Dimorphic changes of some features of loving relationships during long-term use of antidepressants in depressed outpatients

Abstract

The present study aimed at investigating the possible changes of some features of loving relationships during long-term treatment of depression with both selective serotonin reuptake inhibitors (SSRIs) and tricyclics (TCAs), by means of a specifically designed test, the so-called “Sex, Attachment, Love” (SALT) questionnaire.

The sample was composed by 192 outpatients (123 women and 69 men, mean age±SD: 41.2±10.2 years), suffering from mild or moderate depression, according to DSM-IV-TR criteria, that were selected if they were treated with one antidepressant only for at least six months and were involved in a loving relationship.

The results showed that SSRIs had a significant impact on the feelings of love and attachment towards the partner especially in men, while women taking TCAs complained of more sexual side effects than men. These data were supported also by the detection of a significant interaction between drug and sex on the “Love” and “Sex” domains.

The present findings, while demonstrating a dimorphic effect of antidepressants on some component of loving relationships, need to be deepened in future studies.

Introduction

In the last decades, the use of antidepressants, particularly of selective serotonin reuptake inhibitors (SSRIs) has increased progressively, so that nowadays they represent one of the most commonly prescribed drugs in the medical practice (Bauer et al., 2008, Pratt et al.,). This is due to different factors, such as their indication and significant effectiveness in both depression and anxiety disorders, coupled with fewer side effects and lower toxicity/lethality, as compared with older antidepressants (Stahl, 2008). Currently, the wide use of SSRIs has been also promoted by the easier recognition and prompter psychiatric diagnoses, as well as acceptance of psychotropic medications by patients and clinicians (Borch Jacobson, 2002, Paulose-Ram et al., 2007, Olfson and Marcus, 2009). Undoubtedly, if on one side SSRIs are very effective in improving some negative and debilitating symptoms of depression, on the other, they seem to dampen some rewarding and joyful emotions (Barnhardt et al., 2004). Therefore, nowadays a greater concern is emerging that SSRIs may provoke previously unrecognized side effects, such as cognitive and/or emotional blunting and apathy. In the scientific literature, such effects have been also named SSRIs-induced indifference, but disagreements exist on how to label this phenomenon (Wongpakaran et al., 2007, Price et al., 2009). Some reports are available showing that patients treated for long periods with SSRIs experience decreased emotional response to both aversive and pleasurable events. Taken together, such data would indicate that SSRIs would blunt positive emotions and potentially alter personality (Hoehn-Saric et al., 1990; Kramer, 1993, Opbroek et al., 2002, Sansone and Sansone, 2010). Although depressed patients may suffer from anhedonia even after clinical remission (Raskin et al., 2012), emotional blunting seems to be a different phenomenon strictly related to SSRI intake (Price and Goodwin, 2009).

At the moment, as there are no large epidemiological studies on this topic, data on the prevalence rate of SSRIs-induced emotional blunting should be interpreted with caution. In one study (Bolling and Kohlenberg, 2004) 16.1%, out of a total of 161 depressed patients were reported to suffer from loss of ambitions, while in another (Fava et al., 2006) the prevalence was between 30% and 40%. Other studies carried out in smaller samples provided the same data (Opbroek et al., 2002, Sato and Asada, 2011). The rate in anxiety disorder seems to be lower (5%), but the sample was constituted by children only (Reinblatt and Riddle, 2006). Further, other observations in children and adolescents confirmed the phenomenon in these populations (Murphy et al., 2000, Garland and Baerg, 2001).

Besides the little data on the magnitude of the phenomenon, its pathophysiology is largely unknown and different hypotheses have been put forward to explain it. According to some authors, it could be due to the inhibitory influence of serotonin (5-HT) on the dopaminergic system (Barnhart et al., 2004), or on the frontal lobe and interference with the reward system (Harmer, 2008, Harmer et al., 2003a, Harmer et al., 2003b, Abler et al., 2012). Recently, interesting suggestions came from a study showing that a treatment with citalopram decreased the neural processing of reward and aversive stimuli in healthy subjects (McCabe et al., 2010), although it should be underlined that the effects of antidepressants may be different in healthy conditions and pathological states (for review, see Serretti et al., 2010).

Given the paucity of information on this topic and the total absence of data in our country, the aim of this paper was to explore and compare the eventual changes of some components of loving relationship during a long term-treatment of depression with SSRIs and tricyclics (TCAs). For this purpose, we developed a specific instrument, the so-called “Sex, Attachment, Love” questionnaire (SALT) (Appendix 1: translation into English of the original questionnaire in Italian). The possible differences between men and women were examined as well.