Dr. Piazza and Colleagues Reply

To the Editor: We thank Richard Balon, M.D., for his thoughtful response to our article. We agree that our results represent pilot work and leave many questions unanswered. As we stated, some of the observed effects may be explained by 1) a ceiling effect—e.g., baseline orgasm delay and dissatisfaction with orgasm in women may have precluded further deterioration; 2) reporting differences between men and women; and 3) differences in the timing of onset of change. As in the study by Labatte et al. that Dr. Balon cites, treatment-emergent sexual dysfunctions reported at 2 and 4 weeks in our study were larger than those reported at 6 weeks and may have continued to decline if followed further.

Dr. Balon recommends that we report the frequencies of subjects experiencing treatment-emergent sexual dysfunction. Two of 14 women noted a decline in sexual functioning (both experienced orgasm delay, one of whom also reported decreased psychological arousal and lubrication), whereas 50% of the women experienced improvement in sex drive and psychological arousal. Changes in sexual functioning during treatment were also found in about half of the male patients and include male orgasm delay (six out of 11) and male loss of orgasm satisfaction (five out of 11). Dr. Balon also questioned whether large changes in item scores in small numbers of patients accounted for group differences. We do not believe this was the case. The mean change scores for patients reporting these dysfunctions were all approximately 2 points on a scale of 0 to 4. Furthermore, we used nonparametric statistical tests, which are not disproportionately influenced by outliers.

We join Dr. Balon in calling for randomized, controlled clinical trials assessing sexual functioning as it is affected by psychiatric illness and the pharmacologic treatments we employ. Our study suggests a need for controlling for gender and possible illness effects. We also recommend the development of standardized measures that take into account the potential for bidirectional change.