Strategies for managing sexual dysfunction induced by antidepressant medication

Matthew J Taylor, Lisa Rudkin, Philippa Bullemor-Day, Jade Lubin, Christopher Chukwujekwu, Keith Hawton

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Sexual dysfunction (including altered sexual desire, orgasmic and ejaculatory dysfunction, erectile and other problems) is a relatively common side effect of antidepressant medication. These sexual side effects may compromise a person's lifestyle and result in a lack of compliance with the prescribed antidepressant to the detriment of the person's mental health. A wide range of management strategies are possible to address this problem including behavioural, psychological and pharmacological approaches.

The objective of this review was to assess the effectiveness of management strategies for sexual dysfunction caused by antidepressant medication.

Search methods  
Search of the Cochrane Depression, Anxiety and Neurosis Group's Specialized Register (CCDANCTR, to 1 January 2013), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Additional searches were carried out by the author team on the same biomedical databases (using terms for 'sexual dysfunction' only) together with CINAHL (1982 to Jan 2012). The reference lists of reports of all included studies were screened.

Selection criteria  
Randomised controlled trials comparing management strategies for antidepressant induced sexual dysfunction against each other or versus placebo were included.

Data collection and analysis  
Two reviewers independently extracted data and assessed trial quality. Study authors were contacted for additional information.

Main Results  
We included 23 trials involving 1,886 people in the updated review. 22 of these trials investigated the addition of medication to treat the identified dysfunction, with most agents studied in only single studies. One study investigated switching to an alternative antidepressant.
In men, data for the phosphodiesterase inhibitors sildenafil (three studies, 255 participants) and tadalafil (one study, 54 participants) indicated they led to a greater improvement in erectile function than placebo. Combined data from three sildenafil studies found benefit over placebo on IIEF ratings of ability to achieve (MD 1.04; 95% CI 0.65 to 1.44) and maintain erections (MD 1.18; 95% CI 0.78 to 1.59). A single point improvement on these ratings is equivalent to an improvement in frequency from 'sometimes' to 'most times'. Men receiving tadalafil were more likely to report improved erectile function (RR 11.50 [3.03, 43.67]). For women it remains uncertain whether sildenafil is more effective than placebo. Unpublished data could reduce this uncertainty.
Data from three studies of bupropion 150mg twice daily indicate a benefit over placebo on rating scale scores (SMD 1.60; 95% CI 1.40 to 1.81), but response rates in two studies of bupropion 150mg once daily were consistent with either increased or decreased likelihood of response (RR 0.62; 95% CI 0.09 to 4.41).
Other augmentation strategies failed to demonstrate significant improvements in sexual dysfunction compared with placebo.
One trial involving 75 people with sexual dysfunction due to sertraline assessed changing antidepressant. Switching to nefazodone was significantly less likely to result in the re-emergence of sexual dysfunction than restarting sertraline (RR 0.34, 95% CI 0.195 to 0.60 - 0.6) however nefazodone is no longer available for clinical use.
There is an absence of randomised data assessing switching to currently-available antidepressant agents with lower rates of sexual adverse effects, the role of psychological or mechanical interventions, or of techniques such as drug holidays.
We identified no data for any of the strategies assessed indicating they lead to a worsening of psychiatric symptoms. However, the relatively small numbers assessed for many of the interventions studied means that the possibility of such an effect cannot be confidently excluded in all cases.
Given the small numbers of studies assessing most of the strategies assessed, the presence of any unpublished trials could have substantial effects on estimates of effect. In some cases, only results from particular items or subscales within ratings scales are available. It is likely that this could act to bias estimates of effect obtained, increasing apparent effectiveness.

Authors' conclusions  
The currently available evidence is rather limited. For men with antidepressant-induced erectile dysfunction, the addition of sildenafil or tadalafil appears to be an effective strategy. For women with antidepressant-induced sexual dysfunction the addition of bupropion at higher doses appears the most promising approach studied so far.
Original languageEnglish
Number of pages136
JournalCochrane Database of Systematic Reviews
Issue number5
Publication statusPublished - 31 May 2013


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