Transcript Prathima Apurva - Forensic Network

Anti-libidinal medication
Dr Prathima Apurva
ST5 Forensic psychiatry
Nov 2013
Overview
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Context
What is anti-libidinal medication?
Why might we need it in managing sex
offenders?
How does it work?
Availability in Scotland.
Some legal and ethical issues
Sex offenders with ID
Static variables
 Anti social attitude, poor relationship with
mother, low self esteem, lack of
assertiveness, poor response to treatment,
 Offences involving physical violence, staff
complacency, an attitude tolerant of
sexual crimes
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Low treatment motivation, erratic
attendance and unexplained break from
routine, deterioration in family attitudes.
Unplanned discharge
Dynamic variables
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Social effective functioning
Distorted attitudes and beliefs
Self management and self regulation
Sexual preference and sexual drive
Social effective functioning
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This refers to the way in which the
individual relates to the other people and
includes aspects of negative affect.
Low self esteem and loneliness.
Distorted cognitions and beliefs
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Counterfeit deviance
Whilst assessing to be cautious about
processes such as suppression, social
desirability and lying.
Self management and self
regulation
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Deficits in self regulation and ability to
engage in appropriate problem solving
strategies and impulse control.
Sexual preference and sexual drive
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Interest rather than accessibility
Paedophilia
What is antilibidinal medication
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Primary effect is to either stop androgens
from being produced or to prevent them
from working altogether.
Testosterone is thought to influence sexual
arousal and responsiveness.
Therefore a reduction in testosterone = a
reduction in a man’s libido and desire to
engage in sexual activity.
Why?
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It not to completely suppress sexual drive
and create an asexual individual.
To selectively suppress deviant sexual
urges and fantasies.
Hormones and neuro-transmitters involved in
sexual response
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Dehydroepiandrosterone
(DHEA)
Oxytocin
Phenylethylamine (PEA)
Oestrogen
Testosterone
Progesterone
Prolactin
Vasopressin
Dopamine
Serotonin
Acetylcholine
1.
DESIRE
(LIBIDO)
2.
AROUSAL
3.
ORGASM
Types of medication
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Anti-libidinal medications:
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Medroxyprogesterone Acetate (MPA).
Cyproterone Acetate (CPA).
Long-acting Gonadotropin-releasing
Hormones (GnRH) agonists. ( Leuprorelin,
Triptorelin & Goserelin.
Psychotropic medication:
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Selective Serotonin Reuptake Inhibitors
(SSRIs)
Cyproterone acetate
LICENSED FOR MALE HYPERSEXUALITY
MODE OF ACTION
Blocks testosterone receptors
Also decreases GnRH and LH
secretion
DOSE
50 – 200 mg orally
300 – 600 mg fortnightly
intramuscular depot
(named patient basis)
COST
£300 – 400 per year
Cyproterone acetate
ADVERSE EFFECTS
 menopausal symptoms (hot flushes, depression, weight gain,
cardiovascular)
 gynaecomastia
 osteoporosis
 carbohydrate metabolism, other endocrine
CAUTIONS / CONTRA-INDICATIONS
 under 18 (or incomplete growth)
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liver disease
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malignancy (except prostate)
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cardiovascular disease
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severe diabetes
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severe chronic depression
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metabolic bone disease
Leuprorelin
NOT LICENSED
MODE OF ACTION
GnRH agonist: exhausts
LH and FSH
DOSE
 3.75 mg 4 weekly titrate
between every 2 weeks
and every 8 weeks
 or 22.5mg every 3
months
COST
3.75mg = £125.40 = £1630
annually
Triptorelin
SALVACYL LICENSED FOR SEVERE SEXUAL DEVIANCE
MODE OF ACTION
GnRH agonist: exhausts LH and
FSH
DOSE
3.75mg – 7.5 mg every 4 weeks
11.5mg every 3 months
COST
3.75mg = £105.05 = £1366
annually
Goserelin
NOT LICENSED
MODE OF ACTION
GnRH agonist: exhausts
LH and FSH
DOSE
 3.6mg every 4 weeks
 long acting 10.8mg
every 12 weeks
COST
 3.6mg = £122.27 =
£1590 annually
 10.8 mg = £366.82 =
£1559 annually
GnRH agonists
ADVERSE EFFECTS
 menopausal symptoms (hot flushes, depression, weight gain,
cardiovascular)
 gynaecomastia
 osteoporosis
 carbohydrate metabolism, other endocrine
 BUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATE
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initial increase in testosterone – not need flutamide
CAUTIONS / CONTRA-INDICATIONS
 under 18 (or incomplete growth)
 malignancy (except prostate)
 cardiovascular disease
 severe diabetes
 severe chronic depression
 metabolic bone disease
GnRH agonists
STUDIES
 Case studies and case series
 118 patients in systematic review (Briken et
al., 2003)
 Very low re-offending
 Better outcome for those previously on MPA
or CA
 Sexual urges and fantasies may disappear
 Frequency of masturbation reduced
drastically
 Side-effects less problematic
SSRIs
NOT LICENSED
MODE OF ACTION
Potentiate serotonin activity by decreasing re-uptake
from synapse
DOSE
 fluoxetine:
20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4
weeks
 sertraline:
50mg, 100mg, 150mg
COST
£50 - 500 annually
SSRIs
ADVERSE EFFECTS
 nausea
 agitation, restlessness
 insomnia
 sexual dysfunction (decreased libido; delayed ejaculation)
 too much coffee feeling
 raised prolactin
CAUTIONS / CONTRA-INDICATIONS
 mania
 epilepsy (poorly controlled)
 history of bleeding disorders
 hypersensitivity
 akathisia
SSRIs
STUDIES
 over 200 case reports and open studies reported in
the literature (Kafka, 2003; Greenberg & Bradford,
1997)
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most report success in reducing the frequency and
intensity of sexual fantasy, urges and arousal
often without negative effects on normal sexual behavior
systematic review (Adi et al., 2002)
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very few trials of reasonable methodological quality
outcomes positive
use of SSRI medication in sex offenders warranted
SSRIs
HOW DO THEY WORK?
May have effect through:
 Impulsivity
 Mood
 Obsessive-compulsive
 Decreased deviant fantasizing
 Attachment
Legal and Ethical issues
Voluntary or Mandatory
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Mandatory in many USA states
If Voluntary – issues with consent
Voluntary more like to work?
Most psychiatrist feel treatment should be
voluntary.
If capacity is an issue then AWI and DMP
opinion.
Treatment or Punishment
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Voluntary = treatment?
Mandatory = punishment?
Side effects
Risk management tool?
Concluding thoughts
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Pharmacotherapy can work.
More guidance on legal and ethical
concerns.
Advice from SOLS