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Question. What mental illnesses may cause impotence? What psychotropics may contribute to the problem?

Answer. Impotence, or erectile dysfunction [ED], is usually not due to psychiatric disorders, contrary to the conventional view of twenty or thirty years ago. In most cases, ED is due to an underlying medical condition, ranging from diabetes to liver disease to nerve damage. Low levels of the hormone testosterone may also be involved.

Among psychiatric causes of erectile dysfunction, simple anxiety and fear of sexual failure are probably among the most common factors. Major depression is also frequently associated with decreased libido (sexual drive), which may show up as ED. Marital conflict may also underlie some cases of erectile dysfunction. As your question implies, drugs and medications are often the culprit. Several drugs used to treat high blood pressure may cause ED, for example, beta blockers, such as propranolol.

Among the psychotropics, antidepressants are probably the most common causes of erectile dysfunction, with some agents much more likely than others to have this effect. For example, with so-called SSRIs, like fluoxetine (Prozac) and sertraline (Zoloft), rates of sexual dysfunction (including but not limited to ED) may be as high as 20-40% of patients. Erectile dysfunction is rarely a problem with the antidepressant bupropion (Wellbutrin), in fact, this is sometimes added to an SSRI to counteract the sexual side effects of the latter. Nefazodone (Serzone) is also rarely associated with sexual dysfunction.

Antipsychotic agents, such as clozapine or olanzapine, may also cause ED and other forms of sexual dysfunction, as may benzodiazepines such as diazepam (Valium) or clonazepam (Klonopin). Less commonly, anticonvulsant/mood stabilizers, such as valproate (Depakote), may cause erectile dysfunction. Usually, dosage reduction, change to a different agent, or addition of a counteracting agent can deal with most cases of medication-induced erectile dysfunction. (There are a few case reports finding that the anti-ED drug sildenafil (Viagra), may be helpful in counteracting antidepressant-induced erectile dysfunction). However, all cases of sexual dysfunction not clearly due to a medication should be evaluated with a complete medical examination.