BRIEF
COMMUNICATIONS
chronically psychotic outpatients who received the least amount of fluphenazine decanoate necessary to control their symptoms, the results indicate that these patients who received decanoate had fewer and less severe EPS than the fluphenazine enanthate patients studied by Chien and associates. There are three other reports in the literature that support this finding (810). Therefore, on the basis ofthis and other studies, I feel that in terms of the incidence and severity of EPS, fluphenazine decanoate is preferable to fluphenazine enanthate.
2.
RB. Parrish
DD: Reversibility
ism. AmJ Psychiatry 116:1022-1023. Mandel W, Oliver WA: Withdrawal
Thioridazine BY JOEL
and
KOTIN,
M.D.,
ofdrug-induced
parkinson-
1960 of maintenance
antiparkin-
Sexual
DONALD
E. WILBERT,
M.D.,
DAVID
have been associated with thionidazine in numerous case reports (1-10). Thionidazine has even been proposed as a treatment for premature ejaculation (1 1). Other tranquilizers have also occasionally been noted to cause ejaculatory difficulties (8, 12-14). Various other forms of sexual dysfunction, including diminished sexual interest, difficulty achieving and maintaining erection, and inability to achieve orgasm, have been associated with most if not all of the major tranquilizers, including thionidazine (8, 15). DIFFICULTIES
/33:!.
Jantian’
A: Towards
a more
rational
use
of antiparkinson
Praag
HM.
Dols
LCW:
decanoate: side effects.
experience.
Fluphenazine
a comparison of Am J Psychiatry
fluphenazines: Am
enanthate
132:
and Nerv
and
their duration 130:801-804,
a reappraisal
J Psychiatry
and
flu-
of action 1973
after
491-500,
10 years
1975
Dysfunction
.
J Psychiatry
of drug-in-
drugs in psychiatry. Drug Therapy 1:23-29, 1971 7. Chien CP, DiMascio A, Cole JO: Antiparkinsonian agents depot phenothiazine. Am J Psychiatry 131:86-90, 1974 8. Itil T. Keskiner A: Fluphenazine hydrochloride, enanthate decanoate in the management of chronic psychosis. Dis Syst 31:37-42, 1970
clinical
.
Am
6. DiMascio
10. Ayd FJ Jr: The depot
.
82
5.
reac-
DiMascio A. Demirgian E: Antiparkinson drug overuse. Psychosomatics 11:596-601. 1970 Orlov P, Kasparian G, DiMascio A, et al: Withdrawal of antiparkinson drugs. Arch Gen Psychiatry 25:410-412, 1971
phenazine and motor
The authorsfound a 60% incidence ofdifficulties in sexualfunctioning in 57 tnale patients ss’ho had taketi thioridazine Ejaculatory problems vere the most f requent dysfunction: a third ofthese patients experienced retrograde ejacula tion The incidence of se.wal difficulties in 64 patients who had taken other major tranquilizers t’as on/v 25%. None ofthe latter group experienced retrograde ejaculation-most had difficulty achie ving and maintaining erection The authors recommend consideration ofthe possibility of sexual dysfunction in patients given thioridazine.
EJACULATORY
4.
9. Van
REFERENCES I . Cahan
son drugs in the phenothiazine-induced extrapyramidal tion. Am J Psychiatry 118:350-351, 1961 3. Stratas NE, Phillips RD. Walker PA, et al: A study duced parkinsonism. Dis Nerv Syst 24:180, 1963
/976
VERBtJRG,
AND
SIMON
M. SOLDINGER
It has been our clinical impression that thionidazineinduced impotence is common. There are few figures on the incidence of this effect, however. Since Singh’s first case report in 1961 (1), only 31 cases of ejaculatory failure have been reported to Sandoz Pharmaceuticals (who produce Mellanil, the only brand of thionidazine available in this country). although some 12 to 15 million patients have received the drug since its introduction in 1959, and it is currently the most frequently prescribed major tranquilizer in the United States (16). Witton (4) found that 7 of2l male patients on thionidazine had severe disturbances of sexual function with loss oferection and/or ejaculation,” and ‘ ‘
The
authors
are with
the University
of California,
Irvine,
School
of
Medicine, where Dr. Kotin is Assistant Adjunct Professor and Dr. Wilbert is Assistant Clinical Professor, Department of Psychiatry and Human Behavior, and Mr. Verburg and Mr. Soldinger are senior medical students. Address reprint requests to Dr. Kotin at 1201 West La Veta Ave. , Suite 303, Orange, Calif. 92668. The authors wish to thank the staffs of the Long Beach ministration Hospital, Long Beach, Calif. , the Veterans tion Wadsworth Hospital Center, Los Angeles, Calif.
Central Regional ment of Mental The
opinions
necessarily conducted.
Mental Health.
expressed reflect
the
Health Anaheim, herein
views
Services, Calif. are those
of the
facilities
Orange
,
County
of the authors where
Veterans AdAdministraand the West
the
Departand
research
do not was
BRIEF
Blair and Simpson (8) estimated that 30% of their patients on thionidazine experienced ejaculatory difficulties. We could find no other overall incidence figures. Therefore, we undertook an empirical study to determine the clinical incidence and nature of sexual difficulties associated with thionidazine and to cornpane these findings with those for a group of patients taking other major tranquilizers.
METHOD
We began the study by reviewing charts of male patients in medication clinics and inpatient wards at two Veterans Administration (VA) hospitals and a community mental health center (CMHC). We selected for study patients who had been taking either thioridazine alone or other major tranquilizers for at least 2 weeks. Other major tranquilizers included chlorpromazine, tnifluoperazine, thiothixene fluphenazine prochlorpenazine acetophenazine chlorprothixene perphenazine, and halopenidol. Combinations were acceptable in the other-major-tranquilizer group if they did not include thionidazine.’ Because of the frequency of polypharmacy in these patients, substantial effort was required to find a sufficient number of patients on thionidazine alone. (The difficulty of specifically identifying side effects constitutes yet another angument against the use of multiple drugs.) Patients with histories of treatment for impotence, diabetes, hypertension, and neurological illnesses, and those who were using other medications were excluded from the study. The only exceptions were a few patients in the thionidazine group and many in the other-major-tranquilizer group who were taking antiparkinsonian agents. Patients who met the criteria described above (N=l15) were interviewed individually. After an attempt to establish rapport, the patient was asked if he had had intercourse or masturbated since starting on his present medication. If the patient’s response was negative, the interview was terminated shortly thereafter and the patient was not included in the study. If the response to either part of the question was affinmative, he was then asked whether since starting on his present medication he had observed changes in achieving erection, maintaining erection, ejaculation, and/on quality oforgasm, or had experienced pain during sex. These questions were also asked about any prior drug experiences as well. In the interview, we attempted to distinguish clearly between global sedative effects of tranquilizers and specific sexual dysfunctions. ,
,
‘Some ing
,
ylhydantoin,
of these from
,
patients other
doxepin
parison taking
,
,
in the other-major-tranquilizer group were also takpsychotropic medications (imipramine, amitriptyline, hyroxyzine , chlordiazepoxide , lithium carbonate . diphenphenobarbital, and methaqualone); the concurrent use
medications we were making other medications
the thioridazine
in this
group
in this study. concurrently
group.
was
not felt to affect However, were
patients rigorously
the
com-
who were excluded
RESU
COMMUNICATIONS
LTS
Of the I 15 patients interviewed initially, 87 responded affirmatively to the question related to sexual activity since starting their present medication; 77 of these were outpatients at a VA hospital, 5 were VA hospital inpatients, and 5 were outpatients at a CMHC. The age range was 21 to 68 years, with a median age of 49. Seventy-five were diagnosed as schizophnenic; the other 12 patients were diagnosed in eight different categories. When a patient could identify a previous discrete period of drug use during which he was on a medication different from that presently in use, we considered that period as a separate episode. Using this method we analyzed 121 episodes of drug prescription among the 87 patients. This figure represents 23 patients who had taken only thioridazine, 30 who had taken other major tranquilizers but not thionidazine, and 34 who had taken both thionidazine and other major tranquilizers at different times and were thus included in the data analysis of both groups. Differences between the two groups were assessed by chi-square tests. Some type of sexual dysfunction associated with thionidazine was reported by 60% of the patients who had taken the drug, while only 25% of the patients neported such problems with other major tranquilizers (p