Antidepressants can be a blessing but a curse for sexual satisfaction. While the medication can improve mood and aspects to well-being, one primary drawback to taking any type of SSRI (selective serotonin reuptake inhibitors) is contending with sexual side-effects such as erectile dysfunction and inorgasmia.
About 13 percent of the population ages 12 and older said they took an antidepressant in the last month. Moreover, 16.1 million people in the U.S. are affected by clinical depression. The increase in diagnoses across the country indicates the willingness of people to express concerns about their mental health with their medical practitioners, which is a positive and progressive sign. As well, the influx in prescribed antidepressant use also signifies that the medication is safe. According to Dr. Anita Clayton, chair of Psychiatry and Neurobehavioral Sciences at University of Virginia School of Medicine, the development of SSRI Prozac (Fluoxetine) in 1988 and its subsequent family of drugs was a breakthrough; not only was it well tolerated, but it was safe to take.
Compared with Tricyclic-based antidepressants (TCAs and the earliest class developed) such as Nortriptyline (Pamelor) and and Protriptyline (Vivactil), these were not only riddled with side effects but proved fatal if you overdosed on them. Although we’ve opened communication channels in treating people with depression and sharing our struggles with it, what we’re not addressing enough in patient rooms is sex-specific repercussions: primarily, inorgasmia and erectile dysfunction that stem from antidepressant usage.
In order to understand how these drugs affect sexual desire and response, we must briefly explore how antidepressants work and how it affects our mind and body: Firstly, there is an abundance of antidepressant classes on the market which include Serotonin and norepinephrine reuptake inhibitors (SNRIs), Tricyclic antidepressants (TCAs), Dopamine reuptake blocker, Noradrenergic antagonist, Monoamine oxidase inhibitors (MAOIs), and 5-HT receptor antagonists; however, the focus here is on SSRIs because they are the most widely prescribed and used family of antidepressants in the United States. Furthermore, the highest rates of sexual dysfunction have been reported with SSRIs.
If you have depression, you’re more likely to have a sexual dysfunction; and if you have a sexual dysfunction, then you’re more likely to develop depression.
Meanwhile, serotonin (a type of inhibitory neurotransmitter) doesn’t actually stimulate the brain, but you need adequate amounts to have a stable mood and to balance out excessive excitatory stimulation in the brain. This is where antidepressants enter the picture: if you have an imbalance of serotonin levels, the SSRI drugs help preserve the levels in the brain and enhance absorption; in medical speak, this is called reuptake.
But as a consequence, while the drugs are helping to alleviate serotonin issues, it is also inhibiting “communication” with excitatory neurotransmitters that pertain to pleasure and sexual desire (dopamine and norepinephrine). In simplest terms: the medication alters the chemistry in the brain and subsequently how the mind is then able to “talk” to the body. SSRIs such as sertraline (Zoloft), fluoxetine (Prozac, Sarafem), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil, Pexeva, Brisdelle), fluvoxamine (Luvox) will contribute to sexual dysfunction.
If the issue is bothersome to the patient and not addressed, what can arise from this trade-off scenario is the creation of a vicious cycle. Dr. Clayton points out an overlooked but obvious fact: “Sexual dysfunction and depression work in a bidirectional way with one another. In other words, if you have depression, you’re more likely to have a sexual dysfunction; and if you have a sexual dysfunction, then you’re more likely to develop depression.” The reason is because both operate on the same neurotransmitters that relate to reward and pleasure. But Dr.Clayton is reassuring: “You do not have to settle with a lack of sex satisfaction because you’re on medication. You have options.”
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THE CURRENT LANDSCAPE
MedicalRates of always experiencing an orgasm during sexual intimacy are between 89-95% for men, so if something is amiss, they’ll automatically attribute the experience (inorgasmia and/or erectile dysfunction) to their medication and the situation is remedied. Women are not as fortunate; rates of orgasm are between 50-70% and sometimes as low as 25% (during vaginal intercourse). If females experience sex-related woes that are further exacerbated by antidepressants, the medication will not be associated as a contributing factor to the issue; and moreover, it will be accepted as a “new reality”. Dr. Clayton therefore encourages all patients to self-report because “helping us allows us to, in turn, help you”; MDs can not only help connect the dots, but there’s always an option to switch and try other drugs or a combination of drugs.
For instance, Bupropion (Wellbutrin) or Mirtazapine (Remeron) which don’t operate on serotonin reuptake inhibitors (both do not enhance serotonin), are not likely to cause sexual dysfunction. Wellbutrin and Remeron are examples of norepinephrine–dopamine reuptake inhibitors (NDRI); similar to how SSRIs act as a reuptake inhibitor for serotonin, here, NDRIs focus on enhanced absorption of norepinephrine and dopamine instead.
However, with any prescribed drug, there are pros and cons to consider. With Wellbutrin, one of the side-effects is the risk of epileptic seizures and for Remeron, in rare cases, it can cause skin rashes and shortness of breath. The aforementioned drugs can also be used in combination with an SSRI but the risk is a drug interaction which can “increase or decrease the effectiveness of a drug or side-effects of the drugs.
Moreover, the likelihood of drug interactions increases as the number of drugs being taken increases.” - Dr. Omudhome Ogbru The takeaway here is that a good medical professional is observant in such situations and willing to match to the needs of the patient, so it is important to voice concerns in order for adjustments to be made.
StaggeringAnother option is to reduce dosage or skip medication on strategic days (e.g. alternating days) which Dr. Clayton observes has worked for short-acting SSRIs such as sertraline (Zoloft) and escitalopram (Lexapro); however, she cautions that the patient must be very disciplined. It is advisable to consult your doctor and work out a schedule before venturing down this path. Potential issues that could arise from staggering (in addition to forgetfulness) is exhibiting discontinuation (e.g. withdrawal, flu-like symptoms); as a consequence, it will defeat the purpose of this strategy because you’ll lose all desire for sex and intimacy.
PsychotherapyFor those on antidepressants, Dr. Clayton recommends coupling medication with mindfulness through psychotherapy. Individual sessions with a licensed practitioner or psychiatrist helps patients cultivate awareness through talk therapy and understand the causes of their depression. Once the patient gains perspective and feels more in control of their circumstances, they are taught/guided on how to handle future situations that can be triggering. In certain respects, patients are asked to track their moods and re-train their mind and find alternative/productive ways to react to external stimuli (environment, social exchanges). This strategy can be applied to sexual side-effects; the objective is to reconnect mind with body via awareness and being more attuned to your needs. She cites that it is a treatment that has been proven to be very effective.
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Cognitive Behavioural Therapy (CBT)CBT falls under the Psychotherapy category and it is considered a “dynamic” and “assertive” approach to treating mental disorders. Dr. Clayton explains that those with depression who opt for this treatment can be on or off antidepressants. Dr. Neha Pathak defines CBT as a “problem-focused and action-oriented way to treat mental disorders such as depression.” The therapist assists the client to find effective skills to achieve specific goals and decrease symptoms of the disorder. Clayton adds that it is about recognizing thoughts that enter your mind and changing the “automatic scripts” or reactions. Oftentimes, individuals are not even aware that they’ve reacted or behaved in a certain way, so the awareness aspect identifies the nature or heart of a problem.
Dr. Clayton has observed that CBT can sometimes offer more fulfilling results than being on medication because it empowers the client with strategies to address issues that stem from their past, present and/or future. She comments on CBT as it relates to sexual function: “It is a bio-psycho-social-phenomenon and has to do with the biology in the person, which could be influenced by the processes of person’s psyche. The processes are a result of many things such as interpersonal relationships, social and cultural influences (e.g. religion); the range is extensive, from progressive to probationary.” Dr. Clayton explains that all of these variables can unconsciously or consciously affect performance and sexual satisfaction. CBT therefore “unlocks” these thoughts, allows you to work through them, and helps you find productive and constructive ways to manage.
WHAT YOU NEED TO DO
Communicate Needs With Your PartnerDepression and sex-related woes stemming from medication use should be addressed openly with your partner; it can be discussed privately or with a couples/sex therapist present. JoEllen Notte, sex writer and educator, encourages couples to think of it as a “couple vs. depression” scenario rather than “the person with depression and the partner without it.” She encourages open communication from the outset and as a team. “Ensure that he or she is always in the loop and part of the conversation the whole way through. Otherwise, communication gaps can lead to assumptions and result in the person can feel ‘rejected’ or ‘unattractive’.”
Notte also advises that couples set themselves up for success, “when you’re depressed, the world tells us we’re ‘not interested in sex’ which is far from the truth.” JoEllen encourages couples to make “conscious sexual decisions” such as mental-preparedness for sexual satisfaction and further bolstering this state of mind by creating the environmental circumstances to ensure that you will be aroused and can attain pleasure. She calls this the “sexual skeleton key” which is unlocking all the elements that “turn you on”. Notte says that the most important aspect to be mindful of is to never put pressure and stress on yourself or that you “must set to work on getting an orgasm”; it results in anxiety and frustration.
Communicate Needs With Your Medical ProfessionalThis is tricky territory to navigate. “It is an incredibly sensitive topic to talk about,” Dr. Clayton admits. The medical climate’s comfort levels in openly talking about sex side-effects (related to antidepressants) is still in its infancy. It’s not easy for anyone to fully express themselves at the doctor’s office, let alone their sexuality. JoEllen adds, “talking to your doctor about mental health can be daunting. Talking to your doctor about sex can be daunting -- so when you put the two together, it’s like a ‘big bad’ ”.
In research for her upcoming book The Monster Under the Bed, Notte surveyed over 1,300 people and asked them about navigating the frustrations associated with sex and depression. Notte says that in many cases the “sex side-effect” is not taken seriously because it isn’t considered a “priority problem”, but what many of these patients want the medical community to understand is that “the inability to have sexual satisfaction impacts your entire life, not just your sex life.”
Although Notte says that it is understandable that an air of discomfort exists because “we’re all human,” what really needs to happen is that sex is normalized to the point where it can be asked on intake forms and in-person questioning like “are you sleeping well? How are your energy levels? How is your sexual health?” It boils down to education; Notte says that “unless you specialize in sex health, those in residency are not getting enough training and therefore do not know how to speak with patients who contend with antidepressant, sex-related ailments.” Until it is deemed an important chapter to understanding the overall story, Notte says that it remains an uphill battle.
However, there is hope. Notte offers the following: “Don’t suffer quietly. If it bothers you, speak up. The more people who address these issues with doctors is how we will achieve a critical mass of popular support.” Dr. Clayton also encourages the following: “Openly address it with your doctor or psychiatrist about it. From the outset, when psychiatrists and medical professionals are doing in-take assessments, they should ask patients if they’re comfortable talking about their sexual health. The relationship will only be mutually beneficial if sharing is open; clinical data and accuracy depends on the willingness of patients to self-report.” As a result, MDs will be able to make more informed decisions and understand the need to rank this side-effect as high of a priority as the others.