In Spain, no medical specialty includes training in sexology. This is probably why sexuality remains taboo in consultations: most doctors consider it something intimate, not linked to the patient's health. However, the reality is very different: sexual problems have a great impact on people's health and certain medical decisions and treatments create or interfere with these problems.
This is emphasized by psychiatrist Ángel Luis Montejo (Salamanca, 1959), creator and scientific director of the Spanish Association of Sexuality and Mental Health (AESexSAME), which every year organizes a conference aimed primarily at primary care doctors and psychiatrists to convince them that, Just as they ask their patients about their diet or sleeping habits, they should ask them about their sexual life, especially before prescribing certain drugs, such as antidepressants. Because, he warns, the patient's life as a couple, his emotional health, and even his life or that of other people may depend on it.
Life?
I had a patient in consultation who had tried to commit suicide, and it turned out that he wanted to die because he thought that his wife no longer loved him, because he saw that she never wanted to have sex with him and when they had sex she didn't enjoy it; and what happened was that his wife was being treated for depression. That is why it is very important that those who prescribe antidepressants investigate the patient's sexual life before and after treatment.
What is the relationship between depression and sexual dysfunction?
They share a bidirectional relationship, such that depression is associated with a 50% to 70% increased risk of sexual dysfunction and sexual dysfunction increases the risk of depression by 130% to 200%.
So, can dysfunction be a symptom of depression?
It can be a symptom and a consequence, both. In general, depression is a state of emotional failure dominated by sadness and the inability to enjoy any type of pleasure, including sexual pleasure. But there are depressed people who have normal sexual function and who, however, get much worse with treatment, which affects their quality of life and their prognosis.
Because?
The most commonly prescribed antidepressants, especially by primary care doctors, are the successors to the famous Prozac. They have in common that they increase the functionality of serotonin, which is an anxiety inhibitor, it takes away fear, obsessiveness and makes problems worry you less, but it is also an anti-impulsive that makes you calmer, more relaxed and with less appetite, food and also sexual. What happens with this type of antidepressants almost immediately is that it anesthetizes the pleasure signals from the genital organs to the brain nuclei and orgasm or ejaculation is greatly delayed. So much so that some people do not perceive it and feel that they can no longer make love. Added to this, after a few weeks or months of treatment, is the problem of loss of desire.
How does that impact someone who already suffers from depression?
It affects unequally depending on the person and depending on the relationship. People who have an active sexual life find that suddenly their desire has disappeared and that affects the couple and, sometimes, a lot. There are those who go from being a sexual couple to living together as if they were brothers or friends, and that can cause conflicts or be the trigger for them to separate, because they do not always tell each other what they are going through and when they see that there is no desire, they they confuse with falling out of love. Because the sexual function is not a luxury, secondary function, but rather it is something that unites and links couples.
Does it affect men and women equally?
No, men complain more; women only when the dysfunction is quite intense and they had a very active sexual life prior to depression. Erectile dysfunction and premature ejaculation are the most common disorders in them, while low sexual desire and altered sexual arousal are common in them. Age also has an influence: postmenopausal women tolerate it better that sexual life is secondary. But young sexually active people (80% are, whether they have a partner or not) find it very annoying, they see it as a major quality of life problem that can hinder their relationships and more than half stop treatment as soon as they are found. a little good
With what consequences?
Premature abandonment - the WHO recommends maintaining antidepressants for at least six months if it is the first episode and between one and two years if it is the second - carries a greater risk of relapse, sick leave, health costs and poorer quality of life. Therefore, before prescribing them, you must ask the person what their sexual life is like and how it would impact them if it were affected by the treatment. And if he says he couldn't stand it, it is better to prescribe other antidepressants that act through pathways other than serotonin and do not cause sexual dysfunction or do so to a lesser extent.
Equally effective?
Agomelatine or bupropion may not have as significant an antidepressant effect as serotogenics, but for people who care about their sexuality, they should start there. And vortioxetine, which is serotogenic but modulates neurotransmitter activity, also produces less sexual dysfunction, and patients who switch to it have been seen to improve.
That is why patients' sexual lives must stop being taboo and doctors must ask before and after any treatment if they are satisfied with it. Because it's not just antidepressants; Antipsychotics and drugs for hypertension or heart attack also increase the risk of sexual dysfunction, and if you have asked before and after prescribing them about the patient's sexual life, without being intrusive you will realize if the treatment causes problems for that person. person and you can look for alternatives.
