Abstract
Major depressive disorder is a serious mental disorder in which treatment with antidepressant medication is often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) has a low rate of spontaneous reports by patients, and this side effect therefore remains underestimated in clinical practice and in technical data sheets for antidepressants. Moreover, the issue of TESD is rarely routinely approached by clinicians in daily praxis. TESD is a determinant for tolerability, since this dysfunction often leads to a state of patient distress (or the distress of their partner) in the sexually active population, which is one of the most frequent reasons for lack of adherence and treatment drop-outs in antidepressant use. There is a delicate balance between prescribing an effective drug that improves depressive symptomatology and also has a minimum impact on sexuality. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antidepressant with a low rate of TESD) to possible pharmacological interventions aimed at improving patients’ tolerability when TESD is present. The suggested recommendations include the following: for low sexual desire, switching to a non-serotoninergic drug, lowering the dose, or associating bupropion or aripiprazole; for unwanted orgasm delayal or anorgasmia, dose reduction, “weekend holiday”, or switching to a non-serotoninergic drug or fluvoxamine; for erectile dysfunction, switching to a non-serotoninergic drug or the addition of an antidote such as phosphodiesterase 5 inhibitors (PD5-I); and for lubrication difficulties, switching to a non-serotoninergic drug, dose reduction, or using vaginal lubricants. A psychoeducational and psychotherapeutic approach should always be considered in cases with poorly tolerated sexual dysfunction.
Highlights
Treatment emergent sexual dysfunction (TESD) is common in the sexually active population
The most practical way to approach TESD seems to be following a simple three-step sequence: (1) Prevent TESD in susceptible population; (2) Conduct routine checks for TESD in sexually active patients who are prescribed ADs; (3) Perform clinical intervention when TESD is a problem for the patient and/or their partner or causes a potential risk for treatment drop-out
The initial level of concern about TESD is low at the beginning of treatment or in short-term treatments, some patients will abandon long-term treatment if TESD persists [47]
Summary
Treatment emergent sexual dysfunction (TESD) is common in the sexually active population. TESD is one of the most long-lasting side effects in users of antidepressants (ADs), despite its occurrence being underestimated in technical data sheets for ADs, where the incidence is stated as 2%–16% [1] These percentages are remarkably low compared with those that are estimated in everyday praxis and specific studies [2,3,4] including systematic reviews [5,6] and meta-analysis [7] (Table 1). The reasons for this underestimation include the fact that the incidence of sexual dysfunction (SD) is obtained from registered drug trials and short-term efficacy studies, which are unreliable since they either include sexually inactive patients [5] or do not use specific and validated questionnaires, rather relying solely on spontaneous reports. Since sexual dysfunction (SD) is widely associated with depression, screening for TESD as a possible depressive symptom [11] is advisable when screening for affective disorders in people with TESD [12]
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