Strategies for managing sexual dysfunction induced by antidepressant medication

Understanding the Experiences of People with Post-SSRI Sexual Dysfunction

The purpose of this study was to explore the experiences of people with post-SSRI sexual dysfunction (PSSD). Ten participants were recruited through a patient advocacy group to participate in individual, semi-structured interviews. The results were analyzed using descriptive phenomenological analysis. Eight themes emerged to describe participants' experiences with PSSD. Findings indicate that people with PSSD can undergo psychological, physical and sexual effects of withdrawal that cause suffering, hopelessness and alienation. In addition, findings suggest that there was a lack of understanding, awareness, informed consent or acceptance among healthcare providers about PSSD, which (1) compounded the suffering, trauma, hopelessness and alienation that people with PSSD experience about their condition and (2) contributed to an overall lack of trust in physicians and/or medicine in general and therefore reliance on oneself to find relief from the symptoms of PSSD.

Current Utilization of Bupropion Treatment in Children, Young Adults, and Adults in the United States

Introduction: While available for decades, the use of bupropion has increased in recent years. To provide an updated review on the use of bupropion, this article aimed to describe bupropion prescription details, potential indication, and treatment duration in children, young adults, and adults starting bupropion treatment. Methods: Individuals aged 6-64 newly initiating bupropion hydrochloride treatment were identified from commercial claims data (MarketScan, 1/1/2016-12/31/2022). New bupropion use was defined as at least 1 year without any prior bupropion dispensed prescription. Potential indications for bupropion treatment were identified from inpatient/outpatient records (ICD-10-CM diagnoses) in the 30 days prior to bupropion initiation. All analyses were stratified by age: children (6-17 years), young adults (18-29 years), and adults (30-64 years) and treatment duration up to 1 year was estimated with Kaplan-Meier estimation. Results: The study sample included 39,833 children, 177,710 young adults, and 548,557 adults newly initiating bupropion treatment. Bupropion extended-release 24-hour 150 mg was the most common (62%) formulation and dose at initiation. Depression was the most prevalent potential indication (children = 57%, young adults = 47%, adults = 36%) and attention-deficit/hyperactivity disorder (ADHD) was the next most common potential indication in children (25%) and young adults (12%); tobacco cessation and weight loss also identified as potential indications. Twenty-two percent of bupropion initiators were on concurrent selective serotonin reuptake inhibitor treatment. In children, suicidal ideation (16.3%), poisoning (5.9%), and anorexia or bulimia nervosa (2.2%) were relatively common diagnoses prior to bupropion initiation. Overall, 39%-45% remained on bupropion treatment for at least 6 months, with variation by potential indication. Conclusion: The antidepressant bupropion is prescribed to children, young adults, and adults for a variety of indications in the United States, with depression and ADHD the most common indications in children. As the prescribing of bupropion becomes more widespread, additional safety and effectiveness data will be necessary to inform prescribing decisions, particularly in populations with unknown efficacy.

Sexual health and wellbeing and the menopause: An EMAS clinical guide

INTRODUCTION

Sexual health and wellbeing are significant aspects of quality of life. However, taking a sexual history is often avoided in medical practice, leaving a void in management and awareness. As the menopause can have a major impact on sexual health, it is imperative that healthcare providers are appropriately trained in sexual health and wellbeing and the aligned disciplines in order to achieve optimal care.

AIM

To provide an evidence-based clinical guide for the assessment and management of sexual problems at the menopause and beyond.

MATERIALS AND METHODS

Review of the literature and consensus of expert opinion.

RESULTS AND CONCLUSION

The assessment of sexual problems includes history taking, examination and laboratory investigation (if indicated), and occasionally the use of specific validated questionnaires. Management of sexual problems requires a multidimensional approach using biopsychosocial measures. Medical management and psychosexual counselling include pharmacological and non-pharmacological interventions, and sex therapy and psychoeducation. Furthermore, perimenopausal women should be advised about the need for contraception if they wish to avoid pregnancy. Also, sexually transmitted diseases can be acquired at any age. To conclude, taking a sexual history should be incorporated into medical practice and healthcare providers should be appropriately trained to assess and manage sexual problems at the menopause and beyond.

Safety Profile of Selective Serotonin Reuptake Inhibitors in Real-World Settings: A Pharmacovigilance Study Based on FDA Adverse Event Reporting System

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed agents to treat depression. Considering the growth in antidepressant prescription rates, SSRI-induced adverse events (AEs) need to be comprehensively clarified.

OBJECTIVE

This study was to investigate safety profiles and potential AEs associated with SSRIs using the Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

A retrospective pharmacovigilance analysis was conducted using the FAERS database, with Open Vigil 2.1 used for data extraction. The study included cases from the marketing date of each SSRI (ie, citalopram, escitalopram, fluoxetine, paroxetine, fluvoxamine, and sertraline) to April 30, 2023. We employed the reporting odds ratio and Bayesian confidence propagation neural network as analytical tools to assess the association between SSRIs and AEs. The Medical Dictionary for Regulatory Activities was used to standardize the definition of AEs. AE classification was achieved using system organ classes (SOCs).

RESULTS

Overall, 427 655 AE reports were identified for the 6 SSRIs, primarily associated with 25 SOCs, including psychiatric, nervous system, congenital, familial, genetic, cardiac, and reproductive disorders. Notably, sertraline (n = 967) and fluvoxamine (n = 169) exhibited the highest and lowest signal frequencies, respectively. All SSRIs had relatively strong signals related to congenital, psychiatric, and nervous disorders.

CONCLUSIONS AND RELEVANCE

Most of our findings are consistent with those reported previously, but some AEs were not previously identified. However, AEs attributed to SSRIs remain ambiguous, warranting further validation. Applying data-mining methods to the FAERS database can provide additional insights that can assist in appropriately utilizing SSRIs.

A novel reuptake inhibitor, IP2015, induces erection by increasing central dopamine and peripheral nitric oxide release

BACKGROUND AND PURPOSE

An estimated 40% of patients with erectile dysfunction have a poor prognosis for improvement with currently available treatments. The present study investigated whether a newly developed monoamine transport inhibitor, IP2015, improves erectile function.

EXPERIMENTAL APPROACH

We investigated the effects of IP2015 on monoamine uptake and binding, erectile function in rats and diabetic mice and the effect on corpus cavernosum contractility.

KEY RESULTS

IP2015 inhibited the uptake of 5-HT, noradrenaline and dopamine by human monoamine transporters expressed in cells and in rat brain synaptosomes. Intracavernosal pressure measurement in anaesthetized rats revealed that IP2015 dose-dependently increased the number and the duration of spontaneous erections. Whereas pretreatment with the dopamine D2-like receptor antagonists, clozapine and (-)-sulpiride, or cutting the cavernosal nerve inhibited IP2015-induced erectile responses, the phosphodiesterase type 5 inhibitor sildenafil further enhanced the IP2015-mediated increase in intracavernosal pressure. IP2015 also increased the number of erections in type 2 diabetic db/db mice. Direct intracavernosal injection of IP2015 increased penile pressure, and in corpus cavernosum strips, IP2015 induced concentration-dependent relaxations. These relaxations were enhanced by sildenafil and blunted by endothelial cell removal, a nitric oxide synthase inhibitor, NG-nitro-l-arginine and a D1-like receptor antagonist, SCH23390. Quantitative polymerase chain reaction (qPCR) showed the expression of the dopamine transporter in the rat corpus cavernosum.

CONCLUSION AND IMPLICATIONS

Our findings suggest that IP2015 stimulates erectile function by a central mechanism involving dopamine reuptake inhibition and direct NO-mediated relaxation of the erectile tissue. This novel multi-modal mechanism of action could offer a new treatment approach to erectile dysfunction.

Anti-Depressant Like Effects of Aethoscytus Foveolus Oil by Improving Stress-mediated Alterations of Monoamine Oxidase, Oxidative Stress, and Neuroinflammation In-vivo

Depression is a neuropsychological disorder with a complex pathophysiology and its pharmacotherapy is compromised by adverse side effects. Addressing the need for effective treatment for depression, the current study aims to characterize the antidepressant activity of oil extract derived from Aethoscytus foveolus, bugs that are widely available in India, in a mice model of stress-induced depression. Chemical moieties characterized by GC-MS of A. foveolus oil extract have shown good affinity for monoamine oxidase A (MAO-A) in-silico. In-vitro MAO-inhibitory assay using mouse brain homogenates also showed similar results at IC50 1.363 nM (R2 = 0.981, SD ± 0.05, n = 3) of it. These results encouraged us to investigate the antidepressant potential of this oil extract in vivo. Stress-exposed mice (Swiss Albino, either sex, 25-30 gm) were administered 5 and 10 mg/kg doses of oil extract and classified as separate groups (N = 6 per group). Behavioral tests like the forced-swim test, tail-suspension test, and open-field test demonstrated significant attenuation of stress-induced depressive-like behavior of mice by both doses (p < 0.0001 with positive control group i.e., stress group), while biochemical tests on mice brain tissues showed amelioration of stress-induced hyperactivation of MAO (p < 0.0001) and oxidative stress (by increasing Superoxide dismutase and catalase, while reducing lipid peroxidase and nitric oxide) (p < 0.0001). The altered mRNA expression of proinflammatory cytokines (NF-κB, IL-6, IL-12, and TNF-α) (p < 0.015) was also improved by this oil extract. In addition, histopathology of hippocampus tissues of mice supports that this oil recovers stress-mediated structural changes of the brain. In conclusion our findings suggest that oil derived from A. foveolus could be beneficial in the alleviation of stress-mediated depressive-like behavior of mice, and in our knowledge, this is the first report identifying anti-neurodegenerative potential of A. foveolus.

Effects of Pharmaceutical Substances with Obesogenic Activity on Male Reproductive Health

Obesogens have been identified as a significant factor associated with increasing obesity rates, particularly in developed countries. Substances with obesogenic traits are prevalent in consumer products, including certain pharmaceuticals. Specific classes of pharmaceuticals have been recognized for their ability to induce weight gain, often accompanied by hormonal alterations that can adversely impact male fertility. Indeed, research has supplied evidence underscoring the crucial role of obesogens and therapeutic agents in the normal functioning of the male reproductive system. Notably, sperm count and various semen parameters have been closely linked to a range of environmental and nutritional factors, including chemicals and pharmacological agents exhibiting obesogenic properties. This review aimed to explore studies focused on analyzing male fertility parameters, delving into the intricacies of sperm quality, and elucidating the direct and adverse effects that pharmacological agents may have on these aspects.

The effect of drug holidays on sexual dysfunction in men treated with selective serotonin reuptake inhibitors (SSRIs) other than fluoxetine: an 8-week open-label randomized clinical trial

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) are widely used for the treatment of various mental disorders. Sexual dysfunction is one of the most common side effects of SSRIs, and often leads to poor adherence and treatment discontinuation. While several strategies have been employed to manage SSRI-induced sexual dysfunction, drug holidays has not been extensively studied for this purpose. This clinical trial aims to assess the effect of drug holidays on sexual dysfunction in married men under treatment with SSRIs other than fluoxetine (as its long half-life makes drug holidays ineffective).

METHODS

This 8-week double-center, randomized, open-label, controlled trial was conducted in the outpatient clinics of Iran Psychiatric Hospital and Tehran Institute of Psychiatry, from January 2022 to March 2023. We included married men aged between18 and 50 years who had experienced sexual dysfunction during treatment with SSRIs, other than fluoxetine. The Male Sexual Health Questionnaire (MSHQ) and the 28-Question General Health Questionnaire (GHQ-28) were used for the assessment of sexual function and mental health status. The drug holidays group was instructed not to take their medications on the weekends. The control group was asked to continue their regular medication regimen without any changes. Both groups were assessed at baseline, and weeks 4 and 8.

RESULTS

Sixty-three patients were included and randomly assigned to the drug holidays group (N = 32) or the control group (N = 31). Fifty patients (25 in each group) completed the trial. Drug holidays significantly improved erection, ejaculation, satisfaction, and the overall sexual health of the participants (P < 0.001). No significant change was observed in their mental health status. No major side effects were recorded.

CONCLUSIONS

Drug holidays significantly improved the MSHQ scores in 'erection', 'ejaculation', 'satisfaction' and 'total' in married men with sexual dysfunction induced by SSRIs, other than fluoxetine, without causing any significant changes in their mental health status. Further research is needed to reach a certain conclusion.

TRIAL REGISTRATION

The trial was registered at the Iranian Registry of Clinical Trials on 2021.10.25 ( www.irct.ir ; IRCT ID: IRCT20170123032145N6) before the trial.

A drug target for erectile dysfunction to help improve fertility, sexual activity, and wellbeing: mendelian randomisation study

OBJECTIVE

To investigate the association of genetically proxied (using a surrogate biomarker) inhibition of phosphodiesterase 5 (PDE5), an established drug target for erectile dysfunction, with fertility, sexual behaviour, and subjective wellbeing.

DESIGN

Two sample cis-mendelian randomisation study.

SETTING

Summary data on genetic associations obtained from the International Consortium for Blood Pressure and UK Biobank.

PARTICIPANTS

Individuals of European ancestry from the International Consortium for Blood Pressure (n=757 601) for estimating PDE5 inhibition (using the surrogate biomarker of diastolic blood pressure reduction), and UK Biobank (n=211 840) for estimating the fertility, sexual behaviour, and subjective wellbeing outcomes in male participants.

INTERVENTION

Genetically proxied PDE5 inhibition.

MAIN OUTCOME MEASURES

Number of children fathered, number of sexual partners, probability of never having had sexual intercourse, and subjective wellbeing.

RESULTS

Genetically proxied PDE5 inhibition was associated with male participants having 0.28 (95% confidence interval 0.16 to 0.39) more children (false discovery rate corrected P<0.001). This association was not identified in female participants. No evidence was found of an association between genetically proxied PDE5 inhibition and number of sexual partners, probability of never having had sexual intercourse, or self-reported wellbeing in male participants.

CONCLUSIONS

The findings of this study provide genetic support for PDE5 inhibition potentially increasing the number of children fathered by male individuals. Absence of this association in female participants supports increased propensity for sustained and robust penile erections as a potential underlying mechanism. Further studies are required to confirm this, however, and these findings should not promote indiscriminate use of PDE5 inhibitors, which can also have harmful adverse effects.

[Sexual dysfunction on the background of antidepressant therapy]

The review is devoted to the problem of sexual dysfunction caused by taking antidepressants. Sexual dysfunction is widespread, but it is not reported, and its impact on the quality of life and compliance of patients is underestimated. Partly because of its bidirectional association with depression, sexual dysfunction is difficult to diagnose. Possible mechanisms and risk factors associated with sexual dysfunction in patients with depression are considered. The data on the frequency of sexual dysfunction with the use of various antidepressants are given. Therapeutic strategies for sexual dysfunction associated with taking antidepressants are described. The advantages of agomelatin as an antidepressant associated with a low risk of sexual side effects are emphasized.

Testosterone Replacement Therapy in the Treatment of Depression

BACKGROUND

Depression is a common disorder that affects millions globally and is linked to reduced quality of life and mortality. Its pathophysiology is complex and there are several forms of treatment proposed in the literature with differing side effect profiles. Many patients do not respond to treatment which warrants augmentation with other treatments and the investigation of novel treatments. One of these treatments includes testosterone therapy which evidence suggests might improve depressed mood in older patients with low levels of testosterone and helps restore physical impairments caused by age-related hormonal changes.

OBJECTIVE

The objective of this review is to synthesize information regarding clinical depression, its treatment options, and the efficacy and safety of testosterone treatment for the treatment of depression.

METHODS

This review utilized comprehensive secondary and tertiary data analysis across many academic databases and published work pertaining to the topic of interest.

RESULTS

Within some subpopulations such as men with dysthymic disorder, treatment resistant depression, or low testosterone levels, testosterone administration yielded positive results in the treatment of depression. Additionally, rodent models have shown that administering testosterone to gonadectomized male animals reduces symptoms of depression. Conversely, some studies have found no difference in depressive symptoms after treatment with testosterone when compared with placebo. It was also noted that over administration of testosterone is associated with multiple adverse effects and complications.

CONCLUSION

The current evidence provides mixed conclusions on the effectiveness of testosterone therapy for treating depression. More research is needed in adult men to see if declining testosterone levels directly influence the development of depression.

Female sexual dysfunctions: an overview on the available therapeutic interventions

INTRODUCTION

There are different types of female sexual dysfunctions (FSDs), and FSD in general has a high prevalence worldwide. Studies of FSD should consider it as a multifactorial disorder that has biological, psychological, environmental, and relational aspects. In this review we discuss the available therapeutic interventions for FSD.

EVIDENCE ACQUISITION

For the current narrative review the PubMed database was searched to identify all publications up to 30 March 2021 that were systematic reviews and meta-analyses which examined therapeutic interventions for FSDs based on the diagnostic classifications of ICD-10 and ICD-11.

EVIDENCE SYNTHESIS

Thirty systematic reviews and meta-analyses were included in this review. Hormone therapy (HT) and testosterone are effective to improve sexual desire in menopausal women. In these women HT and ospemiphene may improve pain during intercourse. Flibanserin may improve sexual desire and may reduce desire-related distress in premenopausal women. Bremelanotide is effective to improve desire, arousal, and orgasm scores. Evidence are still limited on the efficacy of psychoactive drugs, phosphodiesterase type 5 (PDE5), oxytocin, herbal drugs, and tibolone to treat FSDs. Psychological interventions such as cognitive-behavior therapy, mindfulness training, sensate focus, bibliotherapy are effective for the management of several different FSDs.

CONCLUSIONS

The management of FSDs may require multidisciplinary and interdisciplinary approaches. Pharmacological and nonpharmacological interventions appears to have potential as a treatment for FSDs, but there are currently no gold standards regarding recommended treatment modalities, and the duration, frequency, and intensity of therapy sessions.

Impact of Social Determinants of Health on Women's Satisfaction with Their Sexual Life and Its Relationship with the Use of Psychotropic Drugs: A Cross-Sectional Study

Sexual satisfaction (SS) is defined as an affective response arising from one’s subjective evaluation of the positive and negative dimensions associated with one’s sexual relationship. It is an important indicator of health. In women, SS has an important personal component consisting of the physical experiences of pleasure and the positive feelings and emotions that they experience in their affective-sexual relationships. The socioeconomic position is determined by income, educational level, and work, and it conditions women’s sexual health. We aimed to assess whether social determinants of health (income, education, work, and gender) are associated with women’s sexual satisfaction and to identify whether the impact of social determinants on sexual satisfaction differs with psychotropic consumption. We conducted a cross-sectional study designed to assess the association between variables related to the social determinants of health (work, education, income, and gender) and sexual satisfaction in women of reproductive age in La Rioja (Spain). The women in this study ranged in age from 17 to 52 years, with a mean age of 33.4 (Standar Deviation 8.6). Most were Spanish (82.9%), had undertaken non-compulsory specialized education (84%), and worked (72.7%). Regarding their relationships, 87% maintained monogamous relationships, 84.5% had stable relationships, and 65.7% lived with their partners. In total, 12.3% of the women were taking psychotropic drugs prescribed for the treatment of anxiety and/or depression. We observed that SS is significantly lower among women who have only undertaken compulsory education (Student-t = −4.745; p < 0.01), in those who have unstable affective-sexual relationships (Student-t = −2.553; p < 0.01), and in those who take psychotropic drugs (Student-t = −4.180, p < 0.01). We conclude that the social determinants of health such as education, not continuing to study beyond compulsory education, gender, and taking psychoactive drugs have a significant impact on women’s degree of satisfaction with their sexual life.

Combining Antidepressants vs Antidepressant Monotherapy for Treatment of Patients With Acute Depression: A Systematic Review and Meta-analysis

IMPORTANCE

Combining antidepressants is frequently done in the treatment of acute depression, but studies have yielded conflicting results.

OBJECTIVE

To conduct a systematic review and meta-analysis assessing efficacy and tolerability of combination therapy. Combinations using presynaptic α2-autoreceptor antagonists or bupropion were investigated separately.

DATA SOURCES

MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials were systematically searched from each database inception through January 2020.

STUDY SELECTION

Randomized clinical trials (RCTs) comparing combinations of antidepressants with antidepressant monotherapy in adult patients with acute depression were included.

DATA EXTRACTION AND SYNTHESIS

Following guidelines from Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and recommendations from the Cochrane Handbook, 2 reviewers independently performed a literature search, study selection, data extraction, and evaluation of risk of bias. Data were pooled in random-effects analyses.

MAIN OUTCOMES AND MEASURES

Primary outcome was efficacy measured as standardized mean difference (SMD); secondary outcomes were response, remission, change from baseline in rating scale scores, number of dropouts, and number of dropouts due to adverse events.

RESULTS

Thirty-nine RCTs including 6751 patients were eligible. Combination treatment was statistically significantly associated with superior treatment outcomes relative to monotherapy (SMD = 0.31; 95% CI, 0.19-0.44). Combining a reuptake inhibitor with an antagonist of presynaptic α2-autoreceptors was superior to other combinations (SMD = 0.37; 95% CI, 0.19-0.55). Bupropion combinations were not superior to monotherapy (SMD = 0.10; 95% CI, -0.07 to 0.27). Numbers of dropouts and dropouts due to adverse events did not differ between treatments. Studies were heterogeneous, and there was indication of publication bias (Egger test result was positive; P = .007, df = 36), but results remained robust across prespecified secondary outcomes and sensitivity and subgroup analyses, including analyses restricted to studies with low risk of bias.

CONCLUSIONS AND RELEVANCE

In this meta-analysis of RCTs comparing combinations of antidepressants with antidepressant monotherapy, combining antidepressants was associated with superior treatment outcomes but not with more patients dropping out of treatment. Combinations using an antagonist of presynaptic α2-autoreceptors may be preferable and may be applied as a first-line treatment in severe cases of depression and for patients considered nonresponders.

Protocol for individual participant data meta-analysis of interventions for post-traumatic stress

INTRODUCTION

Several evidence-based treatments are effective for post-traumatic stress disorder (PTSD), yet a substantial proportion of patients do not respond or dropout of treatment. We describe the protocol for a systematic review and individual participant data meta-analysis (IPD-MA) aimed at assessing the effectiveness and adverse effects of psychotherapy and pharmacotherapy interventions for treating PTSD. Additionally, we seek to examine moderators and predictors of treatment outcomes.

METHOD AND ANALYSIS

This IPD-MA includes randomised controlled trials comparing psychotherapy and pharmacotherapy interventions for PTSD. PubMed, Embase, PsycINFO, PTSDpubs and CENTRAL will be screened up till the 11th of January 2021. The target population is adults with above-threshold baseline PTSD symptoms on any standardised self-report measure. Trials will only be eligible if at least 70% of the study sample have been diagnosed with PTSD by means of a structured clinical interview. The primary outcomes of this IPD-MA are PTSD symptom severity, and response rate. Secondary outcomes include treatment dropout and adverse effects. Two independent reviewers will screen major bibliographic databases and past reviews. Authors will be contacted to contribute their participant-level datasets. Datasets will be merged into a master dataset. A one-stage IPD-MA will be conducted focusing on the effects of psychological and pharmacological interventions on PTSD symptom severity, response rate, treatment dropout and adverse effects. Subsequent analyses will focus on examining the effect of moderators and predictors of treatment outcomes. These will include sociodemographic, treatment-related, symptom-related, resilience, intervention, trauma and combat-related characteristics. By determining the individual factors that influence the effectiveness of specific PTSD treatments, we will gain insight into personalised treatment options for PTSD.

ETHICS AND DISSEMINATION

Specific ethics approval for an IPD-MA is not required as this study entails secondary analysis of existing anonymised data. The results of this study will be published in peer-reviewed scientific journals and presentations.

The Effect of Phosphodiesterase-type 5 Inhibitors on Erectile Function: An Overview of Systematic Reviews

Background: Multiple systematic reviews explore the effect of phosphodiesterase type 5 (PDE5) inhibitors on erectile dysfunction (ED), with each study addressing specific outcomes. However, physicians and policymakers require a holistic approach of this topic.

Objective: To summarize the current evidence regarding the efficacy and safety of PDE5 inhibitors for the management of ED through an overview of systematic reviews.

Methods: Studies were identified by searching PubMed, Web of Science, Cochrane Library and Scopus databases, as well as sources of grey literature until June 12, 2021 (PROSPERO: CRD42020216754). We considered systematic reviews, meta-analyses or network meta-analyses of randomized trials that provided outcomes about the efficacy and safety of any approved PDE5 inhibitor (avanafil, sildenafil, tadalafil and vardenafil). We constructed forest plots for meta-analytic effects regarding the change in erectile function, adverse events and dropouts after administration of PDE5 inhibitors in the general population and in specific patient groups.

Results: We included 23 studies with 154,796 participants and a total of 258 meta-analytic effects. Sildenafil 25 mg [Weighted Mean Difference (WMD): 13.08, 95% Confidence Interval (CI): 10.1-16.06] seemed to be statistically superior to all interventions in improving erectile function compared to placebo, but studies with low-dose sildenafil are lacking. Moreover, comparing among different PDE5 inhibitors, sildenafil 50 mg or sildenafil 100 mg were considered the most effective compounds in the general population. The latter derived, however, predominantly from indirect comparisons among different PDE5 inhibitors. Still, sildenafil 100 mg was associated with more treatment-related adverse events and dropouts. Interestingly, low-dose daily tadalafil may be more effective than high-dose on-demand tadalafil (WMD: 1.24, 95% CI: 0.03-2.44). Furthermore, testosterone and PDE5 inhibitors in patients with ED and hypogonadism seem to further improve symptoms, while the addition of a-blockers in patients with urinary symptoms treated with PDE5 inhibitors does not provide additional benefits (WMD: −0.8, 95% CI: −1.65-0.06).

Conclusion: Although the efficacy and safety of PDE5 inhibitors, compared to placebo, is well-documented, the existing evidence comparing different PDE5 inhibitors is low. Therefore, high-quality, head-to-head, trials comparing different PDE5 inhibitors are necessary to determine their ideal dosage and formulation based on their safety and efficacy profile.

Systematic Review Registration: PROSPERO, identifier [CRD42020216754].

Erectile and Ejaculatory Dysfunction Associated with Use of Psychotropic Drugs: A Systematic Review

BACKGROUND

Sexual dysfunction may be a side effect of treatment with antipsychotics, antidepressants, and other psychotropic drugs.

AIM

To review the evidence concerning male sexual dysfunctions in patients taking psychotropic drugs to provide specific information to nonpsychiatric physicians for the management of these dysfunctions.

METHODS

A systematic search of Medline and Embase databases was performed up to October 15th, 2020. We included randomized controlled trials comparing the effects of psychotropic drugs versus placebo or versus another drug of the same class, for at least 5 weeks.

OUTCOMES

We considered studies whose male population could be evaluated separately from the female population and with a separate analysis of the different phases of the male sex cycle.

RESULTS

We included 41 studies in the final review. There was a significant association between sexual dysfunction and antidepressant drug therapy, compared to placebo (decreased libido OR 1.89, 95% CI:1.40 to 2.56, 22 series, 11 trials, 7706 participants; erectile dysfunction OR = 2.28, 95% CI: 1.31 to 3.97; 11 trials, 3008 participants; ejaculatory dysfunction OR = 7.31, 95% CI: 4.38 to 12.20,19 trials, 3973 participants). When the effects of selective serotonin reuptake inhibitors (SSRIs) were evaluated separately from those of serotonin/norepinephrine reuptake inhibitors (SNRIs), the use of SNRIs but not that of SSRIs was characterized by significantly higher odds of erectile dysfunction compared to placebo. Only limited data were found regarding the effects of antipsychotics on the phases of the male sexual cycle, as it was shown that aripiprazole and risperidone showed lower and higher odds for erectile or ejaculatory dysfunction, respectively, compared to other atypical antipsychotics.

CLINICAL IMPLICATIONS

Treatment of male sexual dysfunction in patients taking psychotropics requires a basic knowledge of the different drugs that affect sexual function with different mechanisms.

STRENGTHS & LIMITATIONS

The effects of psychotropic drugs on erectile function and ejaculation were evaluated separately. The great variability of the mechanisms of action makes it difficult to make comparisons between the effects of the different classes of psychotropic drugs.

CONCLUSIONS

Administration of antipsychotics affects male sexual function with different mechanisms, although the increase in prolactin values associated with the administration of first-generation antipsychotics and some atypical, such as risperidone, seems to play a primary role in determining male sexual dysfunction. Most antidepressants cause decreased libido, ejaculatory and erectile dysfunction, however the administration of SNRIs appears to be possibly associated with a specific risk of erectile dysfunction. Trinchieri M, Trinchieri M, Perletti G, et al. Erectile and Ejaculatory Dysfunction Associated with Use of Psychotropic Drugs: A Systematic Review. J Sex Med 2021;18:1354-1363.

Depression

Most psychiatric care is delivered in primary care settings, where depression is the most common presenting psychiatric symptom. Given the high prevalence of depression worldwide and the well-established consequences of untreated depression, the ability of primary care clinicians to effectively diagnose and treat it is critically important. This article offers up-to-date guidance for the diagnosis and treatment of major depressive disorder, including practical considerations for delivering optimal and efficient care for these patients.

The mechanism of electroacupuncture for depression on basic research: a systematic review

BACKGROUND

Electroacupuncture (EA) is generally accepted as a safe and harmless treatment option for alleviating depression. However, there are several challenges related to the use of EA. Although EA has been shown to be effective in treating depression, the molecular mechanism is unclear.

OBJECTIVE

To reveal the therapeutic effect of EA and its possible mechanism in the treatment of depression.

SEARCH STRATEGY

We performed a systematic search according to PRISMA guidelines. We electronically searched PubMed, Web of Science (WOS), the China National Knowledge Infrastructure (CNKI), Wanfang Data Information Site and the VIP information database for animal studies in English published from the inception of these databases to December 31, 2019.

INCLUSION CRITERIA

Electronic searches of PubMed, WOS, the CNKI, Wanfang and the VIP database were conducted using the following search terms: (depression OR depressive disorder OR antidepressive), (rat OR mouse) AND (acupuncture OR EA).

DATA EXTRACTION AND ANALYSIS

The data were extracted primarily by one author, and a follow-up review was conducted by the other authors.

RESULTS

Twenty-eight articles met the inclusion criteria. The most commonly used method for inducing depression in animal models was 21 days of chronic unpredictable mild stress. For the depression model, the most commonly selected EA frequency was 2 Hz. Among the 28 selected studies, 11 studies observed depression-related behaviors and used them as indicators of EA efficacy. The other 17 studies focused on mechanisms and assessed the indexes that exhibited abnormalities that were known to result from depression and then returned to a normal range after EA treatment. Treatment of depression by EA involves multiple therapeutic mechanisms, including inhibition of HPA axis hyperactivity and inflammation, regulation of neuropeptides and neurotransmitters, modulation of the expression of particular genes, restoration of hippocampal synaptic plasticity, increased expression of BDNF, and regulation of several signaling pathways.

CONCLUSIONS

This review reveals that the mechanisms underlying the effect of acupuncture involve multiple pathways and targets, suggesting that acupuncture is a wholistic treatment for people rather than for diseases. Our findings also explain why acupuncture can treat various disorders in addition to depression.

Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians

Hypoactive sexual desire disorder (HSDD) represents a common condition among transgender women. However, to date no specific guidelines for the management of HSDD in transgender persons are available. The aim of the present narrative Review is to evaluate evidence-based treatment for HSDD and to suggest treatment options for HSDD in transgender women. Clinically relevant publications on the management of HSDD (from 1985 to 2020) were searched in PubMed and Medline databases, using the following terms: "sexual desire", "sexual health", "HSDD", "transgender", "gender-affirming treatment", "sexual therapy", "testosterone treatment", "Central nervous system-active medications", and variants. Since sexual desire could be affected by several factors, a comprehensive assessment of HSDD- exploring biological, psychological, and social domains- is recommended, in order to identify possible predisposing, precipitating and maintaining factors. Among treatment options, transgender women may benefit of different sex therapy strategies and/or central nervous system-active medications-such as flibanserin, bremelanotide, bupropion and buspirone-and transdermal testosterone, bearing in mind that this option could be poorly accepted by patients due to the risk of virilizing effects. The lack of data regarding the efficacy of HSDD treatment options in transgender women emphasize the need for literature to focus more on this topic in the future.

Management Strategies for Antidepressant-Related Sexual Dysfunction: A Clinical Approach

Major depressive disorder is a serious mental disorder in which treatment with antidepressant medication is often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) has a low rate of spontaneous reports by patients, and this side effect therefore remains underestimated in clinical practice and in technical data sheets for antidepressants. Moreover, the issue of TESD is rarely routinely approached by clinicians in daily praxis. TESD is a determinant for tolerability, since this dysfunction often leads to a state of patient distress (or the distress of their partner) in the sexually active population, which is one of the most frequent reasons for lack of adherence and treatment drop-outs in antidepressant use. There is a delicate balance between prescribing an effective drug that improves depressive symptomatology and also has a minimum impact on sexuality. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antidepressant with a low rate of TESD) to possible pharmacological interventions aimed at improving patients’ tolerability when TESD is present. The suggested recommendations include the following: for low sexual desire, switching to a non-serotoninergic drug, lowering the dose, or associating bupropion or aripiprazole; for unwanted orgasm delayal or anorgasmia, dose reduction, “weekend holiday”, or switching to a non-serotoninergic drug or fluvoxamine; for erectile dysfunction, switching to a non-serotoninergic drug or the addition of an antidote such as phosphodiesterase 5 inhibitors (PD5-I); and for lubrication difficulties, switching to a non-serotoninergic drug, dose reduction, or using vaginal lubricants. A psychoeducational and psychotherapeutic approach should always be considered in cases with poorly tolerated sexual dysfunction.

Characteristics of stakeholder involvement in systematic and rapid reviews: a methodological review in the area of health services research

OBJECTIVE

Engaging stakeholders in reviews is considered to generate more relevant evidence and to facilitate dissemination and use. As little is known about stakeholder involvement, we assessed the characteristics of their engagement in systematic and rapid reviews and the methodological quality of included studies. Stakeholders were people with a particular interest in the research topic.

DESIGN

Methodological review.

SEARCH STRATEGY

Four databases (Medline, Embase, Cochrane database of systematic reviews, databases of the University of York, Center for Reviews and Dissemination (CRD)) were searched based on an a priori protocol. Four types of reviews (Cochrane and non-Cochrane systematic reviews, rapid and CRD rapid reviews) were retrieved between January 2011 and October 2015, pooled by potential review type and duplicates excluded. Articles were randomly ordered and screened for inclusion and exclusion criteria until 30 reviews per group were reached. Their methodological quality was assessed using AMSTAR and stakeholder characteristics were collected.

RESULTS

In total, 57 822 deduplicated citations were detected with potential non-Cochrane systematic reviews being the biggest group (56 986 records). We found stakeholder involvement in 13% (4/30) of Cochrane, 20% (6/30) of non-Cochrane, 43% (13/30) of rapid and 93% (28/30) of CRD reviews. Overall, 33% (17/51) of the responding contact authors mentioned positive effects of stakeholder involvement. A conflict of interest statement remained unmentioned in 40% (12/30) of non-Cochrane and in 27% (8/30) of rapid reviews, but not in Cochrane or CRD reviews. At most, half of non-Cochrane and rapid reviews mentioned an a priori study protocol in contrast to all Cochrane reviews.

CONCLUSION

Stakeholder engagement was not general practice, except for CRD reviews, although it was more common in rapid reviews. Reporting factors, such as including an a priori study protocol and a conflict of interest statement should be considered in conjunction with involving stakeholders.

Frequency of Sexual Dysfunction in Patients Treated with Desvenlafaxine: A Prospective Naturalistic Study

Despite being clinically underestimated, sexual dysfunction (SD) is one of the most frequent and lasting adverse effects associated with antidepressants. Desvenlafaxine is an antidepressant (AD) with noradrenergic and serotonergic action that can cause a lower SD than other serotonergic ADs although there are still few studies on this subject. Objective: To check the frequency of SD in two groups of depressive patients: one group was desvenlafaxine-naïve; the other was made up of patients switched to desvenlafaxine from another AD due to iatrogenic sexual dysfunction. A naturalistic, multicenter, and prospective study of patients receiving desvenlafaxine (50–100 mg/day) was carried out on 72 patients who met the inclusion criteria (>18 years old and sexually active), who had received desvenlafaxine for the first time (n = 27) or had switched to desvenlafaxine due to SD with another AD (n = 45). Patients with previous SD, receiving either drugs or presenting a concomitant pathology that interfered with their sexual life and/or patients who abused alcohol and/or drugs were excluded. We used the validated Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX) to measure AD-related sexual dysfunction and the Clinical Global Impression Scale for psychiatric disease (CGI-S) and for sexual dysfunction (CGI-SD) at two points in time: baseline and three months after the commencement of desvenlafaxine treatment. Results: In desvenlafaxine-naïve patients, 59.2% of the sample showed moderate/severe sexual dysfunction at baseline, which was reduced to 44% at follow-up. The PSexDQ-SALSEX questionnaire total score showed a significant improvement in sexual desire and sexual arousal without changes in orgasmic function at follow-up (p < 0.01). In the group switched to desvenlafaxine, the frequency of moderate/severe SD at baseline (93.3%) was reduced to 75.6% at follow-up visit. Additionally, SD significantly improved in three out of four items of the SALSEX: low desire, delayed orgasm, and anorgasmia at follow-up (p < 0.01), but there was no significant improvement in arousal difficulties. The frequency of severe SD was reduced from 73% at baseline to 35% at follow-up. The CGI for psychiatric disease and for sexual dysfunction improved significantly in both groups (p < 0.01). There was a poor tolerability with risk of treatment noncompliance in 26.7% of patients with sexual dysfunction due to another AD, this significantly reduced to 11.1% in those who switched to desvenlafaxine (p = 0.004). Conclusion: Sexual dysfunction improved significantly in depressed patients who initiated treatment with desvenlafaxine and in those who switched from another AD to desvenlafaxine, despite this, desvenlafaxine treatment is not completely devoid of sexual adverse effects. This switching strategy could be highly relevant in clinical practice due to the significant improvement in moderate/severe and poorly tolerated SD, while maintaining the AD efficacy.

Synthesis of isotope – labeled selective PDE5 inhibitor sildenafil (UK 92480-10)

Sildenfil a vasodilating agent is a selective inhibitor of cyclic guanosine monophosphate – specific phosphodiesterase type 5 which is used for the treatment of male erectile dysfunction and pulmonary arterial hypertension. We presented a detailed approach for the synthesis of [2H3]sildenafil, [2H8]sildenafil and N-desmethyl [2H8]sildenafil. By using the approach we successfully synthesized [2H3]sildenafil, [2H8]sildenafil and N-desmethyl [2H8]sildenafil with good isotopic abundance.

Antidepressant Effect of Fraxinus rhynchophylla Hance Extract in a Mouse Model of Chronic Stress-Induced Depression

Prolonged exposure to stress can affect mood and cognition and lead to mood disorders. Research on stress-associated mood disorders is important in modern society as people are increasingly exposed to unavoidable stressors. We used a mouse model with 2 weeks of exposure to electric foot shock and restraint, to determine the effect of Fraxinus rhynchophylla Hance (FX) extract on chronic stress-induced depression. We measured the effect of FX extract using various physiological, behavioral, and biochemical measures. FX extract ameliorated chronic stress-induced body and relative liver weight loss and improved depressive-like behaviors in the open field and forced swim tests. In addition, plasma cortisol and serotonin levels in stress-induced mice following FX treatment were similar to normal mice, and the elevation of proinflammatory cytokines was prevented. Moreover, FX treatment increased the expression of phosphorylated cyclic adenosine-3′,5′-monophosphate response element-binding protein (pCREB)/brain-derived neurotrophic factor (BDNF). Further experiments confirmed the efficacy of FX extract by showing similar results using esculin and esculetin, compounds extracted from FX. Taken together, these results indicate that FX extract has an antidepressant effect on chronic stress-induced depression by associating signaling with neuroinflammation and neurogenesis.

Depression, Quality of Life, Physical Activity, and the Impact of Drugs on Sexual Activity in a Population-Based Sample, Ages 20-59 Years

Sexual quality of life is important for many individuals; therefore, this study examined the frequency of depression in a younger and middle-aged population-based sample, and the impact on physical activity, quality of life, and sexual activity, and the role of antidepressant and cardiac drugs on sexual function. The sample, ages 20 to 59 years, completed relevant items for depression, sexual activity, physical activity, quality of life, and drugs. Data were analyzed using descriptive statistics, Pearson correlations, t-tests, and analysis of variance. Those sexually active had lower mean depression scores and higher ratings of quality of life, while those sexually inactive had greater depression and took more drugs. Thorough assessment of drugs, depression, cardiac and other medical conditions, and interest and engagement in sexual activity should be routinely assessed in all patients, regardless of age.

Sexual functioning and experiences in young people affected by mental health disorders

The majority of mental disorders have their onset in late adolescence and early adulthood and this coincides with important stages of sexual development. Although sexual dysfunction is highly prevalent among people with mental health disorders, little is known about this topic among youth. This study aimed to evaluate the sexual functioning and subjective experience of sex in young people aged between 15 and 26 years attending a youth mental health service. One hundred and three participants were assessed with the Sexual Health Questionnaire, Sexual Functioning Questionnaire, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms and the Medication Adherence Rating Scale. There were 43 males, 52 females, and 8 transgender and gender diverse participants with a range of mental health disorders. Eighty (77.7%) had experienced consensual sexual intercourse. Ninety-nine (95.8%) endorsed at least one item of sexual dysfunction and clinical sexual dysfunction was present in 37 (38.9%) cases. Sexual dysfunction was associated with greater severity of general psychopathology, negative symptoms, antipsychotic use, lower antipsychotic medication adherence, and negative subjective experiences around sex. Addressing this sexual dysfunction in young people could lead to both an improvement in subjective experiences of sexual relationships and potentially improvement in adherence to treatment.

Female Sexual Dysfunction

Female sexual dysfunction can drastically diminish quality of life for many women. It is estimated that in the United States 40% of women have sexual complaints. These conditions are frequently underdiagnosed and undertreated. Terminology and classification systems of female sexual dysfunction can be confusing and complicated, which hampers the process of clinical diagnosis, making accurate diagnosis difficult. There are few treatment options available for female sexual dysfunctions, however, some interventions may be of benefit and are described. Additional treatments are in development. The development of clear clinical categories and diagnostic guidelines for female sexual dysfunction are of utmost importance and can be of great benefit for clinical and public health uses and disease-related research.

S-Adenosylmethionine (SAMe) for Neuropsychiatric Disorders: A Clinician-Oriented Review of Research

OBJECTIVE

A systematic review on S-adenosylmethionine (SAMe) for treatment of neuropsychiatric conditions and comorbid medical conditions.

DATA SOURCES

Searches were conducted in PubMed, EMBASE, PsycINFO, Cochrane Library, CINAHL, and Google Scholar databases between July 15, 2015, and September 28, 2016, by combining search terms for SAMe (s-adenosyl methionine or s-adenosyl-l-methionine) with terms for relevant disease states (major depressive disorder, MDD, depression, perinatal depression, human immunodeficiency virus, HIV, Parkinson's, Alzheimer's, dementia, anxiety, schizophrenia, psychotic, 22q11.2, substance abuse, fibromyalgia, osteoarthritis, hepatitis, or cirrhosis). Additional studies were identified from prior literature. Ongoing clinical trials were identified through clinical trial registries.

STUDY SELECTION

Of the 174 records retrieved, 21 were excluded, as they were not original investigations. An additional 21 records were excluded for falling outside the scope of this review. Of the 132 studies included in this review, 115 were clinical trials and 17 were preclinical studies.

DATA EXTRACTION

A wide range of studies was included in this review to capture information that would be of interest to psychiatrists in clinical practice.

RESULTS

This review of SAMe in the treatment of major depressive disorder found promising but limited evidence of efficacy and safety to support its use as a monotherapy and as an augmentation for other antidepressants. Additionally, preliminary evidence suggests that SAMe may ameliorate symptoms in certain neurocognitive, substance use, and psychotic disorders and comorbid medical conditions.

CONCLUSIONS

S-adenosylmethionine holds promise as a treatment for multiple neuropsychiatric conditions, but the body of evidence has limitations. The encouraging findings support further study of SAMe in both psychiatric and comorbid medical illnesses.

Sex based subgroup differences in randomized controlled trials: empirical evidence from Cochrane meta-analyses

OBJECTIVE

 To evaluate the frequency, validity, and relevance of statistically significant (P<0.05) sex-treatment interactions in randomized controlled trials in Cochrane meta-analyses.

DESIGN

 Meta-epidemiological study.

DATA SOURCES

 Cochrane Database of Systematic Reviews (CDSR) and PubMed.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Reviews published in the CDSR with sex-treatment subgroup analyses in the forest plots, using data from randomized controlled trials.

DATA EXTRACTION

 Information on the study design and sex subgroup data were extracted from reviews and forest plots that met inclusion criteria. For each statistically significant sex-treatment interaction, the potential for biological plausibility and clinical significance was considered.

RESULTS

 Among the 41 reviews with relevant data, there were 109 separate treatment-outcome analyses ("topics"). Among the 109 topics, eight (7%) had a statistically significant sex-treatment interaction. The 109 topics included 311 randomized controlled trials (162 with both sexes, 46 with males only, 103 with females only). Of the 162 individual randomized controlled trials that included both sexes, 15 (9%) had a statistically significant sex-treatment interaction. Of four topics where the first published randomized controlled trial had a statistically significant sex-treatment interaction, no meta-analyses that included other randomized controlled trials retained the statistical significance and no meta-analyses showed statistical significance when data from the first published randomized controlled trial were excluded. Of the eight statistically significant sex-treatment interactions from the overall analyses, only three were discussed by the CDSR reviewers for a potential impact on different clinical management for males compared with females. None of these topics had a sex-treatment interaction that influenced treatment recommendations in recent guidelines. UpToDate, an online physician-authored clinical decision support resource, suggested differential management of men and women for one of these sex-treatment interactions.

CONCLUSION

 Statistically significant sex-treatment interactions are only slightly more frequent than what would be expected by chance and there is little evidence of subsequent corroboration or clinical relevance of sex-treatment interactions.

Sexual Dysfunction Due to Psychotropic Medications

Sexual functioning is important to assess in patients with psychiatric illness as both the condition and associated treatment may contribute to sexual dysfunction (SD). Antidepressant medications, mood stabilizers, antipsychotics, and antianxiety agents may be associated with SD related to drug mechanism of action. Sexual adverse effects may be related to genetic risk factors, impact on neurotransmitters and hormones, and psychological elements. Effective strategies to manage medication-induced sexual dysfunction are initial choice of a drug unlikely to cause SD, switching to a different medication, and adding an antidote to reverse SD. Appropriate interventions should be determined on a clinical case-by-case basis.

Antidepressant-Induced Female Sexual Dysfunction

Because 1 in 6 women in the United States takes antidepressants and a substantial proportion of patients report some disturbance of sexual function while taking these medications, it is a near certainty that the practicing clinician will need to know how to assess and manage antidepressant-related female sexual dysfunction. Adverse sexual effects can be complex because there are several potentially overlapping etiologies, including sexual dysfunction associated with the underlying mood disorder. As such, careful assessment of sexual function at the premedication visit followed by monitoring at subsequent visits is critical. Treatment of adverse sexual effects can be pharmacological (dose reduction, drug discontinuation or switching, augmentation, or using medications with lower adverse effect profiles), behavioral (exercising before sexual activity, scheduling sexual activity, vibratory stimulation, psychotherapy), complementary and integrative (acupuncture, nutraceuticals), or some combination of these modalities.

Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review

Sexual dysfunction is an underdiscussed adverse effect to selective serotonin reuptake inhibitors (SSRIs) and may increase the risk for discontinuation and nonadherence to antidepressant pharmacotherapy. Given the prevalence of depression, health care providers should educate patients about SSRI-associated sexual dysfunction in order to promote patient awareness and medication adherence. This study evaluated primary literature from 1997 to 2015 to identify SSRI-related sexual side effects, therapeutic alternatives, and treatment strategies. The results indicate that paroxetine is associated with the greatest rate of sexual dysfunction among the SSRIs. Potential alternatives to SSRI treatment include bupropion, mirtazapine, vilazodone, vortioxetine, and serotonin-norepinephrine reuptake inhibitors. In the event that a subject responds solely to SSRIs but experiences unwanted sexual side effects, bupropion may be added as an adjunctive medication. Some limited evidence also suggests that saffron may reduce some aspects of sexual dysfunction, excluding ability to reach orgasm.

Comparing the Efficacy of Bupropion and Amantadine on Sexual Dysfunction Induced by a Selective Serotonin Reuptake Inhibitor

BACKGROUND

Antidepressant-induced sexual dysfunction (SD) is a common problem, associated with a significant risk of non-adherence. Selective Serotonin Reuptake Inhibitors (SSRIs) are associated with a substantial risk of SD. Only 10 % of patients show spontaneous improvement during follow up period.

OBJECTIVES

This study aimed to compare two proposed medication (bupropion vs. amantadine) in alleviating SD in patients treated with SSRIs.

PATIENTS AND METHODS

In a randomized, single-blinded, clinical trial in Iran, 46 patients were recruited based on DSM-IV-TR criteria and semi-structured interview. Then, they were randomized into two treatment groups using table of random numbers. Eight patients were excluded and finally 38 patients completed the study which lasted for 4 weeks. Twenty patients were given bupropion, 18 patients were randomly assigned to another group, and given amantadine. Patients were assessed with the Arizona sexual experience scale (ASEX) at baseline and 4 weeks after the treatment.

RESULTS

A total of 38 patients completed the study (18 patients in amantadine vs. 20 patients in bupropion).The mean ASEX scores gradually declined in both study groups during the trial. The reduction of ASEX score in bupropion group was more than that of amantadine group that was statistically significant. So, the addition of bupropion at higher doses appears to be more effective approach in comparison with amantadine.

CONCLUSIONS

These results provide empirical support for conducting a further study on comparing different add-on strategies for treating drug-induced SD.

The Circle of Lifestyle and Erectile Dysfunction

INTRODUCTION

Erectile dysfunction (ED) has been significantly associated with many chronic conditions including obesity, the metabolic syndrome, hypogonadism, diabetes mellitus, cardiovascular disease (CVD), lower urinary tract symptoms, and psychiatric/psychological disorders. ED is also a well-established predictor of CVD.

AIM

This review will focus on the association of ED with cardiovascular, metabolic, and cognitive conditions and discuss the effects of managing lifestyle factors in order to reduce the burden of ED and consequently outcomes in patients with chronic conditions.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1990.

MAIN OUTCOME MEASURES

Main outcome measures were improvements in sexual function.

RESULTS

A total of 59 reviews on the topic were evaluated.

CONCLUSIONS

Targeting several lifestyle factors associated with CVD/metabolic/cognitive disorders, e.g., smoking, alcohol consumption, obesity, and physical activity, can have significant benefits, leading to an improvement in ED as well as testosterone levels and consequently CVD. Kirby M. The circle of lifestyle and erectile dysfunction. Sex Med Rev 2015;3:169-182.

Prevalence and prescription of antidepressants in depression with somatic comorbidity in Asia: the Research on East Asian Psychotropic Prescription Patterns study

Background:

Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC.

Methods:

A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10^th revision. We listed 17 common chronic somatic diseases. Patients’ socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure.

Results:

Of the patients examined, 1240 were diagnosed with depression and 30% of them (n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%).

Conclusions:

SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.

Effect of Vortioxetine vs. Escitalopram on Sexual Functioning in Adults with Well-Treated Major Depressive Disorder Experiencing SSRI-Induced Sexual Dysfunction

INTRODUCTION

Sexual dysfunction is common with serotonergic antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), and does not resolve in most patients. Vortioxetine, an antidepressant with a multimodal mechanism of action, has shown low rates of sexual dysfunction in previous major depressive disorder (MDD) trials.

AIM

This study compared the effects of vortioxetine and escitalopram on sexual functioning in adults with well-treated MDD experiencing treatment-emergent sexual dysfunction (TESD).

METHODS

Participants treated with, and responding to, citalopram, paroxetine, or sertraline were randomized to switch to either vortioxetine (10/20 mg; n = 225) or escitalopram (10/20 mg; n = 222) for 8 weeks. Sexual function was assessed using the Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14), and antidepressant efficacy was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), Clinical Global Impressions (CGI) scale, and Profile of Mood States brief form (POMS-brief). Safety and tolerability were also assessed.

MAIN OUTCOME MEASURES

The primary endpoint was change from baseline in the CSFQ-14 total score after 8 weeks of treatment. The MADRS, CGI, and POMS-brief were used to assess antidepressant efficacy. Safety was assessed via adverse events, vital signs, electrocardiograms, laboratory values, weight, and physical examination findings.

RESULTS

Vortioxetine showed significantly greater improvements in CSFQ-14 total score (8.8 ± 0.64, mean ± standard error) vs. escitalopram (6.6 ± 0.64; P = 0.013). Benefits vs. escitalopram were significant on four of five dimensions and all three phases of sexual functioning assessed by the CSFQ-14 (P < 0.05). Antidepressant efficacy continued in both groups, with similar, but slight, improvements in MADRS and CGI scores. Vortioxetine and escitalopram had similar clinical efficacy profiles in this study, with safety profiles similar to previous trials. Nausea (n = 9, 4.0%) was the most common treatment-emergent adverse event leading to discontinuation of vortioxetine.

CONCLUSION

Switching antidepressant therapy to vortioxetine may be beneficial for patients experiencing sexual dysfunction during antidepressant therapy with SSRIs.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Female sexual dysfunction

Female sexual dysfunction is a common patient concern. After providing an overview regarding the various types of female sexual dysfunction, we will focus on history taking and treatment options for desire, arousal, orgasm, and pain disorders. Testosterone therapy and management of selective serotonin reuptake inhibitor-associated sexual dysfunction are reviewed. Treatments for atrophic vaginitis are appraised. Patient cases lead the discussion, providing the reader with clinically relevant information.

Erotic stimulus processing under amisulpride and reboxetine: a placebo-controlled fMRI study in healthy subjects

BACKGROUND

Impaired sexual function is increasingly recognized as a side effect of psychopharmacological treatment. However, underlying mechanisms of action of the different drugs on sexual processing are still to be explored. Using functional magnetic resonance imaging, we previously investigated effects of serotonergic (paroxetine) and dopaminergic (bupropion) antidepressants on sexual functioning (Abler et al., 2011). Here, we studied the impact of noradrenergic and antidopaminergic medication on neural correlates of visual sexual stimulation in a new sample of subjects.

METHODS

Nineteen healthy heterosexual males (mean age 24 years, SD 3.1) under subchronic intake (7 days) of the noradrenergic agent reboxetine (4 mg/d), the antidopaminergic agent amisulpride (200mg/d), and placebo were included and studied with functional magnetic resonance imaging within a randomized, double-blind, placebo-controlled, within-subjects design during an established erotic video-clip task. Subjective sexual functioning was assessed using the Massachusetts General Hospital-Sexual Functioning Questionnaire.

RESULTS

Relative to placebo, subjective sexual functioning was attenuated under reboxetine along with diminished neural activations within the caudate nucleus. Altered neural activations correlated with decreased sexual interest. Under amisulpride, neural activations and subjective sexual functioning remained unchanged.

CONCLUSIONS

In line with previous interpretations of the role of the caudate nucleus in the context of primary reward processing, attenuated caudate activation may reflect detrimental effects on motivational aspects of erotic stimulus processing under noradrenergic agents.

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.

La sexualité des patients bipolaires : étude comparative de la fonction sexuelle de patients bipolaires versus patients avec trouble dépressif et patients contrôles

Introduction

Des dysfonctions sexuelles sont classiquement décrites dans la dépression ou comme effet secondaire des psychotropes. Cependant, peu de travaux ont étudié le comportement sexuel des patients bipolaires stabilisés. L’objectif de cette étude est de comparer, en phases euthymique et dépressive, la fonction sexuelle des patients bipolaires aux patients avec trouble dépressif (TD) et aux sujets contrôles dans le but de stimuler l’intérêt et le débat dans ce domaine peu connu.

Méthodes

Les informations sur la fonction sexuelle ont été collectées à l’aide des questionnaires CSFQ-M et IIEF chez l’homme, CFSQ-F et BISF-W chez la femme. L’effet des psychotropes sur la sexualité a été évalué par le PRSexDQ.

Résultats

Quatre-vingt deux patients (26 bipolaires euthymiques, 28 TD euthymiques, 12 bipolaires déprimés, 16 TD déprimés) ont été inclus et 24 sujets contrôles. Les patients euthymiques bipolaires et avec TD ne diffèrent pas significativement à l’hétéro-évaluation par le CSFQ des sujets contrôles, bien qu’ils soient plus impactés dans leur sexualité. En effet, 38,5 % des patients bipolaires euthymiques, 39,3 % des patients avec TD euthymiques et 25 % des sujets contrôles ont une dysfonction sexuelle. Les hommes bipolaires euthymiques ont une fréquence significativement plus élevée de dysfonction érectile à l’IIEF (100 %) que les TD euthymiques (66,7 %) et les sujets contrôles (22,2 %) (p = 0,001). Parmi les patients traités par psychotropes, 35 % ont déclaré avoir un problème sexuel secondaire à leur traitement, dont 48 % en ont parlé spontanément avec leur médecin.

Conclusion

Nos résultats suggèrent l’importance d’évaluer les dysfonctions sexuelles des patients bipolaires y compris en phase euthymique. D’autres investigations sur des échantillons plus grands seraient nécessaires pour clarifier les aspects particuliers du comportement sexuel des patients bipolaires.

Caring for the breast cancer survivor’s health and well-being

The breast cancer care continuum entails detection, diagnosis, treatment, and survivorship. During this time, focus on the whole woman and medical concerns beyond the breast cancer diagnosis itself is essential. In this comprehensive review, we critically review and evaluate recent evidence regarding several topics pertinent to and specific for the woman living with a prior history of breast cancer. More specifically, we discuss the most recent recommendations for contraceptive options including long-acting reversible contraception and emergency contraception, fertility and pregnancy considerations during and after breast cancer treatment, management of menopausal vasomotors symptoms and vulvovaginal atrophy which often occurs even in young women during treatment for breast cancer. The need to directly query the patient about these concerns is emphasized. Our focus is on non-systemic hormones and non-hormonal options. Our holistic approach to the care of the breast cancer survivor includes such preventive health issues as sexual and bone health,which are important in optimizing quality of life. We also discuss strategies for breast cancer recurrence surveillance in the setting of a prior breast cancer diagnosis. This review is intended for primary care practitioners as well as specialists caring for female breast cancer survivors and includes key points for evidence-based best practice recommendations.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Bupropion and Escitalopram During Lactation

Objective: To report a case of seizure-like symptoms in an infant exposed to bupropion and escitalopram through breastfeeding. Case Summary: A 6.5-month-old female infant, breastfed by a mother treated with bupropion XL 150 mg/d and escitalopram 10 mg/d for depression, presented to our hospital with severe emesis and tonic seizure-like symptoms. The symptoms resolved with supportive therapy. Urine toxicology screen in the infant revealed bupropion and escitalopram. Bupropion, and its active metabolite, hydroxybupropion, were analyzed and quantified both in the infant’s serum and in the breast milk. Diagnostic workup for seizure etiologies was otherwise negative. After being asymptomatic for 48 hours, her discharge diagnosis was adverse events associated with bupropion and escitalopram in lactation. An objective causality assessment (Naranjo assessment) revealed that this adverse effect was probable. Discussion: The adverse events in our case were associated with serum concentrations of bupropion and hydroxybupropion that are lower than the reported therapeutic range, perhaps suggesting that infants, compared with adults, may have a higher susceptibility to the epileptogenic effects of bupropion and/or hydroxybupropion. Furthermore, although we do not have escitalopram serum concentrations, this drug interaction may have had a contributing role in this case, possibly because of cytochrome P4502D6 inhibition by bupropion and metabolites. Conclusion: As the number of reproductive-aged women requiring polytherapy to control their depression is increasing, further research is needed to establish the safety of combined antidepressants, such as selective serotonin reuptake inhibitors and bupropion, during lactation.

Antidepressant-like effect of nitric oxide synthase inhibitors and sildenafil against lipopolysaccharide-induced depressive-like behavior in mice

Inflammation, oxidative and nitrosative stress underlie depression being assessed in rodents by the systemic administration of lipopolysacharide (LPS). There is an increasing body of evidence of an involvement of nitric oxide (NO) pathway in depression, but this issue was not investigated in LPS-induced model. Thus, herein we evaluated the effects of NO-pathway-modulating drugs, named aminoguanidine, l-NAME, sildenafil and l-arginine, on the behavioral (forced swimming test [FST], sucrose preference [SPT] and prepulse inhibition [PPI] of the startle) and neurochemical (glutathione [GSH], lipid peroxidation, IL-1β) alterations in the prefrontal cortex, hippocampus and striatum as well as in BDNF levels in the hippocampus 24h after LPS (0.5mg/kg, i.p.) administration, a time-point related to depressive-like behavior. Twenty-four hours post LPS there was an increase in immobility time in the FST, decrease in sucrose preference and PPI levels accompanied by a decrease in GSH levels and an increase in lipid peroxidation, IL-1β and hippocampal BDNF levels suggestive of a depressive-like state. The pretreatment with the NOS inhibitors, l-NAME and aminoguanidine as well as sildenafil prevented the behavioral and neurochemical alterations induced by LPS, although sildenafil and l-NAME were not able to prevent the increase in hippocampal BDNF levels induced by LPS. The iNOS inhibitor, aminoguanidine, and imipramine prevented all behavioral and neurochemical alterations induced by LPS. l-arginine did not prevent the alterations in immobility time, sucrose preference and GSH induced by LPS. Taken together our results show that the NO-cGMP pathway is important in the modulation of the depressive-like alterations induced by LPS.