Patterns and treatment of sexual dysfunction in major depressive disorder: A cohort and case-control study in Sweden

BACKGROUND: Sexual dysfunction (SD) is a consequence of major depressive disorder (MDD) and a common adverse effect of antidepressants. However, population-level evidence on SD in MDD remains limited. OBJECTIVE: To examine the incidence, prevalence, and predictors of SD among individuals with MDD. METHODS: We conducted a nationwide Swedish cohort study (2006-2014) of 169,430 adults (18-65 years) with incident MDD. SD was identified via diagnoses and prescriptions for erectile dysfunction medications (predominantly PDE5 inhibitors). We estimated 3-year incidence and prevalence pre- and post-diagnosis. A nested case-control analysis among men assessed associations between SD, antidepressants, and clinical factors using conditional logistic regression. RESULTS: Among 67,783 men and 101,647 women, SD incidence peaked within one year post-MDD diagnosis. Three-year prevalence increased from 6.1% pre-diagnosis to 8.5% post-diagnosis in men, and from 0.11% to 0.18% in women. In case-control analyses, SSRIs (aOR 1.36, 95% CI 1.15-1.61), SNRIs (aOR 1.75, 95% CI 1.40-2.18), and multiple antidepressants (aOR 1.68, 95% CI 1.39-2.02) were associated with increased SD risk within one year post-diagnosis. Mirtazapine showed no significant association. Bupropion was associated with increased odds for SD (aOR 2.01, 95% CI 1.16-3.48). CONCLUSION: SD is infrequently recorded in psychiatric care, particularly among women, which likely reflects differential ascertainment. Associations with SSRIs and SNRIs suggest pharmacological contributions, whereas the association for bupropion likely reflects confounding by indication, given its preferential prescribing for pre-existing anhedonia or SD.