Managing treatment-emergent sexual dysfunction associated with serotonergic antidepressants: before and after sildenafil

Sexual dysfunction is a common and troublesome side effect associated with selective serotonin reuptake inhibitors and other antidepressants that reportedly occurs in 40%-70% of patients prescribed selective serotonin reuptake inhibitors. Management of this iatrogenic condition has relied on "clinical wisdom" derived over decades primarily from open-label, non-placebo-controlled, selected case and literature review studies. Management approaches fall into four broad categories: 1) antidote, 2) avoidance, 3) augmentation/switching, and 4) adaptation. Until the development of sildenafil (Viagra), none of the existing managements demonstrated clear efficacy in systematic, double-blind, placebo-controlled trials. Renewed interest in treatment-associated sexual dysfunction emerged because of advances in our knowledge of the biological mechanisms of sexual functioning, awareness that sexual dysfunction compromises patient adherence to treatment, and an improved focus on improving disease management outcomes of depression. Recent placebo-controlled studies provide evidence for questioning the effectiveness of earlier approaches to the management of sexual dysfunction side effects, and suggest improved treatment options with sildenafil. Effective management of treatment-emergent sexual dysfunction is a medical necessity in order to prevent relapse and recurrence of serious disorders such as major depression, which are highly treatment responsive but frequently compromised by medication noncompliance due to side effects such as sexual dysfunction.