Psych Medication Induced Sexual Dysfunction

It’s the ultimate insult to mental illness injury.

Toby Keith once said, “I’m not as good as I once was, but I’m good once as I ever was.” It’s also pillow talk for many people on psych meds.

Treatment emergent sexual dysfunction (TESD) is more stigmatized than mental illness itself. This is why so few patients report it, resulting in an underestimation of its numbers in clinical practice. Moreover, clinicians rarely ask patients about their sexual activity due to a lack of time, preparation, or interest. But given the statistics, it’s essential to consider one’s full psychosexual history before starting medication.

For a quiet majority, it’s “Netflix and pill.”

In addition to reducing interest in sex, selective serotonin reuptake inhibitors (SSRIs) can make it difficult to become aroused, sustain arousal, and reach orgasm. Some people taking SSRIs aren’t able to have an orgasm at all. And medications with the greatest serotonin effect have the highest rates of sexual dysfunction.¹ This creates a state of “climaxiety.” At a minimum, these meds can leave patients with the libido of a starfish or block of cheese. Yet quitting isn’t the answer. By the time sex drive returns, so does the anxiety or depression. It’s a sexual catch-22.

“I thought being an adult would involve more sex.”

A 2003 survey found that approximately 41.7 percent of men and 15.4 percent of women discontinued psychiatric medications due to perceived sexual side effects. With twice as many women as men affected by anxiety, many women could be experiencing the problem but not reporting it.² In fact, one in six women in the United States takes antidepressants, and a substantial proportion of them describe some disturbance of sexual function while taking them. These symptoms tend to become more common with age when a trail of clothes leading to the bedroom just means someone dropped them on the way from the dryer.

Impotence is anxiety’s way of saying “no hard feelings.”

The issue often leads to patient distress, or the distress of their partner, in the sexually active population.³ But there’s a delicate balance between prescribing an effective drug that improves symptoms while having minimal effect on sexuality. No one should have to trade sexual prowess for mental health.

About 35 percent to 50 percent of people with untreated major depression experience some type of sexual dysfunction prior to treatment. In such cases, sexual difficulties may stem not from the SSRI but from the depression itself. If medication is indeed the problem, sexual side effects sometimes lessen with time, making it worthwhile to see if problems diminish in a sort of libidinal Dark Ages.

Fortunately, most forms of sexual dysfunction associated with antipsychotic drugs appear to be medically benign and reversible with drug discontinuation. An exception is priapism (prolonged erection of the penis, usually without sexual arousal), which necessitates prompt urological help and may require surgical intervention.⁴ Priapism can also be caused by the bite of the Brazilian wandering spider (Phoneutria nigriventer). If a man has the misfortune of being bitten while also on SSRIs, I assume his penis just explodes.

The main focus of clinicians should be starting a treatment with drugs that preserve sexual function in patients who require long-term medication. When adverse sexual side effects occur, treatment can include dose reduction, switching or discontinuation of drugs, augmentation, or using medications with fewer side effect profiles. There are also behavioral and complementary tactics such as exercising before sexual activity, scheduling sexual activity, vibratory stimulation, psychotherapy, acupuncture, taking maca root, watching episodes of Bachelor in Paradise, or some combination of these modalities.⁵

Some medications are easier on the libido and sexual performance than others. Bupropion (Wellbutrin), nefazodone (Serzone), and amitriptyline (Elavil) have been shown to cause less sexual dysfunction than SSRIs. Among SSRIs, fluvoxamine (Luvox) may cause less sexual dysfunction than sertraline (Zoloft).⁶

In any case, clinicians should tailor each strategy to the individual patient while addressing its impact on their TESD and its possible improvements. In short, improvement of TESD will lead to increased tolerance of antidepressant treatment, better treatment adherence, and better patient quality of life. And, better whoopee.

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