Effective management of antidepressant-induced sexual dysfunction

For many people taking antidepressant medications for mental health issues, sexual dysfunction is a relatively common side effect where compliance with prescribed use can lead to a reduction in quality of life.

As such, managing sexual dysfunction in people on prescribed antidepressants is an important component of their overall health. Among the strategies that can be used to address sexual dysfunction in this setting are behavioral strategies that focus on modifying sexual technique, individual and couple psychotherapy, changes in antidepressant usage (e.g., dose reduction, taking dose after sexual activity, taking a drug holiday), switching to a different antidepressant, or using medications to specifically treat the dysfunction.¹

Unfortunately, evidence remains limited on effective strategies to manage this side effect, as highlighted in a recent Cochrane Review.² The review was conducted to determine the effectiveness of management strategies for antidepressant-induced sexual dysfunction as well as to determine the adverse effects and acceptability of the different management strategies, and is an update to a similar Cochrane review first published in 2004.³

Published in 2013, the updated review included 23 randomized controlled trials involving 1886 people in which strategies to manage antidepressant-induced sexual dysfunction were compared to placebo or any alternative strategy. All people included in the study were at least 16 years of age with antidepressant-induced sexual dysfunction that included problems with sexual arousal and reduced sexual satisfaction for both men and women, erectile problems in men and problems with lubrication, dyspareunia and vaginismus in women.

The strategy used in most of the trials (n=22) was the use of an additional medication to treat the sexual dysfunction. One study looked at the strategy of the effect of switching to an alternative antidepressant.

Key Findings

Given that most of the studies to date have looked at prescribing an additional medication to treat sexual dysfunction, current evidence is weighted toward the use of this strategy. However, most of the drugs studied in these trials were only examined in single studies and, therefore, evidence on their effectiveness is limited.

The medications studied the most were the phosphodiesterase inhibitors (sildenafil and tadalafil) and bupropion. Results of the trials of these medications are shown in Tables 1 and 2. The benefit of these medications by sex is shown in Table 3.

In addition to the medications above, 1 promising study suggests that the addition of the drug bethanecol may benefit men. Although only tested in a small cross-over trial, the study showed bethanecol may benefit men with antidepressant-induced delayed ejaculations or anorgasmia.

Other Strategies

Another strategy to managing sexual dysfunction related to antidepressant use is switching the antidepressant medication, which was examined in one trial. Involving 75 people with sexual dysfunction related to the use of sertraline, the trial assessed the benefit of switching patients to nefazodone. The study found a significantly less likelihood of re-emergent sexual dysfunction in patients who switched to nefazodone compare to restarting sertraline. However, as the investigators point out, this finding is limited given the unavailability of nefazodone for clinical use.

Other potential strategies, including strategies focused on psychological or mechanical interventions, or drug therapy techniques such as drug holidays, were not looked at in any of the randomized trials included in the review.

Conclusion

Based on the current evidence, the best data to date show that the addition of sildenafil or tadalafil may be the most effective strategy to treat antidepressant-induced sexual dysfunction in men. For women, the addition of higher doses of bupropion may be the most promising strategy. However, the investigators emphasize that the current data remains limited and more randomized trials are needed.  A particular need is more research on strategies to manage sexual dysfunction in women.

Reference

 Baldwin DS. Sexual dysfunction associated with antidepressant drugs. Expert Opinion on Drug Safety. 2004;3:457-70.

Taylor MJ, Rudkin L, Bullemor-Day P, et al. Strategies for managing sexual dysfunction induced by antidepressant medication (Review). Cochrane Database of Systematic Reviews 2013; Issue 5. Art. No.:CD003382. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003382.pub3/epdf

Rudkin L, Taylor MJ, Hawton KKE. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database of Systematic Reviews 2004; Issue 4. Art. No. CD003382. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003382.pub2/full