Sexual dysfunction, depression, and the impact of antidepressants

Treatment-emergent sexual dysfunction in randomized trials of vortioxetine for major depressive disorder or generalized anxiety disorder: a pooled analysis

OBJECTIVE

Antidepressants are frequently associated with treatment-emergent sexual dysfunction (TESD). Vortioxetine, which was approved for patients with major depressive disorder (MDD), has a receptor profile that suggests limited impact on sexual functioning.

METHODS

Arizona Sexual Experiences Scale (ASEX) patient-level data were pooled from 7 short-term vortioxetine trials (6 in MDD, 1 in generalized anxiety disorder) and analyzed for incidence of TESD at any post-baseline visit in patients without sexual dysfunction at baseline (defined as ASEX total score ≥19; individual ASEX item score ≥5; or a score ≥4 on any 3 ASEX items). The primary objective was to confirm the non-inferiority of vortioxetine 5-20 mg/day to placebo on the incidence of TESD. Comparisons were based on the common risk difference (95% confidence interval). Additional analyses compared vortioxetine to duloxetine and duloxetine to placebo. A sensitivity analysis, defined as TESD at 2 consecutive post-baseline visits, was conducted.

RESULTS

TESD incidence, relative to placebo, generally increased with vortioxetine dose with vortioxetine 5 mg non-inferior to placebo. Vortioxetine 10, 15, and 20 mg did not meet the non-inferiority criterion, but no dose had a significantly higher risk of developing TESD versus placebo. Changes in ASEX individual item scores supported the similarity of vortioxetine doses to placebo. Significantly higher TESD risk occurred with duloxetine 60 mg/day versus placebo and versus vortioxetine 5 or 10 mg. The sensitivity analysis was generally consistent with the primary analysis. Rates of spontaneously reported sexual adverse events were low.

CONCLUSIONS

Vortioxetine was associated with rates of TESD that were not significantly different from placebo in short-term clinical trials.

Determinants of HIV Transmission Risk Among HIV-Infected Persons Engaged in Care

People living with HIV (PLWH) engaged in medical care represent an accessible group to focus HIV prevention efforts. In an analysis of 1,883 PLWH from 2007 and 2015, we determined the proportion at risk of HIV transmission and identified factors associated with HIV transmission risk using multivariable mixed effects logistic regression models with random intercepts. HIV transmission risk was defined by an HIV viral load > 1,500 copies/mL and self-reported unprotected sex. We found that 174 (9.2%) individuals were at risk for HIV transmission at least once. Factors associated with HIV transmission risk included younger age (adjusted OR [95% CI] per decade decrease = 2.30 [1.84, 2.89]), illicit drug use (adjusted OR = 5.36 [3.02, 9.56]), depression (adjusted OR = 1.88 [1.10, 3.21]), and education <12th grade (adjusted OR = 2.05 [1.15, 3.67]). Thus, nearly 1 in 10 HIV-infected individuals engaged in care between 2007 and 2015 were potentially at risk of transmitting HIV. Behavioral interventions to decrease HIV transmission should focus on younger, less educated patients who are depressed and actively using illicit drugs.

Sexual Functioning in Adolescents With Major Depressive Disorder

OBJECTIVE

To examine sexual functioning in adolescents with depression.

METHODS

Between September 2010 and March 2014, 235 participants who were between 15 and 20 years old and were unmedicated or within 1 month of beginning antidepressant treatment completed the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Changes in Sexual Functioning Questionnaire (CSFQ). They were also assessed to establish the presence of a DSM-IV-TR major depressive episode (MDE). The Student t test and χ² test were used to compare continuous and categorical variables, respectively, across participants with versus without MDE. Multivariable linear regression analysis examined the association between depression and sexual functioning.

RESULTS

After the investigators controlled for age, female sex, antidepressant use, and the presence of generalized anxiety disorder, the presence of MDE was associated with a lower score on the CSFQ overall (P < .0007) and on its desire (P < .09), arousal (P < .001), and orgasm (P < .007) subscales. Antidepressants were not associated with sexual functioning either in the sample overall or in those with MDE. Beck Depression Inventory items related to affective symptoms (P < .03), rather than those tapping into neurovegetative or cognitive functioning, accounted for the association between depression and lower sexual functioning. Furthermore, with higher BDI scores, males exhibited a steeper decline than females in both the CSFQ total score and the desire subscale (sex × BDI score interaction effect: P < .03). Anxiety was not significantly associated with sexual functioning.

CONCLUSIONS

Major depressive disorder in older adolescents is associated with lower sexual functioning, particularly in males. This appears most related to affective symptoms. The potential impact of such impairment on future sexual functioning deserves further examination.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02147184.

Drug-resistant focal epilepsy in women of childbearing age: Reproduction and the effect of epilepsy surgery

OBJECTIVE

Women with epilepsy (WWE) have lower birth rates than expected. The reasons for this are multifactorial and involve a complex interaction between reproductive endocrine and psychosocial factors. The effect of epilepsy surgery on reproduction in women with drug-resistant focal epilepsy has not previously been studied.

METHODS

Adult women of childbearing age (18-45years old) with drug-resistant focal epilepsy who had undergone a focal cortical resection between 1997 and 2008 at the Mayo Clinic in Rochester, MN were included in the study. Patients who had a history of hysterectomy or tubal ligation or who were menopausal at the time of surgery were excluded. Data on prior pregnancies and births, epilepsy history, surgical treatment, hormonal dysfunction, and socioeconomic status were obtained using a retrospective chart review. Associations between various clinical and demographic variables with changes in pregnancies and births from pre- to postsurgery were assessed using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. All tests were 2-sided, and p-values less than 0.05 were considered statistically significant. All analyses were performed using SAS software version 9.2 (SAS INC, Cary NC).

RESULTS

One hundred and thirteen women (average age: 30.5years) were included in the study. Average length of follow-up was 5.7years (SD-3.90). Sixty-four patients (57.5%) were nulliparous at the time of surgery. Sixty-one patients (54%) had never been married. Average number of pregnancies per patient prior to surgery was 0.93, and average number of births prior to surgery was 0.73. After surgery, a total of 17 women had a total of 35 pregnancies and 25 births. The average number of pregnancies and births after surgery was 1.27 and 0.96, respectively. Infertility was reported in one patient postoperatively. Patients who were younger at the time of surgery experienced a greater change in the number of pregnancies and births after surgery (p=0.0036 and 0.0060, respectively). Patients who received fewer antiepileptic drug medication trials by the time of surgery also had a greater change in the number of births after surgery (p=0.0362). Seizure onset localization and lateralization, presurgical seizure frequency, age at seizure onset, duration of epilepsy, and postoperative seizure outcome were not statistically significant factors.

CONCLUSION

The present retrospective observational study provides additional evidence for the importance of early surgical treatment in women with drug-resistant focal epilepsy. Patients who had received fewer medications prior to surgery were more likely to experience an increase in births following surgery. The significance of these findings requires further investigation but may support a role for earlier surgical intervention in the management of drug-resistant focal epilepsy.

Depression symptoms across cultures: an IRT analysis of standard depression symptoms using data from eight countries

PURPOSE

Prevalence estimates of depression vary between countries, possibly due to differential functioning of items between settings. This study compared the performance of the widely used Hopkins symptom checklist 15-item depression scale (HSCL-15) across multiple settings using item response theory analyses. Data came from adult populations in the low and middle income countries (LMIC) of Colombia, Indonesia, Kurdistan Iraq, Rwanda, Iraq, Thailand (Burmese refugees), and Uganda (N = 4732).

METHODS

Item parameters based on a graded response model were compared across LMIC settings. Differential item functioning (DIF) by setting was evaluated using multiple indicators multiple causes (MIMIC) models.

RESULTS

Most items performed well across settings except items related to suicidal ideation and "loss of sexual interest or pleasure," which had low discrimination parameters (suicide: a = 0.31 in Thailand to a = 2.49 in Indonesia; sexual interest: a = 0.74 in Rwanda to a = 1.26 in one region of Kurdistan). Most items showed some degree of DIF, but DIF only impacted aggregate scale-level scores in Indonesia.

CONCLUSIONS

Thirteen of the 15 HSCL depression items performed well across diverse settings, with most items showing a strong relationship to the underlying trait of depression. The results support the cross-cultural applicability of most of these depression symptoms across LMIC settings. DIF impacted aggregate depression scores in one setting illustrating a possible source of measurement invariance in prevalence estimates.

Orgasm, Serotonin Reuptake Inhibition, and Plasma Oxytocin in Obsessive-Compulsive Disorder. Gleaning From a Distant Randomized Clinical Trial

Introduction

Serotonin reuptake inhibitors (SRIs) are widely used for the treatment of psychiatric disorders, including obsessive-compulsive disorder (OCD). SRIs commonly cause delayed orgasm, the mechanism of which is poorly understood. Oxytocin is involved in sexual function and is interconnected with serotonin within the brain. SRIs are reported to affect the oxytocin system, but possible relations between SRI-induced changes of sexual function and oxytocin are unexplored in humans. In a randomized, double-blinded, placebo-controlled trial of OCD, the anti-obsessive efficacy and adverse events of SRIs and oxytocin measurements were studied.

Aims

To identify possible correlates between oxytocin levels and sexual function; find out whether sexual side effects correlate with levels of oxytocin and/or paroxetine and clomipramine; and test whether changes in sexual functioning are related to an anti-obsessive response.

Methods

Reported sexual function and oxytocin plasma levels at rest were studied in 31 adults (15 men and 16 women) with OCD who participated in a randomized, double-blinded trial comparing the SRIs clomipramine and paroxetine with placebo. Sexual adverse effects were quantified by a clinician-administered semistructured interview. Anti-obsessive response was based on the Yale-Brown Obsessive-Compulsive Scale.

Main Outcome Measures

Ratings on the Sexual Symptom Checklist, plasma oxytocin, serum paroxetine and clomipramine levels, and Yale-Brown Obsessive-Compulsive Scale scores.

Results

Baseline oxytocin levels were positively correlated with baseline OCD severity, but not with sexual functioning. Impaired orgasm at week 6 was reported by 73% of SRI-treated and 20% of placebo-treated patients (P = .03). Impaired orgasm was related to higher oxytocin levels after 4 weeks of SRI treatment (P < .01) but not to SRI concentrations. In men, an association between impaired orgasm and anti-obsessive treatment response was found (P = .028).

Conclusion

This pilot study suggests that some collateral effects of SRIs, particularly delayed orgasm, might be influenced by changes within the oxytocinergic system and are related to anti-obsessive mechanisms. Early-onset delayed orgasm in SRI-treated patients could serve as a predictor for OCD treatment response.

When the party is over: depressive-like states in rats following termination of cortical D1 receptor overexpression

RATIONALE

Increased activity of prefrontal D1 dopamine receptors (D1R) is involved in reward-related behavior found in bipolar disorder and drug addiction. While the effects of elevated D1R are known, depressive-like behaviors also occur in these disorders after reward-seeking ends.

OBJECTIVES

The goal is to characterize how termination of D1R overexpression influences depressive-like behaviors.

METHODS

An inducible (Tet.On), lentiviral vector was used to manipulate the expression of the DRD1 gene in glutamate neurons within the prefrontal cortex in male, adult rats. Sexual activity and sucrose preference were studied in both D1R elevated ON and relatively reduced OFF states. Following termination of the D1R ON state, depressive-like behavior was determined in the OFF state. Expression of the transcriptional regulator, cyclic AMP-responsive element-binding protein (CREB), was used as an indication of downstream effects in the nucleus accumbens (NA).

RESULTS

ON D1R expression increased sexual activity that returned to baseline in the OFF state. Sucrose preferences increased ~6 % in ON state but fell 11 % below control levels when OFF. Consistent with a depressive-like phenotype, D1R OFF decreased activity by 40 %, impaired the ability to control (43 %) and motivation to escape shock (27 % more impaired) relative to dsRed OFF. CREB increased 29 % in the NA in the D1R OFF state relative to the ON state.

CONCLUSIONS

This novel approach demonstrates that elevated D1R expression increased hedonic behavior, whereas the termination of D1R overexpression often resulted in depressive-like behavior. These observations support a role for D1R expression cycling in bipolar-associated behaviors and addiction.

Are depression and poor sexual health neglected comorbidities? Evidence from a population sample

OBJECTIVE

To examine associations between sexual behaviour, sexual function and sexual health service use of individuals with depression in the British general population, to inform primary care and specialist services.

SETTING

British general population.

PARTICIPANTS

15,162 men and women aged 16-74 years were interviewed for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), undertaken in 2010-2012. Using age-adjusted ORs (aAOR), relative to a comparator group reporting no treatment or symptoms, we compared the sexual health of those reporting treatment for depression in the past year.

OUTCOME MEASURES

Sexual risk behaviour, sexual function, sexual satisfaction and sexual health service use.

RESULTS

1331 participants reported treatment for depression (5.2% men; 11.8% women). Relative to the comparator group, treatment for depression was associated with reporting 2 or more sexual partners without condoms (men aAOR 2.07 (95% CI 1.38 to 3.10); women 2.22 (1.68 to 2.92)), and concurrent partnerships (men 1.80 (1.18 to 2.76); women 2.06 (1.48 to 2.88)), in the past year. Those reporting depression treatment were more likely to be dissatisfied with their sex lives (men 2.32 (1.74 to 3.11); women 2.30 (1.89 to 2.79)), and to score in the lowest quintile on the Natsal-sexual function measure. They were also more likely to report a recent chlamydia test (men 1.92 (1.15 to 3.20)); women (1.27 (1.01 to 1.60)), and to have sought help regarding their sex life from a healthcare professional (men 2.92 (1.98 to 4.30); women (2.36 (1.83 to 3.04)), most commonly from a family doctor. Women only were more likely to report attending a sexual health clinic (1.91 (1.42 to 2.58)) and use of emergency contraception (1.98 (1.23 to 3.19)). Associations were broadly similar for individuals with depressive symptoms but not reporting treatment.

CONCLUSIONS

Depression, measured by reported treatment, was strongly associated with sexual risk behaviours, reduced sexual function and increased use of sexual health services, with many people reporting help doing so from a family doctor. The sexual health of depressed people needs consideration in primary care, and mental health assessment might benefit people attending sexual health services.

Depressive symptomatology and the influence of the behavioral avoidance and activation: A gender-specific investigation

BACKGROUND

Depression is a highly prevalent disorder which is usually considered as differentially experienced depending on gender. Behavioral theories of depression pinpoint the importance of the behavioral avoidance in the maintenance of depression. However, little is known about the specific impact of the behavioral avoidance and activation on each depressive symptom as well as on gender differences on the behavioral features of depression.

METHODS

This study's aim was two-fold: (1) to assess the presence of gender differences on the BDI-II; (2) to investigate the respective predictive value of behavioral avoidance and of behavioral activation on each depressive symptom assessed by the BDI-II depending on gender. Community adults and adults attending mental healthcare composed the sample.

RESULTS

Results showed differences in symptomatology profiles depending on gender (e.g. higher scores of sadness, self-criticalness in women, higher scores of past failure and loss of pleasure in men). Behavioral avoidance positively predicted almost all depressive symptoms in women and in men while behavioral activation negatively predicted almost all symptoms in both gender. Nevertheless, the strengths of these relationships were different for some symptoms (e.g. pessimism).

LIMITATIONS

The use of self-report instruments; the lack of assessment of causal or precipitating factors of the depressive symptomatology; the higher number of women in the sample.

CONCLUSIONS

Results are discussed with respect to previous findings and present clinical implications: (1) to underline the relevance of the combination of gender-specific assessment tools; (2) to highlight the need of tailored psychological intervention.

Differential effects of vilazodone versus citalopram and paroxetine on sexual behaviors and serotonin transporter and receptors in male rats

RATIONALE

Sexual side effects are commonly associated with selective serotonin reuptake inhibitor (SSRI) treatment. Some evidence suggest that activation of 5-HT1A receptors attenuates SSRI-induced sexual dysfunction.

OBJECTIVE

This study in male rats compared the effects of vilazodone, an antidepressant with SSRI and 5-HT1A receptor partial agonist activity, with other prototypical SSRIs (citalopram and paroxetine) on sexual behaviors and 5-HT receptors (5-HT1A and 5-HT2A) and transporter (5-HTT) levels in select forebrain regions of the limbic system using quantitative autoradiography.

METHODS

Rats received vilazodone (1, 3, and 10 mg/kg), citalopram (10 and 30 mg/kg), or paroxetine (10 mg/kg) treatment for 14 days. Sexual behaviors (frequency and latency of mounts, intromissions, and ejaculations) were measured in the presence of an estrous female rat on days 1 (acute), 7 (subchronic), and 14 (chronic).

RESULTS

Vilazodone-treated rats exhibited no sexual dysfunction compared with controls; in contrast, the citalopram- and paroxetine-treated rats exhibited impaired copulatory and ejaculatory behaviors after subchronic and chronic treatments. Chronic vilazodone treatment markedly decreased 5-HT1A receptor levels in cortical and hippocampal regions, while the SSRIs increased levels of this receptor in similar regions. All chronic treatments reduced 5-HTT levels across the forebrain; however, the magnitude of the decrease was considerably smaller for vilazodone than for the SSRIs.

CONCLUSIONS

The current studies showed that chronic treatment with vilazodone, in contrast to citalopram and paroxetine, was not associated with diminished sexual behaviors in male rats, which may be related to the differential effects of vilazodone on 5-HT1A receptor and 5-HTT levels relative to conventional SSRIs.

Prenatal Depressive Symptoms and Postpartum Sexual Risk Among Young Urban Women of Color

STUDY OBJECTIVE

To determine whether prenatal depressive symptoms are associated with postpartum sexual risk among young, urban women of color.

DESIGN

Participants completed surveys during their second trimester of pregnancy and at 1 year postpartum. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression Scale, excluding somatic items because women were pregnant. Logistic and linear regression models adjusted for known predictors of sexual risk and baseline outcome variables were used to assess whether prenatal depressive symptoms make an independent contribution to sexual risk over time.

SETTING

Fourteen community health centers and hospitals in New York City.

PARTICIPANTS

The participants included 757 predominantly black and Latina (91%, n = 692) pregnant teens and young women aged 14-21 years.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The main outcome measures were number of sex partners, condom use, exposure to high-risk sex partners, diagnosis of a sexually transmitted disease, and repeat pregnancy.

RESULTS

High levels of prenatal depressive symptoms were significantly associated with increased number of sex partners (β = 0.17; standard error, 0.08), decreased condom use (β = -7.16; standard error, 3.08), and greater likelihood of having had sex with a high-risk partner (odds ratio = 1.84; 95% confidence interval, 1.26-2.70), and repeat pregnancy (odds ratio = 1.72; 95% confidence interval, 1.09-2.72), among participants who were sexually active (all P < .05). Prenatal depressive symptoms were not associated with whether participants engaged in postpartum sexual activity or sexually transmitted disease incidence.

CONCLUSION

Screening and treatment for depression should be available routinely to women at risk for antenatal depression.

Characterizing sexual function in patients with generalized anxiety disorder: a pooled analysis of three vilazodone studies

BACKGROUND

Vilazodone has been shown to reduce core symptoms of generalized anxiety disorder (GAD) in three randomized, double-blind, placebo-controlled trials. Since sexual dysfunction (SD) is not well characterized in GAD, a post hoc analysis of these trials was conducted to evaluate the effects of vilazodone on sexual functioning in GAD patients.

MATERIALS AND METHODS

Data were pooled from one fixed-dose trial of vilazodone 20 and 40 mg/day (NCT01629966) and two flexible-dose studies of vilazodone 20-40 mg/day (NCT01766401, NCT01844115) in adults with GAD. Sexual functioning was assessed using the Changes in Sexual Functioning Questionnaire (CSFQ). Outcomes included mean change from baseline to end of treatment (EOT) in CSFQ total score and percentage of patients shifting from SD at baseline (CSFQ total score ≤47 for males, ≤41 for females) to normal functioning at EOT. Treatment-emergent adverse events related to sexual functioning were also analyzed.

RESULTS

A total of 1,373 patients were included in the analyses. SD at baseline was more common in females (placebo, 46.4%; vilazodone, 49%) than in males (placebo, 35.1%; vilazodone, 40.9%). CSFQ total score improvement was found in both females (placebo, +1.2; vilazodone, +1.6) and males (placebo, +2.1; vilazodone, +1.0), with no statistically significant differences between treatment groups. The percentage of patients who shifted from SD at baseline to normal sexual functioning at EOT was higher in males (placebo, 40.6%; vilazodone, 35.7%) than in females (placebo, 24.9%; vilazodone, 34.9%); no statistical testing was performed. Except for erectile dysfunction and delayed ejaculation in vilazodone-treated males (2.4% and 2.1%, respectively), no treatment-emergent adverse events related to sexual functioning occurred in ≥2% of patients in either treatment group.

CONCLUSION

Approximately 35%-50% of patients in the vilazodone GAD studies had SD at baseline. Vilazodone and placebo had similar effects on CSFQ outcomes in both females and males, indicating a limited adverse impact on sexual functioning with vilazodone.

Sexual Problems Predict PTSD and Depression Symptom Change Among Male OEF/OIF Veterans Completing Exposure Therapy

OBJECTIVE

A growing literature documents frequent sexual problems among Operations Enduring/Iraqi Freedom (OEF/OIF) veterans with post-traumatic stress disorder (PTSD). However, there has been no examination of how (1) sexual problems may be affected by evidenced-based psychotherapy for PTSD or (2) how the presence of sexual problems might impact effectiveness of evidenced-based psychotherapy for PTSD. As such, the present study investigated associations among symptoms of PTSD, depression, and problems with sexual desire and arousal among 45 male OEF/OIF veterans receiving behavioral activation and therapeutic exposure (BA-TE), an evidence-based behavior therapy targeting co-occurring symptoms of PTSD and depression.

METHOD

Participants completed clinical interviews and several questionnaires including measures of sexual arousal, sexual desire, PTSD symptoms, and depression symptoms at baseline and after completion of 8 sessions of BA-TE treatment. A records review was also conducted to assess for relevant medication use.

RESULTS

Overall, sexual desire and sexual arousal problems did not improve during the course of treatment. Moreover, veterans with co-occurring sexual problems at baseline evidenced significantly less improvement in symptoms of PTSD and depression across treatment as compared to veterans without sexual problems.

CONCLUSIONS

These findings suggest that veterans with co-occurring symptoms of PTSD and sexual problems may require additional assessment and treatment considerations in order to improve their treatment outcomes for both primary psychiatric symptoms as well as sexual problems. Future research on combination treatments of medication for sexual problems and psychotherapy for PTSD is needed.

Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?

Vaginal dryness is a common condition that is particularly prevalent during and after the menopause, and is one of the symptoms of vulvovaginal atrophy/genitourinary syndrome of menopause. The impact of vaginal dryness on interpersonal relationships, quality of life, daily activities, and sexual function can be significant, but is frequently underestimated. Furthermore, barriers exist to treatment-seeking, and this condition is often underreported and undertreated. Greater education about vaginal dryness and the range of available treatments is essential to encourage more women to seek help for this condition.

Personal lubricants and moisturizers are effective at relieving discomfort and pain during sexual intercourse for women with mild to moderate vaginal dryness, particularly those who have a genuine contraindication to estrogen, or who choose not to use estrogen. However, there is a distinction between lubricants and moisturizers, and notable differences between commercially available products. Women should be advised to choose a product that is optimally balanced in terms of both osmolality and pH, and is physiologically most similar to natural vaginal secretions. A series of recommendations for the use of vaginal lubricants and moisturizers, either on their own or in combination with systemic or topical hormone replacement therapy, is presented.

Male sexual function in presymptomatic gene carriers and patients with Huntington's disease

AIMS

To report sexual dysfunction in a systematically studied cohort of men with Huntington's disease (HD), and compare them with control men of a similar age.

METHODS

In men with HD and asymptomatic HD gene carriers, the male sexual dysfunction questionnaire (International Index of Erectile Function--IIEF, covering erectile and orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction), neurologic assessment using the Unified Huntington's Disease Rating Scale (UHDRS) and the Total Functional Capacity (TFC) Score were utilized.

RESULTS

Responses were obtained from 23 HD patients and 2 HD gene carriers. HD patients reported more problems with erection, intercourse satisfaction and overall satisfaction (p<0.05) compared to 41 controls. HD patients generally reported reduced sexual desire and performance. Sexual dysfunction progressed in parallel with patients' decline in motor (UHDRS) and TFC, but was not related to patients' age and duration of disease.

CONCLUSIONS

Our study demonstrated a significant impact of HD on male sexual function that progressed in parallel with motor and total patient (TFC) dysfunction. Physicians helping HD patients should also consider this largely neglected aspect of the disease.

Vilazodone in patients with generalized anxiety disorder: a double-blind, randomized, placebo-controlled, flexible-dose study

Vilazodone is a selective serotonin reuptake inhibitor and a 5-HT1A receptor partial agonist that is approved for treatment of major depressive disorder in adults in the USA and Mexico. The efficacy, safety, and tolerability of vilazodone for generalized anxiety disorder (GAD) were investigated in a clinical trial (NCT01766401 ClinicalTrials.gov). Participants (18-70 years, inclusive) who met Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, criteria for GAD were randomized (1:1) to placebo or flexible-dose vilazodone (20-40 mg/day) for 8 weeks of double-blind treatment. Primary and secondary efficacy parameters were changes from baseline to week 8 in Hamilton Rating Scale for Anxiety and Sheehan Disability Scale total scores, respectively. Analysis was based on a mixed-effects model for repeated measures approach on the intent-to-treat population. The intent-to-treat population comprised 395 patients (placebo=197, vilazodone=198); 77% completed the study. The least squares mean difference in change from baseline to week 8 in the Hamilton Rating Scale for Anxiety total score was statistically significant for vilazodone versus placebo [-1.50 (-2.96, -0.04), P=0.0438]. The mean change from baseline to week 8 in the Sheehan Disability Scale total score for vilazodone versus placebo was not statistically significant. Adverse events were reported in 60% of placebo-treated and 83% of vilazodone-treated patients. This was a positive clinical trial of 20-40 mg/day vilazodone versus placebo in the treatment of GAD.

The effects of common medications on volumetric phallometry

Phallometry is a physiological measure of sexual response widely used for the assessment of paedophilia among sexual offenders. Although many medications decrease penile response sufficiently to interfere with sexual intercourse, it is unknown to what extent such medications might interfere with phallometric testing. In the current study, we utilized a naturalistic convenience sample of 1078 men who attended a clinic for assessment of sexual preferences, mostly related to sexual offence convictions. In the present analyses, we quantified the differences in penile response during phallometric assessment associated with taking a range of common medications. Participants on medication typically showed less penile output than participants not taking medications; however, differences were largely accounted for by age rather than by medication status. Though most medications were associated with decreases in penile responsivity during volumetric phallometric testing, such changes were small in absolute terms and appeared to be associated with ageing rather than with the medications themselves.

Psychiatric disorders and sexual dysfunction

Sexual problems are highly prevalent among patients with psychiatric disorders. They may be caused by the psychopathology of the psychiatric disorder but also by its pharmacotherapy. Both positive symptoms (e.g., psychosis, hallucinations) as well as negative symptoms (e.g., anhedonia) of schizophrenia may negatively interfere with interpersonal and sexual relationships. Atypical antipsychotics have fewer sexual side-effects than the classic antipsychotics. Mood disorders may affect libido, sexual arousal, orgasm, and erectile function. With the exception of bupropion, agomelatine, mirtazapine, vortioxetine, amineptine, and moclobemide, all antidepressants cause sexual side-effects. Selective serotonin reuptake inhibitors (SSRIs) may particularly delay ejaculation and female orgasm, but also can cause decreased libido and erectile difficulties. SSRI-induced sexual side-effects are dose-dependent and reversible. Very rarely, their sexual side-effects persist after SSRI discontinuation. This is often preceded by genital anesthesia. Some personality characteristics are a risk factor for sexual dysfunction. Also patients with eating disorders may suffer from sexual difficulties. So far, research into psychotropic-induced sexual side-effects suffers from substantial methodologic limitations. Patients tend not to talk with their clinician about their sexual life. Psychiatrists and other doctors need to take the initiative to talk about the patient's sexual life in order to become informed about potential medication-induced sexual difficulties.

Sexual dysfunction during treatment of major depressive disorder with vilazodone, citalopram, or placebo: results from a phase IV clinical trial

Sexual dysfunction commonly occurs with major depressive disorder (MDD). Vilazodone, a selective serotonin reuptake inhibitor and 5-HT1A receptor partial agonist antidepressant approved for the treatment of MDD in adults, was evaluated to determine its effects on sexual function. The primary study was a double-blind, randomized, controlled trial comparing vilazodone 20 and 40 mg/day with placebo; citalopram 40 mg/day was an active control (NCT01473381; http://www.clinicaltrials.gov). Post-hoc analyses evaluated change from baseline to week 10 on the Changes in Sexual Functioning Questionnaire (CSFQ); no inferential statistics were performed. CSFQ scores increased for women [1.2 (citalopram) to 3.0 (vilazodone 40 mg)] and men [1.2 (vilazodone 40 mg) to 3.5 (placebo)] in all treatment groups. Greater changes in CSFQ scores were seen in responders [women: 2.33 (citalopram) to 5.06 (vilazodone 40 mg); men: 2.26 (vilazodone 40 mg) to 4.35 (placebo)] versus nonresponders. CSFQ change from baseline was small for patients with normal baseline sexual function; in patients with baseline sexual dysfunction, CSFQ scores improved across groups [women: 2.35 (citalopram) to 4.52 (vilazodone 40 mg); men 2.83 (vilazodone 40 mg) to 6.43 (placebo)]. Across treatment groups, baseline sexual function improved in women and men, MDD responders, and patients with baseline sexual dysfunction.

Psychiatric considerations in the oncology setting

An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.

The facts about sexual (Dys)function in schizophrenia: an overview of clinically relevant findings

A limited number of studies have evaluated sexual functioning in patients with schizophrenia. Most patients show an interest in sex that differs little from the general population. By contrast, psychiatric symptoms, institutionalization, and psychotropic medication contribute to frequently occurring impairments in sexual functioning. Women with schizophrenia have a better social outcome, longer lasting (sexual) relationships, and more offspring than men with schizophrenia. Still, in both sexes social and interpersonal impairments limit the development of stable sexual relationships. Although patients consider sexual problems to be highly relevant, patients and clinicians not easily discuss these spontaneously, leading to an underestimation of their prevalence and contributing to decreased adherence to treatment. Studies using structured interviews or questionnaires result in many more patients reporting sexual dysfunctions. Although sexual functioning can be impaired by different factors, the use of antipsychotic medication seems to be an important factor. A comparison of different antipsychotics showed high frequencies of sexual dysfunction for risperidone and classical antipsychotics, and lower frequencies for clozapine, olanzapine, quetiapine, and aripiprazole. Postsynaptic dopamine antagonism, prolactin elevation, and α1-receptor blockade may be the most relevant factors in the pathogenesis of antipsychotic-induced sexual dysfunction. Psychosocial strategies to treat antipsychotic-induced sexual dysfunction include psychoeducation and relationship counseling. Pharmacological strategies include lowering the dose or switching to a prolactin sparing antipsychotic. Also, the addition of a dopamine agonist, aripiprazole, or a phosphodiesterase-5 inhibitor has shown some promising results, but evidence is currently scarce.

Clinical predictive factors of sildenafil response: a penile hemodynamic study

Phosphodiestrase-5 inhibitors are an important line of treatment for erectile dysfunction (ED). To detect the clinical and hemodynamic predictors of sildenafil response, we conducted this study on 124 Egyptian men with ED. All patients were evaluated by thorough history and clinical assessment with measurement of the abridged international index of erectile function-5 (IIEF-5) score. All patients were then subjected to intracavernosal injection (ICI) of trimix and pharmaco-penile duplex ultrasonography (PPDU). Patients were then classified into sildenafil responders and non-responders after six consecutive doses of 100 mg sildenafil. On doing the binary logistic stepwise regression analysis, only ED duration, IIEF-5 score, and response to ICI were the significant independent predictors of sildenafil response. These three parameters together correctly predicted the sildenafil response by 81.5% (p value <0.001). With the receiver operator characteristic curve analysis, the cut-off value of ED duration was 2.5 years and it was 14 for the IIEF-5 score. These findings indicate that ED duration, the IIEF-5 score and response to ICI are more significant predictors of sildenafil response than the more expensive and time-consuming PPDU testing.

Reduction of patient-reported antidepressant side effects, by type of collaborative care

OBJECTIVE

Antidepressants are effective for treating depression, and collaborative care increases initiation of and adherence to antidepressants. Side effects of antidepressants are common and can adversely affect quality of life. Care managers address antidepressant side effects directly, but the impact of collaborative care on adverse effects is unknown. This secondary data analysis tested the hypothesis that patient-reported antidepressant side effects were lower for depressed patients receiving high-intensity, telemedicine-based collaborative care (TBCC) than for patients receiving low-intensity, practice-based collaborative care (PBCC).

METHODS

This analysis used data from 190 patients enrolled in a pragmatic, multisite, comparative-effectiveness trial from 2007 to 2009 and followed for 18 months. Most patients were female (83%) and Caucasian (80%). The mean age was 50. Patients randomly assigned to PBCC received 12 months of evidence-based care from an on-site primary care provider and nurse care manager. Patients in TBCC received evidence-based care from an on-site primary care provider supported by a nurse care manager available off site by telephone, as well as by a telepharmacist, telepsychologist, and telepsychiatrist. Telephone interviews completed at baseline, six, 12, and 18 months included assessments of sociodemographic characteristics, beliefs about antidepressant treatment, depression severity, psychiatric comorbidity, medications, adherence, and side effects.

RESULTS

With controls for baseline case mix and time-variant medication characteristics, the TBCC group reported significantly fewer side effects at six and 12 months (p=.008 and .002, respectively). The number of antidepressants prescribed increased risk of side effects (p=.02).

CONCLUSIONS

Patients in the TBCC group reported fewer antidepressant-related side effects, which may have contributed to improved quality of life.

Measuring sickness behavior in the context of pancreatic cancer

Sickness behavior has been widely recognized as a symptom cluster that is associated with pro-inflammatory cytokine activation resulting from diverse conditions. The symptoms that comprise sickness behavior overlap substantially with major depressive disorder (MDD), which raises questions about the relationship between these two constructs, both of which occur frequently in patients with cancer. The construct of sickness behavior, while well-established in animal research, has rarely been applied to studies examining cytokines and depression in humans, perhaps because no reliable or validated measure of sickness behavior has been developed. We developed a version of a sickness behavior measure (the Sickness Behavior Inventory or SBI) and conducted a preliminary examination of its scale properties. Specifically, we hypothesized that a measure of sickness behavior would be significantly associated with five biomarkers of immune functioning (serum IL-6, TNF-α, IL-1b, IL-4, IL-10) in a human sample. The sample was comprised of four groups: individuals with pancreatic cancer and MDD (n = 16), individuals with pancreatic cancer and who did not have a diagnosis of MDD (n =2 6), individuals without cancer who had MDD (n = 7), and individuals who did not have cancer or MDD (n = 25). The SBI demonstrated moderate reliability (Cronbach's alpha = .66), and total scores were significantly correlated with IL-6 (rs = .26, p = .03), but not with other markers of immune functioning. Factor analysis supported a 3-factor model of sickness behavior with different associations between the three SBI factors and cytokines. These results highlight the need to further refine symptom measurement to better understand the relationships among immune functioning, cancer, depression, and sickness behavior.

Rosa damascena oil improves SSRI-induced sexual dysfunction in male patients suffering from major depressive disorders: results from a double-blind, randomized, and placebo-controlled clinical trial

BACKGROUND

A substantial disadvantage of psychopharmacological treatment of major depressive disorder (MDD) with selective serotonin-reuptake inhibitors (SSRIs) is the impact on sexual dysfunction. The aim of the present study was to investigate whether the oil of Rosa damascena can have a positive influence on SSRI-induced sexual dysfunction (SSRI-I SD) of male patients who are suffering from MDD and are being treated with SSRIs.

METHOD

In a double-blind, randomized, and placebo-controlled clinical trial, a total of 60 male patients treated with an SSRI and suffering from MDD (mean age =32 years) and SSRI-I SD were randomly assigned to take either verum (R. damascena oil) or a placebo. Patients completed self-ratings of depression and sexual function at baseline, at 4 weeks later, and at the end of the study, 8 weeks after it started.

RESULTS

Over time, sexual dysfunction improved more in the verum group than in the control group. Improvements were observed in the verum group from week 4 to week 8. Self-rated symptoms of depression reduced over time in both groups, but did so more so in the verum group than in the control group.

CONCLUSION

This double-blind, randomized, and placebo-controlled clinical trial showed that the administration of R. damascena oil ameliorates sexual dysfunction in male patients suffering from both MDD and SSRI-I SD. Further, the symptoms of depression reduced as sexual dysfunction improved.

Management of antidepressant-induced sexual dysfunction

OBJECTIVE

Antidepressant-induced sexual dysfunction is a common, troublesome complication of antidepressant treatment that patients often fail to report, which can have major consequences, including non-adherence to treatment with resultant relapse of depressive illness. The aim of this paper is to review the extent, causation and evidence-based management of antidepressant-induced sexual dysfunction to inform clinical practice.

CONCLUSIONS

The preponderance of evidence suggests that antidepressant s can be divided into high risk (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors) and low risk (agomelatine, bupropion, moclobemide and reboxetine) categories with regard to propensity for antidepressant-induced sexual dysfunction, although there is disagreement, particularly about mirtazapine, and methodological issues militate against definitive findings. Antidepressant-induced sexual dysfunction is dose-dependent to an extent, but patient vulnerability factors are also relevant. There are significant differences in antidepressant-induced sexual dysfunction between men and women. It is important to ask antidepressant -treated patients about sexual dysfunction as few self-report; this may well contribute to antidepressant non-adherence. Consider using an antidepressant with low risk of antidepressant-induced sexual dysfunction for initial treatment. When antidepressant-induced sexual dysfunction has developed, try to persuade the patient to wait in case tolerance develops. Then consider changing to a lower risk or use of high/low risk antidepressant combinations but pharmacological expertise is required. Adjunctive sildenafil can help in both sexes.

The evolution of sexual dysfunction in young men aged 18-25 years

PURPOSE

To assess the evolution of sexual dysfunctions among young males after an average of 15 months follow-up to determine the predictive factors for this evolution and the characteristics differentiating young males who continue reporting a sexual dysfunction from those who do not.

METHODS

We conducted a prospective cohort study in two Swiss military recruitment centers mandatory for all Swiss national males aged 18-25 years. A total of 3,700 sexually active young males filled out a questionnaire at baseline (T0) and follow-up (T1: 15.5 months later). Main outcome measures were self-reported premature ejaculation (PE) and erectile dysfunction (ED).

RESULTS

Overall, 43.9% of young males who reported (PE) and 51% of those reporting (ED) at T0 still reported it at T1. Moreover, 9.7% developed a PE problem and 14.4% developed an ED problem between T0 and T1. Poor mental health, depression, and consumption of medication without prescription were predictive factors for PE and ED. Poor physical health, alcohol consumption, and less sexual experience were predictive factors for PE. ED persistence was associated with having multiple sexual partners.

CONCLUSIONS

This is the first longitudinal study to examine sexual dysfunctions among young males. Our results show high prevalence rates among young males for maintaining or developing a sexual dysfunction over time. Consequently, when consulting with young males, health professionals should inquire about sexual dysfunctions as part of their routine psychosocial assessment and leave the subject open for discussion. Future research should examine in more detail the relationship between sexual dysfunctions and poor mental health.

The impact of multimorbidity on sexual function in middle-aged and older women: beyond the single disease perspective

INTRODUCTION

Little is known about sexual activity and function in women with multiple chronic health conditions.

AIM

To examine the impact of multimorbidity on sexual activity and function in middle-aged and older women.

METHODS

Multiethnic cross-sectional cohort of 1,997 community-dwelling women (mean age of 60.2 [±9.5] years) in California. Structured questionnaires assessed prior diagnoses of common cardiometabolic, colorectal, neuropsychiatric, respiratory, musculoskeletal, and genitourinary conditions.

MAIN OUTCOME MEASURES

Sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (i.e., difficulty with arousal, lubrication, orgasm, and pain) were assessed by structured questionnaires.

RESULTS

Seventy-one percent of women had two or more diagnosed chronic conditions. Fifty-nine percent reported low sexual desire, 53% reported less than monthly sexual activity, and 47% reported low overall sexual satisfaction. Multimorbidity was associated with increased odds of reporting low sexual desire (OR = 1.11, 95% CI = 1.06-1.17, per each additional chronic condition), less than monthly sexual activity (OR = 1.11, 95% CI = 1.05-1.17 per each additional condition), and low sexual satisfaction (OR = 1.10, 95% CI = 1.04-1.16 per each additional condition), adjusting for age, race/ethnicity, and partner status. Depression and urinary incontinence were each independently associated with low desire (OR = 1.53, 95% CI = 1.19-1.97, and OR = 1.23, 95% CI = 1.00-1.52, respectively), less than monthly sexual activity (OR = 1.39, 95% CI = 1.06-1.83, and OR = 1.29, 95% CI = 1.02-1.62, respectively), and low sexual satisfaction (OR = 1.49, 95% CI = 1.14-1.93, and OR = 1.38, 95% CI = 1.11-1.73, respectively), adjusting for other types of conditions. After adjustment for total number of chronic conditions, age remained a significant predictor of low desire and less than monthly sexual activity, but not sexual satisfaction.

CONCLUSIONS

Women with multiple chronic health conditions are at increased risk for decreased sexual function. Depression and incontinence may have particularly strong effects on sexual desire, frequency of activity, and satisfaction in women, independent of other comorbid conditions. Women's overall sexual satisfaction may be more strongly influenced by multimorbidity than age.

Sexual performance and precontact 50-kHz ultrasonic vocalizations in WAG/Rij rats: effects of opioid receptor treatment

WAG/Rij rats are genetically selected animals that model absence epilepsy in rats. Ultrasonic vocalizations and sexual behavior - both ethologically relevant markers of reward system functioning - are poorly described in this strain. The aim of our experiment was to investigate reward-dependent precontact 50-kHz vocalizations (PVs) and copulatory behavior as well as the effects of opioid receptor treatment on such behaviors in sexually experienced WAG/Rij males and rats from two control strains: Sprague-Dawley and Crl: Han Wistar. We analyzed the effects of the opioid receptor antagonist naltrexone (3 mg/kg) and the agonist morphine (1 mg/kg) administration. Additionally, we analyzed the initiation of copulation in sexually naïve males before drug treatment. A significantly lower number of sexually naïve WAG/Rij rats initiated copulation. Sexually experienced WAG/Rij males differed at the control session (after physiological saline treatment) compared with Sprague-Dawley rats: WAG/Rij rats displayed more 50-kHz precontact vocalizations and had longer mount and intromission latencies, longer ejaculation latency, longer postejaculatory latency to exploration, longer 22-kHz vocalization duration after ejaculation, and longer postejaculatory intromission latency. Compared with Crl: Han Wistar rats, WAG/Rij males displayed longer mount latency and shorter 22-kHz vocalization duration. Neither naltrexone nor morphine affected PVs in all groups. On the other hand, opioid receptor treatment differently influenced the number of intromissions required to achieve ejaculation and 22-kHz postejaculatory vocalization duration in WAG/Rij rats than in both control groups. This suggests functional differences in the opioid system in this strain. As a result of the number of males that initiated copulation as well as the number of intromissions to ejaculation and 22-kHz postejaculatory vocalizations which all depend on D1 receptor activation, we suggest that the proportion of opioid receptor to D1 receptors in WAG/Rij rats is different when compared with the control strains. The reward system of Wag/Rij rats with absence epilepsy is sensitive to social rewards (high level of precontact 50-kHz ultrasounds) although this strain displays a lower level of sexual motivation (longer mount latency) compared with other control strains. A lower number of sexually naïve rats initiating copulation and longer mount latency in sexually experienced males could suggest a moderate depressive-like syndrome in this strain of rats.

Distress, anxiety and depression in patients with brain metastases before and after radiotherapy

BACKGROUND

Many patients with cancer suffer from distress, anxiety and depression. However, studies on patients with brain metastases are lacking. In this exploratory study we prospectively assessed distress, anxiety and depression in patients with brain metastases from different solid primary tumour treated with radiotherapy to the brain.

METHODS

Patients were recruited between May 2008 and December 2010. Distress, anxiety and depression were subjectively evaluated before radiotherapy, 6 weeks, 3 months and 6 months after radiotherapy using the validated National Comprehensive Cancer Network Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). The treatment group consisted of adult patients (n = 67) with brain metastases who were treated with whole-brain radiotherapy (n = 40) or hypofractionated stereotactic radiotherapy (n = 27). The control group comprised of patients (n = 32) diagnosed with breast cancer without cranial involvement who received adjuvant whole breast radiotherapy. Forty-six patients (24 in the treatment group) completed the study after six months.

RESULTS

Before radiotherapy, the treatment group experienced higher distress than the control group (p = 0.029). Using a cut-off ≥ 5, 70% of the treatment group were suffering from significant distress (66% of the control group). No significant time-by-group interaction on distress, anxiety and depression was observed. At all time points, a high proportion of patients reported psychological stress which featured more prominently than most of the somatic problems. Global distress correlated strongly with the Hospital Anxiety score before radiotherapy, but only moderately or weakly with both HADS scores after radiotherapy with the weakest association 6 months after radiotherapy.

CONCLUSION

In conclusion, the course of distress, anxiety and depression does not differ significantly between patients with brain metastases and breast cancer patients without cranial involvement. This finding suggests that both groups need similar psychological support during their treatment. Both screening instruments should be used as they cover different facets of distress.

Psychotropic-induced sexual dysfunction

Psychotropic-induced sexual dysfunction is a common and bothersome side effect of psychotropic medications. The majority of information available on the subject primarily pertains to antidepressants, but antipsychotics can also cause significant sexual dysfunction. The mechanisms behind these adverse events are thought to be primarily due to antidepressants' effects on serotonin and to antipsychotics' anti-dopaminergic activity. Sexual dysfunction can have many causes, not just psychotropic medication, therefore this article aims to examine the etiology of sexual dysfunction, as well as discuss differential diagnoses. Treatment for psychotropic-induced sexual dysfunction will be discussed, with more data available for the treatment of antidepressant-induced sexual dysfunction. The paucity of data for antipsychotic-induced sexual dysfunction does make it more difficult to treat.

Sexual and fertility adverse effects associated with chemotherapy treatment in women

INTRODUCTION

Earlier diagnosis and novel chemotherapy strategies have resulted in a considerable improvement in cancer survival, but the quality of that survival is influenced by late effects of chemotherapy. Premature ovarian failure is a common consequence of chemotherapy in reproductive-aged women, and, as a result, fertility issues and sexual dysfunction occur frequently in women who have undergone chemotherapy.

AREAS COVERED

This article reviews what is known about the effects of chemotherapy on fertility and sexuality. We also discuss risk factors for premature ovarian failure, fertility preservation options in patients willing to have a child after treatment, and sexual changes associated with estrogen withdrawal and psychological factors.

EXPERT OPINION

Chemotherapy-induced ovarian failure in young women is associated with poorer quality of life, decreased sexual functioning, psychosocial distress related to fertility concerns, and infertility. Fertility preservation options should be considered in women at risk of premature ovarian failure caused by chemotherapy. Sexual dysfunction associated with estrogen withdrawal and psychological stress is common in cancer survivors. Women who suffer from sexual dysfunction may benefit from brief counseling and targeted intervention.

Managing female sexual dysfunction

Female sexual dysfunctions (FSDs) range from short-term aggravations to major emotional disturbances adversely affecting family and workplace. This review highlights diagnosis and management of the four most widely diagnosed FSDs. It initially focuses on hypoactive sexual desire disorder (HSDD) as a driving force at the heart of all other FSDs; nothing happens without sexual desire. Successful resolution of HSDD frequently facilitates resolution of other disorders. Central to understanding HSDD is the impact of aging female sexual endocrinology and its effect on both prevalence and expression patterns of FSD. Advances in this field have enabled introduction of some the most effective treatments yet described for HSDD. Sexual arousal disorder, though commonly affected by the same factors as HSDD, is heavily associated with psychotropic drugs and mood elevators. Orgasmic disorder is frequently the downstream result of other sexual dysfunctions, particularly HSDD, or the result of a major psychosexual trauma. Successful management of the underlying disorder often resolves orgasmic disorder. Sexual pain disorder is frequently the result of a gynecologic disorder, such as endometriosis, that can be substantially managed through successful treatment of that disorder. This article ends with the article's most important note: how to initiate the conversation.

Relationship between SSRI-induced sexual dysfunction and central serotonergic activity based on the loudness dependence of auditory evoked potentials

RATIONALE

It has been hypothesized that selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction can occur more frequently in patients with higher central serotonergic activity, and that this higher serotonergic activity can induce inhibition of sexual desire, ejaculation, and orgasm. Thus, the aim of this study was to determine the relationship between SSRI-induced sexual dysfunction and increased serotonin.

METHOD

Event-related potentials for the loudness dependence of auditory evoked potentials (LDAEP) were measured in 46 patients at a single time point. The subjects' scores on the Hamilton Depression Rating Scale and Antidepressant Side-Effect Checklist were also determined by the investigators at the same time point. All patients had received SSRI monotherapy.

RESULTS

Overall, 37 % (17/46) of the patients experienced some form of SSRI-induced sexual dysfunction: lack of sexual desire, impotence, orgasm, and menstrual abnormality or mastalgia were experienced by 21.7, 8.3, 15.2, and 20.6 % of the patients, respectively. The subjects were thus divided into two groups-those with and without sexual dysfunction-and their data were compared. There was a tendency for the LDAEP to be lower in the group with sexual dysfunction (1.04 ± 0.77 μV) than the group without sexual dysfunction (1.45 ± 0.86 μV), although the difference was not statistically significant (p = 0.086). Furthermore, the distribution of the frequency of SSRI-induced sexual dysfunction differed marginally significantly between patients with low and high LDAEP, dichotomized according to the median LDAEP on the Cz electrode (χ (2) = 3.664, p = 0.056).

CONCLUSIONS

There was a relatively high frequency of SSRI-induced sexual dysfunction in patients with low LDAEP.

Association of depression, anxiety, and suicidal ideation with high-risk behaviors among men who inject drugs in Delhi, India

BACKGROUND

Sharing of needles and syringes and unprotected sex remain a common practice among people who inject drugs (PWID) in India and are important drivers of new HIV infections. Whether engagement in risk behaviors among PWID is associated with symptoms of common mental disorders in India is unknown.

METHODS

We analyzed the data collected in April and May of 2012 from a community-based sample of 420 PWID in Delhi using time location sampling. Self-report symptom scales were used to measure the severity of symptoms of depression (Patient Health Questionnaire 9) and anxiety (Generalized Anxiety Disorder scale 2) within the preceding 2 weeks. We assessed the presence of suicidal thoughts within the past 12 months.

RESULTS

PWID with severe depressive symptoms and those with suicidal thoughts were 4 and 2 times more likely to share needles/syringes, respectively. PWID experiencing suicidal thoughts had 82% more female sexual partners and were 5 times more likely to have had unprotected sex at last sex with a paid female partner. Conversely, symptoms of anxiety were associated with a 30% decrease in the likelihood of needle/syringe sharing and a 70% decrease in the likelihood of unprotected sex at last sex with a paid female partner.

CONCLUSIONS

We found a high prevalence of symptoms of depression, anxiety, and suicidal ideation among men who inject drugs in Delhi and that depression and suicidal ideation are independently positively associated with HIV risk behaviors, whereas anxiety is associated with a reduction in such behaviors. Ameliorating mental health problems among PWID in India may aid in reducing HIV infections.

Newly diagnosed major depressive disorder and the risk of erectile dysfunction: a population-based cohort study in Taiwan

INTRODUCTION

The primary aim of this study was to explore the incidence rate of erectile dysfunction (ED) among major depressive disorder (MDD) patients in an Asian country. The second aim was to compare the risk of ED in MDD patients that were treated using antidepressants with a high risk-ED, antidepressants with a low risk-ED, or without treatment.

METHODS

We identified 4339 male patients with newly diagnosed MDD using the National Health Database. Four matched controls per case were selected for the study.

RESULTS

The mean age of the participants was 42.3 ± 16.9. A higher crude HR of 3.6 (95% CI: 2.8-4.6) was seen in the male patients with MDD. After adjusting for obesity, monthly income, urbanization level, and comorbidity, the MDD patients had a 3.2-fold higher HR for an ED diagnosis than the controls. Patients with untreated depression had the highest risk of ED, compared to the control group (HR=3.9). Patients treated with IHiRA had a medium risk of developing ED (HR=3.6), and patients treated with ILoRA had the lowest risk of ED (HR: 2.5).

CONCLUSION

This prospective cohort study found an association between ED and prior MDD. Patients with untreated depression may have the highest risk of developing ED.

Sexuality in advanced age in Jewish thought and law

Judaism has a positive attitude to sexual relations within a marriage, and views such sexual relations as important not only for procreation but also as part of the framework of marriage. This is true for any age group, and sexuality is seen as an essential element of marriage for couples of advanced age. In this article, the authors present the views of Jewish law and thought regarding sexuality among older couples. The authors illustrate this using 3 case studies of couples who sought guidance in the area of sexuality. In addition, this area of counseling benefits greatly from an ongoing relationship and dialogue between expert rabbis in the field and therapists treating older Orthodox Jewish patients for sexual dysfunction. The triad relationship of couple, therapist, and rabbi enhances the ability to treat and assist such couples to seek treatment and overcome their difficulties.

Sexual side effects of serotonergic antidepressants: mediated by inhibition of serotonin on central dopamine release?

Antidepressant-induced sexual dysfunction adversely affects the quality of life of antidepressant users and reduces compliance with treatment. Animal models provide an instructive approach for examining potential sexual side effects of novel drugs. This review discusses the stability and reproducibility of our standardized test procedure that assesses the acute, subchronic and chronic effects of psychoactive compounds in a 30 minute mating test. In addition, we present an overview of the effects of several different (putative) antidepressants on male rat sexual behavior, as tested in our standardized test procedure. By comparing the effects of these mechanistically distinct antidepressants (paroxetine, venlafaxine, bupropion, buspirone, DOV 216,303 and S32006), this review discusses the putative mechanism underlying sexual side effects of antidepressants and their normalization. This review shows that sexual behavior is mainly inhibited by antidepressants that increase serotonin neurotransmission via blockade of serotonin transporters, while those that mainly increase the levels of dopamine and noradrenaline are devoid of sexual side effects. Those sexual disturbances cannot be normalized by simultaneously increasing noradrenaline neurotransmission, but are normalized by increasing both noradrenaline and dopamine neurotransmission. Therefore, it is hypothesized that the sexual side effects of selective serotonin reuptake inhibitors may be mediated by their inhibitory effects on dopamine signaling in sex brain circuits. Clinical development of novel antidepressants should therefore focus on compounds that simultaneously increase both serotonin and dopamine signaling.

Depression-like behavioral phenotypes by social and social plus visual isolation in the adult female Macaca fascicularis

Major depressive disorder (MDD) is a debilitating psychiatric mood disorder that affects millions of individuals globally. Our understanding of the biological basis of MDD is poor, and current treatments are ineffective in a significant proportion of cases. This current situation may relate to the dominant rodent animal models of depression, which possess translational limitations due to limited homologies with humans. Therefore, a more homologous primate model of depression is needed to advance investigation into the pathophysiological mechanisms underlying depression and to conduct pre-clinical therapeutic trials. Here, we report two convenient methods--social isolation and social plus visual isolation--which can be applied to construct a non-human primate model of depression in the adult female cynomolgus monkey (Macaca fascicularis). Both social and social plus visual isolation were shown to be effective in inducing depression-like behavior by significantly reducing socially dominant aggressive conflict behavior, communicative behavior, sexual behavior, and parental behavior. The addition of visual isolation produced more profound behavioral changes than social isolation alone by further reducing parental behavior and sexual behavior. Thus, the degree of behavioral pathology may be manipulated by the degree of isolation. These methods can be applied to construct a non-human primate model of depression in order to assess physiological, behavioral, and social phenomena in a controlled laboratory setting.