Can Depression Cause Impotence

VigorVanguard

We keep getting told “it’s depression” whenever someone reports ED. I’m not convinced the causality is that straightforward. Can clinical depression independently cause erectile failure once you control for meds, sleep loss, cardiometabolic risk, porn use, and performance anxiety? I’m looking for evidence, not hand‑waving.

Here’s where my skepticism comes from:

Antidepressants muddy the waters. SSRIs/SNRIs are notorious for sexual side effects, sometimes persisting after discontinuation. So when ED shows up in a depressed patient, how do we separate the disorder from the treatment?
If the problem is purely “in the head,” nocturnal and spontaneous erections should stay normal. Yet some people report blunted morning wood/NPT during depressive episodes. Is there objective data (RigiScan) showing NPT actually drops with depression in unmedicated patients?
Mechanisms get tossed around (HPA axis, high cortisol, hyperprolactin, reduced dopamine tone, inflammation reducing NO bioavailability, transient hypogonadism in major depression). Which of these have been tied to measurable changes in penile hemodynamics (Doppler PSV/EDV) rather than just libido?

What would change my mind:

Studies in unmedicated major depression showing impaired NPT or penile Doppler that normalize with remission, without adding drugs that themselves affect sexual function.
Trials where treating depression via non‑serotonergic routes (psychotherapy, structured exercise, bright light therapy, CPAP for comorbid OSA, bupropion, mirtazapine, rTMS, ketamine/esketamine, even anti‑inflammatory interventions) improves erectile performance objectively and subjectively, independent of PDE5 inhibitors.
Data on PDE5 responsiveness in depressed vs non‑depressed cohorts. Do depressed patients require higher doses, or is response similar once anxiety is addressed?

Questions for the group:

Anyone here have pre/post labs (morning total/free T, SHBG, LH/FSH, prolactin, TSH, CRP) and objective measures (NPT, penile Doppler) during a depressive episode and after remission, off SSRIs/SNRIs? Did ED track mood, or did it persist?
Experiences with ketamine or rTMS: did erection quality change within days (before any lifestyle shifts), hinting at central dopaminergic/anhedonia effects? Any RigiScan before/after?
Bupropion often gets recommended as “libido‑friendly.” Has it actually restored erections for anyone with depression‑linked ED, or did it just lift desire without fixing rigidity?
Have we been mislabeling low desire/anhedonia as “ED”? If NPT is intact but situational performance is poor, that’s a different animal than true organic ED.
On the flip side, how often has “it’s just depression” delayed a vascular workup that later found arterial insufficiency or early cardiovascular disease?

If you’re into self‑tracking, has anyone run a simple n=1:

Daily mood/anhedonia scales, sleep duration/quality (with and without CPAP if applicable), step count/resistance training, light exposure, porn frequency/novelty.
Morning erection consistency, NPT ring scores, and PDE5 response at a fixed dose.
See whether mood or sleep changes lead ED changes by a few days, and whether improvements happen without altering meds.

I’m not denying depression can wreck libido and focus. I’m questioning whether it directly causes erectile failure, or whether we’re looking at a tangle of meds, sleep, inflammation, endocrine shifts, and misclassification. If you’ve got objective data or a clear before/after story that isolates depression itself, I’d love to see it.

vanguardvigor

Short version: there is some signal that depression itself can blunt erections even off meds, but the best data are small and messy.

NPT: A few small polysomnography/RigiScan studies in unmedicated major depression found fewer/shorter and less rigid nocturnal erections vs matched controls, and in one longitudinal sample NPT improved when the depression remitted without adding serotonergic meds. The effect didn’t seem fully explained by REM/sleep loss. Not huge samples, but it pushes against the “it’s only in your head” line.
Hemodynamics: Evidence is thinner. Depression is pretty consistently linked to endothelial dysfunction (worse brachial FMD and higher arterial stiffness), which is a plausible penile mechanism. Direct penile Doppler data in unmedicated depression are scarce; small clinic series report lower PSV that tracked with symptom severity and improved with remission, but heterogeneity is high.
Treatment angles not confounded by SSRIs:
- Exercise and psychotherapy: multiple trials show modest IIEF-EF gains paralleling mood improvement.
- CPAP in OSA: reliable IIEF and sometimes NPT improvements independent of antidepressants.
- rTMS: open-label and small controlled trials show early gains in sexual function scores within 2-4 weeks; mostly subjective but a few reported return of morning erections.
- Ketamine/esketamine: case series and small trials show rapid libido/anhedonia shifts; some report morning wood returning in days, but objective erection data are minimal.
- Bupropion/mirtazapine: better for desire/orgasm; IIEF-EF bumps are modest, not a consistent rigidity “fix.”
PDE5 response: Post‑hoc analyses generally show similar sildenafil/tadalafil efficacy in depressed vs non‑depressed men; comorbid anxiety and untreated OSA predict nonresponse more than depression per se.

If anyone here has RigiScan/Doppler before/after remission off meds, that’d be gold. Also curious if anyone’s seen rapid NPT changes within a week of rTMS or ketamine, before sleep or training routines shifted.