The Effects of Art Therapy and Psychosocial Skills Training on Symptoms and Social Functioning in Patients with Schizophrenia and Their Relatives. / Sizofreni Hasta ve Yakinlariyla Yapilan Sanatla Terapi ve Ruhsal Toplumsal Beceri Egitiminin Hastalik Belirtileri ve Sosyal Islevsellik Üzerine Etkileri.

OBJECTIVE: The effects of antipsychotics on negative symptoms are limited. The most appropriate approach in the treatment of schizophrenia is the integration of drug therapy with psychological and social interventions. The purpose of this study was to evaluate and compare the effects of art therapy and psychosocial skills training (PSST) in the treatment of schizophrenia. METHODS: A total of 15 patients diagnosed with schizophrenia according to the criteria in DSM-5 and 12 patient relatives were included in the study. The patients were randomly divided into 2 groups, 7 were included in the art therapy program and 8 were included in the PSST program for schizophrenia. 90-minute sessions of art therapy and PSST were carried out once a week for 17 weeks. Participants with schizophrenia were evaluated with the Positive and Negative Syndrome Scale (PANSS), Social Functioning Scale (SFS) and the Calgary Depression Scale for Schizophrenia and the relatives were given Beck Depression Inventory, Beck Anxiety Inventory and Zarit Burden Interview. RESULTS: There was a significant decrease in the PANSS negative symptoms, PANSS general psychopathology, SFS pro-social activities and SFS recreation scores in both groups, while the SFS social withdrawal scores decreased significantly only in the art therapy group. In the PANSS negative symptoms subscale, passive social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation and stereotyped thinking scores were significantly lower in the art therapy group. In the PSST group only the score for difficulty in abstract thinking declined significantly. CONCLUSION: The findings of the present study suggest that art therapy and PSST have positive effects on the improvement of negative symptoms as well as improvements in social and cognitive functionality in schizophrenia.

The Impact of theCovid-19 Pandemic on the Admission of Psychiatric Patients in Emergency Department During the Early Pandemic Period. / Covid-19 Pandemisinin Erken Dönemde Psikiyatrik Hastalarin Acil Servis Basvurulari Üzerindeki Etkisi.

OBJECTIVE: The COVID-19 pandemic and its restrictions cause increasing mental health problems in both the general population and psychiatric patients. In this study, it was aimed to compare the number and characteristics of emergency psychiatric consultations in the earlypandemic period and in the same period of 2019, in order to understand how the COVID-19 pandemic affects psychiatric emergencies and the health care seeking behavior of people with psychiatric disorders. METHOD: A retrospective cross-sectional study was designed in which patients who applied to Emergency Department of Bursa Uludag University and were consulted to psychiatry between 11 March 2019 - 1 September 2019 and 11 March 2020 - 1 September 2020 were included. Sociodemographic characteristics of the patients, psychiatric diagnoses, hospitalizations, psychotropic drug use and treatment compliance, frequency of admission, indications for hospitalization/ referral and suicide attempts were compared. RESULTS: It was observed that the ratio of psychiatric admissions to the emergency department to all emergency department admissions was significantly higher in the early-pandemic period than in the prepandemic period. In the early-pandemic period, emergency department admissions due to depression disorders were found to be significantly lower; schizophrenia and other psychotic disorders, and psychotropic drug side effects were found to be significantly higher than in the prepandemic period. CONCLUSION: In this study, it was shown that the COVID-19 pandemic may have a negative impact on psychiatric patients. Prompt implementation of measures to deal with the psychiatric effects of the pandemic, using online health services, developing coping strategies and identifying early signs of psychiatric illness exacerbations can reduce the negative effects of this stressful period on vulnerable individuals.

Examination of plasma zonulin levels in bipolar I disorder: a case-control study with follow-up.

There is an accumulation in studies which strive to reveal zonulin's potential role in mental disorders. To date, one cross-sectional recent study examined zonulin in patients with bipolar disorders (BDs); however, its role still remains vague due to high fluctuation. Our aims are to determine plasma zonulin levels in exacerbation and treatment response periods, and to examine the associations between zonulin and symptom severity in BD. 30 patients with BD type I and 29 healthy controls participated in the current study. Socio-demographic form, Young Mania Rating Scale (YMRS), and Hamilton Depression Rating Scale (HAM-D) were administered. Enzyme-linked immune assay (ELISA) method was used to measure the plasma zonulin levels of the participants. The groups did not differ in plasma zonulin-level comparisons. Plasma zonulin did not alter between the exacerbation and treatment response periods of the patients. Besides, no associations were found between plasma zonulin-level and disease symptoms. Intestinal barrier integrity was not found to be altered among patients with BD type I. The lack of alterations in plasma zonulin level between different periods may be attributable to several factors. One possible factor might be the ELISA method which can detect other proteins (e.g., properdin) rather than zonulin. Therefore, it might fail to indicate direct observation of intestinal permeability. However, future study designs with more accurate estimation of zonulin in a larger sample may provide a different perspective on intestinal permeability's possible role in BD etiology.

Rates and correlates of employment in patients with schizophrenia: A multicenter study in Turkey.

BACKGROUND: There is not enough information regarding the participation in the working life of the patients with schizophrenia in Turkey. AIMS: The aim of this study was to examine the occupational experiences of patients with schizophrenia before and after the illness and to investigate the factors that predict work participation. METHODS: The data on occupational life of the patients with schizophrenia, which were treated as outpatients in six different centers, were examined. The rates of participation in working life before and after the disease were evaluated. Patients with and without occupational life history after the disease were compared in terms of demographic characteristics. Factors predicting participation in work life after the disease were analyzed by logistic regression analysis. RESULTS: Out of the 587 patients evaluated in the study, 73% were males, 73% were single, the mean age was 42, mean level of education was 9 years and the average duration of illness was 18 years. The duration of the employment before the disease was higher than that after the disease regarding expected working time. The rate of employment was 11% currently, 14% in the last year, 62% after the disease and 83% for the lifetime. While the factors that predicted to be in working life after the illness were male gender (odds ratio (OR) = 2.9), diagnosis of schizoaffective disorder (OR = 2.6), high level of education (OR = 1.2) and employment history before the onset of the illness (OR = 1.0), only the shorter duration of illness (OR = 1.1) predicted the current working status when the gender variable was excluded. CONCLUSION: Rate of employment of patients with schizophrenia living in Turkey was low as in other countries. Good premorbid functioning seems to determine participation in occupational life after the illness.

First-episode psychosis is associated with oxidative stress: Effects of short-term antipsychotic treatment.

AIMS: In the present study, our aim was to investigate the oxidative-antioxidative systems in unmedicated first-episode psychosis (FEP) patients at the beginning and after short-term treatment. METHODS: This study consisted of 29 patients who experienced an FEP and 25 control subjects. In order to investigate the oxidative status, we determined plasma malondialdehyde (MDA) levels, oxidizability of red blood cells, oxidation and oxidizability of apolipoprotein B-containing lipoproteins (apo B-basal MDA and apo B-ΔMDA). In order to evaluate the antioxidative defense, we measured serum total antioxidative capacity, uric acid, albumin, total bilirubin and vitamin E levels and serum paraoxonase/arylesterase, whole blood glutathione peroxidase (GPx) and red blood cell superoxide dismutase activities before and after 6 weeks of treatment in patients with FEP. RESULTS: Plasma MDA and apo B-basal MDA levels and red blood cell superoxide dismutase activity were significantly higher and serum arylesterase and whole blood-GPx activities were lower in the FEP group than those of the healthy control group. There were not any significant changes in the oxidative and antioxidative system parameters (except increased vitamin E levels) after treatment. CONCLUSIONS: The results of this study suggest that FEP is accompanied by oxidative stress. However, further studies are needed to clarify the role of oxidative stress in the physiopathologic mechanisms of FEP, so that oxidative and antioxidative system parameters can be used in the management of these patients. In accordance with psychiatric evaluation, for a better management, patients with FEP may require a multidisciplinary approach, including oxidative and antioxidative system parameters.

Increased plasma agmatine levels in patients with schizophrenia.

Agmatine is an endogenous substance, synthesized from l-arginine, and it is proposed to be a new neurotransmitter. Preclinical studies indicated that agmatine may have an important role in the pathophysiology of schizophrenia. This study was organized to investigate plasma agmatine in patients with schizophrenia and in healthy controls. Eighteen patients with schizophrenia and 19 healthy individuals constituted the subjects. Agmatine levels in the plasma were measured using the HPLC method. The S100B protein level, which is a peripheral biomarker for brain damage, was also measured using the ELISA method. While plasma levels of agmatine in patients with schizophrenia were significantly increased (p < 0.0001) compared to those of healthy individuals (control), there were no significant changes in the levels of S100B protein (p = 0.660). An ROC (receiver operating characteristic) curve analysis revealed that measuring plasma agmatine levels as a clinical diagnostic test would significantly differentiate between patients with schizophrenia and those in the control group (predictive value: 0.969; p < 0.0001). The predictive value of S100B measurements was not statistically significant (p > 0.05). A multiple regression analysis revealed that the age of the patient and the severity of the illness, as indicated by the PANSS score, significantly contributed the plasma agmatine levels in patients with schizophrenia. These results support the hypothesis that an excess agmatine release is important in the development of schizophrenia. The findings also imply that the plasma agmatine level may be a potential biomarker of schizophrenia.

Androgens and sexual dysfunction in naturally and surgically menopausal women.

AIM: To evaluate the influence of surgical versus natural menopause on sexual dysfunction, and the role of androgens in that context. MATERIAL & METHODS: Sexual functioning and androgen levels were studied in 35 surgically and 83 naturally menopausal women. Sexual dysfunction was defined as a total score of less than 23 on the Female Sexual Function Index. RESULTS: Sexual dysfunction was significantly more common in surgically than in naturally menopausal women (65.7% vs 44.6%; P = 0.036). The mean total testosterone level in women with sexual dysfunction was significantly lower than that in their counterparts (49.3 ± 21.0 vs 58.8 ± 23.6 ng/mL; P = 0.022). On the other hand, androgen levels did not differ significantly between surgically and naturally menopausal women. Androstenedione (B = 2.253; P = 0.039) and dehydroepiandrosterone sulfate levels (B = 0.222; P < 0.001), and time from menopause (B = -0.064; P = 0.040) were found to be independent determinants of total testosterone levels. While the duration of menopause was significantly longer in surgically menopausal women, this co-factor was not an independent predictor of sexual dysfunction. Logistic regression analysis proved mode of menopause and total testosterone levels to be the only two independent determinants of sexual dysfunction. CONCLUSIONS: Our findings suggest that while surgical menopause is detrimental to sexual functioning by itself, lower testosterone levels are predictive of sexual dysfunction, especially in naturally menopausal women.

Reversible escitalopram-induced hypothyroidism.

Some drugs can cause alterations in the concentration of thyroid hormones in blood even without clinical signs of dysfunction or pathology of the thyroid gland. Apart from the well-known relationship between depression and hypothalamic-pituitary-thyroid (HPT) axis, and the impact of selective serotonin reuptake inhibitors (SSRIs) on thyroid indices, hypothyroidism is a very rare adverse effect of SSRI treatment. However, the case presented here demonstrates that escitalopram may have the potential to induce hypothyroidism without any significant clinical signs and symptoms. Therefore, the possibility of SSRI-induced asymptomatic hypothyroidism presented here may help clinicians in this regard.

Are there differences between serotonergic, noradrenergic and dual acting antidepressants in the treatment of depressed women?

BACKGROUND: This study aims to investigate if there is a differential outcome of serotonergic and noradrenergic antidepressant treatment and if menopausal status has an impact on antidepressant response in depressed women. METHODS: Data of the 111 depressed women who were included and completed the previous four open-label studies where patients were evaluated six times during a 10-week period, were pooled in the current study. Each of the reboxetine, sertraline and venlafaxine groups consisted of 37 depressed women. Patients were also divided into two subgroups of age, determining the 44 years as the cut-off point representing the menopausal status. RESULTS: No significant difference was observed in the percent change of Hamilton Depression Rating Scale-17 (HDRS) and remission rates among treatment groups. Percent changes in Clinical Global Impression-Severity of Illness scale (CGI-S) and response rates were in favour of venlafaxine group at week 10. Individual HDRS items 2, 3, 4, 5 and 6 demonstrated significant improvement in the sertraline group, whereas HDRS item 7 demonstrated significant improvement in the venlafaxine group. An early reduction in anxiety subscale was observed in the venlafaxine group. Menopausal status had no impact on the outcome measures. CONCLUSIONS: These results suggest that noradrenergic and serotonergic activity do not differ from each other in treating depressed women. However, serotonergic activity appears to be more prominent in some particular symptoms such as feelings of guilt, suicidal ideation and sleep. Also, menopause does not appear to affect antidepressants' benefit in depressed women.

[Reliability and validity of the Turkish version of the Social Adaptation Self-Evaluation Scale (SASS)]. / Sosyal Uyum Kendini Degerlendirme Olçegi (SUKDO) Türkçe formunum geçerlik ve güvenilirligi.

OBJECTIVE: SASS is a new self-evaluation scale that assesses the level of social functioning in depressed patients for clinical research purposes. The aim of this study was to investigate the validity and reliability of the Turkish version of SASS. METHOD: Data were obtained from 2 different sample groups that had no physical disturbances that could impair social functioning; healthy participants between the ages of 18 and 65 years (n = 66) and patients (n = 227) diagnosed with major depressive disorder (MDD). Assessment tools used in the study were SASS, Hamilton Depression Rating Scale, 17-item version, and Global Assessment of Functioning Scale. RESULTS: In the reliability analysis of both groups combined and the MDD group Cronbach's alpha values for the internal consistency of the scale were 0.90 and 0.87, respectively. Item-total score correlations were between 0.22 and 0.66 for both groups combined, and between 0.21 and 0.59 for the MDD group. The correlation coefficient of the scale's test-retest reliability was 0.770 (P < 0.0001) and the SASS value rose from 29.4 +/- 8.1 to 37.8 +/- 8.1 following treatment of depression (P < 0.0001). Four factors with Eigen values > 1 were obtained from the factor analysis. Factor 1, with an Eigen value of 7.169 explained 35.8% of the total variance and represented the entire scale alone. CONCLUSIONS: The Turkish version of SASS, as the original scale, demonstrated adequate validity and reliability for the measurement of loss of social functioning in MDD patients and demonstrated that scores changed in accordance with treatment for depression.

Effects of second generation antipsychotics on leptin and ghrelin.

BACKGROUND: Weight gain is a major side effect of antipsychotic treatment. Some atypical antipsychotic agents have profound effects on weight. Body weight is regulated by a complex system, including both peripheral and central factors. Two of the hormones that seem to play an important role in the regulation of food intake, energy metabolism, and body weight are leptin and ghrelin. Leptin is a mediator of long-term regulation of energy balance, suppressing food intake and thereby inducing weight loss. Ghrelin on the other hand is a fast-acting hormone, seemingly playing a role in meal initiation. In this present study it is aimed to compare the effects of five different atypical antipsychotic medications on leptin and ghrelin. METHOD: 112 patients who were treated either with clozapine (n=20), olanzapine (n=28), risperidone (n=22), quetiapine (n=20) or amisulpride (n=22) as monotherapy for at least one year and age, gender, and body mass index (BMI) matched control group (n=23) were assessed cross-sectionally. Ghrelin and leptin levels were measured with enzyme-immunoassay. RESULTS: When fasting serum leptin levels were compared between groups, control group had the highest mean value (9.2+/-6.7) and amisulpride group had the lowest mean value (3.7+/-2.1) but still there was no statistically significant difference between six groups (F=1993, p=0.084). In the comparison of the mean values of fasting serum ghrelin levels there was a statistically significant difference between groups (F=11,473, p=0.00). In post-hoc analysis it was seen that the control group had the lowest ghrelin level (194.5+/-86.8). Quetiapine treated group (378.1+/-260.4) had similar fasting serum ghrelin levels to control group. All the other antipsychotic treatment groups had significantly higher levels of fasting serum ghrelin compared to control group, highest in amisulpride treated group (597.0+/-150.0). CONCLUSION: The weight-gain side effect of atypical antipsychotics can be related with the orexigenic effect of elevated serum ghrelin rather than leptin deficit. Among the five widely used atypical antipsychotics quetiapine is the only one which does not elevate the ghrelin level.

Effects of various antidepressants on serum thyroid hormone levels in patients with major depressive disorder.

A total of 62 patients with major depressive disorder were analyzed in the study. Patients were evaluated for 11 weeks in an open label design to investigate the differential effects of reboxetine, sertraline and venlafaxine on thyroid hormones. Serum thyrotrophin (TSH), thyroxine (T4) and free (f)T4 levels were measured before and after treatment. All groups showed significant improvement in HAM-D scores. TSH level significantly reduced and T4 level significantly increased in the reboxetine group, however TSH level significantly increased and T4 level significantly reduced in the sertraline group. Percent changes of TSH (p=0.007) and T4 (p=0.001) were significantly different between the reboxetine and sertraline groups. In the sertraline group, baseline TSH levels were correlated with response to treatment as determined by the change in HAM-D scores (p=0.03, r=0.648). There was a significant association between the percent changes in TSH values and the reduction in HAM-D scores in the reboxetine group (p=0.03, r=-0.434). In the whole study group, female patients had lower values of basal T4 compared with men (p=0.043), however percent changes of T4 did not differ between genders. In the treatment-responders significant increase in the reboxetine group and significant decrease in the sertraline group regarding the T4 values were found. We observed that various antidepressants had different effects on thyroid hormone levels and this could be attributed to the different mechanisms of actions of these antidepressants.

Retrospective database analysis on the effectiveness of typical and atypical antipsychotic drugs in an outpatient clinic setting.

OBJECTIVE: To report the outcomes of a retrospective database analysis to compare the effectiveness of atypical and typical antipsychotic drugs. METHODS: Medical records of patients admitted to the psychiatry outpatient clinic between January 1998 and October 2005 were retrospectively reviewed. Data obtained from patient records were noted on a special form assessing four aspects of the treatment history: socio-demographic features, disease characteristics, initial treatment at the time of admission, and course of treatment. Patient groups (typical/atypical and Risperidone/Haloperidol/Olanzapine) were compared for time to all-cause medication discontinuation and rate of discontinuation. RESULTS: There was no statistically significant difference in the duration of treatment between patients using atypical (n = 150) and typical (n = 124) antipsychotics. The duration of treatment was significantly longer in patients on Haloperidol (n = 91) compared with those on Risperidone (n = 63). Rates of discontinuation over 18 months were 59.3% for patients on atypical antipsychotics and 57.3% for those on typical antipsychotics, and 68.3% for patients on Risperidone, 51.6% for patients on Haloperidol and 54.3% for patients on Olanzapine. CONCLUSION: Despite our hypothesis patients with chronic schizophrenia discontinued their atypical and typical antipsychotics, at a high rate with no significant difference indicating substantial limitations in the effectiveness of these drugs.

Coronary artery disease risk factors in patients with schizophrenia: effects of short term antipsychotic treatment.

The aim of the present study was to investigate serum paraoxonase/arylesterase activities and oxidation/oxidizability of apolipoprotein B-containing lipoproteins and several coronary artery disease risk factors, including homocysteine, high sensitive C-reactive protein, tumour necrosis factor-alpha, leptin and adiponectin in patients with schizophrenia. Oxidation of lipoproteins plays an important role in atherogenesis, and the enzyme paraoxonase has been shown to prevent lipoprotein oxidation. Furthermore, low paraoxonase activity has been suggested to predict coronary artery disease. Forty patients who fully met the fourth Diagnostic and Statistical Manual of Mental Disorders criteria for schizophrenia and 35 healthy control subjects were included in the study. Serum paraoxonase/arylesterase activities were determined spectrophotometrically. Malondialdehyde levels of apolipoprotein B-containing lipoproteins were determined before and after incubation with copper-sulphate, which yielded basal- and Delta-malondialdehyde values, respectively. Homocysteine and highly sensitive C-reactive protein levels were determined using a fluorescence-polarization immunoassay and immunonephelometry, respectively. Leptin and adiponectin levels were measured with radioimmunoassay and tumour necrosis factor-alpha was determined by enzyme linked immunosorbent assay. Serum paraoxonase and arylesterase activities were significantly lower and Delta-malondialdehyde levels were significantly higher in the schizophrenia group compared with the control group. However, there were not any significant differences in other parameters of the study between the study groups. There was a significant increase in body mass index and serum triglyceride and very low density lipoprotein cholesterol levels in the schizophrenic group after 6 weeks of treatment. These parameters were significantly increased in patients treated with atypical antipsychotics but not in patients treated with typic or long acting antipsychotics. The results of the present study suggest that patients with schizophrenia might have increased risk for coronary artery disease related to reduced serum paraoxonase activity and increased oxidizability of apolipoprotein B-containing lipoproteins.

Oxidative-antioxidative systems and their relation with serum S100 B levels in patients with schizophrenia: effects of short term antipsychotic treatment.

Oxidative stress may be a contributing factor in the etiopathophysiology of schizophrenia, which may be exacerbated by the treatment with antipsychotics with pro-oxidant properties. Increased levels of S100 B are associated with neurodegenerative disorders, including schizophrenia. The aim of the present study was to investigate the role of oxidative cell damage in the pathogenesis of schizophrenia. Forty patients who fully met the fourth Diagnostic and Statistical Manual of Mental Disorders criteria for schizophrenia and 35 healthy control subjects were included in the study. Serum S100 B level was determined to investigate brain damage. Plasma malondialdehyde (MDA) levels and susceptibility of red blood cell (RBC) to oxidation were determined to investigate the oxidative status and plasma vitamin E, vitamin C, serum total carotenoid levels and total antioxidant capacity and RBC superoxide dismutase (SOD) and whole blood glutathione peroxidase activities were measured to investigate the antioxidative defence before and after 6 weeks of antipsychotic treatment. Plasma MDA and serum S100 B levels and RBC-SOD activity were significantly higher in the schizophrenia group than those of the control group. Treatment did not modify any of the oxidative-antioxidative system parameters or serum S100 B levels. S100 B level was significantly higher in patients with negative symptoms than the patients with positive symptoms and the control subjects. S100 B levels were significantly reduced after 6 weeks of treatment in patients with negative symptoms. The results of the present study might support the oxidative cell injury hypothesis of the schizophrenia. Furthermore, the underlying mechanisms of the subgroups of schizophrenia might be different as suggested by the increased S100 B levels and its decrement after treatment in patients with negative symptoms.

Urticaria and angio-oedema due to ziprasidone.

Antipsychotic medications are commonLy associated with adverse cutaneous reactions (ACRs) in approximately 5% of patients. Angio-oedema accompanying urticaria is one of the most serious ACRs. The 36-year-old female patient who was diagnosed with ;Paranoid schizophrenia' 6 years ago, was commenced on ziprasidone 120 mg/day. On day 30 of the treatment, the patient presented urticarial papules and plaques all over the body and angio-oedema in the face. The patient was diagnosed as ;Urticaria + Angio-oedema'. The development of ACRs after the initation of ziprasidone monotherapy, disappearance of lesions after the discontinuation of this antipsychotic, and positive intradermal skin test all suggests a possible causal relationship between ACRs and ziprasidone. To our knowledge, this is the first reported case of urticaria and angio-oedema due to ziprasidone monotherapy. Ziprasidone is a valid and effective choice amongst antipsychotic medications, but this case calls for caution regarding ACRs at the time of prescribing.

Major depressive disorder is accompanied with oxidative stress: short-term antidepressant treatment does not alter oxidative-antioxidative systems.

OBJECTIVE: The aim of the present study was to investigate the oxidative-antioxidative systems and effects of different antidepressants on these systems in patients with major depressive disorder (MDD). METHOD: Ninety-six patients with a Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) diagnosis of MDD and 54 healthy controls were included in the study. Plasma malondialdehyde (MDA) levels and susceptibility of red blood cells (RBCs) to oxidation were determined to investigate the oxidative status, plasma vitamin E, vitamin C, serum total carotenoid levels, total antioxidant capacity (TAOC), RBC superoxide dismutase (SOD) and whole blood glutathione peroxidase (GPx) activities were measured to investigate the antioxidative defence before and after 6 weeks of antidepressant treatment. RESULTS: Plasma MDA levels and susceptibility of RBCs to oxidation were significantly higher in the MDD group compared with the control group. RBC SOD activity was significantly increased in patients with MDD, and furthermore there was a significant positive correlation between the severity of the disease and SOD activity. CONCLUSION: MDD is accompanied with oxidative stress; however, oxidative-antioxidative systems do not seem to be affected by 6 weeks of antidepressant treatment.

Reboxetine induced erectile dysfunction and spontaneous ejaculation during defecation and micturition.

This is a case report of reboxetine induced erectile dysfunction, seminal emission and ejaculation during defecation and micturition. A 44 year old male who had been suffering from depression without any sexual dysfunction was put on venlafaxine XR treatment. Due to delayed ejaculation and occasional episodes of absence of ejaculation he was switched to reboxetine. At the second week of treatment he reported erectile dysfunction and premature ejaculation, and seminal emission and ejaculation during defecation and micturition occurred later at 8th week of treatment. After he was switched to sertraline 50 mg/day, his erectile dysfunction, premature and spontaneous ejaculation symptoms subsided in 2 weeks. Although reboxetine is reported to be free of sexual side effects, individual vulnerabilities to such unwanted effects should be considered, and sexual dysfunction should be assessed thoroughly during the treatment.