A 43-year-old man comes to the office for follow-up 12 weeks after starting sertraline for major depressive disorder. The patient was initially started on sertraline 50 mg and started to improve when his dose was increased to 100 mg. He now feels that he is back to baseline and reports significant improvement in mood, sleep, appetite, and energy over the past several weeks. He is painting again and feels more optimistic. Despite these improvements, the patient is troubled by a 2-month history of erectile dysfunction that started shortly after sertraline was titrated up to 100 mg. He still sometimes wakes up with an erection. He is distressed by this sexual dysfunction and says that it is straining his relationship with his wife. The patient has no previous history of sexual dysfunction. Medical history includes hypertension, for which he takes lisinopril.
Blood pressure is 130/80 mm Hg and pulse is 72/min. Physical examination shows clear lung fields, normal S1 and S2, and intact bilateral dorsalis pedis pulses.
Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old man comes to the office for follow-up 12 weeks after starting sertraline for major depressive disorder.  The patient was initially started on sertraline 50 mg and started to improve when his dose was increased to 100 mg.  He now feels that he is back to baseline and reports significant improvement in mood, sleep, appetite, and energy over the past several weeks.  He is painting again and feels more optimistic.  Despite these improvements, the patient is troubled by a 2-month history of erectile dysfunction that started shortly after sertraline was titrated up to 100 mg.  He still sometimes wakes up with an erection.  He is distressed by this sexual dysfunction and says that it is straining his relationship with his wife.  The patient has no previous history of sexual dysfunction.  Medical history includes hypertension, for which he takes lisinopril.
Blood pressure is 130/80 mm Hg and pulse is 72/min.  Physical examination shows clear lung fields, normal S1 and S2, and intact bilateral dorsalis pedis pulses.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98c4_6ce0_853d_1d82f2318a75_MD0002_00 Up to 50% of patients treated with selective serotonin reuptake inhibitors (SSRIs) may experience some degree of sexual dysfunction (eg, impaired orgasm, decreased libido, erectile dysfunction) as a side effect of treatment. The choice of management strategy should take into account the patient's response to antidepressants. In SSRI responders, such as this patient, augmentation with a second agent is preferred to switching to an alternate agent. In men with erectile dysfunction, augmentation with a phosphodiesterase-5 inhibitor (eg, sildenafil) is recommended. For women, augmentation with bupropion is typically suggested, although a phosphodiesterase-5 inhibitor is a reasonable option in those whose sexual dysfunction is limited to anorgasmia. For patients with no response or only modest benefit from their SSRI, switching to a non-SSRI antidepressant is recommended. Options include bupropion and mirtazapine, as these antidepressants are associated with lower rates of adverse sexual effects compared with SSRIs. (Choice B) Switching to mirtazapine would be indicated for a patient with poor response to SSRI treatment. In this patient, discontinuing sertraline would risk the loss of the antidepressant response. (Choice C) Venlafaxine is a serotonin norepinephrine reuptake inhibitor shown to impair sexual function at a rate comparable to SSRIs. (Choice D) This patient responded to the 100-mg dose; decreasing the dose may diminish the therapeutic effects. (Choice E) Although watchful waiting may be a reasonable approach initially, it is typically ineffective. Intervention is indicated as this patient has experienced persistent and distressing sexual dysfunction for 2 months. Educational objective: Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors (SSRIs). In SSRI responders, augmentation with a phosphodiesterase-5 inhibitor (eg, sildenafil) or bupropion can be beneficial. SSRI nonresponders are best managed by switching to a non-SSRI antidepressant (eg, bupropion, mirtazapine) for lower rates of treatment-related sexual dysfunction. __________ References: Strategies for managing sexual dysfunction induced by antidepressant medication. (http://www.ncbi.nlm.nih.gov/pubmed/23728643) Antidepressant drugs and sexual dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23732933)

A 43-Year-Old Man Comes to the Office for Follow-Up 12