[NEJM]Question of the Week

https://knowledgeplus.nejm.org/question-of-week/1319/answer/C/

 

A 25-year-old man reports that he has felt depressed for the past 3 months. He awakens much earlier than usual, feeling fretful. He has low energy, poor concentration, and limited interest in his usual activities throughout the day. He also notes that since becoming depressed, he has had difficulty having sexual relations with his steady girlfriend, including decreased ability to obtain or maintain an erection and a decreased frequency of orgasms.

Which one of the following treatment strategies is most appropriate to restore this patient’s erectile function?

 

1)Prescribe venlafaxine

2)Prescribe sildenafil

3)Prescribe bupropion

4)Refer for sex therapy

5)Refer to urology for intracavernous alprostadi

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The most appropriate initial treatment to restore erectile function in a patient with untreated major depressive disorder is an antidepressant with a low incidence of sexual side effects, such as bupropion.

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Sexual dysfunction is likely a symptom of major depression in this young man, so treating the depression is the most appropriate first step. Bupropion is a good choice, because it is an effective antidepressant that does not typically cause sexual side effects or decreased libido. The antidepressant alone may solve the erectile dysfunction and the depression.

Venlafaxine is an effective antidepressant but carries a higher risk for sexual side effects than bupropion.

Bupropion is the best choice among the options listed, but psychosocial treatment would also be appropriate in this setting, usually in the form of cognitive behavioral therapy. Such treatment requires an ongoing commitment from the patient and involves finding an appropriate therapist with whom the patient can build a relationship. If the patient will accept it, a combination of medication and psychotherapy is generally more effective than either treatment alone.

Sildenafil, alprostadil, and sex therapy should not be considered for this patient at this point. If sexual dysfunction persists even after depression symptoms improve, a search for causes should be carried out before implementing any other treatment for sexual dysfunction.

Last reviewed Mar 2019. Last modified Aug 2017.

Citations

Clayton AH et al. Bupropion extended release compared with escitalopram: effects on sexual functioning and antidepressant efficacy in 2 randomized, double-blind, placebo-controlled studies. J Clin Psychiatry 2006 Jul 18; 67:736.   > View Abstract

Thase ME et al. A double-blind comparison between bupropion XL and venlafaxine XR: sexual functioning, antidepressant efficacy, and tolerability. J Clin Psychopharmacol 2006 Sep 16; 26:482.   > View Abstract

Patel K et al. Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Ther Adv Psychopharmacol 2016 Apr; 6:99.   > View Abstract