~Teachingcenter的醫學筆記~

Sexual dysfunction associated with major depressive disorder and antidepressant treatment (2)

Antidepressant and SD
= Bidirectional association: improvement; cause or worsen.
= Treatment-emergent sexual dysfunction (TESD):
----Worsening of pre-existing dysfunction.
----Development of new dysfunction in previously untroubled patients.
----Often result in noncompliant or discontinued drug treatment.
= Frequency of antidepressant-associated SD (AASD):
----SSRIs and SNRIs 57%~72% [J Clin Psychiatry 2001]
----5-HT2 blockers 8~24% [J Clin Psychiatry 2001]
----MAOIs about 4% [J Clin Psychiatry 2001]
----Bupropion sustained-release (SR) 7% [J Clin Psychiatry 2002]

Assessment
= Mostly use: Arizona Sexual Experiences Scale (ASEX)
= Grading:
----1 extremely strong
----2 very strong
----3 somewhat strong
----4 somewhat weak
----5 very weak
----6 no or never
= Sexual activity recently
----Desire: 1. How strong is your sex drive?
----Arousal: 2. How are you sexually aroused (turned on)?
= For MALE only
----Penile erection: 3. Can you easily get and keep an erection?
= For FEMALE only
----Vaginal lubrication: 3. How easily does your vagina become moist or wet during sex?
= If Sexual activity in past week
----Orgasm: 4. How easily can you reach an orgasm?
----Satisfaction: 5. Are your orgasms satisfying?
= The higher score means more satisfied with sexual activity.
= This tool is designed for comparison.

Assessment and management of sexual dysfunction in the context of depression, Pratap Rao Chokka, Jeffrey R. Hankey, Therapeutic Advances in Psychopharmacology 2018.

Pathophysiology
= Sexual response is the result of a combination of psychosocial and organic factors.
= Drug-specific effects:
----Selective serotonin reuptake inhibitors (SSRIs)
----Serotonin and norepinephrine reuptake inhibitors (SNRIs)
----Tricyclic antidepressants (TCAs)
----Mono-amine oxidase inhibitors (MAOIs)
----Other antidepressants
= Biochemical mechanisms:
----The main anatomical areas involved are the hypothalamus, limbic system and cortex.
----Sexual response can be looked at in terms of its different phases.
----Initial phase of sexual response, desire, predominantly controlled by dopamine.
----Arousal of genital tissue resulting in erection in men, controlled by acetylcholine and nitric oxide.
----Orgasm, accompanied by ejaculation in men, is regulated by serotonin, norepinephrine and prolactin, and is associated with oxytocin release.
= SD results from
----Increased serotonin affecting 5HT-2 and 5HT-3 receptors (inhibits ejaculation and orgasm)
----Decreased dopamine
----Blockade of cholinergic and α-1 adrenergic receptors
----Inhibition of nitric oxide synthetase
----Elevation of prolactin levels

Meston CM, Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry 2000