Antidotes to Antidepressant Sexual Side Effects

While at the ISSWSH conference in San Diego, Anita Clayton, MD of Charlottesville, VA, presented research that will prove very interesting to me and to many of the clients in my therapy practice. She reviewed ways to reverse the negative sexual side effects of SSRI type antidepressants.

First, the ways that work for only a few people.

A small number of people who take an SSRI will simply acclimate to the medication and find that they develop a type of tolerance that allows them to function sexually while still getting the benefit of combating their depression. This can take four to six months to occur (if at all) and it works for only about 5% of patients.

Some people will try changing to another SSRI, but this, according to Dr. Clayton, only works with about 10% of patients. In addition, many people worry that if they change from the medication that is working for their depression they will wind up sacrificing the gain against their depression for the possibility (and it's a slight one) of restoring their sexual function. If a patient is willing to risk that situation and make a change, there are also non-SSRI medications that may offer relief from the depression with less likelihood of sexual difficulties: Bupropion (Wellbutrin), and Mirtazapine (Remeron).

Some research on Bupropion has included placebo-controlled trials. This means that these studies involved some patients taking a pill that looked identical to the real medication but did not contain that medication. To get an antidote effect to an SSRI, doses of 300 to 400 mgs. of Bupropion are typically used. Typically, a dose can begin with 150 mgs for one week. Then, 300 mgs. for three weeks and ultimately 400 mgs if needed to get the desired effect. In some cases, the dose of the SSRI can also be lowered when Bupropion is added on.

Buspirone (Buspar) may be selected to treat what is called anxious depression. This type of depression has a restless quality. It can also be added to an SSRI (30 to 60 mgs) to alleviate negative sexual side effects.

SSRIs tend to decrease testosterone levels in both men and women, so some supplementation of testosterone can help -- particularly with issues of sexual desire and sometimes with arousal during sexual activity. Also adequate levels of testosterone are needed for PDE5 inhibitors (Viagra, Cialis, and Levitra) to work.

Cyproheptadine has been studied as an antidote, but it seems to have an effect that is often too sedating for patients. And, on the other end of the spectrum is the use of psychostimulants such as methylphenidate (Ritalin). About 10 mgs per day is often used, but not with patients who are bipolar or possibly psychotic.

Pharmaceutical companies realize the downside of the current batch of antidepressants. No doubt, they are working to develop other medications that don't solve one problem while creating another. Until then, these are some coping strategies that are worth trying for people interested in treating their depression and maintaining their sexual interest and abilities.

Related Topics:

• WebMD Video: Understanding Antidepressants
• WebMD Video: Side Effects of Medications

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Breast Cancer Survivors and Low Sexual Desire

Claudia Panzer, M.D., an endocrinologist from Denver, was a presenter at the International Society for the Study of Women's Sexual Health (ISSWSH) . She covered several topics that were relevant to my therapy practice -- among them was breast cancer.

Between my clients and personal friends, I know a lot of women affected by breast cancer. Most of the treatments that keep them alive turn out to be quite devastating to their sexual interest. So, what can be done?

For those women who wish to have a quality of life that includes sexuality, testosterone supplementation has some good potential. Panzer cited studies that addressed the concerns that many women have: Will I feel more like having sex? Will it cause my cancer to return?

Supplementing with a transdermal testosterone gel product like Androgel or Testim (both off-label use) can raise total testosterone levels and free testosterone levels. These can increase libido. Not all women will find this effect, but many do. Of course, depression needs to be addressed in these situations because women with cancer may feel depressed. Testosterone itself may not be sufficient to alleviate the depression and the use of an antidepressant may be helpful. (There can be side effects of SSRI-type antidepressants that are negative for sexuality, but that is another blog post.)

So, what do the studies show?

Women who have PCOS (polycystic ovarian syndrome) have rather high levels of testosterone, but they have no higher occurrence of breast cancer than other women.

When the breast tissue of transsexuals (females changing into males) is examined after a mastectomy, their tissue is comparable to women who have breast reduction surgery. Of course, these transsexuals would have much, much higher levels of testosterone (as an early part of their treatment), but their histology (how the tissue looks under a microscope) is similar to women with "female" (much lower) levels of testosterone.

A study by Adelaide (Dimitrakakis, Menopause 11:531, 2004) showed that women who used estrogen and testosterone had only 115 cases of breast cancer per 100,000 women years while women who never used it had 283 cases.

Panzer summarized her findings (and I am only mentioning a few here) by stating that there is no evidence of increase of breast cancer with use of testosterone supplementation and that it may be protective when low doses that are effective are used . The risk of negative side effects (facial hair growth, deepening of voice, acne, etc.) is low and they are reversible by simply reducing the dose of testosterone. She also stated that liver function, sleep apnea, and aggression in women are "non-issues."

Low sexual desire is a common problem in breast cancer survivors, but there are choices that women can make to promote greater sexual interest if they wish. I know some women who will be glad to hear that.

Related Topics:

• Breast Cancer Survivors: A Return to Sex and Intimacy
• Breast Cancer Survivors: Life After the Treatments End

Technorati Tags: Sex Matters, breast cancer, testosterone, sex drive, sexual desire, sexual health

Why Do Men Like Eliot Spitzer Seek Out Prostitution?

I don't know Eliot Spitzer personally, but I certainly have had men like him as clients in my therapy office. How do they get themselves into such a mess?

There are lots of reasons. Some think that because they are rich and powerful, they are above the law. The law applies to others but not to them. By the tone and content of Spitzer's public admission, I doubt that this reason has much relevance in his case.

Some people, by virtue of their life paths (work, friends, coincidence, etc.) wind up having exposure to slices of life that they ordinarily wouldn't seek out. And, just as people can't take their eyes off of a traffic accident, there's a type of fascination that can spring up when one rubs shoulders with sex workers - even when one is trying to destroy their livelihood and making a living while doing so.

Spitzer wouldn't be the first person to walk near "the gutter" and get muddy while doing so. And, like many other hypocrites who have prosecuted and persecuted sex workers, their zeal for doing so is equally matched by their horrified recognition of the over-powering attraction to this facet of sexuality. Dostoyevsky couldn't have invented more conflicted characters than the prominent list of men we've recently seen whose relationship to sex is out of control.

But, what else? Maybe he's like many accomplished men who seldom do anything special for themselves. These are the same guys who spend small fortunes on a Super Bowl tickets or fancy sports cars. And, while these decisions may be insane, they aren't illegal.

And, speaking of sports cars - for some it's the adrenaline rush. Playing along life's edge can be very compelling for certain men. I recall suggesting to one former client that made decisions similar to Spitzer's (also with a lot to lose) that racing cars or jumping out of airplanes (with a parachute) offered the adrenaline rush but no risk of illegality.

Another prominent client who risks a lot, pursues problematic sex in part because of sexual exploitation he experienced as a child and teen. He got accustomed to sex with the risk of discovery and "naughty" written all over it. He finds it almost unbeatable - and we're still working on that. This is different from the man who is looking for an adrenaline rush and so has risky sex as one way to get that rush. This is about preferring sex that contains risk - it's the type of sex he prefers.

The last group of reasons has to do with the style of sex also. Some men seek out prostitution because they do not wish to end their marriage for all sorts of reasons, but they are still looking to have sex that stimulates them. The sexual style of their wife no longer or never did match their own. Some are avoiding a wife at home who can only have sex while drunk. Some are hoping to get oral sex that feels more than obligatory - or any at all! And, it could be that he simply didn't think he could reveal what he truly wanted sexually at home - or if he did, that he'd get it there. Or if he did, how he'd handle her ridicule, rejection or disgust.

And, last there's the issue of what sex means to such a man.

Having sex with drop dead gorgeous 20-something women can be highly meaningful to a man - particularly when in his late 40s, he is invisible to these same women. Intercourse with such a woman lets a man relive what he may think are his most virile years. And, debates about whether Silda Spitzer is "hot" aside - she's in her forties too and has three daughters (and I'll assume gave birth to them). That's a different body than a 25-year old model which is what you'll see at the website for The Emperor's Club. Men who can't face their own aging and mortality sometimes think that aging can be reversed by osmosis during sex. And maybe that's what this is all about.

It takes courage and tenacity to keep on having sex with the same partner and finding a way to make it fulfilling - but that assumes that it was ever there in the first place. And, like the Clintons, we'll probably never know - nor really need to.

Related Topics:

• Sex Drive: How Do Men and Women Compare?
• Great Sex Unzipped

Technorati Tags: Eliot Spitzer, prostitution, sexual health, Sex Matters

PTSD and Sexuality

Although it is not a requirement for diagnosing a woman with Post-Traumatic Stress Disorder (PTSD), about 90% of them report sexual dysfunction, according to Rachel Yehuda, Ph.D. at the conference for the International Society for the Study of Women's Sexual Health (ISSWSH) I attended recently in San Diego. Many therapists who have clients with PTSD make the assumption that this shows up when women have "psychological" reasons to have low sexual desire and activity. They often think that if the traumatic event was sexual in nature (such as sexual exploitation or rape), of course there would be a sexual difficulty. But, it turns out that loss of libido is present regardless of the type of upsetting event that happened.

Yehuda went on to explain why. In the brain, the amygdala is involved in the emotion of perceiving an event. For example, one might think, "A tiger! I'm afraid!" But, also in the brain is the hippocampus which is involved in assessing the context of an experience. So, one would adjust one's response but noting, "Oh, but this tiger is in a zoo. I'm safe."

In the brain, substances called catecholamines affect what one thinks about a situation. Those thoughts can trigger distress. And, as it turns out, distress can trigger more catecholamines, which can trigger more thoughts and, in turn, more distress. Yehuda stated that if catecholamine levels are too high, this may result in what she called an "over consolidation" of memory and that leads to PTSD. This happens if the event is very distressing or if normal coping mechanisms are not engaged.

It's difficult to engage "normal coping mechanisms" when an event happens that is highly unpredictable and cannot be controlled. These two factors contribute to the occurrence of PTSD. So, the overconsolidation occurs.

So, where does sex fit into all of this?

A woman who can think about a life event and say, "These things happen," will not develop PTSD. But, a woman who after a life event says, "I'm not going to be the same," will develop PTSD.

Women who have PTSD are in a state of being numb. They tend to avoid the feelings of general arousal (not sexual, but more what we think of as alertness and vigilance) because it takes them out of their numbness. That is stressful and exhausting.

Arousal (the sexual kind) is required for sexual interest and response, but it is very difficult for women to choose to be aroused since it requires that they not be numb. It can also bring them closer to the memory in the amygdala of feeling afraid. And, it turns out, they are lacking a safety context because during the stressful event, safety was very much in doubt for them. So, staying numb feels like a safer choice and that makes sex out of the question.

In addition to this dynamic, people with PTSD may also have sleep disturbance, medication side effects, chemical dependency and abuse, and other psychiatric conditions that do not easily predispose a person to choose to be sexual. All in all, sexual lack of interest caused by PTSD must be treated with an understanding of the brain structures and neurotransmaitters, the nature of sexual arousal's similarities to general arousal, and other difficulties that can develop as a result of a traumatizing event.

I received an email inquiry about therapy yesterday from an Iraq War soldier and I have a hunch that I'll be putting Dr. Yehuda's ideas into practice.

Related Topics:

• Sexual Dysfunction Quiz
• WebMD Video: How Does Sexual Dysfunction Develop?

Technorati Tags: PTSD, sexuality, sexual dysfunction