Depression and Erectile Dysfunction

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Depression and erectile dysfunction (ED) clearly are associated. Although urologists and psychiatrists have long recognized that antidepressant medications affect erectile function negatively, the interplay between the two conditions remains underappreciated. Psychiatrists may be reluctant to question a patient in detail about ED, and urologists seldom perform a formal assessment of the presence of depression in patients who have ED. This article gives a quick overview of the relationship between these two conditions and provides the clinician with the knowledge required to effectively manage ED with comorbid depression.

Section snippets

Epidemiologic association

Depression is an affective disorder with a heterogeneous manifestation and multifactorial etiology. Excluding bipolar (manic-depressive) disorders, clinical depression generally is classified as major depressive disorder (MDD) or dysthymia, depending on severity. In this article we use depression to refer to both conditions. The hallmark symptoms of depression include feelings of sadness and hopelessness, loss of interest in pleasurable activities (anhedonia), changes in appetite, disturbance

Causality

Epidemiologic data and common sense suggest that the relationship between ED and depression is bidirectional. In the model proposed by the authors of the MMAS study, ED and depression are depicted as two conditions that reinforce each other in a downward spiral [1]. Additional factors, such as lifestyle, social context, and medical interventions, can hasten or reverse this interaction [1]. The underlying mechanism of the link between ED and depression, however, has not been established. In

Hypogonadism, depression, and erectile dysfunction

Hypogonadism and depression share several symptoms, such as loss of libido, fatigue, poor appetite, and dysphoria [6], [30]. They also may be linked epidemiologically. In a study of 856 men in southern California, depressed mood (measured by the Beck Depression Inventory questionnaire) correlated with lower bioavailable testosterone levels, independent of age [31]. In a cohort of 278 men attending a single hospital, the 2-year incidence of depression was 21% in men who had hypogonadism (defined

Antidepressants and erectile dysfunction

Sexual dysfunction is associated often with depression. Antidepressant therapy is highly effective in treating depression. Unfortunately, improvement of sexual function as a result of antidepressant therapy is seldom seen (with the notable exception of premature ejaculation) [46], [47]. Rather, exacerbation of de novo development of sexual dysfunction can occur as an untoward side effect of antidepressants [48], and the incidence of sexual dysfunction in men who are on antidepressant therapy is

Management of antidepressant-associated erectile dysfunction

The management of the sexual side effects of SSRIs has been reviewed extensively in the psychiatric literature [68], [69], [70]. This falls into two general categories: manipulation of psychotropic drugs and ED-directed therapy.

Summary

Comorbid ED and depression are seen commonly in practice. The association between the two conditions is bidirectional, with each factor reinforcing the other. Additional factors, such as hypogonadism or cardiovascular disease, could contribute to the vicious cycle. Medical antidepressant therapy can exacerbate ED. The various classes of antidepressants vary in their sexual side effect profile, with the conventional SSRIs (paroxetine, fluoxetine, sertraline) being the worst offenders. Management

References (100)

  • E.M. Hull et al.

    Dopamine and serotonin: influences on male sexual behavior

    Physiol Behav

    (2004)
  • M.J. Millan et al.

    5-HT2C receptors mediate penile erections in rats: actions of novel and selective agonists and antagonists

    Eur J Pharmacol

    (1997)
  • G.J. Ahn et al.

    DA-8159 reverses selective serotonin reuptake inhibitor-induced erectile dysfunction in rats

    Urology

    (2005)
  • J.L. Pryor et al.

    Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials

    Lancet

    (2006)
  • M.J. Taylor et al.

    Strategies for managing antidepressant-induced sexual dysfunction: systematic review of randomised controlled trials

    J Affect Disord

    (2005)
  • I.R. Edwards

    Withdrawing drugs: nefazodone, the start of the latest saga

    Lancet

    (2003)
  • A.B. Araujo et al.

    The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging Study

    Psychosom Med

    (1998)
  • J.M. Ferguson

    The effects of antidepressants on sexual functioning in depressed patients: a review

    J Clin Psychiatry

    (2001)
  • A.N. Rothschild

    Sexual dysfunction associated with depression

    J Clin Psychiatry

    (2001)
  • D.P. Moore et al.

    Handbook of medical psychiatry

    (2004)
  • R.C. Kessler et al.

    The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)

    JAMA

    (2003)
  • R.C. Kessler et al.

    Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

    Arch Gen Psychiatry

    (2005)
  • S.H. Kennedy et al.

    Antidepressant-induced sexual dysfunction during treatment with moclobemide, paroxetine, sertraline, and venlafaxine

    J Clin Psychiatry

    (2000)
  • L.R. Derogatis et al.

    The DSFI: a multidimensional measure of sexual functioning

    J Sex Marital Ther

    (1979)
  • E.A. Nofzinger et al.

    Sexual function in depressed men. Assessment by self-report, behavioral, and nocturnal penile tumescence measures before and after treatment with cognitive behavior therapy

    Arch Gen Psychiatry

    (1993)
  • R.J. Mathew et al.

    Biological symptoms of depression

    Psychosom Med

    (1979)
  • R.J. Mathew et al.

    Sexual dysfunctions in depression

    Arch Sex Behav

    (1982)
  • L.R. Derogatis et al.

    Psychopathology in individuals with sexual dysfunction

    Am J Psychiatry

    (1981)
  • S.P. Roose et al.

    Reversible loss of nocturnal penile tumescence during depression: a preliminary report

    Neuropsychobiology

    (1982)
  • A. Steiger et al.

    Studies of nocturnal penile tumescence and sleep electroencephalogram in patients with major depression and in normal controls

    Acta Psychiatr Scand

    (1993)
  • L.S. Radloff

    The CES-D scale: a self-report depression scale for research in the general population

    Applied Psychological Measurement

    (1977)
  • R. Haringsma et al.

    The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology

    Int J Geriatr Psychiatry

    (2004)
  • R.C. Rosen et al.

    Men's Attitudes to Life Events and Sexuality (MALES) Study. The multinational Men's Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population

    Curr Med Res Opin

    (2004)
  • J. Kantor et al.

    Prevalence of erectile dysfunction and active depression: an analytic cross-sectional study of general medical patients

    Am J Epidemiol

    (2002)
  • A.W. Meisler et al.

    Depressed affect and male sexual arousal

    Arch Sex Behav

    (1991)
  • E. Koukounas et al.

    Sexual and emotional variables influencing sexual response to erotica: a psychophysiological investigation

    Arch Sex Behav

    (2001)
  • S. Stoleru et al.

    Neuroanatomical correlates of visually evoked sexual arousal in human males

    Archives of Sexual Behavior

    (1999)
  • I. Goldstein

    The mutually reinforcing triad of depressive symptoms, cardiovascular disease, and erectile dysfunction

    Am J Cardiol

    (2000)
  • D.L. Musselman et al.

    The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment

    Arch Gen Psychiatry

    (1998)
  • M. Wald et al.

    Testosterone replacement therapy for older men

    J Androl

    (2006)
  • E. Barrett-Connor et al.

    Bioavailable testosterone and depressed mood in older men: the Rancho Bernardo Study

    J Clin Endocrinol Metab

    (1999)
  • M.M. Shores et al.

    Increased incidence of diagnosed depressive illness in hypogonadal older men

    Arch Gen Psychiatry

    (2004)
  • A.A. Makhlouf et al.

    Hypogonadism is associated with overt depression symptoms in men with erectile dysfunction

    Int J Impot Res

    (2007 Aug 16)
  • S.N. Seidman et al.

    Low testosterone levels in elderly men with dysthymic disorder

    Am J Psychiatry

    (2002)
  • A.M. Traish et al.

    Effects of medical or surgical castration on erectile function in an animal model

    J Androl

    (2003)
  • K. Baba et al.

    Delayed testosterone replacement restores nitric oxide synthase-containing nerve fibres and the erectile response in rat penis

    BJU Int

    (2000)
  • C. Wang et al.

    Transdermal testosterone gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men

    J Clin Endocrinol Metab

    (2000)
  • A.D. Seftel et al.

    Restorative increases in serum testosterone levels are significantly correlated to improvements in sexual functioning

    J Androl

    (2004)
  • R.C. Schiavi et al.

    Effect of testosterone administration on sexual behavior and mood in men with erectile dysfunction

    Arch Sex Behav

    (1997)
  • C. Wang et al.

    Testosterone replacement therapy improves mood in hypogonadal men–a clinical research center study

    J Clin Endocrinol Metab

    (1996)
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