Oct 18, 2022

Untangling the relationship between sexual functioning and antidepressants

A sad woman sits with her head bowed, while her frustrated partner sits with a hand to his face behind her
By Ben Gane
A portrait photo of Dr. Venkat Bhat

Sexual functioning is the process of experiencing and responding to sexual desire and arousal. It is a key aspect of quality of life. Many people who take antidepressant medications to treat depression experience disruptions in their sexual functioning, and it is frequently cited as a reason for people to stop taking antidepressants. This motivated Dr. Venkat Bhat and his team to explore the relationship between antidepressant medication and sexual functioning at a deeper level.

What is sexual functioning?

Sexual Functioning (SF) has two aspects. The first aspect consists of sensations and physical responses that can be measured, such as desire, arousal, and orgasm. The second aspect of SF is made of more experiential elements that can’t easily be measured, such as sexual satisfaction and enjoyment of sexual and romantic experiences. While SF has a biological basis, it is influenced by many cultural, psychological, and social factors.

What motivated this research?

Altered SF is a symptom of depression, but it is also a side-effect of antidepressants. Altered SF often causes people to stop taking antidepressants, but determining if it is a side-effect of medication or a symptom of the depression itself can be difficult. This motivated us to examine the sequence of SF before and after antidepressant initiation. 
Men and women have different experiences with SF and antidepressants, and these differences continue when antidepressants improve other symptoms. We wanted to break down the constituent parts of SF and understand where the different experiences originated.

What was the most important finding of this study, in your opinion?

We found two key similarities between men and women. First, improved symptoms of depression with an antidepressant are associated with improved sexual satisfaction. Second, problems with SF before initiating an antidepressant are associated with problems with SF after, regardless of whether other symptoms of depression have improved.

We also found two key differences between men and women. Among women, overall sexual frequency does not change with an antidepressant, regardless of whether depressive symptoms improve. Among men, overall sexual frequency worsens with lack of improvement, and is associated with a disruption to the ability to orgasm.  

How does this change treatment for patients with major depressive disorder in the future?

First, our findings support the importance of incorporating sex- and domain-specific SF assessments into routine care and specifically inquiring about pre-treatment SF.  Measurement-based care can have positive impacts on SF.

Second, when antidepressant use improves symptoms, sexual satisfaction universally improves among both men and women.

Third, in the absence of significant symptomatic improvement with an antidepressant, SF diverges more among men and is driven by the orgasm sub-domain. 

Any next steps?

The results presented in this paper are the short-term SF effects during 8 weeks after starting the antidepressant escitalopram. We are examining long-term SF associated with other conventional antidepressants and short-term SF associated with the new/emerging interventions being explored within our Interventional Psychiatry Program. We are systematically incorporating sex- and domain-specific SF assessments into our clinical practice. 

What is the major take home message for the public?

We have three key take home messages when making a decision on starting an antidepressant: the state of SF before antidepressant treatment begins matters, symptomatic improvement in depression correlates with improved sexual satisfaction, and lack of symptom improvement is differentially experienced by men and women.

SF has a biological basis but is experienced in a cultural, interpersonal, intrapersonal, and psychosocial context-it is at the nexus of interdisciplinary research and a key aspect to evaluate during treatment of depression.
 

ImPACT logo: Psychiatry articles that change treatment

Acknowledgements

ImPACT Committee includes Krista Lanctôt, Alastair Flint, Meng-Chuan Lai and Simone Vigod.

Espinola CW, Khoo Y, Parmar R, Demchenko I, Frey BN, Milev RV, Ravindran AV, Parikh SV, Ho K, Rotzinger S, Lou W, Lam RW, Kennedy SH, Bhat V. Males and females differ in reported sexual functioning with escitalopram treatment for major depressive disorder: A CAN-BIND-1 study report. J Psychopharmacol. 2022 May;36(5):604-613. doi: 10.1177/02698811221095832.