By Tom Rue, M.A., LMHC, CASAC
Reasons given by people suffering from mood or anxiety disorders, as well as other mental health conditions, for stopping medication against or without their doctor's advice often include complaints about sexual side-effects of the drugs used to treat these conditions (Manisses, 2002).
Selective serotonin reuptake inhibitors (SSRIs), which are currently a first line treatment for many mental health conditions, as well as most antipsychotic medications are notorious for causing or contributing to erectile dysfunction, vaginal dryness, reduced desire, orgasmic dysfunction, menstrual irregularities, or other sexual problems (Smith, 2002). It is noteworthy that some street drugs (opioids, for example, as well as addiction treatments methadone and buprenorphine) can also produce decreased libido and/or sexual dysfunction.
Other drugs known to cause sexual problems include some prescribed for hypertension, diabetes, cancer, urinary frequency, birth control (ironically), and a host of other medical conditions. This short article will look at the mental health perspective. However, it is possible that similar concepts may be applied to other situations and conditions as well. Additional side-effects attributed to antidepressant medications sometimes given as reasons for non-compliance include weight gain, dizziness, or feelings of sedation.
For both women and men, the loss or impairment of sexual function such as reduced interest in sex or ability orgasm or ejacuulate, can become depressing or at least distressing in and of itself. However, before taking action it must be clarified whether the sexual dysfunction is a result of the antidepressant or of the underlying depression. Additionally, simply stopping therapeutic medication on one's own is not a useful solution since it can lead to depressive relapse or choosing to self-medicate emotional pain with alcohol or illicit drugs, brought about by the underlying chemical or emotional imbalance which the medication was intended to treat. In the case of alcohol, which itself is a depressant, as well as with other mood-altering drugs, the emotional fallout can be a devastating self-perpetuating downward spiral.
Sex can feel like an awkward topic to discuss, even with a counselor or psychiatrist -- especially for the first time. The subjects of sexuality and of sexual dysfunction in western society are surrounded by shame, religious guilt, machismo, and denial. Not just patients, but even some physicians may find themselves uncomfortable inquiring about sexuality, concluding that if the patient is not complaining there must not be a problem (Fallowfield, 2002; Medscape, 2002 and 2004; Jack, 2005).
Ultimately, the responsibility falls to the person in treatment to make the problem known to his or her healthcare professional, particularly when the problem is caused or exacerbated by the treatment being provided. For those who are reluctant to talk about sexual issues with their doctors, perhaps another place to start is with a counselor or psychotherapist instead. Some studies suggest that antidepressant medications may be most effective when taken at the same time as engaging in cognitive-behavioral therapy or other forms of counseling (Fava, et al., 2004).
Other researchers found no significant difference between those who took medication and those who engaged in CBT for social phobia (Davidson, et al., 2004).
Psychotropic medications are most commonly prescribed by psychiatrists, but bringing compliance-related issues up in counseling first, and discussing what alternative treatments might exist, may be easier for some than in the relatively rushed setting of a doctor's office visit.
When discussing sexual issues in a professional setting, the patient or client should understand that there is nothing that he or she could have to say that an experienced professional has not been heard before or is unable to understand; and that human sexuality is as legitimate a focus of treatment as depression, anxiety, diabetes, heart disease, or any other condition of the body or spirit.
Patients who do not feel comfortable bringing up the subject of sex in such a setting would benefit from asking themselves why they feel this way. If the answer lies with the perceived manner or attitudes of the doctor or counselor and this does not seem like something that can be solved by discussion, perhaps a change in healthcare providers is in order. However, if the is comes from embarrassment or privacy issues, then the challenge is for the client to examine his or her priorities as matters of stability, adjustment, and personal growth.
To use erectile dysfunction or vaginal dryness as two examples, at the beginning of the office visit when the doctor or therapist asks how things are, the patient might explain that a concern has come up about the medication that she or he wants to discuss. Once the point of thinking about quitting the medication because of sexual problems has been reached, it certainly is worth talking about the idea first.
A few choices that might be considered (Rosenblate, 2001). include a dose adjustment, augmenting hormones, or trying alternative treatment approaches to either offset a reduction in antidepressant dose or perhaps to take its place. Wellbutrin is an antidepressant that can be taken at the same time as SSRIs because it acts on a different neurotransmitter in the brain.
Scheduling doses early in the day when sex is planned in the evening, or of taking a "drug holiday" can also be discussed with the prescribing doctor. (See "Drug Holiday" in Google for popular references to this practice.)
Alternative treatments, regular exercise (Piette, 2005; Tkachuk & Martin, 1999), changes in diet, massage therapy (Touch Research Institute, 2005), phototherapy (particularly for seasonal depression, also known as seasonal affective disorder), acupuncture and other methods.
Counseling sessions can be a setting in which to explore the roots of the discomfort that the person has with discussing sexuality. This can be done either individually, or in couples counseling. Although sexual issues between parents are typically not discussed outside the marital dyad, when there are children in the home there may be famiy issues that impact on intimacy. Family therapy has been shown to be a useful adjunct in the treatment of mood disorders in parents.
Generally, an important task is to help the sexual partner understand the medical causes of the difficulties, and that sexual attractiveness and love have not diminished. Local chapters the National Alliance for the Mentally Ill or other face-to-face or online groups can also be useful sources of interpersonal support and information.
The act of talking openly with a partner about sexual fears or worries builds intimacy and strengthens relationships. This may be harder for some men than women in western society, but sex is a sensitive area for anyone. Communication can lead to discoveries that what has worked in the past in bed might need some adjustment. Regardless of whether medications are a contributing factor or not, aging, chronic pain, surgery, injuries, and other physical changes can also impact sexual performance and may also require open discussion.
Masturbation, which need not necessarily be a solitary activity, either with or without the use of erotica, may help with physical arousal and orgasm. Changing the setting can also make a difference. Maybe making out in the living room, or in the back seat of an old Chevrolet, will help to get things flowing. Whenever disability affects sexual functioning, it is important for both partners to realize that an active and happy sex life need not necessarily include erections, bodily juices, or even orgasm. Of course all these processes are desirable, but they are certainly not essential elements for mutual pleasure and loving, or to human fulfillment at any age or in either gender.
One common sexual dysfunction in men is rapid climax. Surprising to some is that Prozac and similar SSRI drugs are sometimes prescribed specifically to treat premature ejaculation, since part of the drug's effect is to slightly decrease physical sensitivity in the penis. In such cases, the so-called "sexual side-effect" of the medication actually becomes the treatment objective. Seen in this manner, the delay caused by the medication can be a positive thing, extending the time to male orgasm, which can intensify pleasure for both.
Women who find lubrication has decreased during intercourse, either because of medications, because of age, or for other reasons, can feel safe and confident using commercially available moisteners like KY Jelly. For most problems there is a solution. For those which can not be solved, acceptance becomes the answer.
Enjoyment of life, including but certainly not limited to sexual encounters, helps improve mental health generally. Meditation, relaxation, breathing exercises (including Tantric Yoga), long walks, or creative expression (writing, painting, music, drama, etc.) can help a person to feel more appreciative and alive, which most often carries over into the bedroom.
As in most cases in life, people can make conscious choices about whether to view experiences positively or negatively, and similar results will follow.
Whether it be a sexual partner; or a doctor or a psychotherapist, there is no way for anyone else to know that a hidden problem exists as long as it remains undisclosed. Self-disclosure and openness are equally essential to the nurturance of intimate relationships as they are to a therapeutic alliance aimed at health and personal growth.
The key is self-advocacy and to keep talking.
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