The impact of severe mental disorders and psychotropic medications on sexual health and its implications for clinical management

Abstract

Sexual dysfunction often accompanies severe psychiatric illness and can be due to both the mental disorder itself and the use of psychotropic treatments. Many sexual symptoms resolve as the mental state improves, but treatment‐related sexual adverse events tend to persist over time, and are unfortunately under‐recognized by clinicians and scarcely investigated in clinical trials. Treatment‐emergent sexual dysfunction adversely affects quality of life and may contribute to reduce treatment adherence. There are important differences between the various compounds in the incidence of adverse sexual effects, associated with differences in mechanisms of action. Antidepressants with a predominantly serotonergic activity, antipsychotics likely to induce hyperprolactinaemia, and mood stabilizers with hormonal effects are often linked to moderate or severe sexual dysfunction, including decreased libido, delayed orgasm, anorgasmia, and sexual arousal difficulties. Severe mental disorders can interfere with sexual function and satisfaction, while patients wish to preserve a previously satisfactory sexual activity. In many patients, a lack of intimate relationships and chronic deterioration in mental and physical health can be accompanied by either a poor sexual life or a more frequent risky sexual behaviour than in the general population. Here we describe the influence of psychosis and antipsychotic medications, of depression and antidepressant drugs, and of bipolar disorder and mood stabilizers on sexual health, and the optimal management of patients with severe psychiatric illness and sexual dysfunction.

Psychosexual medicine and psychiatry are overlapping disciplines, and there is much interest among psychiatrists in improving their theoretical knowledge and clinical skills in addressing sexual dysfunction.

Adverse sexual effects are frequent with commonly prescribed psychotropic drugs, such as selective serotonin reuptake inhibitors (SSRIs) and prolactin‐raising antipsychotics. Deterioration of libido, and arousal and orgasmic dysfunction are frequent disturbances, adversely affecting quality of life. Sexual dysfunction tends to be under‐reported and under‐recognized and systematic enquiries are needed to assess the incidence, severity and impairment associated with untoward sexual effects of psychotropic drugs.

Recent developments in the field include recognition of the beneficial effects of a healthy sexual life in patients with severe mental disorders; the need to incorporate this aspect in assessment and management within routine clinical practice1; a more in‐depth understanding of the adverse effects of psychotropic drugs on sexual life; and more detailed guidelines about how to manage sexual dysfunction in these already deeply disadvantaged people.

PSYCHOSIS AND SEXUAL DYSFUNCTION

Influence of psychosis on sexuality

Disturbances in sexual functioning in patients with schizophrenia and related disorders may arise from multiple factors, including negative symptoms (apathy, avolition), depressive symptoms, and adverse effects of some antipsychotics2. People diagnosed with psychotic disorders often have unmet needs relating to sexuality and intimacy, which impact negatively on recovery and the ability to lead a fulfilling life. Psychosis tends to be a barrier to the expression of sexuality and intimacy3.

It can be difficult to study sexuality in some cultures. However, a questionnaire study found a high frequency (70%) of sexual dysfunction in female patients with schizophrenia in India4. An investigation of sexual dysfunction in Chinese patients with schizophrenia found a similar frequency5. A Korean study found that sexual satisfaction was negatively correlated with length of illness in schizophrenic patients receiving risperidone6.

Despite what many clinicians believe, adequate sexual expression can improve overall well‐being, restore confidence and dignity, and allow patients with psychosis to overcome problems such as social disengagement and stigma. A study comparing sexual life in patients with psychosis and healthy controls found that sexual activity improved self‐esteem, feelings of acceptance and additionally sleep, anxiety and mood in patients in a similar way as in controls7. Sexual relationships were considered highly relevant by the vast majority of patients, who were more concerned about affection and companionship than physical pleasure. Only 13% were able to maintain a steady partner and only 20% had coital activity, but more than half believed that sexual life was still important to them.

Some psychotic patients put their health at risk through sexually transmitted diseases, including HIV, by not using condoms8. This emphasizes the need to systematically evaluate potentially risky behaviours in these patients, and provide education designed to promote safer sexual practices.

The presence of psychotic symptoms should not be incompatible with healthy sexual relationships. Whilst not all patients attach the same importance to sexual life, many young patients who previously had satisfactory sexual relationships are not prepared to lose this aspect of interpersonal functioning after diagnosis and start of pharmacological treatment. Many young male patients who drop out from antipsychotic medication report the onset of sexual dysfunction – especially erectile and orgasm problems in the short term and loss of desire over the longer term – as reasons for stopping treatment.

Influence of treatment of psychosis on sexuality

Sexual dysfunction is common during short‐ and long‐term treatment with antipsychotics, and is associated with a considerable impact on quality of life in adult and adolescent patients9. Depending on the measurement method, it affects between 38 and 86% of patients10, 11, 12, 13, including remitted ones and those experiencing a first episode of schizophrenia14, 15.

Symptoms include decreased desire, difficulties in sexual arousal; problems with penile erection, vaginal lubrication and orgasm; and reduced sexual satisfaction. The most frequent complaints in clinical practice include orgasmic and erectile difficulties in the short term and decreased desire in the longer term. The most frequent pattern in male patients is the combination of lowered libido with erectile dysfunction, which is usually unacceptable16, 17.

Several factors are involved, including blockade of dopaminergic activity, hyperprolactinemia, and alpha‐1 receptor blockade18. Hyperprolactinemia and related hypogonadism seems to be strongly implicated in sexual dysfunction, being sometimes accompanied by infertility, amenorrhea, gynecomastia and galactorrhoea19, 20. Higher plasma prolactin levels are associated with higher rates of erectile and ejaculatory dysfunction in patients with a first episode of schizophrenia16.

Dopamine‐blocking and hyperprolactinaemia‐inducing antipsychotics such as haloperidol, risperidone, paliperidone and amisulpride are more likely to be associated with decreased libido and/or arousal difficulties. By contrast, aripiprazole, quetiapine, olanzapine and ziprasidone have been linked to low rates of sexual dysfunction (16‐27%) in open studies21, 22 and in meta‐analyses23. A lower risk for prolactin elevation and sexual dysfunction was found with aripiprazole once‐monthly when compared to long‐acting paliperidone, this difference being associated with a greater improvement in quality of life24.

Erectile problems with antipsychotic drugs may be specifically related to endothelial dysfunction linked to decreased nitric oxide production due to inhibition of endothelial nitric oxide synthetase25 and vasoconstriction from beta 2‐adrenergic effects26.

Sexual dysfunction tends to be under‐estimated in psychotic patients, for several reasons including lack of confidence in health providers, shame, cultural difficulties and lack of interest by psychiatrists. The extent of sub‐optimal communication about sexuality in patients with a psychotic disorder assessed within routine clinical practice is considerable, affecting 50‐73% of those with sexual dysfunction13. Lack of adequate discussion is more common in female patients, of whom 80% reported not to have discussed sexual function with their mental health care providers27. Cross‐cultural factors are important, as a recent survey conducted in India found that the majority (73.2%) of professionals did not enquire about sexual problems in routine clinical settings, many admitting that they lacked expertise28. Furthermore, many patients with severe mental illness have received little sexual education, and have insufficient time allowed for the discussion of emotional relationships in general.

Reliable comparisons between antipsychotics are difficult, due to the wide variety of assessment techniques29. Only six questionnaires have been validated to assess sexual dysfunction in psychotic patients. Following a systematic review of psychometric and other properties, only the Antipsychotics and Sexual Functioning Questionnaire (ASFQ)30, the Changes in Sexual Functioning Questionnaire (CSFQ)31, and the Psychotropic‐Related Sexual Dysfunction Questionnaire (PRSexDQ‐SALSEX)32 were found to address all aspects of sexual functioning, making them preferable for clinical practice and research33.

Young men with psychosis consider impairment of sexual function as the most important adverse effect of antipsychotic medication affecting treatment adherence34, 35. In a US‐based nationwide survey of patients with schizophrenia, side effects relating to prolactin and other endocrine disturbance were significantly related to lower levels of treatment adherence36. Again, cross‐cultural factors are probably important, as an investigation in India, using the PRSexDQ‐SALSEX questionnaire, found that most patients (91.7%) reported good to fair tolerance of any sexual side effects28.

Management of treatment‐induced sexual dysfunction in psychotic patients

Decreasing the dosage, switching the antipsychotic, add‐on strategies with a dopamine agonist, addition of aripiprazole, or use of a phosphodiesterase‐5 (PDE‐5) inhibitor have all shown some beneficial effects.

However, reducing antipsychotic dosage may sometimes engender relapse, so switching to another antipsychotic medication may be preferable in managing many patients with treatment‐emergent sexual dysfunction. Switching to aripiprazole was found successful in several studies, improving delayed ejaculation/orgasm in some naturalistic settings37, normalizing prolactin levels38, and maintaining the clinical efficacy of previous treatment39. A careful switching protocol is needed to avoid the reappearance of troublesome psychotic symptoms40. Adjunctive aripiprazole reduces antipsychotic‐induced hyperprolactinaemia41 and sexual dysfunction42. When differing strategies were compared, switching to aripiprazole monotherapy was found superior to the addition of aripiprazole in patients with schizophrenia. Positive results have also been reported after switching to quetiapine or ziprasidone in 3 to 6‐month prospective studies43, 44.

A Cochrane review of randomized controlled trials involving patients with schizophrenia and sexual dysfunction found that sildenafil can improve erectile function and sexual satisfaction when compared with placebo, and that switching to olanzapine and quetiapine may have a positive impact on sexual functioning in male and female patients45.

A recent multidisciplinary consensus process concluded that switching an antipsychotic to a non‐hyperprolactinaemic one is probably the best way to ameliorate antipsychotic‐related sexual dysfunction, with aripiprazole being the first‐line option46. Systematic screening for sexual dysfunction is strongly recommended47. Psychosocial interventions – i.e., psychoeducation, supportive psychotherapy and psychiatric rehabilitation – also play a crucial role, with the restoration of sexual function as an achievable recovery target3. Compounds with a lower frequency of sexual dysfunction should be considered as potential first‐line options in psychotic patients with an active and satisfactory sexual life.

DEPRESSION AND SEXUAL DYSFUNCTION

Influence of depression on sexuality

Depressive symptoms are strongly associated with sexual difficulties and dissatisfaction, and screening for depression has been recommended in patients with sexual dysfunction and chronic illness48. Conversely, depressed patients should be screened for sexual dysfunction49. A longitudinal study found the prevalence of sexual problems in depressed individuals to be approximately twice the prevalence in controls (50% vs. 24%)50.

Recurrent depressive disorder seems especially associated with sexual problems. For example, the US Study of Women's Health Across the Nation found that women with recurrent depressive episodes (but not those who experienced only a single episode) were more likely to report problems in sexual arousal, physical pleasure and emotional satisfaction, when compared to controls51. The Netherlands Mental Health Survey and Incidence Survey‐2 found that the presence of 12‐month mood disorders was associated with a significantly lower likelihood of reported sexual satisfaction52.

Depression affects mood, energy, interest, capacity for pleasure, self‐confidence and self‐esteem, so it should be expected that depression lowers sexual interest and satisfaction; this effect seems more marked in younger patients53. Depressive symptoms commonly coexist with anxiety symptoms, which are also associated with reported sexual difficulties and dissatisfaction54, 55, and with obsessive‐compulsive symptoms, themselves associated with loss of sexual pleasure and sexual dissatisfaction56, 57. But depression can exert adverse effects on all aspects of the sexual response, including the ability to achieve and maintain penile erection, to attain adequate vaginal lubrication, and to achieve ejaculation or orgasm58. Most antidepressants can exert unwanted effects on sexual function and satisfaction, but the adverse effects of depression itself (and of comorbid mental or physical disorders and concomitant medication) are often overlooked when considering the management of patients with sexual dysfunction associated with antidepressant treatment.

Patients and health professionals can feel embarrassed to mention and discuss sexual symptoms, and consultation and recognition rates in primary medical care are low51, 59, 60. Unfortunately, reliance on spontaneous reports of sexual adverse events leads to a substantial under‐estimate of sexual problems in depressed patients61, 62. Screening and severity questionnaires can facilitate recognition and assessment, but cannot fully substitute for a comprehensive but sensitive assessment. The Arizona Sexual Experiences Scale (ASEX)63, the CSFQ31, the PRSexDQ‐SALSEX³² and the Sex Effects Scale (SexFX)64 all have adequate key psychometric properties (validity, reliability and sensitivity to change) and have been recommended for assessing sexual function and satisfaction in depressed patients before and during antidepressant treatment62.

Influence of treatment of depression on sexuality

It has proved difficult to accurately identify the incidence of treatment‐emergent sexual dysfunction (encompassing both the worsening of pre‐existing problems and the development of new sexual difficulties in previously untroubled patients) during antidepressant treatment. Two international studies of the prevalence of sexual dysfunction in depressed patients undergoing treatment with either an SSRI or serotonin‐noradrenaline reuptake inhibitor (SNRI), which both accounted for self‐reported sexual problems before starting treatment and the potential adverse effects of concomitant medication, found that 27‐65% of female and 26‐57% of male patients experienced either a worsening of pre‐existing difficulties or the emergence of new sexual difficulties in the early weeks of treatment65, 66.

An early meta‐analysis which included studies with differing designs (incorporating open‐label, double‐blind, cross‐sectional and retrospective investigations) found that “treatment‐emergent sexual dysfunction” was no more common with the antidepressants agomelatine, amineptine, bupropion, moclobemide, mirtazapine or nefazodone than with placebo. All other antidepressants were significantly more likely than placebo to be associated with “sexual dysfunction” (as a unitary category), and nearly all were significantly more likely than placebo to be associated with dysfunction in each phase of the sexual response67. Bupropion appears associated with a significantly lower rate of treatment‐emergent sexual dysfunction than the SSRIs escitalopram, fluoxetine, paroxetine or sertraline68, which may reflect the predominantly noradrenergic‐dopaminergic mechanism of action of that drug69.

A second meta‐analysis, of 58 randomized controlled trials and five observational studies, found only minor differences between most antidepressants, although there were relative disadvantages for paroxetine and venlafaxine, and relative advantages for bupropion70. A systematic review of the relative efficacy and tolerability of mirtazapine and comparator antidepressants found the former to be less likely than other antidepressants to cause adverse sexual effects71, possibly reflecting its antagonist effects at alpha‐2 adrenergic and 5‐HT2C receptors72.

Some novel antidepressants may have a relatively low propensity for adverse effects on sexual function73. Randomized controlled trials with agomelatine suggest it has fewer adverse effects on sexual functioning than some other antidepressants, which is probably due to its antagonist effects at the 5‐HT2C receptor, rather than the agonist effects at melatonin receptors74, 75, 76, 77, although the absence of effects on nitrergic relaxation of corpus cavernosum smooth muscle may also be relevant78. Vilazodone appears to have a low incidence of spontaneously reported adverse effects on sexual function, which may be related to partial agonist effects at the 5‐HT1A receptor: it does not differ from placebo in improvement of sexual function during acute treatment of major depressive episodes, and the “number needed to harm” for sexual adverse effects has been estimated as 7 in men and 23 in women79, 80, 81. Treatment with the novel “multimodal” antidepressant vortioxetine is associated with a low incidence of reported adverse effects on sexual function in men (3‐5%) and women (1‐2%), which may relate to its antagonist effects at the 5‐HT3 receptor, and to indirect effects in increasing the availability of dopamine and noradrenaline82.

Risk factors for developing sexual dysfunction during antidepressant treatment include male gender, older age, lower academic achievement, absence of full‐time employment, physical ill‐health, multiple drug treatment, and troubled interpersonal relationships. Inter‐individual variation in pharmacokinetic parameters may be important, as “poor metabolizer” status for cytochrome P450 2D6 contributes to sexual dysfunction with paroxetine83, 84, as does a genetic variation in P‐glycoprotein which affects transfer of paroxetine across the blood‐brain barrier85.

Not all sexual effects of antidepressants are unwanted in all patients. Although behavioural approaches to premature ejaculation are effective in most patients86, many men (including those without depression) troubled by persistent problems can benefit from treatment with either the tricyclic antidepressant clomipramine or SSRIs87. The short‐acting SSRI dapoxetine is efficacious in treating premature ejaculation, with either daily dosing or “on demand” dosage88. It has similar efficacy to paroxetine, though it may be less well tolerated89. A systematic review of randomized placebo‐controlled trials with trazodone (which has partial agonist effects at 5‐HT1A receptors and antagonist effects at 5‐HT2A and alpha‐1 adrenergic receptors) indicates that it can be efficacious in reducing “psychogenic” erectile dysfunction, when prescribed at higher daily dosage (150‐200 mg)90.

Many patients experience treatment‐emergent sexual dysfunction whilst taking an antidepressant68, but in others the reduction of depressive symptoms through successful treatment can be accompanied by reported improvements in sexual desire and satisfaction91, 92. Improvement in sexual function appears more common among patients who respond to antidepressant treatment93.

The proportion of patients who stop treatment because of sexual problems is not established94, 95, nor is the time course of sexual dysfunction in patients who continue with antidepressant treatment96.

Management of treatment‐induced sexual dysfunction in depressed patients

Many interventions have been proposed for managing patients who report sexual dysfunction associated with antidepressants, but there are limited randomized controlled data evaluating the effectiveness and acceptability of psychological and pharmacological interventions97, and no approach can be considered “ideal”98, 99.

When patients are concerned to preserve usual sexual functioning, choosing an antidepressant thought to have fewer sexual adverse effects is reasonable, when other considerations allow. However, some of these antidepressants have other side effects, limited availability, or questionable efficacy. Sexual side effects of some antidepressants may be dose‐related, so reduction in daily dosage is commonly adopted as a first‐line approach to management100. However, dosage reduction may contribute to depressive symptom relapse, and should only be considered when patients have achieved full remission, and after satisfactory completion of continuation treatment. Regular brief interruptions of treatment (so‐called “drug holidays”) have been proposed101, but sexual function will improve in only a proportion of patients and with only some antidepressants: depressive symptoms may worsen, and troublesome discontinuation symptoms can emerge, making this approach potentially hazardous101.

Many adjuvant interventions have been proposed for relieving sexual dysfunction associated with antidepressants, but few have been subjected to rigorous evaluation. Randomized placebo‐controlled trials provide evidence of possible efficacy for bupropion and olanzapine102, testosterone gel103, and the PDE‐5 inhibitors sildenafil (both in male and female patients104, 105) and tadalafil106. Comparative studies are rare, but a placebo‐controlled study found no evidence of efficacy for augmentation with mirtazapine or yohimbine in female patients107. Augmentation of antidepressants with aripiprazole can improve sexual interest and satisfaction in depressed women, independent of an improvement in depressive symptoms108.

Switching from one antidepressant drug to another seems reasonable and is commonly adopted103, but placebo‐controlled evidence of efficacy rests on a single study of switching from sertraline to (now withdrawn) nefazodone97. Switching from one drug to another may lead to discontinuation symptoms, and the replacement drug may prove less effective in controlling depressive symptoms. A single study found that regular exercise prior to sexual activity improved sexual desire and global sexual functioning in depressed women taking antidepressants109.

Nitric oxide is involved in the physiology of the male and female sexual response. In men, nitric oxide in the corpus cavernosum of the penis binds to guanylate cyclase receptors, which results in increased levels of cyclic guanosine monophosphate (cGMP), leading to smooth muscle relaxation (vasodilation) in the intimal cushions of the helicine arteries, which in turn leads to vasodilation, increased blood flow into the spongy tissue of the penis, and subsequent erection. Sildenafil, tadalafil and vardenafil are potent and selective inhibitors of cGMP‐specific PDE‐5, which is responsible for degradation of cGMP in the corpus cavernosum, resulting in more cGMP and facilitation of erection110. In women, the role of nitric oxide and its interplay with estrogen is less well understood, but the PDE‐5 inhibitor enhancement of nitric oxide‐cGMP in non‐adrenergic‐non‐cholinergic signalling for women seems similar to the effect in men, and nitric oxide release results in vasodilatation in clitoral and vaginal tissues111.

A series of randomized placebo‐controlled trials demonstrate that PDE‐5 inhibitors are efficacious in resolving sexual dysfunction associated with antidepressants104, 105, 106. Studies of men with erectile dysfunction and depressive symptoms (but not undergoing antidepressant treatment) also show that prescription of PDE‐5 inhibitors is often accompanied by a reduction in depressive symptoms, enhanced quality of life, and improved interpersonal relationships112, 113, 114. Furthermore, preclinical studies suggest that nitric oxide activity is an important vulnerability factor in the Flinders rat depressive phenotype115, that passage of PDE‐5 inhibitors across the blood‐brain barrier can occur116, and that sildenafil has antidepressant‐like effects after central muscarinic receptor blockade117. PDE‐5 inhibitors are often helpful when managing patients with sexual dysfunction associated with antidepressants, but side effects such as headache, dyspepsia and visual disturbances, and the need for cautious use in patients with cardiovascular disease, are all potential limitations.

BIPOLAR DISORDER AND SEXUAL DYSFUNCTION

Influence of bipolar disorder on sexuality

Bipolar disorder can involve sexual disturbances directly related to the illness phase. Male and female patients in manic or hypomanic episodes often experience hypersexuality, with an increased incidence of risky sexual behaviours118. By contrast, in depressive episodes, reduction of sexual desire is common. Overall, sexual dissatisfaction is often associated with bipolar disorder52.

Patients with bipolar disorder tend to have more stable sexual partners and a more intense sexual activity than those with schizophrenia119, 120. When compared to females, males with bipolar disorder tend to have more sexual partners and are more likely to have sexual intercourse with strangers121. Sexual dysfunction is a common residual symptom in euthymic patients with bipolar disorder, and has a significant negative impact on quality of life, similar to that of residual depressive symptoms and occupational stigma122. Moreover, impairment in desire, excitement and ability to achieve orgasm is significantly associated with suicide plans or a feeling that life is not worth living123. In addition, sexual dysfunction has been identified as a predictor of poor medication adherence124.

A meta‐analysis indicated a statistically significant association between a history of sexual abuse and a lifetime diagnosis of anxiety disorder, depression, eating disorders, sleep disorders and suicide attempts125. Unfortunately, no longitudinal studies assessing patients with bipolar disorder are available in this respect. Sexual aggression is common in youth with bipolar disorder, particularly in those with a lifetime history of comorbid post‐traumatic stress disorder126. Prompt identification and treatment of these youth is highly needed.

Routine enquiries about sexual life, including questions about sexual drive during manic episodes, accompanied by simple psychoeducation, is highly recommended in bipolar patients to mitigate the physical, psychic and family consequences of promiscuous and risky sexual behaviour.

Influence of treatment of bipolar disorder on sexuality

Pharmacological management in bipolar disorder involves the use of lithium, anticonvulsants, antipsychotics, antidepressants and benzodiazepines, either in monotherapy or in combination. Sexual dysfunction is one of the most common side effects of these medications, has a high impact on quality of life, and is rated by patients as one of the most disabling problems.

Lithium is regarded as the first‐line treatment in bipolar disorder, but several studies suggest some negative impact of this drug on sexual function, as it may reduce sexual desire, worsen erectile function and decrease sexual satisfaction127, 128. Approximately one‐third of patients receiving lithium experience sexual dysfunction, which usually involves more than a single domain, in both male and female patients119. Patients are significantly less likely to experience sexual intercourse, sexual fantasies, sexual desire, pleasure and satisfaction, and 30% of them attribute these problems to lithium treatment129. Despite this, it seems that lithium has a less pronounced adverse impact on sexual function compared to other treatments in bipolar disorder130, especially antipsychotics131. The combination of benzodiazepines with lithium seems to be associated with an increased risk of sexual dysfunction, while this dysfunction does not appear to be related to serum lithium levels132.

Anticonvulsants are often associated with sexual dysfunction in people with epilepsy (35‐55% of patients)133, but there is limited evidence of these adverse effects in patients with bipolar disorder134, 135, 136.

Valproate may induce an increase of serum testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS) concentrations, while prolactin levels typically remain within normal limits137. The increase in androgen levels is associated with a higher incidence of menstrual disorders and polycystic ovarian syndrome in women treated with this drug138, 139. Decreased sexual desire and anorgasmia have also been described in bipolar women receiving valproate140. In men, valproate treatment may cause erectile dysfunction141.

Carbamazepine is often associated with reduced levels of estradiol, progesterone and testosterone, and may cause hypogonadism, amenorrhea and decreased sexual function and sexual desire129, 142. It may also increase sexual hormone‐binding globulin (SHBG) concentration, leading to diminished bioactivity of testosterone and estradiol, and consequently reduced libido and erectile dysfunction143.

Oxcarbazepine is not usually associated with changes in hormonal levels and sexual dysfunction127, but there are occasional reports of anorgasmia and retrograde ejaculation144, 145. Lamotrigine is not associated with sexual adverse effects in patients with bipolar disorder146, 147.

Management of treatment‐induced sexual dysfunction in bipolar patients

There is little evidence about management of sexual dysfunction associated with mood stabilizers. Using the lowest effective dose of the drug, switching to alternatives, or some add‐on strategies may be useful148.

A small randomized placebo‐controlled trial suggests that adjunctive aspirin (240 mg/day) may improve erectile dysfunction in patients undergoing lithium treatment149. There is currently no information on the potential utility of PDE‐5 inhibitors such as sildenafil, but it seems reasonable to consider them based on clinical experience in other patients. There is some evidence that switching from enzyme‐inducing (valproate, carbamazepine) to non‐enzyme‐inducing (oxcarbamazepine, lamotrigine) anticonvulsants can be beneficial138.

In epileptic patients, switching to lamotrigine can be associated with an improvement in desire, pleasure, excitement and orgasm in women, but only in the pleasure dimension in men150. Addition of lamotrigine to carbamazepine or valproate can ameliorate sexual dysfunction in male patients151.

CONCLUSIONS

Severe mental illness and many psychotropic drugs impair sexual function and reduce sexual satisfaction. Systematic enquiries in all patients about previous and current sexual life are needed to assess potential sexual dysfunction, and to manage it with the aims of preserving quality of life, maintaining emotional experiences and continuing partner relationships.

Treatments with fewer adverse sexual effects should be considered as potential first‐line options in patients with severe mental illness interested in maintaining a sexual life. Managing treatment‐emergent side effects adequately is crucial to facilitate compliance and achieve the best possible outcomes.