A 24-year-old graduate student from Pittsburgh April, who is a friend of mine, started taking the popular antidepressant medication Zoloft in February. She says the medication is wonderful. April is calmer and much less anxious – even though when she pauses to think about it, the 50-milligram blue tablet she takes each 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, either it takes extremely long time for me to experience an orgasm, or I don’t have it at all. That has never happened to me before," claims tall, willowy April who, like other people in this story, has been given a pseudonym.
April’s drug-induced frigidity is making her feel enough anxiety to consider taking an additional drug to relax her. "I’m afraid that my partner will ask me to give up the Zoloft, but I feel too good on it. I’m beginning 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 could I do."
April is not the single case. The antidepressant medication she is taking is an SSRI (selective serotonin reuptake inhibitor) and, like other medicines in the same family (Prozac, Paxil, Luvox, Effexor, and Celexa), they clobber sex drive in up to 60 per cent of those who take them. But SSRIs are so tremendously effective that, for most people who take them, the pleasures of sex take a back seat to a sense of calm and tranquillity that the medications provide.
SSRIs are the contemporary medications of choice for treating depression, and the most popular still is Prozac. According to market research firm IMS Health, at 2.6 billion dollars, Prozac, that costs about $90 dollars monthly, has the third-best annual sales of any pharmaceutical sold in the United States.
Such medications may be wonderful for prisoners, priests, and recovering nymphomaniacs. But what about the rest of the population?
Claire, a 46-year-old writer from Detroit, is a case in point. Before she got married twenty 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.
Due to the health-related problems and difficulties at her job, Claire started taking Paxil four years ago. "I was completely stressed out. I was crying every day. Everything seemed too much to cope with. No small thing was too small to set me off. I felt I was in a tornado constantly sucking me down. If I snagged my sweater on barbed wire, I’d not be able to get free. I’d stay snared for days or whole weeks. Paxil was marvelous. But unfortunately I was not warned about the side effects - although, really, it didn’t take care because unexpectedly there was peace, some days I wasn’t crying. And shortly after, I never felt the need to cry."
The cost: Claire’s libido - which had been such a central part of her life - declined and then dried up. She and her husband, with whom she was still deeply in love, stopped having sex with any regularity. They had become like their parents; sex took place only for special occasions, like their anniversary night.
But still, Claire was feeling so great on the antidepressant medications 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 medication any longer …"), so she began to cut back on the Paxil and within weeks her libido appeared again. This was the old Claire.
Unfortunately, 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 at all. I didn’t want to turn to Paxil again. It had resulted in me having night sweats, my heart would race. Therefore, when I returned to my psychiatrist, he recommended Celexa, but informed me about the sexual side effects."
"Please prescribe me anything that is going to work the fastest,’ I told him, and my husband (who was in the waiting room) agreed."
Unlike Paxil, Celexa didn’t result in the weird side effects in Claire. Her viewpoint on life became rosy again. However, again, the medication seriously influenced 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 aren’t aroused - but with the medication, nothing is easily aroused. We possibly have sex once or twice a week. But this is not me who initiates that. I initiate it intellectually and psychologically, but for me it always can wait. I love my husband and I want to have sexual interaction, but it always can wait till tomorrow."
To jump-start their sex life, Claire and her husband started to use 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 be effective. It’s very participatory on the part of my husband, and it’s made my orgasms very strong. I used to define myself by my sexuality, and I don’t do it any more. Currently, all my orgasms are vibrator-orgasms," Claire explains in a reflective tone.
Still, she claims that going off Celexa would be too much of a gamble. "At present, when I snag myself, I can untangle myself very fast and move on."
Holly, my other friend, a self-described divorced Atlanta housewife with two teenage children, started Prozac therapy in 1989 when her gynecologist recommended it for nervousness. "I had two small children at the time, was working full time, and I had just too much to juggle. I observed a slow but very striking 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 children from day care, and in the past, that would bring me about much stress; but with the Prozac, I’d just accept the reality and was much, much tranquil. You roll with everything. You notice things in a different way. I’d have a peaceful response to things that in the past would make me get mad."
But as with Claire, the medication nailed her sex life. "I remember that when I began Prozac therapy I had little interest in sex. It really was a horrible 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 years old, works out with a personal trainer every week, and is engaged to remarry in the fall - her libido steadily came back after about a year on the medication. Psychiatrists claim that some people neutralize the influence that the medication has on their sex drive, but it can last for a few months, sometimes years.
Holly observed something else about the Prozac, something commonly recognized as "Prozac poop-out." The longer she took the medication, the less effective it seemed to be. In 1992, her gynecologist prescribed her 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 returned but it took quite a lot of time, probably a year."
Eventually, two years ago, Holly decided to visit a psychiatrist who recommended 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 my emotions back. It still has a negative influence on my sex drive, but at least it’s the least of the three medications."
Everywhere I turned, I heard the same story. The medications were wonderful, so fantastic that they were worth quitting 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 solution. She credits Prozac with saving her life. For the first year on this medication, 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 claimed that her body seems to have compensated for the Prozac and her libido seems to be returning, although she can’t say for sure due to the fact that currently she’s not in a relationship.
When I canvassed my male friends on antidepressant medicines and about their sex lives, I received a different story. Either these guys are super studs and nothing can deaden their ardor - or maybe it was an Arnold Schwarzenegger macho-guy thing.
Greg, a 48-year-old television producer (and marathon runner) in Los Angeles, started taking Prozac for depression in 1990, but developed chronic insomnia (a common side effect), and therefore he switched to Zoloft a year later. Greg claims that 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 claims his interest in sex hasn’t been diminished, 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 trips for up to two weeks at a time.
Another friend of mine, Todd, a 41-year-old Manhattan media executive who is a drop-dead double for actor/playwright Sam Shepard, underwent a devastating bout of depression while living abroad two years ago, so bad that he thought he’d have to be hospitalized. His psychiatrist recommended Effexor, which steadily seemed to lift the dark clouds. Todd isn’t sure about what sexual side effects the medication had on him. "I was so depressed, I didn’t want to have sex. And with the Effexor, my mood got better, the depression was alleviated, so I think, in that way, the medication probably helped me sexually." Todd weaned himself off the medication and now takes no antidepressant drugs, and he says he hasn’t had a relapse.
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 relevant. Bandwidth is one’s calling card. But mention orgasms, and the lattes go cold.
I’m not making light of depression. Surveys constantly suggest that as many as one out of three women and one out of eight men will, sometime during their lives, be classified as clinically depressed. And the World Health Organization claims that by 2020, depression will have topped 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 tremendous popularity of antidepressant medications 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 advantageous pharmaceutical that can pinpoint with awesome accuracy the neurotransmitters and receptor sites that result in depression.
The world’s first SSRI, Prozac, was introduced to the market in 1986 in Belgium and approved a year later for use in the United States. Since then, about 17 million American citizens have taken the cream-and-lettuce-colored capsule. Prozac remains the most widely prescribed antidepressant medication all over the world.
Since its introduction, other medications with similar qualities have come down the pike: The most widely known include: Paxil, Zoloft, Luvox, Effexor, and Celexa. Each is a bit different in its formulation and, hence, affects users in different ways. Effexor, for example, 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 destroy your sex drive: Higher levels of serotonin in the brain generally result in enhanced moods. Prozac and its family of medications increase the level of serotonin by preventing its uptake in receptor nerve cells, thereby assisting brain cells to communicate better with one another. For unknown and not understandable reasons, the rush of serotonin causes in many people an effect that restores confidence, alleviates nervousness, and improves self-esteem. The downside is that while the serotonin is doing all this great stuff, another chemical in the brain, dopamine - believed to increase sexual desire - is suppressed.
Unfortunately, the proposition was too optimistic to be true. There is no free lunch. No rights to sexy morning reveries or sweet-dream dalliances that provide 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 the doctors are able to conclude, there are four kinds of sexual dysfunction as far as SSRIs are concerned: 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 strength 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 perhaps is even greater than reported. The underlying problem is that physicians and patients often don’t talk about the sexual side effects of antidepressant medications. 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 have to pay.
Why SSRIs dampen sexual ardor is still under examination. Three healthcare providers at the University of Goteborg in Sweden (J. Matuszcyk Vega, K. Larsson, and E. Eriksson) injected a male rat with fluoxetine (the chemical compound of Prozac) and found that the rodent couldn’t ejaculate when he frequented a female rat nearby.
Fellows at the department of psychiatry and neurosexology concocted another pioneering research at The Hague’s Leyenburg Hospital. While making love with their partners, volunteers equipped with stopwatches timed how long it took them to ejaculate while on SSRIs. The investigators came to conclusion that the men’s ejaculations were terribly slowed, and in several cases, stopped by the SSRIs. Off the SSRIs, the men performed much better.
For those on SSRIs, don’t despair. There are a host of legal medications and herbs that may help restore your libido and bring your orgasms back. However, as in prescribing SSRIs, it’s a hit-and-miss proposition. Some medications and herbs work to return libido; others fail to do so.
Before you mainline yet another dose of a potent herb or medication (which, too, may bring about several side effects), most psychiatrists recommend one of the following strategies to help stoke your libido. Don’t try the following at home until you consult your healthcare provider.
* Talk to your physician about a drug-free holiday. For instance, go off your SSRI Thursday through Sunday and then try to have sex (even wild sex!) on Sunday night. This may work with Paxil, Zoloft, Celexa, or Effexor, but it will not if you’re taking Prozac, which remains in your system for a longer time than the other medications. Drug half-life is the time it takes for the pharmaceutical to reduce by half of its original dose in your blood stream. Prozac’s half-life is about a week; Paxil and Zoloft take about a day. The drug-free holiday strategy is a gamble. Many patients are unwilling to risk being off their SSRI, even for one day.
* Ask your physician about reducing your dosage. The standard daily dose of Prozac, for example, is 20 milligrams. Decrease it to 10 milligrams, by either getting a new prescription or (the less expensive way) by taking a 20-milligram capsule once every other day. This works particularly well with Prozac, precisely due to its half-life is so long; results with other SSRIs may be mixed.
* Switch antidepressant drugs. Wellbutrin, Remeron, Effexor, Luvox, Celexa, Serzone, and Desyrel may be less probable to destroy libido but, for many people, aren’t as effective in combating depression as Prozac, Paxil, or Zoloft. (What’s interesting, the smoking-cessation medication, Zyban, is the exact same formula as Wellbutrin in a smaller dose.)
* Wait. Give your organism some time to compensate for the rush of serotonin that bathes the sensitive receptor tissues of the brain. Some or most of your sex drive may finally come back. Some people, like Holly, develop tolerance to the sexual side effects and in the end bounce back.
If you are capable of maintaining your serenity and return to your sexual equilibrium after trying the above, read no further. If not, here are some extra prompts: The medicine yohimbine has proven to reverse the sexual side effects of SSRIs, claims M.J. Gitlin, a psychiatrist at UCLA. Yohimb, an African bark, is available over the counter; your doctor will have to write a prescription for yohimbine, a pharmaceutical agent. It is a non-hormonal medication, in the form of a pill, designed to reduce the outflow of blood from the penile tissue. Yohimb? chewing gum is available in some health food stores.
Some healthcare providers recommend taking a half-tab to one tab (5.4 milligrams each) of the pill an hour or so before the "event." However, be careful, yohimbine can result in insomnia, already a side effect for many people on SSRIs.
The herb ginkgo biloba may be also helpful. Alan Jay Cohen, a psychiatrist at the University of California at San Francisco, conducted research on ginkgo-tree leaf extracts in which he reported that 86 per cent of patients who took two 60- to 120-milligram capsules twice a day observed considerable improvement in their sexual function, with no side effects. Cohen is of the opinion that ginkgo biloba restored the blood flow to the genitalia often blocked by the serotonin-enhancing medications. The popular prescription medicine, Viagra, does much of the same.
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 both in men and women, if taken one hour before sexual interaction. But the medication, available as Kytril (and labeled for chemotherapy-related nausea control), costs 50 dollars per pill. That means it would have to be a very hot date.
