This is the third video as part of a series of brief interviews with Prof Anita Clayton focusing on sexual function and antidepressants. Prof Clayton’s clinical practice and research interests focus on women’s mental health and sexual dysfunctions.

I think it is a difficult topic for both patients and providers.  So, one way to approach it is to plan in advance that you’re going to talk about it with everybody.  If you’re always going to bring up the topic of what is going on in people’s sexual lives – just like you’re going to ask about people’s sleep, or appetite, then that opens up the topic and gives patients permission to talk about it. 

In our study, 70% of people wanted to talk about it and 30% mostly wanted to talk about it but they had other things to do.  So, if you say, ‘let’s talk about this’, they’re going to want to talk about it. 

Then you want to ask about the problem with that developing along with the depressive symptoms, some time prior to them developing depression, or potentially, you’re going to follow this over time and look at what the impact of the antidepressant therapy is going to be. 

We often administer a questionnaire in the first visit and let them know we are going to keep following their sexual function and see if it gets better with this medication or if it worsens with this treatment. 

We also ask patients about their preference with regard to sexual dysfunction with antidepressants.  So we give them the pros and cons of each of the medications and ask what they would like to do.  Many people will say ‘I don’t want to have sexual dysfunction,’ so again, it’s allowing them to speak to their needs. 

The PAM-D approach provides an easy stepwise approach to the issue.

• Plan – Plan in advance that you’re going to talk about sexual dysfunction with everybody
• Ask -If you ask the question, it allows patients to talk about it (Remember in the study that 70% of people wanted to talk about it)
• Monitor -Monitor sexual side effects at each visit after the medication has been initiated.
• Discuss – Discuss the pros and cons of different medications – this allows the patient to decide according to their needs.

 

Management Principles in Sexual Dysfunction with Antidepressants

Rule out other causes

• Organic conditions: diabetes, peripheral nervous system dysfunction, cardiac disease, alcohol and substance misuse.

Treat depression adequately

Switch to lower risk antidepressants:

• e.g. Agomelatine, bupropion, mirtazapine and vortioxetine. Bupropion, agomelatine and vortioxetine have the best evidence for a favourable side effect profile. [Clayton A et al., 2016]

Wait and watch: spontaneous remission can occur in 5-10% of patients

Reduce dose

Drug holidays (missing one or two doses before planned sexual activity)- the risk of discontinuation symptoms

Phosphodiesterase inhibitors: Sildenafil and Tadalafil

Bupropion, Mirtazapine or agomelatine augmentation of SSRI or SNRI: monitor for side effects

Transdermal testosterone

Cyproheptadine

Take-Home Messages:

• Patients want to talk about the issue of sexual dysfunction
• Plan in advance that you are going to discuss sexual dysfunction with everybody
• Provide the pros and cons of antidepressants to your patients so that they can make choices in alignment with their preferences

Learn more

1. Key Points in the Assessment of Sexual Dysfunction – Conversations with Prof Clayton
2. Mechanisms of Sexual Dysfunction with Antidepressants – Conversations with Prof Anita Clayton
3. Sexual Dysfunction with Antidepressants – Conversations with Prof Anita Clayton
4. Article on Assessment and Management of Sexual Dysfunction with antidepressants. (Algorithm for management and medications ranking included)