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Clinicians Urged Not to Sidestep Patient Sexual Dysfunction
SAN DIEGO—Mental health clinicians aren't talking to their patients enough about sexual dysfunction issues that could be resulting from use of antidepressants or the underlying depressive illness, University of Virginia Professor of Psychiatry Anita Clayton, MD, said at Psych Congress 2019.
“If we wait for the patient to tell you about it, often they won't,” Dr. Clayton said in a session on addressing sexual dysfunction in patients receiving psychotropics. “We need to ask, and we need to try to do it systematically.”
In fact, patient surveys have suggested that many patients hesitate to bring up topics involving sex for fear that their health care provider will either minimize them or simply feel uneasy addressing the subject, Dr. Clayton said. “They're worried about us feeling uncomfortable,” she said.
The conference session with Dr. Clayton, who chairs the university's Department of Psychiatry and Neurobehavioral Sciences, addressed strategies for switching or augmenting medication to address treatment-emergent sexual dysfunction. She emphasized, however, that professionals need to see depression and sexual dysfunction as a bidirectional issue, with either potentially causing the other in the individual patient.
More from Dr. Clayton: When Antidepressant Treatment Leads to Sexual Dysfunction
While she pointed out that most psychotropic medication classes can inhibit sexual desire or performance, Dr. Clayton focused on the evidence around antidepressants. She said selective serotonin reuptake inhibitors (SSRIs) are linked most closely with sexual side effects, with serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) conferring slightly less risk.
Among the antidepressants shown to produce the lowest rates of sexual dysfunction at the highest level of evidence are bupropion, vilazodone, aripiprazole and vortioxetine, Dr. Clayton said. However, there is no federally approved adjunctive treatment for sexual dysfunction in patients receiving treatment for depression, she added.
If a medication substitution is pursued because of antidepressant-related sexual dysfunction, Dr. Clayton suggested that vortioxetine has the greatest amount of supporting data. She would recommend a daily dose of 10 mg of the SSRI in these cases.
The Broader Picture
It is important for professionals to look at sexual issues in the broader context of the many factors that could be affecting a patient's health and wellness, Dr. Clayton said. Sexual dysfunction can be a symptom of depression, an effect of antidepressant medication, or a result of other illnesses, use of substances, or relationship issues.
Moreover, for some patients sexual dysfunction could be a primary concern while others may see it as less of a problem. “You've got to know what your patients' preferences are for treatment,” and what symptoms they absolutely cannot live with, she said.
Some patients may want to stay on their current antidepressant even if they are experiencing sexual effects, for fear that no other antidepressant will work as well for their depression.
Understanding the many ways sexual dysfunction may be affecting the patient, from its pattern of onset to the degree to which it is generating distress in the patient's life, will help professionals identify a productive strategy to pursue, Dr. Clayton said.
—Gary Enos
Reference
“What to do when an antidepressant is effective, but your patient has sexual dysfunction.” Presented at Psych Congress 2019: San Diego, CA; October 5, 2019.
