Sex-free bliss?

Depressed people often have to choose between drug-induced happiness and sexual fulfillment.

Published May 17, 2000 4:00PM (EDT)

My friend April, a 24-year-old graduate student from Pittsburgh, began taking the popular antidepressant Zoloft in February, and says the drug is fabulous. April's calmer and much less anxious -- although when she pauses to think about it, the 50-milligram blue tablet she takes every morning seems to be causing her all kinds of anxiety.

"My sex drive is still there and the arousal is the same. But when I have intercourse, it takes way longer for me to have an orgasm, or I don't have one at all. That never happened to me before," says tall, willowy April who, like others in this story, has been given a pseudonym.

April's drug-induced frigidity is causing her enough anxiety to consider taking an additional drug to relax her. "I'm afraid my partner will ask me to go off the Zoloft, but I feel too good on it. I'm starting to think I'm going to have to fake it, and I don't want to do that, but I don't really know what else to do."

April is not alone. The antidepressant she is taking is an SSRI (selective serotonin reuptake inhibitor) and, like other drugs in the same family (Prozac, Paxil, Luvox, Effexor and Celexa), they clobber sex drive in up to 80 percent of those who take them. But SSRIs are so awesomely effective that, for most people who take them, the pleasures of sex take a back seat to a sense of calm and serenity that the drugs create.

SSRIs are the current drugs of choice for treating depression, and the most popular still is Prozac. At $2.6 billion, Prozac, which costs about $90 a month, has the third-best annual sales of any pharmaceutical sold in the United States, according to market research firm IMS Health.

Such drugs may be great for prisoners, priests and recovering nymphomaniacs. But what about the rest of us?

Claire, a 46-year-old writer from Detroit, is a case in point. Before Claire got married 20 years ago, she prided herself on her libertine ways. At any given moment, Claire would have three or four lovers stashed away. Sex was Claire's middle name.

Because of health-related problems and difficulties at her job, Claire started taking Paxil four years ago. "I was totally stressed out. I was in tears every day. Everything seemed too much to handle. No small thing was too small to set me off. I felt I was in a tornado continually sucking me down. If I snagged my sweater on barbed wire, I'd be unable to get free. I'd stay snared for days or weeks. Paxil was terrific. But no one warned me about the side effects -- although, really, it didn't matter because suddenly there was peace, some days I wasn't in tears. And soon, I never felt the need to cry."

The cost: Claire's libido -- which had been such a central part of her life -- diminished and then dried up. She and her husband, with whom she was still deeply in love, ceased to have sex with any regularity. They had become their parents; sex was reserved for special occasions, like their anniversary night.

Still, Claire was feeling so great on the antidepressant that in the summer of 1998, she thought she could go it alone ("A little voice inside me said I didn't need to rely on a drug any longer ..."), so she started cutting back on the Paxil and within weeks her libido kicked back in. This was the old Claire.

Alas, by late winter, Claire was back to weeping every day, not sleeping, not eating. "My sex drive may have come back, but in that condition I wasn't interested. I didn't want to go on Paxil again. It had caused me to have night sweats and my heart would race. So, when I returned to my psychiatrist, he suggested Celexa, but warned me about the sexual side effects."

"'Start me on whatever is going to work the fastest,' I told him, and my husband (who was in the waiting room) agreed."

Unlike Paxil, Celexa didn't cause the weird side effects in Claire. Her outlook on life became rosy again. But, again, the drug did a number on Claire's libido -- and still does. "It's not as though I don't want to cuddle or kiss. It's just that my genitalia isn't aroused, but with the drug, nothing is easily aroused. We probably have sex once or twice a week. But I don't initiate it. I initiate it intellectually and psychologically, but for me it always can wait. I love my husband and I want to connect, but it always can wait till tomorrow."

To jump-start their sex life, Claire and her husband started using a vibrator, and now routinely rely on it whenever they get intimate. "It was taking a long, long time, and I would get frustrated. So this [the vibrator] seems to work. It's very participatory on the part of my husband, and it's made my orgasms very intense. I used to define myself by my sexuality, and I don't any more. Nowadays, all my orgasms are vibrator-orgasms," Claire says in a wistful tone.

Still, she says that going off Celexa would be too much of a gamble. "Now, when I snag myself, I can untangle myself quickly and move on."

Another friend of mine, Holly, a self-described divorced Atlanta housewife with two teenage children, started taking Prozac in 1989 when her gynecologist prescribed it for anxiety. "I had two small children at the time, was working full time, and I had just too much to juggle. I noticed a slow but very dramatic change in everything once I was on the Prozac. In one sense, nothing changes, but your reaction to everything changes. I could be stopped in traffic, late to pick up my kids from day care, and in the past, that would cause me a lot of stress, but with the Prozac, I'd just accept the reality and was much, much calmer. You roll with everything. You observe things differently. I'd have a peaceful response to things that in the past would cause me to freak."

But as with Claire, the drug nailed her sex life. "I remember initially on Prozac I had little interest in sex. It really was a nasty side effect. But it was a trade-off: Everything functioned so much more smoothly that I never got too concerned about what it was doing to my sex drive."

With Holly -- who is 48, works out with a personal trainer every week and is engaged to remarry in the fall -- her libido gradually returned after about a year on the drug. Psychiatrists say some people neutralize the effect the drug has on their sex drive, but it can take months, sometimes years.

Holly noticed something else about the Prozac, something commonly known as "Prozac poop-out." The longer she took the drug, the less effective it seemed to become. In 1992, her gynecologist switched her to Paxil, but that seemed to deaden her much more than the Prozac did -- and not just her sex drive. "My emotions, reactions, feelings were numbed with the Paxil. Again, though, my sex drive came back but it took time, maybe a year."

Finally, two years ago, Holly went to a psychiatrist who prescribed Celexa. "For the first three weeks, I felt euphoric, almost giddy. Then I came down a little, but I don't feel deadened. I have back my emotions. It still has an negative effect on my sex drive, but at least it's the least of the three drugs."

Everywhere I turned, I heard the same story. The drugs were great, so great that they were worth giving up great sex for. Cassie, a pixieish, freckle-faced, 33-year-old Web site developer from San Francisco, told me that a crushing, traumatic divorce two years ago sent her crashing into a downward spiral, and Prozac was the only way out. She credits Prozac with saving her life. For the first year on the drug, her sex drive was minimal, but "who wants to have sex when you're trying to climb back to being yourself again?" In the last year, she said, her body seems to have compensated for the Prozac and her libido appears to be coming back, although she can't say for sure because she's not currently in a relationship.

When I canvassed my male friends on antidepressants about their sex lives, I got a different story. Either these guys are super studs and nothing can deaden their firm, erect ardor -- or maybe it was an Arnold Schwarzenegger macho-guy thing.

Greg, a 48-year-old television producer (and marathon runner) in Los Angeles, went on Prozac for depression in 1990, but developed chronic insomnia (a common side effect), so he switched to Zoloft a year later. Greg says he doesn't really know whether the SSRI has done anything to his sex drive. Now married and the father of a 2-year-old daughter, he says his interest in sex hasn't dampened, but his frequency is off from what it used to be. "I'm not prowling around as I did when I was 29." Still, Greg says he has no problem getting and keeping an erection, masturbating and fantasizing. That also might have something to do with his wife's travel schedule: She's away on business for up to two weeks at a time.

Another friend, Todd, a 41-year-old Manhattan media executive who is a drop-dead double for actor/playwright Sam Shepard, underwent a debilitating bout of depression while living overseas two years ago, so bad that he thought he'd have to be hospitalized. His psychiatrist prescribed Effexor, which gradually seemed to lift the dark clouds. Todd isn't sure about what sexual side effects the drug had on him. "I was so depressed, I didn't want to have sex. And with the Effexor, my mood got better, the depression eased, so I think, in that way, the drug probably helped me sexually." Todd weaned himself off the drug and now takes no antidepressants, and says he hasn't had a relapse.

It seems that in the trade-off between feeling blissed out and having orgasms, blissed out wins big. It used to be that anyone in the make-love-not-war generation would regale total strangers with the intimate details of their sex life -- blow jobs in movie theaters; mile-high-club trysts; threesomes in the backyard swimming pool. No one talked about money, except for how poor you were. Sex in all its multipositional glory was eminently worthy of conversation.

Welcome to the New Millennium, where the dot-com generation happily chats about IPOs, their nifty Palm VII handhelds and their accessory-dripping Lincoln Navigator SUVs. RAM size is what's important. Bandwidth is one's calling card. But mention orgasms, and the lattes go cold.

I'm not making light of depression. Surveys variously indicate that as many as 1 out of 3 women and 1 out of 8 men will, sometime during their lives, be classified as clinically depressed. And the World Health Organization says that by 2020, depression will top the list of health-related maladies in the developed world, and that severe depression will be the second-greatest cause of disability. It is a real disease; a crushing feeling that the world is closing in on you, that a thick black curtain is crashing down on your life.

Considering the enormous popularity of antidepressant drugs like Prozac, Paxil and Zoloft, and the drug culture that spawned them and now adores them, it makes sense that modern-day pharmacology has perfected such an effective and profitable pharmaceutical, which can pinpoint with awesome accuracy the neurotransmitters and receptor sites that cause depression.

The world's first SSRI, Prozac, was launched in 1986 in Belgium, and approved a year later for use in the United States. Since then, about 17 million Americans have taken the cream-and-lettuce-colored capsule. Prozac is the most widely prescribed antidepressant in the world.

Since its introduction, other drugs with similar properties have come down the pike: The most-widely known include Paxil, Zoloft, Luvox, Effexor and Celexa. Each is slightly different in its formulation and, therefore, affects users differently. Effexor, for instance, is not a straight SSRI; it blocks reuptake of not just serotonin, but also norepinephrine and dopamine.

A very short chemistry lesson on how SSRIs work and why they can massacre your sex drive: Higher levels of serotonin in the brain generally lead to enhanced moods. Prozac and its family of drugs increase the level of serotonin by preventing its uptake in receptor nerve cells, thereby assisting brain cells to communicate better with one another. For reasons not completely understood, the rush of serotonin causes in many people an effect that restores confidence, eases anxiety and improves self-esteem. The downside is that while the serotonin is doing all this great stuff, another chemical in the brain, dopamine -- known to increase sexual desire -- is suppressed.

Alas, the proposition was too good to be true. There is no free lunch. No rights to morning reveries of fellatio or sweet-dream send-offs of cunnilingus and a (legally) drug-induced feeling that makes you happy. If you want to be chemically induced confident and serene (or, at least, no longer depressed), you may have to kiss off such sexual luxuries once thought to be absolute generational rights.

As far as physicians (and anyone who's ever had sex before) can determine, there are four kinds of sexual dysfunction when it comes to SSRIs: loss of sexual desire, difficulty getting aroused (in men, erectile flaccidity; in women, lack of lubrication and similar lack of engorgement), duration of time from arousal to orgasm, and intensity and length of orgasm. Both women and men report about the same incidence of dysfunction when they take SSRIs.

But the incidence of dysfunction while on SSRIs probably is even greater than reported. The underlying problem is that physicians and patients often are too uptight to talk about the sexual side effects of antidepressants. Some patients are too embarrassed to fess up. Many are so happy that they're not depressed any longer that the dip in their sex lives becomes secondary to their spectacularly upturned mood. It's a price, but one that most SSRI-users happily pay.

Leave it to the world of fluorescent-tanned scientists to study just why SSRIs dampen sexual ardor. Three physicians at the University of Gvteborg in Sweden (J. Matuszcyk Vega, K. Larsson and E. Eriksson) injected a male rat with fluoxetine (the chemical compound of Prozac), and the poor little guy couldn't ejaculate when he frequented a female rat nearby.

Fellows at the Department of Psychiatry and Neurosexology concocted another pioneering study at the Hague's Leyenburg Hospital. While having sex with their partners, volunteers equipped with stopwatches timed how long it took them to ejaculate while on SSRIs. The doctors concluded that the men's ejaculations were dramatically slowed, and in some cases, stopped by the SSRIs. Off the SSRIs, the men performed splendidly. I wonder where the men put the watch while they were pumping away.

It thus should come as no surprise that Prozac and other antidepressants of their ilk are extraordinarily effective when it comes to curing one sexual malady: premature ejaculation. The guy who used to come in five seconds before taking SSRIs can now last a manly 20 minutes.

For those on SSRIs, don't despair. There are a host of legal drugs and herbs that may help restore your libido and return your orgasms to 21-gun salutes. But as in prescribing SSRIs, it's a hit-and-miss proposition. Some drugs and herbs work to bring back libido; others fail with flagging colors.

Before you mainline yet another dose of a potent herb or drug (which, too, may carry side effects), most psychiatrists suggest one of the following strategies to help stoke your libido. Don't try the following at home, kids, until you discuss it with your physician.

Plan a drug-free holiday. For example, go off your SSRI Thursday through Sunday and then attempt sex (even wild sex!) Sunday night. This may work with Paxil, Zoloft, Celexa or Effexor, but it won't if you're taking Prozac, which stays in your system for a longer time than the other drugs. Drug half-life is the time it takes for the pharmaceutical to decrease by half of its original dose in your blood stream. Prozac's half-life is about a week; Paxil's and Zoloft take about a day. The drug-free holiday strategy is a gamble. Many users don't want to risk being off their SSRI, even for a day.

Lower your dosage. The standard daily dose of Prozac, for instance, is 20 mgs. Reduce it to 10 mgs., by either getting a new prescription or (the less expensive way) by taking a 20-mg. capsule once every other day. This works especially well with Prozac, precisely because its half-life is so long; results with other SSRIs may be mixed.

Switch antidepressants. Wellbutrin, Remeron, Effexor, Luvox, Celexa, Serzone and Desyrel may be less likely to destroy libido but, for many, aren't as effective in combating depression as Prozac, Paxil or Zoloft. (Interestingly, the smoking-cessation drug, Zyban, is the exact same formula as Wellbutrin in a smaller dose.)

Wait. Give your body time to compensate for the rush of serotonin that bathes the delicate receptor tissues of the brain. Some or most of your sex drive may eventually return. Some people, like Holly, develop tolerance to the sexual side effects and eventually bounce back.

If you are able to maintain your composure and return to your sexual equilibrium after trying the above, read no further. If not, some additional gambits: The drug yohimbine has shown to reverse the sexual side effects of SSRIs, says M.J. Gitlin, a psychiatrist at UCLA. Yohimbe, an African bark, is available over the counter; your physician will have to write a script for yohimbine, a pharmaceutical agent. It is a non-hormonal drug, in pill form, designed to decrease the outflow of blood from the penile tissue. Yohimbe chewing gum is available in some health food stores. One patient reported to his physician that he chewed 10 to 15 pieces immediately before he "had an incredible sexual time with his girlfriend."

Some physicians suggest taking a half-tab to one tab (5.4 mg. each) of the pill an hour or so before the "event." Beware, though, yohimbine can produce insomnia, already a side effect for many people on SSRIs.

The herb ginkgo biloba may also work. Alan Jay Cohen, a psychiatrist at the University of California at San Francisco, did a study on ginkgo-tree leaf extracts in which he reported that 86 percent of patients who took two 60-120-mg. capsules twice a day reported substantial improvement in their sexual function, with no side effects. Cohen says that ginkgo biloba restored the blood flow to the genitalia often blocked by the serotonin-enhancing drugs. In the business, ginkgo biloba is called a vasodilating agent. The popular prescription drug, Viagra, does much of the same.

The key issue is that the SSRI-related drop in libido is related to dopamine down-regulation. Some shrinks suggest Ritalin (methylphenidate) as an antidote for sexual dysfunction. Methylphenidate and Symmetrel (amantadine) trigger dopamine. Others prescribe Periactin (cyproheptadine) to be taken several hours before sex. Another option is Buspar (buspirone), administered concurrently with the SSRI, to get sexual responsiveness back.

Clearly, what worries some physicians and positively terrifies Eli Lilly and Company, the maker of Prozac, is that such onerous side effects will cause people to abandon the drug. In 1998, Lilly spent more than $95 million on promoting Prozac, which put the drug on a list of the 10 most-promoted pharmaceuticals in the U.S., and made it the list's only antidepressant.

Lilly ostensibly wants to make a last-ditch try to hook as many new customers on Prozac as possible. Lilly's Prozac patents expire in 2004, when drugmakers will be able to formulate a generic version at prices 60 percent to 80 percent less than what Prozac goes for now. Lilly, though, has something else up its lab-coat sleeve. It plans to license a variant of Prozac, called R-fluoxetine, and that patent doesn't expire until 2015. Lilly is touting R-fluoxetine, saying it has fewer severe impotence side effects and won't keep people up nights.

When I asked Lilly flack Blair Austin about worries that Prozac takers' loss of sexual interest will cut into the company's business, this is what I got: "It is difficult to determine the level of impact by SSRIs on sexual function and interest. Some patients do experience problems with sexual functioning during treatment with SSRIs; others have shown improvement during SSRI therapy." So much for going out on a limb.

If all else fails, here's another idea: Three psychiatrists wrote in the Journal of Clinical Psychiatry that granisetron (a sexual stimulant in rats) works great in men and women, if taken one hour before sex. But the drug, available as Kytril (and labeled for chemotherapy-related nausea control), costs $50 a pill. That means it would have to be a very hot date.

By Stephen G. Bloom

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