A Rare Case of Sildenafil Associated Psychosis in a Newlywed Young Female

Introduction

Sildenafil citrate (Viagra) is a US Food and Drug Administration (FDA)-approved drug for the management of pulmonary artery hypertension ¹ and erectile dysfunction (ED). ² Sildenafil is a selective inhibitor of Cyclic Guanosine Monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5). Elevated cGMP levels cause the corpus cavernosum’s smooth muscles to relax, resulting in improved blood flow and an erection. Sildenafil is available generically and even as a non-prescription over-the-counter medication in some countries, including India. Several studies have also evaluated the effects of sildenafil citrate in women with female sexual arousal disorder because of the parallels between male and female sexual responses. However, the findings are controversial and contradictory. ³

Sildenafil’s side effects are often modest and primarily caused by vasodilatation linked to PDE5 inhibition. These include headache, nasal congestion, dizziness, face flushing, hypotension, diarrhea, gastric reflux, dyspepsia, and visual abnormalities. ⁴ Neuropsychiatric adverse effects include headache, lightheadedness, nightmares, anxiety, depression, and behavioral abnormalities. ⁵ Studies on sildenafil in females are scarce, although the adverse effects are nearly the same for both sexes. So far, there has been little discussion about a rare neuropsychiatric side effect, “psychosis,” and there has been no report, as per our knowledge, on “sildenafil associated psychosis” in a female, thus highlighting a rare but serious phenomenon. Here we present a case of a female patient, without a known psychiatric history, who developed psychotic symptoms following the intake of two tablets of 50 mg sildenafil.

Case Report

A 21-year-old female, recently married 5 days ago, presented to the hospital with complaints of irrelevant talk, suspiciousness, anger-irritability, reduced sleep, decreased self-care, and oral intake for 3–4 days. To increase sexual pleasure during their first sexual experience, the patient and the husband reportedly took two off-label 50 mg sildenafil tablets. The patient experienced a significant headache and dizziness after 30 minutes of taking the medicine, which led to difficulty sleeping the entire night. According to family members, her behavior changed the very day after the incident. She began to believe that her family members were plotting against her and attempting to hurt her. She became extremely agitated, hollering abuses, and displaying bouts of rage. On one occasion, she grew aggressive toward family members and threw household items outside her house. Her ability to sleep was seriously impaired, and she barely slept for 1 or 2 hours. In spite of being newlywed, she stopped keeping up her personal appearance and cleanliness.

The patient never had any similar episode in the past, and there is no history of any other prior psychiatric illness. There were no symptoms consistent with a mood disorder. Family members deny any history of fever, seizure, head injury, chronic medical illness, any toxin exposure, or substance intake. There was no family history suggestive of any psychiatric illness. Birth and early development were apparently within normal limits, and premorbid personality was well-adjusted. There were no apparent findings in her physical examination. On mental status examination, she was awake, conscious, oriented to time, place, and person with increased psychomotor activity. Mood and affect were irritable, and in thought content, a delusion of persecution was present. Judgment was impaired, and insight was grade 1. All routine blood tests, toxicology screening, urine drug screening, and radiological investigations, including MRI, came out to be normal. Naranjo’s adverse drug probability scale was applied to establish a cause-and-effect relationship, and the patient scored 5, indicating a “probable” relation of adverse event with drug.

Patient was prescribed tablet olanzapine 10 mg during hospital stay with tablet lorazepam 2 mg at night. All of the psychotic symptoms remitted only 4–5 days after the initiation of olanzapine, and subsequently, she was discharged after 7 days of hospitalization with a diagnosis of “sildenafil induced psychotic disorder” as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In follow-up visits during the next 3 months, olanzapine was tapered off gradually, but there was no recurrence of the symptoms.

Discussion

Sildenafil is usually safe and rarely causes any psychiatric complications. In this article, we present the case of a newlywed young female who took off-label sildenafil to enhance her sexual pleasure, leading to a full-blown psychotic episode. Although various other side effects of sildenafil, such as agitation, sad mood, nightmares, uneasiness, and suicidal attempts have been published so far, ⁶ literature about sildenafil-induced psychosis is scanty. Neuropsychiatric adverse events due to sildenafil in females have been rarely reported, and there is no literature on sildenafil induced psychosis in females. Shalbafan et al. 2022 report a case of psychosis in a 32-year-old Iranian male, without a known psychiatric history, who was taking sildenafil to treat ED. ⁷ Gupta and Ambaliya also reported a case of a 42-year-old man in 2023 who developed psychosis after taking sildenafil for the management of ED. ⁸ Deskins et al., 2024 also report a case of sildenafil-induced acute psychosis in a 66-year-old patient with pulmonary hypertension. ⁹ Although the exact mechanism of action behind sildenafil’s neuropsychiatric side effects is unclear, nitric oxide interacts with the dopaminergic and glutamatergic circuits, has been linked to acute psychosis. ¹⁰

Conclusion

In our scenario, the onset of psychotic symptoms and sildenafil use were temporally related. The psychosis subsided in four to 5 days. Even though sildenafil is usually well accepted, it is crucial to be mindful of the possibility of adverse effects on mental health, especially psychosis in women.