Managing antipsychotic-related sexual dysfunction in patients with schizophrenia

ABSTRACT

Introduction

Schizophrenia is a psychotic disorder and one of the most severe and impactful mental illnesses. Sexual dysfunction is highly prevalent in patients with schizophrenia but remains underdiagnosed and undertreated. Sexual dysfunction is frequently attributed to antipsychotics which may reduce medication adherence, but negative symptoms can also reduce sexual drive.

Areas covered

This review provides an overview of the current knowledge about sexual dysfunction in patients with schizophrenia. The authors first review the literature concerning the mechanisms of sexual dysfunction and explore the impact of antipsychotics on sexual function. Finally, they present the available non-pharmacological and pharmacological treatment strategies for sexual dysfunction in patients with schizophrenia.

Expert opinion

Sexual dysfunction in patients with schizophrenia is still underrated by clinicians despite having a negative impact on the quality of life and therapeutic adherence. Antipsychotic treatment is still perceived as a major cause of sexual impairment. Psychiatrists must be aware of this condition and actively question the patients. A comprehensive approach, addressing pharmacological and non-pharmacological aspects, is fundamental for managing sexual dysfunction in schizophrenia. Pharmacological strategies include (1) Serum-level adjustment of the antipsychotic dose, if possible (2) switching to a well-tolerable antipsychotic (aripiprazole, brexpiprazole) and (3) adding a coadjuvant drug (phosphodiesterase-5 inhibitors).

KEYWORDS:

• antipsychotics
• female sexual dysfunction
• male sexual dysfunction
• schizophrenia
• sexual dysfunction

Article highlights

• Sexual dysfunction (SD) is highly prevalent in patients with schizophrenia.

• SD can reduce the quality of life and medication adherence.

• Several factors may contribute to SD including cardiovascular and endocrine diseases, substance abuse, schizophrenia-related symptoms, namely, negative and cognitive symptoms, and antipsychotic medication.

• Antipsychotics may cause SD through (1) histamine receptor antagonism, (2) dopamine receptor antagonism, (3) cholinergic receptor antagonism, and (4) alpha-adrenergic receptor antagonism.

• Antipsychotics can increase prolactin levels and potentially cause loss of libido and infertility in men as well as hypoactive sexual desire disorder, irregular menstruation, and infertility in women.

• Correctly assessing symptoms of SD is of the utmost importance. Psychiatrists routinely and actively question the patient about symptoms related to SD.

• Treatment of antipsychotic-related SD includes non-pharmacological and pharmacological strategies.

• Once SD is identified, clinicians should (1) explore possible psychological or somatic factors and intervene on modifiable risk factors; and/or (2) serum-level adjustment of antipsychotic dose, if possible; (3) switch to another antipsychotic (well-tolerable antipsychotic, if possible); (4) add a coadjuvant medication to improve sexual function (phosphodiesterase-5 inhibitors proved effective).

• First-generation antipsychotics but also risperidone and paliperidone are associated with severely impaired sexual function leading to diminished therapeutic adherence.

• Aripiprazole, cariprazine, and brexpiprazole act as D₂/D₃ partial agonists normalizing prolactin compounds and minimizing unwanted sexual effects.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.