Post-SSRI sexual dysfunction
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m754 (Published 27 February 2020) Cite this as: BMJ 2020;368:m754
Sexual difficulties after treatment with selective serotonin reuptake inhibitors (SSRIs) were first reported to regulators in 1991, but it was only in 2006 that these symptoms were formally characterised as a syndrome, now known as post-SSRI sexual dysfunction.12
In May 2019, the pharmacovigilance risk assessment committee of the European Medicines Agency concluded that post-SSRI sexual dysfunction is a medical condition that can persist after discontinuation of SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs). A month later, EMA recommended that product information on all relevant antidepressants should be updated to reflect reports of long term sexual dysfunction after treatment.3
Post-SSRI sexual dysfunction is under-recognised and can be debilitating both psychologically and physically. Symptoms include genital numbness, decreased sex drive (libido), erectile dysfunction, failure to become aroused or orgasm, pleasureless or weak orgasm, and premature ejaculation. The sensory changes may extend beyond the genital area to a more general dampening of reactivity, sometimes termed emotional numbing.4
One of my patients described it like this: “I feel misunderstood by the medical professionals, disabled because I feel unwell, and when people are talking about sex I don’t feel like I’m a part of sexual life—I’m left out.” His description shows the serious effect this condition has on patients’ emotional wellbeing.
Lack of knowledge
We currently know little about the mechanisms underlying sensory changes associated with SSRIs. Genital numbing may be mediated through the action of SSRIs at sodium channels in the cell membrane.56 Antidepressants that act on sodium channels are widely used to treat neuropathic pain, for example.
Post-SSRI sexual dysfunction has been reported by patients of all ages, of both sexes, and from all ethnic groups. Case reports show that it can begin after a few doses or become apparent only after years of exposure and can persist for decades afterwards. Some patients report a degree of spontaneous recovery with time (sometimes several years), while others experience brief remissions (for days). This suggests that these effects do not stem from permanent damage.78
Prevalence and incidence are both currently unknown, as is the risk of post-SSRI sexual dysfunction among patients taking antidepressants.1 Only a few people are warned about the possibility of long term sexual side effects when these drugs are prescribed, and controlled studies examining this outcome are lacking.
The condition is difficult to diagnose with certainty since no clear and reproducible diagnostic criteria have been evaluated or agreed. Diagnosis currently relies on symptoms alone, and symptoms are highly variable, both in severity and persistence. Underdiagnosis is likely, not least because of patchy awareness of the condition among healthcare workers. Many patients describe difficult experiences when approaching healthcare providers about their symptoms. Diagnosis is further complicated by the variable course of symptoms, which may appear only when antidepressant treatment is tapered or stopped.7
No effective treatment exists for post-SSRI sexual dysfunction. Drugs acting on various dopamine and serotonin receptors have been tried anecdotally, along with phosphodiesterase inhibitors. None have reduced symptoms.4
Post-finasteride syndrome is closely related to post-SSRI sexual dysfunction, which occurs in men taking 5-α reductase inhibitors (such as finasteride) to stall hair loss9 or to treat urinary symptoms caused by prostate enlargement.10 The two conditions share several clinical features including genital anaesthesia, loss of libido, erectile dysfunction, and ejaculation difficulties.
Better recognition of post-SSRI sexual dysfunction is the first step towards essential research into this condition to quantify true prevalence and to identify pathophysiological mechanisms and potential treatments.
This is an iatrogenic condition triggered by widely used medications. Symptoms are well described, but we need rigorous research to help disentangle the effects of medication from those of any underlying mental health condition, including depression. Most importantly, recognition of post-SSRI sexual dysfunction by the European drug regulator means prescribers must inform patients of the risk when discussing possible treatment with an SSRI or SNRI so they can make a fully informed choice about their options.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: YR has received a speaking honorarium from Besins Health Care and travel funding from Coloplast Netherlands to give a lecture during a symposium sponsored by Coloplast. These lectures are not related to the content of this editorial. He was president of the European Society for Sexual Medicine (ESSM), a non-profit scientific organisation, during 2018-19. The BMJ policy on financial interests is here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Patient participation: A patient described his experience and reviewed the clinical description of post-SSRI sexual dysfunction.
Provenance and peer review: Commissioned; not externally peer reviewed.