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ORIGINAL PAPER
Sexual Side Effects of Antidepressant Medications: An Informed
Consent Accountability Gap
Audrey S. Bahrick ÆMark M. Harris
ÓSpringer Science+Business Media, LLC 2008
Abstract Sexual side effects of antidepressant medica-
tions are far more common than initially reported, and their
scope, quality, and duration remain poorly captured in the
literature. Antidepressant treatment emergent sexual dys-
functions may decrease clients’ quality of life, complicate
psychotherapy, and damage the treatment alliance. Poten-
tial damage to the treatment alliance is greatest when
clients have not been adequately informed of risks related
to sexual side effects. It had previously been assumed that
sexual side effects always resolve shortly after medications
are discontinued. Emerging evidence, however, suggests
that in some individuals, sexual dysfunction side effects
may persist indefinitely. The authors argue that all psy-
chologists should be well-informed about sexual side
effects risks of antidepressant medications, should rou-
tinely conduct a pre-medication baseline assessment of
sexual functioning, and take an active role in the informed
consent process.
Keywords Antidepressant sexual side effects
SSRIs Sexual dysfunction Iatrogenic Informed consent
Professional psychologists have long been involved, either
directly or indirectly, in patients’ decision-making process
regarding psychotropic medications. A recent survey
indicated that approximately 43% of the clients of psy-
chologists take psychotropic medications adjunctively to
psychotherapy, and virtually all practicing psychologists
make recommendations for medication evaluations, engage
in consultations with prescribing professionals regarding
psychotropic medications, and discuss medication-related
issues with their patients in individual psychotherapy
(VandenBos and Williams 2000). Barnett and Neel (2000)
take the stance that knowledge about psychotropic medi-
cation effects and side effects has become a necessary
professional competency and ethical obligation held by all
psychologists who practice or supervise, and aids in our
ability to best meet patients’ needs, provide appropriate
informed consent in the presentation of treatment alterna-
tives, and to do no harm.
Antidepressants are currently the most commonly pre-
scribed class of medications of all (Burt et al. 2007), with
recent estimates of one in eight adult American having
taken or taking an SSRI over the last ten years (Raz 2005),
and 11 million prescriptions written for children and ado-
lescents during 2002 (Goode 2004). The present article is
concerned with sexual side effects of antidepressant med-
ications including the Selective Serotonin Reuptake
Inhibitors fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), citalopram (Celexa), escitalopram (Lexapro), and
fluvoxamine (Luvox), and the Serotonin Norepinephrine
Reuptake Inhibitor (SNRI)
1
venlafaxine (Effexor). Sexual
dysfunctions associated with antidepressants are acknowl-
edged as a significant treatment risk (Rivas-Vasquez et al.
2000). Yet the existing literature, which is heavily focused
on prevalence rates and treatment compliance, poorly
captures the scope, quality, and potential impact of the
sexual side effects (Bahrick 2006; Bahrick 2008; Michels
A. S. Bahrick (&)M. M. Harris
University Counseling Service, The University of Iowa,
3223 Westlawn S., Iowa City, IA 52242-1100, USA
e-mail: audrey-bahrick@uiowa.edu
1
SNRIs include venlafaxine (Effexor), desvenlafaxine (Pristiq) and
duloxetine (Cymbalta). Sexual side effects of desvenlafaxine and
duloxetine are less well studied and are not a specific focus of the
present article. However as desvenlafaxine is the major metabolite of
venlafaxine, the medications are likely to prove to have similar sexual
side effect profiles.
123
J Contemp Psychother
DOI 10.1007/s10879-008-9094-0
1999). Little attention has been focused on the ways that
the addition of a new sexual dysfunction to a client’s
presenting problem may complicate and confuse the clin-
ical picture, exacerbate the client’s distress, destabilize
intimate relationships, weaken the treatment alliance, and
create mistrust in mental health professionals, especially if
the client has not been adequately informed of sexual side
effect risks. The current article explores these themes and
seeks to raise clinicians’ awareness of client welfare issues
related to antidepressant sexual side effects. Challenges are
raised about the psychologists’ role in the informed consent
process, and recommendations are made for training.
Antidepressant Sexual Side Effects
No clinically meaningful differences have been established
in the tendency of the various SSRIs and venlafaxine to
cause sexual dysfunction (Montgomery et al. 2002), and no
reliable remedies established (Balon 2006). Because no
clinically significant differences in efficacy are recognized
among the medications (American Psychiatric Association
2000), the choice of which medication to prescribe is often
based on the medication’s known side effect profile. The
current drug insert literature for all of the SSRIs includes
acknowledgement that the 2–16% listed rates of sexual side
effects may be an underestimate. Indeed, large prospective
studies in which participants report no sexual dysfunctions
at baseline, have shown that between 30 and 73% of adult
patients experience SSRI and venlafaxine -emergent sexual
dysfunctions (Montejo-Gonzalez et al. 1997; Montejo et al.
2001).
SSRIs and/or SNRIs are approved and considered first
line treatments for depressive disorders, generalized anxiety
disorder, panic disorder, social phobia, obsessive-compul-
sive disorder, bulimia, premenstrual dysphoric disorder, post
traumatic stress disorder, and diabetic peripheral neuro-
pathic pain: issues with which a large number of our clients
present. Increasingly, the medications are also prescribed
off-label (Chen et al. 2006) to treat conditions such as peri-
menopausal hot flashes, chronic fatigue syndrome, chronic
pain syndromes, premature ejaculation (i.e. see Waldinger
2007) and paraphilias (i.e. see Kafka 1996). In the later two
conditions, the sexual side effects are intended as the pri-
mary desirable therapeutic effect, with SSRIs reported to be
the most common first line treatment for premature ejacu-
lation among urologists (Shindel et al. 2007). Given the
frequency with which the medications are prescribed, and
the pervasiveness with which they may affect all phases of
the sexual response cycle (Clayton et al. 2002; Clayton et al.
2006; Montejo-Gonzalez et al. 1997; Montejo et al. 2001),
psychologists should be well-informed about the potential
for the medications to impact sexual functioning.
Antidepressant-emergent sexual difficulties noted by
men include decreased nocturnal and morning erections,
difficulty achieving or maintaining an erection sufficient
for penetration, ejaculatory delay or anorgasmia, difficulty
with arousal, and decreased libido. Women report delayed
orgasm or anorgasmia, difficulty with arousal, lubrication
problems, and decreased libido. Ejaculatory delay in men,
and anorgasmia in woman are the problems believed to be
unequivocally medication-induced (Balon 2006). Loss of
genital tactile sensitivity and diminished intensity of
orgasm, or pleasureless orgasm, are also not uncommon in
both men and women (Zajecka et al. 1997), but are often
missed by assessment instruments (Bahrick 2006,2008).
Serotonergic medications are known to decrease genital
sensitivity, probably by way of interference with nitric
oxide function (Clayton and Montejo 2006), which is
integral to penile and clitoral tumescence. Genital anes-
thesia and pleasureless orgasm are not known in the
general population and are unassociated with the condi-
tions for which the medications are prescribed, thus these
symptoms provide a clear link to the treatment rather than
the condition being treated (Bahrick 2008).
The lack information about the impact of antidepressant
sexual side effects on the psychosexual development of
adolescents and children is especially troubling. Yet little
concern has been raised, and no studies have been con-
ducted with the aim of determining the impact and long
term outcome of SSRIs on adolescents’ and children’s
psychosexual development. While adolescents may be
presumed to experience sexual side effects at rates similar
to adults (Sharko 2004), and while the medications’ sexual
side effects are intended as the primary therapeutic effect
in off-label treatment of paraphilias in adolescents (e.g.
Aguirre 1999; Galli et al. 1998), no age-appropriate
instruments have been developed to assess sexual side
effects in adolescents, and the area remains ignored in
current research (Sharko 2004).
Post Medication Persistence of Sexual Side Effects
Antidepressant sexual side effects persist in most individ-
uals who experience them for at least as long as they take
the medications (Montejo et al. 2001; Landen et al. 2005).
The conventional wisdom holds that the side effects
resolve shortly after discontinuing the medications. The
research literature, however, has failed to include system-
atic follow-up in support of this assumption. While it is
likely that sexual side effects resolve for most individuals,
of particular concern to this inquiry are indications that for
some individuals, antidepressant-emergent sexual dys-
functions do not always resolve upon discontinuation of the
medications, and may persist indefinitely (see Bahrick
J Contemp Psychother
123
2008 for a review). Signs from recent case reports (Bolton
et al. 2006; Csoka et al. 2008; Csoka and Shipko 2006;
Kauffman and Murdock 2007); Internet based consumer
reports (http://health.groups.yahoo.com/group/SSRIsex/),
and findings of post SSRI persistence of ejaculation delay
in men treated for premature ejaculation (Arafa and
Shamloul 2006; Safarinejad 2007; Safarinejad and Hosse-
ini 2006), converge to point to an emergent problem.
In all the case reports noted above, the presenting
problems have long resolved, however the antidepressant-
emergent sexual dysfunctions have persisted for years
beyond medication discontinuation, and no alternative
etiologies for the persistent symptoms could be found. The
SSRIsex Internet group membership of over 1600 indi-
viduals has generated more than 12,000 postings of
consumer experiences of persistent post- antidepressant
sexual side effects (accessed June 14, 2008). These post-
ings provide an alternative database of qualitative
information not capturable within current research para-
digms, and not encompassed by existing post market
pharmacovigalence mechanisms. The present authors urge
attentiveness to such signals of emerging problems.
Empirical evidence of the persistence of SSRI-emergent
sexual side effects well beyond medication discontinuation
is found in the literature related to premature ejaculation
(PE). Three, random assignment, placebo controlled stud-
ies of healthy men treated for PE (Arafa and Shamloul
2006; Safarinejad 2007; Safarinejad and Hosseini 2006;)
with sertraline (n=147), escitalopram (n=276), and
citalopram (n=58) respectively, all found robust evidence
of continuation of the benefit of medication-emergent
delayed ejaculation over a six month post-treatment
assessment period. Yet none of the researchers raised
concerns about medication-induced delayed ejaculation in
men being treated for reasons other than PE and for whom
delayed ejaculation may not be a desirable treatment or
post-treatment effect. Neither were questions raised about
possible post-treatment persistence of other sexual side
effects that both men and women may find far less desir-
able. When SSRIs are used to treat premature ejaculation, it
is an irony that in this instance it is advantageous to
industry to acknowledge the robustness of treatment
induced sexual side effects, and also to emphasize a lasting
post-treatment effect.
Given the lack of qualitative information in the litera-
ture, the absence of systematic follow-up, the limited scope
and aims of current research paradigms, the lack of
inclusiveness of consumer voices in the post market
pharmacovigalence system, and the many ways in which
industry financial and marketing motives result in mis-
leading information regarding risks vs. benefits (i.e.
Antonuccio et al. 2003; Pachter et al. 2007), it is not sur-
prising that there remain significant gaps in knowledge
about SSRI/SNRI sexual side effects. These gaps may be of
public health significance, particularly when they involve
iatrogenic sexual dysfunctions that persist beyond treat-
ment discontinuation, and when the side effects impact the
psychosexual development of adolescents and children. If
post-medication aberrations of normal sexual response
persist even in a small number of people, such findings
should come to light (Kauffman 2008). The literature has
failed to consider the ways in which medication-related
sexual side effects may complicate the efforts of individ-
uals who take them to improve their lives as well as their
moods. Further, the literature appears to entirely miss the
possibility that, in some cases, the treatment-emergent
sexual side effects may be worse than the condition for
which treatment has been sought, and even become a cause
of long term anguish. Given limits of knowledge, psy-
chologists should be especially attentive to client-reported
medication experiences as a credible and worthy source of
information about the impact of antidepressant sexual side
effects. Psychologists, by virtue of our frequent regular
contact with patients, are in an optimal position to assess
and monitor emergent medication effects and to help cli-
ents formulate a response to concerns in this area of
functioning.
Problems with Informed Consent
The doctrine of informed consent requires that health
professionals provide sufficient information so that a rea-
sonable person may decide whether or not to accept the
treatment in question. While (non-prescribing) psycholo-
gists function primarily in an advisory and referral role
with regards to medication decisions, they hold responsi-
bility for protecting client welfare. Clients must trust
psychologists to protect their best interests and to ensure
that all risks for harm are minimized (Barnett 2007). The
amount and type of information deemed adequate to con-
stitute full disclosure is a matter of some debate, however
the process of providing ongoing and current information
relevant to the client’s situation is the critical aspect of
informed consent to which psychologists must aspire
(Johnson-Greene 2007). Moreover, research involving
psychiatric residents (Rutherford et al. 2007) and psychi-
atric nurses (Higgins et al. 2006), indicates that informed
consent is often inadequate, particularly with regards to
sexual side effects (Higgins et al. 2006), and that patients
are specifically dissatisfied with the information they
receive about the impact of medications on sexual func-
tioning (Happell et al. 2004).
Higgins et al. (2006) studied how psychiatric nurses
approached providing information about possible sexual
side effects in the informed consent process with patients.
J Contemp Psychother
123
These registered nurses acknowledged that their responsi-
bilities included providing education about and monitoring
of medication effects, and that this commitment was in
keeping with the rights of consumers to make informed
treatment decisions. The researchers found that despite
positive aspirations regarding informed consent, in prac-
tice, information about drug-related sexual side effects was
relegated to the bottom of a hierarchy of information,
rarely proactively verbally disclosed at drug initiation, and
rarely directly inquired about once patients were taking the
medications. This hierarchy was based on nurses’ percep-
tion that disclosure about possible sexual side effects could
lead to a high risk of medication non-compliance, their
personal unease talking about sexual side effects, as well as
their (mis)perception of the prevalence of sexual side
effects.
In cases where patients spontaneously initiated com-
plaints about the medication’s effect on sexual functioning,
Higgins et al. (2006) describe the nurses as acting out their
role in relation to medication in paternalistic and compli-
ance terms: that is by providing their professional
perspective regarding the importance of remaining on the
medication, a disinclination to hear about the quality-of-
life impact of the sexual problems, and a desire to achieve
the predetermined outcome of medication compliance.
Nurses’ assumptions about the impact of sexual side effects
differed depending on gender of the patient. Male patients
tended to initiate complaints about medication-induced
sexual dysfunction more often than women and were
viewed as more concerned about performance and the erect
penis as a center of male sexual expressiveness. Women
were viewed as being less concerned with sexual perfor-
mance and therefore assumed to be more willing to silently
tolerate the sexual dysfunctions.
Are problems with informed consent and the compli-
ance-based interactions described by Higgins et al. (2006)
reflective more generally of prescribing practices beyond
this community? The authors indicate that that the nurses
veiling of sexual side effects information mirrors their
training, role-modeling, and socialization into the culture
of psychiatry and psychiatric nursing practice, where if and
when sexual side effects were mentioned, they were ‘‘quite
far down the list’’ (p. 441).
A recent study of the informed consent practices of
psychiatric residents would seem as well to support and
extend Higgins’ et al.’s (2006) conclusions. Rutherford
et al. (2007) found that psychiatric residents failed to
appreciate that it is the physicians’ responsibility to initiate
an informed consent discussion. Instead of initiating
informed consent discussions with hypothetical patients,
residents reported that they would provide appropriate
information when asked by the patient. No significant
differences were found in the adequacy of information
provided among residents based on year of residency.
While Rutherford et al. note that the degree to which
adequate informed consent occurs in the community is
unclear, they question how psychiatrists would learn to
obtain informed consent, if not during residency.
Adults are presumed capable of making informed con-
sent decisions if given reliable and understandable
information upon which to base a decision. Adults may
have a clear appreciation of sexual changes and losses
associated with medication use, and therefore are capable
of weighing potential risks against possible therapeutic
benefits in their treatment decisions. Indications are that
only a small minority of antidepressant-treated patients
(3% of 5356 patients surveyed) consider sexual functioning
not at all important, and that the vast majority of patients
are willing to talk about sexual functioning (Clayton et al.
2002). As evidenced by the large discrepancy, up to 60%
(Balon 2006), between sexual side effect rates obtained by
spontaneous patient report vs. via direct inquiry, it cannot
be assumed that patients experiencing them, and who are
willing to discuss them, will initiate such discussion.
The question of SSRI informed consent for adolescents
and children is considerably more problematic. From what
basis may adolescents and children, or their parents in their
behalf, evaluate the current or potential future meaning and
impact of medication induced changes in sexual function-
ing? As previously noted, sexual side effects can be
expected to occur in adolescents at rates similar to those in
adults (Sharko 2004). With little or no stable baseline from
which to assess sexual changes, how would children,
adolescents, their parents, or prescribing professionals
become aware of the medications having an impact on
sexual functioning or development? Case reports of per-
sistent post-medication sexual dysfunction, evidence of
SSRI-linked growth suppression in children (Weintraub
et al. 2002), and animal studies in which early exposure to
SSRIs persistently negatively impacts adolescent and adult
sexual behavior (deJong et al. 2006; Maciag et al. 2006;
Gouve
ˆa et al. 2008) raise concern that antidepressants
could alter pubertal development in adolescents. As noted
by Antonuccio (2007) children are essentially ‘‘involuntary
patients’’ who are compelled by parents to take their
medicine. Thus he argues that treatment decisions should
be guided by a stringent ‘‘first do no harm’’ approach.
Given the indications of potential harm along with the
inestimable value of future sexual health, it is the present
authors’ position that until reliable long-term safety data
become available, neither children nor adolescents are
capable of providing informed consent for treatment with
SSRIs, nor can their parents provide it competently in their
behalf.
Based on the above discussion, and in the context of
continued underestimation of sexual side effects by
J Contemp Psychother
123
psychiatrists (Osvath et al. 2003); primary care physicians
(Clayton et al. 2002; Hu et al. 2004), and psychiatric nurses
(Higgins et al. 2006), there are reasonable grounds for
asking questions about the degree to which patients con-
sidering taking antidepressant medications are being
adequately informed about the known risk of sexual side
effects. Beyond the more easily remediable underestima-
tion by prescribing professionals of sexual dysfunction
rates are process issues more challenging to address. These
may include: discomfort with initiating discussion about
sexual functioning; presumption of patient discomfort; lack
of professional training in sexuality issues; assumption that
sexual functioning is unimportant due to client level of
distress or other client variables such as age, gender or
partner status; lack of awareness that initiating such a
discussion is the prescribing professional’s responsibility;
time pressures; and, in a misconstrual of the doctrine of
informed consent, apparently also the concern that the
information may lead to medication non-compliance. An
accountability gap arises from the inadequacies inherent in
the literature, the unevenness with which prescribers pro-
actively inform patients about the possibility of sexual side
effects, along with the failure of manufacturers to update
SSRI/SNRI product information. How do psychologists
best proceed when there is reason to believe that clients are
inadequately informed of sexual dysfunction risks of anti-
depressant treatment?
Case Scenarios and Implications for Psychotherapy
When clients are not proactively informed about sexual side
effects, treatment emergent sexual dysfunctions may be
poorly understood as medication-related by both patients
and prescribers (Osvath et al. 2003). This is especially true
if no baseline assessment of sexual functioning was con-
ducted. Consider the following three hypothetical but in our
own clinical experience, not uncommon case scenarios. In
each, psychotherapy clients’ medication-emergent sexual
side effects create new difficulties which may be chal-
lenging to interpret in light of presenting issues, and that
may even work in direct opposition to the goals the client
came in to address in psychotherapy. In each scenario, the
psychologists’ role may vary from having urged the client
to consider pharmacotherapy, to having suggested phar-
macotherapy as one of several viable options, to the client
having initiated pharmacotherapy outside of the psycho-
therapy relationship.
1 A depressed, albeit sexually active and sexually
functional young woman begins SSRI treatment. She
feels better on the medication, but develops sexual side
effects that lead to sexual disinterest and withdrawal,
destabilizing an important intimate partnership and
major source of support, and leading to new and
unexpected relational conflict, stress, or even loss. Her
mood, previously buoyed by the medication, begins to
gradually return to near baseline levels of distress.
Session time that had been devoted to focusing on her
depressive symptoms now gradually begins to shift
toward a focus on emergent relationship concerns.
Some of the previously made gains in therapy are lost,
and confusion is added regarding the meaning of the
absence of physical longing or sexual interest in her
partner.
2 A socially anxious young man’s anxiety has prohibited
him from meeting potential romantic partners. His
frustration and loneliness finally motivate him to
endure the social discomfort of psychotherapy itself.
Treated with an SSRI, his anxiety decreases but he
develops medication-induced anorgasmia and erectile
dysfunction. These symptoms create new anxieties and
vulnerability about adequacy to engage in a romantic
partnership, perhaps contributing as well to perceived
sexual failure experiences if attempted. In turn, such
experiences raise new, potentially even more challeng-
ing anxieties which further entrench his avoidant
behavior as his concerns about adequacy grow even
more profound.
3 A young man seeks counseling with depressive symp-
toms related to a lack of meaningful intimacy. While
clear about same sex attractions, internalized homo-
phobia and concern about family disapproval have been
barriers to acting on his attractions. An SSRI has a
positive impact on depressive symptoms, and psycho-
therapy helps him to affirm a more positive gay identity.
He experiences increased energy to pursue a longstand-
ing same sex attraction. Once with a potential partner,
however, he finds the physical arousal is difficult to
maintain, leading him to confusion and return to earlier
sexual identity questions he believed he had resolved.
In all the scenarios noted, it is preferable for psycholo-
gists to be in a position of having proactively discussed the
possibility of sexual dysfunction directly with clients as a
psychotherapy treatment issue, rather than to assume that
accurate or complete information was provided by the
prescribing professional. Providing information or con-
firming that the client is aware of the possibility of sexual
side effects signals openness to addressing the concern
collaboratively with the client if it arises, is likely to pre-
serve the psychotherapy treatment alliance, and increases
the likelihood that symptoms may be accurately inter-
preted. It should be emphasized that ongoing and
transparent collaboration with the prescribing professional
regarding medication concerns is equally essential to
J Contemp Psychother
123
promote client welfare, and that clients should of course be
encouraged to raise concerns regarding medication effects
directly with prescribers. When appropriate, and with client
permission, psychologists’ roles may also include advo-
cating for our clients about possible changes to a
medication regimen based on concerns about observed
client responses.
Sorting out the meaning of new, treatment-emergent
sexual dysfunctions with clients can be challenging and
delicate. This task is facilitated by ensuring an adequate
and ongoing informed consent process, and by routinely
attending to baseline sexual functioning and history at the
outset of treatment. Our role is to raise the possibilities, and
in collaboration with the client hypothesize about the rel-
ative impact of contributing factors. In the first case, libido
was not affected at baseline during the depressive episode,
thus, the medication may be suspected as having impacted
libido. The relational conflict itself, however, may con-
tribute to lowered libido and sexual withdrawal, leaving a
puzzling circularity. In the second and third cases, medi-
cation rather than a psychological basis for the sexual
changes may be strongly suspected if the individual is also
newly unable to masturbate to satisfaction, as few indi-
viduals will experience performance anxiety while
masturbating. Initiating exploration regarding the emer-
gence of ‘‘markers’’ of medication exposure (Bahrick
2008), including decreased genital sensitivity or genital
anesthesia, and decreased orgasmic intensity or pleasure-
less orgasm may provide further support for clarifying the
contribution of medication vs. psychological factors.
Well-informed psychologists are aware of the perva-
siveness of sexual side effects of antidepressant
medications, and given this awareness, cannot then ethically
justify withholding the information from clients. Instead,
they must grapple with tone and content of delivery, and
with consideration for an existing treatment alliance with a
prescribing professional when one is already in place. Such
conversations with clients require that psychologists be
knowledgable about medication side effects as well as
competent in exploring and addressing sexuality issues.
Information about sexual side effects to share with adult
clients contemplating taking antidepressant medications
might be provided as follows: ‘‘You may already be aware
that the medication you are considering taking is associated
with a considerably higher level of sexual side effects than
was known at the time of marketing and which are listed in
the product leaflet. Prior to your starting the medication, I
would like for us to explore your current sexual functioning
and history of any sexual problems and concerns, so that if
you do begin to notice sexual changes once on the medica-
tion, you and I, in collaboration with your prescriber, can
more confidently attribute them to medication vs. psycho-
logical factors. I would like for you to be aware in your
decision-making that the long term impact of this class of
medications on sexual functioning is unknown and has not
been studied systematically. While most individuals who
experience sexual side effects return to baseline sexual
functioning shortly after discontinuing the medications, a
small number of reports have surfaced suggesting this is not
the case for all.’’
It is of course possible that some clients may be sug-
gestible regarding sexual side effects as a result of such
information, that anxiety may be raised, and that clients
may elect non-drug treatments. These possibilities, while
real and significant, must be weighed against the potential
for new-onset sexual dysfunctions to confound therapy,
create confusion and distress in intimate relationships,
damage the working alliance, and diminish client auton-
omy to choose treatment options based on accurate
information, the hallmark of a truly informed consent. As
argued by Wise (2007), if our agenda is to seek client
agreement with our treatment plan rather than to genuinely
engage in collaborative decision-making ‘‘we are arguably
engaging in risk management rather than truly meeting the
aspirational goal of informed consent’’ (p. 183).
An adequate informed consent for antidepressants and
other psychotropic medications goes far beyond the pro-
vision of information about sexual side effects, and is
beyond the scope of the present article. Informing patients
about risks and benefits of medications has become a major
challenge for health care providers (Berry 2006). The
present authors have chosen to highlight sexual side effects
because of their pervasiveness, underestimation in the
product literature and by prescribing professionals, poten-
tial to confound therapy and decrease quality of life, and
emerging indications that the side effects do not always
resolve for all patients. Sorting out the responsibility of
psychologists to respond to broader inadequacies of
informed consent for psychotherapy patients who are tak-
ing or considering taking psychotropic medications is a
highly challenging task and will require a dialog among
psychologists. The reader is referred to Cohen and Jacobs’
(2000) model consent form for psychotropic drug treat-
ment. This consent form highlights the limits of knowledge
regarding the use of psychotropic medications, and pre-
sents easily comprehensible information regarding somatic
and psychological effects of drug use and drug withdrawal.
The content may serve as a stimulus to help psychologists
clarify a better-informed stance regarding participation in
medication recommendations and referrals.
Recommendations for Training
Psychologists’ training must keep pace with the changing
demands of practice. Given the numbers of clients taking
J Contemp Psychother
123
psychotropic medications and our frequent influence in
patient’s decision-making regarding medication usage, all
psychologists need to be well-informed about medication
main effects and common side effects. Sexual side effects
are only one of many potential adverse drug effects that
clients under our care may experience; awareness about the
impacts, side effects, and interactions among a range of
common medications and substances is also necessary. The
American Psychological Association (APA) has endorsed
basic knowledge in psychopharmacology as imperative for
all providers in psychology (American Psychological
Association board of Educational Affairs 1995, p. ii).
Barnett and Neel (2000) argue that that Level 1 training in
psychopharmacology is the minimum requirement neces-
sary to meet the standard of care and avoid doing harm.
Many graduate programs have already incorporated such
training, and a basic curriculum for professional psychol-
ogy internships was proposed by Dunivin and Southwell
(2000). Practicing psychologists should seek out training
opportunities available as continuing education courses or
graduate level university courses.
Basic, Level I training in psychopharmacology is not
enough. Most psychologists will not become experts in psy-
chopharmacology. All psychologists, however, can become
educated, critical consumers of information about psycho-
tropic medications. Ethical practice entails awareness of
limits to competence. This includes awareness of limits to
one’s own professional repertoire as well awareness of the
limits of the science upon which professional practices are
based. As Cohen (2004) notes, all mental health professions
must examine how they can minimize iatrogenic harm. The
responsibility to do no harm requires careful consideration of
which ideas and practices merit allegiance. Training pro-
grams must expose students to viewpoints other than the
conventional: an alternative curriculum is needed which
includes historical perspectives regarding psychiatric medi-
cations, critical perspectives regarding biological theories of
mental illness and medication treatments, awareness of
marketing influences in the science base and on prescribing
practices, and the limits of pharmacovigilance systems. In
short, this is an awareness of the nature of and reasons for the
gap between widespread psychotropic medication usage and
the tested evidence to justify it. Such a curriculum, intended
to educate non-medical health professionals such as psy-
chologists and social workers about evolving best practices
with regards to serving clients taking or contemplating taking
psychotropic medications, is available at Critical Think Rx:
http://www.criticalthinkrx.org/. The program, developed by a
team of health care professionals without financial conflicts
of interest and funded by a settlement of consumer fraud
claims against a pharmaceutical company, will be available
as a 12 credit, on-line, continuing education course in the near
future.
Conclusion
Sexual side effects occurring in response to taking anti-
depressant medications are more common than previously
reported and may not always resolve once the medication
has been discontinued. Informed consent regarding the use
of these medications is most effectively accomplished
when all professionals responsible for a patient’s care are
educated about these side effects and work collaboratively
to educate patients, thus increasing their ability to make an
informed choice. The frequency with which the medica-
tions are prescribed, the evidence that sexual side effects
have been underestimated, and the deleterious effects that
such medication side effects may have on treatment and
patient functioning make it imperative that psychologists
educate themselves in order to best help those whom they
serve. This entails a necessary expansion of psychologists’
knowledge base and scope of practice. Current efforts at
informed consent are most likely inadequate, particularly
for the treatment of children and adolescents, and leave a
void that psychologists, given our often more frequent
contact with patients, are particularly suited to fill.
References
Aguirre, B. (1999). Fluoxetine and compulsive sexual behavior.
Journal of the American Academy of Child and Adolescent
Psychiatry, 38, 943. doi:10.1097/00004583-199908000-00008.
American Psychiatric Association. (2000). Practice guidelines for the
treatment of patients with major depressive disorder (revision).
The American Journal of Psychiatry, 157(Suppl 4), 1–45.
American Psychological Association board of Educational Affairs.
(1995, December). Final report of the BEA working group to
develop a level I curriculum for psychopharmacology education
and training. Washington DC: Curriculum for Level I training in
psychopharmacology.
Antonuccio, D. O. (2007, April). Informed parental choice about anti
depressants for their children. American Society for the
Advancement of Pharmacotherapy Tablet, 8(1), 1, 6–7.
Antonuccio, D. O., Danton, W. G., & McClanahan, T. M. (2003).
Psychology in the prescription era: Building a firewall between
marketing and science. The American Psychologist, 58, 1028–
1043. doi:10.1037/0003-066X.58.12.1028.
Arafa, M., & Shamloul, R. (2006). Efficacy of sertraline hydrochlo-
ride in treatment of premature ejaculation: A placebo-controlled
study using a validated questionnaire. International Journal of
Impotence Research, 18, 534–538. doi:10.1038/sj.ijir.3901469.
Bahrick, A. (2006, September). Post SSRI sexual dysfunction.
American Society for the Advancement of Pharmacotherapy
Tablet, 7(3), 2–3, 10–11.
Bahrick, A. (2008). Persistence of sexual dysfunction side effects
after discontinuation of antidepressant medications: Emerging
evidence. The Open Psychology Journal, 1, 42–50. doi:10.2174/
1874350100801010042.
Balon, R. (2006). SSRI-associated sexual dysfunction. American
Journal of Psychiatry, Sep:163(9), 1504–1509.
Barnett, J. E. (2007). Informed consent: Too much of a good thing or
not enough? Seeking an understanding of informed consent.
J Contemp Psychother
123
Professional Psychology: Research and Practice, 38(2), 179–
182. doi:10.1037/0735-7028.38.2.179.
Barnett, J. E., & Neel, M. L. (2000). Must all psychologists study
psychopharmacology? Professional Psychology: Research and
Practice, 31(6), 619–627. doi:10.1037/0735-7028.31.6.619.
Berry, D. (2006). Informing people about the risks and benefits of
medicines: Implications for the safe and effective use of medicinal
products. Current Drug Safety, 1, 121–126. doi:10.2174/
157488606775252638.
Bolton, J. M., Sareen, J., & Reiss, J. P. (2006). Genital anaesthesia
persisting six years after sertraline discontinuation. Journal of
Sex and Marital Therapy, 32(4), 327–330.
Burt, C.W., McCaig, L. F., & Rechtsteiner, E. A. (June, 2007).
Ambulatory medical care utilization estimates for 2005. Advance
Data from Vital and Health Statistics,Number 388. Retrieved
from http://www.cdc.gov/nchs/data/ad/ad388.pdf. Accessed Jan
7, 2008.
Chen, H., Reeves, J. H., Fincham, J. E., Kennedy, W. K., Dorfman, J.
H., & Martin, B. C. (2006). Off-label use of antidepressant,
anticonvulsant, and antipsychotic medications among georgia
medicaid enrollees in 2001. Journal of Clinical Psychiatry,
67(6), 972–982.
Clayton, A. H., Keller, A., & McGarvey, E. L. (2006). Burden of
phase-specific sexual dysfunction with SSRIs. Journal of Affec-
tive Disorders, 91(1), 27–32. doi:10.1016/j.jad.2005.12.007.
Clayton, A. H., & Montejo, A. (2006). Major depressive disorder,
antidepressants, and sexual dysfunction. The Journal of Clinical
Psychiatry, 67(Suppl. 6), 33–37. Review.
Clayton, A. H., Pradko, J. F., Croft, H. A., Montano, C. B.,
Leadbetter, R. A., Bolden-Watson, C., et al. (2002). Prevalence
of sexual dysfunction among newer antidepressants. Journal of
Clinical Psychiatry, 63(4), 357–366.
Cohen, D. (2004, May). Needed: Critical thinking about psychiatric
medications. Keynote Address, 4th International Conference on
Social Work in Health and Mental Health. Quebec City. Retrieved
from http://www.ahrp.org/about/CohenPsychMed0504.pdf.
Cohen, D., & Jacobs, D. (2000, Winter). A model consent form for
psychiatric drug treatment. Journal of Humanistic Psychology.
Retrieved from http://ssri-research.com/informed_consent.
Csoka, A. B.,Bahrick, A. S., & Mehtonen, O. P. (2008). Persistent sexual
dysfunction after discontinuation of selective serotonin reuptake
inhibitors (SSRIs). Journal of Sexual Medicine, 5, 227–233.
Csoka, A. B., & Shipko, S. (2006). Persistent sexual side effects after
SSRI discontinuation. Psychotherapy and Psychosomatics,
75(3), 187–188. doi:10.1159/000091777.
de Jong, T. R., Snaphaan, L. J., Pattij, T., Veening, J. G., Waldinger, M.
D., Cools, A. R., et al. (2006). Effects of chronic treatment with
fluvoxamine and paroxetine during adolescence on serotonin-
related behavior in adult male rats. Eur Neuropsychopharmoco-
logical, 16(1), 39–48.
Dunivin, D. L., & Southwell, G. D. (2000). Psychopharmacology
training in psychology internships: A brief curriculum. Profes-
sional Psychology: Research and Practice, 31, 610–614.
Galli, V. B., Raute, N. J., McConville, B. J., & McElroy, S. L. (1998).
An adolescent male with multiple paraphilias sucessfully treated
with fluoxetine. Journal of Child and Adolescent Psychophar-
mocology, 8, 195–197.
Goode, E. (2004, February). Stronger warning is urged on antide-
pressants for teenagers. New York Times, p. A12.
Gouve
ˆa, T. S., Morimoto, H. K., de Faria, M. J., Moreira, E. G., &
Gerardin, D. C. (2008). Maternal exposure to the antidepressant
fluoxetine impairs sexual motivation in adult male mice.
Pharmacology, Biochemistry and Behavior, 90(3), 416–419.
Happell, B., Manias, E., & Roper, C. (2004). Wanting to be heard:
Mental health consumers’ experiences of information about
medication. International Journal of Mental Health Nursing,
13(4), 242–248.
Higgins, A., Barker, P., & Begley, C. M. (2006). Iatrogenic sexual
dysfunction and the protective withholding of information: In
whose best interest? Journal of Psychiatric and Mental Health
Nursing, 13, 437–446.
Hu, X. H., Bull, S. A., Hunkeler, E. M., Ming, F., Lee, J. Y., Firemen,
B., et al. (2004). Incidence and duration of side effects and those
reported as bothersome with selective serotonin reuptake inhib-
itor treatment for depression: Patient report vs. physician
estimate. Journal of Clinical Psychiatry, 65(7), 959–965.
Johnson-Greene,D. (2007). Informedconsent: Too much of a good thing
or not enough? Commentary: Evolving standards for informed
consent: Is it time for an individualized and flexible approach?
Professional Psychology: Research and Practice, 38(2), 183–184.
Kafka, M. P. (1996). Therapy for sexual impulsivity: The paraphilias
and paraphilia-related disorders. Psychiatric Times, XIII(6).
Retrieved from http://www.psychiatrictimes.comp960627.html.
Kauffman, R. P. (2008). Persistent sexual side effects after discontin-
uation of psychotropic medications. Primary Psychiatry, 15, 24.
Kauffman, R. P., & Murdock, A. (2007). Prolonged post-treatment
genital anesthesia and sexual dysfunction following discontin-
uation of citalopram and the atypical antidepressant nefazodone.
The Open Women’s Health Journal, 1, 1–3.
Landen, M., Hogberg, P., & Thase, M. E. (2005). Incidence of sexual
side effects in refractory depression during treatment with
citalopram or paroxetine. Journal of Clinical Psychiatry, 66(1),
100–106.
Maciag, D., Coppinger, D., & Paul, I. A. (2006). Evidence that the
deficit in sexual behavior in adult rats neonatally exposed to
citalopram is a consequence of 5-HT(1) receptor stimulation
during development. Brain Research, 1125, 171–175.
Michels, K. B. (1999). Problems assessing nonserious adverse drug
reactions: Antidepressant drug therapy and sexual dysfunction.
Pharmacotherapy, 19(4), 424–429.
Montejo, A. L., Gines, L., Izquierdo, J. A., & Rico-Villademoros, F.
(2001). Incidence of sexual dysfunction associated with antide-
pressant agents: A prospective multicenter study of 1022 out-
patients. Journal of Clinical Psychiatry, 62(Suppl 3), 10–21.
Montejo-Gonzalez, A. L., Llorca, G., Izquierdo, J. A., Ledesma, A.,
Bousono, M., Calcedo, A., et al. (1997). SSRI-induced sexual
dysfunction: Fluoxetine, paroxetine, sertraline, and fluvoxamine
in a prospective, multicenter, and descriptive clinical study of 344
patients. Journal of Sex and Marital Therapy, 23(3), 176–194.
Montgomery, S. S., Baldwin, D. S., & Riley, A. (2002). Antidepresant
medications: A review of the evidence for drug-induced sexual
dysfunction. Journal of Affective Disorders, 69(1–3), 119–140.
Osvath, P., Fekete, S., Voros, V., & Vitrai, J.(2003). Sexualdysfunction
among patients treated with antidepressants: A Hungarian retro-
spective study. European Psychiatry, 18(8), 412–414.
Pachter, W. S., Fox, R. E., Zimbardo, P., & Antonuccio, D. O. (2007).
Corporate financing and conflicts of interest: A primer for
psychologists. American Psychologist, 62(9), 1005–1015.
Raz, A. (2005). Perspectives on the efficacy of antidepressants for
child and adolescent depression. Public Library of Science:
Medicine, 3(1), e9.
Rivas-Vasquez, R. A., Rey, G. J., Blais, M. A., & Rivas-VAsquez, A.
A. (2000). Sexual dysfunction associated with antidepressant
treatment. Professional Psychology: Research and Practice,
31(6), 641–651.
Rutherford, B. R., Aizaga, K., Sneed, J., & Roose, S. (2007). A survey
of psychiatry residents’ informed consent practices. Journal of
Clinical Psychiatry, 68, 558–565.
Safarinejad, M. R. (2007). Safety and efficacy of escitalopram in
the treatment of premature ejaculation: A double-blind, placebo-
J Contemp Psychother
123
controlled, fixed-dose, randomized study. Journal of Clinical
Psychopharmacology, 27, 444–450.
Safarinejad, M. R., & Hosseini, S. Y. (2006). Safety and efficacy of
citalopram in the treatment of premature ejaculation: A double-
blind placebo-controlled, fixed dose, randomized study. Inter-
national Journal of Impotence Research, 18, 164–169.
Sharko, A. M. (2004). Selective serotonin reuptake inhibitor-induced
sexual dysfunction in adolescents: A review. Journal of the
American Academy of Child and Adolescent Psychiatry, 43(9),
1071–1079. Review.
Shindel, A., Nelson, C., & Brandes, S. (2007). Urologist practice
patterns in the management of premature ejaculation: A
nationwide survey. Journal of Sexual Medicine, 5, 199–205.
VandenBos, G. R., & Williams, S. (2000). Is psychologists’
involvement in the prescribing of psychotropic medication really
a new activity? Professional Psychology: Research and
Practice, 31, 615–618.
Waldinger, M. D. (2007). Premature ejaculation: Definition and drug
treatment. Drugs, 67(4), 547–568.
Weintraub, N., Cohen, D., Klipper-Aurbach, Y., Zadik, Z., &
Dickerman, Z. (2002). Deareased growth during therapy with
selective serotonin reuptake inhibitors. Archives of Pediatrics
and Adolescent Medicine, 156(7), 696–701.
Wise, E. H. (2007). Informed consent: Too much of a good thing or
not enough? Commentary: Informed consent: Complexities and
Meanings. Professional Psychology: Research and Practice,
38(2), 183–184.
Zajecka, M. D., Mitchell, B. S., & Fawcett, J. (1997). Treatment-
emergent changes in sexual function with selective serotonin
reuptake inhibitors as measured with the Rush Sexual Inventory.
Pharmacology Bulletin, 33(4), 755–760.
J Contemp Psychother
123
