Letters to the Editor
Antidepressant-Induced Sexual Dysfunction Treated with Vardenafil
Dear Editor:
The selective serotonin reuptake inhibitors (SSRIs) are used to treat a wide array of psychiatric conditions (1). Patients experience fewer side effects, compared with the older antidepressants (2). However, sexual dysfunction may occur in up to 75% of patients taking antidepressants (3). I report a case in which a patient taking sertraline experienced decreased to almost nonexistent erections, with a return to his baseline functioning following treatment with vardenafil. To my knowledge, this is the first reported case of vardenafil used to treat antidepressant-induced sexual dysfunction.
Mr A, aged 32 years, was diagnosed with dysthymic disorder according to DSM-IV criteria. He was in good health and did not use alcohol, tobacco, or illicit substances. He had been married for 6 years and described his marriage as excellent. He was active in psychotherapy and referred for medication. He agreed to a trial of sertraline started at 50 mg dialy and titrated to 150 mg at 3 weeks’ time. I obtained a baseline sexual history prior to his starting the sertraline and informed him that the medication could affect his sexual functioning. Mr A stated that he understood and agreed to a trial. Within 2 weeks of initiating sertraline, he began to notice diminished erections but no change in libido. Although he was discouraged about this side effect, he had noted an improvement in his dysthymic symptoms and desired to remain on sertraline. He was interested in adding bupropion sustained release (SR) in an attempt to improve sexual functioning. He began bupropion SR 100 mg daily with no improvement at 1 week, and the dosage was increased to 150 mg daily, with no success after 1 week. The bupropion SR was increased to 200 mg daily; again, there was no success at the end of 1 week, and it was discontinued. A trial of vardenafil 10 mg taken 30 minutes prior to sexual activity was initiated, with noted improvement within 3 days of initiation. Mr A has on occasion taken it 15 minutes prior to sexual activity, with positive results. The patient tolerated the medication without any noted side effects. Mr A has returned to his baseline sexual functioning and is fully satisfied with the quality of his erections.
As noted, a baseline sexual functioning history was taken prior to initiating treatment with sertraline, and the patient was informed about the possibility of sexual dysfunction. These factors facilitated discussion of this commonly occurring problem in patients treated with antidepressants. Taking this history also allows clinicians to distinguish between an antidepressant side effect or a preexisting condition that can occur in up to 31% of men (4). Clinicians frequently are called upon to manage sexual dysfunction as a result of antidepressants. According to a recent survey by Dording and others, 43% of psychiatrists add bupropion to existing medication (5). Bupropion SR has been shown to be beneficial at dosages between 100 and 200 mg taken once daily, with most improvement noted within the first 2 weeks of treatment (6). My patient did not benefit from this strategy and required an alternate agent. I chose vardenafil, a new a phosphodiesterase 5 (PDE5) inhibitor, on the basis of work by Fava and others (7) and Nurnberg and others (8). These authors successfully treated patients suffering from antidepressant-induced sexual dysfunction with sildenafil, a PDE5 inhibitor. Vardenafil is a highly selective PDE5 inhibitor used to treat erectile dysfunction (9). It is generally well tolerated and significantly enhances sexual functioning (10). Improvement in other aspects of sexual functioning, including confidence, orgasmic functions, and satisfaction, were noted in a recent review of vardenafil (11). Although my patient experienced the successful return of his pretreatment sexual functioning, caution is advised when interpreting case report results. Vardenafil may be valuable in expanding treatment options for clinicians managing the common side effect of antidepressant-induced sexual dysfunction, but further controlled studies will be needed.
References
1. Rosenbaum JF, Tollefson GD. Fluoxetine. In: Schatzberg AF, Nemeroff CB, editors. The American Psychiatric Press textbook of psychopharmacology. 3rd ed. Washington (DC): American Psychiatric Press; 2003. pp 231–46.
2. Boland RJ, Keller MB. Treatment of depression. In: Schatzberg AF, Nemeroff CB, editors. The American Psychiatric Press textbook of psychopharmacology. 3rd ed. Washington (DC): American Psychiatric Press; 2003. p 847–64.
3. Segraves RT. Antidepressant-induced sexual dysfunction. J Clin Psychiatry 1998;59(Suppl 4):48–54.
4. Lauman EO, Palik A, Rosen RC. Sexual dysfunction in the United States. JAMA 1999;281:537–44.
5. Dording CM, Mischoulon D, Petersen TJ, Kornbluh R, Gordon J, Nierenberg AA, and others. The pharmacologic management of SSRI-induced side effects: a survey of psychiatrists. Ann Clin Psychiatry 2002:14:143–7.
6. Gitlin MJ, Suri R, Altshuler L, Zuckerbrow-Miller J, Fairbanks L. Bupropion sustained release as a treatment for SSRI-induced sexual side effects. J Sex Marital Ther 2002;28:131–8.
7. Fava M, Rankin MA, Alpert JE, Nierenberg AA, Worthington JJ. An open trial of oral sildenafil in antidepressant-induced sexual dysfunction. Psychother Psychosom 1998;67:328–31.
8. Nurnberg HG, Lauriello J, Hensley PL, Parker LM, Keith SJ. Sildenafil for iatrogenic serotonergic antidepressant medication-induced sexual dysfunction in 4 patients. J Clin Psychiatry 1999;60(1):33–5.
9. Keating GM, Scott LJ. Vardenafil: a review of its use in erectile dysfunction. Drugs 2003;63:2673–703.
10. Goldstein I, Young JM, Fischer J, Bangerter K, Segerson T, Taylor T. Vardenafil, a new phosphodiesterase type 5 inhibitor, in the treatment of erectile dysfunction in men with diabetes: a multicenter double-blind placebo-controlled fixed-dose study. Diabetes Care 2003;26:777–83.
11. Hellstrom WJ. Vardenafil: a new approach to the treatment of erectile dysfunction. Curr Urol Rep 2003;4:479–87.
Tim Berigan, MD
Vail, Arizona
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