With Placebo in Healthy Adults: A Randomized, Controlled Trial. J Sex Med 2019; 16:1638-1649.

Sexual Dysfunction in Women with Depressive Disorder: A Prospective, Hospital Based Study

Background: Depression causes emotional and physical disturbances which impacts biological functions such as sleep, appetite, libido, and disinterest in sexual function. Since discussing sexual problems is considered a taboo, there is limited data available concerning the prevalence of sexual dysfunction in women with depression and its response to treatment.

Aim: To assess the prevalence of sexual dysfunction in females with depressive disorder and the effects of treatment.

Material and Methods: A total of 53 females with recurrent depression and age and sex matched normal control group were included in the study with their informed consent. All the subjects were assessed with the Hamilton Rating Scale for Depression (HAM-D), Arizona sexual experience scale (ASEX), and female sexual functioning index (FSFI), which were re-administered after 6 weeks of treatment.

Results: There was a significant difference in the HAM-D, ASEX, and FSFI scores between index and control groups at baseline. There was a significant correlation between the scores of HAM-D, ASEX, and FSFI before treatment. The correlation between the HAM-D and ASEX scores after treatment was not significant. A significant correlation was found between the HAM-D scores and the scores of arousal, lubrication, orgasm, satisfaction, pain, total domains of FSFI after treatment. No correlation was found between the HAM-D scores and desire domain score of FSFI after treatment.

Conclusion: Women with depression have a high prevalence of sexual dysfunction. A highly significant improvement in depression and sexual functioning was observed at the end of 6 weeks of antidepressant therapy. Despite the improvement in sexual dysfunctions, the individual domains of sexual functions were not comparable to the normal subjects at the end of 6 weeks suggesting the need for longer treatment.

Sex differences in the pharmacology of itch therapies-a narrative review

BACKGROUND

Chronic itch is the most common skin-related condition, associated with a high psychosocial and economic burden. In recent years, increasing evidence of sex differences in the perception, clinical presentation and treatment requirements of itch points towards potential benefits when using sex-adapted therapies. It is well-known that body composition, absorption, metabolism, elimination and adverse drug reactions (ADRs) differ between sexes, but only little is known about the impact of sex in the pharmacology of itch treatments, which could help to rationalise sex-adapted treatment strategies.

AIM

To evaluate and review sex effects in the pharmacokinetics and /-dynamics of drugs used to treat itch.

METHODS

In this narrative review we performed a PubMed and MEDLINE (Ovid) search using the terms (itch OR pruritus) AND (gender OR sex) AND (drug OR medication OR pharmacokinetics OR pharmacodynamics). Additional searches were performed for the topical and systemic drugs recommended by the European Guideline on Chronic Pruritus.

RESULTS

We found numerous reports with variable levels of evidence of sex effects with respect to the pharmacokinetics and/or pharmacodynamics of 14 drug classes used for the treatment of itch, including a total of 19 systemic and 3 topical drugs. Women seem to present higher plasma levels of several drugs used in itch treatment, including tri- and tetracyclic antidepressants (e.g. doxepin, amitriptyline, mirtazapine), serotonin reuptake inhibitors (e.g. paroxetine, sertraline, fluoxetine), immunosuppressive drugs (e.g. cyclosporine, mycophenolate mofetil), serotonin receptor antagonists (e.g. ondansetron) and betablockers (e.g. propranolol). Adverse drug reactions (ADRs) were generally more common in women. Being female was reported to be an independent risk factor for QTc-prolongation associated with antihistamines and tetracyclic antidepressants. Additionally, women seem to be more prone to sedative effects of antihistamines, and to suffer from a higher frequency as well as severity of side effects with systemic calcineurin inhibitors, opioid agonists, and opioid antagonists. Women were also sensitised more often to topically applied drugs. Of note, apart from only one experimental study with capsaicin, none of these reports were designed specifically to assess the effect of sex (and gender) in the treatment of itch.

DISCUSSION/CONCLUSION

Our review supports previous reports that sex is of importance in the pharmacokinetics and /-dynamics of several drugs used to treat itch although those drugs were mostly evaluated for non-itch indications. However, the results are limited by methodological limitations evident in most studies such as underrepresentation of women in clinical trials. This emphasises the need to study the impact of sex (and gender) in future itch trials to yield better outcomes and prevent ADRs in both sexes.

Frequency of Sexual Dysfunction in Patients Treated with Desvenlafaxine: A Prospective Naturalistic Study

Despite being clinically underestimated, sexual dysfunction (SD) is one of the most frequent and lasting adverse effects associated with antidepressants. Desvenlafaxine is an antidepressant (AD) with noradrenergic and serotonergic action that can cause a lower SD than other serotonergic ADs although there are still few studies on this subject. Objective: To check the frequency of SD in two groups of depressive patients: one group was desvenlafaxine-naïve; the other was made up of patients switched to desvenlafaxine from another AD due to iatrogenic sexual dysfunction. A naturalistic, multicenter, and prospective study of patients receiving desvenlafaxine (50–100 mg/day) was carried out on 72 patients who met the inclusion criteria (>18 years old and sexually active), who had received desvenlafaxine for the first time (n = 27) or had switched to desvenlafaxine due to SD with another AD (n = 45). Patients with previous SD, receiving either drugs or presenting a concomitant pathology that interfered with their sexual life and/or patients who abused alcohol and/or drugs were excluded. We used the validated Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX) to measure AD-related sexual dysfunction and the Clinical Global Impression Scale for psychiatric disease (CGI-S) and for sexual dysfunction (CGI-SD) at two points in time: baseline and three months after the commencement of desvenlafaxine treatment. Results: In desvenlafaxine-naïve patients, 59.2% of the sample showed moderate/severe sexual dysfunction at baseline, which was reduced to 44% at follow-up. The PSexDQ-SALSEX questionnaire total score showed a significant improvement in sexual desire and sexual arousal without changes in orgasmic function at follow-up (p < 0.01). In the group switched to desvenlafaxine, the frequency of moderate/severe SD at baseline (93.3%) was reduced to 75.6% at follow-up visit. Additionally, SD significantly improved in three out of four items of the SALSEX: low desire, delayed orgasm, and anorgasmia at follow-up (p < 0.01), but there was no significant improvement in arousal difficulties. The frequency of severe SD was reduced from 73% at baseline to 35% at follow-up. The CGI for psychiatric disease and for sexual dysfunction improved significantly in both groups (p < 0.01). There was a poor tolerability with risk of treatment noncompliance in 26.7% of patients with sexual dysfunction due to another AD, this significantly reduced to 11.1% in those who switched to desvenlafaxine (p = 0.004). Conclusion: Sexual dysfunction improved significantly in depressed patients who initiated treatment with desvenlafaxine and in those who switched from another AD to desvenlafaxine, despite this, desvenlafaxine treatment is not completely devoid of sexual adverse effects. This switching strategy could be highly relevant in clinical practice due to the significant improvement in moderate/severe and poorly tolerated SD, while maintaining the AD efficacy.

Sexual Dysfunction and Quality of Life in Chronic Heroin-Dependent Individuals on Methadone Maintenance Treatment

This study examined whether methadone (hereinafter referred to as MTD) maintenance treatment (MMT) is correlated with sexual dysfunction (SD) in heroin-dependent men. This was conducted to determine the prevalence of sexual dysfunction and if there is a relationship between duration and dose among men on MMT and its impact on the quality of life. The study combined a retrospective and a cross-sectional survey based on the Kinsey Scale, TECVASP, and PRSexDQ-SALSEX clinical interviews of 85 patients who are currently engaged in MMT. Sexual dysfunction in all five PRSexDQ-SALSEX domains (lack of libido, delay in orgasm, inability to orgasm, erectile dysfunction, and tolerance or acceptance of changes in sexual function) was associated with dose and long-term use of heroin. All dimensions of SD were affected by the MTD intake. From the analysis of our sample, we may conclude that dose of MTD and overall score of SD were directly associated. However, no evidence was found to prove that treatment duration and severity of SD were linked. It is notable that only one tenth of the patients spontaneously reported their symptoms of the sexual sphere, but up to a third considered leaving the MMT for this reason.