The Hidden Link Between Mental Health and Sexual Dysfunction

Dr. Giedrė Jonušienė

LSMU MA Psychiatry clinic

Sexual dysfunctions often occur in mental disorders and may be related both to psychopathology and pharmacotherapy. Changes in the phases of sexual response may develop either in isolation or diffusely and may improve with appropriate treatment of the underlying mental illness. Understanding the relationship between sexual function and mental disorders helps to select the most appropriate individualized treatment for the prevention or management of these dysfunctions.

Even today, specialists often underestimate patients' sexual function, and spontaneous complaints from patients remain relatively rare.

Physiology and Psychology of Sexual Response

Normal sexual response depends on the coordinated functioning of the nervous, psychological, cardiovascular, and endocrine systems. These processes are regulated by the hypothalamus, limbic system, and cerebral cortex and mediated by neurotransmitters responsible for sexual response [1, 2].

Sexual response consists of several phases: desire, arousal, orgasm, and resolution. Dopamine enhances sexual motivation, arousal, and behavior, whereas serotonin suppresses sexual desire, ejaculation, and orgasm. Norepinephrine is associated with the initiation, maintenance, and arousal phases [1, 2].

Cholinergic fibers are involved in the filling of the cavernous bodies of the penis, while the alpha-adrenergic system contributes to their emptying [3, 4].

Sex hormones also play a crucial role. Testosterone is important for sexual desire in both men and women. In women, the conversion of testosterone to estrogens is essential not only for desire but also for arousal mechanisms. Increased prolactin levels reduce arousal and other phases of sexual response [2].

Sexual behavior is influenced by a complex interplay of biological, psychological, and social factors. These include interpersonal relationships, cultural and religious aspects, partner’s sexual function, inadequate stimulation, dissatisfaction, negative experiences, trauma, and the use of substances, as well as medical and psychiatric conditions [5, 6].

Mental health and sexual dysfunction (SD) are closely related [2, 7], and this relationship is bidirectional—sexual dysfunction can also negatively affect mental health [8].

Mood Disorders and Sexual Function

It is estimated that 10–16% of the population experience depressive episodes [9–11]. Globally, depression is one of the most disabling conditions [12]. It is characterized by low mood, loss of interest and pleasure, decreased activity, and other negative symptoms [13].

Mood disorders significantly affect sexual function. During major depressive episodes, sexual dysfunction occurs in 40–65% of patients, depending on antidepressant use [14–20].

An epidemiological study in Zurich found that sexual function is impaired in approximately every second person with depression compared to controls [7]. Depression negatively affects mood, energy, self-confidence, and self-esteem, which is reflected in reduced sexual desire, interest, and satisfaction [21–23], as well as impaired arousal, orgasm, and ejaculation [17, 20].

Untreated depression may reduce sexual desire by about 40% in men and 50% in women [24, 25], and in some cases up to 72% [17].

Neuroimaging studies show differences in brain activity related to sexual function in men and women with depression [26, 27]. Erectile dysfunction (ED) is strongly associated with the severity of psychiatric symptoms [28, 29].

In women, depression negatively affects all stages of sexual response, including arousal, lubrication, and satisfaction [30, 31]. A Lithuanian study showed that in postmenopausal women, depression and anxiety are major risk factors for sexual dysfunction [32].

Depression often coexists with anxiety disorders, which further impair sexual function [33], and with obsessive-compulsive disorder, which is associated with reduced sexual pleasure [34].

Depression, anxiety, and stress are associated with ED in 2–80% of cases and premature ejaculation (PE) in 11–30% [8, 31].

Interestingly, not all patients experience reduced sexual interest—some men report increased sexual interest during depression [7]. In women, increased masturbation has been observed, possibly as a mood-regulating mechanism [35].

Sexual interest and activity may increase during mania or hypomania [35], and hypersexual behavior is often associated with mood and anxiety disorders [37].

Overall, the relationship between mood disorders and sexual dysfunction is considered bidirectional [39, 40].

Anxiety Disorders and Sexual Function

Anxiety disorders significantly impair sexual function. Up to 75% of patients report a worsened sexual life. Almost half avoid sexual activity, compared to only 2% in healthy individuals.

During sexual activity, individuals with anxiety may fear loss of control or experience panic attacks, which negatively affect satisfaction [41, 42].

Panic disorder affects 3–5% of the population and is associated with poor psychosexual adaptation, reduced satisfaction, and feelings of guilt and shame [43]. Sexual dysfunction is present in up to 75% of individuals with panic disorder and in about 33% of those with social phobia.

Social anxiety disorder is strongly associated with avoidance of intimacy. Men more often report premature ejaculation, while women experience disturbances in desire, arousal, and satisfaction [41, 44].

Antidepressants and Sexual Function

Antidepressants (ADs) are the main treatment for depression [45]. Their use has increased significantly over recent decades [46].

However, sexual dysfunction is a common side effect. The prevalence ranges from 22–59% [48], and in some reports up to 73% [49].

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most commonly used ADs and are strongly associated with sexual dysfunction [46].

These medications may impair all phases of sexual response—desire, arousal, orgasm, and ejaculation [49].

SSRIs increase serotonin levels, which reduces libido and may cause delayed ejaculation or anorgasmia [1, 4]. The strongest effects are observed with paroxetine, fluvoxamine, sertraline, and fluoxetine [4].

Erectile dysfunction occurs in up to 73% of patients using citalopram and 63% using sertraline [49].

SNRIs such as venlafaxine also frequently cause sexual dysfunction, while duloxetine has a milder effect [51].

Tricyclic antidepressants negatively affect desire, arousal, and satisfaction [20].

Less common side effects include decreased genital sensitivity, painful orgasms, priapism, and reduced ejaculate volume [1, 52].

However, not all effects are negative—SSRIs may help patients with premature ejaculation by prolonging intercourse [55], and may be useful in treating compulsive sexual behaviors [4].

Some antidepressants have minimal sexual side effects, including bupropion, mirtazapine, agomelatine, tianeptine, and trazodone [1, 24, 56, 57].

Switching to or adding mirtazapine may improve sexual function [1, 58].

When choosing treatment, it is important to consider the patient’s sexual life and balance benefits and risks [21].

Healthcare Provider’s Role

Sexual dysfunction remains under-recognized in clinical practice. Both patients and doctors often avoid discussing sexual health due to embarrassment or misconceptions.

However, direct questioning significantly increases detection rates—from about 14–24% up to 58% when questionnaires are used.

Healthcare providers should actively assess sexual function and determine whether dysfunction is related to mental illness or treatment. Patients should always be informed about potential side effects.

Conclusions

Sexual dysfunction occurs in at least half of patients with mood and anxiety disorders. The relationship between sexual dysfunction and mental disorders is bidirectional.

Antidepressants may worsen, cause, or improve sexual function depending on the situation.

Proper evaluation, open communication, and individualized treatment are essential for effective management.

**References** 1. Montejo AL, Majadas S. Sexual disturbances associated with antidepressant treatments. In: Moussaoui D, editor. Depression, antidepressants, and sexual function. WPA Bulletin on Depression 2004;9(28):7–10. 2. Marzani-Nissen G, Clayton A. Sexual disturbances in depression. In: Moussaoui D, editor. Depression, antidepressants, and sexual function. WPA Bulletin on Depression 2004;9(28):3–6. 3. Zajecka J, Fawcett J, Schaff M, Jeffriess H, Guy C. The role of serotonin in sexual dysfunction: fluoxetine associated orgasm dysfunction. J Clin Psychiatry 1991;52(2):66–68. 4. Montejo-Gonzalez AL, Llorca G, Izquierdo JA, Ledesma A, Bousono M, Calcedo A, et al. SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176–94. 5. Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 2003;24(4):221–229. 6. Hartmann U, Philippsohn S, Heiser K, Ruffer-Hesse C. Low sexual desire in midlife and older women: personality factors, psychosocial development, present sexuality. Menopause 2004;11(6):726-40. 7. Angst J. Sexual problems in healthy and depressed persons. Int Clin Psychopharmacol 1998;13(Suppl 6):S1–4. 8. Mialon A, Berchtold A, Michaud PA, Gmel G, Suris JC. Sexual dysfunctions among young men: prevalence and associated factors. J Adolesc Health 2012;51(1):25–31. 9. Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety 1998;7(1):3–14. 10. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095–3105. 11. Zemishlany Z, Weizman A. The impact of mental illness on sexual dysfunction. In: Balon R, editor. Sexual dysfunction. The brain-body connection. Adv Psychosom Med. (29) Basel, Karger; 2008. Lithuanian Physician Journal No.7