Wednesday, May 14, 2008

Sexual Side Effects of SSRI's: Is the Blindfold Coming Off?

This is my 613th post. One of my most popular posts was called "Sexual Side Effects of SSRIs: Even More Troubling". Well, now there is more information on the topic, courtesy of Audrey Bahrick, a psychologist at the University of Iowa University Counseling Service. Dr. Bahrick has published an article in the Open Psychology Journal regarding the long-term sexual side effects of SSRIs. It is disturbing, important and one of the best articles I've read in quite some time. Quotes from the piece are interspersed with my commentary. [UPDATE: If the link to the article is not working, please scroll to the update at the bottom of the page and try the alternate link.]

Don't Ask, Don't Tell. Because they were often not assessed in clinical trials, sexual side effects were reported to be relatively rare occurrences. If you've followed this story much at all, this is not necessarily news, but it is certainly worth mentioning anyway.
Post market research has clearly established that the SSRIs and SNRIs can affect most every aspect of sexual functioning at rates significantly higher than the 2-16% rates reported in pre-market trials and currently listed in the drug insert literature. Large prospective studies in which baseline assessment excludes participants with pre-existing sexual dysfunction have found rates of treatment-emergent sexual dysfunctions such as decreased libido, delayed orgasm, anorgasmia, erectile dysfunction, and difficulties with arousal, of between 36 and 70%.
"Evidence-Based" Guidelines. Bahrick notes that the literature contains advice that sexual side effects are "medically benign" and "all data suggest return of sexual functioning to baseline once the medication is stopped." Which would be fine if such statements weren't wrong. A lot wrong. Bahrick cites research indicating that:
An estimated 5 to 10% of individuals may experience a diminution of the SSRI or SNRI emergent sexual side effects over time as they remain on the medication, but for the vast majority, the sexual side effects are intractable and will continue for at least as long as they take the medication.

Numb Genitals, Anyone? A variety of SSRI-induced sexual side effects have been reported. Bahrick goes into depth about some of those that are less commonly reported in the literature (maybe because nobody bothers to ask about such effects).
There are indications that some SSRI/SNRI sexual side effects thought to be rare are actually common. The most frequently documented sexual side effects are diminished libido, unspecified problems with arousal, and delayed orgasm or anorgasmia. Delayed ejaculation or orgasm, and anorgasmia have been those symptoms that the literature links most clearly and most frequently to SSRI treatment, vs. to depression itself. However the symptoms of genital anesthesia and pleasureless orgasm, outside the range of common experience and appearing to often occur together, are frequently reported among men and women in Internet communities, in an accumulating case reports literature, and in one research investigation.
Sounds like fun, no? Bahrick then briefly describes the cases of one man and one woman who clearly experienced treatment-induced genital anesthesia. Even after researchers belatedly began to examine the sexual side effects of SSRIs, their measures do not assess for the presence of genital anesthesia. Again, don't ask, don't tell. Only one measure (Rush Sexual Inventory) was reported to assess genital anesthesia, and here's what research found using this measure:
Ferguson did not report specific symptom results, and Zajecka et al. reported only partial results. Zajecka et al. found that among 42 depressed patients taking a variety of SSRIs, 28% of women reported treatment-emergent decreased genital sensitivity and 25% of men reported treatment-emergent decreased intensity of orgasm, suggesting the symptoms are not uncommon.
Zajecka et al. was a small study, to be sure, but this clearly indicates that more research needs to be done on the topic.

In the Long Term. Bahrick also went over some of the evidence she presented in an earlier paper, which I discussed months ago as follows...
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.
Bahrick also noted that there is quite credible evidence from two trials that SSRIs can prolong ejaculatory latency after the discontinuation of treatment. For some individuals, this is a desired effect. For others, not so much. Likely because they are perceived as so benign, it was also noted that, among urologists, SSRIs are the most widely used treatment for premature ejaculation.

The Internet. Over 1500 individuals belong to one internet-based group whose main focus is the discussion of SSRI-related sexual side effects. Bahrick's review of their discussion indicated:
Sexual side effects are reported also to sometimes change over time: for example, there are indications that what was initially experienced as a positive ejaculation delay evolved over time into persistent post-medication low libido, impotence, leaking semen, and a precipitous decline in quality of orgasm and genital sensation.
Again, sounds like fun, right? Some naysayers may say that this is just a bunch of internet crazies who bonded together based on some bogus perceptions, who blamed treatment for their psychological problems. Alternatively, one might note that the small body of available evidence all converges on SSRIs causing sexual dysfunction in a relatively high percentage of people, so the concerns of this internet group are likely well-founded in reality.

And More. Bahrick also notes that there are four published case reports, totaling eight cases, where the symptoms described in the article have occurred in patients who had no history of sexual difficulties prior to starting SSRIs. On top of that, another report recently appeared in Primary Psychiatry, which noted, among other items...
Sexual side effects manifest in a variety of presentations and severities, but sexual functioning is assumed to return to normal once antidepressants are discontinued. In the recent peer-reviewed literature, three separate case reports have detailed sustained persistence of sexual dysfunction and genital anesthesia well after termination of SSRIs in the absence of residual psychopathology or another identifiable disorder. In each report, the annoying symptoms were absent prior to antidepressant therapy. Oddly, these case reports have not appeared in the psychiatric or psychopharmacology literature, but rather, two have been published in psychology journals and the third in a gynecology/women’s health journal.
Starting a Movement. I often get hits to my site based on Google searches for genital anesthesia combined with various SSRI drugs. These hits have come from across the world. There appears to be a real problem with long-lasting sexual side effects from SSRIs, but the "key opinion leaders" in psychiatry seem much more interested in lining their pockets with drug company money, badly misinterpreting research findings, and looking the other way. And this is what passes for evidence-based medicine?

Read Bahrick's article regarding long-term sexual side effects of SSRIs and ask your doctor about these effects. You are certain to receive an awkward glance. When that happens, feel free to pass along a copy of the article to your physician. If continuing medical education and drug reps aren't going to educate doctors on this issue, I suppose a grassroots effort is in order. Let me know how it goes.

Update. Thanks to an alert commenter for noting that the link to the article does not work. A less direct way to access the article is to follow this link then look for the article in Volume 1. The journal publisher has not yet mastered decent web design. The point of an open access journal is to allow easy access!


Sara said...

Just curious if you know if SNRIs, including Strattera, also have these same sexual side effects. Are there any articles published to that effect? Also the link to the article is not working. I think maybe the one you are citing is on Blackwell Synergy? Let us know.

CL Psych said...


Thanks for the tip on the link. I updated the post to reflect an alternate method to access the Bahrick article.

I am not familiar with all of the research on atomoxetine (Strattera) and how it may impact sexual functioning, but I wouldn't be surprised if there was a link.

flawedplan said...

This problem isn't general knowledge in psychiatry? Shoot.

Now that you mention it I recall when I was still on drugs getting that "awkward glance" from my former pdoc when I reported this exact genital numbing and pleasureless orgasm, and in pretty much those words. We switched meds and the problem went away, though I insisted he make a "covenant" with me to never again let any medication get in the way of my general hotness.

Monica Cassani said...

I can assure you both from personal experience and from working with clients that SNRI's have the same side effect.

Also neuroleptics seem to effect libido too, although it's not as commonly talked about because traditionally only the severely impaired were on neuroleptics and no one gave a shit if a schizophrenic or other "severely mentally ill" person had a libido or not...

Having been on high doses of all these drugs myself I can tell you I had normal libido before--- and completely destroyed libido and functioning after antidepressants
of the SRRI and SNRI varieties...all of them...I've been on just about all but the most recent ones.

Once off antidepressants I was able to orgasm again but it was a strange orgasm devoid of pleasure. After I got off virtually all the neuroleptics I again could orgasm with pleasure, but my libido has yet to return to normal. I'm still withdrawing from odds and ends so maybe I'm still being effected by the stuff I'm still on.

This is a great post and an important one and it's profoundly disturbing that doctors don't give a shit about the sexual well-being of those they treat.

And the importance of sexual health is completely denied for the elusive stability that is supposed come about by taking these drugs.

Anonymous said...

And if the pt with the sexual side effect of ED is a male the doc can throw a script for viagra or cialis at him. If the pt is a anorgasmic woman....well....who cares? She can just fake it, right? This topic infuriates me. I had a doc tell me to wait three more months and see how things go. Three months??!? He knew that symptom was not going away and he didn't care. It's bad enough to be depressed, but to be depressed and feel sexually dead is really awful.

Anonymous said...

The first psychiatrist I ever saw (only saw him once, wasn't the right fit), told me to tell him immediately if I had any loss of sexual desire from the SSRI he was putting me on. That this was in his opinion the worst side effect possible. This was in 1996, and I was twenty. I had NEVER had a libido at that time, kissing did (and does) make me want to puke, and when I had tried self pleasuring to see what the hype was about,I got no results.
I am now 32 and still have never had a sex drive. I don't think I ever will. Some people think I was a late bloomer, and because of the SSRI's I will never bloom. I don't know. I have never even had a sexual fantasy at all in my life--I don't understand the concept, and consider myself to be asexual.
Currently, I am off all SSRI's (they make me manic), but have only been off them for a short while. I was on wellbutrin (without SSRI's) for a short while, and then had an SSRI added. (the doc who treats me inpatient only sees me when I'm depressed, and doesn't believe I go manic, my regular doc definitely sees me manic). I didn't notice any change with the wellbutrin, though I have heard from some on the internet that it can cause hypersexuality.
I am interested in romance, just not sex. I'd love to find a life partner (I consider myself an asexual lesbian), but I don't think I'll ever find someone willing to give up all sex.

Anonymous said...

It is a crying shame that these drugs are allowed and everyone is so scared to tel the docs and the docs are clueless.
Anonymous said...

And if the pt with the sexual side effect of ED is a male the doc can throw a script for viagra or cialis at him.

Sorry Viagra and Cialis...don't solve the problem of giving you your libido back or the sensations back in your genitials. Viagra only gets the blood pumping...but if you can't feel much it doesn't do much good.

Anonymous said...

I am a pharmacist and I always warn my patients of either gender that they may experience sexual side effects and if they are disturbing to contact their physician. The incidence of sexual side effects based on the conferences I have attended excedes 50%.

Infact the side effects are so well known that low dose paroxetine is used to treat premature ejaculation. I live in California so I don't know if this is done in the rest of the world.

The antidepressants cause sexual dysfunction through the same way that ecstasy causes sexual dysfunction, but they are not as potent as ecstasy.

Anonymous said...

Your post is so true, but I thought this was already well known. My docs have not denied it. Unfortunately, for people who are severely depressed, the options are not good.

Anonymous said...

Current Depression Medications: Do The Benefits Outweigh the Harm?

Presently, for the treatment of depression and other what some claim are mental disorders, as they are questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others.
Some Definitions:
Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.
Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.
And depression is only one of those mood disorders that may exist, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis is dependent on subjective criteria, such as questionnaires. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed?
Several decades ago, less than 1 percent of the U.S. populations were thought to have depression. Today, it is believed that about 10 percent of the populations have depression at some time in their lives. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds, as this industry clearly desires market growth of these products. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders are suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related disease states.
Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year, with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to being promoted for treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
Furthermore, these meds have received additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, and as a layperson, I consider such activities dangerous and inappropriate for several reasons.
Danger and concerns by others primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically, as I recall.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities
Finally, if SSRIs are discontinued, immediately in particular instead of a gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.
SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber.

“I use to care, but now I take a
pill for that.” --- Author unknown

Dan Abshear

k-seeker said... there any solution? I have been taking fluxotene for about a year and was previously on and off the medication. It works...for my depression, but the decrease in libido is increasingly difficult to deal with. Are there any potential treatments, ideally natural ones, for those like me who are having good results with the SSRI..EXCEPT for the libio issue? I've read that ginkgo biloba might help.

shrink on the couch said...

I'm shocked but at same time, not surprised. I knew/suspected drugs companies design their studies to minimize findings of sexual side effects but had no idea that in 2008 the emperor is still not officially outed. I would estimate at least 50% (if not 75%) of SSRI users (in my workplace) report sexual side effects. Its distressing that pharma has been successful in keeping the documented lid on this for so long.

Thank you ClPsych for the valuable information on your blog. Its such a help to those of us in the field.

Anonymous said...

What about Wellbutrin?? I heard that this does not cause the same sexual side effects? Does anyone know if this is true??

Randi said...

I was on Paxil for several years and did experience loss of libido and delayed/impossible orgasm. I decided to switch to Wellbutrin and the sexual side effects went away several weeks after I stopped taking Paxil. I did, however, notice that Wellbutrin didn’t control my depression as well as Paxil but it does make it manageable. This, to me, is an acceptable trade off.

Anonymous said...

THANK YOU!!! I just knew it wasn't just me. I have been on Zoloft and Wellbutrin for several years for lupus induced depression. I have felt almost guilty not being interested in sex. My poor husband!
Currently, I am transitioning to Cymbalta to try to help with my fibromyalgia. Am I going from the frying pan and into the fire or is there hope for me.

Finally seeing the terms gential anesthesia and feeling dead down there has opened a door for me.

Monica Cassani said...

Cymbalta is notorious for sexual dysfunction too...and while I've not taken it, it's in the same class as Effexor which made me completely dead sexually.

I hope you find something that can help.

Perhaps research other means of fighting depression...there are many effective ways to deal with depression other than meds but most of them take a lot more discipline than popping a pill...

I know very well the devastation Lupus can cause as I have a dear friend with it, so I certainly do not pretend to know what is best for you....

best wishes.

Anonymous said...

still haven't found out what to do to overcome the side effect. i'm an unhappy hubby. at least tell me how to sue the company

Anonymous said...

I was taking Zoloft (50 mg) for about 12 years for an episode of depression and decided to get off the drug 2 weeks ago. I'm having some withdrawal, but nothing is upsetting me more than finding out from my on-line research that my progressive inability to orgasm over the years was due to this drug. After reading the other comments, I am sitting here crying for all the years of sexual enjoyment that I have lost and the possibility that I may never get back to normal. I suppose the only thing I can do is hope that my sexual "anesthesia" will wear off. I'm 50 years old and probably missing the best sex of my life that should have happened in my 40's. (I'm female.) If anyone can offer me some hope and encouragement, please write. thanks.

Monica Cassani said...

most people do regain function and feeling after coming off an SSRI...try not to add to your burden right now by imagining the worst.

In the meantime be sure to withdraw very slowly and carefully...withdrawal from Zoloft can be nasty, but if you go super slwo and carefully you don't have to suffer.

stop by my blog if you want info and resources on safe withdrawal...most docs don't know how difficult it can be for some people...

Monica Cassani said...

for further encouragement, I did not have an orgasm for about 12 years either...and now I'm fine. For me it took getting off both the Zoloft and the neuroleptics which also cause sexual dysfunction but that doesn't get talked about as often...

I came off Zoloft and started having sort of muted orgasms...then once off the!! it was like I was in my early 20's again...

hang on, have hope and take good care of you body mind and spirit as you carefully withdraw from Zoloft.

Anonymous said...

Thank you for this article. I have been taking Paxil for 2 months now. Not for depression, but for a sleeping disorder. I have never had any problems with sex drive or sensations before taking the drug, now I still have a strong sex drive and am turned on mentally, but my genitals feel like they got a shot of novicane. I can feel nothing at all. The symtoms listed on the paxil sheet only list,"may lower sex drive," no mention of loss of sensation so I was confused and didnt consider my new problem as being from my new med.

Jabber said...

Go to any of the anxiety forums and you will see that 90% of people experience sexual side-effects on SSRIs over the long-term use of the drug. As someone with an anxiety disorder, I have to choose between sex and the possibility that the SSRI may do something positive.

Anonymous said...

I've been on SSRIs for some time now and, even when I take a long drug holiday, the sexual side effects remain. It's really frustrating - I can't be or do what normal people do. I'd prefer valium (to treat anxiety) even though narcotic.