Health Canada has now recognized that patients taking certain antidepressants face potential risk of long lasting sexual dysfunction—even after usage stops. 

LATE IN 2019, I met a 23-year-old woman with an unimaginably tragic story. Believing that I might be able to help create some awareness of what she was experiencing, she travelled to Victoria from her home on central Vancouver Island. I knew it was a drug story, but I had no idea what kind of drug story it was. 

Emily met me in my office in Victoria and I turned on my voice recorder. For the next two hours, her voice often quivering with emotion, she told me how, at 17 and still in high school, she was prescribed the antidepressant citalopram. It is one in a class of selective serotonin reuptake inhibitor (SSRI) antidepressants, a class that includes drugs like escitalopram (Cipralex), sertraline (Zoloft), venlafaxine (Effexor), fluoxetine (Prozac) and paroxetine (Paxil). The psychiatrist told her that it might help her deal with her impulsiveness and depression. Emily admitted that over the years the drug might have helped some, but there was also something very worrying happening: she felt she was losing whatever libido she had. 

Growing increasingly concerned about how it might be affecting her sexuality, she asked her physician directly if her drug could be the problem. She was assured that the antidepressant might “lead to some loss of libido, but it would come back after she stopped the drug.” Emily was persistent, and eventually her doctor switched her to a different antidepressant which she stopped several months later. 

She described what happened then: “I woke up one morning to abruptly discover that all sexual sensation I had, disappeared from my body. My clitoris was now no more than an inert and sensationless nub of flesh. I was unable to feel attraction, arousal or orgasm.” Not only did her body seem incapable of responding, the emotional blunting that came with it was almost too hard to take. 

“Now I wonder if I will ever find romance or love, or have a normal life,” she says, eyes brimming with tears, “Instead of desire and libido returning, they disappeared.”

How much do we know? 

Depending on who you talk to, the syndrome described by Emily, known as PSSD, (Post SSRI Sexual Dysfunction) is either widely known, or completely unknown. Sixty years ago psychiatrist Frank Ayd, credited with discovering the early antidepressant amitriptyline, noticed that this drug affected the libido, causing effects that weren’t otherwise due to the patients’ depression. While psychiatrists might maintain that being depressed can have a seriously debilitating effect on one’s sexual function, over the years published reports and case studies have accumulated, detailing a condition definitely linked to antidepressants, which some people can suffer for months, years or decades. It can include genital numbness, total lack of arousal or orgasm, and a blunted ability to feel emotions.  

Drug warnings are found in the official, regulator-approved product monograph for antidepressants. The monograph outlines a drug’s pharmacology, research evidence and adverse effects. When SSRIs were launched in the late 1980s, the monographs stated that less than 5 percent of patients reported experiencing some form of sexual dysfunction. This seemed a far cry from what was seen later in unpublished phase 1 trials, where as many as half the healthy volunteers reported some kind of severe sexual dysfunction, even cases where the dysfunction lasted after the treatment was stopped.

It was only two years ago that PSSD was officially recognized by the European Medical Agency. 

Canada, slow as usual on these things, issued a warning in January 2021, signalling that the condition was now officially recognized by our drug regulator. The warning reads, in part:

Health Canada will work with manufacturers to update the product safety information for all SSRIs and SNRIs to recommend that healthcare professionals inform patients about the potential risk of long lasting (possisbly weeks to years) sexual dysfunction despite discontinuation of SSRIs or SNRIs.” (serotonin-norepinephrine reuptake inhibitors, another class of antidepressant)…

Thirty years to recognize a problem

Thirty years ago the data establishing the link between sexual dysfunction and SSRIs in both men and women may have been hard to find in medical journals. Perhaps our prescribing physicians may have been lulled into complacency, hearing nothing from the drug salespeople of the potential sexual dysfunction linked to these drugs. 

Then along came something that was going to help change all that: the internet. What if there could be a simple, yet systematic way to actually document the experience of real-world patients, so that you could discover, beyond the drug company-massaged medical literature, the experience of the Emilys out there, who were enduring this life-altering, pharmaceutical-induced condition? 

Wondering how frequent these effects occurred, and generally concerned about the growing sexual problems linked to drugs like SSRI antidepressants, as well as drugs for prostate problems (finasteride) and acne (isotretinoin), Dr David Healy started a website to collect case studies. The key principle of his website, Rxisk.org, is captured in its subtitle: “No one knows a prescription drug’s side effects like the person taking it.”

An Irish psychiatrist and psychopharmacologist who works at McMaster University in Hamilton, Dr David Healy has become, probably by accident, the world’s foremost expert on PSSD. Not only does he know the history of sexual dysfunction and psychiatric drugs, he knows about it from the ground up—from first-hand accounts of patients. He has studied and written about this extensively and told me that while some early reports were made to British regulators of a patient with post-treatment genital arousal disorder in the late 1980s, the first report of PSSD was filed with regulatory agencies in 1991.

In 2000, he saw his first patient with what was later called PSSD, a 35-year-old woman who told him that three months after stopping treatment, “she could rub a hard-bristled brush across her genitals and feel nothing.”  

By the end of 2017, he had enough reports to publish his results, a series of almost 300 cases of sexual dysfunction collected from 37 countries and linked to 14 different drugs. He wrote that some symptoms were unique to antidepressants, such as premature ejaculation and persistent genital arousal disorder (PGAD), but other drugs were also linked to “genital anaesthesia, pleasureless or weak orgasm, loss of libido and impotence.” 

The implications of his paper were huge, because, finally, here was a body of research that could make regulators around the world act, and start warning physicians, and in turn patients, of the sex-destroying potential of these drugs. 

To strengthen the warnings on these drugs, Dr Healy and his colleagues filed petitions on the sexual side effects of SSRIs and SNRIs with the US FDA, Health Canada and the European Medicines Agency (EMA). Two years ago the EMA was the first to issue warnings of SSRI/SNRI antidepressants and their links to sexual side effects.

Concerned that our regulator was dragging its feet, in March of 2020 he wrote Health Canada and said that if the regulator didn’t warn our doctors about the “persistent sexual dysfunction” associated with these drugs then patients were going to continue to be dismissed by their physicians when they try to report these problems. 

How aware are our physicians?

It seems astonishing to say this but Dr Healy contends that almost everyone taking an SSRI/SSNI experiences some form of sexual dysfunction. Thankfully, some of that effect is transitory and minimal, yet for others, people like Emily who have been reporting their symptoms and joining online chat groups around the world to exchange information, this is no small matter. For them, the impact is profound, with faint hope of any cure at the moment. And they are angry.

For David Healy, the facts indisputably show that SSRI and SNRI antidepressants often cause sexual dysfunction in both men and women. He estimates that given current prescribing rates, as much as 20 percent of the population may not be able to make love the way they want as a result of the drugs. He also believes that for the sake of prescribers and patients our regulators need to act immediately to implement an effective warning system that can reduce the potentially catastrophic impact on the sexual lives of our citizens.

It all comes down to what Emily refers to as “informed consent.” She doesn’t think that antidepressants should be banned or that people shouldn’t be prescribed them, when there is no alternative. It was the not knowing that stings so much. 

“None of the doctors over the years ever mentioned the sexual side effects of these drugs. Not a word,” said Emily, the anger rising in her voice. Asked why she came to me to tell me her story she was firm: “I don’t want anyone else to go through what I’m going through.”

What does this have to do with the pandemic?

If there is one thing that is clear about the pandemic, it’s that many people are struggling with mental health issues. Physician visits via the internet are now a fixture, and a model that may even more rapidly expedite the prescribing of psychiatric drugs. SSRI/SNRIs are among the most widely prescribed antidepressants in the world and it is pretty clear that the use of these drugs during the pandemic has been skyrocketing. 

Reflecting a rate that is slightly lower than the Canadian average, about 15 percent of the population in BC was, pre-COVID, taking some form of antidepressant. The pandemic-related growth in those rates over the last year are concerning. A recent CBC news report says that insurance claims in Canada for SSRIs have grown by 25 percent over the last year. Time will tell whether that means many more people will suffer sexual difficulties due to antidepressants, but we know one thing: people in Canada cannot now say that they haven’t been warned. 

Alan Cassels is a drug policy researcher who lives in Victoria, BC.