Clinical Opal #6 - Sexual dysfunction
Terry is a 64-year-old retired sales manager and a long-term patient of the practice. He has been struggling with depression over the past couple of years since being retrenched.
Six weeks ago, he commenced escitalopram 10mg as the first trial of antidepressant medication. He presents today saying that while he thinks that his mood is a little better, he is having decreased sexual arousal and delayed ejaculation since starting the medication. He is very troubled by these side effects and keen to talk to you about what to do.
In particular, he asks you a few specific questions:
- Are the sexual side effects likely to improve with time?
- Would another antidepressant medication be better?
- Could he reduce the dose?
What do you advise him?
Sexual dysfunction is a common and potentially distressing adverse effect of antidepressants and a leading cause of non-adherence. The most commonly reported adverse effects in women are decreased libido, decreased arousal and anorgasmia. Men more frequently report problems with decreased desire and delayed ejaculation.
In 2020, a narrative review on antidepressant-induced sexual dysfunction was published in the MJA.1 It described a high risk of sexual dysfunction for SSRIs (with escitalopram and paroxetine possibly having the highest risk), SNRIs, vortioxetine and clomipramine; a moderate risk for all other TCAs; and a low risk for other agents.
The authors recommended an approach to assessing and managing antidepressant associated sexual dysfunction, including
- Considering other causes
- Watchful waiting (6-12% improvement over 4-6 months)
- Dose reduction (limited evidence and risk of undertreatment)
- Switching to another antidepressant with a lower risk e.g. moclobemide, agomelatine, mirtazapine.
Importantly, they recommended that sexual function should be proactively assessed at baseline, and at regular intervals during treatment. It is well known that patients are reluctant to raise issues of sexual dysfunction, and GPs play an important role in initiating conversations about sex and sexual difficulties with their patients.2
References
- Rothmore J. Antidepressant-induced sexual dysfunction. MJA 2020
- Goodwach R. Let’s talk about sex. AFP 2017
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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