Friday, December 08, 2006

Sexual Side Effects of SSRIs: Even More Troubling

I just bumped into a very interesting gem of an article by Dr. Audrey Bahrick, a psychologist at the University of Iowa University Counseling Service, which deals with SSRI-induced sexual side effects. While we are all aware that sexual side effects are common with SSRIs, the general assumption that these side effects are transient and that they vanish within a few weeks or when medication is terminated. Indeed, that the SSRIs cause a decrease in males’ perception of sexual pleasure has led some to believe that SSRIs should be used to treat premature ejaculation.

As Dr. Bahrick aptly points out, there is no evidence that SSRI side effects disappear. Indeed, sexual side effects can be long-lasting.

She starts out by noting “Depending on definitions of sexual dysfunction and methodology, post-market prevalence studies have found rates between 36% and 98%. The 5 to 15% rates of SSRI and SNRI-induced sexual side effects listed in the current drug-insert literature are based on information obtained in the initial trials via spontaneous reports of individuals who had been on the medications for a short time. The differences in reported rates between the pre-market trials and post-market prevalence studies are an artifact of methodology; we now know that when individuals are directly asked about their experience of sexual side effects via either a structured clinical interview or a self-report inventory, we obtain vastly different rate information than if we rely on individuals to spontaneously volunteer personally sensitive information about changes in sexual functioning.”

It was easy to NOT find sexual side effects by making sure to not look for them! Likewise, she notes that although researchers have now noted that sexual side effects occur, they have avoided asking if they persist upon treatment discontinuation. To top if off, researchers have designed measures of sexual side effects that may miss some of the most common and impairing sexual side effects. Note what Bahrick has to say about these effects, which include

“…erections that may be easily achieved and maintained yet are numb or nearly numb; orgasms that are preceded by little sense of building arousal and are experienced as pleasureless or nearly so; and genitals that respond to touch by erection or lubrication but without attendant subjective feelings of arousal. Aspects of normal sexual functioning seem to be mimicked without the attendant capacity to experience pleasure. While SSRI/SNRI-related decreased genital sensation or genital anesthesia, and decreased orgasmic intensity or ejaculatory anhedonia are reported to be uncommon, it is more accurate to say that they are uncommonly assessed. Our literature appears to be building upon the assumption that the symptoms are rare by failing to systematically include such symptoms in our instruments, and by failing to transparently report them when they are included.”

She points out that the most common measure of sexual side effects does not include an item on genital anesthesia. Additionally, “The instrument does include an item related to reduced pleasure of orgasm and its severity. However the item is not separately scored, but rather folded in with two other items related to frequency and timing of orgasm.”

Zajecka and colleagues examined these symptoms in a 1997 publication, yet the data were apparently not reported fully. According to Bahrick, there is only one study (Montejo et al., 1999) that has examined the emergence of sexual side effects after cessation of SSRI medication. In this study, patients who had experienced significant reductions in depressive symptoms in response to an SSRI were switched to amineptine (which impacts the dopaminergic system and noradrenergic systems to a much greater extent than it impacts serotonin) or to Paxil. A third group received amineptine only (they were not switched from an SSRI). Amineptine-only treatment resulted in 4% incidence of sexual dysfunction, whereas the switched-to-Paxil group had an 89% incidence of sexual dysfunction, and the switched-to-amineptine group decreased from a 100% to a 55% incidence of sexual side effects. Mind you, these treatments lasted for six months, so those who switched to amineptine, a drug that rarely induces sexual side effects, still had a high rate of sexual side effects six months after SSRI treatment discontinuation.

In Bahrick’s article, an internet community known as SSRIsex is described, in which discussion of post-SSRI discontinuation sexual side effects is prominent. Indeed, the group is reported to have coined the term Post SSRI Sexual Dysfunction (PSSD). In addition, two case reports (here and here) have been published in 2006 regarding PSSD.

In sum, there is emerging evidence from case reports, an internet discussion group, and at least one empirical study that SSRI-induced sexual dysfunction may last longer than previously thought and is causative of genital anesthesia, ejaculatory anhedonia, and decreased orgasmic intensity.

Here’s hoping that more thorough investigation of this topic will be done. I have a feeling the investigation will occur at about the same time a new antidepressant emerges that does not cause sexual side effects. Wellbutrin has gone generic, so there is no incentive for its manufacturer (Glaxo-Wellcome) to demonstrate the prevalence of long-term SSRI side effects or of the other treatment-emergent side effects mentioned above.

In fact, I’ll lay down an idea here. A drug company could make a me-too ripoff of bupropion (Wellbutrin) and then conduct these very studies on the sexual side effects of SSRIs. Wellbutrin tried to market their drug in such a fashion. Indeed, I’ll not soon forget the Wellbutrin commercial with the man getting on the horse while talking about a lack of sexual side effects. Freud must have been rolling over in his grave! Maybe Wellbutrin’s campaign did not go far enough – they should have sponsored more research on the topic. Or maybe reboxetine can be pulled off the shelf (Are you listening, Pfizer?) and run through trials for FDA approval, though one should read the following case study regarding reboxetine due to its bizarre nature. In any case, if we assume that further research would find long-term sexual side effects related to SSRI’s, there is actually money to be made by making an antidepressant that does not cause sexual side effects, so step to it! Or, God forbid, we can start referring depressed patients for psychotherapy due to its propensity to not cause sexual side effects and its better long-term performance? Nah, that’s crazy talk!

Read the full text of Dr. Audrey Bahrick’s excellent article here. Alas, this link will cease functioning at some point soon because Div. 55 of the APA apparently does not provide a permanent link to back issues of their publication. Email me if the link is broken and you’d like a copy.

11 comments:

Anonymous said...

Actually, there is an SSRI that does not cause sexual side-effects, nefazadone (Serzone), but the FDA black-boxed it.

Anonymous said...

I think serzone was black-boxed because it causes liver failure.

http://depression.about.com/cs/nefazodone/a/serzonewarning.htm

Anonymous said...

My husband took Leproxo for 2 weeks. It was prescribed by a family doctor for anxiety/depression. He very quickly experienced difficulty achieving orgasm--arriving just at that point and then being unable to climax.He was, however, able to climax sometimes while masturbating.

Last Wednesday, after having been on the drug for about 10 days, he saw a psychiatrist and told her of the sexual dysfunction. She saw his issue as more anxiety than depression and said that, since the dose was low, he should be able to easily taper off.

Yesterday, Saturday, he found that, despite the lowered dose, he was completely unable to orgasm. He quit the medication altogether--Friday was his last dose.

His sexuality has always been very important for him, and we have had a good sex life. I am desperately afraid of the consequences if he is denied the one pleasure he has right now.

Is permanent dysfunction likely after only 2 weeks of the medication, and 10 days of a full dose?

Anonymous said...

Correction: I gave the incorrect name for the SSRI that my husband was taking: it is Lexapro, not Lepraxo, as I had mistakenly said.

It is also ironic that he had suggested serzone to the doctor, since he had used that before without side-effects, but the doctor argued that that was good for depression, not anxiety. Well, now he has something else to be both extremely anxious and majorly depressed about.

Anonymous said...

Yes, it is possible to continue experiencing Lexapro's negative sexual side effects after only two weeks of dosing.

I am a 28 year-old male and I was prescribed a 10 mg/day Lexapro trial kit in the fall of 2006 for depression. I took 10 mg per day for only 3 days before noticing acute severe genital anesthesia, degrees of anorgasmia, and ejaculatory anhedonia. I stopped taking the medication immediately and I still suffer the side effects to this day. That's right, just three 10 mg doses almost two years ago. I also suffer erectile dysfunction and decreased libido as side effects, but they have become marginally improved since 2006. I never had any sexual problems of this severity prior to my 3 day exposure to Lexapro.

I hope your husband is a lucky one whose dysfunction improves quickly. I know how devastating and maddening these afflictions can be.

Has he improved at all since your last post?

Anonymous said...

I am so grateful. Yes, he has improved. It took about 7-10 days after he stopped taking Lexapro. I am so sorry to hear that you have had only marginal improvement after 2 years. I would advise anyone I know to avoid SSRIs.

Thank you for your reply and I wish you the very best of luck.

Anonymous said...

I like anonymous had a 10mg Lexapro trial kit. I split the 10mg pill in half and took two 5mg doses. TWO and then I quit. Was sleepy for the next two-three days. 10 days later experienced problems in all areas of sexual function. Finally after six months some feeling is returning but I am sorry I ever tried the darn drug. When I talk to the doctor he sees no connection. I will keep trying different dr until I find someone who will listen. Anybody had any luck getting their doctor to believe in post-ssri effects?

de man van visvliet said...

This sends shivers down my spine.

I have been on paroxetine (Paxil, Seroxat in Holland) for two and a half years about five years ago. Ever since, my physical libido hasn't been the same, while my mental libido is high as it ever was. What's worse, since quitting paroxetine I experience unsatisfactory orgasms, which should be a contradictio in terminis. It hasn't so much to do with a lack of genital sensation as with what I can only describe as an uncomfortable feeling in my head right after I climax. (Where I may unfortunately have to put 'climax' between brackets).

I also experience this uncomfortable feeling in my head after heavy exercise, where SSRI-naive people would feel contented.

I do think that most drugs that cause any kind of high, be it shortlived (nicotine, stimulants) or more stretched out over time (SSRIs), spoil the brain in some way or other.

Anonymous said...

Lexapro is a permanent life long cure for any depression if you can survive the treatment. I was prompted by a marriage counselor to go to my doctor and request drugs for my OCD symptoms (checking, intrusive sad thoughts, previous eating disorders as a teen and heavy drinking-probably perpetuated by my father’s suicide in 1981 while he was on imipramine and numerous other psych med’s) I went to my husband’s pcp who never met me before. He gave me a depression self-test and diagnosed me with depression and anxiety, and then prescribed me Lexapro and Rozerem since I had a terrible insomnia problem. He also decided it was a good idea to start kissing me and grabbing me in his office. The Lexapro did such a good job getting me up and doing things, lots of things, but unfortunately, I believe it also may have made me nervous because it raised my blood pressure from it’s usual 120/80 to 145/110. I was really up, up, up. I could drink twelve shots of straight liquor and still be walking around for hours. This was the busiest year of my life. I managed to get 2 DUI’s 4 drunk in publics and an involuntary commit for suicide, attend 2 rehab’s, a hypnotherapist, weekly ASAP programs, all while working full time. During the course of my medical treatment, I was seen by 3 psychiatrists, 4 doctors, and numerous counselors. Most of the follow up treatment involved numerous more drugs, anti-buse, campral, and Buspar. All of which I had to stop taking due to side effects such as full body tremors and falling down. Finally, after the second DUI which I was also charged with a felony for pinching a police officers butt, I decided maybe I should stop taking the Lexapro b/c I seemed to have developed some obsession with alcohol and I could see I was also becoming delusional. So, while in jail, I requested no more medication for 1 week and was able to fully withdraw from Lexapro, although the depression side effects of the withdrawal lasted about three months. I met numerous other women in jail for DUI’s while on Zoloft, Lexapro and Abilify and others for shoplifting on Zanax. My depression is 100% permanently cured. I no longer ever feel sad about my life. I have never killed anyone driving drunk, I didn’t kill myself, I am no longer in jail, I didn’t get my kid taken away from me, I am not in a mental institution, and I don’t have a lethal diastolic blood pressure of 110 anymore. No matter what happens in my life now, I am always hopeful and never depressed. I know things could be much worse.

Anonymous said...

I took Effexor and later Zoloft for depression. They did nothing for the depression and so after 1.5 years I quit the drugs. I have since recovered from the depression on my own.

However one thing still makes me depressed, and that is that my sexual function was totally destroyed by the drugs. After a year and a half of not taking them I have only seen minor improvements. These problems are real and not enough doctors know about them or take them seriously. I am only 26 and never had a problem until the day I took a drug.

Don't let your uniformed doctor tell you these problems do not exist. I luckily am a graduate student in biological science so I can generally hold my own with them and have convinced me doctor it is real, but too many think it is psychological (it is not). I don't know what can be done about it though.

Anonymous said...

I am reading these comments and related links on the web with dismay. My partner and I have been together for nearly three years, during which time he suffered from frequent cyclical moodswings which made us suspect cyclothymia (never formally diagnosed because it's so hard to do). Last fall he began to suffer from more enduring depressions and was prescribed escitalopram. He experienced marked sexual dysfunction--anhedonia, anorgasmia, priapism. I urged him to switch medications but he was too anxious about the depression returning and at this time we knew nothing about PSSD. He gave up the medication in December and regained full sexual function. He then began taking it again a few weeks later and this time, when he stopped treatment in March, some of the sexual side-effects did not go--he reports significantly reduced semen volume and an almost complete absence of desire. The flip side to this is that his depressive episodes, which he would have at a frequency of every 7-12 days, have also not returned and he has now had an extended period without any sort of depression for the first time in 16 years since he began to develop cyclothymia-like symptoms. If I understand the Wikipedia article correctly, these two things could be related if what is going on is some kind of methylation process. We had long suspected that his mood symptoms had a strong hereditary component and that this involved the dopaminergic system. My partner also reports some effects on one other drive in particular, namely his interest in sport. All other sorts of drives--for food, or career-related, seem unaffected. We are now uncertain about what will happen in the medium term and whether my partner will regain the lost sexual function--and of course whether the depressions will return with it.