Digest of recent discussions on ISSM mail (Sept 2009 - Dec 2009)

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PRITHY RAMLACHAN

Lack of Desire and SSRI Use

2 Sep 2009:  14 messages

1

I have a 40 yr old accountant who has been on SSRIs for 10 years. He has found that fluoxetine 40 mg works best for him and no other drug (having tried them all, incl. Wellbutrin). His work carries very high stress. Despite psychological and medical support, his desire for sex has remained low. His partner too is very supportive and really wants the marriage to work. They have 2 children aged 3 and 6. Bloods were normal and included T and PRL. His SHIM score was 22 and he has not had any ED. The couple is now desperate and I have run out of therapeutic approaches. Your valuable inputs will be appreciated.

Prithy Ramlachan (drprithy@medis.co.za)

2

I can think of a few things to try: (1) Do he and his wife ever get to plan `get away’ weekends where they can focus on their ability to relax and have fun together again ? (2) Has he tried any courses in stress reduction, usually including guided relaxation, yoga, tai chi, etc. to quiet his anxiety/stress and allow for more normal sexual function? (3) Does he masturbate regularly? I have read in the medical literature that increased masturbation can increase testosterone levels and make him want to make love with his wife more often. More frequently than not, with a busy work schedule and two small children, this is a common state, which is why I always recommend to couples to make a `date night’ weekly, and a monthly `get away’ commitment to themselves and their marriage. I am a clinical and health psychologist in California. Hope this helps.

 Linda Banner (llbanner@earthlink.net)

3

There are several ways to deal with this problem. If you cannot substitute with other anti-depressants, you could: (a) Decrease the Prozac. This may be an SSRI side effect. (b) Add Wellbutrin XR 300mg am daily. I see no other solution.

Pierre Assalian (pierreassalian@3web.net)

4

Is he able to take a 'drug holiday’? - where he stops the SSRI before he plans sex in order to have a better response, and this in turn might help him want to do it more often.

Linda Banner (llbanner@earthlink.net)

5

I wonder if in our efforts to help everyone achieve 'idealized' sexual behavior patterns we forget that the normal bell curve has low functioning individuals in it who are normal. If all avenues have been

explored, I've found that it sometimes helps to explain to the couple that it can be normal to have a low sex drive, and that this is not necessarily malfunction, illness, or dislike of partner or sexual activity. Then I try to engage the lower drive person into seeing couple sexual activity as just another couple activity. If important to the loved partner then one must try to accommodate their needs. Plan to make time and make the sexual experience as good as possible for oneself by including elements in it that one does enjoy. It is important to give generously. Rewards come back in other aspects of the relationship.

Margaret Redelman (redels@medemail.com.au)

6

This is really encouraging.

P. Ramlachan (drprithy@medis.co.za)

7

I am wondering whether your patient's lack of desire is at all SSRI-related or not. What exactly is the couple's desperation about? If the wife really wants the marriage to work, is she putting pressure on him (deliberately or inadvertently) to have intercourse? Does he experience her ‘support’ as a reminder of yet another role or task he is expected to fulfill in his stressful life? Does he masturbate and/or prefer sex on his own? Did the couple's sexual relationship decline after the birth of their children? How does he feel about fatherhood? Do they want more children? There are many possibilities, and I would explore the couple's expectations of life, each other, and sex.

Susan Pacey (susanpacey@yahoo.com)

8

I find that encouraging the low desire partner to experiment with fantasy is often helpful.  Long-term use of SSRIs combined with sexual familiarization in a long-term relationship often requires some work to increase desire levels. I presume he has morning/night time erections?  A little imagination and the recommendation of a good book can often help.

Carol Featherstone (carol.featherstone@btinternet.com)

9

Lack of desire does not imply lack of arousal. If a man (or woman) is on an SSRI, adding a PDE5I like 5mg tadalafil per day gives a constant blood level and obviates the need to think about when to take the medication. It also enables the couple to get into genital arousal phase reasonably easily. They, of course, have to make an intellectual decision that they want engage in sex. Teaching mindfulness helps as they then are accepting of moment to moment sensory change without too much cognitive feedback/interference.

David Goldmeier (David.Goldmeier@imperial.nhs.uk)

10

I have several thoughts to share on the subject that I hope will be helpful.  

First, I am assuming that you have established a relationship with the gentleman that will allow him to be absolutely candid about his sexual preferences, both in terms of orientation and activities, so that any discordance in that area may be addressed.  From your brief description, it seems that the Prozac is being unfairly blamed for causing his lack of desire for sex, but that is a rare side effect if it occurs at all.  Sex is initiated for a number of reasons, ranging from lust, desire to express romantic love, to an accessible way of self medicating for depression or anxiety.  SSRIs may sometimes remove an important reason for a given patient to initiate sexual contact, though for others it is just as likely to remove an obstacle to initiation of sexual contact. It sounds as if your patient may have an actual aversion to sex, at least with this partner for whatever reason, or in general, that has become more dominant than his urge to have sex.  You may find some clues by asking him about his masturbation habits and what he would describe as an ideal fantasy sexual encounter. Another fruitful avenue is to ask about his spouse’s reactions to his sexual failures, whether they are taken as a criticism of her or as a ‘challenge’ (positive sense intended here), with a playful response that provides gratification without intercourse being necessary, or as a disappointment.  Frequent negative reactions may create an (very difficult to overcome) expectation of failure and an aversion to sexual contact. 

Second, if there is a medical reason for his lack of interest, you may find that DHEA as a supplement may be helpful, (males 50-100mg/day) but often patients who are in the low end of normal will profit from a low dose of testosterone propionate gel daily.  I have found that the addition of low dose bupropion (50-150mg) is sufficient to relieve the ejaculatory inhibition of SSRIs. Thyroid investigations are also occasionally useful.

Richard T Wynn (Richard.Wynn@carolinashealthcare.org)

11

I am very surprised by this email. Prozac causes low sexual desire. It is a common problem. It is NOT rare.

Pierre Assalian (pierreassalian@3web.net)

12

I agree. Antidepressants cause loss of desire very often.

 Anup Dhir (dranupdhir@hotmail.com)

13

We see many, many cases world-wide on our bulletin boards where SSRIs cause sexual problems and where Wellbutrin has seemed to help resolve many of those problems. The boards are linked at all my sites.

Stan Felder (stan.felder@vibranceassociates.com)

14

Dear colleagues, in my experience, the effect of antidepressant drugs is variable, and depends on the cause of depression. The question is: Is depression caused by a lack of desire ? Or other sexual problems? Or, on the contrary, is the lack of desire caused by depression? I’ve seen many patients with sexual problems successfully treated with Prozac therapy. I’ve also seen many other patients with low testosterone and high prolactin caused by antidepressant drugs and consequently with lack of desire. Perhaps we can also treat patients with testosterone. It is not simple to find a balance.

I find the proposal of giving the patient Wellbutrin interesting.

Ida Bianchessi (idabianchessi@libero.it)