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British Medical Bulletin 57:81-99 (2001)
© 2001 Oxford University Press
Depression and sexual dysfunction
Community Clinical Sciences Research Division, Faculty of Medicine, Health and Biological Sciences, University of Southampton, Southampton, UK
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Abstract |
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Top
Abstract
IntroductionAdequate sexual expression is an essential part of many human relationships, and may enhance quality of life and provide a sense of physical, psychological and social well-being. Epidemiological and clinical studies show that depression is associated with impairments of sexual function and satisfaction, even in untreated patients. Most antidepressant drugs have adverse effects on sexual function, but accurate identification of the incidence of treatment-emergent dysfunction has proved troublesome, as disturbances of the sexual response can only be detected in a reliable fashion when systematic enquiries are made before and during the course of treatment. Growing awareness of the adverse effects of many antidepressants on sexual function has led to attempts to resolve dysfunction though adjuvant or substitution treatment approaches. There is a need for further studies of the effects of antidepressants on sexual function.
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Introduction |
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Interest in human sexual function has increased considerably in recent years. Western societies are more open about sexual matters and sexual images are used in advertising and entertainment. These shifts in social attitudes may increase the number of people who wonder whether their sexual performance is less than ideal, and increase the number who consult health professionals1
. The introduction of sildenafil (Viagra), the first orally active drug for male erectile disorder, created wide-spread comment and increased public awareness of sexual dysfunction, which is now often regarded as a medical condition that can be treated by a doctor.
Sexual dysfunction can arise from physical conditions (e.g. circulatory disorders may cause erectile dysfunction in men) and from psychological factors (e.g. unsatisfactory interpersonal relationships, psychiatric illness). Many drugs can cause sexual dysfunction, including antihypertensives2, antipsychotics3, and antidepressants4,5. However, it can be difficult to separate drug-induced adverse effects from consequences of illness, particularly in psychiatric disorders with major effects on interpersonal relationships. There is relatively little scientific information on the incidence of antidepressant-induced sexual dysfunction, even though this may be important to the patient and contribute to non-compliance with treatment.
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The human sexual response and sexual dysfunctions |
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The normal human sexual response cycle is conventionally divided into four phases. Disorders of the sexual response can occur at one or more of these phases.
- Desire: typically this consists of fantasies about, and the desire to have, sexual activity.
- Excitement: the subjective sense of sexual pleasure and accompanying physiological changes, namely penile tumescence and erection in men, and pelvic vasocongestion, swelling of the external genitalia, and vaginal lubrication and expansion in women.
- Orgasm: sexual pleasure peaks, with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs. In men, the sensation of ejaculatory inevitability is followed by ejaculation of semen. In women, contractions of the outer third of the vaginal wall occur.
- Resolution: the sense of muscular relaxation and general well-being. Men are physiologically refractory to erection and orgasm for a variable period, whereas women may be able to respond to further stimulation.
The tenth edition of the International Classification of Mental and Behavioural Disorders (ICD-10)6 uses the term ‘sexual dysfunction’ to cover the ways in which an individual is unable to participate in a sexual relationship as he or she would wish. The ICD-10 classification of sexual dysfunction, not caused by organic disorder or disease is as shown below. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)7 uses a broadly similar classificatory scheme.
- F52.0 Lack or loss of sexual desire
- F52.1 Sexual aversion and lack of sexual enjoyment
- F52.2 Failure of genital response
- F52.3 Orgasmic dysfunction
- F52.4 Premature ejaculation
- F52.5 Non-organic vaginismus
- F52.6 Non-organic dyspareunia
- F52.7 Excessive sexual drive
- F52.8 Other sexual dysfunction, not caused by organic disorder or disease
- F52.9 Unspecified sexual dysfunction, not caused by organic disorder or disease
Some types of dysfunction occur in both men and women, although women tend to present with complaints about the subjective quality of sexual experience (e.g. lack of interest or enjoyment) whereas men often describe the failure of a specific response such as erection, whilst reporting a continuing sexual appetite. It has been argued8 that the categorical approach to sexual dysfunction adopted by the ICD-10 and DSM-IV simply serves ‘to obscure the varied and often unique ways in which individuals and couples present with sexual problems’. When one aspect of the sexual response is affected, other aspects are also likely to be impaired, and it is important to ‘look beyond’ any presenting complaint, to find the most appropriate diagnosis.
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Epidemiology of sexual dysfunction |
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This area has not been studied extensively (Table 1). In an attempt to derive prevalence data for sexual dysfunctions as defined in DSM-III, Nathan surveyed 22 studies of sexual behaviour in the general population, but concluded that methodological problems in the surveys meant that only broad estimates could be made9
. The prevalence of inhibited sexual desire was 16% for men, 35% for women; erectile dysfunction and premature ejaculation, 10–20% and 35% of men, respectively; and female orgasmic difficulties had a prevalence of 5–15%.
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A recent study in the US has shown that sexual dysfunction in the general population is more prevalent in women (43%) than men (31%)1
. Using latent class analysis, symptoms of sexual dysfunction during the previous 12 months could be grouped into three categories. For women, these were low sexual desire (22% prevalence), arousal problems (14%), and sexual pain (7%). The categories in men were premature ejaculation (21%), erectile dysfunction (5%) and low sexual desire (5%).
Rates of sexual dysfunction vary considerably between studies, probably reflecting differences in study population and types of dysfunction being assessed. The studies which provided data for both genders show a higher prevalence of sexual dysfunction in women than men1,10,11. Among men, the most commonly encountered sexual dysfunction appears to be premature ejaculation, whereas women are more likely to complain of reduced sexual desire, or difficulties in getting excited and reaching orgasm.
Many factors influence the reported incidence of sexual dysfunction. First, the method of enquiry; for example, in a prospective study of depressed out-patients, the incidence of sexual dysfunction was 14% when relying on spontaneous reporting, but 58% when patients were questioned directly by doctors14. Second, the expectations people have of their sexual performance and their willingness to discuss problems varies widely between different cultures15. Third, many terms used to define sexual dysfunction are subjective and dependent on ideas of what is normal. Finally, temporal trends can occur as increased awareness of sexual matters and availability of medical treatments increase the number who perceive themselves as suffering from sexual dysfunction.
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Sexual dysfunction in depressed patients |
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Depression is characterised by loss of interest, reduction in energy, lowered self-esteem and inability to experience pleasure: irritability and social withdrawal may impair the ability to form and maintain intimate relationships. This constellation of symptoms may be expected to produce difficulties in sexual relationships, and depression has long been associated with sexual problems16
. In 132 patients with depressive disorders, loss of sexual interest, characterised by loss of libido or decrease of sexual desire or potency, was reported by 72% of patients with unipolar depression, and 77% of patients with bipolar depression17. Conversely, loss of sexual desire may be the presenting complaint of some patients, who only after direct questioning are found to have significant depressive symptoms. In others, low sexual desire may precede the onset of depression18.
Comparative studies reveal higher levels of sexual dysfunction in depressed patients than in non-depressed controls (Table 2). The specific type of sexual dysfunctions vary in incidence, but loss of sexual desire may be more common than disorders of arousal and orgasm: in a comparative study, changes in libido were significantly more common in depressed patients than controls, but differences in the prevalence of impotence, orgasmic or ejaculatory problems were not19. The prospective Zurich cohort study shows that the prevalence of sexual problems in depressed subjects (including those with major depression, dysthymia and recurrent brief depression) is approximately twice that in controls (50% versus 24%). This difference encompassed emotional problems, sexual dysfunction, and both decreased and increased libido. The data in this study are from a group of young people (28–35 years) and may not be applicable to older age groups20.
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The Zurich study provides comparative data on the prevalence of sexual problems in untreated depressed patients and depressed patients receiving either medication (50% benzodiazepines, 50% antidepressants) or psychotherapy. Sexual problems were more prevalent in the 78 depressed patients who received treatment (62%) than in the 122 who did not (45%), and both groups had a higher prevalence of sexual dysfunction than controls (26%). However, there were no statistically significant differences in the prevalence of any type of sexual dysfunction between patients treated with medication (62%) or psychotherapy alone (63%)20
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Sexual dysfunction associated with antidepressants |
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Papers for this review were identified by searching the Medline, Toxline, Embase, Biosis, DDFU, Scisearch, PsychLit and ADIS Newsletter databases. Sexual dysfunction was used as an index term, and combined with names of antidepressant drugs. Further papers were obtained from Current Contents 1995–1999. These were supplemented by papers identified from reference lists, abstracts presented at congresses, and through scanning library copies of relevant journals. Studies were included if they were published in English, reported an incidence of sexual dysfunction in patients receiving antidepressant medication and if there were 10 or more subjects. All studies reporting data on drug-associated sexual dysfunction were assessed on the following criteria: design (randomised, prospective, double-blind); comparative; type of control (placebo-controlled and/or baseline-controlled); use of defined diagnostic criteria; use of validated rating scale for assessing sexual dysfunction.
Although the high prevalence of sexual dysfunction in the general population and in depressed patients can make evaluation difficult, treatment-emergent sexual dysfunction can occur with tricyclic antidepressants (TCAs), selective serotonin re-uptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs)5,21. Some antidepressants (bupropion, mirtazapine, moclobemide, reboxetine, nefazodone) may be associated with a relatively lower incidence of sexual dysfunction4,22, but most data for these newer drugs come from reviews of clinical trial adverse event databases or work with healthy volunteers.
Studies which made no direct comparison between antidepressants
Table 3 lists studies conducted in mixed populations of patients receiving antidepressants for depressive or anxiety disorders. The prevalence of sexual dysfunction may not differ according to diagnosis23,24. One study found no significant difference between patients undergoing drug or non-drug therapy, across a range of sexual function variables assessed using the Social Adjustment Scale (SAS) and Hamilton Rating Scale for Depression (HRSD)25. Few data have been published on sexual dysfunction occurring with TCAs, although anorgasmia was common in a study of clomipramine in patients with obsessive-compulsive disorder26.
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The majority of the studies assess sexual dysfunction with SSRIs. It is difficult to interpret these findings, as the study populations include patients with varying degrees of depression and/or anxiety, and no two studies used the same method of assessing sexual dysfunction. Few studies assessed sexual function at baseline (4 studies), and 8 of the studies involved fewer than 100 subjects. Large patient populations and placebo control were mainly confined to controlled clinical trials, which invariably failed to include a baseline control. Fluoxetine had both the highest (75%) and the lowest (8%) reported prevalence of treatment-emergent sexual dysfunction, one figure derived from specific questioning about abnormal ejaculation27
, the other derived from spontaneous reports of orgasmic problems28.
Studies which made direct comparisons between antidepressants
Table 4 summarises studies which directly compared two or more active agents. As with the non-comparative studies, the methodology varies considerably. Several are not true comparisons, but report differences between drugs in manufacturers' databases29,30, adverse events spontaneously reported to a national body31,32 or hospital monitoring scheme33. These evaluations are troublesome to interpret, through differences in coding of adverse events, possible bias in reporting, and inadequate data on dosage and number of exposed patients.
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Comparative studies of SSRIs have generally found no significant differences between drugs14
,34,35, but one study reported more sexual dysfunction with sertraline than fluvoxamine36. Bupropion may be associated with a low incidence of sexual adverse effects, being significantly superior to sertraline in one study37 and to SSRIs in another34. A comparative study with nefazodone found it to be significantly superior to sertraline on some measures of sexual function38. All the studies had some methodological flaw. Only two39,40 used a recognised rating scale for sexual dysfunction (the Sexual Function Questionnaire), the others relying on patients reporting adverse events. Only two37,39 used a baseline assessment and placebo control.
The findings of a randomised controlled trial comparing moclobemide (a reversible inhibitor of monoamine oxidase type A) with the TCA doxepin suggest that moclobemide is relatively free of adverse effects on sexual function41. This is supported by a study in healthy volunteers42 and post-marketing surveillance43.
Augmentation or switching studies
Several studies have investigated whether SSRI-associated sexual dysfunction can be resolved by adding, or changing to, a different antidepressant. For example, a retrospective review of 16 patients who complained of sexual dysfunction during SSRI treatment found that 11/16 (69%) rated their sexual function as much or very much improved when buspirone was added to the drug regimen: however, buspirone was associated with increased irritability in 4 (25%) of patients44.
Mirtazapine may be a useful alternative in depressed patients who develop sexual dysfunction with SSRIs. In a study of 20 patients with SSRI-associated sexual dysfunction who switched to mirtazapine, sexual function improved in 9 of 12 patients (75%) who completed at least 6 weeks’ treatment, although 6 patients developed irritability and 9 reported sedation45. A second study in 11 patients who stopped SSRIs because of sexual problems found that mirtazapine treatment did not result in the re-emergence of sexual dysfunction46. These observations are supported by recent findings in a group of 25 depressed out-patients, indicating that mirtazapine treatment had beneficial effects on sexual function47.
The largest body of data is for bupropion. Adjunctive treatment improved sexual dysfunction in 31 of 47 (66%) patients previously treated with SSRIs, but 7 (15%) discontinued bupropion because of anxiety and tremor48. In another study, switching to bupropion improved sexual function in 24 of 28 men who had experienced sexual dysfunction during treatment with TCAs or MAOIs49. Similar effects have been reported in 31 patients (men and women) who developed anorgasmia or delayed orgasm while taking fluoxetine: after switching to bupropion for 8 weeks, orgasm dysfunction completely or partially resolved in 29 patients (94%), and libido was much or very much increased in 25 (81%)50. However, not all data with bupropion are consistent: a retrospective review in 27 patients found that sexual dysfunction occurred in 11 patients (41%) when they were receiving combination bupropion-SSRI treatment, not significantly different to the rate (52%) when they were taking either agent alone51.
All of these studies were of open design, none had a placebo-control or double-blind design, or a baseline assessment, all had fewer than 40 patients, and only one45 used a validated scale for measuring sexual dysfunction. The results, therefore, need to be replicated in controlled clinical studies.
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Method for assessing sexual dysfunction |
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Studies investigating antidepressant drug-induced sexual dysfunction must be especially stringent, in order to differentiate between normal variations in sexual function, sexual problems related to depression or anxiety, and sexual dysfunction associated with antidepressant treatment. Ideally, these studies should be prospective, randomised, double-blind, placebo-controlled and conducted in a defined diagnostic population. The studies should make direct comparisons between different drugs, and the dose ranges should be of equivalent efficacy.
Sexual dysfunction should be assessed using a rating scale administered to all patients, rather than relying on spontaneous reporting or open questions which may be interpreted differently by different patients. The rating scale chosen should be valid and reliable, able to discriminate between normal variations in sexual behaviour and sexual dysfunction, and sensitive to change. A baseline measure of sexual dysfunction is needed to identify treatment-emergent changes, and in comparative studies groups should be balanced according to degree of sexual function at baseline. Many sexual functioning questionnaires exist, but most have not been thoroughly tested and remain unvalidated52. Some of the most well-known scales are the Sexual Function Questionnaire39, the Sexual Functioning Questionnaire53, and the Arizona Sexual Experience Scale (ASEX)54. The latter has been validated for multiple comparisons, but is not yet used widely55.
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Treatment of sexual dysfunction |
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Sexual dysfunction occurring in a depressed patient should be assessed sensitively, and treatment tailored to individual needs and circumstances. Several strategies may be beneficial in the management of treatment-associated sexual dysfunction in depression56
, including:
- behavioural strategies to improve sexual technique
- waiting for the development of tolerance
- reduction in dosage
- delaying drug intake until after sexual activity
- ‘drug holidays’
- adjuvant treatments
- changing to a different antidepressant
Drug holidays, involving brief interruptions of treatment, have been advocated as an approach to SSRI-induced sexual dysfunction57. However, this approach can put the patient at risk of discontinuation symptoms and possible relapse of depression: furthermore, a drug holiday is only possible with drugs with a short half-life and not with fluoxetine, where sexual side effects may not resolve until a few weeks after stopping treatment21. Many adjuvant compounds have been advocated for the treatment of psychotropic drug-induced sexual dysfunction, including buspirone, cyproheptadine, mianserin, yohimbine, neostigmine, amantadine and dexamphetamine56. However, there have been very few double-blind placebo-controlled studies of these drugs58, and it is wise to be cautious when using unfamiliar treatments. Finally, it seems likely that sildenafil may come to have a role in relieving sexual dysfunction in depression. In a sub-group of 136 depressed patients included within the placebo-controlled clinical trial database, 76% described improvements with sildenafil, compared to 18% of the group receiving placebo59: in a second report, sildenafil was effective in 10 of 14 patients with antidepressant drug-induced sexual dysfunction60.
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Conclusions |
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Accurate assessment of sexual function in depression is subject to many difficulties, including the little data on prevalence of sexual dysfunction in the general population, and the effects of antidepressant drugs. Obtaining accurate data on an intimate subject is potentially prone to under-reporting unless careful attention is paid to the method of data collection. Until data from rigorous, controlled, comparative studies are available, the perceived likelihood of sexual side effects should not unduly influence the choice of antidepressant drug, and prescribing decisions should be made on an assessment of the overall balance of the benefits and risks of treatment.
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Acknowledgements |
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Thanks are due to Jon Birtwistle for his help with the literature search, and to Stuart Montgomery and Alan Riley for shared discussions regarding the assessment of sexual dysfunction in depression.
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Footnotes |
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Correspondence to: Dr David S Baldwin, University Department of Mental Health, Royal South Hants Hospital, Brintons Terrace, Southampton SO14 0YG, UK
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