Sex, Drugs, and Psychosis: Reviewing Psychiatric Medication’s Taboo Side Effect

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Sex, Drugs, and Psychosis: Reviewing Psychiatric Medication’s Taboo Side Effect

The sexual side effects of psychiatric medications are troubling enough that some patients consider treatment cessation. The authors review 5 strategies for managing sexual dysfunction.

It has been said that individuals avoid discussing religion, politics, and money. In this article, we will address another taboo topic: sexual dysfunction (SD), which occurs when an individual has difficulty with 1 or more components of the sexual response cycle, presenting as decreased libido, early or delayed ejaculation, orgasmic dysfunction, impaired genital sensation, erectile dysfunction, and/or insufficient lubrication in women.1

SD is relatively common. In the general adult population, the estimated prevalence of SD is 20% to 30% in men and 40% to 45% in women.1 Certain risk factors may increase the risk, including psychiatric disease. For example, based on International Classification of Diseases, Tenth Revision (ICD-10) definitions, 74% of men and 82% of women with schizophrenia, reported at least 1 sexual problem.2 However, psychiatric patients experiencing SD are often hesitant to disclose concerns to health care professionals.2,3

Medicinal treatment of psychiatric diseases is also a significant cause of SD. Antidepressants, antipsychotics, and benzodiazepines are 3 drug classes that are potent etiologies of SD (Table 1).4-10 According to a validated survey for assessing SD (SalSex), nearly half of patients treated for a psychotic disorder developed SD.3 Another study suggested that 25% to 80% of patients treated with antidepressants developed SD.11 This is a major concern, as some patients have shown poor tolerance to the sexual side effects of psychiatric medications and have considered treatment cessation as a result.3,12 Furthermore, emerging evidence suggests that the sexual side effects of psychiatric medications persist even after medication discontinuation, causing patients great distress.13

Table 1

SD is a significant concern for patients on psychiatric medications. However, SD is often inadequately addressed.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS. Selective serotonin reuptake inhibitors (SSRIs) are commonly utilized in the treatment of major depression, anxiety disorders, posttraumatic stress disorder, and obsessive-compulsive disorder, among others.13 The prevalence of sexual side effects is not well defined. One post-market study estimated SD prevalence in patients treated with SSRIs between 5% and 15%,4 while some studies reported up to 80% of patients experienced sexual side effects.5 Although some patients experiencing sexual side effects may see their symptoms resolve over the course of treatment, the vast majority will continue to experience side effects during SSRI treatment.13 Some patients may continue to suffer from persistent side effects despite the discontinuing medication, a condition known as post-SSRI sexual dysfunction (PSSD).13 Although there is limited clinical trial data, available studies found the highest incidence of sexual side effects in patients treated with paroxetine, followed by fluvoxamine, sertraline, and fluoxetine.6,7

A proposed mechanism for SSRI-induced SD lies within the interaction between serotonin and 5-hydroxytryptamine receptors (5HT1A).13 SSRIs are hypothesized to cause downregulation of 5HT1A due to the persistent stimulation by serotonin and resulting epigenetic changes that have implications for regulation of sexual motivation. It is likely that other 5HT receptor subtypes are similarly affected. The effect of elevated serotonin on levels of other hormones and neurotransmitters that play an important role in sexual function, such as testosterone and dopamine, may also account for some of SSRIs’ sexual side effects. These effects appear to be dose-dependent, with higher doses increasing one’s risk of SD.14,15 Thus, providers must weigh the potential benefits of increasing drug doses with increasing risk of adverse effects.15

ANTIPSYCHOTICS. SD is a common adverse effect (present in up to 48% to 75% of patients) of both oral and depotantipsychotic medications.8,16 Results of a recent meta-analysis described SD prevalence in those treated with oral antipsychotics to be between 16% to 60%.9,17 Treatment with quetiapine (16%), ziprasidone (18%), and aripiprazole (27%) were associated with the lowest rates of SD. Olanzapine (40%), risperidone (43%), haloperidol (45%), clozapine (52%), and thioridazine (60%) were associated with higher prevalence of SD. In long-acting depot antipsychotics, first- versus second-generation antipsychotics are more strongly associated with SD.18,19