Post-Selective Serotonin Reuptake Inhibitor Sexual Dysfunctions (PSSD): Clinical Experience with a Multimodal Approach
Yacov Reisman; Tommaso Benedetto Jannini; Emmanuele Angelo Jannini
Journal of Men's Health2022
In plain terms
Researchers looked back at 12 men seen at their clinics in 2019–2020 with sexual problems that began on an antidepressant (mostly SSRIs) and lasted after stopping it. Each man followed a six-month programme combining exercise and lifestyle advice, two dietary supplements and talking therapies, and some also took an erection drug or another medicine called buspirone. On questionnaires about desire, erections, orgasm and satisfaction, the group's average scores were higher after six months than before, and no one dropped out.
What it doesn’t show: It can't show that the programme caused the improvement or which part of it helped: there was no comparison group, and the authors themselves say the problems may have eased on their own or through a placebo effect.
Summary (paraphrased)
The authors reported their clinical experience managing 12 men with PSSD (selected from 17 referred) with a six-month multimodal protocol combining lifestyle and exercise advice, L-arginine and L-carnitine supplements, and pharmacological and behavioral interventions given according to each patient's needs. Correcting hormonal abnormalities was part of the protocol, but none of the men's laboratory results required it. They characterized PSSD as a heterogeneous set of disorders that can begin during SSRI/SNRI treatment and persist afterward, commonly accompanied by marked distress and poor quality of life. All IIEF-15 domain scores and the male Orgasmometer score rose from baseline to 6 months, with erectile function on average in the mild-ED range at both points, and no patient dropped out.
Evidence
Extracted from the full text; page numbers refer to the paper. The library’s own notes are labelled as such.
- Design
- Case seriesRetrospective, uncontrolled before-and-after case series of men treated with a six-month multimodal protocol
- Setting
- The authors' sexual-medicine clinics (affiliations in Amstelveen, the Netherlands, and Rome, Italy); men from 7 European countries, 8 of the 17 referred assessed remotely because of COVID-19; July 2019 to July 2020
- Population
- Men aged 18–60 with sexual dysfunction that began while taking one SSRI or SNRI and persisted after stopping it at least 1 month before interview; no sexual dysfunction before treatment; no medical condition, medication or addictive substance use associated with sexual dysfunction; "high probability" of PSSD by published criteria. The Beck Depression Inventory-II was used to exclude co-existing depression. Mean age 31.3 ± 6.21 years; mean BMI 25.3 ± 2.18.
- Size
- 12 · 12 men selected of 17 referred with suspected PSSD
- Exposure
- Six-month protocol: lifestyle advice (no drugs of abuse, no more than 2 alcohol units a day, stopping nicotine); supervised aerobic exercise, 40 minutes 4–5 times a week; L-arginine 3 g/day and L-carnitine 2 g/day for all; correction of hormonal abnormalities if needed (none was); PDE-5 inhibitors (4 men); buspirone 5 mg three times a day (5); mindfulness and cognitive-behavioural therapy (10); sex therapy and sensate focus (2). Visits every 2 weeks.
- Compared with
- None; each man's own baseline scores
- Outcome
- IIEF-15 domain scores (erectile function, orgasmic function, sexual desire, intercourse satisfaction, overall satisfaction) and the male Orgasmometer (a 0–10 orgasm-intensity scale), at baseline and 6 months. Paired t-tests with bootstrapped 95% confidence intervals (3,000 samples); no p-values are reported.
- Follow-up
- 6 months; no drop-outs
Key results
- Erectile function domain 19.11 (SD 4.76) at baseline and 23.69 (SD 3.12) at 6 months, difference 4.58 (95% CI 1.50–7.51); on average both values fall in the mild-ED band · p. 3; Table 4, p. 6
- Sexual desire 3.78 to 5.53 (difference 1.75; 95% CI 1.08–2.58); orgasmic function 4.67 to 5.83 (1.16; 0.50–2.17); intercourse satisfaction 5.22 to 7.88 (2.66; 1.83–3.58); overall satisfaction 3.56 to 6.22 (2.66; 2.42–2.83). Table 4 gives the differences as negative (baseline minus follow-up); recomputed differences match · Table 4, p. 6
- Orgasmometer 3.22 (SD 1.42) at baseline and 4.39 (SD 1.19) at 6 months, difference 1.17 (95% CI 0.09–1.81) · Table 4, p. 6
- Symptoms at presentation: loss of libido in 11 of 12; reduced sexual activity, pleasureless orgasm and loss of morning erections in 9 each; genital numbness in 8; ED and a brain–genital "disconnection" in 6 each; emotional blunting and reduced orgasm intensity in 5 each. Most complaints began on the drug and continued after stopping; pleasureless orgasm (3 men), genital numbness (3), memory impairment (2) and fatigue (2) appeared after withdrawal · p. 3; Table 3, p. 5
- Antidepressants: escitalopram 5, fluoxetine 2, paroxetine 2, sertraline 1, venlafaxine 1, amitriptyline 1; taken for a median 12 months (range 3–36) and stopped a median 10.5 months (range 3–26) before assessment · Table 2, p. 4
- All men adhered to the programme and none dropped out; they needed encouragement in the first 2–3 months, when improvement was limited. Hormone and other laboratory values were within normal ranges and none needed treatment · pp. 3–4; Table 1, p. 3
Limitations the authors note
- Retrospective, with self-administered outcome measures; recall bias may affect the results
- Small and not randomised
- No control group, so spontaneous remission or a placebo effect cannot be excluded; caution in generalising; no room for causal inference
Also worth weighing (library’s note)
- Several components were given together (exercise, alcohol and nicotine limits, supplements, drugs, psychological therapy), so any change cannot be attributed to one of them
- The authors cite the men's adherence as suggesting the treatment was effective; adherence does not measure benefit
- Inclusion required one SSRI or SNRI, but one man had taken amitriptyline, a tricyclic
- IIEF items are answered on whole-number scales, so a mean of 12 men's domain scores should be a multiple of 1/12. All five baseline domain means in Table 4 (e.g. 19.11, 3.78, 3.56) are instead multiples of 1/9, and four of the five follow-up means fit neither; the paper reports no missing questionnaires, so how many men contribute to Table 4 is unclear
- Beck Depression Inventory-II scores, used to exclude depression, are not reported
- Small percentage slip; 2 of 12 men in sex therapy is given as 16.3% (2 of 12 is 16.7%)
Funding: No external funding Interests: The authors declare no conflict of interest, but disclose that E. A. Jannini has been a speaker and/or paid consultant for Bayer, Ibsa, Lundbeck, Menarini, Otsuka, Pfizer, Shionogi and Viatris, and Y. Reisman a speaker and/or consultant for Lundbeck, Pfizer, Coloplast, Ohhmed and Besins. Reisman is an editorial board member and guest editor of the journal, with no involvement in this article's peer review.
What it can support (library’s note): That 12 men meeting PSSD criteria reported higher sexual-function and orgasm-intensity scores after six months of a combined lifestyle, supplement, drug and psychological programme. It cannot show that the programme caused the change, or which part of it helped.
Why it’s in the corpus
A senior sexual-medicine group's treatment framework for PSSD. Complements the De Luca cohort with a clinical-management perspective.
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