Genitourinary and sexual adverse effects of psychotropic medication

Pharmaceutical management of sexual dysfunction in men on antidepressant therapy

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study

Introduction

An increasing number of young men have been found to develop nonorganic erectile dysfunction (NOED) in recent years. The NOED has been shown to respond better to cognitive behavior sex therapy (CBST) in a few past studies.

Aim

The present research aims to establish the efficacy of CBST as a promising treatment option in young men suffering from NOED by administering a feasibility pilot trial.

Methods

28 young men (M = 31 years) out of a total of 39 men (7 excluded, 4 quit treatment) diagnosed with NOED from sexual health clinics in Pakistan were recruited to receive CBST treatment (n = 13) on average twice a week for a period of 50 minutes per session for a period of 4, 6, 8, and 12 weeks for the mild, mild to moderate, moderate, and severe forms of NOED, respectively, and sildenafil citrate group (n = 15) receiving sildenafil citrate 50 mg on demand. The trial design was sequential random assignment clinical trial.

Main Outcome Measures

International Index of Erectile Functoning-5 and Depression Anxiety Stress Scale-21 were used before treatment, after treatment, and in follow-up as the main outcome measures.

Results

The repeated measures analysis of covariance established a nonsignificant difference between CBST and sildenafil citrate 50 mg in NOED scores improvement, NOED severity reduction, and reduction in depression scores at posttreatment assessment. There were significant differences among different CBST modalities in improving NOED scores, reduction in NOED severity, and depression scores. There was significant difference in CBST and sildenafil citrate 50 mg in anxiety reduction at posttreatment assessment. The covariates age, age groups, and NOED duration did not significantly impact the treatment outcome for both treatment groups except age which impacted the interaction of treatment and anxiety scores.

Conclusion

The CBST is an emerging and promising treatment choice in younger men suffering from NOED.

Bilal A, Abbasi NuH. Cognitive Behavioral Sex Therapy: An Emerging Treatment Option for Nonorganic Erectile Dysfunction in Young Men: A Feasibility Pilot Study. J Sex Med 2020;8:396–407.

A survey of psychosexual arousability in male patients on depot neuroleptic medication

Sexual and endocrine function in a geographically defined population of male patients receiving depot neuroleptic medication were studied (n = 119). It was predicted that psychosexual arousability would be reduced in this patient group, perhaps because of the endocrine effects of medication. Arousability was measured in 63 patients (53% of the population) using a validated questionnaire of sexual function for which normative data were available (Sexuality Experience Scales, SES 2). Blood levels of prolactin, testosterone and gonadotrophins were assayed. Physical sexual dysfunction was common, as was endocrine dysfunction. However, the sample's mean score on the global arousability scale was not significantly different from the normative mean. Arousability was negatively correlated with age and positively correlated with frequency of spontaneous penile erections, but not significantly correlated with endocrine variables or exposure to neuroleptic medication. These results suggest that sexual arousability in response to imagined or audio-visual erotic stimuli is surprisingly unimpaired in medicated male patients suffering from chronic mental illness.

Sexual dysfunction: The unspoken side effect of antipsychotics

Although only a few studies have been performed and published data are scarce, it seems clear that sexual dysfunctions frequently occur during treatment with antipsychotics in 30–60% of patients with schizophrenia. It is important to evaluate the occurrence of sexual dysfunction and its relation to antipsychotic treatment.

Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors

INTRODUCTION

Erectile dysfunction (ED) is an important health concern that can significantly affect a man's psychosocial well-being. ED has traditionally been considered a disease of old age; however, contemporary evidence suggests a growing incidence of ED in men younger than 40 years. The process of achieving an erection is multifaceted; there are many potential mechanisms that can be disrupted. It is critical to identify the specific causes of ED before proceeding with potentially costly and invasive therapeutic options. Advances in diagnostic and treatment modalities offer opportunities to identify and manage young men with ED.

AIM

To provide an update on the prevalence and risk factors of ED in young men and to provide a framework to guide clinicians in identifying and managing the affected young man.

METHODS

Comprehensive review of the literature pertaining to ED in young men.

MAIN OUTCOME MEASURES

ED in young men was assessed by outlining the prevalence according to recent epidemiologic studies. The pathophysiology, diagnostic considerations, risk factors, and etiologies were reviewed.

RESULTS

Large multinational studies have estimated the prevalence of ED in young men to be as high as 30%. Several studies have stratified the etiologies of ED into psychogenic and organic causes. Psychogenic etiologies of ED include depression, anxiety, and partner-related difficulties. These patients tend to experience sudden onset of symptoms, with decreased libido and good quality of spontaneous or self-stimulated erections. Organic etiologies include vasculogenic, endocrinologic, neurogenic, iatrogenic, and structural components. These patients usually experience gradual onset of symptoms and a low to normal libido. Conservative treatments such as phosphodiesterase type 5 inhibitors continue to be the mainstay treatment.

CONCLUSIONS

ED in young men is an increasingly common condition. A careful diagnostic evaluation should focus on the identification of any underlying etiology to ensure appropriate management of patients. Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men-A Review of the Prevalence and Risk Factors. Sex Med Rev 2017;5:508-520.

A clinical guide to the management of genitourinary symptoms in breast cancer survivors on endocrine therapy

There is increasing attention and concern about managing the adverse effects of adjuvant endocrine therapy for women with early breast cancer as the side effects of therapy influence compliance and can impair quality of life (QoL). Most side effects associated with tamoxifen (TAM) and aromatase inhibitors (AIs) are directly related to estrogen deprivation, and the symptoms are similar to those experienced during natural menopause but appear to be more severe than that seen in the general population. Prolonged estrogen deprivation may lead to atrophy of the vulva, vagina, lower urinary tract and supporting pelvic structures, resulting in a range of genitourinary symptoms that can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of QoL. The genitourinary side effects may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment. We provide an overview of practical clinical approaches to understanding the pathophysiology and the management of genitourinary symptoms in postmenopausal women receiving adjuvant endocrine therapy for breast cancer.

Sexual Disorders Caused by Antidepressants: Considerations in the Context of Brain Hemisphere Functions

All phases of normal sexual activity are under the control of the right hemisphere coupled with limbic structures, and depression is characterized by the functional insufficiency of this system. At the same time, those modern antidepressants that cause sexual disorders are activating the left hemisphere and determine its domination on the expense of the right one and disturb free and spontaneous emotional interrelationships, sexual behavior and pleasure. Those antidepressants that do not cause sexual dysfunction are not activating predominantly the left hemisphere structures and activate the limbic brain zones responsible for reward, reinforcement and emotional excitement.

Erectile dysfunction in fit and healthy young men: psychological or pathological?

Epidemiological studies consistently show that prevalence of erectile dysfunction (ED) increases with ageing. Nonetheless, complaints of ED even in younger men are becoming more and more frequent. Healthcare professionals working in Sexual Medicine but even those operating in different clinical contexts might be adequately prepared to answer this increasing requirement. ED in younger men is likely to be overlooked and dismissed without performing any medical assessment, even the most basic ones, such as collection of medical history and physical exam. This is due to the widespread assumption that ED in younger individuals is a self-limiting condition, which does not deserve any clinical evaluation or therapy and can be managed only with patient reassurance. However, evidence shows that, in younger subjects, organic, psychological and relational conditions can contribute to the pathogenesis of ED and all these conditions might be evaluated and treated, whenever necessary. Among the organic conditions contributing to the onset of ED, metabolic and cardiovascular (CV) risk factors are surprisingly of particular relevance in this age group. In fact, in younger men with ED, even more than in older ones, recognizing CV risk factors or conditions suggestive of cardio-metabolic derangements can help identifying men who, although at low absolute risk due to young age, carry a high relative risk for development of CV events. In this view, the assessment of a possible organic component of ED even in younger individuals acquires a pivotal importance, because it offers the unique opportunity to unearth the presence of CV risk factors, thus allowing effective and high quality preventive interventions.

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.

Validation of sexual functioning questionnaire in Indian patients

OBJECTIVE

To establish norms for sexual functioning questionnaire (SFQ) in Indian population.

MATERIALS AND METHODS

100 male subjects, diagnosed with depressive disorder and currently in a state of clinical remission for a period of at least 4 weeks were evaluated on SFQ and Arizona Sexual Experience Questionnaire (ASEX).

RESULT

By using receiver operating characteristics (ROC) curves a score of 14 was considered to be a cutoff for sexual dysfunction as per SFQ. This cutoff yielded a sensitivity of 91.7% and specificity of 86.4% for the detection of sexual dysfunction. The PPV of the instrument at this cutoff was 87%.

CONCLUSION

A cutoff of 14 should be used to define sexual dysfunction as per SFQ.

Treating symptomatic hyperprolactinemia in women with schizophrenia: presentation of the ongoing DAAMSEL clinical trial (Dopamine partial Agonist, Aripiprazole, for the Management of Symptomatic ELevated prolactin)

Prolactin elevations occur in people treated with antipsychotic medications and are often much higher in women than in men. Hyperprolactinemia is known to cause amenorrhea, oligomenorrhea, galactorrhea and gynecomastia in females and is also associated with sexual dysfunction and bone loss. These side effects increase risk of antipsychotic nonadherence and suicide and pose significant problems in the long term management of women with schizophrenia. In this manuscript, we review the literature on prolactin; its physiology, plasma levels, side effects and strategies for treatment. We also present the rationale and protocol for an ongoing clinical trial to treat symptomatic hyperprolactinemia in premenopausal women with schizophrenia. More attention and focus are needed to address these significant side effects and help the field better personalize the treatment of women with schizophrenia.

Male erectile dysfunction: integrating psychopharmacology and psychotherapy

OBJECTIVE

Erectile dysfunction (ED), defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance, is the most common sexual problem in men. ED arises when there is disruption of the complex interplay between vascular, neurologic, hormonal and psychologic factors necessary for normal erectile function. It may have a significant effect on quality of life and portend undetected cardiovascular disease. Risk factors for development of ED include advancing age, tobacco use, a history of pelvic irradiation or surgery and antipsychotic use (Table 1) [1]. Treatment guidelines continue to evolve for optimal management of ED. In this article, we review diagnostic and treatment strategies for ED relevant to psychiatrists.

METHOD

We present an integrative approach to the treatment of ED based on a review of the urologic and psychiatric literature.

RESULTS

ED is multifactorial in origin and responsive to a variety of therapeutic interventions, including psychopharmacology and psychotherapy in which cognitive underpinnings of poor sexual performance, including diminished self-esteem, lack of confidence and perceived failures in the male role, are examined.

CONCLUSIONS

Psychiatrists can readily perform a basic workup for ED as they integrate both a medical and therapeutic model when confronted with such patients.

Prevalence and pattern of sexual dysfunction in married females receiving antidepressants: An exploratory study

Objective:

To study the prevalence and patterns of sexual dysfunctions in female patients receiving antidepressants.

Materials and Methods:

Eighty married female patients with a diagnosis of depressive disorder, currently in remission, and receiving a single antidepressant at least for 3 months, were assessed for sexual dysfunction on female sexual function index (FSFI) scale.

Results:

Thirty four patients (42.5%) receiving antidepressants had FSFI score less than 26.55 and were considered to have sexual dysfunction. When only the domain cutoff scores were used for the whole study sample (n=80), it was found that 95% had decreased desire, 60% had decreased arousal, 37.5% had decreased lubrication, 63.8 had decreased orgasm, 55% had decreased satisfaction and 25% had pain during sexual activity.

Conclusions:

To conclude, our study suggests that sexual dysfunction is quite prevalent in married female patients receiving antidepressants and all the domains of sexual functioning are impaired by antidepressants.

Genome-wide pharmacogenomic study of citalopram-induced side effects in STAR*D

Affecting about 1 in 12 Americans annually, depression is a leading cause of the global disease burden. While a range of effective antidepressants are now available, failure and relapse rates remain substantial, with intolerable side effect burden the most commonly cited reason for discontinuation. Thus, understanding individual differences in susceptibility to antidepressant therapy side effects will be essential to optimize depression treatment. Here we perform genome-wide association studies (GWAS) to identify genetic variation influencing susceptibility to citalopram-induced side effects. The analysis sample consisted of 1762 depression patients, successfully genotyped for 421K single-nucleotide polymorphisms (SNPs), from the Sequenced Treatment Alternatives to Relieve Depression (STAR(*)D) study. Outcomes included five indicators of citalopram side effects: general side effect burden, overall tolerability, sexual side effects, dizziness and vision/hearing side effects. Two SNPs met our genome-wide significance criterion (q<0.1), ensuring that, on average, only 10% of significant findings are false discoveries. In total, 12 additional SNPs demonstrated suggestive associations (q<0.5). The top finding was rs17135437, an intronic SNP within EMID2, mediating the effects of citalopram on vision/hearing side effects (P=3.27 × 10(-8), q=0.026). The second genome-wide significant finding, representing a haplotype spanning ∼30 kb and eight genotyped SNPs in a gene desert on chromosome 13, was associated with general side effect burden (P=3.22 × 10(-7), q=0.096). Suggestive findings were also found for SNPs at LAMA1, AOX2P, EGFLAM, FHIT and RTP2. Although our findings require replication and functional validation, this study demonstrates the potential of GWAS to discover genes and pathways that potentially mediate adverse effects of antidepressant medications.

Pharmacogenomic study of side-effects for antidepressant treatment options in STAR*D

BACKGROUND

Understanding individual differences in susceptibility to antidepressant therapy side-effects is essential to optimize the treatment of depression.

METHOD

We performed genome-wide association studies (GWAS) to search for genetic variation affecting the susceptibility to side-effects. The analysis sample consisted of 1439 depression patients, successfully genotyped for 421K single nucleotide polymorphisms (SNPs), from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Outcomes included four indicators of side-effects: general side-effect burden, sexual side-effects, dizziness and vision/hearing-related side-effects. Our criterion for genome-wide significance was a prespecified threshold ensuring that, on average, only 10% of the significant findings are false discoveries.

RESULTS

Thirty-four SNPs satisfied this criterion. The top finding indicated that 10 SNPs in SACM1L mediated the effects of bupropion on sexual side-effects (p = 4.98 × 10(-7), q = 0.023). Suggestive findings were also found for SNPs in MAGI2, DTWD1, WDFY4 and CHL1.

CONCLUSIONS

Although our findings require replication and functional validation, this study demonstrates the potential of GWAS to discover genes and pathways that could mediate adverse effects of antidepressant medication.

No association between hormonal abnormality and sexual dysfunction in Japanese schizophrenia patients treated with antipsychotics

OBJECTIVE

Although sexual dysfunction is believed to be caused by hormonal abnormalities, few reports have studied sexual dysfunction and its association with hormonal abnormalities in Asian populations with schizophrenia.

METHODS

We employed a cross-sectional, case-control survey design to collect data from 191 (108 men) Japanese schizophrenia outpatients treated with antipsychotics and 182 (49 men) healthy subjects. Sexual dysfunction was evaluated using the Udvalg for Kliniske Undersøgelser (UKU) Side Effect Rating Scale. We measured plasma concentrations of prolactin in both genders and testosterone in men and estradiol in women.

RESULTS

Multiple regression analyses revealed the following findings: the number of antipsychotics correlated with diminished sexual desire (standardized beta = 0.241, p < 0.05); the dose of antipsychotics correlated with gynecomastia (standardized beta = 0.277, p < 0.01), increased sexual desire (standardized beta = 0.229, p < 0.05), and ejaculatory dysfunction (standardized beta = 0.248, p < 0.05); and the dose of antipsychotics correlated with menorrhagia in women (standardized beta = 0.284, p < 0.05). However, neither plasma concentrations of prolactin, testosterone nor estradiol correlated with sexual dysfunction.

CONCLUSIONS

The present study demonstrated that an association between sex hormone abnormalities and sexual dysfunction is unlikely but that the dose or number of antipsychotics is associated with some sexual dysfunction.

Sexual dysfunction with the use of antidepressants in a tertiary care mental health setting - a retrospective case series

Sexual dysfunction affects patients’ quality of life. It can occur secondary to physical or mental disorders, substance abuse and treatment with prescription drugs like antidepressants. We wanted to study the prevalence of sexual dysfunction associated with antidepressant use in the psychiatric unit of a tertiary care hospital and assess for causality, severity and preventability. We did a retrospective data collection from case records of patients on antidepressants from the Psychiatry outpatient clinic of a tertiary care teaching hospital during the period 1^st January 2006 to 31^st December 2006, excluding those with complaints of sexual dysfunction prior to treatment. Data are presented as a case series. Documented adverse events were subjected to analysis for causality, severity and preventability using Naranjo's, modified Hartwig and Siegel and modified Schumock and Thornton's Preventability scales respectively. Out of 169 patients, four patients developed sexual dysfunction (2.36%) associated with duloxetine, mirtazapine, trazodone and sertraline. We observed a possible causal relationship of mild to moderately severe ADR (sexual dysfunction) which was not preventable. Prevalence of antidepressant associated sexual dysfunction was lower than quoted in Western literature probably due to the retrospective nature of our study design. Active monitoring and intervention can greatly improve the quality of life and compliance to treatment.

Prevalence and psychological impact of antidepressant-associated sexual dysfunction: a study from North India

This study attempted to estimate the prevalence and impact of sexual dysfunction on quality of life, treatment compliance, and dyadic adjustment with spouse. For this, 100 consenting subjects who had history of unipolar depression (as per Mini International Neuropsychiatric Interview) and were in remission (Hamilton Depression Rating Scale, <7) at time of intake and met the selection criteria were recruited. Then, they were assessed on Hamilton Anxiety Scale, Global Assessment of Functioning Scale, Compliance Rating Scale, Arizona Sexual Experience Questionnaire, World Health Organization Quality Of Life scale-BREF Version, and Dyadic Adjustment Scale. Twenty-three subjects were found to have sexual dysfunction. Nine subjects had dysfunction in the domain of desire, 5 had arousal difficulty, 6 subjects had problem with erection, and 8 subjects had problem with orgasm. Some of the subjects (n = 5) had sexual dysfunction in more than 1 domain. Significant difference was found between those with and without sexual dysfunction on dyadic adjustment scale and quality of life scale. However, no significant difference was seen on compliance rating scale and global assessment of functioning scale. From this study, it can be concluded that approximately one fourth of married male subjects experience antidepressant-associated sexual dysfunction. Antidepressant-associated sexual dysfunction contributes to poor quality of life and possibly contributes to poor marital adjustment. Hence, proper identification and management of sexual dysfunction is important to improve overall outcome of depression.

Sexual side effects of pharmacological treatment of psychiatric diseases

Since the introduction of psychiatric medications with relatively good safety profiles, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors, increasing attention has been given to side effects such as sexual dysfunction (SD), which, although unrelated to risks of mortality, could undermine compliance with treatment regimens and impair quality of life. Indeed,there is consistent evidence to suggest that a large number of psychiatric medications adversely affect one or more of the three phases of normal sexual response: desire, arousal, and orgasm.

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.

Sexual function during bupropion or paroxetine treatment of major depressive disorder

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Safety and efficacy of tramadol in the treatment of premature ejaculation: a double-blind, placebo-controlled, fixed-dose, randomized study

PURPOSE

To evaluate the efficacy and safety of a new serotonergic centrally acting drug tramadol in delaying ejaculation in patients with premature ejaculation.

MATERIALS AND METHODS

Sixty-four potent men with premature ejaculation were randomly assigned to receive 50 mg tramadol (group 1, n = 32) or placebo (group 2, n = 32) approximately 2 hours before planned sexual activity, for 8 weeks. Pretreatment evaluation included history and physical examination, intravaginal ejaculatory latency time, International Index of Erectile Function, and Meares-Stamey test. The efficacy of 2 treatments was assessed using responses to International Index of Erectile Function, intravaginal ejaculatory latency time evaluation, and several general assessment questions.

RESULTS

Fifty-seven (89%) completed the whole treatment schedule. The mean intravaginal ejaculatory latency time after tramadol and placebo increased from 19 and 21 seconds to approximately 243 and 34 seconds, respectively (P < 0.001). The mean weekly intercourse episodes increased from pretreatment values of 1.07 and 1.1 to 2.3 and 1.3, for tramadol and placebo, respectively (P < 0.05). Baseline mean intercourse satisfaction domain values of International Index of Erectile Function 10 and 11 reached to 14 and 10 at 8-week treatment in groups 1 and 2, respectively (P < 0.05). There was no withdrawal caused by adverse effects with tramadol or placebo, but more adverse events were associated with tramadol treatment (P < 0.05).

CONCLUSIONS

Tramadol seems to provide significantly better results in terms of intravaginal ejaculatory latency time and intercourse satisfaction versus placebo. Further studies are required to draw final conclusions on the efficacy of this drug in premature ejaculation.

First-episode schizophrenia: a focus on pharmacological treatment and safety considerations

Schizophrenia is a debilitating disorder, which is usually chronic, and is one of the most devastating medical illnesses. Early and appropriate treatment with antipsychotics is an important strategy for patients with first-episode schizophrenia. However, there are many possible safety issues for patients with schizophrenia that should be considered and properly addressed. Depressive symptoms and suicidal behaviour commonly occur in first-episode schizophrenic patients, and every effort should be made to treat and minimise these symptoms. There are also important issues and considerations in young and first-episode patients that should also be considered in the emergency treatment setting and for minimising medication nonadherence in this population. Most importantly, adverse effects should be considered, minimised and addressed. While first- and second-generation antipsychotics (SGAs) both appear to offer similar efficacy for amelioration of positive symptoms in first-episode patients, SGAs may offer better tolerability, specifically regarding extrapyramidal symptoms (EPS) and tardive dyskinesia risk, and some prolactin-sparing benefits. However, these medications do cause a host of adverse effects, including weight gain, metabolic disturbances, corrected QT interval prolongation and prolactin-related adverse effects, which are important considerations relating to both the short- and long-term safety of patients with schizophrenia being treated with SGAs. Clozapine and olanzapine are most likely to cause weight gain and metabolic effects, while risperidone is more likely to cause EPS and prolactin elevations. Most antipsychotics should be used in low doses to minimise adverse effects and each medication should be optimised in a highly individualised way to maximise adherence and treatment outcomes and minimise tolerability and safety concerns. At some point in their lives, these patients will most probably experience periods of depression, suicidal behaviours, adverse effects and nonadherence, and every effort should be made to minimise or prevent these from occurring. Thus, safety concerns in this group of young patients, in the beginning of their first psychotic episode, are a major issue as they are starting a journey of antipsychotic treatment that is likely to last for the remainder of their lives.

Safety and efficacy of citalopram in the treatment of premature ejaculation: a double-blind placebo-controlled, fixed dose, randomized study

We evaluate the efficacy and safety of citalopram, a potent and highly selective serotonin reuptake inhibitor (SSRI) antidepressant, in patients with premature ejaculation (PE). In total, 58 potent men with PE were included in the study. Patients were randomly assigned to receive 20 mg oral daily citalopram (group 1, n = 29) or placebo (group 2, n = 29), during a 12-week period for each agent. Pretreatment evaluation included history and physical examination, intravaginal ejaculatory latency time (IVELT) evaluation, International Index of Erectile Function (IIEF) and Meares-Stamey test. The efficacy of two treatments was assessed every 2 weeks during treatment, at the end of study and in 3- and 6-month follow-up after cessation of treatment, using responses to IIEF, IVELT evaluation, mean intercourse satisfaction domain, mean weekly coitus episodes and adverse drug effects. The trial was completed by 51 (88%) men. Analysis revealed a difference in the evolution of IVELT delay over time (P < 0.001). The IVELT after citalopram and placebo gradually increased from 32 and 28 s to approximately 268 and 38 s, respectively. The mean weekly intercourse episodes increased from pretreatment values of 1.3 and 1.2 to 2.4 and 1.4, for citalopram and placebo, respectively (P < 0.05). Baseline mean intercourse satisfaction domain values of IIEF 10 and 11 reached to 16 and 10 at 12-week treatment in groups 1 and 2, respectively (P < 0.05). Mean IVELT in group 1 was 210 and 198 s at 3- and 6-month follow-up, while in group 2 it was 27 and 25 s (P < 0.001), respectively. At 3- and six-month intercourse satisfaction domain values of IIEF were 15 and 14 in group 1 and 10 and 10 (P < 0.05) in group 2, respectively. Group 1 patients reported a significantly higher number of intercourse episodes per week (P < 0.05). Mean number of adverse events was 12 for citalopram and 4 for placebo (P < 0.05). In conclusion, these results indicate that citalopram has significantly better results in terms of IVELT and intercourse satisfaction versus placebo. Further studies with different dosages and treatment regimens are necessary to draw final conclusions on the efficacy of this drug in PE and to prolong the efficacy.

Venlafaxine extended release for the treatment of patients with premature ejaculation: a pilot, single-blind, placebo-controlled, fixed-dose crossover study on short-term administration of an antidepressant drug

In this study, we aimed at evaluating the efficacy and safety of venlafaxine extended release 75 mg, a serotonin and noradrenaline reuptake inhibitor, in the treatment of patients with premature ejaculation. Thirty-one patients with intravaginal ejaculation latency of less than 2 min received venlafaxine XR (75 mg/day) or placebo during a 2-week period for each agent with a washout period of 1 week between agents. Efficacy was assessed for each agent with changes in ejaculation latency measured with a stopwatch and sexual satisfaction scores of patients and partners. Side-effects, pre- and post-treatment levels of biochemical and spermiogram parameters, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin and total testosterone were recorded for each agent. Statistical analysis was performed on 21 patients. After 2 weeks of treatment with placebo and venlafaxine, ejaculation latency time was significantly increased from 60.1 +/- 39.1 to 126.9 +/- 98.3 sec and to 178.1 +/- 122.8 sec, respectively (p < 0.0001 for each one). However, the difference between the two agents was insignificant (p = 0.144). Venlafaxine and placebo increased sexual satisfaction scores of both patients and partners similarly, no statistically significant difference was found between them in this respect. The incidence of side-effects with venlafaxine was indifferent than that of placebo (p > 0.1) except nausea (p = 0.035). Both agents did not change the blood and spermiogram parameters significantly, except FSH increases. Short-term use of venlafaxine XR 75 mg has only a placebo effect on ejaculation latency and sexual satisfaction scores, therefore, is not appropriate for the patients with premature ejaculation. Further dose-time studies are required to draw final conclusions on the inefficacy of this drug in premature ejaculation.

A randomized open-label study of the impact of quetiapine versus risperidone on sexual functioning

OBJECTIVE

To compare sexual functioning in patients treated with quetiapine or risperidone.

METHODS

This open-label study included patients with schizophrenia or a related psychotic illness who were randomized to quetiapine (200-1200 mg/d) or risperidone (1-6 mg/d) for 6 weeks. Sexual dysfunction was assessed by a semistructured interview, the Antipsychotics and Sexual Functioning Questionnaire (ASFQ), based upon the Utvalg for Kliniske Undersogelser (UKU).

RESULTS

Four of 25 quetiapine-treated patients (16%) and 12 of 24 risperidone-treated patients (50%) reported sexual dysfunction (chi 2 = 6.4; df = 1; P = 0.006) on the ASFQ. Six patients (11.7%; 4 on risperidone, 2 on quetiapine) spontaneously reported sexual dysfunction. The mean+/-SD dose was 580+/-224 mg/d for quetiapine and 3.2 +/- 1.3 mg/d for risperidone. Mean +/- SD prolactin levels in quetiapine- and risperidone-treated patients were 13.8 +/- 17.9 and 57.7 +/- 39.7 ng/mL, respectively.

CONCLUSION

Sexual dysfunction was less common in patients treated with quetiapine than with risperidone. Direct questioning about sexual functioning is necessary to avoid underestimating the frequency of sexual side effects in patients with schizophrenia and related psychotic disorders.

What are the effects of antipsychotics on sexual dysfunctions and endocrine functioning?

The literature is reviewed and preliminary results of new studies are presented showing that treatment with classical antipsychotics, as well as risperidone, induces sexual dysfunctions in 30-60% of the patients. These antipsychotics also frequently induce amenorrhoea and galactorrhoea. Although comparative studies are rare, it is likely that prolactin-sparing antipsychotics, as recently shown in a randomized trial of olanzapine versus risperidone, induce less sexual side effects.From these studies, it becomes apparent that prolactin elevation induced by classical antipsychotics and risperidone is probably a factor in inducing sexual dysfunctions, amenorrhoea and galactorrhoea. The role of other factors inducing sexual dysfunctions like sedation, proportional, variant -blockade, testosterone, dopamine, and serotonin is discussed. Finally, it is concluded that sexual and hormonal effects of antipsychotics, although clearly important, are often neglected in research as in clinical practice. Lowering the dosage or switching to a prolactin-sparing antipsychotic often reduces sexual side effects, amenorrhoea, and galactorrhoea.

The nature of human orgasm: a critical review of major trends

This critical review presents a synthesis of the available theoretical and empirical literatures on human orgasm. Findings from both normal and clinical human populations are included. Two major trends in the literature, the dichotomization of biological and psychological perspectives and the assumption of gender differences, are highlighted. A new multidimensional model of the psychological experience of orgasm is described with a view to futhering a biopsychological approach applicable to both sexes. Clinical applications of this new model are discussed.

Failure of tolterodine to treat clozapine-induced nocturnal enuresis

OBJECTIVE

To report the use and subsequent failure of the bladder-selective agent tolterodine, to treat clozapine-induced nocturnal enuresis in an adolescent patient with psychotic illness.

CASE SUMMARY

A 16-year-old Hispanic girl was admitted to the state psychiatric hospital with a diagnosis of bipolar disorder with psychotic features. Clozapine therapy was initiated, and after three months of treatment the patient began experiencing episodes of nocturnal enuresis. The bladder-selective agent tolterodine was tried and subsequently failed to resolve the enuresis episodes. Desmopressin was initiated, which resulted in amelioration of symptoms.

DISCUSSION

This is the first published report of using tolterodine to treat clozapine-induced nocturnal enuresis. Several methods to decrease clozapine-induced urinary incontinence have been used and typically include the addition of agents with high anticholinergic properties. Tolterodine is a bladder-selective anticholinergic agent indicated for the treatment of urinary urge incontinence and may be employed as a treatment for antipsychotic-induced incontinence.

CONCLUSIONS

Nocturnal enuresis is an adverse effect that infrequently occurs with use of clozapine therapy. Although tolterodine was ineffective in our patient to treat clozapine-induced nocturnal enuresis, further trials are required to appropriately evaluate the effectiveness of tolterodine to treat this adverse drug reaction.

Who develops severe or fatal adverse drug reactions to selective serotonin reuptake inhibitors?

OBJECTIVE

To ascertain the risk factors associated with the development of severe and fatal adverse drug reactions (ADRs) or intentional overdoses by patients on selective serotonin reuptake inhibitors (SSRIs).

METHODS

We undertook a data analysis of Health Canada's database of Adverse Drug Reactions to SSRIs from 1986 to 1996, as well as a literature review.

RESULTS

Among the complete ADR reports in the SSRI database, there were no sex differences in occurrences of all ADRs (n = 1011), severe ADRs (n = 295), drug-drug interactions (n = 312), deaths (n = 87), or intentional overdoses (n = 79), when sex differences in prescription practices were considered. There were no differences in ADR rates among different SSRIs. The most common cause of death among patients taking SSRIs was intentional overdose (n = 65, 74.7%). This was reported in 47 (72.3%) women and 18 (27.7%) men. The most common drugs taken with SSRIs in patients who died of intentional overdoses were benzodiazepines, tricyclic antidepressants (TCAs), narcotics, alcohol, and diphenhydramine. Patients who had severe or fatal ADRs were more likely to be taking an SSRI with 2 or more other drugs, including alcohol. Drug combinations that included another CYP-450 drug were especially problematic. A total of 129 cardiovascular ADRs were reported, most of which were severe. These included rhythm disturbances, blood pressure perturbations, and chest pain or angina. Cardiovascular ADRs most often occurred with concomitant drug use of benzodiazepines, TCAs, histamine H2 antagonists, lithium, and calcium channel blockers. There were 3 deaths from malignant neuroleptic syndrome unassociated with intentional overdose.

CONCLUSIONS

SSRIs are relatively safe when their widespread use is compared with the prevalence of ADRs. SSRIs may, however, be associated with ADRs, and even death, following intentional overdose or when taken with 2 or more other drugs or alcohol (particularly another drug metabolized by CYP-450). Physicians prescribing SSRIs need to consider drug-drug interactions and carefully monitor patients with severe affective disorders, comorbid medical conditions (especially cardiovascular disease), alcohol abuse, or a history of overdosing.

Serum prolactin levels and sexual dysfunctions in antipsychotic medication, such as risperidone: a review

Classical antipsychotic drugs increase the level of serum prolactin. The atypical antipsychotic clozapine barely increases prolactin levels. An open naturalistic study in the University Hospital of Groningen suggests that treatment with risperidone in comparison to classical antipsychotics seems to increase the risk of erectile and ejaculatory disorders in male patients and to menstrual disturbances in female patients. In the literature reviewed, risperidone is associated with higher prolactin levels in comparison to classical antipsychotics. It is still unclear which mechanism is responsible for the increase of serum prolactin levels and sexual dysfunctions in patients using risperidone. Dopaminergic and serotonergic receptor blockade seems to play an important role. Other mechanisms are discussed.

Effects of SSRIs on sexual function: a critical review

Sexual problems are highly prevalent in both men and women and are affected by, among other factors, mood state, interpersonal functioning, and psychotropic medications. The incidence of antidepressant-induced sexual dysfunction is difficult to estimate because of the potentially confounding effects of the illness itself, social and interpersonal comorbidities, medication effects, and design and assessment problems in most studies. Estimates of sexual dysfunction vary from a small percentage to more than 80%. This article reviews current evidence regarding sexual side effects of selective serotonin reuptake inhibitors (SSRIs). Among the sexual side effects most commonly associated with SSRIs are delayed ejaculation and absent or delayed orgasm. Sexual desire (libido) and arousal difficulties are also frequently reported, although the specific association of these disorders to SSRI use has not been consistently shown. The effects of SSRIs on sexual functioning seem strongly dose-related and may vary among the group according to serotonin and dopamine reuptake mechanisms, induction of prolactin release, anticholinergic effects, inhibition of nitric oxide synthetase, and propensity for accumulation over time. A variety of strategies have been reported in the management of SSRI-induced sexual dysfunction, including waiting for tolerance to develop, dosage reduction, drug holidays, substitution of another antidepressant drug, and various augmentation strategies with 5-hydroxytryptamine-2 (5-HT2), 5-HT3, and alpha2 adrenergic receptor antagonists, 5-HT1A and dopamine receptor agonists, and phosphodiesterase (PDE5) enzyme inhibitors. Sexual side effects of SSRIs should not be viewed as entirely negative; some studies have shown improved control of premature ejaculation in men. The impacts of sexual side effects of SSRIs on treatment compliance and on patients' quality of life are important clinical considerations.

A critical review of selective serotonin reuptake inhibitor-related sexual dysfunction; incidence, possible aetiology and implications for management

There is a high incidence of sexual dysfunction in the general population and sexual dysfunction is often an integral symptom of a depressive disorder. In addition, all antidepressants have effects on sexual functioning, as the result of side-effects of these medications and as a reflection of therapeutic success. The selective serotonin reuptake inhibitors (SSRIs) are clearly associated with delayed ejaculation, inability to ejaculate and absent or delayed orgasm. Furthermore, the incidence of sexual dysfunction obtained by patient self-report does not appear to reflect the true incidence of sexual dysfunction associated with antidepressant therapy and systematic inquiry is needed as sexual dysfunction may be an unrecognized cause of noncompliance. The SSRIs may have advantageous effects on sexual functioning and these may also be underreported due to the same factors resulting in an under-reporting of sexual side-effects in general. In addition, studies have suggested a role for the SSRIs in the management of premature ejaculation. The effects of SSRIs on sexual functioning are clearly dose-related and may vary amongst the group due to their relative effects on the serotonin and dopamine systems and the extent to which plasma levels of these drugs accumulate in the body over time. A variety of strategies have been found useful in the management of SSRI-induced sexual dysfunction including waiting for tolerance to develop, dosage reduction, drug holidays, switching to a different antidepressant and various augmentation strategies with 5-HT2, alpha2 adrenergic receptor antagonists and dopamine receptor agonists.

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

The authors analyzed the incidence of sexual dysfunction (SD) with different selective serotonin reuptake inhibitors (SSRIs; fluoxetine, fluvoxamine, paroxetine, and sertraline) and hence the qualitative and quantitative changes in SD throughout time in a prospective and multicenter study. Outpatients (192 women and 152 men; age = 39.6 +/- 11.4 years) under treatment with SSRIs were interviewed with an SD questionnaire designed for this purpose by the authors and that included questions about the following: decreased libido, delayed orgasm or anorgasmia, delayed ejaculation, inability to ejaculate, impotence, and general sexual satisfaction. Patients with the following criteria were included: normal sexual function before SSRI intake, exclusive treatment with SSRIs or treatment associated with benzodiazepines, previous heterosexual or self-erotic current sexual practices. Excluded were patients with previous sexual dysfunction, association of SSRIs with neuroleptics, recent hormone intake, and significant medical illnesses. There was a significant increase in the incidence of SD when physicians asked the patients direct questions (58%) versus when SD was spontaneously reported (14%). There were some significant differences among different SSRIs: paroxetine provoked more delay of orgasm or ejaculation and more impotence than fluvoxamine, fluoxetine and sertraline (chi 2, p < .05). Only 24.5% of the patients had a good tolerance of their sexual dysfunction. Twelve male patients who suffered from premature ejaculation before the treatment preferred to maintain delayed ejaculation, and their sexual satisfaction, and that of their partners, clearly improved. Sexual dysfunction was positively correlated with dose. Patients experienced substantial improvement in sexual function when the dose was diminished or the drug was withdrawn. Men showed more incidence of sexual dysfunction than women, but women's sexual dysfunction was more intense than men's. In only 5.8% of patients, the dysfunction disappeared completely within 6 months, but 81.4% showed no improvement at all by the end of this period. Twelve of 15 patients experienced total improvement when the treatment was changed to moclobemide (450-600 mg/day), and 3 of 5 patients improved when treatment was changed to amineptine (200 mg/day).

Management of chronic pain. Part I

Chronic pain is associated with substantial psychosocial and economic stress, coupled with functional loss and various levels of vocational dysfunction. The role of a pain center is to focus on chronic pain in a multidisciplinary, comprehensive manner, providing the patient with the most effective opportunity to manage his or her chronic disease syndrome. This article focuses on methods to manage many types of chronic pain and describes a broad range of pharmacologic and nonpharmacologic interventions and options available to the patient. Part I of this two-part monograph describes pharmacotherapeutic interventions and regional nerve blocks. Part II focuses on psychologic assessment and treatment and physical therapy. A multimodal management strategy offers patients the greatest improvement potential for specific chronic pain syndromes. Cognitive and behavioral therapies and physical therapies are described. This combination of therapies may provide patients with the skills and knowledge needed to increase their sense of control over pain. The integration of appropriate pharmacotherapeutic regimens, neural blockades, physical therapy, and psychologic techniques maximizes a patient's effectiveness in dealing with chronic pain. Three case studies are presented in Part II.

Treatment of antidepressant-induced sexual side effects

Sexual side effects of antidepressant medications are becoming more frequently encountered by patients who require pharmacotherapy. A MEDLINE search was conducted to generate articles that address methods of treating these iatrogenically induced clinical situations. We report here on treatment strategies to alleviate these adverse events. We conclude that clinicians should routinely ask about sexual side effects due to antidepressants and that they should be treated promptly to ensure patient compliance with antidepressant pharmacotherapy.

Antidepressants in the treatment of premature ejaculation

The SSRI antidepressants have emerged as effective new treatment for patients with premature ejaculation whether or not these patients suffer from depression. Clomipramine, fluoxetine, paroxetine, and sertraline seem to be a safe treatment option for patients with premature ejaculation, especially in cases of failed psychological treatment, in rejection of psychological treatment, and when partners are unwilling to cooperate in treatment. Further controlled and larger studies that focus on clinically relevant issues such as dose, length of treatment, maintenance of beneficial effects after treatment discontinuation, and the combination of pharmaco- and behavior therapy for premature ejaculation are warranted. Other medications, such as benzodiazepines, may be useful in some cases of premature ejaculation.

Sexual disorders in nonacute psychiatric outpatients

One hundred schizophrenics and 58 patients with an affective psychosis who were in relatively stable condition and were being treated as outpatients, as well as 30 patients receiving dermatological treatment, were questioned in a semistructured interview about their sexual history. Forty-nine percent of schizophrenics, 36.2% of those with affective disorders, and 13.3% of control patients had a sexual dysfunction. The most frequent form experienced by psychiatric patients was hypoactive sexual desire disorder. Underlying causes were presumed to be multifactorial in most cases (expert rating). The patients most frequently affected by sexual dysfunctions were schizophrenics on neuroleptic medication, whereas schizophrenic patients not on any medication had fewer dysfunctions and control patients were only minimally affected. Neither the nature of the psychopharmaceuticals nor the dose level had a specific influence on the frequency of sexual dysfunctions.

Sexual side effects of antidepressants: a review

Antidepressant-induced adverse sexual effects are becoming more frequently reported by patients who require pharmacotherapy. A MED-LINE search was conducted to generate articles reporting such events. We report here on the sexual side effects associated with tricyclics, monoamine oxidase inhibitors including moclobemide, selective serotonin reuptake inhibitors, bupropion, and on the newer antidepressants venlafaxine and nefazadone. We conclude that adverse sexual effects are an increasingly important side effect of antidepressant medications, and patients must be routinely asked about their occurrence.

Female sexual side effects associated with selective serotonin reuptake inhibitors: a descriptive clinical study of 33 patients

OBJECTIVE

After the advent of selective serotonin reuptake inhibitors on the U.S. market in 1988, American psychiatrists have been faced with more choices of antidepressants for the treatment of depression. The prescribing of SSRIs has been increasing in popularity because they are easily titrated by the physicians and tolerated by patients. However, the SSRI use is frequently associated with female sexual dysfunction. The aim of this study was to describe these SSRI-associated female sexual side effects.

METHODS

In a retrospective series, clinic records of 110 female SSRI-treated outpatients were reviewed for loss of or decreased libido, orgasmic disturbances (anorgasmia or delayed orgasm), as well as clinical management patterns to alleviate sexual side effects.

RESULTS

Twenty-one fluoxetine-, nine paroxetine-, and five sertraline-treated cases with female sexual inhibition were identified. The fates of SSRI-associated sexual adverse effects and clinical managements of restoring these side effects were described.

CONCLUSIONS

With some limitations in interpreting the data, the findings of this study suggest that SSRI-associated female sexual dysfunction occurs at a higher rate than we previously thought, equal potentials in implicating female sexual side effects among three SSRIs, and the absence or the low incidence of female sexual adverse effects from bupropion, and that these side effects can be managed by waiting for a spontaneous remission, dosage reduction of SSRIs, substitution with bupropion and other antidepressants, or the use of an antidote.