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e are ‘programmed’ to be happy, at least some of the time. Most of us have a place on the spectrum between happy and sad. Equally, some of us are laid-back, while others are anxious. Most are in between.
It is obvious therefore that we human beings are very complex and have a range of emotions, which can be positive or negative, depressed or happy. This range of emotions has two aspects.
First of all, we have what is called the ‘normal’ range. So it is Monday morning, you did not sleep well last night, it is raining and the car will not start; naturally, you feel depressed — depression with a small ‘d’. Depression with a small d is an appropriate emotional response to a particular situation.
Overwhelming depression with low mood, reduced energy and interest, loss of the joy in life, and even thoughts of suicide, is defined as depression with a capital ‘D’.
As a GP, I practice in a holistic way; a family doctor knows their patient, their circumstances, work, family and history.
Intervention in depression may not necessarily involve medication, but exercise and advice on sorting out a family or work problem may be sufficient. Something as simple as normalising the patient’s feelings and reassuring them that many others suffer or have suffered similar symptoms can be enough to solve the problem.
Medications are sometimes appropriate but we need to remember that they can also have side-effects.
Unfortunately, some of the pharmacological treatments for depression have a negative effect on human sexuality. As Danish psychiatrist and sexual medicine expert Dr Annamaria Giraldi points out: “People with psychiatric problems are also sexual beings. Patients with psychiatric problems often have more sexual problems than people without psychiatric problems. Psychopharmacological treatment often induces sexual problems, which may cause premature discontinuation of medication.”
Quoting Dr Giraldi again, there is a bidirectional association between depression and sexual dysfunction. So patients presenting with sexual dysfunction should be routinely screened for depression and patients presenting with depression should be routinely screened for sexual dysfunction.
So you have assessed your patient and are recommending an antidepressant. How to mitigate any side-effects that may crop up?
Advising the patient of what may happen is a good way of ensuring they will not stop the medication without telling you.
Unfortunately, most antidepressants act on the serotonergic, noradrenergic and dopaminergic system. Sexual behaviour is mainly inhibited by antidepressants, which increase serotonin neurotransmission via serotonin reuptake inhibition and can cause sexual problems.
Agents that mainly increase the levels of dopamine and noradrenaline have fewer side effects. One drug in this category is readily available in Ireland. I frequently switch patients who come in having experienced sexual side-effects, which are unacceptable to them, onto mirtazapine, and sometimes this has the desired effect and solves the problem. Unfortunately, however, mirtazapine may cause weight gain and people who have experienced low mood and reduced self-esteem will find the fact that the medication is making them put on extra weight unacceptable. What can we do with them?
Up until now, dealing with sexual side-effects involved a good degree of creativity, changing medication, agreeing on drug holidays, and in the final analysis perhaps being unsuccessful — not a satisfactory situation.
So your patient has unacceptable, distressing side-effects, which have wrought havoc with their sex life, devastated their relationship and exacerbated rather than relieved their depressive symptoms — where does that leave you?
A formulation of St John’s Wort (Pacifa) has recently been licensed for prescription-only use in Ireland as an antidepressant; it certainly looks to me like a solution to many of our problems. While St John’s Wort has a weak antidepressant action, it therefore may only benefit people with depression with a small d.
However, the early stages of depression may have symptoms that are mild; this may be a depressive illness in evolution, which may in time become depression with a capital D. St John’s Wort has been extensively researched and was found to be as effective as standard antidepressants, and to have fewer side-effects than standard antidepressants.
The Cochrane review group looked at 29 studies in over 5000 patients with depression and confirmed the above.
An extract of St John’s Wort seems to be more acceptable to patients than what could be described as ‘mainstream’ medicine, even though many of our medications were originally derived from herbs.
In the studies on St John’s Wort I have looked at to date, I found no references to sexual side-effects. I have therefore prescribed it for young people who are sexually active, and indeed older people, because there is no date at which sexual activity should stop.
It remains to be seen how well this particular formulation of St John’s Wort (Pacifa) will perform. I am sure there will be clinical trials measuring its effectiveness and I hope that sexual side-effects will be looked out for and reported, should they occur.
In the meantime, however, I am happy to have access to a medication that is less likely to cause the devastation of sexual side-effects on patients who are already suffering from depression.