Rx of Sexual dysfunction Blunt effect Anhedonia Poor memory Inability to have erection Inability to feel sexual arousal Loss of libido

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Treatment of Sexual Dysfunction with Blunted Affect, Anhedonia & Poor Memory

The symptom cluster you've listed - sexual dysfunction + blunted affect + anhedonia + poor memory + inability to erect + inability to feel sexual arousal + loss of libido - is a classic picture of one of two main conditions (often overlapping):

Antidepressant-induced sexual dysfunction (especially SSRI/SNRI-related, including Post-SSRI Sexual Dysfunction / PSSD)
Hypogonadism / testosterone deficiency

Both must be assessed simultaneously. Here is the full treatment framework from the evidence base:

Step 1: Rule Out and Treat Underlying Causes First

Before prescribing antidotes, identify the root cause. The Maudsley Prescribing Guidelines emphasize this is mandatory:

Possible Cause	Assessment
SSRI/SNRI/antipsychotic use	Compare sexual function before vs. after starting the drug
Hypogonadism	Morning serum testosterone (check if <275 ng/dL / <9.5 nmol/L)
Hyperprolactinemia	Prolactin level (dopamine blockers, antipsychotics raise prolactin)
Diabetes / Vascular	Fasting glucose, HbA1c, lipid profile
Cardiovascular disease	BP, BMI, cardiovascular risk assessment
Other drugs	Beta-blockers, thiazides, spironolactone, antiandrogens, opiates
Depression itself	Untreated depression causes anhedonia, loss of libido, and blunted affect independent of any drug

Step 2: Optimize the Primary Treatment

If on an SSRI/SNRI:

Switch to a lower-risk antidepressant. These have the best evidence for a favorable sexual adverse effect profile:

Drug	Sexual Risk Profile	Notes
Agomelatine	Lowest risk	Best evidence for sparing sexual function
Bupropion	Low risk	Dopamine/noradrenaline reuptake inhibitor - can actually improve sexual function
Vortioxetine	Low risk	Also improves cognitive symptoms (memory, concentration)
Mirtazapine	Low risk	5-HT2 antagonist; also helpful for anhedonia
Moclobemide	Low risk	Reversible MAOI

The Maudsley Prescribing Guidelines in Psychiatry, 15ed, p.453
Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Step 3: Pharmacological "Antidote" Treatments

These can be added when switching is not possible or when dysfunction persists:

A. For Erectile Dysfunction (PDE5 Inhibitors)

First-line for erectile dysfunction regardless of cause:

Drug	Dose	Duration of Action
Sildenafil	Start 50mg, up to 100mg (taken 20-60 min before sex)	4-6 hrs - best evidence for antidepressant-induced ED
Tadalafil	10-20mg on demand; or 5mg daily (best for frequent use)	Up to 36 hrs
Vardenafil	5-20mg	4-6 hrs

Daily tadalafil 5mg (start 2.5mg) is preferred if intercourse expected >2x/week
Effective in ~60% of men; slightly lower response in diabetes, post-prostatectomy, spinal cord injury
Goldman-Cecil Medicine, p.2543

B. For Low Libido, Anhedonia, Blunted Affect (Dopaminergic Agents)

These symptoms respond to dopaminergic enhancement:

Drug	Mechanism	Use
Bupropion 150-300mg/day	NE + dopamine reuptake inhibitor	SSRI-induced loss of desire, arousal, anorgasmia; also improves anhedonia and cognition
Amantadine	Dopamine agonist	Prolactin-induced loss of desire and arousal
Bromocriptine	Dopamine agonist	Hyperprolactinemia-induced loss of desire/arousal
Aripiprazole 5-10mg	Partial D2 agonist	Normalizes prolactin, improves sexual function; added to antipsychotics

Maudsley Prescribing Guidelines, Table 1.46, p.223

C. For Arousal Problems / Anorgasmia (Cholinergic/Serotonin Modulation)

Drug	Mechanism	Use
Bethanechol	Cholinergic agonist	Anticholinergic-induced arousal problems (from TCAs, antipsychotics)
Cyproheptadine 4-16mg	5-HT2 antagonist	SSRI-induced anorgasmia/arousal dysfunction - but causes sedation
Buspirone	5-HT1A partial agonist	Antidepressant-induced sexual dysfunction
Yohimbine	α2-adrenoceptor antagonist	SSRI-induced ED, decreased libido, anorgasmia

Step 4: Testosterone Replacement (If Deficient)

If morning testosterone is <275 ng/dL (<9.5 nmol/L) with symptoms of deficiency:

Formulation	Dose
Testosterone gel (topical)	40-50 mg applied daily
Testosterone enanthate/cypionate (IM)	100-200 mg IM every 2 weeks

Testosterone replacement improves libido, erectile function, energy, mood, and lean muscle mass in confirmed hypogonadal men
In men with ED + testosterone deficiency considering PDE5 inhibitors, testosterone should be corrected first - it enhances PDE5 inhibitor response
Washington Manual of Medical Therapeutics; Goldman-Cecil Medicine, Harrison's 22E

Step 5: Post-SSRI Sexual Dysfunction (PSSD)

If symptoms persist after stopping the SSRI/SNRI, this is PSSD - a recognized syndrome characterized by:

Decreased libido, genital numbness, pleasureless orgasm, ED, delayed ejaculation
May persist months to years after stopping the drug

Management of PSSD (evidence limited, no single ideal approach):

PDE5 inhibitors (sildenafil, tadalafil) for erectile component
Bupropion - useful for desire/arousal
Buspirone
Pine bark extract (limited data)
Flibanserin - FDA-approved for hypoactive sexual desire disorder in premenopausal women; no data yet for PSSD specifically
Psychosexual therapy / sex therapy alongside pharmacotherapy
Maudsley Prescribing Guidelines, p.453

For Blunted Affect, Anhedonia & Poor Memory Specifically

These cognitive-affective symptoms suggest either:

Residual depressive symptoms - optimize antidepressant (vortioxetine has pro-cognitive effects; bupropion reduces anhedonia via dopamine)
SSRI-induced emotional blunting - dose reduction or switch to agomelatine/bupropion/vortioxetine
Testosterone deficiency - testosterone replacement improves mood, memory, and motivation

Vortioxetine is particularly worth highlighting here because it uniquely addresses both sexual dysfunction (low risk) and cognitive symptoms (memory, concentration, processing speed) simultaneously.

Summary Decision Tree

Sexual dysfunction + anhedonia + poor memory + blunted affect
    │
    ├── On SSRI/SNRI/antipsychotic?
    │       YES → Dose reduction / switch to bupropion, agomelatine, or vortioxetine
    │             + Add sildenafil/tadalafil for ED
    │             + Add bupropion for desire/arousal if not already using
    │
    ├── Testosterone low (<275 ng/dL)?
    │       YES → Testosterone replacement (gel or IM)
    │             + PDE5 inhibitor for ED if needed
    │
    ├── Prolactin high?
    │       YES → Switch antipsychotic / add aripiprazole 5-10mg
    │             OR bromocriptine / amantadine
    │
    └── All normal, no drug cause?
            → Psychosexual therapy + treat any underlying depression
              + PDE5 inhibitor for erectile dysfunction
              + Testosterone if borderline low

Note: Always exclude cardiovascular disease before prescribing PDE5 inhibitors. They are contraindicated with nitrates. Sexual activity itself is a cardiovascular stress test - patient must be cleared for moderate exercise.

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