Sexual side effects on SSRIs are so common that psychiatrist David Healy once argued these drugs more reliably lower libido than treat depression. Yet the problem isn’t limited to SSRIs, and it’s not unmanageable. In this episode Chris Aiken, MD, and Kellie Newsome, RN, discuss some useful strategies to manage sexual dysfunction on antidepressants, antipsychotics, and mood stabilizers.
Publication Date: 5/13/19
Runtime: 9 mins, 10 seconds
Article Referenced: "Treating Sexual Side Effects," The Carlat Psychiatry Report, May 2019
Kellie: Last night, I was laying in my bed finishing reading this particular article on my iPad and as I put my iPad down, I stared at the ceiling and felt really glad that the Carlat Report covered this topic on sexual dysfunction and psychiatric medications.
Dr. Aiken: And we’ll be bringing you some highlights from that article in this podcast.
Kellie: Welcome to the inaugural edition of The Carlat Psychiatry Podcast, a weekly podcast brought to you by The Carlat Psychiatry Report, a CME publication, keeping psychiatry honest since 2003. I’m Kellie Newsome, a psychiatric NP student and a dedicated reader of every issue.
Dr. Aiken: And I’m Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.
Kellie: Dr. Adam Strassberg’s mention of how SSRI’s are capable of lowering libido, more than treating actual depression which is the very reason that these medicines are prescribed to begin with, which was really astounding to me. Dr. Aiken, can you sort of share some insight into this?
Dr. Aiken: Yes. He drew that from the rather astonishing fact that only 30% of people who take an SSRI for depression actually recover fully on them. That’s what we know from the STAR-D trial and from other metanalyses of depression trials. But around 60 to 70 percent actually have sexual dysfunction on them. So, yes, statistically he’s right. These meds are more reliable at lowering sexual function than they are at treating depression.
Kellie: Those numbers are awful!
Dr. Aiken: I agree.
Kellie: Ugh. Well, it seems that we in psychiatry can’t seem to figure out if our patients are depressed because they aren’t having sex or if it’s because of taking the SSRI medications.
Dr. Aiken: Depression is caused by many things and we need to bear in mind that sexual dysfunction itself can cause depression. We know that in part from studies of men with erectile dysfunction. I’ll tell you about a few. They took men with ED who had mild depression and gave half of them Viagra and the other half a sugar pill and, lo and behold, of course the Viagra treated their ED, but it also lifted their depression.
Kellie: Okay. So, I want to understand more about this Viagra medication, especially the part where it mentions it can work in both genders.
“And the Carlat Report slipped in a nice chart for easy reference on the medications with a low risk of side effects, as well as one with the seven antidotes for sexual dysfunction when on a serotonergic antidepressant.”
I cut mine out, personally, and I’m going to use it as a handy reference, but I want to know more.
Dr. Aiken: The way we developed that chart was simply taking everything that had at least one randomized controlled trial for sexual dysfunction. And most of the studies were done on SSRI’s. There were other studies done on antipsychotics and mood stabilizers that we touched on elsewhere. And you notice that at the top of the chart is Viagra/sildenafil both for men and women. And yes, indeed. It is the best studied antidote for sexual dysfunction on SSRI’s in both genders. I have always been surprised by that.
You know, a lot of our readers may know the study in women was a large one in the medical journal, JAMA. But it’s really hard to get women to take that. Women don’t want to bring a prescription for Viagra to the pharmacy. And one thing I learned from Dr. Strassberg’s work is these medications don’t just work by enhancing blood flow to the penis and clitoris. They actually work in the brain. Taking sildenafil increases dopamine transmission in the nucleus accumbens, also known as “the pleasure center”. So, they’re having central effects and I think that’s helpful to educate all patients, particularly women, as to why we’re giving them these medications to treat their sexual dysfunction.
Kellie: So, it seems to me like it’s such a sensitive issue, but what’s the best way? How do we ask them about their sex lives?
Dr. Aiken: Most patients aren’t going to readily bring up their sex lives in an interview, unless you’ve let that patient know that you’re comfortable hearing about it and that you’re an ally with them along the way. So, what Dr. Strassberg recommends doing is addressing it very neutrally and directly at the beginning before you prescribe the medication, warning them that this might happen and that you’ll be there to troubleshoot it with them.
And I find that to be true, too, regardless of what the symptom is, we need to create an environment where patients are comfortable talking with us about anything and they know that we’re comfortable as medical providers listening to what they have to say; that talking about their sex drive, really, to us is no different from talking about weight gain or hair loss.
Kellie: This is really helpful. I found this article totally informative on all the strategies to improve sexual dysfunction, sex lives, and all things that people can do. But I have to ask this one. At what point do we just give up and get a new partner. I mean, if all this doesn’t work, I think that has to be looked at and addressed.
Dr. Aiken: That’s a good point and it reminds me of a story I don’t often tell, but I’ll let it out here. A friend of mine is a French psychiatrist and he told me that his patients with SSRI-induced sexual dysfunction, it somehow goes away when they go out with their mistress. So, novelty can change this, but that’s not really a permanent solution, right? Because novelty wears off. But it is something that therapists for sexual dysfunction use and Dr. Strassberg talks about that, that antidotes and medications are not the only answer but often referring for couples counseling or sex therapy. And one thing they’ll do is have the couple do more novel things together, so try new activities, new experiences – both sexual and nonsexual – to stimulate that nucleus accumbens and hopefully regenerate some of that dopamine that’s being depleted, which is one of the possible pathways by which this happens.
Kellie: That actually reminds me of that term “emotional blunting”.
Dr. Aiken: Yes. Emotional blunting or apathy is another potential side effect to SSRI’s and some people speculate that it is related to sexual dysfunction. That in other words, these patients might be having apathy across the board, not just to sexual encounters. The one person who believes that is Dr. Helen Fisher. We didn’t get into this in the article, but I think it is worth mentioning. She’s a biological anthropologist and she does studies of sexual behavior.
One way she looks at that is having young adults look at pictures of the opposite sex to see how they react. And she has a study, at least one, where she was able to show that taking an SSRI blunted the reaction to just pictures. So, they might be affecting romantic behavior as well as sex itself. Specifically what she found is that the women who were put on the SSRI rated the pictures of men as less attractive and they looked at them for shorter periods of time. They just weren’t as interested.
So, if a patient brings up apathy on a serotonergic agent, I would definitely wonder if their sex drive is also squashed and ask them about that.
Well, that’s all until next Monday where I hope you’ll be joining us for our second edition. We’ll be talking about a certain lap dancing drug rep who’s been making headlines lately.
Kellie: Wait! Are we going to be talking about sex again?
Dr. Aiken: No. Actually, next week we’re going to talk about money and some really disgusting things that the pharmaceutical industry has been doing recently. The lap dancing drug rep is unfortunately real, and it’s just the tip of the iceberg.
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