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Depression and Sexual Dysfunction

in Primary Practice
Dr.Lahargo Kembaren, SpKJ

Pertemuan Ilmiah Tahunan XII – IDI Kota Bogor, 20-21 Juli 2019
 Normal sexual function is a biopsychosocial process;
sexual dysfunction almost always has organic and
psychological components and requires multidisciplinary,
goal-directed evaluation and treatment.
 Sexual dysfunction is a common symptom of depression.
 Sexual dysfunction is also a frequent adverse effect of
treatment with most antidepressants and is one of the
predominant reasons for premature drug discontinuation.
Symptoms of Depression

Persistent sadness, Lack of interest or Changes in appetite

restlessness, pleasure in hobbies or with significant weight
anxiousness, irritability activities once enjoyed, loss or weight gain not
and/or tension including SEX due to dieting

Sleeping too much or Loss of energy or Feelings of

too little; insomnia; increased fatigue; worthlessness,
middle of the night or feeling tired despite hopelessness or
early morning waking lack of activity inappropriate guilt

Difficulty thinking,
Thoughts of suicide or Persistent physical
death or attempts at symptoms that do not
remembering or
suicide respond to treatment
making decisions
Stahl's Essential Psychopharmacology
How common are antidepressants used?

Skye Gould and Lauren F Friedman, 2016

Sexual Dysfunction

 Sexual dysfunction could affect

any of the following phases of the
sexual response cycle:
 Desire  decreased libido
 Arousal/ erection  Erectile
 Orgasm  Anorgasmia
 Ejaculation  Delayed ejaculation
The relationship between sexual dysfunction and depression

 Depression itself can cause sexual dysfunction in 50%

of patients.
Angst J. (1998) and Kennedy SH et al (1999).

 Treatment with SSRI helps improving sexual

satisfaction in those with depression and sexual
Baldwin DS and Foong T (2013).
The relationship between sexual dysfunction and depression

 A systematic review and meta-analysis by Atlantis and

Sullivan (2012) concluded the presence of
bidirectional association between depression and
sexual dysfunction, and that the presence of one
necessitate the screening of the another.
Atlantis and Sullivan (2012).
 Amongst those presenting with sexual dysfunction,
some will see an improvement, some no change and
some a worsening when taking on antidepressant.
Werneke U et al (2006)
Antidepressants-induced sexual dysfunction

 Consequences of antidepressants-induced sexual

 Early discontinuation of antidepressant.
 Relapse of depression.
 Poor quality of life.

Gregorian et al 2002; Rosenberg et al 2003; Clayton and Balon 2009,

in Reichenpfader et al 2014.
 Men showed more incidence of sexual dysfunction than
women, but women's sexual dysfunction was more intense
than men's.
 Incidence of antidepressant-indeuced sexual dysfunction was
higher when asked directly (58%) than when reported
spontaneously (14%).
(Montejo-González et al 1997)
 Both men and women who are taking
antidepressants should be asked whether
sexual side effects are occurring with these
Practice guideline for the treatment of patients with major depressive disorder.
American Psychiatric Association (APA).
Mechanisms by which antidepressants
cause sexual dysfunction
 The mesolimbic system has an essential role in sexuality,
mediated by dopaminergic neurotransmission
Segraves (1989), Bitran et al (1988) and Baldessarini and Marsh (1990) in Serretti and
Chiesa (2009)
 Serotonin reuptake blockade reduce dopamine activity in
that area through 5-HT₂ receptors
Baldessarini (1990) and Meltzer (1979) in Serrtti and Chiesa (2009)
Mechanisms by which antidepressants
cause sexual dysfunction

Arousal dysfunction
 Low dopamine in the mesolimbic system.
 Inhibition of peripheral spinal reflexes of the sympathetic
and parasympathetic systems which mediate erection and
clitoral engorgement and this is influenced by several
neurotransmitters including serotonin.

Segraves (1989), Bitran et al (1988) and Pollack (1992) in Serretti and Chiesa (2009).
Mechanisms by which antidepressants
cause sexual dysfunction
Orgasm dysfunction
 related to low dopamine and noradrenaline levels caused
by 5-HT₂ activation.
Pollack et al (1992), Zajecka et al (1991) and Crenshaw (1996) in Serretti and Chiesa
 Those changes seems to alter the sympathetic and
parasympathetic systems, that are essential for orgasm
and ejaculation.
Bitran et al (1988) and Pollack et al (1992) in Serretti and Chiesa (2009)
Managements of Sexual Dysfunction

Drugs and Medicines Psychological induced sexual
• Endocrine • Cardiovascular • Predisposising • Wait for
• Vascular • Psychotropics factors spontaneous
• Neurological • Gastrointestinal • Precipitating factors resolution.
• Local genital disease • Maintaning factors • Drug holiday.
• Systemic disease • Decrease the dose.
• Surgical post • Switch to another
operative antidepressants.
• Augmentation with
(add) another
Medical and Surgical Condition

Shafer L (2016)
Medical and Surgical Condition

Shafer L (2016)
Drugs and Medicines

Shafer L (2016)
Drugs and Medicines

Shafer L (2016)

Shafer L (2016)
How to treat Antidepressant-induced
sexual dysfunction

Wait for Switch to Augmentation

spontaneous Drug holiday. another anti with (add)
the dose.
resolution. depressants. another agent.
Wait for Spontaneous resolution

 19-30% of patients with antidepressant-induced sexual

dysfunction have moderate to total regain of their sexual
functions after 6 months of using antidepressants.

Serretti and Chiesa (2009) and Montejo-González et al (1997).

Drug holiday
 Rothschild (1995) concluded that holding the
antidepressant during the weekend for those on
paroxetine or sertraline (but not fluoxetine) significantly
improved sexual functioning without significant worsening
of depressive symptoms.
 Maudsley prescribing guidelines in psychiatry doesn’t
prefer this strategy as it may carry a risk for relapse of
depression or experiencing antidepressant
discontinuation symptoms.
Decrease the dose
 Antidepressant-induced sexual dysfunction appears to be
Zajecka (2001)
 In a prospective observational study, 77% had moderate
to complete improvement in sexual functioning when
antidepressant dose was reduced by 50%.
Montejo-González et al (1997).
Switch to another antidepressant:

 Bupropion
 Agomelatine
 Mirtazapine
 Nefazodone
 Moclobemide
 Selegiline

5 inhibitors


 A systematic review and meta-analysis (Taylor MJ et al

2013) favoured bupropion as an augmenting agent over
(SMD: 1.60, 95% CI 1.40 to 1.81)
 ‘The most promising approach studied so far’ in treating
women with antidepressant-induced sexual dysfunction.
(Taylor et al 2013)
Phosphodiesterase-5 inhibitors

 Sildenafil: Metal-analysis (Taylor MJ et al 2013) found that

sildenafil (50 to 100 mg on demand) was associated with
greater improvement of antidepressant-induced erectile
dysfunction than placebo.
(MD 1.04, 95%CI 0.65 to 1.44)
 An 8-week trial found that sildenafil (50 to 100 mg on
demand) helped women who have disturbed orgasm due to
antidepressants more than placebo (72 vs 27 %).
(Nurnberg et al. 2008)

 Phosphodiesterase-5 inhibitors: The most favoured approach

for men with erectile dysfunction caused by antidepressants.
(Taylor 2013).

 A systematic review and meta-analysis (Taylor MJ et al

2013) found no benefit of mirtazapine as an augmenting
 Another two studies showed reduction of sexual
side‐effects in patients treated with duloxetine or SSRIs
when mirtazapine was added.
Ravindran LN et al (2008) and Ozmenler NK et al (2008).
 30 minutes of moderate strength training and
cardiovascular exercise immediately before sexual activity
improved sexual desire and global sexual function in
women compared to exercise separate from sexual
 High dropout rate (46 %).
(Lorenz TA and Meston CM 2014)

 Improved overall sexual satisfaction in SSRI-induced

sexual dysfunction in both men and women.
Modabbemia et al (2012) and Kashani et al (2013)

 Sexual dysfunction is one of the most frequent and

problematic side effects of antidepressants.
 It can affect not only sexual functioning, but also worsen
the depressive illness and quality of life.
 It's prevalence is underreported.
 Direct questioning is essential to pick up patients with
this side effect.

 Depression and sexual dysfunction has a reciprocal

 A thorough assessment for risk factors contributing to
 sexual dysfunction is important to improve overall
 Many strategies have been suggested to manage
antidepressantinduced sexual dysfunction, many of which
are with insufficient body of evidence.
Thank You!