How Common is Post-SSRI Sexual Dysfunction (PSSD)?

The level of risk of developing Post-SSRI Sexual Dysfunction (PSSD) from using an SSRI or SNRI antidepressant is currently unknown. Patients are never warned about persisting sexual side effects when these drugs are prescribed.

Calls for informed consent are often met with the response that PSSD appears to be quite rare. Given the huge number of antidepressants prescribed every year, the number of people complaining of PSSD is comparatively small. Doctors wouldn’t normally be expected to discuss every rare side effect of a medication when prescribing it.

To the uninformed, this might seem like a reasonable argument. However, there are a number of complex dynamics involved in the issue of PSSD that not only make it difficult to establish its true prevalence, but they also suggest that the condition may be significantly more common than is generally assumed.

Obtaining a diagnosis

One of the most obvious reasons for the under-diagnosis of PSSD is the inconsistency in awareness within the medical community.

It is difficult to get a clear picture of how this might differ across medical specialties, though there is some suggestion that urologists and those doctors who specialize in sexual medicine are usually more familiar with the condition, sometimes commenting that they have seen cases in their clinics from time to time. (See PSSD: Getting a Diagnosis)

While some PSSD sufferers are fortunate in their dealings with the healthcare system, others can face a more difficult experience.

The fact that antidepressants were originally prescribed can often present a barrier to having any subsequent health complaints assessed objectively and without significant bias towards an underlying mental health disorder. This not uncommonly results in PSSD being completely dismissed as a possible cause. It is also part of a more widespread issue of doctors failing to engage with patients on the subject of treatment-related problems.

In some cases, the symptoms only appear when the antidepressant is actually stopped or the person begins to taper the dosage. This undoubtedly adds another level of difficulty when trying to obtain a diagnosis. It is worth noting however that it matches the profile of antipsychotic-induced tardive dyskinesia, in which the problem can either develop while on the drug or when stopping.

The need to battle against an unhelpful medical community can prove too much for some PSSD sufferers, particularly if they are also dealing with other side effects such as withdrawal problems.

There is also the very legitimate concern that disagreeing with doctors will be regarded as evidence of an increasing mental health disorder and could put the person at risk, or at the very least affect how they are perceived in any future consultations due to comments in the medical records.

Faced with these difficulties, some simply abandon trying to obtain any assistance for their condition from the healthcare system, which means that these cases then disappear from clinical practice.

The value of seeking help

For most medical conditions, a patient seeks the assistance of the medical community because they are hoping to receive an effective treatment. If faced with an unhelpful doctor who isn’t knowledgeable about the condition or one who is unwilling to engage, the patient would usually persevere and take the matter further. They might ask to see a different doctor for a second opinion or request to see a specialist. They might even attempt to seek out and consult with known experts at their own expense.

However, in some ways there is much less value in pursuing this course of action in relation to PSSD. Anyone who researches the published literature and the various on-line information will soon realize that there is little that can be done for the condition. There is no cure and currently no viable treatments. Even with a formal diagnosis, there is ultimately very little that a doctor has to offer. There is therefore less incentive for a PSSD sufferer to pursue medical intervention, particularly if they encounter resistance from their doctor.

Sexual apathy

As part of the condition, men and women can sometimes be left with a reduced or loss of libido. This seems to produce two different results in terms of a sufferer’s reaction to it.

There are those who are acutely aware of this impairment and find the experience very disconcerting. Their reduced or lack of desire feels abnormal. They know that they are meant to be attracted to people and have a desire for sex, yet these feelings are strangely missing or subdued. Together with the other features of PSSD, this can produce a very distressing situation for those affected.

However, other sufferers are completely unconcerned by it, even when they seem to recognize that it is a drug side effect. They find that they simply no longer care about sex and relationships or they regard them as fairly unimportant in their life. Consequently, any accompanying physical difficulties that they might have also become less important.

Some sufferers note that they would rather have these abilities and feelings back and to once again be able to pursue sexual relations, but it seems to be regarded as something that would be nice to have as opposed to a pressing concern that is causing any particular distress.

This sexual apathy means that these people are less likely to seek medical assistance.

Near normal?

While some cases of PSSD involve sexual side effects that remain completely unchanged when the drug is stopped, there are a number of people who find that their sexual function improved on stopping the SSRI, but it isn’t the same as it used to be. Some of them remain a long way from their pre-drug baseline and fit a typical case of PSSD, but others seem to return to what could loosely be described as near normal.

Unlike some of the more severe cases, these people generally report being able to engage in normal or reasonably normal sexual activity, but nevertheless something isn’t the same. They can have less interest in sex or find it more difficult to become aroused. Orgasms are sometimes weaker. There can be a sense that sex doesn’t feel the same as it used to – something indefinable seems to be missing.

The fact that their sexual function showed a substantial improvement when the antidepressant was stopped leads them to assume that the drug is no longer involved, and that any remaining deficiency must be due to something else, despite the fact that they had completely normal functioning immediately prior to starting the medication.

Even those who deny any persisting effects and claim that their sexual function completely returned to normal after stopping an antidepressant will sometimes admit that on reflection it isn’t quite the same.

Some of those affected try to make sense of this by assuming that it must be related to other aspects of their health or other things going on in their life. They may not even regard themselves as having a significant sexual dysfunction, just a reduced interest or enjoyment of sex. Those who have been on an antidepressant for a while may assume that it is a normal part of life.

The important point is that these people generally aren’t complaining about the problem, and certainly not about the medication. They often only mention it because they were specifically asked. Even when the person recognizes a link to the drug, they are sometimes just pleased that their sexual function came back to the extent that it did, and they consider it a fair trade-off for helping with their mental health issue. Whether this represents a degree of sexual apathy or simply a pragmatic view is difficult to know.

Anyone who reports to their doctor that sex doesn’t seem as good as it used to will probably find the conversation steered very quickly towards mood, relationship issues, etc.

The bigger picture

A quick search of the medical literature and on-line information about PSSD will reveal cases of a complete loss of libido, profound genital anesthesia, pleasureless orgasm and an inability to engage in sexual activity.

These types of cases are important. They describe the potentially devastating consequences of the condition and help to define its characterizing features.

However, it is also becoming increasingly clear that the condition includes a broad range of cases, from the most severe to those people who notice that their sexual function just isn’t quite the same as before, and everything in between.

In efforts to raise awareness it is important to illustrate this diversity within the condition, otherwise there is a risk of PSSD being perceived solely as a rare and extreme side effect, and therefore something that can too easily be dismissed as being irrelevant to the majority of people.

Evidence of this misconception can be seen on-line. Some people comment that although they have a degree of persisting genital numbness and weaker orgasms, they are able to have sex and therefore they don’t have PSSD. Others have said that their condition improved naturally over time to a point where they are now able to have sex again, and therefore they have recovered and no longer have PSSD, despite reporting that there wasn’t a return to baseline.

Any impairment to a person’s sexual functioning or sensation that fails to return to a pre-drug state after stopping an antidepressant belongs firmly in the conversation about PSSD, regardless of the level to which it interferes with their ability to engage in normal sexual activity.

Far from diluting the seriousness of the condition, this actually brings into view the very real possibility that persisting sexual side effects may be more common than is generally assumed, and that many of these cases may be going under the radar.

Sensation: a missing side effect

A study published in 1999 looked at the effectiveness of fluoxetine as a possible treatment for premature ejaculation [1]. It found that the antidepressant increased the time to ejaculation and was therefore regarded as helpful.

The interesting point is that in addition to measuring time to ejaculation, a number of additional parameters were assessed using neurophysiological testing. One of these was penile sensory threshold. Electrodes were placed on the subject’s penis and very small electric currents were generated until the subject could feel the sensation. The current was then decreased until it could no longer be perceived. This second figure was taken as a measurement of penile sensitivity.

This test was carried out on both the study group (fluoxetine) and the control group (placebo), both prior to, and at the end of the treatment period of one month.

At the end of the study, it was discovered that fluoxetine had increased penile sensory threshold by almost 25% compared to placebo which remained the same as pre-treatment. In other words, fluoxetine was found to have reduced penile sensation. The study concluded that this reduction in sensation was likely responsible for the increased time to ejaculation.

An earlier study from 1990 found that the tricyclic antidepressant, clomipramine, also caused an increase in penile sensory threshold [2]. It is worth noting that while clomipramine is classed as a tricyclic antidepressant, it is also a serotonin reuptake inhibitor.

In addition to these studies, published case reports of genital numbness while on an SSRI have appeared in the literature since 1991, including a report of anesthesia of the nipples in 2000 [3-9]. This is without including the cases of genital anesthesia from the PSSD literature.

None of this is surprising as reduced genital sensitivity is a known and common side effect of SSRI antidepressants. If they pay close attention to it, most people who take an SSRI will notice a degree of reduced genital sensation within 30 minutes of taking the first dose.

However, a search of drug information leaflets and health websites will find very little mention of it. Instead, the information that dominates the public domain focuses on side effects such as libido, erectile/lubrication problems and difficulty having an orgasm.

If you were to ask your doctor whether SSRIs can reduce genital sensation, you would probably receive a strange look and be told that SSRIs don’t do this.

Most people seem to be aware that antidepressants can affect arousal and make it more difficult to have an orgasm, but the fact that they can reduce genital sensation (and sexual sensations more generally eg. reduced feeling of pleasure during orgasm) doesn’t appear to be in the public consciousness. It is completely missing from the general dialogue about antidepressant side effects.

Subsequent studies of premature ejaculation

In 2006-07, three large randomized placebo-controlled studies were published that looked at the effectiveness of citalopram, sertraline and escitalopram for premature ejaculation [10-12]. These are all SSRIs.

Unlike the earlier trials mentioned above, they didn’t test penile sensory threshold. However, they included something that the earlier trials did not: a 3- and 6-month follow-up.

It was discovered that the ejaculation-delaying effect of the SSRIs had continued for a significant number of participants, several months after the drugs had been stopped.

An analysis of the results from the citalopram and sertraline trials and their significance in relation to PSSD has previously been discussed in the literature [13]. Of particular note is the fact that the study participants had no pre-existing mental health disorder on which the persisting effect could be attributed.

But there may be another important point.

The fluoxetine study from 1999 concluded on the basis of its neurophysiological testing, that the drug’s ability to delay ejaculation was likely due to its effect of increasing penile sensory threshold. It also noted the findings of the 1990 trial in which clomipramine was found to have the same effect.

If this conclusion is correct and it is applied to the three large studies from 2006-07, then it means that in addition to showing a persisting effect of delayed ejaculation, these studies are also potentially evidence of a persisting reduction in genital sensation in a significant number of participants after stopping three different SSRIs.

Putting the pieces together

A common view of PSSD is that it is a severe condition that a person either does or doesn’t develop – and that the vast majority of people don’t. Therefore, prevalence is generally assumed to look something like example 1:

However, this idea seems increasingly unconvincing. Taking everything into account, it raises the possibility that the true picture could look more like example 2 or some variation of it:

The original question was – how common is Post-SSRI Sexual Dysfunction? This article may not have provided an answer, but perhaps it suggests a number of reasons why some sufferers may not identify with the condition, despite experiencing persisting sexual side effects.

SSRIs and SNRIs can have very complex sexual effects and can produce changes that some sufferers may find difficult to make sense of, particularly when it comes to altered sensations and muted sexual feelings. Depending on the level of severity, some people may feel that the severe dysfunction often associated with PSSD is not a good fit for what they are experiencing.

Perhaps the real question is:

Does anyone who takes an SSRI or SNRI actually regain 100% of their original sexual function and sensation, or are they almost always left with some degree of long-term alteration?

References

1. Yilmaz U, Tatlişen A, Turan H, Arman F, Ekmekçioğlu O. The effects of fluoxetine on several neurophysiological variables in patients with premature ejaculation. J Urol. 1999 Jan;161(1):107-11. PMID 10037380.

2. Colpi GM, Fanciullacci F, Aydos K, Grugnetti C. Effectiveness mechanism of chlomipramine by neurophysiological tests in subjects with true premature ejaculation. Andrologia. 1991 Jan-Feb;23(1):45-7. PMID 1897755.

3. Neill JR. Penile anesthesia associated with fluoxetine use. Am J Psychiatry. 1991;148:1603. PMID 1928483.

4. Measom MO. Penile anaesthesia and fluoxetine. Am J Psychiatry. 1992;149:709. PMID 1575264.

5. King VL, Jr, Horowitz IR. Vaginal anesthesia associated with fluoxetine use. Am J Psychiatry. 1993;150:984–5. PMID 8494083.

6. Ellison JM, DeLuca P. Fluoxetine-induced genital anesthesia relieved by Ginkgo biloba extract. J Clin Psychiatry. 1998;59:199–200. PMID 9590676.

7. Diesenhammer EA, Trawoger R. Penile anesthesia associated with sertraline use. J Clin Psychiatry. 1999;60:869–70. PMID 10665639.

8. Michael A, Mayer C. Fluoxetine-induced anaesthesia of vagina and nipples. Br J Psychiatry. 2000;176:299. PMID 10755087.

9. Michael A, Andrews S. Paroxetine-induced vaginal anaesthesia. Pharmacopsychiatry. 2002;35:150–1. PMID 12163985.

10. Safarinejad MR, Hosseini SY (2006). Safety and efficacy of citalopram in the treatment of premature ejaculation: a double-blind placebo-controlled, fixed dose, randomized study. Int J Impot Res. 18: 164–9. PMID 16107866.

11. Arafa M, Shamloul R (2006). Efficacy of sertraline hydrochloride in treatment of premature ejaculation: a placebo-controlled study using a validated questionnaire. Int J Impot Res. 18 (6): 534–8. PMID 16554853.

12. Safarinejad MR (October 2007). Safety and efficacy of escitalopram in the treatment of premature ejaculation: a double-blind, placebo-controlled, fixed-dose, randomized study. J Clin Psychopharmacol 27 (5): 444–50. PMID 17873675.

13. Bahrick AS. Persistence of sexual dysfunction side effects after discontinuation of antidepressant medications: Emerging evidence. The Open Psychology Journal. 2008;1:42-50. doi:10.2174/1874350100801010042.