Diagnosing long-term sexual dysfunction from SSRIs
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With more than 13.2% of the American adult population refilling prescriptions for SSRI antidepressants on a monthly basis, a figure implicating at least 45 million Americans, it is disconcerting that several studies conclude that SSRIs “can cause dysfunction sexual activity in 40 to 65% of individuals” prescribed them. . Some estimate the incidence rate at 72.7% (2001) and 81.4% (1997).
Drugmakers and regulators have long known about the condition, first known as “antidepressant-induced sexual dysfunction.” The UK Medicines and Health Products Regulatory Agency (MHRA) began noting reports of sexual dysfunction after withdrawal of an SSRI in 1987, with fluvoxamine (Luvox) followed in 1991 by fluoxetine (Prozac) .
Later studies, including one in 2001 involving 1,022 outpatients, found that citalopram (Celexa) had an even higher incidence rate at 72.7%, followed closely by paroxetine (Paxil) at 70.7 %.
The same study determined that “men had a higher frequency of sexual dysfunction (62.4%) than women (56.9%) after discontinuation of antidepressants,” although women had higher severity. “.
Overall, nearly four in ten described their symptoms after SSRI treatment as intolerable, with delayed or premature ejaculation among the most common, alongside low libido, reduced sexual satisfaction or without pleasure, anorgasmia, genital anesthesia (marked numbness of the genital area) and erectile dysfunction.
The European Medicines Agency officially recognized the iatrogenic condition as post-SSRI sexual dysfunction (PSSD) in June 2019.
In another 1999 study, an international team of 37 medical experts in a just published journal noted that “55% of participants still had sexual dysfunction six months after switching from an SSRI to amineptine” . [a tricyclic antidepressant] against 4% who were treated only with amineptine, a drug without action on the serotoninergic system. Additionally, “almost all people taking an IRS experience altered genital sensitivity within an hour of starting treatment” (Healy 2021).
Hence the importance of using these results to formalize the “diagnostic criteria for persistent sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin”, with the same 37 experts collaborating on the most large public collection of relevant data on these conditions.
The proposed criteria – led by psychiatrist David Healy and involving senior researchers from Europe, North America and India – have provided much-needed insight into a medical condition that poses unique challenges, as the symptoms may present or persist long after the causative drug treatment has ended. and which themselves are often mistaken for a relapse into depression, as reduced or lost libido is a common feature.
Researchers Elizabeth Jing and Kristyn Straw-Wilson warned in 2016 that “although depression may play a role in sexual dysfunction, SSRIs may cause sexual side effects unrelated to depression.” Often overlooked or overlooked, this key distinction has in practice led to widespread diagnostic confusion over a condition that, five years later, is still “little known and poorly understood by medical professionals” (Healy 2021).
To address these and related issues, Healy and colleagues noted of PSSD: “Significant sexual dysfunction may occur during treatment and after discontinuation of any serotonin reuptake inhibitor (SRI) medication. .” They propose the following diagnostic criteria:
(1) Prior treatment with a serotonin reuptake inhibitor.
(2) A lasting change in somatic (tactile) or erogenous (sexual) genital sensation after discontinuation of treatment.
(3) Sustained reduction or loss of sexual desire.
(4) Persistent erectile dysfunction (men).
(5) Persistent inability to orgasm or decreased sensation of pleasure during orgasm.
(6) The problem is present for ≥ 3 months after stopping treatment.
There should be:
(7) No evidence of pre-drug sexual dysfunction matching current profile.
(8) No current medical condition that could explain the symptoms.
(9) No current medication or substance abuse that could explain the symptoms.
PSSD can vary in severity,” they added, but generally “there is a marked escalation in genital sensory effects…. The condition can be triggered by exposures as brief as several days. The sexual dysfunction that accompanies normal use of antidepressants may persist for a few days or weeks after stopping treatment. The current consensus is that once the malfunction lasts for three months, it is more likely to be a PSSD.
The researchers provided comparable criteria for persistent genital arousal disorder (PGAD), relating to “persistent adverse feelings of genital arousal or irritability” during SRI treatment. They also established diagnostic criteria for post-finasteride syndrome (PFS), regarding erectile dysfunction associated with finasteride products designed to treat male pattern baldness, and for post-retinoid sexual dysfunction (PRSD), regarding the number increasing cases of sexual dysfunction linked to isotretinoin, a retinoid drug used in the treatment of acne.
Timely by predating textual revisions to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due in March, the collaboration on PSSD and related conditions provides clarity and confidence to physicians and reassurance patients, whose toll of long-term sexual dysfunction on relationships and individual mental health was well captured in a 2019 study by Healy, Joanna Le Noury, and Dee Mangin.
A qualitative analysis based on 62 participants from 23 countries, “Post-SSRI sexual Dysfunction: Patient Experiences of Engagement with Healthcare Professionals” identified recurring areas of patient concern:
Degree of physician awareness/knowledge of condition, non-listening, insensitive responses, suggestion to return to medication, response to published medical literature, lack of treatment, not talking about it anymore, and impact of disabling responses.
Representative statements included:
I asked my new psychiatrist if he could kindly provide me with the letter. He agreed but seemed relieved at the same time that he was not prompted to say directly that the SSRIs were the cause of my condition.
Another patient was told, “I noticed in your records that you’ve spoken to other doctors here about this. I think you shouldn’t keep talking about it.
Another participant reported that “their GP said SSRIs were ‘safe’ and ‘laughed at the idea that they might make long-term changes to a patient’.”
The doctor’s disbelief is an additional obstacle:
I spoke to my GP and she doesn’t believe my symptoms could be related to the medication that was stopped years ago. The medicine was prescribed by the doctor.
The study revealed that participants feared that the dysfunction they were experiencing
was dismissed as a psychological problem without a good understanding of sexual symptoms or the specifics of the original problem: “I have fairly mild OCD, but OCD has never made my genitals numb, or orgasms without pleasure, or to have zero libido. ‘
Another participant reports:
I visited my psychiatrist, under whose supervision I took the drug for eight years, and when I informed him of my ongoing sexual dysfunctions, he said I was talking absolute nonsense and that he s It was about my psychological constructs.
The failure of doctors to warn of common adverse drug effects has led to frequent frustration and despair over their long-term consequences:
I’m quite angry with the doctors I’ve seen so far, but especially my psychiatrist for not informing me of the possible long-term side effects the pill can cause. I had never had any problems with my sexual functioning before taking the drug, and I don’t think genital anesthesia can be considered a symptom of depression.
Regarding the exact causes of PSSD and thus the prospects for corrective treatment, Jing and Straw-Wilson hypothesized that “many side effects of SSRIs are attributed to increased serotonin at subtypes specific for serotonin receptors.
They focus on the prospects of other pharmaceuticals as adjunctive or replacement therapies, such as bupropion (Wellbutrin), which they say “reverses SSRI-induced sexual dysfunction in 66% of subjects when ‘it’s used consistently’, but also has a higher impact. risk of seizures and overdose.
They also summarized a systematic review of randomized controlled trials determining that
phosphodiesterase 5 (PDE5) inhibitors, such as sildenafil (Viagra) and tadalafil (Cialis), improved erectile dysfunction better than placebo in male subjects with sexual dysfunction following antidepressant treatment
but pointed out that neither provides a “solution to the most common sexual side effect associated with SSRIs, difficulty achieving orgasm”, with unclear prospects also for long-term treatment. term of PSSD in women.
Jing and Straw-Wilson added that saffron, a spice derived from the Crocus sativus flower, “has implications for producing aphrodisiac effects in animals and humans” and that – again focusing on treatment Men – “There is evidence that saffron may inhibit serotonin reuptake and affect nitric oxide levels in the body, which plays a role in achieving an erection.
Other researchers – skeptical of these hypotheses and their insufficient studies, and aware of the significant number of patients whose sexuality has not recovered, despite the end of drug treatment months earlier – point to the risk of harm to term as a built-in feature of SSRIs, not an exception to them, and urge prescribers to weigh lingering risks with greater caution: “RxISK is not aware of anything that helps PSSD.”
Sertraline (Zoloft) tapering neuroscience patient and student PSSD’s “worst” summed up in powerful recent testimony about the condition, following prior optimistic stress on neural pathway “plasticity”,
is that these changes may be permanent, and I’m afraid that’s me. I’m almost out of sertraline and don’t see any change. I don’t have a frame of reference [having taken the SSRI as prescribed since age 12], so I can’t compare my progress to a sexuality that was there once. I have nothing to miss! But I still feel like I’m missing a key aspect of intimacy that other adults may take for granted.