Saturday, December 20, 2008

What I Never Knew about Sex and Anti-Depressants

From I Can Has Cheezburger?

By now, I think it's pretty common knowledge that Prozac, Paxil, Zoloft, and all the other anti-depressants in that class (SSRIs - selective serotonin reuptake inhibitors) can cause serious sexual side effects. They can cause delays in arousal and orgasm. Some people lose the ability to have orgasms altogether. Some men develop erectile dysfunction. Some people lose their libido altogether.

In this week's Boston Globe, journalist Carey Goldberg reports that the scope of SSRI-induced sexual problems is greater than had previously been recognized. Early studies put the number of Prozac users who developed sexual dysfunction at about four percent. Now, Goldberg says, that percentage is being revised dramatically upward:
But more recent studies, in which patients were more likely to be asked about specific sexual side effects and thus more likely to report them, suggest that the ballpark range of those affected by SSRIs is between 30 percent and 50 percent, said researchers including Dr. Richard Balon, a psychiatry professor at Wayne State University who studies the symptoms.

That would translate into millions of affected sex lives among the estimated 1 in 8 American adults who have tried these antidepressants in the past decade or so. Some studies have found the range still higher.
Wow. Fancy that. Doctors hadn't bothered to ask specifically about sexual problems. I guess they were trusting that patients would volunteer the information? And then they just assumed that no news was good news?

This goes way beyond naivete or cluelessness. This is not just another instance of doctors being pathetically repressed when it comes to sex - although it's true that far too many doctors are embarrassed to talk about sex ... and then they wonder why their patients don't raise the issue? This is also more than just the drug companies not wanting to know the complete downside of some of their most profitable products.

This is boneheadedness. Plain and simple. This is the ostrich approach to practicing medicine. Just prescribe a powerful drug, then stick your head in the sand of comfortable ignorance and assume all is well.

However, the wide prevalence of SSRI-induced sexual dysfunction is not even the worst news. The most disturbing part of Goldberg's article is this:
[A] handful of recent medical and psychological journal articles document a small number of cases in which sexual problems remain even after a patient goes off the drugs.
This is something I'd never heard. And I'm one of the folks who's been paying attention. I know plenty of people who've taken SSRIs for short periods or long-term, and I'm willing to bet very few of them realize that sexual side effects may be permanent.

Goldberg reports that the scope of this problem is unknown because - surprise, surprise! - it hasn't been studied.

Based on recent case reports of persistent effects, an article earlier this year in the Journal of Sexual Medicine said patients should "be told that in an unknown number of cases, the side effects may not resolve with cessation of the medication." ...

In the past two or three years, scattered published case reports from around the country have described patients whose sexual symptoms failed to resolve after going off antidepressants.

Dr. Robert P. Kauffman, chair of obstetrics and gynecology at Texas Tech University, has published accounts of three cases in his practice. "It's probably a small number of men and women," he said, "but I really think it deserves investigation."

Psychologist Audrey Bahrick at the University of Iowa said she became concerned when she observed that several clients whom she followed went off SSRIs and "very, very credibly to me, they did not recover" sexually.

Among their symptoms, she said, were "telltale signs" of SSRI-caused dysfunction, unrelated to the known effects of mental illness. They had "pleasureless orgasms," and "genital anesthesia," in which sex feels no more intense than a handshake. She became particularly concerned about adolescents put on antidepressants, whose sexuality might never have a chance to develop normally.

Bahrick began to explore. She found that post-SSRI sexual effects had never been systematically studied, but she came across a Yahoo group called SSRIsex, a support group for people with "persistent SSRI sexual side effects" that now has more than 1,800 members.

I'm not suggesting that this figure of 1800 sufferers tells us anything about the true scope of the problem. The thing is, no one knows how big the problem may be. And the ostrich approach isn't miraculously going to shed any light on it.

Now, I'm not trying to demonize anti-depressants. I've seen them drag people out of despair. At the risk of sounding overdramatic, I'll even say I've seen them save lives.

I'm just saying we need to have a grip on the full range of these medications' possible side effects and their probability, so that patients can decide, in consultation with their doctors, when the risks just might outweigh the benefits.

And if that's not happening - if patients are tinkering with their brain chemistry without fully informed consent - well, that's just depressing.


Heather Munro Prescott said...

Just a note -- lack of libido is a hallmark symptom of depression. So, one wonders whether that is playing a role in these observations of sexual dysfunction.

Also, some of the newer SSRIs-- e.g. Lexapro -- have lower risk of these side effects.

Sungold said...

I've heard that about Lexapro. The risk is still substantial, I think, but I'm glad research is moving to minimize it.

I'm aware of that loss of libido is a major symptom of depression. My understanding is that the 30 to 50 percent figure represents de novo sexual dysfunction - so it wouldn't count pre-existing lack of libido, though it should count any exacerbations of it.

Carla said...

Wow. Permanent? Never heard that. Yikes.

Sungold said...

Yeah, it's the *permanency* that made my head explode. I know plenty of people who complained of at least some loss of libido due to antidepressants. I can think of at least two people who complain of it still, now that they are no longer on SSRIs - but it's hard to tell what confounders might be in play, such as relationship issues, other health problems, etc. I think it'd be hard to prove causation in either of their situations, but it does make me wonder.

hesperia said...

Another problem is that some people are permanently on anti-depressants, so also experiencing permanent sexual dysfunction.

I've heard people/doctors argue that since lack of libido is a side effect of depression, the fact that anti-depressants relieve the depression makes it a good trade, since depression is a life threatening illness.

As you say, though, negotiating your way through these issues takes an open and sympathetic M.D. - they're rare, partly because they rarely have the time.

I worry a lot about the numbers of people who are given anti-depressants and the unlikelihood that physicians will deal with mild to moderate depression by offering counselling services and recommending changes to diet, exercise and so forth, since these things, together and apart, have been proven to be just as effective for some people as a course of anti-depressants, without the side effects.

Sungold said...

For people who can expect to take antidepressants for the rest of their lives, the issues are a little different than for those who may eventually go off them again. What would make a difference for long-term users is medications with milder side effects (as Heather mentioned) and also more possibilities for counteracting those side effects. I see the problem with adding yet another pill to neutralize the effects of the first pill. Even so, if I were on an SSRI and experienced sexual side effects, I wouldn't hesitate to try adding Wellbutrin - or even Viagra (a recent study suggested it can help women on SSRIs who have trouble reaching orgasm).

And yes, major depression can be life threatening, so the first priority has to be getting it under control.

I think the pressure on doctors to find a quick fix is probably greater here in the U.S. than in Canada, due to both our broken insurance "system" and our culture. This is problematic when it comes to people with mild situational depression, who might respond to other interventions and whose lives aren't at any acute risk.

Another issue is that most antidepressants are prescribed by doctors who aren't psychiatrists. I don't think this can be changed without creating a host of other problems - all those folks who are uninsured or underinsured would be even less likely to get the care they need. And in my town, for instance, I don't think we even *have* a psychiatrist. But non-specialists are less likely to be well versed in managing side effects.

hesperia said...

Because I'm a person on anti-depressants for life, I just want to let you know that it doesn't mean I'm on the same one for life. Every two years or so, the one I'm using stops working and I have to go through the unholy terror of coming off it and trying new ones until I find the one, or the combination, that works. The side-effect of loss of libido usually comes at the bottom of my list after headaches, nausea, actual vomiting, insomnia, urinary retention, and so on. The ideal for me is a drug that I can tolerate in any way. I know too many people in my position.

We've come a long, long way in terms of treating depression but some people think that all that's necessary is to take the magic pill, leaving those of us in my position even further stigmatized because we don't do well on them.

I know from experience and from the research that many people are helped a great deal by counselling and things like meditation and exercise, but all that requires a great deal of support. And money. Unfortunately, even in Canada, few doctors have the time for any of that or even believe in it. Only rich people can afford it. So I get pills. Although I must say, at this point, after decades, I've found my own ways to obtain other services that aren't so costly.

Psychologists and social workers and others who do counselling are not covered by provincial medical plans - and that's pretty short-sighted. Psychiatrist are covered, if you can find one with a space for you, but psychiatrist know one thing these days - pills.

Sungold said...

Hesperia, I've heard of this happening, and it's got to be pretty rough. I tried Prozac once briefly (for a non-psych indication, though by then I'd been sick long enough that I had some situational depression as a result). It made me really jittery.

This just highlights the need for ongoing development of new drugs. But even more, there needs to be more awareness that none of these drugs are magic bullets. The general public definitely doesn't realize that; I can't speak for doctors. But as you say, the conditions under which they practice make it increasingly hard for them to find time to follow up thoroughly.

It's so discouraging that even Canada is still in the dark ages when it comes to covering mental health services. Our coverage through our employer is actually quite a bit better than what you describe. But my guess is that most Americans have little or no coverage for psychological services.

SnowdropExplodes said...

I'm currently taking an SSRI called Citalopram, and have been for over a year now.

I definitely experienced a distinct difference in sexual potency as a result of taking it.

I suffered depression on and off for several years but always had a pretty powerful libido; I still do. But I definitely noticed that I was finding it a lot harder to go all the way to orgasm/ejaculation when masturbating (I haven't had a partner since taking the tablets, so I can't compare for sex with a partner!)

After filling the prescription, I did research the possible side effects of the drug on wikipedia, so I knew that there might be some side effects like that, and I spoke with my GP about it as well when I experienced it (despite the embarrassment that often goes with discussing masturbation).

I figure in some ways I am lucky in that my libido hasn't been affected much, and since I don't view male (i.e. my) ejaculation/orgasm as the be-all and end-all of sex, I am still capable of having a lot of pleasure from sex without worrying too much about whether or not I climax at the end. But it is definitely something that I think should be more up-front, because sex can be good for us too.

Sungold said...

Thanks so much for stopping by, SnowdropExplodes - it's great to see you here and to get a man's first-hand perspective on this.

Good for you, bringing this up with your GP. It's a bit pitiful that you had to do your own research. He or she should have informed you more fully (and it's just this problem that motivated this post in the first place). For the sake of their other patients, I hope you managed to spread some enlightenment.

Good for you, too, being able to take a broad view of sexual pleasure. (I know from your own blog that your views are actually a whole lot more expansive than mine - at least on the level of one's personal proclivities.) The default presumption for men is definitely still that it's not really sex if it doesn't culminate in orgasm for you.

And yet - if you lose the capacity for orgasm altogether, that's a real loss - also in terms of mental health. I know that if I'm feeling a bit blue, sex can really lift my mood. The couple of times in my life when I felt worse than just blue, I wasn't really having regular sex, so I don't know if it can help people manage actual depression. But I'm betting sex sure wouldn't hurt one's mood even in cases of moderate to severe depression.