Sexual function during bupropion or paroxetine treatment of major depressive disorder

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 health and serotonin 4 receptor brain binding in unmedicated patients with depression-a NeuroPharm study

Sexual dysfunction is prominent in Major Depressive Disorder (MDD) and affects women with depression more than men. Patients with MDD relative to healthy controls have lower brain levels of the serotonin 4 receptor (5-HT₄R), which is expressed with high density in the striatum, i.e. a key hub of the reward system. Reduced sexual desire is putatively related to disturbed reward processing and may index anhedonia in MDD. Here, we aim to illuminate plausible underlying neurobiology of sexual dysfunction in unmedicated patients with MDD. We map associations between 5-HT₄R binding, as imaged with [¹¹C]SB207145 PET, in the striatum, and self-reported sexual function. We also evaluate if pre-treatment sexual desire score predicts 8-week treatment outcome in women. From the NeuroPharm study, we include 85 untreated MDD patients (71% women) who underwent eight weeks of antidepressant drug treatment. In the mixed sex group, we find no difference in 5-HT₄R binding between patients with sexual dysfunction vs normal sexual function. However, in women we find lower 5-HT₄R binding in the sexual dysfunctional group compared to women with normal sexual function (β = -0.36, 95%CI[-0.62:-0.09], p = 0.009) as well as a positive association between sexual desire and 5-HT₄R binding (β = 0.07, 95%CI [0.02:0.13], p = 0.012). Sexual desire at baseline do not predict treatment outcome (ROC curve AUC = 52%[36%:67%]) in women. Taken together, we find evidence for a positive association between sexual desire and striatal 5-HT₄R availability in women with depression. Interestingly, this raises the question if direct 5-HT₄R agonism can target reduced sexual desire or anhedonia in MDD.

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

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS AND LIMITATIONS

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

CONCLUSION

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

CLINICAL TRIAL REGISTRATION

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

The Role of Bupropion in the Treatment of Women with Sexual Desire Disorder: A Systematic Review and Meta-Analysis

Although few clinical trials examined the efficacy of bupropion to treat sexual dysfunction among female patients, a comprehensive and objective synthesis of the best available evidence is still lacking. To date, to the best of our knowledge, there are no published systematic reviews or meta-analyses specifically focusing on the role of bupropion in the treatment of female sexual dysfunction. The main objective of the present study was to evaluate the efficacy of bupropion in the treatment of female sexual dysfunction, and we hypothesized that bupropion is efficient in treating female patients with sexual dysfunction. This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search for published literature was performed using Ovid, Medline, Scopus, Cochrane Library, Science Direct, and PubMed databases. In our study, we found that bupropion was almost three-fold more favorable in improving problems with sexual desire (pool estimate 2.845, 95% CI: 0.215 to 5.475, I2= 95.6%, p=0.034). A meta-regression was performed to explore heterogeneity and we found that only the dosage of bupropion was statistically significant in explaining the variance, i.e., the lower the dosage (150 mg vs. 300 mg), the better the improvement in the sexual desire of women with hypoactive sexual desire disorder (HSDD). Based on the results of this systematic review and metaanalysis, there is a potential role of bupropion as an effective treatment for women with HSDD.

Males and females differ in reported sexual functioning with escitalopram treatment for major depressive disorder: A CAN-BIND-1 study report

BACKGROUND

Antidepressant use for major depressive disorder (MDD) is frequently associated with sexual dysfunction.

AIMS

Cross-sectional and longitudinal relationships between antidepressant treatment outcomes and sexual functioning (SF) were evaluated separately for males and females receiving escitalopram. We further assessed the association between pre- and posttreatment SF.

METHODS

In all, 208 of the 211 CAN-BIND-1 trial participants (77 males and 131 females) with MDD and detectable drug blood levels were eligible for the analyses. All received escitalopram (10-20 mg) for 8 weeks. At baseline and Week 8, participants completed the Montgomery-Åsberg Depression Rating Scale (MADRS) and the SexFx scale, which measures sexual satisfaction and SF frequency. Mixed-model repeated measures assessed baseline to Week 8 SF changes among participants with different response/remission statuses. Multiple linear regression analyses examined SF differences between treatment outcomes at Week 8 as well as associations between pretreatment and eventual SF.

RESULTS

For both sexes, overall sexual satisfaction improved among responders but not among nonresponders (p < 0.05). For females, overall SF frequency did not change significantly over time regardless of response status. For males, overall SF decreased significantly among nonresponders; orgasm decreased significantly among nonresponders and, to a lesser extent, among responders (p < 0.05). For both sexes, pretreatment SF was significantly associated with SF at Week 8 across all domains (p < 0.05).

CONCLUSION

For both sexes, sexual satisfaction improves with response to escitalopram. For females, the response does not correspond to improvements in SF frequency. For males, SF frequency, particularly that of orgasm, declines regardless of response/nonresponse.ClinicalTrials.gov identifier: NCT01655706.

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

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

Female Sexual Dysfunction

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

Função e disfunção sexual na depressão: uma revisão sistemática

RESUMO Objetivo Revisar sistematicamente as informações disponíveis acerca da função sexual e/ou disfunção sexual em pacientes com transtorno depressivo maior (TDM) e/ou distimia (DIS). Métodos Foi realizada uma busca sistematizada na base eletrônica Medline por estudos que avaliavam a função/disfunção sexual em pacientes com TDM e DIS. Foram incluídos estudos publicados até junho de 2017. Artigos relevantes presentes nas referências dos artigos foram pesquisados manualmente e incluídos nesta revisão. Resultados Vinte estudos foram elegíveis para análise. Foi observada uma grande diversidade de resultados decorrente da heterogeneidade dos delineamentos empregados e devido aos diferentes métodos de avaliação utilizados. De forma geral, os dados provenientes demonstraram uma redução das principais funções sexuais em pacientes com TDM e DIS, tais como: libido (31%-32%), drive (31%-87%), excitação (29%-85%), ereção (18%-46%), lubrificação (18%-79%) e orgasmo (26%-81%). Aumento de libido (15%-22%) também foi descrito em alguns estudos. Conclusão A disfunção sexual é altamente prevalente na DIS e no TDM. Foram notadas diversas alterações de funcionamento sexual na população estudada. Discrepâncias acerca de suas prevalências podem ter ocorrido devido às variadas metodologias de análise utilizadas nos estudos.

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

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

Brysocarpus coccineus (Schum & Thonn) root reinstates sexual competence and testicular function in paroxetine-induced sexual dysfunction in male Wistar rats

The effects of aqueous extract of Brysocarpus coccineus roots (AEBCR) were studied on sexual behaviour and testicular function of paroxetine-induced sexual dysfunction (SD) in male rats. Ninety, sexually matured male rats (150.88 ± 5.53 g) were assigned into two groups: A and B. Fifteen SD animals from group B were each allotted to B1, B2, B3, B4 and B5 and received distilled water (DW), Powmax M (7.14 mg/kg body weight, b.w.) 50, 100 and 150 mg/kg b.w of AEBCR, respectively, for 7 days while the non-SD animals (group A) received DW. Eleven secondary metabolites were present in AEBCR. The lowered (p < .05) ejaculation frequency, penile erection index and penile grooming, higher mount and intromission frequencies, prolonged (p < .05) latencies of mount, intromission, ejaculation, and post-ejaculatory interval, reduced (p < .05) serum luteinising hormone, follicle stimulating hormone, testosterone, nitric oxide and testicular function indices, degenerated seminiferous tubules and low luminal spermatozoa contents by paroxetine were significantly (p < .05) attenuated and/or reinstated by AEBCR and Powmax M. The restoration of androgen-dependent sexual and testicular functions in SD male rats by AEBCR validates its folkloric use as aphrodisiac. Clinical studies are desirable to ascertain the efficacy of AEBCR in SD.

Female Sexual Dysfunction

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

Attachment, dysfunctional attitudes, self-esteem, and association to depressive symptoms in patients with mood disorders

BACKGROUND

Cognitive factors might be the link between early attachment experiences and later depression. Similar cognitive vulnerability factors are discussed as relevant for both unipolar and bipolar disorders. The goals of the study were to test if there are any differences concerning attachment style and cognitive factors between remitted unipolar and bipolar patients compared to controls, and to test if the association between attachment style and depressive symptoms is mediated by cognitive factors.

METHODS

A path model was tested in 182 participants (61 with remitted unipolar and 61 with remitted bipolar disorder, and 60 healthy subjects) in which adult attachment insecurity was hypothesized to affect subsyndromal depressive symptoms through the partial mediation of dysfunctional attitudes and self-esteem.

RESULTS

No differences between patients with remitted unipolar and bipolar disorders concerning attachment style, dysfunctional attitudes, self-esteem, and subsyndromal depressive symptoms were found, but both groups reported a more dysfunctional pattern than healthy controls. The path models confirmed that the relationship between attachment style and depressive symptoms was mediated by the cognitive variables 'dysfunctional attitudes' and 'self-esteem'.

LIMITATIONS

With the cross-sectional nature of the study, results cannot explain causal development over time.

CONCLUSIONS

The results emphasize the relevance of a more elaborate understanding of cognitive and interpersonal factors in mood disorders. It is important to address cognitive biases and interpersonal experiences in treatment of mood disorders.

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.

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.

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.

Better sexual acceptability of agomelatine (25 and 50 mg) compared to escitalopram (20 mg) in healthy volunteers. A 9-week, placebo-controlled study using the PRSexDQ scale

The present double-blind, placebo-controlled study evaluates the effects of agomelatine and the selective serotonin reuptake inhibitor escitalopram on sexual dysfunction in healthy men and women.

METHODS

A total of 133 healthy volunteers (67 men, 66 women) were randomly assigned to agomelatine (25 or 50 mg) or escitalopram (20 mg) or placebo for nine weeks. Sexual acceptability was evaluated by using the psychotropic-related sexual dysfunction questionnaire 5-items total score and sexual dysfunction relative to each sub-score (in 110 volunteers with sexual activity). Sexual dysfunction was evaluated at baseline and after two, five and eight weeks of treatment and one week after drug discontinuation.

RESULTS

The psychotropic-related sexual dysfunction questionnaire 5-items total score was significantly lower in both agomelatine groups versus escitalopram at all visits (p < 0.01 to p < 0.0001) with no difference between agomelatine and placebo nor between both agomelatine doses. Similar results were observed after drug discontinuation. The total score was significantly higher in the escitalopram group than in the placebo group at each post-baseline visit (p < 0.01 to p < 0.001). Similar results were observed regardless of volunteers' gender. Compared to placebo, only escitalopram significantly impaired dysfunction relative to "delayed orgasm or ejaculation" (p < 0.01) and "absence of orgasm or ejaculation" (p < 0.05 to p < 0.01). The percentage of participants with a sexual dysfunction was higher in the escitalopram group than in agomelatine groups (p < 0.01 to p < 0.05) and placebo (p < 0.01).

CONCLUSION

The study confirms the better sexual acceptability profile of agomelatine (25 or 50 mg) in healthy men and women, compared to escitalopram.

TRIAL REGISTRATION NAME

Evaluation of the effect of agomelatine and escitalopram on emotions and motivation in healthy male and female volunteers.

TRIAL REGISTRATION NUMBER

ISRCTN75872983.

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.

Paroxetine versus other anti-depressive agents for depression

BACKGROUND

Paroxetine is the most potent inhibitor of the reuptake of serotonin of all selective serotonin reuptake inhibitors (SSRIs) and has been studied in many randomised controlled trials (RCTs). However, these comparative studies provided contrasting findings and systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to paroxetine alone. The present systematic review assessed the efficacy and tolerability profile of paroxetine in comparison with tricyclics (TCAs), SSRIs and newer or non-conventional agents.

OBJECTIVES

1. To determine the efficacy of paroxetine in comparison with other anti-depressive agents in alleviating the acute symptoms of Major Depressive Disorder.2. To review acceptability of treatment with paroxetine in comparison with other anti-depressive agents.3. To investigate the adverse effects of paroxetine in comparison with other anti-depressive agents.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR, to 30 September 2012), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing paroxetine and experts in this field were contacted for supplemental data.

SELECTION CRITERIA

All randomised controlled trials allocating participants with major depression to paroxetine versus any other antidepressants (ADs), both conventional (such as TCAs, SSRIs) and newer or non-conventional (such as hypericum). For trials which had a cross-over design, only results from the first randomisation period were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a standard form. Data were then entered in RevMan 5.2 with a double-entry procedure. Information extracted included study and participant characteristics, intervention details, settings and efficacy, acceptability and tolerability measures.

MAIN RESULTS

A total of 115 randomised controlled trials (26,134 participants) were included. In 54 studies paroxetine was compared with older ADs, in 21 studies with another SSRI, and in 40 studies with a newer or non-conventional antidepressant other than SSRIs. For the primary outcome (patients who responded to treatment), paroxetine was more effective than reboxetine at increasing patients who responded early to treatment (Odds Ratio (OR): 0.66, 95% Confidence Interval (CI) 0.50 to 0.87, number needed to treat to provide benefit (NNTb) = 16, 95% CI 10 to 50, at one to four weeks, 3 RCTs, 1375 participants, moderate quality of evidence), and less effective than mirtazapine (OR: 2.39, 95% CI 1.42 to 4.02, NNTb = 8, 95% CI 5 to 14, at one to four weeks, 3 RCTs, 726 participants, moderate quality of evidence). Paroxetine was less effective than citalopram in improving response to treatment (OR: 1.54, 95% CI 1.04 to 2.28, NNTb = 9, 95% CI 5 to 102, at six to 12 weeks, 1 RCT, 406 participants, moderate quality of evidence). We found no clear evidence that paroxetine was more or less effective compared with other antidepressants at increasing response to treatment at acute (six to 12 weeks), early (one to four weeks), or longer term follow-up (four to six months). Paroxetine was associated with a lower rate of adverse events than amitriptyline, imipramine and older ADs as a class, but was less well tolerated than agomelatine and hypericum. Included studies were generally at unclear or high risk of bias due to poor reporting of allocation concealment and blinding of outcome assessment, and incomplete reporting of outcomes.

AUTHORS' CONCLUSIONS

Some possibly clinically meaningful differences between paroxetine and other ADs exist, but no definitive conclusions can be drawn from these findings. In terms of response, there was a moderate quality of evidence that citalopram was better than paroxetine in the acute phase (six to 12 weeks), although only one study contributed data. In terms of early response to treatment (one to four weeks) there was moderate quality of evidence that mirtazapine was better than paroxetine and that paroxetine was better than reboxetine. However there was no clear evidence that paroxetine was better or worse compared with other antidepressants at increasing response to treatment at any time point. Even if some differences were identified, the findings from this review are better thought as hypothesis forming rather than hypothesis testing and it would be reassuring to see the conclusions replicated in future trials. Finally, most of included studies were at unclear or high risk of bias, and were sponsored by the drug industry. The potential for overestimation of treatment effect due to sponsorship bias should be borne in mind.

Resolution of sleepiness and fatigue: a comparison of bupropion and selective serotonin reuptake inhibitors in subjects with major depressive disorder achieving remission at doses approved in the European Union

Unlike selective serotonin reuptake inhibitors (SSRIs), bupropion may be classified as a dual noradrenaline and dopamine reuptake inhibitor, a difference with potential implications for the treatment of residual sleepiness and fatigue in major depressive disorder (MDD). Post-hoc analysis of subjects with remitted MDD was performed on data pooled from six double-blind, randomized trials comparing the European Union (EU)-approved dose of ≤300 mg/day bupropion with SSRIs (sertraline, paroxetine or escitalopram) for the resolution of sleepiness and fatigue. Hypersomnia score was defined as the sum of scores of the Hamilton Depression Rating Scale (HDRS) items 22, 23, and 24; fatigue score as HDRS item 13 score; and remission as HDRS-17≤7. Similar proportions of bupropion- and SSRI-treated subjects achieved remission at study endpoint (169/343, 49.3% vs 324/656, 49.4%; last observation carried forward (LOCF), p=0.45). Fewer bupropion-treated remitters had residual symptoms of sleepiness (32/169, 18.9% vs 104/324, 32.1%; p<0.01) and fatigue (33/169, 19.5% vs 98/324, 30.2%; p<0.05). Bupropion-treated remitters also showed greater improvement (mean change from baseline) in sleepiness (p<0.05) and fatigue scores (p<0.01) at endpoint: benefits were evident from week 2 for sleepiness (p<0.01) and week 4 for fatigue (p<0.01). Bupropion treatment at the EU-approved dose of ≤300 mg/day may offer advantages over SSRIs in the resolution of sleepiness and fatigue in remitted MDD patients.

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.

Drug addiction and sexual dysfunction

This article attempts to review the most current and the well-established facts concerning drug addiction and sexual dysfunction. Surprisingly, even though alcohol is prevalent in many societies with many myths surrounding its sexual-enhancing effects, current scientific research cannot provide a solid conclusion on its effect on sexual function. Unfortunately, the same concept applies to tobacco smoking; however, most of the current knowledge tends to support the notion that it, indeed, can negatively affect sexual function. Similar ambiguities also prevail with substances of abuse.

Chronic administration of imipramine but not agomelatine and moclobemide affects the nitrergic relaxation of rabbit corpus cavernosum smooth muscle

Sexual dysfunction is a common and underestimated effect of antidepressants. However, the mechanism by which these drugs cause erectile dysfunction is unclear. We investigated the reactivity of the corpus cavernosum of rabbits that were treated with either chronic imipramine, which is a tricyclic agent; agomelatine, which is a melatonergic agonist and serotonin 5HT(2c) antagonist; or moclobemide, which is a reversible inhibitor of monoamine-oxidase A. Twenty rabbits were randomly divided into four groups: the control group (n=5), the imipramine-treated group (n=5), which received i.p. injections of 10 mg/kg/day of imipramine, the moclobemide-treated group (n=5), which received i.p. injections of 20 mg/kg/day of moclobemide, and the agomelatine-treated group (n=5), which was orally administered 10 mg/kg/day of agomelatine. The reactivities of corpus cavernosum tissue obtained from the antidepressant-treated and the control groups were studied in organ chambers after the animals were subjected to 21 days of drug administration. The acetylcholine-induced endothelium-dependent and the electrical field stimulation (EFS)-induced neurogenic relaxation of the corpus cavernosum of the imipramine-treated group was significantly decreased compared with the control group. However, neither the acetylcholine- nor EFS-induced relaxation was changed in the moclobemide- or agomelatine-treated groups. There were no change in the relaxant response to the nitric oxide (NO) donor sodium nitroprusside and contractile response to KCl between the groups. This study suggests that chronic imipramine treatment but not agomelatine and moclobemide treatments causes significant functional changes in the penile erectile tissue of rabbits and that these changes may contribute to the development of impotence.

Sexual functioning in patients with recurrent major depressive disorder enrolled in the PREVENT study

The incidence of treatment-emergent sexual dysfunction in the acute and continuation phases of the prevention of recurrent episodes of depression with venlafaxine ER for two years (PREVENT) study was assessed. Adult outpatients with recurrent major depressive disorder were randomly assigned to receive venlafaxine extended release (ER; 75-300 mg/day) or fluoxetine (20-60 mg/day). Sexual dysfunction was assessed using items from the 17-item Hamilton Rating Scale for Depression (HAM-D(17)) and the Inventory of Depressive Symptomatology-Self-Report (IDS-SR). The baseline rates of sexual dysfunction based on the HAM-D(17) and IDS-SR items were 57.9% and 48.8%, respectively. The rates of new-onset sexual dysfunction for the venlafaxine ER-treated (44.8%, HAM-D(17); 38.4%, IDS-SR) and fluoxetine-treated patients (52.9%, HAM-D(17); 50.0%, IDS-SR) were similar; approximately 80% of the cases resolved during treatment. Treatment response was associated with lower rates of new-onset sexual dysfunction compared with nonresponse. The patients who remitted were the least likely to experience sexual dysfunction during antidepressant treatment.

Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project

OBJECTIVE

Relatively few studies have evaluated the clinical implications of lifetime attention-deficit/hyperactivity disorder (ADHD) in adults with bipolar disorder or major depressive disorder (MDD). Herein, we sought to determine the prevalence as well as the demographic and clinical correlates of lifetime ADHD in persons with a mood disorder.

METHOD

The first 399 patients enrolled in the International Mood Disorders Collaborative Project (IMDCP) were evaluated for lifetime ADHD using the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus) as the primary instrument to derive current and lifetime DSM-IV diagnoses. All analyses of variables of interest were conducted utilizing the MINI-Plus, the Adult ADHD Self-Report Scale-v1.1, and the Wender Utah Rating Scale-Short Form. The effect of ADHD on clinical presentation, course of illness variables, comorbidity, anamnesis, treatment, and outcome are reported. The IMDCP is a joint initiative of the Mood Disorders Psychopharmacology Unit at the University Health Network, University of Toronto, Toronto, Ontario, Canada, and the Cleveland Clinic Center for Mood Disorders Treatment and Research at Lutheran Hospital, Cleveland, Ohio. All data for this study were procured between January 2008 and January 2009.

RESULTS

The percentages of subjects with MDD or bipolar disorder meeting the DSM-IV criteria for lifetime adult ADHD were 5.4% and 17.6% (P < .001), respectively. Lifetime comorbid ADHD in both mood disorder populations was associated with earlier age at illness onset (MDD, P = .049; bipolar disorder, P = .005), a higher number of psychiatric comorbidities (eg, MDD and current panic disorder with agoraphobia [P = .002]; bipolar disorder and social phobia [P = .012]), and decreased quality of life (MDD, P = .018).

CONCLUSIONS

The overarching findings herein are that the adult ADHD phenotype is commonly reported by individuals with MDD or bipolar disorder and is associated with a greater illness burden and complexity.

How should primary care doctors select which antidepressants to administer?

Clinicians can choose among various second-generation antidepressants for treating depressive disorders, such as major depressive disorder, subsyndromal depression, or dysthymia. Systematic reviews indicate that available drugs differ in frequency of administration, costs, and the risks of some adverse events but have similar efficacy for treating major depressive disorder. Furthermore, evidence does not support the choice of one antidepressant over another based on accompanying symptoms, such anxiety, insomnia, or pain. Available studies provide little guidance for clinicians about the benefits of second-generation antidepressants for treating dysthymia and subsyndromal depression. Evidence is also unclear about the comparative risks of serious adverse events, such as suicidality, seizures, fractures, increased bleeding, or serotonin syndrome. This article summarizes the best available evidence regarding comparative benefits and harms of second-generation antidepressants for treating depressive disorders.

Sexual function in nondepressed women using escitalopram for vasomotor symptoms: a randomized controlled trial

OBJECTIVE

To evaluate sexual function in midlife women using selective serotonin reuptake inhibitors for vasomotor symptoms. Selective serotonin reuptake inhibitors effectively treat vasomotor symptoms but adversely affect sexual function in depressed populations. Information on sexual function in nondepressed midlife women using selective serotonin reuptake inhibitors for vasomotor symptoms is lacking; any treatments that might impair function are of concern.

METHODS

This was a randomized controlled trial comparing 8 weeks of escitalopram with placebo in women ages 40-62 years with 28 or more bothersome vasomotor symptoms per week. Change in Female Sexual Function Index composite score (ranges from 2 [not sexually active, no desire] to 36) and six sexual domains (desire, arousal, lubrication, orgasm, satisfaction, pain) and the Female Sexual Distress Scale, and a single-question of sexually-related personal distress from the Female Sexual Distress Scale, were compared between groups.

RESULTS

Among all women, median composite baseline Female Sexual Function Index score was 18.1 (interquartile range 2.4-26.5, n=200) and among sexually active women was 22.8 (interquartile range 17.4-27.0, n=75) in the escitalopram group and 23.6 (interquartile range 14.9-31.0, n=70) in the placebo group. Treatment with escitalopram did not affect composite Female Sexual Function Index score at follow-up compared with placebo (P=.18 all women; P=.47 sexually active at baseline). Composite mean Female Sexual Function Index change from baseline to week 8 was 0.1 (95% confidence interval [CI] -1.5 to 1.7) for escitalopram and 2.0 (95% CI 0.2-3.8) for placebo. The Female Sexual Distress Scale results did not differ between groups (P=.73) nor did adverse reports of sexual function. At week 8, among those women sexually active at baseline, there was a small difference between groups in Female Sexual Function Index domain mean score change in lubrication (P=.02) and a marginal nonsignificant difference in orgasm (P=.07).

CONCLUSION

Escitalopram, when used in the treatment of vasomotor symptoms, did not worsen overall sexual function among nondepressed midlife women.

CLINICAL HETEROGENEITY IN SYSTEMATIC REVIEWS AND HEALTH TECHNOLOGY ASSESSMENTS: SYNTHESIS OF GUIDANCE DOCUMENTS AND THE LITERATURE

Objectives: The aim of this study was to synthesize best practices for addressing clinical heterogeneity in systematic reviews and health technology assessments (HTAs).

Methods: We abstracted information from guidance documents and methods manuals made available by international organizations that develop systematic reviews and HTAs. We searched PubMed® to identify studies on clinical heterogeneity and subgroup analysis. Two authors independently abstracted and assessed relevant information.

Results: Methods manuals offer various definitions of clinical heterogeneity. In essence, clinical heterogeneity is considered variability in study population characteristics, interventions, and outcomes across studies. It can lead to effect-measure modification or statistical heterogeneity, which is defined as variability in estimated treatment effects beyond what would be expected by random error alone. Clinical and statistical heterogeneity are closely intertwined but they do not have a one-to-one relationship. The presence of statistical heterogeneity does not necessarily indicate that clinical heterogeneity is the causal factor. Methodological heterogeneity, biases, and random error can also cause statistical heterogeneity, alone or in combination with clinical heterogeneity.

Conclusions: Identifying potential modifiers of treatment effects (i.e., effect-measure modifiers) is important for researchers conducting systematic reviews and HTAs. Recognizing clinical heterogeneity and clarifying its implications helps decision makers to identify patients and patient populations who benefit the most, who benefit the least, and who are at greatest risk of experiencing adverse outcomes from a particular intervention.

Paroxetine for the treatment of depression: a critical update

INTRODUCTION

A growth in the market for antidepressants, paired with an ever-increasing population affected from depressive disorder, requires a critical re-evaluation of most prescribed antidepressants, in order to provide up-to-date practical prescribing information for clinicians. Paroxetine represents a widely prescribed and reliable antidepressant for the expert clinician, but the latest data do not rank it amongst the most effective and tolerable newer antidepressants.

AREAS COVERED

This paper reviews latest data on paroxetine and investigates its clinical efficacy and safety in different groups of patients.

EXPERT OPINION

In previous subanalysis and metaregression analysis, paroxetine failed to show clear differences in terms of efficacy across clinical subgroups. Thus, nowadays the pharmacokinetic and pharmacodynamic properties of the molecule are fundamental to guiding its prescription, both for efficacy and tolerability issues, for example, it can have a high impact on sexual function and weight should also be considered at the beginning of treatment. Since prescription is still based mainly on its side-effect profile, newer and more accurate directions for an individualized prescription are needed.

Barriers to achieving treatment goals: a focus on sleep disturbance and sexual dysfunction

BACKGROUND

Patients who meet the criteria for a major depressive episode experience a constellation of symptoms, and different symptom configurations may reflect distinct underlying neurological disturbances. Similarly, the differing receptor profiles of the various antidepressants may explain relatively low remission rates and persistent symptoms even after remission. In particular, depressed patients frequently display altered circadian rhythms, sleep disturbances, and diurnal mood variation. Exploring treatments that can restore mood while having a positive impact on circadian rhythms and sleep would greatly improve the ability to treat this core features of depression.

METHODS

The mechanisms of action of the various classes of antidepressants, their effects on sleep and issues beyond sleep, including sexual dysfunction, are explored, along with questions relating to adherence.

RESULTS

Unfortunately, persistent sleep problems are among the most difficult-to-treat residual symptoms of depression. Many of the currently available antidepressants have adverse effects on circadian processes, including sleep, and may actually worsen sleep problems. Tolerability is also an enduring issue; SSRI and SNRI antidepressants are associated with central nervous sysytem and gastrointestinal effects, sexual side effects and suicidality. Improved drug tolerability would not only minimize distressing adverse effects, but would also improve adherence, thus maximizing the chances of successful treatment.

CONCLUSIONS

The complexity of managing a major depressive episode is well illustrated by sleep disturbance and sexual dysfunction, two core symptoms of MDD that may also be caused or exacerbated by antidepressant therapy. Future antidepressants should alleviate symptoms without adversely affecting sleep or sexual function.

Reversal of SSRI-induced female sexual dysfunction by adjunctive bupropion in menstruating women: a double-blind, placebo-controlled and randomized study

A significant number of patients undergoing treatment with selective serotonin reuptake inhibitors (SSRIs) report sexual dysfunction. SSRI-induced sexual dysfunction adversely affects quality of life and patient adherence to and compliance with treatment regimens. This trial examined the efficacy and safety of adjunctive bupropion in the treatment of SSRI-induced female sexual dysfunction. Sexual function was assessed by using the sexual function domains of the Female Sexual Function Index (primary efficacy outcome measure) and the Clinical Global Impression Scale adapted for sexual function (secondary efficacy outcome measure). End point treatment satisfaction was assessed using a Visual Analog Scale. A total of 218 women (25-45 years old) with SSRI-induced sexual dysfunction were randomized to receive 12 weeks of double-blind fixed dosed treatment with bupropion sustained release 150 mg b.i.d. (n = 109) or placebo (n = 109). The mean (SD) for Female Sexual Function Index total score was higher in the bupropion sustained release group (25.9 (5.12), 95% confidence interval (CI) 22.2-29.4) than in the placebo group (17.2 (4.9), 95% CI 15.8-20.1) (p = 0.001). Mean (SD) Clinical Global Impression Scale score for the bupropion group (2.4 (0.6), 95% CI 2.0-3.6) was significantly lower than that for the placebo group (4.2 (0.8), 95% CI 3.4-5.4) (p = 0.001). At the end of the trial the mean (SD) scores for desire (4.1 (0.7), 95% CI 3.5-4.8) (p = 0.001), arousal (4.4 (0.6), 95% CI 3.7-4.8) (p = 0.01), lubrication (4.4 (0.4), 95% CI 3.3-4.8) (p = 0.001), orgasm (4.4 (0.5), 95% CI 3.7-4.7) (p = 0.001), and satisfaction (4.2 (0.7), 95% CI 3.4-4.8) (p = 0.001) were significantly higher in the bupropion group. The highest improvement was observed in sexual desire, followed by lubrication. Compared with baseline, desire and lubrication domains increased by 86.4% (95% CI 64.9-102.2%, p = 0.001) and 69.2% (95% CI 44.7-82.6%, p = 0.001) in the bupropion group. Adjunctive treatment with bupropion sustained release during a 12-week period significantly improved key aspects of sexual function in women with SSRI-induced sexual dysfunction.

Instruments to measure sexual dysfunction in community and psychiatric populations

Sexual dysfunction is a significant issue for many individuals. This can be the result of existing disorders, side effects of medications, or both. In order to effectively assess and, if appropriate, manage sexual dysfunction in various populations, it is important to consider the use of validated instruments that can provide a baseline to detect dysfunction and measure change over time. This review will assess the psychometric properties of scales (self-report and interview-based) that have been used in community, psychiatric, and gender-specific populations, with a particular emphasis on depressed patients before and during antidepressant therapy. Key considerations for scale selection and development are also discussed.

Differences in efficacy and safety of pharmaceutical treatments between men and women: an umbrella review

Being male or female is an important determinant of risks for certain diseases, patterns of illness and life expectancy. Although differences in risks for and prognoses of several diseases have been well documented, sex-based differences in responses to pharmaceutical treatments and accompanying risks of adverse events are less clear. The objective of this umbrella review was to determine whether clinically relevant differences in efficacy and safety of commonly prescribed medications exist between men and women. We retrieved all available systematic reviews of the Oregon Drug Effectiveness Review Project published before January 2010. Two persons independently reviewed each report to identify relevant studies. We dually abstracted data from the original publications into standardized forms. We synthesized the available evidence for each drug class and rated its quality applying the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Findings, based on 59 studies and data of more than 250,000 patients suggested that for the majority of drugs no substantial differences in efficacy and safety exist between men and women. Some clinically important exceptions, however, were apparent: women experienced substantially lower response rates with newer antiemetics than men (45% vs. 58%; relative risk 1.49, 95% confidence interval 1.35–1.64); men had higher rates of sexual dysfunction than women while on paroxetine for major depressive disorder; women discontinued lovastatin more frequently than men because of adverse events. Overall, for the majority of drugs sex does not appear to be a factor that has to be taken into consideration when choosing a drug treatment. The available body of evidence, however, was limited in quality and quantity, confining the range and certainty of our conclusions.

The change of prefrontal QEEG theta cordance as a predictor of response to bupropion treatment in patients who had failed to respond to previous antidepressant treatments

The aim of the study was to examine whether the reduction of theta prefrontal quantitative EEG (QEEG) cordance after one week of bupropion administration is a predictor of response to a 4-week treatment in patients that had failed to respond to previous antidepressant treatments.

METHOD

EEG data of 18 inpatients were monitored at baseline and after one week. QEEG cordance was computed at 3 frontal electrodes (Fp1, Fp2, Fz). Response to treatment was defined as a >/=50% reduction of MADRS score.

RESULTS

Nine of the eleven responders and one of the seven non-responders showed decreased prefrontal cordance value after the first week of treatment (p=0.01). Positive and negative predictive values of cordance reduction for the prediction of response to the treatment were 0.9 and 0.75, respectively.

CONCLUSION

Similar to other antidepressants, the reduction of prefrontal QEEG cordance might be helpful in the prediction of the acute outcome of bupropion treatment.

Better sexual acceptability of agomelatine (25 and 50 mg) compared with paroxetine (20 mg) in healthy male volunteers. An 8-week, placebo-controlled study using the PRSEXDQ-SALSEX scale

Sexual dysfunction (SD) is a common and underestimated effect of antidepressants. Healthy volunteers are the most adequate group to study this adverse event avoiding influence of depression itself. Sexual acceptability of agomelatine (a melatonergic agonist and 5HT(2C) antagonist) paroxetine and placebo by using the Psychotropic-Related Sexual Dysfunction Salamanca Sex Questionnaire (PRSEXDQ-SALSEX) was explored. A total of 92 healthy male volunteers were randomised to agomelatine (25 or 50 mg), paroxetine 20 mg or placebo for 8 weeks. SD, defined as at least one sexual impairment in one of the following PRSEXDQ-SALSEX items (decreased libido, delayed orgasm/ejaculation, anorgasmia/no ejaculation and erectile dysfunction), was evaluated at baseline and after 2, 4 and 8 weeks. At the last post-baseline assessment, SD was significantly lower in each agomelatine group (22.7% on 25 mg and 4.8% on 50 mg) than in the paroxetine group (85.7%; p < 0.0001). In the placebo group, 8.7% of volunteers reported a SD. The percentages of volunteers with moderate or severe SD were 4.5% for agomelatine 25 mg, 4.8% for agomelatine 50 mg, 61.9% for paroxetine 20 mg and 0% in the placebo group (p < or = 0.0001 agomelatine versus paroxetine). There is a much lower risk of having SD with agomelatine than paroxetine in healthy male volunteers, which confirms the better sexual acceptability profile of agomelatine compared with the SSRIs.

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.

Sexual dysfunction in depression and anxiety: conceptualizing sexual dysfunction as part of an internalizing dimension

Sexual dysfunction is often implicated in depression and anxiety disorders, but the current nosology of sexual dysfunction, depression, and anxiety (i.e., DSM-IV) does not adequately address these relationships. Because recent papers (Krueger, R. F., & Markon, K. E. (2006). Reinterpreting comorbidity: A model-based approach to understanding and classifying psychopathology. Annual Review of Clinical Psychology, 2, 111-133) have suggested and provided evidence for latent internalizing and externalizing dimensions that help explain high comorbidity between mental disorders, the current paper suggests that sexual dysfunction might conceptually belong to a latent internalizing factor. To address this, evidence is presented for the relationship among disorders of sexual desire, arousal, and orgasm comorbid with depression and anxiety. A review of sexual disorders is also presented along with a critical examination of the way the current DSM is organized with respect to sexual dysfunction, depression, and anxiety.

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.

Sexual dysfunction, depression, and the impact of antidepressants

Sexual dysfunction is a common symptom of depression. Although decreased libido is most often reported, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse effect of treatment with most antidepressants and is one of the predominant reasons for premature drug discontinuation. Selective serotonin reuptake inhibitors are the most widely prescribed antidepressants and have significant effects on arousal and orgasm compared with antidepressants that target norepinephrine, dopamine, and melatonin systems. The availability of an antidepressant that does not cause or exacerbate sexual dysfunction represents an advance in pharmacotherapy for mood disorders and should reduce treatment noncompliance and decrease the need for switching antidepressants or adding antidotes. The purpose of this review was to provide an update on the prevalence, psychobiology, and relative adverse effect burden of sexual dysfunction associated with different antidepressants.

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.

A double-blind comparison of sexual functioning, antidepressant efficacy, and tolerability between agomelatine and venlafaxine XR

Impaired sexual function is associated with major depressive disorder in the untreated state and is often more prevalent during antidepressant therapy, which frequently results in poor treatment compliance. In this double-blind, multicenter study, the effects of agomelatine (an MT1 and MT2 agonist and 5HT-2C antagonist) and venlafaxine XR on sexual function were compared using the Sex Effects Scale in depressed patients. A total of 276 male and female patients received either agomelatine (50 mg) or venlafaxine XR (titrated to a target dose of 150 mg/d) for 12 weeks. Those who were sexually active at baseline (n = 193) and those who, in addition, achieved remission (n = 111) were defined a priori for analyses of change in sexual function. Treatment-emergent sexual dysfunction was significantly less prevalent among patients who received agomelatine, and venlafaxine XR was associated with significantly greater deterioration on the Sex Effects Scale domains of desire and orgasm. Both treatments resulted in equivalently high rates of remission (agomelatine, 73%; venlafaxine XR, 66.9%), although fewer patients in the agomelatine group discontinued treatment because of adverse events (agomelatine, 2.2%, vs venlafaxine XR, 8.6%). Agomelatine seems to be an efficacious antidepressant with a superior sexual side effect profile compared with venlafaxine XR, although superiority to placebo was not evaluated in this trial.

Insight into urogynecologic features of women with interstitial cystitis/painful bladder syndrome

OBJECTIVE

The prevalence of interstitial cystitis/painful bladder syndrome (IC/PBS) among gynecologic patients attending vulvar disease or pelvic pain clinics is higher than expected. The evaluation of gynecologic characteristics in patients with IC/PBS could be important to delineate a better therapeutic strategy.

METHODS

We compared clinical gynecologic characteristics including localized and generalized vulvodynia and sexual activity of 47 women with a definite diagnosis of IC/PBS versus 47 negative controls.

RESULTS

The prevalence of both generalized or localized vulvodynia was 85.1% (40 of 47) in the patients and 6.4% (3 of 47) in the control group (p<0.0001 by Fisher exact test). The mean visual analogue score on generalized or localized vulvodynia evaluated with the cotton swab test was 6.1+/-2.6 (SD) among women with IC/PBS and 0.6+/-1.7 in the control group (p<0.0001 with Mann-Whitney U test). Pain during intercourse was described as unbearable by 15 women with IC/PBS (31.9%) and 2 controls (4.3%; p=0.001 by Fisher exact test). Sexual function was significantly impaired in women with IC as measured by the median total score of the Female Sexual Function Index in comparison with controls (13.8 vs. 28.7; p<0.0001).

CONCLUSIONS

Patients with a definite diagnosis of IC/PBS appear to have a high risk of vulvodynia with the associated negative implications for sexual activity. The establishment of a multidisciplinary approach with the involvement of the gynecologist appears to be a logical requisite for a correct treatment strategy for these patients.