Prescribing dilemma: balancing risk and benefit when treating sertraline sexual dysfunction

This case example explores how off-label drug holidays and other behavioural changes can be used to treat a patient with obsessive compulsive disorder taking sertraline who is experiencing sexual dysfunction.

Case presentation

The patient is a 28-year-old female with a diagnosis of obsessive compulsive disorder (OCD) with obsessive ruminations, which involves constant and repetitive thoughts and making repeated attempts to solve a perceived problem, as well as compulsions, who takes sertraline 150mg once daily to treat this. As a side effect of this medication, the patient is experiencing decreased sexual desire and delayed/no orgasm that is negatively affecting her marriage. The patient is on no other medication. 

The dilemma

The patient was referred by their GP to the community mental health team and to a pharmacist-led clinic to help manage this side effect. 

Current guidance from the National Institute for Health and Care Excellence for the management of OCD offers little in terms of recommendations for the management of side effects of selective serotonin reuptake inhibitors (SSRIs), such as sexual dysfunction. Such recommendations can be found in the Maudsley Prescribing Guidelines in Psychiatry^​1​, or in the Psychotropic Drug Dictionary.

Prior to referral, and upon the pharmacist’s advice, the patient’s GP had already tried reducing the dose of sertraline to 100mg once daily, as well as trying another SSRI, fluoxetine, but both had led to poorly controlled OCD symptoms. 

Upon review in the pharmacist-led clinic, the patient expressed a reluctance to try another medication and felt that sertraline 150mg once daily was the best option to manage their OCD symptoms. Continued management of their OCD symptoms was seen as essential by the patient, as it allowed her to work and function at a productive level; however, the patient also stated that she was very concerned about the future of her marriage owing to decreased sexual desire and delayed/no orgasm. The patient stated that she was concerned that her partner was losing interest in her and was fearful that her marriage may break down. This presented a dilemma where the therapeutic benefits of sertraline, which was successfully controlling the patient’s OCD symptoms, needed to be considered against the non-medical impact that medication side effects were having on the patient’s life.

Initial plan

The impact of the medication side effects and the patient’s decreased sexual desire and delayed/no orgasm was discussed. The patient was reluctant to engage with talking therapy regarding this, or for her OCD, as they had negative experiences with therapy previously. She also stated that her partner had no interest in relationship counselling. 

The options as a clinician were therefore limited as the medication could not be changed, and the patient could not be referred for psychotherapy. This left limited additional and purely behavioural options such as scheduling sex, exercising before sexual activity and vibrator stimulation^​2​.   

The patient stated that she was already trying vibrator stimulation and exercising before sexual activity, but that side effects seem to be more pronounced in the morning and at night. As a result, it was agreed that scheduling sex for the afternoon could be a potential solution. The patient was happy with this suggestion and resolved to try this. 

Additional actions agreed

The patient was reviewed face to face after four weeks to see if behavioural options had helped manage the side effect; however, the patient stated that although she had a little more sexual desire in the afternoons, she continued to experience delayed/no orgasm. The patient also stated that these failed attempts at scheduled sex were even more frustrating and had conspired to make her relationship worse. She said she was still extremely reluctant to explore talking therapy, relationship counselling or a medication change. 

Scheduling a drug holiday was discussed as a potential course of action, including the benefits and risks.

The patient decided that this approach would be the best course of action. Sertraline has a half-life of 24–32 hours^​5​. In the clinical trial mentioned above, they utilised a two-day sertraline holiday to good effect^​3​. As the patient’s OCD was well controlled and the negative impact on the patient’s life was substantial, it was decided to trial a regimen where the patient would stop taking sertraline every fortnight from Friday to Sunday. A three-day period would still prevent any symptom relapse, while also allowing for enough drug excretion to allow sexual activity to occur^​3​. 

Appropriate monitoring

To manage any potential risk, prompt follow-up and adequate monitoring was required and the patient was booked in for a telephone review following their first drug holiday and a face-to-face review after their second drug holiday, as well as for after two months and four months. The patient was also encouraged to contact the pharmacist and the community mental health team if there were any issues or concerns. 

As the patient had demonstrated a strong commitment to sertraline, as well as a good understanding of the role it plays in managing her OCD symptoms, the prescriber felt that there was a low risk of the patient discontinuing their medicines completely. 

Outcomes

After the first drug holiday (Friday to Sunday) the prescriber contacted the patient on the following Tuesday for a telephone review. The patient reported no change in her OCD symptoms, but also reported no change in their sexual desire or their orgasm; however, both the patient and their partner were happy to continue trialling this approach. 

After the second drug holiday (Friday to Sunday a fortnight later) the patient came into the clinic for a face-to-face review on the Wednesday. The patient was thrilled to report that they had experienced an increased sexual desire on the Sunday, including orgasm. The patient stated that her partner was thrilled also and they really had a positive weekend. The patient also reported no change in her OCD symptoms. As a result, it was decided to continue with the drug holiday every fortnight.  

The patient was reviewed face to face on a further two occasions, one month after the above review and three months after the above review. On both occasions, the patient reported compliance with the fortnightly holiday and reported no change in her OCD symptoms. The patient stated that she continued to experience increased sexual desire and orgasm during the drug holidays, and that her relationship was in a much better place because of this. The patient stated that they had ringfenced these drug holidays as protected time for themselves as a couple and had even managed to take some weekend trips away, which had helped them communicate. 

Follow up

The patient was discharged back into the care of her GP after this face-to-face review. The GP was sent regular letters throughout, and the GP was very much in agreement that the drug regimen holiday should be continued. 

The GP has confirmed that they are still prescribing the drug holiday regimen a year later, and that the patient continues to be doing very well. 

Reflective practice

In the past, I may have been too quick to suggest a dosage or medication change, or a referral to psychotherapy, when managing the sexual dysfunction side effect of SSRIs.

After seeing this patient, who was strongly committed to their medication, I found myself much more likely to suggest behavioural options (such as exercise before sexual activity, scheduling sex, vibrator stimulation) or even occasionally, more drug holidays as first-line options for those whose mental health symptoms are well controlled and where risks can be safely managed. Consult the wider multidisciplinary team and other prescribers for advice, drawing on their experience, in order to fully explore all treatment options. Although there is some understandable reluctance around using drug holidays, it is important to explore behavioural approaches as first-line options when dealing with SSRI sexual dysfunction. 

This prescribing dilemma and the above reflection of the author highlights that, as a prescriber, it is important to:

• Be prepared to have difficult conversations with patients and seek opportunities to develop different consultation approaches;  
• Be able to effectively review and interpret recent trial data and other sources of evidence to support decision-making and effectively communicate risks vs benefits;
• Ask relevant questions that fully explore the thoughts, beliefs and attitudes of the patient, as well as the specific impact their symptoms are having on their daily life to create opportunities for shared decision making and person-centred care;
• Remember to consider the full range of treatments available; these may include pharmacological, non-pharmacological and behavioural options;
• Agree on an appropriate monitoring plan and appropriate follow-up with the patient and ensure that the patient is aware of the signs and symptoms that may mean they need more prompt and urgent follow-up;
• Communicate and inform members of the multidisciplinary team who are involved in the care of the patient of the treatment decision, any outcomes and follow-up.