A comparative study of sexual dysfunction in schizophrenia patients taking aripiprazole versus risperidone

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

Antipsychotic medication can be often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) remains underestimated in clinical practice. However, psychotic patients consider sexual issues as important as first rank psychotic symptoms, and their disenchantment with TESD can lead to important patient distress and treatment drop-out. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antipsychotic 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: prescribing either aripiprazole or another dopaminergic agonist as a first option antipsychotic or switching to it whenever possible. Whenever this is not possible, adjunctive treatment with aripiprazole seems to also be beneficial for reducing TESD. Some antipsychotics, like olanzapine, quetiapine, or ziprasidone, have less impact on sexual function than others, so they are an optimal second choice. Finally, a variety of useful strategies (such as the addition of sildenafil) are also described where the previous ones cannot be applied, although they may not yield as optimal results.

Sexuality and sexual dysfunctions in older people: a forgotten problem

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

Using aripiprazole to reduce antipsychotic-induced hyperprolactinemia: meta-analysis of currently available randomized controlled trials

BACKGROUND

Hyperprolactinemia (HPL) is a common side effect of antipsychotic medications. Recent reports suggest that aripiprazole can ameliorate antipsychotic-induced HPL, but results are inconsistent and the single available systematic review only considered five studies.

AIM

Conduct an updated meta-analysis of all randomized controlled trials (RCTs) about the efficacy and safety of aripiprazole as an adjunctive treatment for antipsychotic-induced hyperprolactinemia.

METHODS

English and Chinese databases were searched for RCTs about the use of aripiprazole in treating antipsychotic-induced HPL published by January 20, 2015. Studies were selected using pre-defined inclusion and exclusion criteria. The Cochrane Risk of Bias tool was used to evaluate risk of biases, the Cochrane GRADE measure was used to assess the quality of evidence, and Review Manager 5.3 software was used for data analysis.

RESULTS

A total of 21 studies, 19 of which were conducted in mainland China, were included in the analysis. Meta-analysis of data from 8 of the studies with a pooled sample of 604 individuals found that compared to the control condition adjunctive aripiprazole significantly increased the proportion of participants who experienced HPL recovery (risk ratio [RR]=19.2, 95%CI=11.0-33.5). The proportion who experienced any adverse effect during follow-up did not differ between the two groups, but the aripiprazole group was more likely to report somnolence (RR=2.76, 95%CI=1.34-5.69) and headaches (RR=2.31, 95%CI=1.08-4.92). High-dose aripiprazole (>5mg/day) was more effective than low-dose (<5mg/day) aripiprazole (RR=30.0, 95%CI=10.2-120.7 v. RR=15.1, 95%CI=8.1-28.1), but this difference was not statistically significant. The risk of bias in the studies was rated as 'high' in 6 of the studies and 'unclear' in 15 studies, and the quality of evidence was rated as 'high' for only 7 of the 57 outcome measures assessed.

CONCLUSIONS

This study systematically reviewed and evaluated all relevant RCTs and found that adjunctive aripiprazole is effective and safe to use in the treatment of antipsychotic-induced HPL. However, the low quality of some of the studies, the incomplete methodological information provided for most of the studies, and the relatively short follow-up time of the studies raises question about the validity of the results. Further work that resolves these methodological and reporting issues is needed.

The influence of atypical antipsychotic drugs on sexual function

Human sexuality is contingent upon many biological and psychological factors. Such factors include sexual drive (libido), physiological arousal (lubrication/erection), orgasm, and ejaculation, as well as maintaining normal menstrual cycle. The assessment of sexual dysfunction can be difficult due to the intimate nature of the problem and patients' unwillingness to discuss it. Also, the problem of dysfunction is often overlooked by doctors. Atypical antipsychotic treatment is a key component of mental disorders' treatment algorithms recommended by the National Institute of Health and Clinical Excellence, the American Psychiatric Association, and the British Society for Psychopharmacology. The relationship between atypical antipsychotic drugs and sexual dysfunction is mediated in part by antipsychotic blockade of pituitary dopamine D2 receptors increasing prolactin secretion, although direct correlations have not been established between raised prolactin levels and clinical symptoms. Variety of mechanisms are likely to contribute to antipsychotic-related sexual dysfunction, including hyperprolactinemia, sedation, and antagonism of a number of neurotransmitter receptors (α-adrenergic, dopaminergic, histaminic, and muscarinic). Maintaining normal sexual function in people treated for mental disorders can affect their quality of life, mood, self-esteem, attitude toward taking medication, and compliance during therapy.

Adjunctive treatment with aripiprazole for risperidone-induced hyperprolactinemia

BACKGROUND

Antipsychotics have been used for more than 50 years in the treatment of schizophrenia and many other psychiatric disorders. Prolactin levels usually increase in patients treated with risperidone. Aripiprazole, which has a unique effect as an antipsychotic, is a D2 receptor partial agonist. It is an atypical antipsychotic with limited extrapyramidal symptoms. Since it acts as an antagonist in hyperdopaminergic conditions and as an agonist in hypodopaminergic conditions, it does not have adverse effects on serum prolactin levels. The present study aimed to investigate the effect of aripiprazole on risperidone-induced hyperprolactinemia.

METHODS

This before-and-after clinical trial was performed in 30 patients. Baseline prolactin levels were measured in all patients who were candidates for treatment with risperidone. In subjects with elevated serum prolactin, aripiprazole was added to their treatment. Serum prolactin levels were measured during the first week, second week, and monthly thereafter for at least 3 months or until prolactin levels became normal. The data were analyzed using Stata version 11 software. Survival analysis and McNemar's test were also performed.

RESULTS

The mean age of the participants was 30.8 years. Prolactin levels normalized in 23 (77%) participants during the study, and menstrual disturbances normalized in 25 (83.3%). Prolactin levels normalized in most patients between days 50 and 110. The median time to recovery based on normalization of prolactin was 84 days. Psychotic symptoms were present in 26 subjects at baseline, but in only two by the end of the study.

CONCLUSION

The results of this study confirm the effects of aripiprazole in reducing risperidone-induced hyperprolactinemia and its sequelae. Aripiprazole also led to significant improvements in psychotic symptoms when compared with those present prior to treatment with aripiprazole.

Sexual dysfunction in outpatients with schizophrenia in Turkey: a cross-sectional study

BACKGROUND

Sexual dysfunction is one of several factors related to medication compliance in patients taking antipsychotic medication but the magnitude of this problem is unknown.

AIM

Compare the self-reported sexual functioning of clinically stable patients with schizophrenia taking antipsychotic medication to that of healthy controls using the Turkish version of the 5-item Arizona Sexual Experience Scale (ASEX). This scale, which has previously been validated in Turkey, assesses 5 components of sexual function: sex drive, sexual arousal, vaginal lubrication/penile erection, ability to achieve orgasm, and satisfaction with orgasm.

METHODS

The Scale for the Assessment of Positive Symptoms, the Scale for Assessment of Negative Symptoms, and ASEX were administered to 101 clinically stable outpatients with schizophrenia (38 females and 63 males). The ASEX was also administered to 89 control subjects (41 females and 48 males) without a history of mental illness. Respondents were classified as having sexual dysfunction if ASEX total score (range 5-30) >18, if any ASEX item score (range 1-6) ≥ 5, or if 3 or more ASEX items ≥4.

RESULTS

Male patients with schizophrenia have significantly more self-reported sexual dysfunction than healthy controls (46% vs. 8%). The prevalence of sexual dysfunction is higher in female patients than in male patients (68% vs. 46%), but it was also very high in healthy female controls (68%), so the sexual dysfunction of female patients cannot be attributed to their illness or to the medications they are taking. Within the patient group, there was no significant relationship between the severity of positive or negative symptoms and the severity of sexual dysfunction, and the severity of sexual function was not different between patients taking first-generation or second-generation antipsychotic medications.

CONCLUSIONS

The very different findings by gender in Turkey highlights the importance of assessing location-specific and gender-specific sexual norms when trying to assess the role of mental illness and medications on sexual functioning. Prospective studies are needed to distinguish the relative importance of cultural norms, the schizophrenic illness, and the use of antipsychotic medication in the etiology and course of sexual dysfunction among individuals with schizophrenia.