Post-SSRI Sexual Dysfunction: PSSD. Wikipedia Stumbles.

February 11, 2014 • 11 comments

Editorial Note: There was until recently a Wikipedia post on Post SSRI Sexual Dysfunction – PSSD, which helped put this condition on the map. On January 27 it was taken down. We reproduce the original post here and in a post tomorrow we will give the debate surrounding its removal.

Post SSRI Sexual Dysfunction – PSSD

Post-SSRI sexual dysfunction (PSSD) [1] is a name given to a reported iatrogenic sexual dysfunction caused by the previous use of selective serotonin reuptake inhibitor (SSRI) antidepressants. While apparently uncommon, it can last for months or years after the discontinuation of SSRIs. [2] It may represent a specific subtype of SSRI discontinuation syndrome. This condition has not been well-established or studied in the field of medicine.

Symptoms

One or more of the following sexual symptoms attributed to PSSD after the discontinuation of SSRIs include:

  • Decreased libido
  • Impotence or reduced vaginal lubrication
  • Difficulty initiating or maintaining an erection or becoming aroused
  • Persistent sexual arousal syndrome despite absence of desire
  • Muted, delayed or absent orgasm (anorgasmia)
  • Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia)
  • Premature ejaculation
  • Weakened penile, vaginal or clitoral sensitivity
  • Genital anesthesia
  • Loss or decreased response to sexual stimuli [3]

Prevalence

The true prevalence of PSSD has yet to be determined, although published calls have been made for post-marketing epidemiological studies. [4][5] It is known that SSRIs can cause various types of sexual dysfunction. Initial studies found that such side effects were reported in less than 10% of patients. When doctors have specifically asked about treatment-emergent sexual difficulties, some have found that they are present in up to 60% [6] of patients. Spontaneous reporting methods are believed to result in lower reporting rates than targeted questions, either due to recall bias or stigma regarding sexual dysfunction. [7]

Study data

While sexual dysfunction can be common while taking SSRIs, the problem of persistent dysfunction after discontinuation does not appear to be as frequent, or at least not as well-known.[8] Onset of sexual problems often occurs during, and sometimes after, extended SSRI use but there have been reports of rapid onset as well. It appears as though the majority of people regain their sexual function after stopping SSRIs [citation needed] but some do not, and are faced with the persistent symptoms of post-SSRI sexual dysfunction (PSSD). In one study in which patients with SSRI-induced sexual dysfunction were switched to the dopaminergic antidepressant amineptine, 55% still had at least some type of sexual dysfunction after six months compared to 4% in the control group treated with amineptine alone.[9] In recent placebo controlled double-blind studies testing the efficacy of SSRIs for treating premature ejaculation, it has been noted that the ejaculation-delaying effect of the medications may last for months after discontinuation in a percentage of the trial participants. [10][11][12]

Case reports

Three cases of hyposexuality following SSRI use [13] and a fourth case describing genital anesthesia following SSRI use were described in 2006. [14] A fifth case of similar findings was published in late 2007. [15] In early 2008, three more cases were published[2] in the Journal of Sexual Medicine, selected from a Yahoo Group composed of over 3500 PSSD sufferers. There have also been several published cases of Persistent Genital Arousal Disorder (PGAD) [16][17][18] and premature ejaculation[19] that start and last long after withdrawal from SSRIs. These symptoms are quite different from, and should not be confused with, hypersexuality.

Sandra Leiblum described persistent genital arousal disorder based on a case where a PSSD was established. [20]

Surveillance and reporting

To establish, monitor, and regulate causation of PSSD in individual patients, one approach in use by consulation-liaison psychiatrists is to assay measurable parameters of patient health (hormone levels, sexual functioning) with a survey or laboratory tests before and after administering a psychiatric drug, based on individual patient concern regarding each of the listed side effects. If PSSD develops, a correlation can be established between assay results and PSSD, guiding further treatment for the individual patient and others. A lack of education on drug side effects and the presence of clinical depression in a patient who is a candidate for antidepressant therapy can combine to reduce the patient’s ability to advocate for tests. Calls have been made for better informed consent regarding the possibility of permanent sexual dysfunction when prescribing SSRIs to potential patients. [21] Post-administration reporting of side effects may provide useful data for development of new drugs and better inform patients of their risks. In The United States, adverse effects are reported with FDA forms, 3500 for optional use (patients can self-report using this form), and 3500A, for mandatory reporting.

Etiology

It is currently not known what causes PSSD. Fluoxetine (Prozac), the prototypical SSRI, is classified as a reproductive toxin [22] by the Center for the Evaluation of Risks to Human Reproduction (CERHR), an expert panel at the National Institute of Environmental Health Sciences at the National Institutes of Health.

Animal studies

Experiments with rodents have shown that chronic treatment with SSRIs at a young age results in permanently decreased sexual behavior that persists into adulthood and is similar to PSSD.[23][24] These studies found reductions in both the rate-limiting serotonin synthetic enzyme, tryptophan hydroxylase, in dorsal raphe and in serotonin transporter (SERT) expression in the cortex. It also appears as though PSSD might be transgenerationally inherited, at least in rodents, since maternal exposure to fluoxetine impairs sexual motivation in adult male mice.[25] It is not known whether these findings in rodents recapitulates the human condition, but the long term neurobehavioral consequences may be similar. [26]

Short-term effects

There are physiological changes while on SSRIs. It has been postulated that drugs can exert epigenetic effects. [27]

Changes include reduced hypothalamic-pituitary-testis axis (HPTA) function, [28] decreased testosterone levels, [29] reduced sperm counts, which showed marked improvement after discontinuation [30] and reduced semen quality with damaged sperm DNA, which is reversible after discontinuation. [31]

Long-term effects

Treatment with fluoxetine (Prozac) has been shown to cause persistent desensitization of 5HT1A receptors after removal of the SSRI in rats. [32] These long-term adaptive changes in 5-HT receptors, as well as more complex, global changes, are thought to be mediated through alterations of gene expression. [33][34][35][36][37] Some of these gene expression changes are a result of altered DNA structure caused by chromatin remodeling, [38][39] specifically epigenetic modification of histones [40] and gene silencing by DNA methylation due to increased expression of the methyl binding proteins MeCP2 and MBD1. [41] Altered gene expression and chromatin remodeling may also be involved in the mechanism of action of electroconvulsive therapy (ECT). [42][43]

Because described gene expression changes are complex, and can involve persistent modifications of chromatin structure, it has been suggested that SSRI use can result in persistently altered cerebral gene expression leading to compromised catecholaminergic neurotransmission and neuroendocrine disturbances. [13] However, without detailed neuropsychopharmacological, pharmacogenomic and toxicogenomic [44] research, the definitive cause remains unknown.

Relationship to “chemical imbalance” theory

Some critics of SSRIs claim that the widely-disseminated television and print advertising of SSRIs promotes an inaccurate message, oversimplifying what these medications actually do. [45] Much of the criticism stems from questions about the validity of claims that SSRIs work by correcting chemical imbalances. Without tools to accurately measure neurotransmitter levels and to allow for continuous monitoring during treatment, it remains difficult to know if one is correctly targeting a deficient neurotransmitter (i.e. correcting an imbalance) or reaching a desirable level of a particular neurotransmitter. It has been argued that without this knowledge for each patient, SSRIs can actually cause chemical imbalances and abnormal brain states. [46] One possible mechanism is by inhibition of dopaminergic neurotransmission, [47] resulting in described persistent sexual dysfunction.

Other drugs

Antipsychotics are also known to cause sexual dysfunction that is similar to PSSD, especially because of their antagonist effects on D2 dopamine receptors, as well as H1, α1 and α2 antagonism. [48] Finasteride, which is used to treat male pattern baldness and benign prostatic hypertrophy, has also been found to cause persistent sexual dysfunction in a subset of patients that are treated with the drug. [49]

Treatment

There is no known cure for PSSD, mostly because its etiology is still poorly understood. Possible treatment options for SSRI-induced sexual dysfunction have been reviewed theoretically. [50][51][52] However, there has been a lack of randomized, placebo-controlled, double-blind trials of potential treatments. Of those that have been done, there is evidence for the following management strategies: for erectile dysfunction, the addition of a PDE5 inhibitor such as sildenafil; for decreased libido, possibly adding or switching to Wellbutrin (Bupropion); and for overall sexual dysfunction, switching to nefazodone. [53]

According to a survey of psychiatrists, Bupropion is the drug of choice for the treatment of SSRI-induced sexual dysfunction, although this is not an FDA-approved indication. Thirty-six percent of psychiatrists preferred switching patients with SSRI-induced sexual dysfunction to bupropion, and 43 percent favored the augmentation of the current medication with bupropion. [54] A higher dose of bupropion (minimum 300 mg) may be necessary: a randomized study with 31 subjects that utilized a lower dose (150 mg) once daily failed to find a significant difference between bupropion, sexual therapy or combined treatment, [55] while a subsequent study with 234 subjects and employing Bupropion SR 150 mg twice daily did show a significant improvement of sexual function. [56]

Some other off-label prescriptions include pramipexole, ropinirole, yohimbine and possibly other molecules increasing the dopamine blood levels, though there have been no double blind placebo-controlled trials to show their efficacy. The chemical cabergoline, which is an agonist of D2 receptors, which in turn decreases prolactin, has fully restored orgasm in 1/3rd of anorgasmic subjects, and partially restored orgasm in another 1/3rd of subjects. [57]

Most studies of sexual dysfunction have been done in men, though some studies done in women have shown benefit from bupropion (at doses >300 mg/d). There has been 1 study showing possible benefit in orgasmic function with sildanefil, though no change in desire or arousal. [58]

References

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Illustration: No Sex Please! (We’re on antidepressants). Based on 17th Century Kama Sutra and Ragamala paintings. © 2014 created by Billiam James.

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Filed Under: Antidepressants, RxISK Stories, Sex | 11 comments

Comments (11)

  1. Lynne Millican says February 11, 2014 at 6:19 pm

    I wanted to add a comment re: Wikipedia. Shortly after my website, http://www.LupronVictimsHub.com, went online (October 2008), someone put a link to my site on Wiki’s “Lupron” page. It was then taken down, and later put back up, and again taken down. (I know nothing about how to add/edit Wiki, nor who was putting up or taking down the link). The “Lupron” page was discontinued about 2009 or 2010, and a “Leuprorelin / leuprolide” page put in its stead … no more links to my site were ever entered. On this page is a ‘link’ to the National Women’s Health Network’s (NWHN) 2008 cover story on Lupron (which is based on my research and highlights Lupron’s serious risks) – but in fact Wikipedia’s link brings one to Wiki’s “NWHN page”, and not to the Lupron article. I just finally asked their editorial/science desk to correct this, and provided Wikipedia the correct link (http://nwhn.org/lupron%C2%AE-%E2%80%93-what-does-it-do-women%E2%80%99s-health).

    While Wiki’s leuprolide page does indeed give a strong warning about Lupron’s use in “children and adolescents”, and gives print to the debunking of the Lupron/autism protocol scam, the drug is otherwise treated quite gently (ie “superior alternative in trans women”, soft references). No mention is made of the multitudes of adverse events, or of Lupron Victims, or of Lupron litigation; and off-label promotion is evident. Imo, Wiki’s leuprolide page is run and/or influenced by the industry.

    Reply

  2. Pingback: PSSD on Wikipedia | RxISK

  3. ekasytab-8959@yopmail.com says March 3, 2014 at 3:42 am

    I’m going to kill myself because of decades of depression and PSSD. I’m planning it now.

    Reply
    • wallstorndown says July 24, 2014 at 6:13 pm

      PLEASE CALL 911 IMMEDIATELY! There is life after depression and PSSD and new research is coming out all the time that can help. You DO have a future and you CAN have a full life! PLEASE DO NOT KILL YOURSELF! I hope you get this message. Your life is precious and worth living.

      Reply
    • James Welsher says June 30, 2015 at 5:19 pm

      Look!I know exactly how you are feeling. I’m going through the same thing myself and have been for year’s. My situation is from effexor , but I know all to well the hell you are going through, I have been to multiple specialists spent thousands of dollars just to get shoulder shrugs. Killing yourself will solve nothing but hurt those that care for you , my goal is to make these bastards pay for the pure hell I’ve been living these past several years, our condition isn’t all that uncommon, to be getting the bullshit answers from the Doctor’s that I have been getting the Most of the Doctor’s I have spoke to are familiar with the condition but have zero clue on how to treat it. I have been from Minnesota( Mayo Clinic) and to San Diego ( Sexual Medicine Clinic. Spending time and money I don’t have to reach dead end after dead end, I didn’t have this issue before Anti- Depressants, and my battle is well documented. I’ll be honest I’ve had the same desperate thoughts that you are having, But I dont need to make my Wife and kids pay for irresponsible pharma. What we need is a Doctor that will officially diagnose this We need to connect and make enough noise that we get recognized. I’m not greedy and I don’t like to sue, but I’am angry and become more so each day. This did not occur in a vacuum, if you knew this could happen , would you have taken the drug that was prescribed to you? I sure as the hell wouldn’t have and I have more issus now then i started with,This is not a rare thing there are a lot of us in the same boat, however the nature of the disorder keeps it fairly quiet and big Pharma keeps making billions off the same poison that put you and I in this situation, I’m willing to try and get a large group to get some attention, you found me that means we can find other’s. stay strong my Friend and contact me.

      Reply
  4. Anonymous says July 19, 2014 at 10:05 am

    i would like to add Paxera which also causing PSSD

    Reply
    • openhead says July 26, 2014 at 2:21 am

      Paxera is paroxetine (HCl) which is one of the SSRIs. All SSRIs — fluoxetine, paroxetine, sertraline, citalopram, escitalopram and so on — can cause PSSD (hence the name of the syndrome) but please note that it is not only them that are known to cause sexuality related damage. Major tranquilizers — quetiapine, risperidone, haloperidol, ziprazidone, aripiprazole, olanzapine and so forth — are also known to cause permanent sexual death.

      PSSD-like syndromes can be observed also in the case of many non-psychiatric drugs like finasteride, dutasteride, minoxidil and isotretinoin to mention a few. Concerning the immense scale of the problem in the population it is a shame that the condition is so incredibly poorly understood, studied and cared about.

      On the one hand it is understandable from psychiatry and pharmaceutical industry point of view to minimize and silence the debate and discussion concerning PSSD since if caught in the public eye the whole antidepressant and major tranquilizer consumption are in danger of going down the tube. I doubt there would be so many people willing to accept the risk of permanent brain damage in return for questionable benefit.

      Reply
  5. Jovvo says October 31, 2014 at 4:19 pm

    Can this webpage be fixed so that a person doesn’t have to scroll to see the info on PSSD?

    Some people may come to this page and only see the Wikipedia removal notice and think there is nothing else on this page.

    Reply
  6. Todd says January 18, 2015 at 8:36 pm

    I was on Effexor XR 300mg, Wellbutrin 300mg, and Adderall 60mg. My doctors were idiotic, I was lied to about the drugs, and these drugs were coerced by doctors while I was in custody. I was not on any drugs before these doctors did this to me. After years I got out of their custody, I quit the drugs over 1 month titrating twice down to nothing on my own. Immediately I experienced serious reaction. I had brown piss, my muscles got tighter, I became sensitive to cold experiencing constriction like I’d never had. My orgasms also stopped working for a month. I was not under the care of a doctor during this time, so I received no care, but lets face it, all they’d do is put me back in the drugs and it probably wouldn’t have fixed it. The orgasms came back a little, however, each orgasm causes extreme muscle tightening, swelling of tissue, pain, burning and stinging that lasts weeks and after weeks my muscles start to loosen a little and the pain goes down just a bit. It’s as if an orgasm activates extreme hyper tonia, aka dystonia..

    Why this is a big problem, is because I was literally in control of the CIA during this period, they began to use this problem to their advantage. Raping me, forcing ejaculation after ejaculation to assault me.

    Details on this @ http://www.obamasweapon.com/

    I am not joking.

    I recommend the symptom be added however, that a strong dystonia or shock can start to occur after orgasm, making it unsafe to orgasm..

    Reply
  7. looking for the cure says January 26, 2015 at 2:36 pm

    I started taking zoloft in 1999. by the end of 2000 my sexual function was gone completely. interestingly in 2003 when i was pregnant the function came back but left again as soon as I delivered. That’s a big clue right there imo. That’s why I think Viagra might help but my doctor refuses to prescribe it to women. I stopped taking the Zoloft in spring of 2009 but still suffer to this day. I want to get together with other victims and try to start a class action law suit. i can’t afford sex therapy that’s not covered by insurance or experimental drugs. If you can sue for spilling coffee on your lap, you would think you could sue for this.

    Reply
    • Marcus says March 24, 2015 at 1:39 am

      I couldn’t agree more…we really need to all band together and form a class action lawsuit. Probably getting on the Yahoo PSSD Group that’s out there is the best way to get a lot of people on board. I’m beyond mad that a doctor sold me on Zoloft and now I’ve been suffering from PSSD for 9 years. Still searching for a solution…

      Reply

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