One of the major complaints of people on antidepressant medication is the effect it has on their sex lives. It does this in three main ways – it affects sexual desire, the ability to achieve and sustain an erection in men and alters the sensation of orgasms and ejaculation.

These side effects are one of the main reasons people stop taking their medication, with potential consequences for their mental health. There are a range of measures used to treat sexual dysfunction – behavioural, psychological and pharmacological interventions.

Objectives

This systematic review by the Cochrane Depression, Anxiety and Neurosis Group set out to answer two issues:

1. To determine which of the strategies currently used are most effective for treating sexual dysfunction caused by antidepressant use; and
2. To determine the side effects and acceptability of the different management strategies to those on antidepressants.

Methods

The authors searched the following databases for relevant placebo-controlled randomised controlled trials: the Cochrane Library, EMBASE, MEDLINE and PsychINFO.

Two authors independently selected trials and assessed trial quality. Study authors were contacted for additional information when necessary.

Results

A total of 23 trials, involving 1886 subjects were included in the review.

In 22 of these trials a medication was added to treat sexual dysfunction, and in the remaining trial subjects were switched to an alternative antidepressant.

There were six major findings:

1. Sildenafil (sold as Viagra) and tadalafil lead to a greater improvement in erectile dysfunction in men than placebo.Studies used the International Index of Erectile Dysfunction which measures aspects of sexual performance like the ability to achieve and sustain an erection. A single point improvement on these rating scales is equivalent to an improvement from ‘sometimes’ to ‘most times’.Three studies for sildenafil found a mean difference of 1.04 (95% CI 0.65 to 1.44) on ability to achieve erections and a mean difference of 1.18 (95% CI 0.78 to 1.59) on ability to sustain erections.

   Men receiving tadalafil were more likely to report improved erectile function (RR 11.50, 95% CI 3.03 to 43.67).

   For women it is still uncertain whether these medications have any significant effect. Unpublished data may be able to shed light on this issue.

2. The addition of bupropion at a dose of 150mg twice daily improved sexual function (standard mean difference of 1.60) in three studies mostly involving female participants. However, two studies using only 150mg daily showed no improvement over placebo.
3. Other strategies involving the addition of different medications failed to show significant improvement in sexual dysfunction compared with placebo.
4. Changing antidepressants was the other strategy used in one trial. Swapping from sertraline to nefazadone significantly reduced the chance of the re-emergence of sexual dysfunction by 66% (95% CI 40% to 81%). However, nefazadone is no longer available for clinical use.
5. There were no randomised studies assessing the efficacy of switching to antidepressants known to have a lower incidence of adverse sexual effects. Nor were there any studies looking at the role of psychological or mechanical interventions, or of techniques like drug holidays.
6. There was no suggestion in the literature that any of the strategies employed lead to a worsening of psychiatric symptoms. However, given the relatively few people involved in many of the trials it is difficult to be confident that this conclusion is robust.

Conclusions

Overall, the evidence base is somewhat scanty. For men with erectile function due to antidepressant use, the use of sildenafil or tadalafil appears to be an effective strategy.

For women, the strategy with the best evidence appears to be the addition of buproprion at higher doses.

One proviso pointed out is that given the small number of studies in this area, the presence of unpublished studies could have a substantial influence on the overall effect size.

Furthermore, the authors point out that some trials only reported particular items or subscales within rating scales suggesting that negative findings were suppressed, leading to the possibility that the positive effects reported might be exaggerations.

Links

Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD003382. DOI: 10.1002/14651858.CD003382.pub3.