Sex Rx: Tricyclic antidepressants and your sex life

Type of medication:

Medications and their commonly used brand names:

What they are most often prescribed for:

• Depression
• Obsessive-compulsive disorder (clomipramine)

How they work:

Possible sexual side effects:

• Decreased sexual desire
• Impotence
• Difficulty reaching orgasm
• Painful, delayed, or inhibited ejaculation

How they cause sexual problems:

Treatment options:

Wait it out

As you adjust to your new medication, the sexual side effects may go away.

Time your dosage

Some anecdotal reports have shown sexual side effects to occur most often when a tricyclic is taken just before sexual activity. Therefore, taking your regular dose after sexual activity or several hours before, rather than immediately before, may help to prevent adverse effects.

Switch medications

Since the medical response to tricyclics and other drugs to treat depression can vary among people, a physician will consider the severity of your depression as well as your response to the drug before switching to another.

When switching is appropriate, your main options are:

• A less anticholinergic tricyclic - for example, switching from amitriptyline, a highly anticholinergic drug, to desipramine or nortriptyline.
• Bupropion (Wellbutrin) - this medication may actually have prosexual effects. However, it is not recommended for patients with bulimia, panic disorder, seizure disorder, or obsessive-compulsive disorder.
• Citalopram (Celexa) - a selective serotonin reuptake inhibitor (SSRI), which is another class of antidepressants. This class may also cause sexual dysfunction, but citalopram is one of the least likely medications to do so.
• Fluvoxamine (Luvox) - also an SSRI that is less likely to cause sexual dysfunction.
• Nefazodone (Serzone) - this is an SSRI, but it blocks only one of the serotonin receptors, whereas other SSRIs block several. It can be used to treat depression and has been found to cause few sexual side effects.
• Mirtazapine (Remeron) - similar to nefazodone, but without as much scientific proof behind it.

Try an antidote

This involves maintaining your current level of tricyclic antidepressant, while adding a second medication to offset the sexual side effects. Keep in mind that these antidotes can also cause side effects.

The three drugs that have shown the most promise as antidotes are:

• Buspirone (BuSpar) - this drug should not be taken in doses exceeding 30 mg/day. BuSpar is generally safe, although the potential side effects include: sedation, akathisia (uncontrollable motor restlessness), dizziness, insomnia, nervousness, GI disturbance, nausea, and headache.
• Cyproheptadine (Periactin) - this is an antihistamine that may be helpful as an antidote
• Sildenafil (Viagra) - commonly known as a treatment for male impotence, sildenafil may also help women with sexual dysfunction. However, the expense of this drug may prohibit many patients from using it.

Take a drug holiday

This involves taking your usual Thursday morning dose and then nothing again until noon on Sunday. Drug holidays have been studied mostly with SSRIs, but in theory, could work for tricyclics as well.

However, this technique carries the risk that you may feel well enough during the short drug holiday to discontinue your medication all together, which can lead to a relapse. It is essential to discuss this option with your physician before trying it.

Consider herbal supplements

The efficacy of herbal supplements to treat the sexual side effects of tricyclics is not clear. There have not been any double-blind clinical studies, only case reports, some of which have shown positive effects and others that have shown no effects. Care should also be taken with herbal products because they are not strictly regulated, as drugs are.

Two herbs commonly used to resolve the sexual dysfunction associated with tricyclics are:

• Yohimbine
• Ginkgo

Try psychotherapy

Talk therapy can be very effective for the treatment of depression and can eliminate the need for medications.