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If you're taking antidepressants and experiencing sexual side effects, you're not alone. Post-SSRI sexual dysfunction (PSSD) is a condition that can occur after stopping antidepressant medication. While the exact cause is unknown, PSSD is thought to be the result of changes in brain chemistry. While there is no cure, there are treatments that can help lessen the symptoms of PSSD. If you're experiencing sexual side effects from antidepressants, talk to your doctor about treatment options.

What is POST-SSRI SEXUAL DYSFUNCTION | PSSD | Antidepressants and Persistent Sexual Dysfunction

Post-SSRI sexual dysfunction (PSSD) is a condition in which sexual side effects persist after discontinuation of SSRI treatment. PSSD was first described in the early 1990s. The most common symptoms include loss of libido, erectile dysfunction, and difficulties with orgasm. Less common symptoms include anorgasmia, decreased vaginal lubrication, and pain during intercourse.

PSSD is thought to be caused by a combination of factors, including changes in neurotransmitter levels, desensitization of serotonin receptors, and changes in gene expression. Treatment for PSSD is typically difficult and often unsuccessful. Some patients have found relief with low-dose SSRIs, 5-HTP, and other supplements.

Symptoms

The most common symptoms of PSSD include loss of libido, erectile dysfunction, and difficulties with orgasm. Less common symptoms include anorgasmia, decreased vaginal lubrication, and pain during intercourse.

PSSD can also cause psychological symptoms such as anxiety, depression, and intrusive thoughts. These symptoms can be just as debilitating as the physical symptoms.

Causes

PSSD is thought to be caused by a combination of factors, including changes in neurotransmitter levels, desensitization of serotonin receptors, and changes in gene expression.

SSRIs work by increasing the level of serotonin in the brain. This can lead to changes in the way the brain regulates sexual function. In some cases, these changes may be permanent.

PSSD may also be caused by changes in gene expression. SSRIs can cause changes in the way certain genes are expressed. These changes may be responsible for the persistent sexual side effects seen in some patients.

Diagnosis

There is no formal diagnostic criteria for PSSD. Diagnosis is typically made based on the patient’s symptoms and medical history.

A thorough medical history should be taken to rule out other potential causes of the patient’s symptoms. Physical examination and laboratory testing may also be performed.

Treatment

There is no known cure for PSSD. Treatment is typically difficult and often unsuccessful.

Some patients have found relief with low-dose SSRIs, 5-HTP, and other supplements. However, these treatments are not always effective and can often cause side effects.

Patients should work closely with their doctor to find a treatment that is safe and effective for them.

Dr Sanil Rege, Consultant Psychiatrist explains Post-SSRI Sexual Dysfunction (PSSD).

PSSD is a condition that arises after the use of SSRIs, in which patients continue to have sexual side effects after the discontinuation of SSRIs.

#postssrisexualdysfunction #pssd #antidepressants

Intro to PSSD: 00:00

Clinical Features of PSSD: 01:17

02:35 – Medications associated with PSSD

04:29 – Causes of Post -SSRI Sexual Dysfunction (PSSD)

08:07 – Diagnosing Post -SSRI Sexual Dysfunction (PSSD)

08:48 – Treatment of Post -SSRI Sexual Dysfunction (PSSD)

The prevalence of persistent sexual side effects after discontinuing SSRIs is not well known.

Common symptoms of PSSD are :

1.Genital Anaesthesia

2. Decreased libido

3. Erectile dysfunction

4. Pleasure-less or weak orgasm

5. Premature ejaculation

6. Vaginal lubrication problems

7. Nipple insensitivity

There are two types of PSSD:

1. Sexual dysfunction occurring while SSRIs are being used and persisting after discontinuing treatments

2. After the discontinuation of SSRIs as an aggravation of SSRI-induced sexual side effects.

Causes:

The exact causes are not known. some postulated mechanisms are:

1. 5HT1A persistent downregulation

2. Dopaminergic system involvement

3. HPA axis and Hormone involvement

4. Effect on Transient receptor potentials via ion channels

5. Decreased nitric oxide synthesis (NO)

6. Axonal damage (Neurotoxicity)

Diagnosis:

Challenging

Other medical conditions and psychiatric disorders should be ruled out.

Treatment:

1. Monitoring and prevention are important

2. Consider agents such as Agomelatine, Vortioxetine, Bupropion, Moclobemide, and Mirtazapine with a lower incidence of sexual side effects youtu.be/b71OzPujQDg

3. Phototherapy (case report)

4. Switch to amineptine

5. Switch to bupropion

6. Complementary therapies (insufficient evidence)

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Video transcription:

Hi everyone I’m Sanil, Rege consultant
psychiatrist today, I’ll be talking about post ssri sexual dysfunction. Pssd I’ve received a
number of requests to make this video, and I think this is a really really important topic, probably
very, very under recognized overall in psychiatry. So without further ado, let’s jump into pssd post
ssri sexual dysfunction is a condition that arises after the use of ssris, which are selective,
serotonin reuptake inhibitors, antidepressants in which patients continue to have sexual side
effects, even after they’ve stopped the medication. Now, interestingly, when I did the video on
emotional blunting, there were some comments that highlighted that, even after stopping the ssris
the emotional blunting persisted, and we know that there is a link between emotional blunting and
sexual dysfunction as well. So many individuals that have emotional blunting also tend to have
sexual dysfunction and we’ll see there are some common mechanisms there. The persistent side,
effects that have been described include, decreased libido, genital anesthesia, erectile dysfunction,
delayed ejaculation in women, loss of lubrication and anorgasmia. Now the prevalence of pssd we’re
not quite sure the difficulty is in order to define post-ssri sexual dysfunction. There are a
number of things that need to be ruled out so many a times. The sexual dysfunction can be attributed
to depression or due to other medical conditions, and that’s what makes it so difficult to diagnose
this condition and we’ll go through diagnosis in more detail. Now, a systematic review that has been
carried out. This is from the netherlands about 86 reports of persistent sexual dysfunction were
analyzed and the longest case was an individual with pssd for 23 years. The main symptoms that
were described were increased libido erectile dysfunction and an orgasmia. Some individuals
have proposed that pssd should be identified as a separate syndrome in the literature, rather
than, just putting it as a side effect of ssris, so really highlighting it as a distinct entity.
Now ssris aren’t the only medications that lead to this pssd persistent sexual
dysfunction and also can occur with five alpha reductase inhibitors that are used in
hair loss treatment, so anti-hair loss treatments, so they’ve shown so finasteride. For example, a
do test to write these shows showed persistent erectile dysfunction in some patients treated
with. These medications, other medications that have been associated with it, are isotretinoin. We
have other antidepressants that increase serotonin such as tricyclic antidepressants, clomipramine,
amitriptyline, imipramine and doxepin they’ve shown the highest incidence of sexual dysfunction.
We have done a separate video on antidepressant induced sexual dysfunction, so it’s worth
looking at that video as well. Now, the most common symptom of post-ssri sexual dysfunction,
is genital anesthesia, and this can occur in approximately 30 minutes after the first dose
of the ssri. Therefore, when clinicians initiate ssris, it’s important to ask about this particular
side effect, and not just about genital anesthesia, but also about whether there are any alterations.
In taste, for example, sensations generally smell, because these can indicate an overall change that
links to sexual dysfunction as well. To recap: the main sort of effects sexual side effects that we
see are decreased, libido, erectile dysfunction, weak orgasm, premature ejaculation, vaginal lubrication,
problems and nipple insensitivity. The classical triad that’s been described is genital, anesthesia,
loss of libido and erectile dysfunction. Psdd is classified into two types, one that is early
onset, which is sexual dysfunction occurring while ssris are being prescribed and persisting after
discontinuing treatments and the other one is the one that occurs after discontinuation,
of ssris as an aggravation of ssri induced sexual side effects. So there’s two types: now: what
are the causes of post ssri sexual dysfunction? Firstly, we know that when serotonin is elevated,
in, the synaptic cleft one of the receptors it activates is the 5-ht 1a receptor and we know
whenever a receptor is activated. The compensatory mechanism is going to be down regulation now,
in some cases it is postulated. There may be persistent down regulation of these five hd1a
receptors and five hd1a receptors actually are necessary or play a crucial role in sexual
function, particularly sexual motivation. So this persistent down regulation is postulated to be one
of. The causes also note that five hd1a activation actually increases dopamine levels, and we know
dopamine is closely linked to libido motivation, drive two hormonal changes. It’s postulated that
there may be changes in prolactin. There may be blockade or antagonism of alpha-1 adrenergic
receptors that potentially may result in decrease in dopamine. Testosterone may be involved, oxytocin
and, even nitric oxide synthesis, may be affected. We know nitric oxide is necessary in the penile
vasculature females as well. So if that’s affected, we don’t have the proper systems for both arousal
but. Also orgasm. Next neurochemical changes within the peripheral nervous system- and this is
where genital anesthesia- may be one of the characteristics. It’s important to note that most
of, the serotonin receptors are situated outside the brain. The other aspect- that’s been postulated
is, neurotoxicity very similar to what happens with mdma. Now we know with mdma. There is a
severe release of serotonin, but there’s also neurotoxicity, and we know that mdma
can result in persistent sexual dysfunction long after it’s discontinuation as well, with
axonal damage or actual nerve damage as its postulated mechanism. So a similar thing may be
happening in vulnerable individuals. It has been proposed that some individuals are more vulnerable,
to, develop the side effects, but we don’t know who may develop these side effects. So an individual
vulnerability to serotonin is being postulated now. Ssris also, we know inhibit dopamine transmission
particularly in the ventral tegmental area, which we know is part of the reward system. This is the
same aspect linked to emotional blunting. So when ssrs are prescribed, they can have a paradoxical
inhibitory effect on, say: frontal subcortical dopamine, resulting in both emotional blunting and
also sexual dysfunction. Other effects are linked to the pomc, which is propio, melanocortin and
melanocortin. Both of these are involved in sexual function overall, as part of the hypothalamus
area what’s been postulated is that serotonin may play a role in hpa axis and some dysregulation
of. These receptors in the hpa axis may result in low free testosterone levels, which we know is
again linked to libido and sexual function. Then there is something known as the transient receptor
potential. Basically, the ion channel transmission, so there may actually be a dysfunction in these
receptor potentials, so think about it from almost like an electrical stimulus that the
electrical stimulus is not passing appropriately, which results in say, erectile, dysfunction, arousal,
disturbances, etc. Let’s come to the diagnosis when we think about the diagnosis. It is a
challenging diagnosis because, in order to diagnose post-ssri sexual dysfunction, firstly, one
needs to rule out many many other things are. The causes of sexual dysfunction need to be ruled out:
pre-morbid condition, diabetes, alcohol use, smoking, etc and also depression, which is, we know, very, very
closely, linked to sexual dysfunction as a whole. Now genital anesthesia is one of those clues that
may actually point more towards a pssd rather than depression. So that’s one of the things to actually
ask proactively and bring up specifically in the discussion, as well as part of the side effects,
monitoring, so general anesthesia, and it’s also linked to the severity of pssd. So what is the
treatment? What are the options that are available for individuals that experience this very very
distressing side effect? Firstly, there has been case reports of low power, laser irradiation or
phototherapy, as they call it, directed towards the scrotal skin and the shaft of the penis in male
patient with pssd, and this patient also had penile anesthesia. Now this low power irradiation may be
linked to that sort of receptor potential that I talked about. It’s postulated to improve those
transient receptor potential, improve the iron channel conduction, but it failed to alleviate the
ejaculatory problems and the erectile dysfunction so helped in one aspect, but not in the other, so
help with the anesthesia aspect. The other aspect that has been talked about is focusing on the
serotonergic and the dopaminergic pathways, because those can be modulated through other
medications, so five ht1a agonists, adding those now note that you might recall that one of
the medications fluvoxamine, has a lower incidence of sexual dysfunction at doses of 100 milligrams,
or less because it activates the 5 ht1a receptor. On the other hand, using 5 ht-2, 5, ht-3 antagonists,
a, 5 ht2, a 5 ht, antagonist mirtazapine, for example. We know these have a lower incidence of sexual
dysfunction buspirone, which is again a 5 ht, 1a, partial agonist. We have trazodone and mirtazapine
which are 5ht 2 antagonists, a 5ht3 antagonist have been trialled, then, from a dopaminergic pathway. We
can use dopamine agonists pramipexole, which is a dopamine agonist cabergoline. These two have also
been trialled with some benefit or in some cases even little benefit has been reported. So we
know that it’s not solving the problem completely, but it’s something that can be trialled.
The other aspect is a switch from say an ssri to a dopaminergic antidepressant. Now this particular
trial is quite interesting, so they evaluated a switch from ssri to a dopaminergic antidepressant
known, as amineptine in patients with sexual dysfunction and observed that 55 of these patients,
using ssris, had persistent sexual dysfunction six months after treatment cessation, whereas only
four percent of patients who had switched to amineptine had these complaints at six months,
so a big difference, 54 versus four percent, who were basically on amineptine now. Patients
have also tried sildenafil vardenafil, as these phosphodiesterase type 5, inhibitors and
testosterone, without any significant improvement in pssd. Bupropion is another agent. We know it’s an
ndri increases, neurotransmitter increases dopamine and that can be worth a trial. Patients treated
with bupropion documented a recovery from their sexual dysfunction, particularly with
desire and their frequency of sexual activity. So it’s worth trialing and be appropriate
because. We know also, when we looked at sexual dysfunction, that bupropion was one of the only
ones that actually improved sexual function so worth a trial. In this condition and of course,
a non-pharmacological treatment would include couples therapy counseling cbt, but we know
it is a difficult condition overall to treat now. There are some complementary aspects that
have been mentioned so saffron, for example, exhibited some benefit in improving sexual arousal,
and lubrication, so that has been talked about. But again we don’t know side effects. Long
term there haven’t been many trials, so we don’t really know other ones that have been mentioned:
ketamine donepezil metformin through very, very different sort of mechanisms. So if I had to kind
of summarize in terms of diagnosis, prevalence, of course, treatment, there’s a lot that
we don’t know about this condition and without a doubt it is an extremely distressing
condition as psychiatrists. It becomes very, very important to think very carefully about the
agents that we’re choosing in treating depression. There are agents with a lower incidence of sexual
dysfunction, agomelatine mirtazapine, trazodone pupropion, of course, so it’s important to think
about, these agents overall in the treatment of depression, but also, if ssris, are prescribed now.
They are useful agents in the treatment of many many disorders, snris included. So this condition
can also occur with snris. It’s important to trazodone recognize when the s component is there. Snris
can also lead to this. It’s important that psychiatrists or doctors ask about any loss of
taste smell skin sensitivity, a genital numbness, so that we can pick this up early and consider
a change or stop that medication before sort of leaving them on. So monitoring and
prevention is probably extremely important. So I hope that this has given you an idea about
post ssri sexual dysfunction. Although it’s called post ssri can occur with snri and some
of, the other agents I talked about. If you like this video leave us a like and
don’t forget to subscribe to our channel, I look forward to seeing you in another
video, soon take care and stay safe, bye.

What users commented:

I have to say id heard about this before and it was the main reason i dont want to take them i dont like the thought that they are taking away my sex drive pretty much i just cant see that id be less depressed at that point

Has anybody cured from this? I’ve hardly seen any cases of people recovering from this, including on the reddit forum

Thank you for posting this video! This condition really needs to be researched into so treatment can be developed!

Is it true that they prescribe these drugs as treatment for paraphilic sexual behavior?

Gracias por hablar sobre pssd tenía 18 años cuando esto destruyo mi vida acá en México es menos hablado sobre esto

Funny how we don’t know the treatment but create the drug that is responsible and have knowledge of the mechanism of action, how dopamine and norepinephrine etc ., are affected. I might be worried for nothing but I find that very unethical and appalling.

Thank you for ur supoort to show the world about this issues

I have PSSD after Brintellix. Should I still consider Bupropion?

I didn’t spell trials in the comments I made thank you for responding Doctor!let me also share some sudjestion for my fellows(vets)that have expressed these symptoms!Please consult your physician before you attempt these sudjestions!for my pain(CBD )oils I choose organic pure oils as an alternative and have found help for erectile dysfunctional conditions so fare the Wholelistic way !I’ll share those for you at latter time if you will thanks agin Doc!

Having you as my doctor is also a positivity that I don’t really have to bother about any sickness or virus,because your herbal medication of erectile dysfunction has shown not only me but the world how good your products are and I’ll keep recommending you..

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I wish this issue gained more strength here in Brazil, many people are going through this here, but most psychiatrists are unaware of the PSSD.

I’ve seen success stories of people who used antidepressants saying their sex drive actually improved on SSRI (Lexapro), honestly after seeing these reviews all the time I’m thinking that PSSD is very rare , i wish it was known how rare it is tho…

Carefully I look see and understanding I have the ability to archive more than I imagined thanks to Dr osaye, I was able to get rid of my erectile dysfunction which I thought was permanent was not,just after taking his medication I could firmly control my erections..

CRIMINALI

Is it possible that tretinoin that is prescribed by dermatologists can cause PSSD ? It’s not a pill, you apply it on your face basically, isotretinoin causes PSSD so that’s why I’m worried about using it on my face

Please could you kindly discuss a video talk on Emetephobia? (Fear of V0miting) I would be especially keen to look at it all from a psychiatrist perspective

We have a group of more than 170 people from all around the world having post finasteride syndrome. (Finasteride/dutesteride for hair loss/alopecia)The side effects are also almost same as pssd, loss of lobido, no sexual desire, depression, brain fog, i am also victim. Ruined our life. Dr. Melcangi is doing research but only for pfs.

Thank you soooo much for addressing this topic. All of the doctors we have been to know nothing about this. Thanks especially for addressing possible treatments. Now if we can only find a doctor that will address the issues.