Frequency of Sexual Dysfunction in Patients with a Psychotic Disorder Receiving Antipsychotics

A review on side effect management of second-generation antipsychotics to treat schizophrenia: a drug safety perspective

INTRODUCTION

Effective side effects management present a challenge in antipsychotic treatment with second-generation antipsychotics (SGAs). In recent years, most of the commonly used SGAs, except for clozapine, have been shown to differ only slightly in their effectiveness, but considerably regarding perceived side effects, safety profiles, and compatibility to preexisting medical conditions.

AREAS COVERED

The current state of available evidence on side-effect management in SGA treatment of patients with schizophrenia spectrum disorders (SSD) is reviewed. In addition, current guideline recommendations are summarized, highlighting evidence gaps.

EXPERT OPINION

SGA safety and side effects needs to be considered in treatment planning. Shared decision-making assistants (SDMA) can support patients, practitioners and relatives to orient their decisions toward avoiding side effects relevant to patients' adherence. Alongside general measures like psychosocial and psychotherapeutic care, switching to better tolerated SGAs can be considered a relatively safe strategy. By contrast, novel meta-analytical evidence emphasizes that dose reduction of SGAs can statistically increase the risk of relapse and other unfavorable outcomes. Further, depending on the type and severity of SGA-related side effects, specific treatments can be used to alleviate induced side effects (e.g. add-on metformin to reduce weight-gain). Finally, discontinuation should be reserved for acute emergencies.

Oral and long-acting injectable antipsychotic discontinuation and relationship to side effects in people with first episode psychosis: a longitudinal analysis of electronic health record data

Background

Discontinuation of treatment in people with first episode psychosis (FEP) is common, but the extent to which this is related to specific adverse effects of antipsychotic medications is unclear.

Objectives

To investigate whether antipsychotic discontinuation is associated with the prescription of particular antipsychotics and particular adverse effects.

Design

Retrospective cohort study.

Methods

We assembled de-identified electronic health record (EHR) data from 2309 adults with FEP who received care from the South London and Maudsley NHS Foundation Trust between 1st April 2008 and 31st March 2019. Associations between antipsychotic medications, clinician-recorded side effects and treatment discontinuation were investigated across a mean follow-up period of 34.2 months using Cox regression.

Results

The mean age of patients was 26.7 years and 1492 (64.6%) were male. Among first prescribed antipsychotic medications, discontinuation occurred earlier with haloperidol [hazard ratio (HR) = 2.78, 95% CI = 1.69-4.60] and quetiapine (HR = 1.43, 95% CI = 1.16-1.80) than with olanzapine. Discontinuation occurred sooner when there was evidence of extrapyramidal symptoms (HR = 1.33, 95% CI = 1.08-1.64) or sexual dysfunction (HR = 1.59, 95% CI = 1.03-2.46). Among antipsychotics prescribed at any point during treatment, lurasidone (HR = 1.40, 95% CI = 1.10-1.78) and aripiprazole (HR = 1.09, 95% CI = 1.01-1.19) were associated with earlier discontinuation than olanzapine. Conversely, clozapine (HR = 0.55, 95% CI = 0.41-0.73) and paliperidone 1-monthly (PP1M) long-acting injectable (HR = 0.80, 95% CI = 0.68-0.94) were associated with later discontinuation. Unexpectedly, for antipsychotics prescribed at any stage of treatment, sedation (HR = 0.89, 95% CI = 0.81-0.97), weight gain (HR = 0.73, 95% CI = 0.64-0.83), and multiple side effects (HR = 0.83, 95% CI = 0.76-0.90) were associated with later discontinuation.

Conclusion

Earlier treatment discontinuation associated with sexual or extrapyramidal side effects could be related to their rapid onset and poor tolerability. Later treatment discontinuation associated with clozapine and PP1M could be related to the relative efficacy of these treatments. These findings merit consideration when selecting antipsychotic therapy for people with FEP.

Sexual Dysfunction in Schizophrenia: A Systematic Review and Meta-Analysis

Importance

In individuals with schizophrenia, antipsychotic-induced dysfunctions are frequent but often underexplored in clinical practice.

Objective

To synthetize the data of observational studies exploring the prevalence of sexual dysfunction in individuals with schizophrenia-spectrum disorders as well as associated factors.

Data Sources

A systematic literature search without language or time restrictions was conducted in Google, Google Scholar, PubMed/MEDLINE, Science Direct, and Université Sorbonne Paris Cité for studies published up to June 8, 2022.

Study Selection

All observational studies reporting a prevalence of sexual dysfunction in schizophrenia-spectrum disorder were included.

Data Extraction and Synthesis

The MOOSE guidelines with independent extraction by 2 observers and random-effects models were used.

Main Outcomes and Measures

The prevalence of sexual dysfunction and each specific dysfunction.

Results

A total of 72 of 1119 studies from 33 countries on 6 continents published from inception to June 2022 were included with a total of 21 076 participants with schizophrenia. The pooled global prevalence of sexual dysfunctions was 56.4% (95% CI, 50.5-62.2), with a prevalence of 55.7% (95% CI, 48.1-63.1) for men and 60.0% (95% CI, 48.0-70.8) for women. The most frequent sexual dysfunction was erectile dysfunction in men (44%; 95% CI, 33.5-55.2), followed by loss of libido in men (41%; 95% CI, 30.7-51.4), ejaculation dysfunction in men (39%; 95% CI, 26.8-51.8), orgasm dysfunction in women (28%; 95% CI, 18.4-40.2), and amenorrhea in women (25%; 95% CI, 17.3-35.0). Factors associated with heterogeneity were study design, time and location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and the use of antidepressants and anxiolytics. Sexual dysfunctions were more frequent in schizophrenia vs schizoaffective disorders, and erectile disorders were less frequent in individuals with longer illness duration. Antidepressant and mood stabilizer prescriptions were associated with lower rates of erection disorders (β, -6.30; 95% CI, -10.82 to -1.78); P = .006 and -13.21; 95% CI, -17.59 to -8.83; P < .001, respectively) and ejaculation disorders (β, -6.10; 95% CI, -10.68 to -1.53; P = .009 and β, -11.57; 95% CI, -16.34 to -6.80; P < .001, respectively). No obvious improvements in the rates of sexual dysfunction at other times were found, and there were conflicting results regarding antipsychotic classes.

Conclusions and Relevance

This systematic review and meta-analysis found a high prevalence of sexual dysfunction among individuals with schizophrenia, with considerable heterogeneity in associated factors. The findings also suggest that some dysfunctions may be explained by schizophrenia. The association between lower rates of dysfunction and antidepressant use suggests that treating comorbid depression could be an effective strategy to improve sexual health. A lack of data on metabolic parameters and physical health in general was also noted, while these issues are frequent in the care of schizophrenia.

Frequency of sexual dysfunction in outpatients with severe mental illness in Greece

Introduction

Patients with psychosis can develop sexual dysfunction, which may be related to the disease itself, psychosocial factors, somatic comorbidities, and the use of psychotropic medication.

Objective

We aimed to investigate the type and frequency of sexual dysfunction in patients diagnosed with schizophrenia or bipolar disorder in order to assess the side effects of antipsychotics in sexual function.

Methods

This is a multicenter, cross-sectional study, involving patients diagnosed with schizophrenia (79.3%) or bipolar disorder (20.7%) treated in the Department of Psychiatry and Community Mental Health Centers from November 2018 to December 2019. Patients were enrolled in the study after signed informed consent. Demographic and clinical data were collected from patients through a semi-structured interview. The Antipsychotics and Sexual Functioning Questionnaire (ASFQ) was administered to assess sexual function.

Results

A total of 87 outpatients on antipsychotics were recruited in the study. The mean age was 43.6 years, while the mean duration of the disease was 16.9 years. Overall, only 9.1% of patients spontaneously reported sexual dysfunction. Patients treated with oral first-generation antipsychotics had more difficulties in achieving orgasm and decreased erection capacity. In contrast, patients treated with oral second-generation antipsychotics had decreased ejaculation capacity. Patients on antipsychotic combination therapy were associated with higher rates of sexual anhedonia.

Discussion

These results suggest that sexual dysfunction is a side effect of antipsychotic treatment, which was spontaneously rarely reported by patients. It seems essential to obtain a psychosexual clinical history before initiating antipsychotic treatment to evaluate following changes and adopt an individualized strategy to manage sexual dysfunction induced by antipsychotics.

Effects of major depression and bipolar disorder on erectile dysfunction: a two-sample mendelian randomization study

BACKGROUND AND AIMS

There are currently no clear conclusions about whether major depression (MD) and bipolar disorder (BD) increase the risk of erectile dysfunction (ED). In our study, we used a Mendelian randomization (MR) analysis to discover the causal associations between MD, BD and ED.

METHODS

We got single-nucleotide polymorphisms (SNPs) related to MD, BD and ED from the MRC IEU Open genome-wide association study (GWAS) datasets. After a series of selection, SNPs left were selected as instrumental variables (IVs) of MD and BD for the following MR test to evaluate the relationship of genetically predicted MD or BD with the incidence of ED. Among them, we used the random-effects inverse-variance weighted (IVW) method as the main analysis. Finally, sensitivity analyses were further performed using Cochran's Q test, funnel plots, MR-Egger regression, Leave-one-out method and MR- pleiotropy residual sum and outlier (PRESSO).

RESULTS

Genetically-predicted MD was causally related to the incidence of ED in the IVW methods (odds ratio (OR), 1.53; 95% confidence interval (CI), 1.19-1.96; p = 0.001), while no causal impact of BD on the risk of ED (OR = 0.95, 95% CI 0.87-1.04; p = 0.306). The results of sensitivity analyses supported our conclusion, and no directional pleiotropy were found.

CONCLUSION

The findings of this research found evidence of a causal relationship between MD and ED. However, we did not find a causal relationship between BD and ED in European populations.

High-risk sexual behaviours in young people experiencing a first episode of psychosis

AIM

The sexual health of adults with schizophrenia is poorer than the general population; however, less is known about young people experiencing a first episode of psychosis (FEP). The aim of this study was to explore the high-risk sexual behaviours and sexual well-being indicators of a cohort of young people with FEP.

METHODS

Data collected from young people (15-24 years) with FEP attending the EPPIC service in Melbourne and participating in a physical health intervention were analysed. Baseline trial data collected on sexual health and high-risk behaviours, psychiatric symptomology, functioning, and substance use are presented by gender. Associations between symptomology and functioning with sexual behaviour are explored.

RESULTS

A total of 69 young people were included in this study; mean age was 19.6 years (SD±2.8), 53.6% were male, 59.6% identified as heterosexual, and 21.7% were currently in a relationship. Within the cohort, 78.3% had ever been sexually active. Of these, 44.2% consistently used a condom at last sex act and 35.7% used barrier contraception consistently, 22.5% had previously been pregnant, and 18.6% had tested positive for an STI. Finally, young people were more likely to have been sexually active if they were currently using substances.

CONCLUSIONS

These findings suggest that high rates of high-risk sexual behaviour remain an issue for young people experiencing a first episode of psychosis. Promoting sexual well-being and communication skills between sexual partners should be targeted to ensure that high-risk sexual health outcomes are mitigated as early as possible.

Sexual knowledge of Queensland forensic mental health patients: A cross-sectional quantitative study

Forensic patients with serious mental illnesses (SMI) encounter significant challenges including active symptomatology, associated social and interpersonal impairments, psychotropic medication side effects and institutionalization, all of which negatively affect sexual functioning and possibly their acquirement of sexual knowledge. Evidence shows an increased prevalence of high-risk sexual behavior by this group however, there is an absence of literature examining the sexual knowledge of forensic patients. This quantitative cross-sectional study enrolled N = 50 patients currently under the treatment requirements of a Forensic Order and utilized the validated General Sexual Knowledge Questionnaire (GSKQ) to quantify the participants' sexual knowledge over the domains of physiology, sexual intercourse, pregnancy, contraception, sexually transmitted diseases, and sexuality. Male forensic patients scored lower than females on all domains of sexual knowledge. All participants had reasonable knowledge of physiology, sexual intercourse and sexuality; of concern were poor scores on pregnancy, contraception and sexually transmitted diseases. Thirty-five (70%) of the respondents indicated that they had some limited sex education, mostly at school. Only six (12%) received any sexual education from a health professional despite extensive contact with the forensic mental health services across many years. There is a need to assess the deficit in sexual knowledge of forensic patients in order to develop sexual health education, intervention and rehabilitative programmes that cater to the specific needs of this group to improve their sexual knowledge, encourage safe and positive sexual experiences, and enhance their quality of life.

Comparison of prolactin level, sexual function, body mass index, and liver function tests in patients using depot antipsychotics

Amaç: Bu çalışmada uzun etkili antipsikotik ilaç formları (uzun etkili paliperidon palmitat, risperidon depo ve zuklopentiksol depo) kullanan hastalarda cinsel işlev bozuklukları, vücut kitle indeksi, karaciğer fonksiyon testleri ve prolaktin düzeylerinin karşılaştırılması amaçlanmıştır. Gereç ve Yöntem: Bu çalışmaya şizofreni tanılı ve uzun etkili antipsikotik tedavisi alan hastalar dahil edildi. Tüm katılımcılara demografik veri formu, Pozitif ve Negatif Sendrom Ölçeği (PANSS), Calgary Şizofrenide Depresyon Ölçeği (CŞDÖ) ve Arizona Cinsel Yaşantılar Ölçeği (ACYÖ) uygulandı. Ardından üre, kreatinin, karaciğer fonksiyon testleri, kolesterol ve prolaktin düzeylerini değerlendirmek için venöz kan örnekleri alındı. Bulgular: Çalışmaya 95 hasta dahil edildi. Dahil edilenlerin 79’u erkek (%83.2) ve 16’sı kadındı (%16.8). Tüm hastaların yaş ortalaması 36.77±10.24 yıl idi. Vücut kitle indeksleri ortalaması ise 27.06±4.95 kg/m2 idi. Gruplar arasında ACYÖ ve CŞDÖ skorları açısından farklılık saptanmadı. Prolaktin değeri paliperidon depo kullanan hastalarda zuklopentiksol depo kullanan hastalardan yüksek olarak hesap edilmiştir. Sonuç: Sonuçlarımıza göre cinsel işlevleri etkileyen prolaktin değerleri, hastalar semptom belirtmese de uzun etkili antipsikotik kullanan hastalarda göz önünde bulundurulmalıdır. Uzun etkili antipsikotik kullanımının hem prolaktin değerleri hem de diğer laboratuvar parametrelerine olan etkileri konusunda ileri araştırmalar yapılmalıdır.

Aripiprazole vs Risperidone Head-to-Head Effectiveness in First-Episode Non-Affective-Psychosis: A 3-Month Randomized, Flexible-Dose, Open-Label Clinical Trial

BACKGROUND

Antipsychotic choice for the acute phase of a first episode of psychosis (FEP) is of the utmost importance since it may influence long-term outcome. However, head-to-head comparisons between second-generation antipsychotics remain scarce. The aim of this study was to compare the effectiveness in the short term of aripiprazole and risperidone after FEP outbreak.

METHODS

From February 2011 to October 2018, a prospective, randomized, open-label study was undertaken. Two hundred-sixty-six first-episode drug-naïve patients were randomly assigned to aripiprazole (n = 136) or risperidone (n = 130) and followed-up for 12 weeks. The primary effectiveness measure was all-cause treatment discontinuation. In addition, an analysis based on intention-to-treat principle was conducted to assess clinical efficacy.

RESULTS

The overall dropout rate at 12 weeks was small (6.39%). Effectiveness measures were similar between treatment arms as treatment discontinuation rates (χ 2 = 0,409; P = .522), and mean time to all-cause discontinuation (log rank χ 2 = -1.009; P = .316) showed no statistically significant differences. Despite no statistically significant differences between groups regarding clinical efficacy, aripiprazole required higher chlorpromazine equivalent dosage (χ 2 = 2.160; P = .032) and extended mean time (W = 8183.5; P = .008) to reach clinical response. Sex-related adverse events and rigidity were more frequent in the risperidone group, whereas sialorrhea was on the aripiprazole group.

CONCLUSIONS

No differences regarding effectiveness were found between aripiprazole and risperidone for the short-phase treatment of FEP. Despite the importance of efficacy during this phase, differences in side effect profiles and patient's preferences are essential factors that may lead clinical decisions for these patients.

CLINICALTRIALS.GOV

NCT02532491. Effectiveness of Second-Generation Antipsychotics in First Episode Psychosis Patients: 1-year Follow-up (PAFIP3_1Y).

Pharmacological strategies for sexual recovery in men undergoing antipsychotic treatment

INTRODUCTION

: First- and second-generation antipsychotics are highly accountable for causing a plethora of medical side effects, ranging from metabolic imbalances to sexual dysfunction (SD), that frequently undermine patient-doctor relationships. Nevertheless, to date antipsychotics are one of the best treatment options for dealing with numerous either acute or chronic conditions like agitation, suicidality, depression, dementia, and of course psychosis. For these reasons, clinicians need to handle them wisely to preserve patients' sexual health, avoid poor therapeutic adherence and prevent high rates of therapy drop-out.

AREAS COVERED

: This article reviews the literature on pharmacologic approaches for management strategies in men who are administered with antipsychotics and developed SD. The etiology of antipsychotic-induced SD is also discussed.

EXPERT OPINION

: Clinicians must consider sexual life as a major health domain. To do so, a first step would be to measure and monitor sexual function by means of psychometric tools. Secondly, primary prevention should be conducted when choosing antipsychotics, i.e., picking sex-sparing compounds like aripiprazole or brexpiprazole. Thirdly, if sexolytic compounds cannot be dismissed, such as first-generation antipsychotics, risperidone, paliperidone, or amisulpride, then aripiprazole 5-20 mg/day adjunctive therapy has proven to be most effective in normalizing prolactin levels and consequently treating antipsychotic-induced SD.

Frequency of Iatrogenic Sexual Dysfunction Associated with Antihypertensive Compounds

Iatrogenic sexual dysfunction (SD) caused by antihypertensive (AH) compounds, provoking sexual desire, orgasm or arousal dysfunction, is a common clinical adverse event. Unfortunately, it is often underestimated and underreported by clinicians and prescribers in clinical practice, deteriorating the adherence and patient quality of life. The objective of this study was to investigate the frequency of SD in patients treated with different antihypertensive compounds; a real-life naturalistic and cross-sectional study in patients receiving AH treatment was carried out. Method: A total of 256 patients were included in the study (188 males and 68 females who met the inclusion and exclusion criteria). The validated Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX) was transversally applied once at least every two months following the onset of the treatment in order to measure possible AH-related SD. Although the spontaneous reporting of SD was very low (6.81% females/24.8% males), 66.40% of the patients reported impaired sexual function through the SALSEX questionnaire after the treatment onset, as follows: decreased desire (55.8% females/54.2% males), delayed orgasm (42.6%/45.7%), anorgasmia (42.6%/43.6%) and arousal difficulties (53%/59.6%). The average frequency of moderate to severe iatrogenic SD was 66.4% with AH in monotherapy as follows: angiotensin II receptor antagonists (ARBs), 29.8%; calcium antagonists, 40%; diuretics, 42.9%; beta blockers, 43.8%; and angiotensin-converting enzyme (ACE) inhibitors, 77.8%. Combined treatments showed a higher percentage of main SD (70.3%): diuretic + ACE inhibitor, 42.3%; ARB + calcium antagonist, 55.6%; diuretic + calcium antagonist, 68.8%; and diuretic + ARB, 74.2%. The greatest risk factors associated with SD were poor general health, age over 60 with a comorbid coronary or musculoskeletal disease, mood disorder and diuretic +ARB combined therapy. Conclusion: SD is common in patients treated with antihypertensive drugs, and it is still underreported. The most harmful treatment deteriorating sexual function was the combination of diuretic +ARB, while the least harmful was monotherapy with ARBs. More research is needed on the clinical management of this problem to preserve the quality of life of patients and their partners.

Examining Side Effect Variability of Antipsychotic Treatment in Schizophrenia Spectrum Disorders: A Meta-analysis of Variance

Side effects of antipsychotic drugs play a key role in nonadherence of treatment in schizophrenia spectrum disorders (SSD). While clinical observations suggest that side effect variability between patients may be considerable, statistical evidence is required to confirm this. Here, we hypothesized to find larger side effect variability under treatment compared with control. We included double-blind, placebo-controlled, randomized controlled trials (RCTs) of adults with a diagnosis of SSD treated with 1 out of 14 antipsychotics. Standard deviations of the pre-post treatment differences of weight gain, prolactin levels, and corrected QT (QTc) times were extracted. The outcome measure was the variability ratio of treatment to control for individual antipsychotic drugs and the overall variability ratio of treatment to control across RCTs. Individual variability ratios were weighted by the inverse-variance method and entered into a random-effects model. We included N = 16 578 patients for weight gain, N = 16 633 patients for prolactin levels, and N = 10 384 patients for QTc time. Variability ratios (VR) were significantly increased for weight gain (VR = 1.08; 95% CI: 1.02-1.14; P = .004) and prolactin levels (VR = 1.38; 95% CI: 1.17-1.62; P < .001) but did not reach significance for QTc time (VR = 1.05; 95% CI: 0.98-1.12; P = 0.135). We found marked differences between individual antipsychotics and increased variability in side effects in patients under treatment with antipsychotics suggesting that subgroups of patients or individual patients may benefit from treatment allocation through stratified or personalized medicine.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Sexuality in Ultra-High Risk for Psychosis and First-Episode Psychosis. A Systematic Review of Literature

A considerable body of literature reports that individuals with psychotic disorders often suffer from sexual dysfunctions (SDs), with these representing a major unmet need. Long-term antipsychotic drug treatment may be the main cause for SDs in psychotic patients, through a plethora of different mechanisms, including prolactin dyscrasia, histamine-mediated sedation, and serotonin-induced sexual demotivation. However, a few pieces of evidence treat sexuality in patients at risk or the onset of psychosis. For this purpose, we systematically reviewed literature of the last 10 years in order to investigate sexuality in ultra-high risk (UHR) for psychosis and first-episode psychosis (FEP). We included in our review 34 articles fitting our research criteria on SDs in UHR and FEP. Evidence of SDs in the transition from UHR to FEP emerges through the selected studies. In FEP, sexuality is affected by the severity of the psychotic symptoms and, in some cases, by the iatrogenic effects of psychopharmacological treatment. Further experimental and clinical studies should systematically investigate the role of sexual functioning in the transition from UHR to FEP and, consequently, clarify whether or not SDs could be considered a possible marker for the onset of psychosis in at-risk populations. Moreover, psychiatrists and clinical psychologists should take into consideration the role of sexual life in young people with prodromal mental symptoms or at the onset of psychosis. Focusing on a thorough sexual evaluation might be a major challenge that could break down barriers of mental health promotion among young people with schizophrenia-spectrum disorders and therefore achieve better clinical outcomes.

Sexual dysfunction in drug- naïve first episode nonaffective psychosis patients. Relationship with prolactin and psychotic symptoms. Gender differences

BACKGROUND

Our aim is to examine differences in sexual functioning (SF) between patients with drug-naïve first episode psychosis (FEP) and healthy controls (HC). We will also examine correlations between prolactin levels, testosterone levels and psychotic symptomatology with SF from a gender perspective.

METHODS

Cross-sectional study. We included 68 FEP patients and 50 HC. A blood sample was extracted. We used the Positive and Negative Syndrome Scale to assess symptom severity, using the five factor structure according to Emsley. The Changes in Sexual Function Questionnaire (CSFQ) was administered.

RESULTS

We found significantly better SF in HC than in patients (in CSFQ total score (p = 0.032) and in CSFQ Desire (p = 0.032)). A significant correlation between prolactin or testosterone and SF was not observed. We found a negative significant correlation between the disorganised subscale of the EMSLEY and total CSFQ (p = 0.027; r = -0.329), CSFQ Desire (p = 0.028; r = -0.329) and CSFQ Arousal (p = 0.026; r = -0.332) in the patient sample. In a regression model, we found sex (p = 0.003) and disorganized symptoms (p = 0.034) as significant predictors.

CONCLUSIONS

We found evidence for better SF in HC than in FEP patients. We could not confirm an association between prolactin or testosterone and SF. Disorganized symptomatology could be a relevant factor in SF.

Structured review of the use of the Arizona sexual experiences scale in clinical settings

BACKGROUND

Approximately 40% of women and 30% of men describe sexual dysfunction, although recognition in medical settings is suboptimal, due to problems in reporting and eliciting concerns relating to sexual function and satisfaction. Screening questionnaires may help to support this aspect of clinical practice. The Arizona sexual experiences scale (ASEX) includes items that quantify sex drive, arousal, vaginal lubrication or penile erection, ability to reach orgasm, and satisfaction from orgasm.

METHOD

We investigated the validity and other psychometric properties of the ASEX, and the findings from the populations in which it has been employed, by searching MEDLINE, EMBASE, and Google Scholar using the terms, Arizona sexual experiences scale, Arizona Sexual Experience Questionnaire, and ASEX. We eliminated duplications, letters, and papers not available in English, and grouped the remaining papers into the categories of psychometric, epidemiological, and outcome-based studies.

RESULTS

After elimination of letters and duplicates, papers not in English, and preclinical and irrelevant studies, 104 papers were analyzed. The ASEX has excellent internal consistency, scale reliability and strong test-retest reliability. Analyses of variance reveal significant differences in total ASEX scores between patients and controls and between females and males. ASEX appears to be useful in a range of clinical situations including patients with primary sexual dysfunction, specific psychiatric disorders, specific physical illnesses, and treatment emergent sexual dysfunction.

DISCUSSION

The ASEX appears to be a reliable instrument for identifying and quantifying sexual dysfunction across a range of populations in various clinical settings. Little is known about its utility in patients with anxiety disorders or relationships between ASEX scores and biological parameters.

Sexual Dysfunction and Marital Relationship in Women With Schizophrenia in Comparison with Caregivers: A Hospital-based Study

Background: Sexual dysfunction is common in females with schizophrenia and is attributed to multiple causes, including individual psychopathology and antipsychotics. Understanding the impact of relationship satisfaction on sexual functioning is not widely studied in schizophrenia. Women caregivers also experience sexual problems and were not studied in the past.

Aim: To assess the nature and occurrence of sexual dysfunction in women with schizophrenia in comparison to caregivers of males without severe mental disorder.

Methods: A cross-sectional study was conducted. A total of 30 women with schizophrenia were recruited as cases and 26 age-matched controls were recruited from female caregivers. All subjects were assessed using standardized tools such as Female Sexual Function Index (FSFI) and Relationship Assessment Scale along with sociodemographic questionnaire.

Results: There was a significant difference in FSFI scores and relationship scores between women with schizophrenia and caregiver control subjects. The relationship quality was better in patients with schizophrenia when compared to caregivers unlike sexual functioning.

Conclusion: Sexual functioning in women is a complex phenomenon. A holistic biopsychosocial approach is necessary to understand women’s sexual function.

Sexual dysfunctions in a sample of male psychiatric patients compared to medically ill patients

Background

Many of the psychiatric disorders and other medical conditions may affect the sexual function of the patients. The present study aims to investigate the frequency of sexual dysfunctions in male psychiatric patients compared to other medically ill patients.

Results

Sexual dysfunction among psychiatric patients (51.2%) was significantly higher than among other medical patients (21%). Among the psychiatric patients, those with schizophrenia (75%) had the highest prevalence rate of sexual dysfunctions. The patients with bipolar disorders, depressive disorders, and anxiety disorders had the following rates respectively: 55%, 45%, and 30%. Among the other medical patients, those with the cardiac diseases (35%) had the highest prevalence rate of sexual dysfunctions. The patients with hepatic diseases, diabetes, urologic diseases, and respiratory diseases had the following rates respectively: 25%, 20%, 15%, and 10%. Prolactin level among psychiatric patients was significantly higher than among the other medical patients, while there was no significant difference between the psychiatric and other medical patients regarding total testosterone level.

Conclusion

Considering the significant relative frequency of sexual dysfunctions in psychiatric patients, more emphasis is recommended to be placed on the prevention and proper treatment of these disorders.

Sexual health of women with schizophrenia: A review

Women with schizophrenia experience low rates of sexual satisfaction and high rates of sexual dysfunction. They are at high risk for adverse sexual health outcomes including unplanned pregnancies, induced abortions, and human immunodeficiency virus (HIV), and face higher rates of sexual violence and various forms of intimate partner violence. This review explores the complex and intersecting biopsychosocial risk factors that explain these outcomes among women with schizophrenia, including factors related to the illness itself, antipsychotic medications, medical and psychiatric comorbidities, stigma, childhood trauma, and social determinants of health including poverty and housing instability. Sexual health interventions designed to help women with schizophrenia achieve pleasurable and safe sexual experiences, free of coercion, discrimination and violence are few and far between, suggesting opportunities for future development in this area.

Sexual dysfunction and central obesity in patients with first episode psychosis

Background

In recent years the association between sexual dysfunction (SD) and obesity in the general population has drawn major attention. Although sexual dysfunction is common in psychosis, its relationship with weight gain and obesity remains unclear.

Aims

To investigate the association between sexual dysfunction and obesity in a cohort of patients with first episode psychosis.

Method

Sexual function was assessed in a cohort of patients with first episode psychosis using the Sexual Function Questionnaire (SFQ). Anthropometric measures, including weight, BMI, waist, waist–hip ratio were investigated. Additionally, leptin and testosterone were investigated in male patients.

Results

A total of 116 patients (61 males and 55 females) were included. Of these 59% of males and 67.3% of females showed sexual dysfunction (SD) according to the SFQ. In males, higher SFQ scores were significantly correlated with higher BMI (Std. β = 0.36, P = 0.01), higher leptin levels (Std. β = 0.34, P = 0.02), higher waist–hip ratio (Std. β = 0.32, P = 0.04) and lower testosterone levels (Std. β = −0.44, P = 0.002). In contrast, in females, SFQ scores were not associated with any of these factors.

Conclusions

While sexual dysfunction is present in both female and male patients with their first episode of psychosis, only in males is sexual dysfunction associated with increased BMI and waist–hip ratio. The association between SD, BMI, low levels of testosterone and high levels of leptin suggest that policies that lead to healthier diets and more active lifestyles can be beneficial at least, to male patients.

Sexual dysfunctions in schizophrenia: Beyond antipsychotics. A systematic review

BACKGROUND

Sexual dysfunctions (SD) in schizophrenia are frequent with strong impact on adherence and quality of life. Current recommendations stipulate to switch to prolactin-sparing antipsychotic in case of SD.

OBJECTIVES

To synthetize in a systematic review data on the SD prevalence and the associated risk factors in schizophrenia (SZ).

METHODS

Medline, Google Scholar, PsychInfo, and Cochrane were explored, without any year or language restriction.

RESULTS

Overall, 89 studies and 25,490 participants were included in the present review. SZ subjects aged 18-70 reported high SD frequency [30%-82%] (men [33%- 85%]; women [25%- 85%]). For SZ men erectile dysfunction [31%-95%] was the most frequent SD vs. loss of libido for women [31%-100%]. The following risk factors were associated with increased SD: 1. Illness severity (including psychotic symptomatology, early age at SZ onset, negative symptomatology, and continuous illness course), 2. Depressive symptomatology 3. Antipsychotics (especially first generation antipsychotics, risperidone and antipsychotic polytherapy). Switching to prolactin-sparing antipsychotics has shown effectiveness in some studies (especially aripiprazole). Antidepressants were not found to be associated with SD in SZ subjects.

CONCLUSION

The prevalence of SD is high in SZ subjects. In addition to the current guidelines, the present review suggests that treating depressive symptoms may be a major intervention to improve SD in SZ subjects. Sociodemographic variables, physical illnesses, metabolic syndrome and peripheral inflammation have been poorly or never explored and should be included in future studies.

Translation and cross-cultural adaptation of the Arizona Sexual Scale (ASEX) into Portuguese

INTRODUCTION

Sexual dysfunction is common in individuals with psychiatric disorders and under psychotropic medication such as antidepressants and antipsychotics. Several scales have been developed to assess sexual function in these patients. The Arizona Sexual Scale (ASEX) is a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. We describe the translation and cross-cultural adaptation of the ASEX into the Portuguese language, with the goal of contributing to the assessment of sexual function in Portuguese-speaking psychiatric patients under treatment with psychotropic drugs.

METHODS

The translation and cross-cultural adaptation process thoroughly followed the steps recommended by the Task Force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), namely: preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing, finalization, proofreading, and final version.

RESULTS

The process was successfully completed and no major differences were found between the translation, reconciliation and back-translation phases, with only small adjustments being made.

CONCLUSION

The translation of the ASEX was completed successfully, following international reference guidelines. The use of these guidelines is a guarantee of a Portuguese version that is qualitatively and semantically equivalent to the original scale. This availability of this new scale version will enable studies evaluating the sexual function of Portuguese-speaking psychiatric patients. Future studies may assess the validity of the scale for Portuguese-speaking populations.

Sexual dysfunction in Chinese rural patients with schizophrenia

BACKGROUND

Sexual dysfunction is common in patients with schizophrenia, however it is poorly studied in China, especially in primary health care institutions in rural areas. We investigated the prevalence of sexual dysfunction and its correlates including quality of life (QoL), in schizophrenia patients treated in primary care in a rural area in China.

METHOD

By using a random numbers table, 21 small town primary care service centers (from 63 totally) were selected in the study. Data of 720 community-dwelling patients with schizophrenia in rural area with diagnoses according to DSM -IV or ICD-10 were collected by interviews. Data on socio-demographic and clinical characteristics including sexual dysfunction and quality of life (QoL) were collected using a standardized protocol and data collection procedure. Data were analyzed using chi-square tests, t-tests, U-tests, ANCOVA and multiple logistic regression as appropriate by SPSS 21.0.The level of significance was set at 0.05 (two-tailed).

RESULTS

In this sample, sexual dysfunction was found in 71.3% of the whole sample, 82.7% of female patients and 64.5% of male patients. Multiple logistic regression analysis showed that older age (OR = 1.06, P<0.001, 95%CI: 1.04-1.09) and higher Brief Psychotic Rating Scale (negative domain) score (OR = 1.16, P = 0.01, 95%CI: 1.02-1.31) were significantly associated with sexual dysfunction. Contrary to previous findings, sexual dysfunction was not associated with quality of life after controlling for confounding variables.

CONCLUSIONS

More than 2/3 of schizophrenia patients living in a rural area complained of sexual dysfunction, which was associated with older age and more negative psychotic symptoms. Primary care physicians should pay attention to sexual dysfunction during the assessment and treatment of patients with schizophrenia in rural areas in China.

Hormonal Contraceptives, Female Sexual Dysfunction, and Managing Strategies: A Review

In recent decades, hormonal contraceptives (HC) has made a difference in the control of female fertility, taking an unequivocal role in improving contraceptive efficacy. Some side effects of hormonal treatments have been carefully studied. However, the influence of these drugs on female sexual functioning is not so clear, although variations in the plasma levels of sexual hormones could be associated with sexual dysfunction. Permanent hormonal modifications, during menopause or caused by some endocrine pathologies, could be directly related to sexual dysfunction in some cases but not in all of them. HC use seems to be responsible for a decrease of circulating androgen, estradiol, and progesterone levels, as well as for the inhibition of oxytocin functioning. Hormonal contraceptive use could alter women's pair-bonding behavior, reduce neural response to the expectation of erotic stimuli, and increase sexual jealousy. There are contradictory results from different studies regarding the association between sexual dysfunction and hormonal contraceptives, so it could be firmly said that additional research is needed. When contraceptive-related female sexual dysfunction is suspected, the recommended therapy is the discontinuation of contraceptives with consideration of an alternative method, such as levonorgestrel-releasing intrauterine systems, copper intrauterine contraceptives, etonogestrel implants, the permanent sterilization of either partner (when future fertility is not desired), or a contraceptive ring.

Psychosexual history-taking in the 21st century: new terminology, new technology and new risks

Sexual and relationships difficulties are not uncommon among psychiatric patients. A presenting complaint of anxiety or depression may relate to an underlying sexual or relationship difficulty; commonly used psychotropic medications cause sexual side-effects that can have a significant impact quality of life, relationship maintenance and treatment adherence; patients may exhibit unusual or excessive sexual behaviours when acutely unwell, including risky use of apps to meet sexual partners and accessing online pornography in unsafe ways; patients may have used technology such as the internet to harm others or they may be victims of such harm; the internet and social media might even be influencing sexual expression, for example gender identity. Therefore, psychosexual history-taking remains a key competency for psychiatrists. They must also understand the new language used to describe sexuality, sexual behaviours and the use of social media, apps and so on to form relationships. This article outlines the key areas to consider in carrying out a structured psychosexual assessment. It also gives an overview of current sexual terminology, observed influences of the internet on sexuality and sexual behaviour, and its implications for mental health and potential sexual offending.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

Sexual dysfunction and hyperprolactinemia in schizophrenia before and after six weeks of D2/3 receptor blockade - An exploratory study

Sexual side-effects along with antipsychotic treatment may be linked to hyperprolactinemia and dopamine D₂ receptor blockade. High prevalence of sexual dysfunction in un-medicated patients challenges the notion of sexual dysfunction as merely a side-effect of antipsychotic medication. Sexual dysfunction was assessed in fifty-six initially antipsychotic-naïve patients with schizophrenia using the UKU (Udvalget for Kliniske Undersøgelser) questionnaire. Serum-prolactin was obtained before and after six weeks of D_2/3 receptor blockade with amisulpride. At baseline 68% of patients reported one or more items of sexual dysfunction (males > females,), but the cumulative load of sexual dysfunction was similar in males and females. After 6 weeks treatment with amisulpride (mean dose 279 mg/day), 65% of patients reported one or more items of sexual dysfunctions (females > males). There was a significant sex*time interaction on mean sexual dysfunction load. All patients developed hyperprolactinaemia, and a significant effect of time and sex was found on s-prolactin (females > males). The results support that patients with schizophrenia report high levels of sexual dysfunction before antipsychotic exposure. After treatment, sexual side-effects were more frequent in females, coinciding with pronounced serum-prolactin increases. These findings suggest sex differences in sexual dysfunction before and after antipsychotic treatment.

Translation and cross-cultural adaptation of the Sexual Function Questionnaire (SFQ) into Brazilian Portuguese

Introduction

Sexual dysfunction is common in patients with psychotic illness. This article describes the translation and cross-cultural adaptation of the Sexual Function Questionnaire (SFQ) into Brazilian Portuguese.

Methods

The translation and cross-cultural adaptation followed the guidelines for adapting self-report instruments proposed by the Task Force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Briefly, ISPOR steps include: preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing and finalization, before proofreading and final version. The original authors authorized the translation and participated in the study.

Results

There was good agreement between translations and between the back-translation and the original English version of the SFQ. The final version was prepared with certificated evaluators in the original language and in Portuguese. Few changes were necessary to the new version in Portuguese.

Conclusion

The translated and adapted Brazilian Portuguese version of the SFQ is reliable and semantically equivalent to the original version. Studies on psychotropic-related sexual dysfunction may now test the validity of the instrument and can investigate sexual dysfunction in Portuguese-speaking patients.

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

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

Effects of TNF-α on penile structure alteration in rats with hyperprolactinemia

This study aimed to investigate the effects of anti-tumor necrosis factor (TNF)-α antibody (Ab) on alteration of penile structure in the hyperprolactinemia (hyperPRL) rat model. HyperPRL was induced in 8-week-old male Sprague-Dawley rats by allografting anterior pituitary (AP) glands under the renal capsule (+AP rats). Rats implanted with cerebral cortex (CX) were used as sham control (+CX rats). At 6 weeks post implantation, rats received either a single intra-testicular dose of TNF-α Ab (12.5 μg/kg) or testosterone replacement (2 doses of testosterone enanthate [TE], 3 mg/kg), and they were sacrificed 1 week later. Blood and penile tissue was collected for analysis. Compared to +CX rats, the +AP group had lower serum testosterone concentration and neuronal nitric oxide synthase (nNOS) expression, but exhibited a higher ratio of collagen III/I in the corpus cavernosum. Smooth muscle content exhibited no significant changes. At 1 week post TNF-α Ab injection, the collagen III/I ratio in the +AP group was decreased, and the smooth muscle content and nNOS expression increased significantly. These findings were comparable to those observed in +AP rats receiving TE. Testicular TNF-α suppresses testosterone release, which in turn results in the erectile dysfunction (ED) seen in hyperPRL. Intra-testicular TNF-α Ab treatment is as effective as testosterone supplementation on penile structure normalization in the hyperPRL model.

Sexual Behavior in Patients with Psychosis Admitted to a Hospital Unit

The sexual dimension is part of a person's functionality. Patients with mental disorders have the same sexual needs as any other person, although they may not always be recognized. This is a retrospective observational study to describe the information on sexuality of patients with mental disorders, admitted to an acute short-stay inpatient unit between 2011 and 2015. We analyzed 293 clinical histories of patients, comprising diagnoses in the ICD-10 (International Classification of Diseases) between F20 and F29, inclusively. The information collected corresponded to the beginning of hospitalization, its duration and discharge. The results showed that 24% of the patients had sexual delusions. These delusions were more frequent in women, who in turn had more emotional symptoms, persecutory deception being the most common. There were few reports found on sexual dysfunction. In conclusion, the lack of data in the reports shows little recognition of sexuality in hospitalized patients with mental disorder, highlighting the need to promote the training of health personnel.

Multidisciplinary consensus on the therapeutic recommendations for iatrogenic hyperprolactinemia secondary to antipsychotics

Hyperprolactinemia is an underappreciated/unknown adverse effects of antipsychotics. The consequences of hyperprolactinemia compromise therapeutic adherence and can be serious. We present the consensus recommendations made by a group of experts regarding the management of antipsychotic-induced hyperprolactinemia. The current consensus was developed in 3 phases: 1, review of the scientific literature; 2, subsequent round table discussion to attempt to reach a consensus among the experts; and 3, review by all of the authors of the final conclusions until reaching a complete consensus. We include recommendations on the appropriate time to act after hyperprolactinemia detection and discuss the evidence on available options: decreasing the dose of the antipsychotic drug, switching antipsychotics, adding aripiprazole, adding dopaminergic agonists, and other type of treatment. The consensus also included recommendations for some specific populations such as patients with a first psychotic episode and the pediatric-youth population, bipolar disorder, personality disorders and the elderly population.

Psychotropics and Male Reproduction

Psychotropic drugs, including antidepressants, antipsychotics, and anticonvulsants, all have negative effects on sexual function and semen quality. These adverse events vary among men and are less pronounced for some medications, allowing their effects to be managed to some extent. Use of specific serotonin reuptake inhibitors (SSRIs) is prevalent in men of reproductive age; and application to treat premature ejaculation increases the number of young men on SSRI therapy. Oxidative damage to sperm can result from prolonged residence in the male reproductive tract. The increase in ejaculatory latency seen with SSRIs likely underlies some of their negative effects on semen quality, including higher sperm DNA fragmentation, seen in all SSRIs evaluated thus far. These medications increase prolactin (PRL) levels in some men, and this is often credited with inhibitory effects on male reproduction; however, testosterone levels are generally normal, reducing the likelihood of direct HPG axis inhibition by PRL. The tricyclic antidepressants have also been shown to increase PRL levels in some studies but not in others. The exception is the tricyclic antidepressant clomipramine, which profoundly increases PRL levels and may depress semen quality. Other antidepressants modulating synaptic levels of serotonin, norepinephrine, and/or dopamine may have toxicity similar to SSRIs, but most have not been evaluated. In limited studies, norepinephrine-dopamine reuptake inhibitors (NDRIs) and serotonin agonist/reuptake inhibitors (SARIs) have had minimal effects on PRL levels and on sexual side effects. Antipsychotic medications increase PRL, decrease testosterone, and increase sexual side effects, including ejaculatory dysfunction. The greatest evidence is for chlorpromazine, haloperidol, reserpine, risperidone, and thioridazine, with less effects seen with aripiprazole and clozapine. Remarkably few studies have looked at antipsychotic effects on semen quality, and this is an important knowledge gap in reproductive pharmacology. Lithium increases PRL and LH levels and decreases testosterone although this is informed by few studies. The anticonvulsants, many used for other indications, generally decrease free or bioavailable testosterone with variable effects on the other reproductive hormones. Valproate, carbamazepine, oxcarbazepine, and levetiracetam decrease semen quality; other anticonvulsants have not been investigated for this adverse reaction. Studies are required evaluating endpoints of pregnancy and offspring health for psychotropic medications.

Chinese version of the Psychotropic-related Sexual Dysfunction Questionnaire (PRSexDQ -SALSEX): Validity and reliability for schizophrenic patients taking antipsychotics

This study was designed to examine the validity and reliability of the Chinese version of the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX) in patients with schizophrenia taking antipsychotics. It was conducted in a sample of 135 patients aged between 18 and 50 years old and diagnosed with schizophrenia. Demographic data and clinical features were assessed with PRSexDQ, the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression (CGI), and the Udvalg for Kliniske Undersøgelser (UKU) Side Effects Rating Scale. The internal consistency of the Chinese version of PRSexDQ using Cronbach's α was 0.902. The test-retest and inter rater reliability was both high with p<0.001. PRSexDQ was correlated with corresponding items in the UKU Side Effects Rating Scale (Items 4.12-4.16), and showed good sensitivity, specificity, positive and negative predictive value. It could also clearly detect differences in SD rates of three monotherapy groups: patients treated with risperidone had the highest scores, followed by patients treated with olanzapine, whereas patients treated with aripiprazole had the lowest scores. The Chinese version of PRSexDQ is a reliable and valid instrument to assess patients with schizophrenia. Assessed by PRSexDQ, 53.2% of total subjects in our study reported symptoms of SD.

Hyperprolactinemia, prolactin-related side effects and quality of life in Chinese psychiatric patients

PURPOSE

To examine the frequency of hyperprolactinemia and the socio-demographic, clinical, and quality of life (QOL) correlates. The frequency of prolactin-related side effects and associated subjective experiences were also examined.

METHODS

A cohort of 1364 psychiatric inpatients were consecutively recruited and evaluated. Basic socio-demographic and clinical data were collected. Psychopathology, prolactin-related side effects were measured using standardized instruments. QOL was assessed using the Medical Outcomes Study Short Form 12.

RESULTS

The frequency of hyperprolactinemia was 61.3% in the whole sample; 61.6% in female and 60.8% in male patients. There was no significant association between hyperprolactinemia and any QOL domain. In the whole sample, 15.1% of patients reported moderately severe breast symptoms and lactation, and 53.9% reported moderate or severe discomfort. Nearly a third of female patients (30.4%) reported at least moderate menstrual changes and 50.2% moderate or severe discomfort, while 24.2% of male patients reported at least moderate erectile dysfunction and 52.6% moderate or severe discomfort. Multiple logistic regression analysis revealed that patients with hyperprolactinemia were less likely to be married, diagnosed with mood disorders, or treated with clozapine, aripiprazole, or antidepressants but more likely to receive risperidone.

CONCLUSIONS

Effective measures to lower the frequency of hyperprolactinemia and the related side effects should be considered in Chinese psychiatric facilities.

How Hyperprolactinemia Affects Sexual Function in Patients Under Antipsychotic Treatment

OBJECTIVE

We aimed to study the relationship between hyperprolactinemia (HPRL) and sexual dysfunction (SED) in a sample of patients being prescribed a dose-stable antipsychotic medication, and to evaluate sex differences in the prevalence of HPRL and SED and their relationship.

METHOD

A cross-sectional study was carried out including patients between 18 and 55 years of age with a psychotic spectrum diagnosis who were attending community mental health services or hospitalized in medium and long stay units. Positive and Negative Syndrome scale, Calgary depression scale for schizophrenia, Personal and Social Performance scale, and Changes in Sexual Functioning questionnaire-short form were administered. Not later than 3 months, a determination of prolactin, follicle-stimulating hormone, luteinizing hormone, estrogen (only in women) and testosterone was performed.

RESULTS

A final sample of 101 patients (30 women and 71 men) was recruited. Seventy-two patients (71.3%) showed HPRL. Sexual dysfunction was significantly higher in HPRL patients than in non-HPRL patients (79.17% vs 51.72%) (P = 0.006), and mean prolactin values were significantly higher in case of SED (P = 0.020). No sex differences were found in prevalence of HPRL or SED. Low Personal and Social Performance scale scores and HPRL were factors independently associated with SED, whereas alcohol use was an independent protector factor.

CONCLUSIONS

In our study, SED was significantly related to HPRL without showing sex differences. Prevalence of HPRL and SED observed was higher than that in previous studies, which should be taken into consideration because these have been associated with higher morbimortality, and noncompliance and relapse, respectively.

Spanish consensus on the risks and detection of antipsychotic drug-related hyperprolactinaemia

INTRODUCTION

Iatrogenic hyperprolactinaemia (IHPRL) has been more frequently related to some antipsychotic drugs that provoke an intense blockade of dopamine D2 receptors. There is a wide variation in clinical practice, and perhaps some more awareness between clinicians is needed. Due to the high frequency of chronic treatment in severe mental patients, careful attention is recommended on the physical risk. IHPRL symptoms could be underestimated without routine examination.

METHODOLOGY

An intense scientific literature search was performed in order to draw up a multidisciplinary consensus, including different specialists of psychiatry, endocrinology, oncology and internal medicine, and looking for a consensus about clinical risk and detection of IHPRL following evidence-based medicine criteria levels (EBM I- IV).

RESULTS

Short-term symptoms include amenorrhea, galactorrhoea, and sexual dysfunction with decrease of libido and erectile difficulties related to hypogonadism. Medium and long-term symptoms related to oestrogens are observed, including a decrease bone mass density, hypogonadism, early menopause, some types of cancer risk increase (breast and endometrial), cardiovascular risk increase, immune system disorders, lipids, and cognitive dysfunction. Prolactin level, gonadal hormones and vitamin D should be checked in all patients receiving antipsychotics at baseline although early symptoms (amenorrhea-galactorrhoea) may not be observed due to the risk of underestimating other delayed symptoms that may appear in the medium term. Routine examination of sexual dysfunction is recommended due to possible poor patient tolerance and low compliance. Special care is required in children and adolescents, as well as patients with PRL levels >50ng/ml (moderate hyperprolactinaemia). A possible prolactinoma should be investigated in patients with PRL levels >150ng/ml, with special attention to patients with breast/endometrial cancer history. Densitometry should be prescribed for males >50 years old, amenorrhea>6 months, or early menopause to avoid fracture risk.

Sexual dysfunction and its impact on quality of life in Chinese patients with schizophrenia treated in primary care

PURPOSE

Sexual dysfunction in schizophrenia patients is common. In China, maintenance treatment for clinically stable patients with schizophrenia is usually provided by primary care physicians. Illness- or treatment-related sexual dysfunction in this patient population has been never studied. This study describes the prevalence and correlates of sexual dysfunction and its impact on quality of life (QOL) in patients with schizophrenia treated in primary care in China.

METHOD

A total of 607 patients with schizophrenia treated in 22 randomly selected primary care services in China formed the study sample. Patients' socio-demographic and clinical characteristics including sexual function and QOL were recorded using a standardized protocol and data collection.

RESULTS

Sexual dysfunction was present in 69.9% of all patients; 60.7% in males and 80.6% in females. Multiple logistic regression analysis revealed that female gender, being single, older age and use of first-generation antipsychotics were independently and significantly associated with more sexual dysfunction accounting for 23.5% of its variance (P<0.001). Unexpectedly, sexual dysfunction was not associated with lower QOL.

CONCLUSIONS

High rate of sexual dysfunction was reported in the majority of patients with schizophrenia treated in primary care in China. Given its negative impact on social adjustment, QOL and treatment adherence, efforts should be made to address sexual dysfunction in this patient population.

Factors associated with self-rated sexual function in Korean patients with schizophrenia receiving risperidone monotherapy

OBJECTIVE

This study aims to investigate the factors associated with sexual function in Korean patients with schizophrenia.

METHODS

This study evaluated 169 patients with schizophrenia who were receiving risperidone monotherapy. The Visual Analog Scale was used to assess sexual function in terms of sexual desire, sexual arousal, and sexual satisfaction. The Positive and Negative Syndrome Scale, the Beck Depression Inventory, the Korean version of the Subjective Well-being under Neuroleptic Treatment-Brief Form (SWN-K) scale, and the Drug Attitude Inventory (DAI) were also administered.

RESULTS

Sexual function was negatively associated with age, duration of illness, gender (female), marital status (single), the presence of tardive dyskinesia, and Beck Depression Inventory score, but positively associated with the SWN-K and DAI scores. A linear regression analysis revealed that being male and married had significant positive associations with sexual arousal, sexual satisfaction, and/or sexual desire, while the presence of tardive dyskinesia and a longer duration of illness were associated with poor sexual arousal and/or sexual desire. Additionally, sexual function was significantly associated with the SWN-K and DAI scores in multivariate analysis.

CONCLUSIONS

The acknowledgement and management of sexual dysfunction in patients with schizophrenia by clinicians may be important for improvement of their quality of life and adherence to medication.

Sexual side-effects of antidepressant and antipsychotic drugs

PURPOSE OF REVIEW

Psychotropic-related sexual dysfunction is a quite frequent issue in clinical practice, mainly in chronic treatments affecting both quality of life and compliance.

RECENT FINDINGS

In the last decade fortunately antidepressants and antipsychotic compounds have been deeply screened in order to identify sexual adverse events that were commonly underdiagnosed and previously underestimated by clinicians and perhaps by pharmaceutical companies as well. Some differences in the mechanism of action are the nucleus of this poorly tolerated adverse event. All antidepressants with serotonergic activity can cause mild to severe sexual dysfunction such as decreased libido and delayed orgasm frequently (>60%) or anorgasmia and arousal difficulties sometimes (30%). In contrast, noradrenergic, dopaminergic, or melatonergic antidepressants do not cause sexual dysfunction but perhaps the clinical profile of patients receiving these compounds could be different. Antipsychotics that highly increase prolactin levels and strongly block dopamine receptors could be related to sexual dysfunction as well. Unfortunately, these dysfunctions are present during the long term after the antipsychotic onset to provide continued symptom control and enable recovery. Young patients suffering psychosis and concomitant sexual dysfunction (erectile and/or orgasmic difficulties) tend to show poor compliance in chronic treatments affecting the outcomes.

SUMMARY

The implications of psychotropic-related sexual dysfunction in clinical practice are relevant mainly in patients under long-term treatment with previous satisfactory sexual life. Implications for future research about sexual dysfunction in all new treatments should be strongly taken into account.

Lithium and sexual dysfunction: an under-researched area

OBJECTIVE

Lithium treatment remains an important part of the management of many patients with bipolar disorder, but the incidence of treatment-emergent sexual dysfunction with lithium is uncertain, and little is known about how it might be managed.

METHOD

Systematic computerised literature search of preclinical and clinical studies.

RESULTS

Thirteen relevant papers were identified. Preclinical studies suggest lithium can reduce testosterone levels and impair nitric oxide mediated relaxation of cavernosal tissue. Clinical reports suggest lithium may reduce sexual thoughts and desire, worsen erectile function and reduce sexual satisfaction. Concomitant benzodiazepine prescription with lithium is associated with an increased risk of sexual dysfunction. Sexual dysfunction during lithium treatment appears significantly associated with a lower level of overall functioning and may reduce compliance.

CONCLUSION

The findings of this systematic review reveal the paucity of information about the incidence, associated factors and management of sexual dysfunction with lithium treatment and highlight the need for well-designed studies in this area.

Fluphenazine decanoate (depot) and enanthate for schizophrenia

BACKGROUND

Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects.

OBJECTIVES

To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations.

DATA COLLECTION AND ANALYSIS

We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table.

MAIN RESULTS

This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions.

AUTHORS' CONCLUSIONS

There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.

Sexual dysfunctions in schizophrenia: Professionals and patients perspectives

BACKGROUND

Sexual dysfunction (SD) is not commonly reported by persons with schizophrenia unless an enquiry is made by a doctor or staff during routine clinical visits.

MATERIALS AND METHODS

A cross-sectional study was carried out to determine reporting of drug-induced sexual side-effects and the attitude of the treating team in clarifying or detecting this issue.

RESULTS

A vast majority of professionals (73.2%) did not enquire about SDs in routine clinical setting and admitted that they lack expertise based on the Attitude Survey Questionnaire. More than one-third of the patients (35.3%) attributed sexual side-effects to medications. Many patients (91.7%) reported good to fair tolerance to sexual side-effects according to the Psychotropic Related Sexual Dysfunction Questionnaire.

CONCLUSION

The treating team plays a crucial role. Sexual side-effects are often under-reported and need to be addressed by the treating physician.