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Originally Posted by HeadDoc thanks Marianco for clarifying that last point. I never understood the "poop out". Regarding the sexual s/e's of SSRI's, it would appear that you are less confident in augmenting the SSRI with Wellbutrin. I have never seen it used, but would a small amount of stimulant be a better choice.
Also have you used any secondary messengers for depression or anxiety, like inositol?
This is a reference that I have relied upon in the past. Any comments? http://www.fpnotebook.com/PSY184.htm |
The reference is good.
Like most psychiatric medications, your mileage will vary. In my experience, dating back to when Wellbutrin was first introduced (1985), I have not seen it work often in improving sexual function (but then I usually treat very severely ill people, thus the population itself may not respond well because they have numerous physical and other co-morbid problems). Yes, it may in some patients - thus making it worthwhile to prescribe first, given its relative safety. But improvement in sexual function has been a rare occurrence. Realizing that Wellbutrin primarily increases norepinephrine, this is then understandable. Dopamine has the much larger role in sexual function. What is good about Wellbutrin as an antidepressant - when not used primarily to improve sex drive - is that it does not interfere, by and large, with sexual function, unless the dose gets too high.
The cleanest (i.e. with fewer side effect and other mechanisms of action) and best way I've seen to improve Dopamine level is by optimizing
testosterone activity for the individual, while maintaining physiologic levels. I like this method because sex can then be spontaneous, in the here-and-now. This is as opposed to having to prepare for it by taking
Viagra or some other medication, which removes spontaneity from sex. If you have to focus on a medication prior to sex, sex isn't as fun. There tends to be too much anxiety about performance, whether the medication will work or not. Being in the here-and-now and being spontaneous during sex is very important to the pleasure of and loving experience for the woman/wife/girlfriend/partner.
A small amount of a stimulant (including pseudoephedrine, Dexedrine, Ritalin) is an option when optimizing
testosterone is not enough (given the multiple other factors that can affect sex drive, arousal, the nervous system, physical illness etc.). I have prescribed Dexedrine or Ritalin for patients in this regard. They tend to not prefer it over time, however. Stimulants increase both norepinephrine and dopamine. The norepinephrine side tends to cause anxiety and insomnia. They end up preferring a phosphodiesterase inhibitor such as
Viagra. (As an aside, cocaine, which I would not recommend using, is a strong multiple re-uptake inhibitor - increasing dopamine, norepinephrine, and serotonin - not just a dopamine reuptake inhibitor as is commonly thought.)
I like
Cialis over the other phosphodiesterase inhibitors because its long half-life allows more spontaneity in sex, and multiple sexual episodes - which is why it is called a "weekend" drug. However some people are very sensitive to the flush reaction, headache, reddened eyes, and nasal drip as side effects.
If possible, reducing the offending sexually-inhibiting drug to restore sexual function is preferable to using another medication to address a side effect.
With the usual severe depressive and anxiety problems in patients I see, psychotherapy and actual medications and hormones have the strongest effect. Supplements (like SAMe, Inositol, etc.) are useful as adjuncts, but do not have a strong enough effect on depression and anxiety to be used on their own. Some (like SAMe) would cost more than prescribed medications at the doses useful to treat depression and anxiety.
In milder cases of depression and anxiety - such as would be treated by a primary care provider, the supplements may be more useful since a small effect is all that may be needed, when coupled with psychosocial interventions.
Supplements are much more useful in the patients I see, for the co-morbid conditions accompanying, possibly contributing to depression and anxiety, and possibly caused by depression and anxiety themselves - i.e. the psychosomatic illnesses. For example, if anxiety and depression has a large component due to adrenal fatigue/insufficiency, then there is a large contingent of supplements (including vitamins, minerals, etc.) which can be very useful to help improve function and reduce symptoms of illness. If there is insulin resistance and diabetes as a component of depression and anxiety, then there are supplements which can be highly useful. If vascular insufficiency or neuropathy is a component of the illness, then there are supplements which can be highly useful.