Research report
Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction

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Abstract

Background: Sexual dysfunction is recognised as a potential side effect of antidepressant therapy. However, there is little detailed information on the prevalence of drug-induced sexual dysfunction or the differences, if any, between available drugs. This article is a critical review of the literature in the area. Methods: English-language studies on sexual dysfunction and depression or antidepressant treatments were identified by searching Medline and supplemented by manual review of their reference lists and recent journal issues available in a library. Trials of antidepressant use in anxiety disorders were identified from a Medline search and their adverse events tables scanned for data on sexual dysfunction. All trials were assessed according to predefined criteria. Results: Sexual dysfunction is widespread in the healthy non-depressed population and is a recognised symptom of depression and/or anxiety disorders. Sexual dysfunction has been reported with all classes of antidepressants (MAOIs, TCAs, SSRIs, SNRIs and newer antidepressants) in patients with depression and various anxiety disorders. Numerous studies have been published, but only one used a validated sexual function rating scale and most lacked either a baseline or a placebo control or both. None met all of the pre-defined assessment criteria. Limitations: The search techniques may have missed some studies and publication bias cannot be ruled out. Conclusions: The existing literature confirms sexual dysfunction as a possible adverse event of all antidepressants, but it is not sufficiently robust to support claims for differences in the incidence of drug-induced sexual dysfunctions between existing antidepressant therapies. Prescribing decisions should be based on a careful assessment of the benefits and risks of therapy in the individual patient.

Introduction

Sexual dysfunction can be defined as a disruption of the normal physiological and psychological processes involved in sexual functioning. It is a complex concept, and includes a range of distinct conditions, such as: inhibited sexual desire; inhibited sexual excitement; inhibited orgasm in women; inhibited, delayed or absent ejaculation in men; premature ejaculation in men; and pain during intercourse (Nathan, 1986). The possible causes of sexual dysfunction include both psychological factors (e.g. unsatisfactory interpersonal relationships, psychiatric illness) and physical conditions (e.g. circulatory disorders may cause erectile dysfunction in men). The area has not been well studied, perhaps because no satisfactory diagnostic framework existed prior to the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 (Nathan, 1986).

In more recent years, however, interest in human sexual dysfunction has increased. Western societies have become more open about sexual matters, and sexual images are widely used in both advertising and entertainment. This contributes to a steadily increasing pressure on both men and women to live up to an idealised (and possibly unrealistic) standard of sexual performance (Frank et al., 1978). The introduction of sildenafil (Viagra) in 1997, the first orally active drug specifically developed for the treatment of a sexual dysfunction (male erectile disorder), created widespread comment in the lay media and cannot have failed to increase public awareness of sexual dysfunction. It also had the important effect of presenting sexual dysfunction as a medical condition that can be treated by a physician. Such shifts in social attitudes may be expected to increase the number of people who wonder where their sexual relationship fits in the continuum from ‘normal’ to ‘dysfunctional’, and to increase the number who consult health professionals in search of an answer (Laumann et al., 1999).

There is increasing awareness of sexual dysfunction as a potential side effect of drugs (Margolese and Assalian, 1996). Sexual dysfunction is a known adverse effect of antihypertensives (Fogari et al., 1998) and antipsychotics (Ghadirian et al., 1982, Rowlands, 1995, Baldwin and Birtwistle, 1997), and is now recognised as a potential side effect of antidepressant therapy (Baldwin, 1995, Davidson, 1995, Goldstein and Goodnick, 1998). Although premature ejaculation tends to be the most commonly reported side effect of medication in men, delayed ejaculation is often reported as a side effect of antidepressant treatment and this may actually be considered beneficial in some circumstances. It is often difficult to separate drug-induced effects from the consequences of the illness itself, particularly with psychiatric disorders which in themselves may have profound effects on relationships and social/sexual function. This has long been recognised as a problem in assessing the effects of drugs on sexual function in patients with schizophrenia (Rowlands, 1995, Baldwin and Birtwistle, 1997), and depression itself is associated with sexual dysfunction (Mathew and Weinman, 1982, Baldwin, 1996). There is a paucity of accurate information in the scientific literature on the incidence of antidepressant-induced sexual dysfunction, and yet it may be an effect of considerable importance to the patient, possibly leading to non-compliance with therapy (Settle, 1998). It is therefore important that patients and physicians are provided with a balanced view of the benefits of antidepressants versus their potential to cause sexual dysfunction. This review is a critical assessment of the available data on sexual dysfunction in depression and anxiety disorders, and the impact of antidepressant drugs on sexual functions and satisfaction.

Section snippets

Methods

Research papers were identified by a search of the Medline, Toxline, Embase, Biosis, DDFU, Scisearch and ADIS Newsletter databases. Sexual dysfunction was used as an index term, combined with ‘SSRI’ or the names of individual selective serotonin reuptake inhibitors (SSRIs) or newer, non-SSRI, antidepressants. Further papers were obtained from Current Contents 1995–1999, using the following search terms: citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline; bupropion, mirtazapine,

Prevalence of sexual dysfunction in the general population

Before any assessment can be made of the significance of sexual dysfunction, drug-induced or otherwise, in patients with affective disorders, it is important to establish the epidemiology of the condition in the general population. However, this area has not been well studied and reliable normative data are scarce (Baldwin, 1996). In 1986, Nathan reviewed 22 surveys of sexual behaviour in the general population in an attempt to derive prevalence data for the sexual dysfunctions defined in

Discussion and conclusions

Accurate assessment of antidepressant-induced sexual dysfunction is subject to many difficulties. First, few data are available on the prevalence of sexual dysfunction in the general population, making it difficult to establish a ‘normal’ baseline.

Second, patients with depression are at greater risk for sexual dysfunction, as would be expected from the effect of depressive symptoms on relationships and behaviour; this has been verified in several studies (Casper et al., 1985, Mathew and

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