Evaluation of sexual functioning in depressed outpatients: a double-blind comparison of sustained-release bupropion and sertraline treatment

Adjuvant administration of probiotic effects on sexual function in depressant women undergoing SSRIs treatment: a double-blinded randomized controlled trial

BACKGROUND

According to the Institute of Health Metrics and Evaluation's Global Health Data Exchange (2023) it is estimated that 5% of all adults will experience depressive disorder. Amongst the general loss of pleasure and interest in everyday activities that are symptoms of low mood, reduced sexual desire and sexual dysfunction can be particularly overlooked. Human sexuality is complex, but finding solutions based on scientific evidence to limit the symptoms of depressive disorder and the iatrogenic impact of antidepressant treatment to improve this outcome is an important step in promoting psychological health and general wellbeing.

OBJECTIVE

The present study aimed is to provide scientific evidence to assess the effect of oral probiotic on sexual function in women with depressive disorder treated with Selective Serotonin Reuptake Inhibitors (SSRIs) in an Iranian population.

DESIGN

This study was a double-blind randomized clinical trial. Eligible women were assigned to lactofem plus SSRIs (n = 58) or SSRIs alone (n = 54). In group A, SSRI antidepressants were prescribed together with Lactofem, and in group B, SSRI antidepressants were prescribed alone. Lactofem including Lactobacillus acidophilus 2 × 109 cfu/g, Bifidobacterium bifidus 2 × 109 cfu/g, Lactobacillus rutri 2 × 109 cfu/g, Lactobacillus fermentum 2 × 109 cfu/g; capsule weight of 500 mg bio-capsule administered orally and daily. The duration of intervention in two groups was two months. All questionnaires were completed by the patients before and after the intervention. The Female Sexual Function Index (FSFI), Hamilton Depression Rating Scale and Larson's Sexual Satisfaction Questionnaire were used to evaluate sexual function, severity of depressive disorder and sexual satisfaction, respectively.

RESULTS

Based on the results of the present study, there was a statistically significant difference in sexual satisfaction and severity of depressive disorder between the groups before and after the intervention (P < 0.05). Also, our findings showed that after eight weeks, the Lactofem plus SSRIs group showed significant improvement in FSFI domains and total scores compared to SSRIs alone group (P < 0.05).

CONCLUSIONS

The results of the present study show that taking probiotics for eight weeks may improve the severity of depressive disorder, sexual function and sexual satisfaction in depressed women treated with SSRIs.

TRIAL REGISTRATION

ClinicalTrials.govidentifier: IRCT20160524028038N14 (19/12/2022).

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.

Bremelanotide for Treatment of Female Hypoactive Sexual Desire

Hypoactive sexual desire disorder (HSDD) is a persistent deficiency or absence of sexual fantasies and desire resulting in significant distress or interpersonal difficulty. Women with this disorder may display a lack of motivation for sexual activity, reduced responsiveness to erotic cues, a loss of interest during sexual activity, and avoidance of situations that could lead to sexual activity. The pathophysiology of HSDD is thought to be centered around inhibitory and excitatory hormones, neurotransmitters, and specific brain anatomy. Due to the multifactorial nature of HSDD, treatment can be complex and must attempt to target the biological and psychosocial aspects of the disorder. Bremelanotide is a melanocortin receptor agonist and has been recently approved by the FDA to treat HSDD. Bremelanotide is administered intranasally or as a subcutaneous injection. The recommended dosage of bremelanotide is 1.75 mg injected subcutaneously in the abdomen or thigh at least 45 min before sexual activity. Studies showed improvements in desire, arousal, and orgasm scores when 1.75 mg of bremelanotide was administered before sexual activity compared to a placebo. Bremelanotide is a promising way to treat HSDD.

Introducing sexual dysfunction in mental care

Introduction: People with any psychiatric disorder tend to have difficulties in responding sexually. However,sexual dysfunction (SD) is usually under-recognized, even the tightly hormonal and neuronal common connexions through the brain-sex axis. Multiple sources of resistance to SD assessment and intervention persist. Areas covered: The present review aims to underline the feasibility to introduce SD evaluation in patients with any psychiatric disorders, evaluating the potential mutual benefits of their management. Expert opinion: Women and men living with mental disorders frequently display sexual difficulties; however, some of them consider sexuality as a relevant parameter of their quality of life. In fact, SD as a side effect is a frequent reason for stopping the intake of medication. What is more, a holistic approach integrating sexual function could foster a better understanding of mental pathologies due to a common origin of pathogenesis. This could improve care quality, in keeping with the global tendency toward the development of personalized medicine. Consistently, the integration of SD assessment is highly recommended in mental health, all the more so when a psychotropic drug is prescribed. An expected consequence would be a reconstruction of the healthcare professional's consideration for the sexuality of people experiencing mental disorders.

Serotonergic, Dopaminergic, and Noradrenergic Modulation of Erotic Stimulus Processing in the Male Human Brain

Human sexual behavior is mediated by a complex interplay of cerebral and spinal centers, as well as hormonal, peripheral, and autonomic functions. Neuroimaging studies identified central neural signatures of human sexual responses comprising neural emotional, motivational, autonomic, and cognitive components. However, empirical evidence regarding the neuromodulation of these neural signatures of human sexual responses was scarce for decades. Pharmacological functional magnetic resonance imaging (fMRI) provides a valuable tool to examine the interaction between neuromodulator systems and functional network anatomy relevant for human sexual behavior. In addition, this approach enables the examination of potential neural mechanisms regarding treatment-related sexual dysfunction under psychopharmacological agents. In this article, we introduce common neurobiological concepts regarding cerebral sexual responses based on neuroimaging findings and we discuss challenges and findings regarding investigating the neuromodulation of neural sexual stimulus processing. In particular, we summarize findings from our research program investigating how neural correlates of sexual stimulus processing are modulated by serotonergic, dopaminergic, and noradrenergic antidepressant medication in healthy males.

Evaluation and Management of Hypoactive Sexual Desire Disorder

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) often has a negative impact on the health and quality of life of women; however, many women do not mention-let alone discuss-this issue with their physicians. Providers of gynecologic services have the opportunity to address this subject with their patients.

AIM

To review the diagnosis and evidence-based treatment of low sexual desire in women with a focus on strategies that can be used efficiently and effectively in the clinic.

METHODS

The Medline database was searched for clinically relevant publications on the diagnosis and management of HSDD.

RESULTS

HSDD screening can be accomplished during an office visit with a few brief questions to determine whether further evaluation is warranted. Because women's sexual desire encompasses biological, psychological, social, and contextual components, a biopsychosocial approach to evaluating and treating patients with HSDD is recommended. Although individualized treatment plan development for patients requires independent medical judgment, a simple algorithm can assist in the screening, diagnosis, and management of HSDD. Once a diagnosis of HSDD has been made, interventions can begin with office-based counseling and progress to psychotherapy and/or pharmacotherapy. Flibanserin, a postsynaptic 5-hydroxytryptamine 1A agonist and 2A antagonist that decreases serotonin levels and increases dopamine and norepinephrine levels, is indicated for acquired, generalized HSDD in premenopausal women and is the only agent approved in the United States for the treatment of HSDD in women. Other strategies to treat HSDD include using medications indicated for other conditions (eg, transdermal testosterone, bupropion). Bremelanotide, a melanocortin receptor agonist, is in late-stage clinical development.

CONCLUSIONS

Providers of gynecologic care are uniquely positioned to screen, counsel, and refer patients with HSDD. Options for pharmacotherapy of HSDD are currently limited to flibanserin, approved by the US Food and Drug Administration, and off-label use of other agents. Clayton AH, Kingsberg SA, Goldstein I. Evaluation and Management of Hypoactive Sexual Desire Disorder. Sex Med 2018;6:59-74.

Treating depression in multiple sclerosis with antidepressants: A brief review of clinical trials and exploration of clinical symptoms to guide treatment decisions

Depression is a common comorbidity in patients with multiple sclerosis (MS). Those with MS and concurrent depression have poorer quality of life and are also less likely to be compliant with disease-modifying treatment, which may ultimately affect their MS disease course. Treating depression in MS with pharmacological agents can improve not only depression, but may also impact the MS disease course. However, no guidelines exist around treating depression in MS. Few randomized-controlled trials using antidepressants in MS exist. Here, we briefly review trials using antidepressant medications to treat depression in MS. We also propose individualizing treatment of depression in MS, as the depressive symptoms and MS symptoms and disease course differ significantly between patients. We explore the heterogeneity in presentation of depression through different comorbid symptoms in MS, and discuss which antidepressant options would be appropriate in each situation. We propose that future clinical trials should incorporate differences in issues between those with depression (e.g. sexual dysfunction, urinary incontinence) into analysis. As MS is incredibly heterogeneous, treating concurrent depression on a case-by-case basis may enable for improving quality of life and the MS disease course.

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.

Antidepressant-Induced Sexual Dysfunction

OBJECTIVE:

To review the evidence regarding antidepressant-induced sexual dysfunction and address implications for treatment strategy and health plan coverage policies for antidepressant medications.

DATA SOURCES:

Primary articles were identified by a MEDLINE and HealthSTAR search to identify English-language studies published between January 1986 and July 2000. Search terms included sexual dysfunction or sexual function and antidepressants, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, venlafaxine, nefazodone, bupropion, and mirtazapine. A cross-check of references cited in 10 published reviews yielded additional in-scope articles.

STUDY SELECTION AND DATA EXTRACTION:

Approximately 200 articles were identified, including 8 randomized controlled trials and numerous open-label studies, case series, and case reports. Of the randomized controlled trials, only 5 were designed to evaluate the incidence of sexual dysfunction associated with antidepressant treatment. Three additional randomized controlled trials included a structured assessment of sexual dysfunction within an efficacy trial. Data extraction excluded case reports, letters, and other limited study designs. A panel survey augmented published reports.

DATA SYNTHESIS:

Sexual dysfunction is a relatively common adverse effect of many of the antidepressants in common use today. Rates of sexual dysfunction observed in clinical practice may be higher than those reported in the product information for several agents. Selective serotonin-reuptake inhibitors (SSRIs) appear to be the class of antidepressants most likely to cause sexual dysfunction. Published studies suggest that between 30% and 60% of SSRI-treated patients may experience some form of treatment-induced sexual dysfunction. Bupropion and nefazodone appear to be much less likely to cause sexual dysfunction (≤10% of patients). Mirtazapine also appears to be associated with a low rate of sexual adverse effects. Panel results largely reflect the consensus of the literature.

CONCLUSIONS:

Sexual dysfunction is a common adverse effect of antidepressant treatment. Physicians should monitor their patients for antidepressant-induced sexual adverse effects, as these may affect compliance with therapy and ultimate treatment success. In addition to the consequences for patient health and well-being, managed-care organizations should be concerned with sexually related adverse effects of antidepressants, insofar as additional healthcare resources may be required to treat depressed patients in whom these adverse effects arise.

Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant

Bupropion has been used as an antidepressant for over 20 years, though its licence for such use varies and it is typically a third- or fourth-line agent. It has a unique pharmacology, inhibiting the reuptake of noradrenaline and dopamine, potentially providing pharmacological augmentation to more common antidepressants such as selective serotonergic reuptake inhibitors (SSRIs). This systematic review and meta-analysis identified 51 studies, dividing into four categories: bupropion as a sole antidepressant, bupropion coprescribed with another antidepressant, bupropion in 'other' populations (e.g. bipolar depression, elderly populations) and primary evaluation of side effects. Methodologically more robust trials support the superiority of bupropion over placebo, and most head-to-head antidepressant trials showed an equivalent effectiveness, though some of these are hindered by a lack of a placebo arm. Most work on the coprescribing of bupropion with another antidepressant supports an additional effect, though many are open-label trials. Several large multi-medication trials, most notably STAR*D, also support a therapeutic role for bupropion; in general, it demonstrated similar effectiveness to other medications, though this literature highlights the generally low response rates in refractory cohorts. Effectiveness has been shown in 'other' populations, though there is an overall dearth of research. Bupropion is generally well tolerated, it has very low rates of sexual dysfunction, and is more likely to cause weight loss than gain. Our findings support the use of bupropion as a sole or coprescribed antidepressant, particularly if weight gain or sexual dysfunction are, or are likely to be, significant problems. However there are notable gaps in the literature, including less information on treatment naïve and first presentation depression, particularly when one considers the ever-reducing rates of response in more refractory illness. There are some data to support bupropion targeting specific symptoms, but insufficient information to reliably inform such prescribing, and it remains uncertain whether bupropion pharmacodynamically truly augments other drugs.

The Female Sexual Response: Current Models, Neurobiological Underpinnings and Agents Currently Approved or Under Investigation for the Treatment of Hypoactive Sexual Desire Disorder

How a woman responds to sexual cues is highly dependent on a number of distinct, yet related, factors. Researchers have attempted to explain the female sexual response for decades, but no single model reigns supreme. Proper female sexual function relies on the interplay of somatic, psychosocial and neurobiological factors; misregulation of any of these components could result in sexual dysfunction. The most common sexual dysfunction disorder is hypoactive sexual desire disorder (HSDD). HSDD is a disorder affecting women across the world; a recent in-person diagnostic interview study conducted in the USA found that an estimated 7.4% of US women suffer from HSDD. Despite the disorder's prevalence, it is often overlooked as a formal diagnosis. In a survey of primary care physicians and obstetrics/gynaecology specialists, the number one reason for not assigning an HSDD diagnosis was the lack of a safe and effective therapy approved by the US Food and Drug Administration (FDA). This changed with the recent FDA approval of flibanserin (Addyi™) for the treatment of premenopausal women with acquired, generalized HSDD; there are still, however, no treatments approved outside the USA. HSDD is characterized by a marked decrease in sexual desire, an absence of motivation (also known as avolition) to engage in sexual activity, and the condition's hallmark symptom, marked patient distress. Research suggests that HSDD may arise from an imbalance of the excitatory and inhibitory neurobiological pathways that regulate the mammalian sexual response; top-down inhibition from the prefrontal cortex may be hyperactive, and/or bottom-up excitation to the limbic system may be hypoactive. Key neuromodulators for the excitatory pathways include norepinephrine, oxytocin, dopamine and melanocortins. Serotonin, opioids and endocannabinoids serve as key neuromodulators for the inhibitory pathways. Evolving treatment strategies have relied heavily on these crucial research findings, as many of the agents currently being investigated as treatment options for HSDD target and influence key players within these excitatory and inhibitory pathways, including various hormone therapies and centrally acting drugs, such as buspirone, bupropion and bremelanotide.

Psychiatric disorders and sexual dysfunction

Sexual problems are highly prevalent among patients with psychiatric disorders. They may be caused by the psychopathology of the psychiatric disorder but also by its pharmacotherapy. Both positive symptoms (e.g., psychosis, hallucinations) as well as negative symptoms (e.g., anhedonia) of schizophrenia may negatively interfere with interpersonal and sexual relationships. Atypical antipsychotics have fewer sexual side-effects than the classic antipsychotics. Mood disorders may affect libido, sexual arousal, orgasm, and erectile function. With the exception of bupropion, agomelatine, mirtazapine, vortioxetine, amineptine, and moclobemide, all antidepressants cause sexual side-effects. Selective serotonin reuptake inhibitors (SSRIs) may particularly delay ejaculation and female orgasm, but also can cause decreased libido and erectile difficulties. SSRI-induced sexual side-effects are dose-dependent and reversible. Very rarely, their sexual side-effects persist after SSRI discontinuation. This is often preceded by genital anesthesia. Some personality characteristics are a risk factor for sexual dysfunction. Also patients with eating disorders may suffer from sexual difficulties. So far, research into psychotropic-induced sexual side-effects suffers from substantial methodologic limitations. Patients tend not to talk with their clinician about their sexual life. Psychiatrists and other doctors need to take the initiative to talk about the patient's sexual life in order to become informed about potential medication-induced sexual difficulties.

Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis

BACKGROUND

Sexual dysfunction (SD) is prevalent in patients with major depressive disorder (MDD) and is also associated with second-generation antidepressants (SGADs) that are commonly used to treat the condition. Evidence indicates under-reporting of SD in efficacy studies. SD associated with antidepressant treatment is a serious side effect that may lead to early termination of treatment and worsening of quality of life.

OBJECTIVES

Our objective was to systematically assess the harms of SD associated with SGADs in adult patients with MDD by drug type.

METHODS

We retrieved English-language abstracts from PubMed, EMBASE, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to October 2012 as well as from reference lists of pertinent review articles and grey literature searches. Two independent reviewers identified randomized controlled trials (RCTs) of at least 6 weeks' duration and observational studies with at least 1,000 participants.

STUDY SELECTION

Reviewers abstracted data on study design, conduct, participants, interventions, outcomes and method of SD ascertainment, and rated risk of bias. A senior reviewer checked and confirmed extracted data and risk-of-bias ratings.

ANALYSES

Random effects network meta-analysis using Bayesian methods for data from head-to-head trials and placebo-controlled comparisons; descriptive analyses calculating weighted mean rates from individual trials and observational studies.

RESULTS/SYNTHESIS

Data from 63 studies of low and moderate risk of bias (58 RCTs, five observational studies) with more than 26,000 patients treated with SGADs were included. Based on network meta-analyses of 66 pairwise comparisons from 37 RCTs, most comparisons showed a similar risk of SD among included SGADs. However, credible intervals were wide and included differences that would be considered clinically relevant. We observed three main patterns: bupropion had a statistically significantly lower risk of SD than some other SGADs, and both escitalopram and paroxetine showed a statistically significantly higher risk of SD than some other SGADs. We found reporting of harms related to SD inconsistent and insufficient in some trials.

LIMITATIONS

Most trials were conducted in highly selected populations. Search was restricted to English-language only.

CONCLUSION AND IMPLICATIONS

Because of the indirect nature of the comparisons, the often wide credible intervals, and the high variation in magnitude of outcome, we rated the overall strength of evidence with respect to our findings as low. The current degree of evidence does not allow a precise estimate of comparative risk of SD associated with a specific antidepressant. In the absence of such evidence, clinicians need to be aware of SD as a common adverse event and should discuss patients' preferences before initiating antidepressant therapy.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Antidepressant-induced sexual dysfunction in men

Most of the available antidepressant medications, including tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, and dual noradrenergic/serotonergic reuptake inhibitors have been reported to be associated with sexual dysfunction in both sexes. This manuscript reviews evidence concerning the relative incidence of treatment emergent sexual dysfunction in men being treated with antidepressant drugs. Both double-blind controlled trials and large clinical series report a high incidence of sexual dysfunction, especially ejaculatory delay, with serotonergic drugs. The incidence of sexual dysfunction in men appears to be much lower with drugs whose primary mechanism of action involves adrenergic or dopaminergic systems.

Evaluation of the pharmacokinetics, safety and clinical efficacy of sertraline used to treat social anxiety

INTRODUCTION

Social anxiety disorder (SAD) is an emerging, often invalidating, syndrome with deep personal, social and psychological implications. While multiple treatment strategies exist, presently none of them can be considered superior to all others.

AREAS COVERED

The aim of this review is to provide the latest information on sertraline (SRT), one of the most important selective serotonin reuptake inhibitors (SSRIs) currently used for the pharmacological therapy of SAD. A literature search was carried out with the keywords 'sertraline', 'social anxiety', 'social phobia' and 'clinical trials'. In this process, particular attention is paid to the pharmacokinetic characteristics of the drug and its safety in clinical use.

EXPERT OPINION

SRT is an effective drug in the treatment of SAD, especially when used in combination with some form of psychological support. While it does not seem to be significantly more effective than other SSRIs, SRT could offer some peculiar advantages: for example, it has a long half-life, allowing a single daily administration, and seems to be particularly indicated for the control of specific symptoms of SAD.

Hypoactive sexual desire among depressed female patients treated with selective serotonin reuptake inhibitors: a comparison between escitalopram and fluoxetine

OBJECTIVE

To determine the risk of hypoactive sexual desire (HSD) in depressed female patients treated with selective serotonin reuptake inhibitors, comparing escitalopram and fluoxetine. The associated factors were also examined.

METHODS

This cross-sectional study involved 112 female patients (56 in each group) diagnosed to have major depressive disorder who were in remission (as defined by the Diagnostic and Statistical Manual-IV (DSM-IV) in the past 2 months and the Montgomery-Asberg Depression Rating Scale (MADRS) score of ≤ 10) from the psychiatric clinic, University Kebangsaan Malaysia Medical Centre (UKMMC). They were interviewed using the Structured Clinical Interview for DSM-IV (SCID). Hypoactive sexual desire was assessed using the Desire subscale of the Malay Version of the Female Sexual Function Index (MVFSFI).

RESULTS

The risk of hypoactive sexual desire was 50.9% for all patients; 64.3% for the fluoxetine group and 37.5% for the escitalopram group. Multivariate logistic regression analysis showed fluoxetine therapy (adjusted OR = 3.08, CI = 1.23, 7.73) and moderate to high dosage of antidepressant (adjusted OR = 4.27, CI = 1.66, 10.95) were significantly associated with hypoactive sexual desire.

CONCLUSION

Those treated with fluoxetine had significantly higher rates of HSD than those on escitalopram. Moderate to high antidepressant dosage is another significant predictor of HSD in depressed women treated with SSRIs.

Erectile dysfunction and depression: screening and treatment

The comorbid conditions erectile dysfunction (ED) and depression are highly prevalent in men. Multiple regression analysis to control for all other predictors of ED indicate that men with high depression scores are nearly twice as likely to report ED than nondepressed men. Depression continues to be among the most common comorbid problems in men with ED, both in the community and in clinical samples. This article reviews the current knowledge about the relationship between ED and depression, the effect of treatments for depression on ED, ways to improve screening for depression, and treatment of ED in patients with this comorbidity.

The use of monoamine pharmacological agents in the treatment of sexual dysfunction: evidence in the literature

INTRODUCTION

The monoamine neurotransmitters serotonin, dopamine, and norepinephrine play an important role in many medical and psychological conditions, including sexual responsiveness and behavior. Pharmacological agents that modulate monoamines may help alleviate sexual dysfunction.

AIMS

To provide an overview of pharmacological agents that modulate monoamines and their use in the treatment of sexual dysfunction.

METHODS

EMBASE and PubMed search for articles published between 1950 and 2010 using key words "sexual dysfunction,""monoamines,""monoaminergic receptors," and "generic names for pharmacological agents."

MAIN OUTCOME MEASURES

To assess the literature evaluating the efficacy of monoamine pharmacologic agents used in the treatment of sexual dysfunction.

RESULTS

The literature primarily cites the use of monoaminergic agents to treat sexual side effects from serotonergic reuptake inhibitors (SSRIs), with bupropion, buspirone and ropinirole providing the most convincing evidence. Controlled trials have shown that bupropion improves overall sexual dysfunction, but not frequency of sexual activity in depressed and nondepressed patients. Nefazodone and apomorphine have been used to treat sexual dysfunction, but their use is limited by significant side effect and safety profiles. New research on pharmacologic agents with subtype selectivity at dopaminergic and serotonergic receptors and those that possess dual mechanisms of action are being investigated.

CONCLUSION

There has been tremendous progress over the past 50 years in understanding the role of monoamines in sexual function and the effect of pharmacologic agents which stimulate or antagonize monoaminergic receptors on sexual dysfunction. Nevertheless, large, double-blind, placebo-controlled studies evaluating the efficacy of currently available agents in populations without comorbid disorders are limited, preventing adequate interpretation of data. Continued research on sexual function and specific receptor subtypes will result in the development of more selective pharmacologic agents with the goal of increasing efficacy without the dose-limiting side effects of nonselective agents.

Antidepressant-associated sexual dysfunction: impact, effects, and treatment

Sexual dysfunction is a common side effect of antidepressants and can have significant impact on the person's quality of life, relationships, mental health, and recovery. The reported incidence of sexual dysfunction associated with antidepressant medication varies considerably between studies, making it difficult to estimate the exact incidence or prevalence. The sexual problems reported range from decreased sexual desire, decreased sexual excitement, diminished or delayed orgasm, to erection or delayed ejaculation problems. There are a number of case reports of sexual side effects, such as priapism, painful ejaculation, penile anesthesia, loss of sensation in the vagina and nipples, persistent genital arousal and nonpuerperal lactation in women. The focus of this article is to explore the incidence, pathophysiology, and treatment of antidepressant iatrogenic sexual dysfunction.

Sexual side-effects of contemporary antidepressants: review

The aim of the present study was to review the sexual side-effects of contemporary antidepressants in Australia, comparing the selective serotonin re-uptake inhibitors (SSRIs) with venlafaxine, reboxetine, mirtazepine, duloxetine, bupropion, desvenlafaxine and agomelatine. Double-blind, randomized comparative studies of these antidepressants that included assessment of sexual dysfunction with validated rating scales in patients with major depressive disorder were identified from the literature using MEDLINE, EMBASE and PsychINFO databases. Bupropion and duloxetine caused significantly less sexual dysfunction than the SSRIs in short-term studies and reboxetine significantly less in both short- and longer term studies. Bupropion and agomelatine caused significantly less sexual dysfunction than venlafaxine. The evidence for mirtazepine having an advantage over the SSRIs is lacking and there are currently insufficient data for desvenlafaxine. Well-designed comparative studies of contemporary antidepressants with direct assessment of sexual side-effects as the primary outcome measure are scarce. Future studies should be randomized, double-blind, active controlled trials in sexually active subjects with major depressive disorder. There should be direct assessment of sexual function and depression using reliable, validated rating scales before and during treatment. Studies should assess treatment-emergent effects in patients with normal function and resolution of baseline dysfunction over treatment, in both the short and long term. Further research should compare available instruments for measuring sexual function, and include separate analyses of both remitters/non-remitters and male/female subjects.

Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis

BACKGROUND

Sexual dysfunction (SD) is an important underestimated adverse effect of antidepressant drugs. Patients, in fact, if not directly questioned, tend to scarcely report them. The aim of the present meta-analysis was to quantify SD caused by antidepressants on the basis of studies where sexual functioning was purposely investigated through direct inquiry and specific questionnaires.

METHODS

A literature search was conducted using MEDLINE, ISI Web of Knowledge, and references of selected articles. Selected studies performed on patients without previous SD were entered in the Cochrane Collaboration Review Manager (RevMan version 4.2). Our primary outcome measure was the rate of total treatment-emergent SD. Our secondary outcome measures were the rates of treatment-emergent desire, arousal, and orgasm dysfunction.

RESULTS

Our analyses indicated a significantly higher rate of total and specific treatment-emergent SD and specific phases of dysfunction compared with placebo for the following drugs in decreasing order of impact: sertraline, venlafaxine, citalopram, paroxetine, fluoxetine, imipramine, phenelzine, duloxetine, escitalopram, and fluvoxamine, with SD ranging from 25.8% to 80.3% of patients. No significant difference with placebo was found for the following antidepressants: agomelatine, amineptine, bupropion, moclobemide, mirtazapine, and nefazodone.

DISCUSSION

Treatment-emergent SD caused by antidepressants is a considerable issue with a large variation across compounds. Some assumptions, such as the inclusion of open-label studies or differences in scales used to assess SD, could reduce the significance of our findings. However, treatment-emergent SD is a frequent adverse effect that should be considered in clinical activity for the choice of the prescribed drug.

Review: Bupropion and SSRI-induced side effects

Selective serotonin reuptake inhibitors (SSRIs) are a first line treatment option for millions of patients, due to the positive balance between efficacy and tolerability. However, some side effects associated with their use, can impair quality of life and compliance with treatment. This paper reviews the prevalence of sexual dysfunction, weight gain and emotional detachment during SSRI treatment, the profile of bupropion for each of these events and the ability of bupropion to reverse them. Double-blind trials, open-label trials and anecdotical reports derived from Medline were included. First, there is robust evidence that SSRIs can induce sexual side effects and that bupropion causes less sexual dysfunction than SSRIs. There is limited, mainly open-label evidence that bupropion can reverse SSRI-induced sexual side effects. Second, there is good evidence that long-term treatment with some SSRIs can result in weight gain and that long-term treatment with bupropion can result in a small weight loss. There is only anecdotical evidence that bupropion can reverse SSRI-induced weight gain. Third, treatment with SSRIs has been associated with ;emotional detachment', although controversy exists about this concept. No data are available on the profile of bupropion for ;emotional detachment' or for the reversal of SSRI-induced ;emotional detachment' by bupropion-addition.

Sexual dysfunction associated with antidepressant therapy

Increasing numbers of patients are on psychiatric drugs, especially antidepressants. When patients complain of sexual dysfunction, it is important that the clinician take a careful history concerning psychopharmacologic agents. It is possible that simple interventions may maintain the desired effect of the psychiatric drugs while also eliminating sexual side effects caused by these agents.

The effect of acute bupropion on sexual motivation and behavior in the female rat

Recent clinical studies have suggested that the atypical antidepressant, bupropion (Wellbutrin), may stimulate sexual desire in women. Two experiments were conducted, testing the effect of acute bupropion administration on the sexual motivation and copulatory behavior of female rats. In the first experiment, 63 sexually-experienced, female Long-Evans rats were tested in a runway for their motivation to approach an empty goalbox, a nonestrous female, and an adult male. Both latency to approach and time spent in close proximity to the targets were used as dependent variables. Subjects were tested in both a nonestrous (OVX) and estrous (OVX+15 microg estradiol+500 microg progesterone) state, and following administration of 0.0, 7.5, or 15 mg/kg bupropion hydrochloride (subcutaneous, 45 min prior to testing). Results indicated that pre-treatment with ovarian hormones significantly increased the sexual motivation of the subjects. Bupropion treatment had no significant effect, either stimulatory or inhibitory, on subjects' socio-sexual motivation. In the second experiment, 60 female subjects were paired with an adult male for a thirty-minute copulatory test. Subjects were tested under one of three hormonal conditions: nonestrous (no hormones), 15 mug estradiol, or 15 microg estradiol+500 microg progesterone. Subjects were also pre-treated with either physiological saline or 15 mg/kg bupropion. Results indicated that while hormonal administration had a strong effect on female sexual behavior, bupropion treatment did not significantly affect either lordosis or the emission of hop-darts. Males paired with bupropion-treated females successfully achieved a greater number of ejaculations and demonstrated significantly shortened post-ejaculatory intervals. It is possible that bupropion treatment enhanced female attractiveness.

An open-label, fixed-dose study of bupropion effect on sexual function scores in women treated for breast cancer

BACKGROUND

Sexual morbidity after chemotherapy and hormonal therapy for breast cancer can seriously affect patients' quality of life. Bupropion is an antidepressant that has been reported to increase libido.

OBJECTIVE

To investigate the improvement of sexual function in female breast cancer patients using bupropion.

PATIENTS AND METHODS

We performed an 8-week open trial using bupropion in women diagnosed with breast cancer who had received chemotherapy and were currently receiving adjunctive hormonal therapy. The Arizona Sexual Experience Scale (ASEX) was used. The ASEX scale includes five questions that evaluate sexual function in the following areas: libido, excitability and ability to reach orgasm. Women received oral Bupropion 150 mg/daily for 8 weeks and were evaluated prior to the initiation of the study and again during Weeks 4 and 8.

RESULTS

Twenty patients were included in the study. At the beginning of the study, the mean ASEX score was 23.45 [21.67-25.24] 95% CI. After 4 weeks of treatment, we observed a reduction in the mean ASEX score that persisted until the end of the study, at eight weeks: 18.45 [16.59-20.31] 95% CI (P = 0.0003) and 18.95 [16.60-21.30] 95% CI (P = 0.0024), respectively.

CONCLUSION

In this non-controlled open trial bupropion 150 mg/daily was associated with improved sexual function in women receiving adjuvant systemic treatment for breast cancer.

Dopaminergic-based pharmacotherapies for depression

The serendipitous discovery of the precursors of two of the major contemporary antidepressant families during the late 1950s, iproniazid for the monoamine oxidase inhibitors (MAOIs) and imipramine for the tricyclic antidepressants (TCAs), has guided the subsequent development of antidepressant compounds with predominantly serotonergic, noradrenergic or combined serotonergic and noradrenergic activity. Unfortunately, however, many depressed patients continue to remain symptomatic despite adequate treatment with pharmacologic agents currently available. When one reviews the list of pharmacologic agents currently approved for the treatment of Major Depressive Disorder (MDD), it is apparent that relatively few treatments with dopaminergic activity have been developed to date. Therefore, developing effective antidepressant treatments with pro-dopaminergic properties which also possess a relatively wide safety margin may further improve the standard of care for depression. In the present article we will briefly review studies focusing on the role of dopamine in depression followed by a comprehensive review of pharmacotherapies for depression with pro-dopaminergic activity.

Sexual function during bupropion or paroxetine treatment of major depressive disorder

OBJECTIVE

The primary objective was to evaluate sexual function (SF) separately in men and women with major depressive disorder (MDD) before and during treatment with bupropion sustained release (SR) or paroxetine. The secondary objectives involved a comparative evaluation of the Sex Effects Scale (Sex FX) and the Investigator-Rated Sexual Desire and Functioning Scale (IRSD-F), as well as a comparison of antidepressant outcomes and an examination of the relation between level of depression and SF over time.

METHOD

There were 141 patients (68 women and 73 men) who met DSM-IV criteria for a current major depressive episode. They were randomly assigned to receive bupropion SR (150 to 300 mg daily) or paroxetine (20 to 40 mg daily) under double-blind trial conditions. Patients were assessed at baseline and at 2, 4, 6, and 8 weeks with the 17-item Hamilton Depression Rating Scale (HDRS17), Sex FX, and IRSD-F.

RESULTS

Prior to treatment, women reported significantly lower SF on both the Sex FX and IRSD-F scales, compared with men. During treatment, there were no significant drug differences on measures of SF over time for women; however, men who were treated with paroxetine reported a worsening of SF, whereas bupropion SR did not significantly alter SF. Both bupropion SR and paroxetine produced clinically and statistically significant reductions in HDRS17 scores as well as comparable rates of response and remission. There was a statistically significant correlation between the 2 measures of SF at all visits. There was also a significant inverse relation between depression and SF in women, but not in men, irrespective of drug.

CONCLUSION

According to the Sex FX scale, a significant difference in antidepressant-related sexual dysfunction was detected in men, but not women, during treatment with bupropion SR or paroxetine.

Erectile dysfunction: etiology, evaluation, and treatment options

The evaluation and treatment of male sexual dysfunction has evolved into a more extensive evaluation. This new evaluation should now include evaluation of hypogonadism, ejaculatory function, lower urinary tract symptoms, and depression. The evaluation may be readily accomplished with the use of questionnaires. The management of these entities is discussed, including the novel phosphodiesterase-5 for male erectile dysfunction. Inclusion of the partner in the evaluation and management scheme will provide added benefit and may produce a better outcome.

A Review of the Neuropharmacology of Bupropion, a Dual Norepinephrine and Dopamine Reuptake Inhibitor

BACKGROUND: The neurochemical and biological effects of antidepressant medications have become better defined over the last decade. When the anti-depressant bupropion was introduced in the United States in 1989, the specific pharmacologic basis of its clinical effects was uncertain. Research conducted over the past decade has significantly advanced the understanding of the neuropharmacology of bupropion and has demonstrated a novel mechanism of antidepressant activity. This article discusses the mechanism of action of bupropion and relates the drug's neuropharmacologic effects to its clinical efficacy and tolerability profiles. DATA SOURCES: Data were obtained via the MEDLINE database in an English-language search spanning the period 1965 to May 2002 and using the search terms bupropion, bupropion SR, and antidepressants, as well as from the manufacturer's bupropion databases. CONCLUSIONS: The preclinical and clinical data show that bupropion acts via dual inhibition of norepinephrine and dopamine reuptake and is devoid of clinically significant serotonergic effects or direct effects on postsynaptic receptors. Dual norepinephrine and dopamine reuptake inhibition is associated with a unique clinical profile. Bupropion has demonstrated efficacy comparable to that of other antidepressants. However, because bupropion is a selective norepinephrine and dopamine reuptake inhibitor with no serotonergic activity, common antidepressant-associated side effects, such as sexual dysfunction, weight gain, and sedation, are not associated with bupropion therapy.

Changes in human in vivo serotonin and dopamine transporter availabilities during chronic antidepressant administration

Few studies have demonstrated in vivo alterations of human serotonin and dopamine transporters (SERTS and DATS) during antidepressant treatment. The current study measured these transporter availabilities with [(123)I]beta-CIT single photon emission computed tomography (SPECT) during administration of selective serotonin reuptake inhibitors (SSRIs) or a non-SSRI, bupropion. A total of 17 healthy human subjects were randomly assigned to two different treatment protocols: (1). citalopram (40 mg/day) followed by augmentation with bupropion (100 mg/day) or (2). bupropion (100-200 mg/day) for 16 days. Citalopram significantly inhibited [(123)I]beta-CIT binding to SERT in brainstem (51.4%) and diencephalon (39.4%) after 8 days of administration, which was similarly observed after 16 days. In contrast, citalopram significantly increased striatal DAT binding by 15-17% after 8 and 16 days of administration. Bupropion and its augmentation to citalopram did not have a significant effect on DAT or SERT. In 10 depressed patients who were treated with paroxetine (20 mg/day), a similar increase in DAT and inhibition of SERT were observed during 6 weeks treatment. The results demonstrated the inhibition of SERT by SSRI in human in vivo during the chronic treatment and, unexpectedly, an elevation of DAT. This apparent SSRI-induced modulation of the dopamine system may be associated with the side effects of these agents, including sexual dysfunction.

Design and reporting modifications in industry-sponsored comparative psychopharmacology trials

This review of recently published pharmaceutical industry-sponsored comparative psychotropic drug trials aims to classify apparent design and reporting modifications that favor the sponsor's product. The modifications have been grouped into 13 discrete categories, and representative examples of each are presented. Strong circumstantial evidence suggests that marketing goals led to these adjustments. The consequences of marketing influences on comparative psychopharmacology trials are discussed in terms of conflicts of interest, the integrity of the scientific literature, and costs to consumers, as well as their impact on physician practice.

Female sexual disorders: psychiatric aspects

OBJECTIVE

This manuscript reviews the current information concerning female sexual dysfunction that is relevant to general psychiatric practice.

METHOD

Research identified by the key words sexual dysfunction and prevalence, comorbidity, psychiatric drugs, or pharmacotherapy is reviewed.

RESULTS

Epidemiologic studies indicate that approximately 30% of female subjects between ages 18 and 59 years have sexual complaints of at least 3 months' duration in the past year. A high comorbidity with other psychiatric syndromes exists. Many psychiatric drugs are associated with sexual dysfunction. Drug treatments for female sexual dysfunction are being investigated.

CONCLUSION

Knowledge concerning the treatment of female sexual dysfunction is important to the general psychiatric clinician.

Bupropion versus selective serotonin-reuptake inhibitors for treatment of depression

OBJECTIVE

To compare the benefits and risks of bupropion and selective serotonin-reuptake inhibitors (SSRIs) in adults with depression.

DATA SOURCES

MEDLINE (1966-September 1999), Embase (1980-August 1999), PsyclNFO (1887-August 1999), International Pharmaceutical Abstracts (1970-August 1999), and CIANHL databases were searched. References from the selected citations, review articles, and the manufacturer were also screened.

STUDY SELECTION

Included studies were randomized, double-blind, controlled trials evaluating bupropion versus SSRIs for depression in adults. Studies were assessed independently in duplicate. Discrepancies were resolved by consensus.

DATA ANALYSIS

Data are reported as absolute weighted mean differences or relative risks and 95% confidence intervals comparing bupropion relative to SSRIs. Data not combined are presented qualitatively.

DATA SYNTHESIS

Six full-length studies were included of 257 citations identified. SSRI comparators were fluoxetine, sertraline, and paroxetine. No differences in Hamilton Rating Scale for Depression (HAM-D) and Clinical Global Impressions Scale for Improvement of illness (CGI-I) were found, but data were not able to be quantitatively combined. The absolute weighted mean differences were 0.10 (95% CI -0.2 to 0.4) for the CGI for Severity of Illness and 0.37 (95% CI -0.85 to 1.6) for the Hamilton Rating Scale for Anxiety measurements. Relative risks of bupropion compared with SSRIs were 0.6 (95% CI 0.41 to 0.89), 0.31 (95% CI 0.16 to 0.57), and 0.27 (95% CI 0.15 to 0.48) for nausea, diarrhea, and somnolence, respectively. Sexual arousal disorder, orgasmic dysfunction, and sexual desire disorder occurred less with bupropion than with SSRIs, with relative risks of 0.46 (95% CI 0.26 to 0.83), 0.22 (95% CI 0.12 to 0.40), and 0.65 (95% CI 0.51 to 0.84), respectively.

CONCLUSIONS

Bupropion and SSRIs have similar effectiveness; however, bupropion was associated with less nausea, diarrhea, somnolence, and sexual dysfunction.

Update on female sexual function

In this review, we briefly discuss recently published data on female sexual desire, arousal, orgasm and pain, and on medical/iatrogenic factors associated with female sexual function. The studies reviewed highlight a number of important methodological and etiological issues in the study of female sexual function. Researchers are urged to use standardized methods for defining sexual disorders and for selecting patient samples. Placebo-controlled studies are essential for examining the pharmacological aspects of female sexual dysfunction. Evidence suggests that free testosterone levels may be associated with sexual desire in women. Sildenafil citrate increases genital blood flow but may not impact on subjective reports of arousal. Past research implicated the serotonin 5-hydroxytryptamine 2 and 5-hydroxytryptamine 1A receptors in female sexual function, while recent data suggest a role for the 5-hydroxytryptamine 3 receptor. Increasing attention is being paid to medical/health conditions that impact sexual function (e.g. neurological conditions, cancer, hysterectomy, and cardiovascular disease).

Bupropion sustained release (SR) for the treatment of hypoactive sexual desire disorder (HSDD) in nondepressed women

This article describes the results of the first report of bupropion sustained release (SR) in nondepressed females with hypoactive sexual desire disorder (HSDD). Eligible females entered a 4-week, single-blind, placebo baseline phase. Subjects, all of whom did not respond to placebo, continued in a single-blind active treatment phase where they received bupropion SR for up to 8 additional weeks. We assessed HSDD by using investigator ratings of sexual desire and sexual functioning. Of the 51 evaluable subjects who entered the active treatment phase, 29% responded to treatment with bupropion SR. Bupropion SR was generally well tolerated. Pending the results of further study, bupropion SR may offer a treatment option for women with HSDD.

The selective serotonin reuptake inhibitor sertraline: its profile and use in psychiatric disorders

The naphthylamine derivative sertraline is a potent and selective inhibitor of serotonin reuptake into presynaptic terminals. Sertraline has a linear pharmacokinetic profile and a half-life of about 26 h. Its major metabolite, desmethylsertraline does not appear to inhibit serotonin reuptake. Sertraline mildly inhibits the CYP2D6 isoform of the cytochrome P450 system but has little effect on CYP1A2, CYP3A3/4, CYP2C9, or CYP2C19. It is, however, highly protein bound and may alter blood levels of other highly protein bound agents. Sertraline is a widely used serotonin reuptake inhibitor that has been shown to have both antidepressant and antianxiety effects. Many clinical trials have demonstrated its efficacy in depression compared with both placebo and other antidepressant drugs. Its efficacy has also been demonstrated in randomized, controlled trials of patients with obsessive-compulsive disorder, panic disorder, social phobia, and premenstrual dysphoric disorder. In short-term, open-label studies it has appeared efficacious and tolerable in children and adolescents and in the elderly, and data are positive for its use in pregnant or lactating women. Typical side effects include gastrointestinal and central nervous system effects as well as treatment-emergent sexual dysfunction; withdrawal reactions may be associated with abrupt discontinuation of the agent. The safety profile of sertraline in overdose is very favorable. Sertraline's efficacy for both mood and anxiety disorders, relatively weak effect on the cytochrome P450 system, and tolerability profile and safety in overdose are factors that contribute to make it a first-line agent for treatment in both primary and tertiary care settings.

A placebo-controlled comparison of the antidepressant efficacy and effects on sexual functioning of sustained-release bupropion and sertraline

Sexual dysfunction, a frequently reported side effect of many antidepressants, may result in patient dissatisfaction and noncompliance with treatment regimens. This paper describes the results of the first placebo-controlled comparison of the efficacy, safety, and effects on sexual functioning of sustained-release bupropion (bupropion SR) and the selective serotonin reuptake inhibitor sertraline. This randomized, double-masked, double-dummy, parallel-group, multicenter trial enrolled 360 patients with moderate-to-severe recurrent major depression. Patients were treated with bupropion SR 150 to 400 mg/d, sertraline 50 to 200 mg/d, or placebo for up to 8 weeks. Patients' depression and sexual functioning were assessed at weekly or biweekly clinic visits; safety was assessed by regular monitoring of adverse events, vital signs, and body weight. Treatment groups were similar at baseline in terms of age, sex, and race, and most patients had a diagnosis of moderate uncomplicated depression. Patients treated with bupropion SR or sertraline showed similar improvements on all efficacy measures; both active treatments were superior to placebo in improving scores on all rating scales for depression at various time points. Significantly more patients treated with sertraline experienced orgasmic dysfunction throughout the study than did patients treated with bupropion SR or placebo (P < 0.001). Headache was the most frequently reported adverse event in all 3 treatment groups and occurred with similar frequency in each group (30% to 40%). Nausea (31%), diarrhea (26%), insomnia (18%), and somnolence (17%) occurred in significantly more patients in the sertraline group than in the bupropion SR group (18%, 7%, 13%, and 3%, respectively) and the placebo group (10%, 11%, 4%, and 6%, respectively). Dry mouth occurred more frequently with bupropion SR (19%) than with sertraline (14%) or placebo (12%), although the differences were not significant. Changes in vital signs were similar in all groups. Similar (small, but not statistically significant) decreases in mean body weight were seen in both the bupropion SR (-1.06 kg) and sertraline (-0.79 kg) groups, whereas the placebo group experienced a minor increase (0.21 kg). Although bupropion SR and sertraline were similarly well tolerated and effective in the treatment of depression, sertraline treatment was more often associated with sexual dysfunction and certain other adverse events compared with bupropion SR and placebo. Therefore, bupropion SR may be an appropriate choice as an antidepressant for the treatment of sexually active patients.