Insomnia, COVID interfere treatment

Dear Dr. Roach: I am an almost 69-year-old man in generally good health. I exercised regularly, but with Pilates studios closed I have only been walking. I have always been troubled with insomnia and have tried every sleep aid. My internist prescribed trazodone 100 mg.

Four years ago, I suffered acute anxiety with no known trigger, for which I was prescribed Xanax. After a heart attack, my internist wanted me off of the Xanax completely and prescribed Lexapro. My sex drive has noticeably dipped. I can achieve an erection but cannot reach orgasm. I am becoming very depressed again. I tried cutting back on the trazadone but then could not sleep. My internist just shrugs and says this is the side effect. Do you have any ideas for me? — B.

There are many factors that need to be balanced in your .

The most important issue here is treating the depression properly. While some of the increase in depression may relate to COVID-19 challenges and other external factors, there may be some ways to help. Regular exercise is itself not a treatment, but has been shown to improve both sexual dysfunction and depressive symptoms.

Escitalopram (Lexapro) can definitely affect both desire and orgasm, and often, reducing the dose can be helpful. I think augmenting treatment with either psychotherapy or a second medication should be considered. My first choice would be bupropion, which works well in combination with SSRIs and has very low incidence of sexual side effects. Unfortunately, it can cause insomnia itself, so I would recommend a small dose.

I am disappointed that your internist does not seem to be taking the sexual side effects seriously. Treatment of the depression is the critical issue, but sexual side effects are important.