Schizophrenia sexual dysfunction

Schizophrenia sexual dysfunction is unfortunately a very common problem and can affect both males and females. It occurs in 30 to 80% of schizophrenia patients and is major cause of a poor quality of life. The reason for such a large disparity in rates is that patients will not always spontaneously volunteer these problems, and must be questioned directly. The mechanism of this dysfunction is varied and not just related to the antipsychotic drugs.

Schizophrenia sexual dysfunction includes erectile dysfunction, decreased libido and disturbances in ejaculation and orgasm. Disturbances of the menstrual cycle can also be included here because it will impact on the sexual experience. Schizophrenia sexual dysfunction is an important subject because it can lead to poor adherance and in turn increase the chances of relapse and cause long-term poor outcomes.

But sexual dysfunction can also be observed in untreated schizophrenia patients, and therefore other factors play a role. For example, negative symptoms can lead to decreased libido and decreased enjoyment.

Causes. The clinician must consider more than just the antipsychotic medication.

Illness itself

Schizophrenia can result in profoundly negative symptoms on its own. Impaired socialisation, anhedonia (lack of enjoyment), and decreased sexual desire and motivation are all factors which can lead to lack of interest and sexual dysfunction.

Antipsychotic drugs

The antipsychotic drugs are responsible for a large percentage of sexual problems. Antipsychotic drugs can interfere with the sexual the experience directly through the many receptors that it interacts with. These include serotonin, adrenergic, cholinergic, dopamine and histamine receptors. Indirectly it can lead to an increase in prolactin levels which can cause schizophrenia sexual dysfunction.

A raised level of prolactin is also called hyperprolactinaemia (hyperprolactinemia) and is caused by the antipsychotics acting on the dopamine D2 receptors at the pituitary gland. This leads to increased release of prolactin. Raised prolactin can lead to menstrual irregularities and fertility problems - menstruation can also stop. Women could experience difficulties in trying to fall pregnant. Prolactin can stimulate breast tissue, and cause breast tissue development in both men and women. In men this is called gynaecomastia. There can also be associated breast pain. Milk can also be produced - this is termed lactation.

The antipsychotics can lead to any of the sexual dysfunctions, viz decreased libido, erectile dysfunction, and disturbances in ejaculation and orgams.

Other psychiatric disorders

These include major depressive disorder, anxiety disorders, eating disorders and personality disorders.

Medical and urological problems

Any major organ disorder (liver, kidney etc), endocrine disorder, diabetes, cardiac and hypertension can all cause sexual dysfunction.

Psychosocial problems
Issues such as self esteem, marital and work-related problems must be considered.

Other medications

Other commonly prescribed medications such as hypertension medication,(beta blockers diuretics and others) and some anti-ulcer treatments can cause sexual dysfunction.

Drugs and alcohol

Both drug and alocol abuse and dependence can cause sexual dysfunction. Amphetamines and other stimulants can cause problems as patiens are coming down from them. Central nervous system depressants like alcohol, heroin and prescription medications like benzodiazepines and over the counter medications (OTC) containing codeine can cause sexual dysfunction. Cannabis may also be a culprit.

Management of schizophrenia sexual dysfunction

Of course, the clinician has to consider and exclude other causes, beside the antipsychotic drugs, discussed above, and then treat this accordingly. In the assessment the clinician needs to take a thorough medical history including a psychosexual history. This might be treatment of the underlying medical problem, treatment of the drug or alcohol issue or psychotherapy or counselling for psychosocial issues.

If the problem is related to the antiposychotic drug, there are certain principles of management that can be applied.
  • wait and see
  • decrease dose
  • drug holidays
  • change to drug with less sexual side effects
  • use adjunctive pharmacotherapy

The first approach can easily be adopted. If this doesn't work then try another one.
A decrease in the dose can be considered if the symptoms are adequately controlled.
Drug holidays are not really an option for someone on antipsychotics. this can be considered if on antidepressants
Changing to a drug with less potential for side effects is a possibility, and this will be based on efficacy and tolerability. A recent study looked at the impact of antipsychotics on sexual function and their summary was as follows,
From greatest to lowest impact: risperidone > typical antipsychotics > olanzapine > quetiapine > aripiprazole.

If on antidepressants, these can be changed to ones with a lower risk of sexual side effects such as bupropion, mirtazapine, nefazadone and reboxetine, or addition of mirtazapine or mianserin.

Viagra is always going to be a popular and effective option. It can be used with any psychiatric medication. Contra-indications for its use is the use of anti-angina medication. The issues with Viagra are cost and 'diversion'. It is a very expensive drug to use, even if you are on medical aid. Beacuse of the high cost, Viagra has a street value and is often diverted to that market, and some psychiatrists therefore do not prescribe it easily.

There are mechanical devices and local medical solutions like injections that are available. Advice from a urologist is probably best. Ultimately what the patient chooses to do will rest on the severity of his illness, response to medications and how tolerable the side effects are.