ssri's and permanent side-effects

May 1, 2007 10:07 PM

Long, complex, embarrassing question about SSRI's and permanent sexual side-effects.

This will be long and detailed, so here's the summary: 35 year old male, spent about 2 years on and off different combinations of Zoloft and Wellbutrin, experienced sexual side effects, have been off all meds for 2 1/2 years, side effects still remain.

And now the details:
After many years of depression, at 31 I saw a doctor and reluctantly went on Zoloft. It worked wonders and made me feel great almost instantly. Only problem was the sexual side effects. It was almost impossible to ejaculate, and when I finally did the orgasm was hardly what it used to be. I barely felt anything, more of a relief that it was over. The doctor added Wellbutrin but that didn't seem to help much. About 6 months in, I started dating a girl so I went off the Zoloft but kept taking the Wellbutrin. I was able to ejaculate but the feeling was still about 20% of what it used to be. Eventually I went off of everything, relationship ended, side effects seemed to go away, but mood of course went south. After about 6 months I started up Zoloft again. Side effects returned. Doctor had me ween off the Zoloft after a few months and added a stronger dosage of Wellbutrin. The Wellbutrin just didn't work for the mood, so he upped the dosage, then upped it again. Eventually I realized this wasn't the way to go so I weened off all meds. This was 2 and 1/2 years ago.

Its now been over 2 years and the side effects remain. It is devastating. To sum my symptoms up, I have the physical ability to have sex but I feel nothing. Somethings wrong with my brain due to SSRI's, but I don't know what it is. Erections have never been stronger, but it takes forever to ejaculate since I feel nothing. I feel almost numb. When I finally do ejaculate, the orgasm is nothing. Just a rush of blood to the head, but the part of my brain that controls the pleasure now feels dead.

I've searched around the internet and have found that I'm not the only one. They've called it PSSD. There's a page on Wikipedia, and also a Yahoo group devoted to this that has 1200 members. The group is helpful in that I know I'm not alone, but there aren't any solutions. Just a bunch of people that are pissed off at their doctors and the drug industry. No one has any helpful answers.

I saw a urologist just to rule out anything physical, but he didn't take me seriously and once he heard the word depression, he seemed to assume that it was all in my head. He did some basic tests but I felt like he was blowing me off.

I saw a therapist (which I think I should have done before I started any of the antidepressants) for about a year. It was helpful but ultimately I realized there wasn't anything she could do for me for this particular issue, which is now the main cause of my problems.

This whole issue has made my depression ten times worse than it ever was. Before it was manageable. Now it is not. I have withdrawn from family and friends and now have a lot of anger built up over the whole thing. You can imagine how hard this is to talk about, and the few people I've told have a hard time believing it. It has helped to ruin a couple of relationships, and I now have no desire to go out and try to meet girls. I pretty much just go to work and thats it.

The irony is that now I feel like I should just go back on Zoloft, because that worked wonders for my mood and the damage is done now anyway.

It's hard to ask one specific question. Has anyone ever heard of this before? Know anyone who has experienced it and recovered? Could a physical symptom cause this? Should I try another urologist? Should I seriously consider going back on medication? Just try to accept it?

Feel free to give me your thoughts on any of those questions, but I'm really just looking for general advice on what to do next.

Thanks

posted by anonymous to health (23 comments total)

I think you need to see a sex therapist. The prognosis for ejaculatory incompetence is much better than you think. You can get better. Not just a regular therapist, a sex therapist.
posted by Ironmouth at 10:34 PM on May 1, 2007

the damage is done now anyway.

Post hoc ergo prompter hoc. Your conclusion might be correct but your logic certainly isn't. It's entirely possible that there are other factors involved, and second opinions from urologists, therapists and other professionals may reveal them.
posted by Neiltupper at 11:17 PM on May 1, 2007

I notice that the post title says "permanent" but the wikipedia page says this: "While apparently uncommon, it can last for months, years, or sometimes indefinitely after the discontinuation of SSRIs." I realize "indefinitely" isn't comforting, but I take it that if the entry says it can last "years," then there have probably been others in your situation who have gotten better.

I would say that you do need to address your depression (though hopefully you can find another means than SSRI's -- have you tried Cognitive Behavioral Therapy?) Loss of sensation is certainly an awful thing to be dealing with, but it doesn't necessarily preclude having a relationship. It may make it more difficult to find an understanding partner, but if relationships are possible for people who are completely non-functional, then it seems they should be possible for you too.

I have no idea whether or not this will help, but I'll throw it out there anyway. I've always had a bit of a kinky side, but it was never a major part of my sexuality until I went on SSRI's and couldn't have an orgasm without utterly exhausting myself. I found myself gradually gravitating toward fantasies and then actual situations in which this phenomenon could incorporated as a part of the play. None of this was fully conscious and it was a long process, fraught with self-doubt, depression, etc -- but I eventually realized that my psyche was finding its own way to adapt to what was essentially a new sexuality. The more I allowed this adaptation to take place, the better I felt about the whole thing -- and the happier I was, sexually speaking.

The moral of the story, I suppose, is that even in the worst case scenario, there's still a chance that your psyche/sexuality will find a way to adapt to your circumstances.
posted by treepour at 12:02 AM on May 2, 2007

It might be worthwhile to try Viagra or an over the counter "aphrodisiac" like damiana. I know, I know... Little Blue isn't supposed to make you hornier or make your orgasms better, it's just supposed to allow you to get an erection. However, a lot of people use it for, shall we say, off-label purposes and if I were in your situation, I'd definitely try it. Same goes for damiana, which I've used before. Yes, fifteen people will line up to tell you that since it's an herb you buy at the health food store it can't possibly be effective, but I've tried it myself and it definitely had an effect. You should check with a doctor, of course, but unless you have any of those conditions they always list at the end of the drug commercial, I'd be surprised if there were any serious risks involved.

Also, you may want to read up on antidepressant withdrawal (or, if you prefer, "antidepressant discontinuation syndrome"). I didn't know there was such a thing until a few years ago when I went through it. Perhaps it's a factor in your current problems.
posted by Clay201 at 2:55 AM on May 2, 2007

The irony is that now I feel like I should just go back on Zoloft, because that worked wonders for my mood and the damage is done now anyway.

it sounds reasonable.
posted by matteo at 3:00 AM on May 2, 2007

Thanks for this post, it has resonated enormously and I am going through exactly what you describe while on Effexor. (An SSRI+). In fact, it led to the break-up of a relationship with a girl with a high sex drive. Would have been helpful to understand more about this.

I would echo both treepour and Clay201 - I definitely found myself *far* more willing to explore my kinky side and that does help, and I have also use Viagra with positive effect.

In a strange way, it has become kind of liberating, and is allowing me to explore a new side of my sexuality "guilt free". Find the positives I guess...
posted by csg77 at 3:57 AM on May 2, 2007

It doesn't sound reasonable to go back on the meds. Having this one side-effect now does not preclude it worsening, or other developing, if you go back on the meds.

Were I in your position I'd see a sex therapist. They know a lot and can be quite helpful for people with all kinds of sexual problems. They aren't some skeevy holdover from the 70s, either. At the very least, it's unlikely to make anything worse, which is more than you can say for meds at this point.
posted by OmieWise at 4:01 AM on May 2, 2007

Welbutrin is not an SSRI and is not associated with sexual side effects of note, at least as I understand it. Permanent physical side effects from 2 years on Zoloft is exceedingly unlikely.

Depression is the obvious horse (as opposed to zebra, as in "when you hear hoofbeats, think . . .") here. Ride it down to a good shrink's office and get some better help than AskMe can offer.

There are newer SSRIs than Zoloft which have fewer sexual side effects. Or if Welbutrin worked well for you, it's an obvious choice to experiment with treating depression again as the source of the problem, since it shouldn't impact your sexual functioning at all.

As with all such questions, the real answer is a good doctor.
posted by spitbull at 4:46 AM on May 2, 2007

there are other antidepressants. talk to your doctor and try something else.

sex therapist wouldn't be a bad idea.

might also want to talk to a regular therapist about making peace with your changed sexuality. you are right to grieve it, but eventually you will have to come to terms with it. people come to terms with all kinds of disabling and disfiguring conditions--a therapist will help you find a way.
posted by thinkingwoman at 5:48 AM on May 2, 2007

See a psychiatrist. There are newer antidepressants, like Cymbalta, that are not SSRIs, and a good psychiatrist can help you find the right drug(s) for your specific brain/body chemistry.
posted by judith at 6:00 AM on May 2, 2007

What treepour said. If you can find a way to incorporate this phenomenon into your sexuality, you'd be turning a negative thing into a very positive one.

I had the same problem, btw. When I talked to my doctor years ago ("Doctor, it takes me so long to come! My partners get worn out!") his reaction was on the lines of "...so this is a problem?" Of course, I should have found another doctor, but instead I took it as a challenge to redefine myself and how I have sex. It isn't about reaching a goal or the end of the experience, but rather about the journey, and how you get there. The attitude change makes a world of difference.
posted by Robert Angelo at 6:14 AM on May 2, 2007

Look, I'm a psychotherapist and a big fan of people finding help for mental health problems wherever they can. That means if meds work, use meds; if psychotherapy works, use psychotherapy. The reason I can confidently say that is because there is very little difference in efficacy between meds and psychotherapy, or indeed between different forms of reputable psychotherapy. Meds are not outstandingly better than placebo, and the differences can plausibly be argued to be artifacts of 1) excluding obvious placebo responders from the studies, and 2) failing to use active placebos (ie, ones which are not anti-depressants, but which have side-effects of their own), making the studies effectively unblinded.

If you feel like meds didn't help you, indeed, if you feel that they hurt you, look elsewhere for help. Even if the problem here is depression rather than lingering side-effects (I can't speculate as to which is which), meta-analyses of psychotherapy show it to have an effect size of 0.80. That's huge. (For instance, aspirin has an effect size of 0.06 for controlling heart attacks. And in this study of Celexa to treat depression in heart disease patients, Celexa was declared very helpful with an effect size of .33!) ~79% of people who are in mental distress and are treated with psychotherapy get better, compared to those who seek it but do not receive it.

Why, at this point, would anon want to seek psychiatric help and get more medications? There might be a time for that, down the road, when all other options are exhausted. But psychotherapy is by no means quackery, it's proven effective, has no side-effects of the type that have bothered anon in the past, works relatively quickly (the average treatment episode is 8 session, versus ongoing med therapy ad infinitum), and there are types of therapy specifically tailored to the described problem (sex therapy). Were anon complaining about psychotherapy I can't imagine that people for whom meds have been helpful would be sanguine about people with an agenda suggesting that they just try more of it.
posted by OmieWise at 6:19 AM on May 2, 2007 [3 favorites]

OmieWise: generally, people are advised to combine psychotherapy and medication, which tends to be very effective. In most cases [e.g. depression rather than stuff like bipolar disorder or schizophrenia], the plan is not "med therapy ad infinitum" - responsible psychiatrists try to combine meds to treat the symptoms [and make life liveable now] with therapy to help the patient learn to cope with depression. Meds might get people past a short depressive episode, but obviously, someone with chronic depression will probably need the help of therapy to eventually go off meds. Under the guidance of a responsible psychiatrist, it's not an either-or thing.

I'm certainly not suggesting that anonymous jump right on to the same Zoloft regime he was on. Obviously, the side effects are a huge problem. But he says "This whole issue has made my depression ten times worse than it ever was. Before it was manageable. Now it is not." Sex therapy, an understanding urologist, or something tailored specifically to the sexual problem is obviously needed, but it sounds like he still needs help on the depression end of things too - and frankly, it's entirely possible that depression is exacerbating his problems. 8 sessions of therapy generally doesn't cure chronic [as opposed to acute or situational] depression, unfortunately. It's entirely possible that an appropriate course of therapy might end up involving meds again [along with ongoing psychotherapy], and if so, there are SSRIs [as well as non-SSRIs] that he may react better to. These things are highly individual - some people have huge problems with one SSRI and none at all with another. If medication ends up being part of his future treatment for depression, he should realize that it's probably not Zoloft or nothing: he may be able to find something that works without causing such devastating side-effects.
posted by ubersturm at 8:43 AM on May 2, 2007

the plan is not "med therapy ad infinitum" - responsible psychiatrists try to combine meds to treat the symptoms [and make life liveable now] with therapy to help the patient learn to cope with depression. Meds might get people past a short depressive episode, but obviously, someone with chronic depression will probably need the help of therapy to eventually go off meds.

I can only think that you haven't been talking to many psychiatrists lately, or maybe just not the ones I work with.

I said in my comment that I'm not against meds, I just think the advice to seek psychiatric help for this problem overlooks the majority of anon's question.
posted by OmieWise at 9:29 AM on May 2, 2007

OmieWise: Really? 80% of mental illnesses can be cured forever in eight 50-minute sessions with a counsellor/nurse/psychologist/kind professor? I don't know where you got your numbers, but this is simply not true. (I'm sure the 79% came up in a study somewhere, but you are waaaay overgeneralising.)

I'm quite prepared to believe that the average time an individual person will see a particular psychotherapist is only eight, but that could have many explanations other than 'individual is completely and permanently cured of mental illness.' I've seen several psychotherapists, probably with a median number of times seen around eight each, but when I stopped seeing them it was because 1) I had no insurance or 2) the psychotherapy was ineffective. Fifteen years later I still have depression, which seems to have evolved into bipolar II. I have a psychotherapist I see when I'm not coping so well (about eight times a year), and my psychiatrist gives me 20 minutes of psychotherapy when I see her (frequency varying from once every six months to once every two weeks depending on whether she likes the look of me or not).

ubersturm: Meds are often used long-term for depression. It's not like antibiotics for occasional bronchitis. For a first episode of depression, the reccommended trial is six months. For a second episode, two years. For the third - quit messing around and just make up your mind to stay on the stuff for the rest of your life because suffering/struggling through repeated depressive episodes are not doing you any good.

OP: Yes, talk to a psychiatrist. You appear to be depressed now, in addition to struggling with sexual dysfunction. There is no reason for delayed/difficult orgasm to make relationships with women impossible (or one third of women and all people with spinal cord injuries would take themselves out of the running before they even started).

Going on and off antidepressants can make depression worse afterwards than it was before. That's one of the risks of taking medication. (Partly because repeated episodes of depression will make each subsequent episode worse, and quitting meds [too quickly] can precipitate another episode.)

There are alternatives to meds like cognitive-behavioural therapy, which (while it is more effective when combined with meds) is the most effective stand-alone psychotherapy for depression.

If your psychiatrist is sufficiently worried about you to really want you on meds as well as CBT, repeat several times that you are very concerned about the sexual side effects and that you don't want to take anything that might make things worse. Your psychiatrist might point out that depression by itself takes the pleasure out of sex just like it takes the pleasure out of everything else, but should take you seriously.

When I was on Paxil, I couldn't read and I couldn't come. It was awful: two things - books and masturbation - I could still get pleasure out of while depressed were now denied me. Counterproductive. I don't think I had any permanent changes, but I'm not sure because I'm a woman and women's responses often do change over the life cycle. So I don't know what changes are due to once having taken a particular SSRI (I take Zoloft now and am just fine with it) and what changes would have happened anyway.

RE approaching sexuality differently: you might want to experiment with prostate massage. It might reach you differently.

So anyway, yeah, this is complex, but you need to have someone you can work with on this. A psychiatrist, since your depression is ongoing and your sexual problems are physically located in your brain, not your penis.

Things can be better. Really. They seem hopeless now, but they aren't. It's just such a struggle.
posted by kika at 9:30 AM on May 2, 2007

kika, you apparently don't know what an effect size is, but if you're interesting in discussing the science rather than just arguing from assertion and anecdote you can read the science in The Great Psychotherapy Debate by Bruce Wampold. You can also feel free to email me if you have any questions.
posted by OmieWise at 9:36 AM on May 2, 2007

If this is a persisting problem so that now you have sexual dysfunction AND a debilitating depression then yes, I certainly think you should look into going back to medication. If the choice is problem+miserable or problem+less miserable then that seems like a slam-dunk to me.

If you've found discussion groups of people who have the same issues then I don't see why you should ask us if we've heard about it.

Personally, at about a decade on Prozac now, I have experienced needing to acclimate to my physical reactions with regards to sex. There have been times when the difficulty in climaxing was so high that it was indeed joyless when it finally happened, but I think part of that was just the frustration and effort. Don't discount the impact that expectation and mood have on the quality of a sexual encounter.

For me the solution was to lower my dose to the limit of where it was effective, so now I take 20mg on M/W/F. This is an approach that likely wouldn't work with the less bio-accumulative SSRIs, however, so talk to your doctor about it if you want to take that kind of approach.

For what it's worth - when I was first coping with the climax difficulties I came to the conclusion pretty quickly that if I could never jizz again I'd rather make that tradeoff in exchange for my ability to enjoy all the rest of my life. One hopes that isn't the case but to be perfectly gloomily accepting there's plenty of people with other life conditions who have to accept physical side effects - including impotence - in exchange for offsetting their other issues, like high blood pressure.
posted by phearlez at 11:21 AM on May 2, 2007

I was on a antidepressant. I stopped taking anti-depressant when i felt better.

Please give exercise a try. It helped me.
posted by tom123 at 12:33 PM on May 2, 2007

Depression is a biochemical illness, whatever else it is, and certainly so when it is major enough to cause or be implicated in a loss of normal social or physical functions. All the best recent science shows that meds plus therapy beat therapy alone nine ways to sunday. No one is saying, I don't think, that one or the other is a magic bullet.
posted by spitbull at 12:36 PM on May 2, 2007

If you've found discussion groups of people who have the same issues then I don't see why you should ask us if we've heard about it.

In my experience, there's a LOT of batshitinsane noise in SSRI-related forums -- if I were the poster, I'd definitely want to get data points from a more general audience. Moreover, he stated he found no solutions in the forums.

But all that aside, if it were me, I'd certainly want to get as many data points as possible.
posted by treepour at 12:43 PM on May 2, 2007

Depression is a biochemical illness, whatever else it is, and certainly so when it is major enough to cause or be implicated in a loss of normal social or physical functions.

I'm sorry, but as far as I know (I could be wrong) this statement isn't supported by the research at this time. It's a hypothesis, heavily funded and investigated, but I'm not aware of any definitive studies that can link specific biochemical brain changes with specific mental disorders. Even were such studies to exist, it does not therefore follow that biochemical processes would be the etiological factor for mental illnesses, since many activities of daily life affect brain chemistry. Neither, of course, is this an argument either for or against medication: my headache may well be ameliorated by ibuprofen even if it isn't caused by an ibuprofen deficiency.

This is not the place for a debate about the etiology of depression, or any mental illness, but I also don't think that it's appropriate to simply allow false assertions to perhaps color the choices made by anonymous.

see, Serotonin and Depression: A disconnect between the advertisements and the scientific literature at the Public Library of Science.
posted by OmieWise at 1:03 PM on May 2, 2007

I was hoping to stay out of this conversation because I'm experiencing something very similar to the OP, and whatever I have to say on the subject often devolves into a rant. I think I was on every SSRI at one point or another, and the effect wasn't just sexual: I felt like I was connecting to the world through a thick semipermeable membrane that only allowed pain in... depression is basically a low-pass filter. But there are some things I haven't read in the comments yet, so here goes:

The correct way to end the sentence that starts with "Somethings wrong with my brain due to SSRI's..." is to put the period after the word 'brain'. Those "many years of depression" you mention aren't symptoms of optimal brain function. Added to whatever the initial problem was, the depression was basically reprogramming your brain the whole time and you need to learn how to get your programming back on track. This is a larger issue that predates, informs, and (though it might not seem like it right now) completely overshadows the sexual dysfunction. Using SSRIs is a crutch, and sometimes crutches are necessary to prevent further damage and to give yourself time to heal... but unless you have some specific physiological neurotransmitter deficiency (and you can argue whether or not SSRI use might have pushed you into such a circumstance, but if you were borderline something was going to get to you eventually... aspartame or stress or cosmic rays or *whatever*), SSRIs are not a good long-term solution.

Based on the rest of what you wrote (many years of depression, withdrawing, anger, 'the damage is done now anyway'), it sounds like you are in the classic vicious cycle. Your mind and body and spirit basically have no incentive to heal... you're off the rails and it probably feels like any energy you put into fixing the problem will be wasted. From the outside (based on all the good advice I get from friends) this is all pretty obvious, but from the inside you're trying to determine what's wrong with your brain by looking at it with your brain... you can see the problem here. I am an engineer, a born problem-solver, and I've always felt that I could solve my own problems. Turns out I was wrong, and it's really obvious when you think about it - trying to get a clear picture through a foggy viewing apparatus is doomed to fail, regardless of how clever you think you are at picking out patterns in the haze.

You said that the sexual dysfunction "is now the main cause of my problems". I know I'm just some guy on the internet, but take it for granted that I am giving you a deep and meaningful look at this point: the sexual dysfunction is not the cause of anything. It is an effect of things that have been building up since long before you started taking SSRIs. Until you figure out what those things are, and how they've progressed over time, you're hosed... and you're not very likely to figure it out on your own. Some of the most intelligent people I have ever known have fallen into this same trap, because it doesn't matter in the slightest how smart your brain is if your brain is broken with regard to examining itself.

And just in case nothing else I wrote was useful, here's a data-point: I started taking SSRIs when I was 34, after almost 20 years of pretty severe depression. Most of the SSRIs had stronger side-effects than effects, and the sexual dysfunction you speak of was a major one - Effexor and Cymbalta were the worst for that, in my experience. When the side-effects became a bigger problem than the one I was trying to solve with the meds (after about three years), I stopped taking them; I still get some relief from Wellbutrin without side-effects, so I still take that. I was off the major SSRIs for more than two years before I got my sexual function back... but it still wasn't the same. I hadn't taken into account two things: stress diminishes libido (and lack of sex increases stress, hrmm, pretty much hosed there), and once you get over 'the hump' age does too... many men find a mellowing-out of their sexual desire/potency/enjoyment as they progress through their thirties, and if your baseline behavior has been masked by other signals (stress, depression, burnout, etc) you may find that even when you get your head on straight you're still not where you were when you started the downhill slide. I learned to enjoy the extra time spent with my mate and to focus more on the emotional experience, and I don't feel like I'm missing out on anything.

I'm not going to say it isn't what it obviously is - the situation sucks. But there might be a way out, if you are willing to trust someone with an objective viewpoint. I'd think twice about going down the SSRI route again - you already know where it leads, and the longer you train your brain that it's ok to stop producing certain neurotransmitters (since you'll be providing them with those little pills) the longer it will take to heal. Using the crutch metaphor again, it's okay to use a crutch but you also need to be exercising and going through therapy if you really want to heal.

I wish you good fortune, and a healthy resolution to all of this.
posted by foobario at 3:40 PM on May 2, 2007

Wait a minute... Is it possible that you've got the cause and effect mixed up? Sexual dysfunction can be an effect of depression. (here's one ref.)

So, perhaps it's the resurgent depression rather than lingering effects of the SSRIs that's giving rise to the sexual problems.

If this is so, then you're in some sort of depression positive feedback loop, which is bad. I'm not the biggest proponent of antidepressants (though who is?), but in fact they can help, and ideally they'd help enough that you could continue to become healthy on your own as you wean off of them. Also, as others have mentioned, being depressed for a significant length of time can have permanent effects on your brain. So, if you're not getting better, then antidepressants could actually be the lesser evil. Maybe talk to a psychiatrist about trying an antidepressant without sexual side effects. Remeron (Mirtazapine) for example. Or, try exercise. Or a psychologist. Basically, try addressing the depression since that could actually be the cause of the sexual issues.

Note - you might be thinking that this explanation is unlikely if you never had the sexual issues associated with depression before, but keep in mind that depression can manifest itself in different ways at different times in the same person. You may also be thinking that the sexual problems you're experiencing are too visceral to be due to depression, but it is possible. The body/brain is quite powerful; look at placebos.

BTW, as long as the depression is not improving, you should see a psychiatrist and/or psychologist. But, if you see one who seems to ignore or dismiss the importance of the sexual issues (whatever the cause), then see a different one. S/he needs to understand and acknowledge how significant it is for you.

Just thought I'd throw this possibility out there. I too wish you a healthy resolution.
posted by sentient at 6:25 PM on May 2, 2007