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Antidepressants and psychosexual dysfunction: Module 1 - Diagnosis
Page 1 of 13
TAKE-HOME NOTES:
Antidepressants and psychosexual dysfunction: Module 1 - Diagnosis
Dr Ursula Werneke
In this module, we have looked at how to diagnose antidepressant-associated sexual dysfunction.
We started by looking at the physiology of sexual function, particularly the neurotransmitters and
hormones which either promote or inhibit a sexual response.
We then explored the possible role of antidepressants in the generation and maintenance of sexual
dysfunction. We looked at the prevalence of clinically reported sexual dysfunction, then
examined how far receptor profiles of individual antidepressants matched the reported prevalence
estimates. Finally, we reviewed how to establish a differential diagnosis of sexual dysfunction.
Here are the key points to remember:
Many patients with depressive disorders suffer from disturbance of sexual function, which can
affect sexual desire (libido), arousal including erection and vaginal lubrication and orgasm including ejaculation.
Establishing the cause of sexual dysfunction in depressed patients can be difficult. The
differential diagnosis must include a primary sexual dysfunction and secondary sexual
dysfunction.
Primary sexual dysfunction implies an absence of normal sexual function ever.
Secondary sexual dysfunction is defined as an acquired loss of sexual function.
Secondary sexual dysfunction can be associated with general medical and psychiatric disorders, and sexual dysfunction associated with treatments for psychiatric disorders.
Sometimes no reason can be found for acquired sexual dysfunction. Age is an important factor to consider in such cases.
Conditions associated with depression and sexual dysfunction include most chronic ailments
including Parkinson’s disease, diabetes, chronic pain, cancer and ischemic heart disease,
anatomical abnormalities of the urogenital tract, environmental factors and substance misuse.
Many drugs including, thiazide diuretics, β-blockers and D2 blocking antipsychotics are associated with sexual dysfunction.
Antidepressants are also associated with sexual dysfunction. However, with a high baseline
prevalence of sexual dysfunction in cases of depression, it may be difficult to identify and
quantify the adverse effects of individual antidepressants.
Sexual desire is promoted by dopamine, testosterone and oestrogen. It is reduced by serotonin, prolactin and progesterone.
Sexual arousal including erection and vaginal lubrication is promoted by nitric oxide,
acetylcholine, dopamine, testosterone, noradrenaline through centrally stimulating effects
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dysfunction: Module 1 - Diagnosis
and additionally in women through oestrogen. It is reduced by serotonin. In men, noradrenergic α1-adrenoceptor stimulation may promote erectile dysfunction.
The orgasmic response and ejaculation is promoted by dopamine, noradrenaline, oxytocin
and acetylcholine. It is reduced by serotonin, particularly through stimulation of the 5HT2
receptor.
Although serotonin can inhibit sexual functioning in all three domains it seems that sexual
interest and orgasmic function including ejaculatory delay are more affected than arousal.
The balance of serotonergic, noradrenergic, dopaminergic and anticholinergic properties of
individual antidepressant agents determine their potential to induce sexual dysfunction.
Tricyclic antidepressants, selective serotonin reuptake inhibitors and venlafaxine are most
likely to cause sexual dysfunction.
The non-serotonergic antidepressants reboxetine and bupropion as well as duloxetine are the
least likely to cause sexual dysfunction.
Antidepressants, which antagonise the 5HT2 receptor have also a lower prevalence of sexual dysfunction. These include mirtazapine and trazodone.
The non-selective MAOIs such as phenelzine or tranylcyclopromine inhibit both MAO-A and
MAO-B so that more dopamine is available. They can enhance sexual function in all domains.
The selective MAOIs only block MAO-A, so that less dopamine is available. Increase of sexual
function is still possible but less likely than with non-selective MAOIs.
Lookup tables from the module are on the following pages.
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dysfunction: Module 1 - Diagnosis
Prevalence range of antidepressant-associated sexual dysfunction
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dysfunction: Module 1 - Diagnosis
TCA receptor affinities and likely effect on sexual functioning
MAOI receptor affinities and likely effect on sexual functioning
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dysfunction: Module 1 - Diagnosis
SSRI receptor affinities and likely effect on sexual functioning
SNRI receptor affinities and likely effect on sexual functioning
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dysfunction: Module 1 - Diagnosis
Mirtazapine receptor affinities and likely effect on sexual functioning
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dysfunction: Module 1 - Diagnosis
Trazodone receptor affinities and likely effect on sexual functioning
Reboxetine receptor affinities and likely effect on sexual functioning
Bupropion receptor affinities and likely effect on sexual functioning
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dysfunction: Module 1 - Diagnosis
Causes of primary sexual dysfunction
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dysfunction: Module 1 - Diagnosis
Causes of secondary sexual dysfunction
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dysfunction: Module 1 - Diagnosis
Other psychotropic medications associated with sexual dysfunction
Other medications for physical conditions associated with sexual dysfunction
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dysfunction: Module 1 - Diagnosis
Blood tests to request
References
Araujo, A.B., Durante, R., Feldman, H.A. et al (1998) The relationship between depressive
symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging
Study. Psychosom Med, 60:458-465
Berney, P. (2005) Dose-response relationship of recent antidepressants in the short-term
treatment of depression. Dialogues Clin Neurosci, 7:249-262
Bymaster, F.P., Dreshfield-Ahmad L.J., Threlkeld, P. et al (2001) Comparative affinity of
duloxetine and venlafaxine for serotonin and norepinephrine transporters in vitro and in vivo, human
serotonin receptor subtypes, and other neuronal receptors. Neuropsychopharmacology, 25:871-880
Clayton, A., Kornstein, S., Prakash, A., Mallinckrodt, C. and Wohlreich, M. (2007) Changes
in sexual functioning associated with duloxetine, escitalopram, and placebo in the treatment of
patients with major depressive disorder. J Sex Med, 4:917-929
Damsa, C., Bumb, A., Bianchi-Demicheli, F., Vidailhet, P., Sterck, R., Andreoli, A. and
Beyenburg, S. (2004) "Dopamine-dependent" side effects of selective serotonin reuptake
inhibitors: a clinical review. J Clin Psychiatry, 65:1064-1084
Düsing, R. (2005) Sexual dysfunction in male patients with hypertension: influence of
antihypertensive drugs. Drugs, 69:773-786
Ellison, J.M. (1998) Antidepressant-induced sexual dysfunction: review, classification and
suggestions for treatment. Harvard Rev Psychiatry, 6:177-189
Halaris, A. (2003) Neurochemical Aspects of the Sexual Response Cycle. CNS Spectrums, 8:211-
216
Page 13 of 13 Antidepressants and psychosexual
dysfunction: Module 1 - Diagnosis
Montejo, A.L., Llorca, G., Izquierdo, J.A. et al (2001) Incidence of sexual dysfunction
associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Spanish
Working Group for the Study of Psychotropic-Related Sexual Dysfunction. J Clin Psychiatry,
62(3):10-21
Montgomery, S.A., Baldwin, D.S., Riley, A. (2002) Antidepressant medications: a review of the
evidence for drug-induced sexual dysfunction. J Affect Disord, 69:119-140
Munhoz, R, (2004) Serotonin syndrome induced by a combination of bupropion and SSRIs. Clin
Neuropharmacol, 27:219-222
Nicolosi, A., Moreira, E.D. J.R., Villa, M. et al (2004) A population study of the association
between sexual function, sexual satisfaction and depressive symptoms in men. J Affect Disord,
82:235-243
Page, C., Curtis, M., Walker, M. et al (2006) Mosby Elsevier 2nd edition: Chapter 8: Drugs and
the nervous system (central and peripheral), Chapter 11: Drugs and the endocrine and metabolic
systems, Chapter 17: Drugs and the genitourinary system. Integrated Pharmacology
Price, L.H., Charney, D.S., Heninger, G.R. (1986) Effects of trazodone treatment on alpha-2
adrenoceptor function in depressed patients. Psychopharmacology (Berl), 89:38-44
Rang, H.P., Dale, M.M., Ritter, J.M. et al (2007) Churchill Livingstone Elsevier (6th Edition):
Chapter 10: Cholinergic transmission, Chapter 11: Noradrenergic transmission, Chapter 12: Other
peripheral mediators: 5-hydroxytryptamine and purines, Chapter 17: Nitric oxide. Rang and Dale’s
Pharmacology
Saenz de Tejada, I., Ware, J.C., Blanco, R. et al (1991) Pathophysiology of prolonged penile
erection associated with trazodone use. J Urol, 145:60-64
Stahl, S.M. (2001) The psychopharmacology of sex, Part 1: Neurotransmitters and the 3 phases of
the human sexual response. J Clin Psychiatry, 62:80-81
Tremblay, P. and Blier, P. (2006) Catecholaminergic strategies for the treatment of major
depression. Curr Drug Targets, 7:149-158
Waldinger, M.D. (2006) Emerging drugs for premature ejaculation. Expert Opin Emerg Drugs,
11:99-109
Werneke, U., Northy, S. and Bhugra, D. (2006) Antidepressants and sexual dysfunction. Acta
Psych Scand, 114:384-397
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