A 27-year-old man comes to the office due to depressed mood and low energy for the past several months. He describes sad and irritable mood, sleeping 12-14 hours a day, decreased appetite, and poor concentration at work. The patient has stopped going to the gym and playing his guitar and has withdrawn from his friends and girlfriend. He has no medical problems and physical examination and routine laboratory tests are normal. Major depressive disorder is diagnosed and he is started on fluoxetine 20 mg. At his 2-month follow-up, the patient reports, "I'm feeling just a little better. I am still down on most days but at least I picked up my guitar once this week. The other thing is sex. In the beginning, I was so depressed that I didn't care whether I had sex. Now, I'm interested and get erections, but it's taking too long to ejaculate and it sometimes fails to happen altogether." The patient says that this is creating problems with his girlfriend and he is considering stopping the antidepressant. He drinks a beer a day and does not use illicit drugs. Which of the following is the best management strategy for this patient?

Question

A 27-year-old man comes to the office due to depressed mood and low energy for the past several months.  He describes sad and irritable mood, sleeping 12-14 hours a day, decreased appetite, and poor concentration at work.  The patient has stopped going to the gym and playing his guitar and has withdrawn from his friends and girlfriend.  He has no medical problems and physical examination and routine laboratory tests are normal.  Major depressive disorder is diagnosed and he is started on fluoxetine 20 mg.  At his 2-month follow-up, the patient reports, "I'm feeling just a little better.  I am still down on most days but at least I picked up my guitar once this week.  The other thing is sex.  In the beginning, I was so depressed that I didn't care whether I had sex.  Now, I'm interested and get erections, but it's taking too long to ejaculate and it sometimes fails to happen altogether."  The patient says that this is creating problems with his girlfriend and he is considering stopping the antidepressant.  He drinks a beer a day and does not use illicit drugs.  Which of the following is the best management strategy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c04d_3b00_8f63_bfbd9a746ebf_MD0005_00 This patient's delayed ejaculation is most likely a side effect of treatment with fluoxetine, a selective serotonin reuptake inhibitor (SSRI). Sexual side effects with SSRIs are common and include decreased libido in women and men, anorgasmia in women, and delayed ejaculation in men. All SSRIs can cause sexual side effects, and there is no definitive evidence that one causes less sexual dysfunction than another. SSRI-induced sexual dysfunction in a patient with modest benefit from SSRI therapy can be managed by switching to a non-SSRI antidepressant, such as bupropion or mirtazapine, that does not cause sexual side effects. Patients who are SSRI responders may benefit from adjunctive therapy with sildenafil (phosphodiesterase-5 inhibitor) or bupropion. (Choice A) SSRI-induced sexual side effects typically do not diminish over time. They are the most common long-term side effect of SSRIs and a frequent cause of nonadherence. Watchful waiting may be a reasonable approach in an SSRI responder but would not be appropriate for this patient, who has only modest improvement and is considering stopping the medication due to this side effect. (Choice B) Although sexual dysfunction may be associated with depression, the temporal relationship of the patient's ejaculatory dysfunction to the initiation of fluoxetine suggests a medication side effect. (Choice C) Decreasing the SSRI dose is most appropriate for patients in remission who are on high doses. This patient is on a low dose of fluoxetine with only modest improvement, and dose reduction would risk worsening his depression. (Choice D) There is limited evidence for drug holidays with short-acting SSRIs (eg, paroxetine, sertraline), but this strategy can also result in antidepressant discontinuation symptoms. A drug holiday would not be an effective strategy for this patient given that he is on fluoxetine, a long-acting SSRI. Educational objective: Sexual dysfunction, including decreased libido, anorgasmia, and delayed ejaculation, is common in patients taking selective serotonin reuptake inhibitors (SSRIs). Management strategies include switching to the non-SSRI antidepressants bupropion or mirtazapine, augmentation with sildenafil or bupropion, and cautious dose reduction in patients taking high-dose SSRIs. References: Selective serotonin reuptake inhibitor-induced sexual dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/19473282) Antidepressants and sexual dysfunction: mechanisms and clinical implications. (http://www.ncbi.nlm.nih.gov/pubmed/24685972)

A 27-Year-Old Man Comes to the Office Due to Depressed