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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. Six weeks ago, he commenced escitalopram 10mg as the first trial of antidepressant medication.

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

  1. Rothmore J. Antidepressant-induced sexual dysfunction. MJA 2020
  2. Goodwach R. Let’s talk about sex. AFP 2017


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Dr Simon Morgan

Simon is a GP and Medical Educator based in Newcastle, NSW.

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