Antidepressant-Induced Sexual Dysfunction
ABSTRACT & COMMENTARY
Source: Kennedy SH, et al. Antidepressant-induced sexual dysfunction during treatment with moclobemide, paroxetine, sertraline, and venlafaxine. J Clin Psychiatry 2000;61:276-281.
Reports on the frequency of antidepressant-induced sexual dysfunction have been inconsistent due to underreporting and lack of systematic data collection. For selective serotonin reuptake inhibitors (SSRIs), the rates have varied from 20% to 50%.1,2 Nefazodone (Serzone) and bupropion (Wellbutrin SR) appear to have fewer such side effects.3,4 Kennedy and associates report from their clinics that sexual dysfunction occurs at rates of 15-45% of depressed patients not taking an antidepressant.
The study recruited physically healthy, adult patients with depression via the Structured Clinical Interview for DSM-IV (SCID) and a minimum of 16 on the 17-item Hamilton Rating Scale for Depression (HAM-D). Subjects were off medication for at least two weeks (5 weeks for those who had recently been on fluoxetine) and were required to have reported sexual activity during the past month. Subjects completed a self-report questionnaire (Sexual Functioning Questionnaire [SFQ]) to assess desire, arousal, and orgasm.5 The SFQ uses a three-point Likert scale with 4-5 questions in each domain. Clinicians prescribed the "most appropriate antidepressant" from among the four study drugs at the initial visit and followed patients every two weeks. The HAM-D and SFQ were completed at baseline (Time 1) and at completion (8-14 week follow-up; Time 2).
Of 174 patients entered, 107 (61%) completed the study; no demographic or clinical differences were found between completers and noncompleters. Only six patients were taking other psychotropic medication (i.e., hypnotics). There were no demographic or clinical differences between the four medication groups: their mean age was 38 years; mean number of prior episodes was two; mean duration of the current episode was 65 weeks; and mean dose was 485 mg (moclobemide), 99 mg (sertraline), 30 mg (paroxetine), and 151 mg (venlafaxine). Compared with women, men experienced a significantly greater level of drug-related impairment in drive/desire (38-50% for men and 26-32% for women); differences in terms of arousal/orgasm were not significant (48-50% for men and 28-34% for women). No differences were found across the antidepressants in men, but sexual dysfunction was significantly worse for women using sertraline and paroxetine compared to moclobemide. The rates of sexual dysfunction of venlafaxine fell between the SSRIs and moclobemide. Time 1 levels of sexual dysfunction did not predict the same at Time 2. All four drugs were equally effective in treating depression. Finally, an unexpected relationship was found between favorable drug response and a decreased level of drug-induced sexual dysfunction. The Kennedy et al data compares favorably with others’ data. They say venlafaxine’s lower rate of sexual dysfunction might be attributable to its noradrenergic activity, particularly at high doses.
COMMENT BY DONALD M. HILTY, MD
In the evaluation and management of sexual dysfunction, two key pieces of information are often overlooked that could lead to misattribution of the problem to medication. First, what is the level of interest and performance at baseline, including the contribution of relationships with spouses, significant others, etc., before the onset of depression. Second, what effect(s) does the depression have on level of interest and performance individually and in relation to others. This study assessed the second issue and nicely evaluated sexual dysfunction in an ongoing fashion. The results of the study should also be considered in light of the antidepressant dosing, which may be a key variable in the incidence of sexual dysfunction; it would be helpful to have fixed dose trials to evaluate incidence. One other potential limitation is the lack of operational definition of clinicians prescribing the "most appropriate antidepressant" for subjects.
It was interesting that a favorable drug response was associated with a decreased level of drug-induced sexual dysfunction. This could be taken at face value. But we do not know specifically if, and how, depressed mood and/or return to euthymia affects one’s perception of sexual dysfunction. In addition, attrition may have "produced" this finding (i.e., subjects who left were not responding or had more sexual dysfunction). v
References
1. Margolese HC, et al. Sexual side effects of antidepressants: A review. J Sex Marital Ther 1996;22:209-217.
2. Physicians’ Desk Reference. Montvale, NJ: Medical Economics; 1995.
3. Feiger A, et al. Nefazodone versus sertraline in outpatients with major depression: Focus on efficacy, tolerability, and effects on sexual function and satisfaction. J Clin Psychiatry 1996;57(suppl 2):53-62.
4. Kavoussi RJ, et al. Double-blind comparison of bupropion sustained release and sertraline in depressed outpatients. J Clin Psychiatry 1997;58:532-537.
5. Kennedy SH, et al. Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord 1999;56:197-204.
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