Antidepressants and psychosexual dysfunction: Module 1 - Diagnosis

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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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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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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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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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Causes of primary sexual dysfunction

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Causes of secondary sexual dysfunction

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Other psychotropic medications associated with sexual dysfunction

Other medications for physical conditions associated with sexual dysfunction

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dysfunction: Module 1 - Diagnosis

Questions to ask

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Blood tests to request

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