Dr Sanil Rege, Consultant Psychiatrist explains Post-SSRI Sexual Dysfunction (PSSD).
Psychiatrist today i’ll be talking about post ssri sexual dysfunction pssd i’ve received a number of requests to make this video and i think this is a really really important topic probably very very under recognized overall in psychiatry so without further ado let’s jump into pssd post ssri sexual dysfunction is a condition
That arises serotonin reuptake inhibitors antidepressants in which patients continue to have sexual side effects even after they’ve stopped the medication emotional blunting there were some comments that highlighted that even after stopping the ssris the emotional blunting persisted and we know that
There is a link between emotional blunting and sexual dysfunction as well so many individuals that have emotional blunting also tend to have sexual dysfunction and we’ll see there are some common mechanisms there the persistent side effects that have been described include decreased libido genital anesthesia erectile
Dysfunction delayed ejaculation in women loss of lubrication and anorgasmia now the prevalence of pssd we’re not quite sure the difficulty is in order to define post-ssri sexual dysfunction there are a number of things that need to be ruled out so many a times the sexual dysfunction can be attributed to depression
Or due to other medical conditions and that’s what makes it so difficult to diagnose this condition and we’ll go through diagnosis in more detail now a systematic review that has been carried out this is from the netherlands about 86 reports of persistent sexual dysfunction were analyzed and the longest case was an
Individual with pssd for 23 years the main symptoms that were described were increased libido erectile have proposed that pssd should be identified as than just putting it as a side effect of ssris so really highlighting it as a distinct entity now ssris aren’t the only medications that lead to five
Alpha reductase inhibitors that are used in hair loss treatment so anti-hair loss treatments so they’ve shown so finasteride for example a do test to write these shows showed persistent erectile dysfunction in some patients treated with these medications other medications that have been associated with it are isotretinoin
We have other antidepressants that increase serotonin such as tricyclic antidepressants clomipramine amitriptyline imipramine and doxepin they’ve shown the highest incidence of sexual dysfunction we have done a separate video on antidepressant looking at that video as well now the most common symptom of post-ssri
Sexual dysfunction is genital anesthesia and this can occur in approximately 30 minutes after the first dose of the ssri therefore when clinicians initiate ssris it’s important to ask about this particular side effect and not just about genital anesthesia but also about whether there are any alterations in taste for
Example sensations generally smell because these can indicate an overall change that links to sexual dysfunction as well to recap the main sort of effects sexual side effects that we see are decreased libido erectile dysfunction weak orgasm premature ejaculation vaginal lubrication problems and nipple insensitivity the
Classical triad that’s been described is genital anesthesia loss of libido and erectile dysfunction psdd is classified into two types one that is early onset which is sexual dysfunction occurring while ssris are being prescribed and persisting after discontinuing treatments and the other one is of ssris as an
Aggravation of ssri induced sexual side effects so there’s two types now what are the causes of post ssri sexual dysfunction firstly we know that when serotonin is elevated in the synaptic cleft one of the receptors it activates is the 5-ht 1a receptor and we know whenever a receptor is activated the compensatory
In some cases it is postulated there may be persistent down regulation of these five hd1a receptors and five hd1a receptors actually are function particularly sexual motivation so this persistent down regulation is postulated to be one of the causes also note that five hd1a activation actually increases dopamine
Levels and we know dopamine is closely linked to libido motivation drive two hormonal changes it’s postulated that there may be changes in prolactin there may be receptors that potentially may result in decrease in dopamine testosterone may be involved oxytocin and even nitric oxide synthesis may be affected
We know nitric oxide is necessary in the penile vasculature females as well so if that’s affected we don’t have the proper systems for both arousal but also orgasm next neurochemical changes within where genital anesthesia may be one of the characteristics it’s important to note that most of the serotonin receptors are
Situated outside the brain the other aspect that’s been postulated is neurotoxicity very similar to what happens with severe release of serotonin but there’s can result in persistent sexual dysfunction axonal damage or actual nerve damage as its postulated mechanism so a similar thing may be happening in
Vulnerable individuals it has been proposed that some individuals are more vulnerable to develop the side effects but we don’t know who may develop these side effects so an individual vulnerability to serotonin is being postulated now ssris also we know inhibit dopamine transmission particularly in the ventral tegmental
Area which we know is part of the reward system this is the same aspect linked to emotional blunting so when ssrs are prescribed they can have a paradoxical inhibitory effect on say frontal subcortical dopamine resulting in both emotional blunting and also sexual dysfunction other effects are linked melanocortin
Both of these are involved in sexual area what’s been postulated is that serotonin may play a role in hpa axis and some dysregulation of these receptors in the hpa axis may result in low free testosterone levels which we know is again linked to libido and sexual function then there is something known as the transient
Receptor potential basically the ion channel transmission so there may actually be a dysfunction in these receptor potentials so think about it from electrical stimulus is not passing appropriately which results in say erectile dysfunction arousal disturbances etc let’s come to the diagnosis challenging
Diagnosis because in order to diagnose post-ssri sexual dysfunction firstly one needs to rule out many many other things are the causes of sexual dysfunction need to be ruled out pre-morbid condition diabetes alcohol use smoking etc and also depression which is we know very very closely linked to sexual dysfunction as
A whole now genital anesthesia is one of those clues that may actually point more towards a pssd rather than depression so that’s one of the things to actually ask proactively and bring up specifically in the discussion as well as part of the side effects monitoring so general anesthesia and it’s also linked
To the severity of pssd so what is the treatment what are the options that are available for individuals that experience this very very distressing side effect firstly there has been case reports of low power laser irradiation or phototherapy as they call it directed towards the scrotal skin and the shaft of the penis in
Male patient with pssd and this patient also had penile anesthesia now this low power irradiation may be linked to that sort of receptor potential that i talked about it’s postulated to improve those transient receptor potential improve the iron channel conduction but it failed to alleviate the ejaculatory problems
And the erectile dysfunction so helped in one aspect but not in the other so help with the anesthesia aspect the other aspect that has been talked about is focusing on the serotonergic and the dopaminergic pathways medications so five ht1a agonists adding those now note that you might recall that one of the
Medications fluvoxamine has a lower incidence of sexual dysfunction at doses of 100 milligrams or less because it activates the 5 ht1a receptor on the other hand using 5 ht-2 5 ht-3 antagonists a 5 ht2 a 5 ht antagonist mirtazapine for example we know these have a lower incidence of sexual dysfunction buspirone which is
Again a 5 ht 1a partial agonist we have trazodone and mirtazapine which are 5ht 2 antagonists a 5ht3 antagonist have been trialled then from a dopaminergic pathway we can use dopamine agonists pramipexole which is a dopamine agonist cabergoline these two have also been trialled with some benefit or in some
Cases even little benefit has been reported so we know that you know it’s not solving the problem completely but it’s something that can be trialled the other aspect is a switch from say an ssri to a dopaminergic antidepressant now this particular trial is quite interesting so they evaluated a switch from ssri to a
Dopaminergic antidepressant known as amineptine in patients with sexual dysfunction and observed that 55 of these patients using ssris had persistent sexual dysfunction six months after treatment cessation whereas only four percent of patients who had switched to amineptine had these complaints at six months so a
Big difference 54 versus four percent who have also tried sildenafil vardenafil as you know these phosphodiesterase type 5 inhibitors and testosterone without any significant improvement in pssd bupropion is another agent we know it’s an ndri increases neurotransmitter increases dopamine and that can be worth
A trial patients treated with bupropion documented a recovery from their activity so it’s worth trialing and be appropriate because we know also when we looked at sexual dysfunction that bupropion was one of the only ones that actually improved sexual function so worth a trial in this condition and of course
A non-pharmacological treatment would include it is a difficult condition overall to treat now there are some complementary aspects that have been mentioned so saffron for example exhibited some benefit in improving sexual arousal and lubrication so that has been talked about but again we don’t know you know side
Effects long term there haven’t been many trials so we don’t really know other ones that have been mentioned ketamine donepezil metformin through very very different sort of mechanisms so if i had to kind of summarize in terms of diagnosis prevalence of course treatment you know there’s a lot that we don’t know about
This condition and you know without a doubt it is an extremely distressing condition as psychiatrists it becomes very very important to think very carefully about the agents that we’re choosing in treating depression there are agents with a lower incidence of sexual dysfunction agomelatine mirtazapine trazodone
Pupropion of course so it’s important to think about these agents overall in the treatment of depression but also if ssris are prescribed now they are useful agents in the treatment of many many disorders snris included so this condition can also occur with snris it’s important to trazodone recognize when the s component
Is there snris can also lead to this it’s important that psychiatrists or doctors ask about any loss of taste smell skin sensitivity a genital numbness so that we can pick this up early and consider a change or stop that medication before prevention is probably extremely important so i hope that this has
Given you an idea about post ssri sexual dysfunction although it’s called if you like this video leave us a like and don’t forget to subscribe to our channel video soon take care and stay safe bye
Transcribed from video
What is POST-SSRI SEXUAL DYSFUNCTION| PSSD | Antidepressants and Persistent Sexual Dysfunction By Dr Sanil Rege’s Hub – Psychiatry SimplifiedliveBroadcastDetails{isLiveNowfalsestartTimestamp2022-06-07T140012+0000endTimestamp2022-06-07T141604+0000}
