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Home , Erectile dysfunction, Libido, Sexual arousal disorder

CASE REPORT Alpha 2021;22(1):70-72 Alpha Psychiatry DOI: 10.5455/apd.108021

Use of in Coexisting Major , Loss of and

ABSTRACT

Erectile dysfunction and low sexual in males are frequently encountered sexual func- tion disorders. Reduced or libido is defined as the low frequency of sexual union or achieving and reduced to initiate or respond to a sexual activity. Individuals with major depression are very frequently observed to have sexual function dis- orders. It is known that agents used for depression treatment are insufficient to regulate sexual function disorder most of the time, whereas some antidepressant agents themselves have side effects of developing a sexual function disorder. Methylphenidate, frequently used for attention-deficit and hyperactivity disorder, is known to affect sexual behavior. Methylphenidate increases (DA) and (NE) neurotrans- mission through DA and NE reuptake inhibition. Increases in DA have long been known to increase sexual desire. This article presents the case of a 40-year-old male patient treated with who had improvements in erectile dysfunction and loss of libido ac- companying depression with the addition of methylphenidate to the treatment.

Keywords: Methylphenidate, decreased libido, erectile dysfunction

Introduction

Sexuality may be defined as ensuring a person’s physical, cognitive, affective, and social integrity; involving sexual fulfillment affected by values, beliefs, and social rules; and a private experience and state of health with biological, social, and psychological aspects.1 Erectile dysfunction and low libido in males are frequently encountered sexual function disorders. Loss of libido is defined as a low frequency of sexual union or achieving orgasm and reduced motivation to initiate or respond to a sexual activity. Individuals with major depression are very frequently observed to have sex- ual function disorders. It is known that antidepressant agents used for depression treatment are insufficient to regulate sexual function disorder most of the time, whereas some antidepressant agents themselves have side effects of developing a sexual function disorder.2 Methylphenidate, frequently used for attention-deficit and hyperactivity disorder, is known to affect sexual behav- ior. Methylphenidate increases dopamine (DA) and norepinephrine (NE) neurotransmission by DA and NE reuptake inhibition. Increases in DA have long been known to increase sexual desire. This article presents the case of a 40-year-old male patient treated with antidepressants who had improvements in erectile dysfunction and loss of libido accompanying depression with the addi- Şerif Bora Nazlı1 tion of methylphenidate to the treatment. Muhammet Sevindik2

Case Presentation 1Department of Psychiatry, Kepez State Hospital, Antalya, Turkey A 40-year-old male high-school graduate, married for 15 years, and working as a laborer lived 2Department of Psychiatry, Ordu University with his family in the city center. Reasons for attending our psychiatry clinic were depression, School of , Ordu, Turkey sexual aversion, sleepiness during the day, attention deficiency, and loss of interest. The com- Corresponding Author: plaints had continued for nearly 3 years; however, sexual aversion had increased within the Şerif Bora Nazlı  [email protected] past 6 months. He experienced problems during the times when he rarely felt sexual Received: June 6, 2020 desire and had not had sexual relations with his wife in the past 6 months. He stated the lack Accepted: July 17, 2020 of motivation to initiate sexual relations and very pronounced difficulty in becoming erect Published Online: January 19, 2021 had continued for 6 months. Cite this article as: Nazlı ŞB, Sevindik M. Use of Methylphenidate in Coexisting Major Copyright@Author(s) - Available online at alpha-psychiatry.com. Depression, Loss of Libido and Erectile Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 Dysfunction. Alpha Psychiatry 2021;22(1):70- International License. 72.

70 Nazlı and Sevindik. Use of Methylpenidate in Erectile Dysfunction Alpha Psychiatry 2021;22(1):70-72

In his sexual history before the onset of the disorder, our patient, who arousal to clear sexual stimuli. This study (with 30 healthy subjects: did not have with someone other than his partner, 15 men and 15 women) showed that individuals using methylphe- had the first sexual experience at the age of 25 after his . Our nidate provided greater responses to clear visual patient had sexual intercourse 2-3 times a week before the onset of the stimuli and emphasized that these results overlapped with the disorders symptoms. known role of DA in sexual impulses.3 Another study indicating the importance of DA in sexual physiology showed that individuals us- Psychiatric examination found open and full orienta- ing levodopa, the DA precursor, had activation in the nucleus ac- tion. Attention was easily distracted, movements were restless, sleep cumbens associated with sexual stimuli, whereas individuals using amount was increased, complaints focused on thought content, and the DA antagonist of haloperidol had inhibition.4 mood was low. His social functioning had reduced. In women and men with depression, methylphenidate is stated to Routine laboratory tests and consultation were requested. resolve through both DA and 5-HT carrier Laboratory tests (follicle-stimulating hormone: 5.85 IU/L, luteinizing blockage.5 DA is associated with libido, , and sponta- hormone: 3.68 IU/L, total : 403.55 IU/L, -specific neous owing to sexual stimuli.6 antigen: 0.62 ng/mL) and urology consultation did not identify any urologic pathology that could explain the erectile difficulties. Another study showed that the intravenous (i.v.) methylphenidate injection group had significantly increased sexual libido and desire The patient was diagnosed with major depression disorder and com- compared with those of the control group.7 In fact, these increas- menced treatment with selective reuptake inhibitors, sero- es occurred even without sexual stimuli in the environment when tonin-NE reuptake inhibitors, and atypical antidepressant agents. De- methylphenidate was administered. The increase in DA, controlling spite increasing to the highest effective dose, there was no positive sexual arousal through mediation of the mesolimbic and mesocor- response, and treatment changes were recommended. tical systems, was greater than expected owing to the i.v. use. More- over, controlled and oral use will cause a more moderate DA increase. Vortioxetine was recommended. Depressive complaints began to reduce with 10 mg/day vortioxetine. The Hamilton Depression Rat- Although the DA increase is emphasized, it is known that NE effica- ing Scale score had regressed to 5 points within 2 months. However, cy of methylphenidate may increase sexual arousal.8 Whether the the patient’s loss of libido and erectile dysfunction persisted. A 10 mechanism is NE increase or DA increase, adding 10-30 mg/day mg/day short-effect methylphenidate was added to the treatment. methylphenidate to treatment is offered as a choice for those ex- After 1 week, methylphenidate treatment increased the libido and periencing orgasm difficulties linked to antidepressants.9 There is no difficulty was experienced with erection during sexual relations. no clear evidence about the possible positive efficacy on erectile Simultaneously, complaints about daytime sleepiness and atten- dysfunction. tion/concentration difficulties improved. Although the majority of depressive complaints had passed before Discussion adding methylphenidate to the treatment of our patient, complete Erectile dysfunction and low sexual desire sometimes cause depres- resolution of sexual function disorder with methylphenidate is not a sive symptoms, whereas sometimes, it is possible that depression definite proof about whether this can treat sexual func- causes sexual function disorder. After excluding all causes of organic tion disorder. DA is known to important roles in each of the 3 etiology in males, the target should be treatment regulation. In our phases of the sexual response (desire, arousal, and orgasm), patient, depressive symptoms had begun slowly 3 years before and it is known to increase with methylphenidate treatment. There is a were accompanied by loss of libido and erectile dysfunction, espe- need for studies on the benefits of added treatment with methylphe- cially in the past 6 months. As a result, we considered that initially, nidate for individuals who have depression with sexual function dis- depression had caused the sexual function disorder. order, especially for the treatment of erectile dysfunction.

Some psychostimulant users state that medication use causes in- 3 creases in sexual desire and sexual arousal. A study by Schmid et al Informed Consent: Informed consent was obtained from the patient who partic- has reported that methylphenidate use may cause increased sexual ipated in this study.

MAIN POINTS Peer-review: Externally peer-reviewed. • Individuals with major depression are very frequently observed to Author Contributions: Design - Ş.B.N.; Analysis and/or Interpretation - Ş.B.N., have sexual function disorders. M.S.; Literature Search - Ş.B.N., M.S.; Writing - Ş.B.N. • Methylphenidate, frequently used for attention-deficit and hyper- activity disorder, is known to affect sexual behavior. Conflict of Interest: The authors have no conflict of interest to declare. • Methylphenidate increases dopamine (DA) and norepinephrine Financial Disclosure: The authors declared that this study has received no finan- (NE) neurotransmission through DA and NE reuptake inhibition. cial support. Increases in DA have long been known to increase sexual desire. • This article presents the case of a 40-year-old male patient treated References with antidepressants who had improvements in erectile dysfunc- tion and loss of libido accompanying depression with the addition 1. Örüm H. Cinselliğin önemi ve cinsel işlev bozuklukları yönetimi. In: Ak- pınar E, ed. Aile Hekimliğinde Güncel Yaklaşımlar. Akademisyen Kitabevi; of methylphenidate to the treatment. 2019:449-456.

71 Alpha Psychiatry 2021;22(1):70-72 Nazlı and Sevindik. Use of Methylpenidate in Erectile Dysfunction

2. Karaş H, Kaşer M. Use of modafinil in co-existing major depression and erectile 6. Melis M, Argiolas A. Dopamine and sexual behavior. Neurosc Biobehav dysfunction: a case report. Turk Psikiyatri Derg. 2019;30(2):142-144. [Crossref] Rev. 1995;19(1):19-38 [Crossref] 3. Schmid Y, Hysek CM, Preller KH, et al. Effects of methylphenidate and 7. Volkow ND, Wang GJ, Fowler JS, et al. Stimulant induced enhanced sexu- MDMA on appraisal of erotic stimuli and intimate relationships. Eur Neu- al desire as a potential contributing factor in HIV transmission. Am J Psy- ro-psychopharmacol. 2014;25(1):17-25. [Crossref] chiatry. 2007;64:157-160. [Crossref] 4. Oei NYL, Rombouts SA, Soeter RP, et al. Dopamine modulates reward 8. Rampin O. Pharmacology of alpha-adrenoceptors in male sexual func- system activity during subconscious processing of sexual stimuli. Neuro- psychopharmacology. 2012;37(7):1729-1737. [Crossref] tion. Eur Urol. 1999;36(Suppl. 1):103-106. [Crossref] 5. Bartlik BD, Kaplan P, Kaplan HS. Psychostimulants apparently reverse sex- 9. Montejo A, Prieto N, Alarcon R, et al. Management strategies for an- ual dysfunction secondary to selective serotonin re-uptake inhibitors. J ti-depressant-related : a clinical approach. J Clin Med. Sex Marital Ther. 1995;21:264-271. [Crossref] 2019;8(10):1640. [Crossref]

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