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LDN's Surprising Effects on Sexual Dysfunction, Addiction and Mental Illness

Dr. Mark Shukhman
January 01, 2017
Interview with Dr. Mark Shukhman of the Northshore University Health System/Private Practice

Mark Shukhman, M.D. is a psychiatrist in private practice in suburbs of Chicago. Dr. Shukhman’s practice is focused on such problems as mood, anxiety, obsessiveness, sleep, sex, appetite control, energy level, chronic pain and addictions. His treatment approach is based on neuropsychiatric interpretation of symptoms and usually includes a combination of medications with nutrient-repletion and sometimes hormonal correction. Dr. Shukhman has served as a primary investigator for several industry-sponsored pharmaceutical research studies. He began prescribing LDN in 2011. For the last few years, he has been presenting his findings at international LDN conferences and wrote a book chapter on uses of LDN in psychiatry.

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Please tell us a bit about your practice.

When I have to describe my patient population, I often say that “my patients are normal people with some problems.” A significant number of my patients also have a chronic medical illness, such as an autoimmune disorder. Since I added it to my prescribing armamentarium many years ago, LDN has become a frequently used tool that I offer to my patients along with the other therapeutic strategies.

...LDN has become a frequently used tool that I offer to my patients along with the other therapeutic strategies.
For what kinds of conditions do you prescribe LDN?

In my practice, I use LDN for these conditions because I see it work:

  • Some subtypes of depression (subtypes that seem to be triggered by inflammation, seasonal type, postpartum, or related to deficiency of dopamine or endorphins);
  • Some subtypes of anxiety (for example, that come with obsessive ruminations or intrusive thoughts);
  • Obsessive-compulsive disorder and OCD-spectrum disorders;
  • Post Traumatic Stress Disorder (PTSD);
  • Modulation of sleep architecture;
  • A variety of sexual problems, including problems of desire, performance and satisfaction;
  • What I call “LDN assisted psychotherapy”. (I think I found how to use it to help extinguish unwanted behaviors and reinforce wanted alternative behaviors. This work is done with therapists I teach and then collaborate with);
  • Appetite control;
  • Addiction to internet, sex, gambling;
  • Alcohol and drug dependence. (While we probably need a “traditional dose” of naltrexone for treatment of alcohol dependence, some other types are doing great on LDN);
  • Helping patients stop opioids and then recover quicker from the prolonged post-opioid use problems, or just decreasing the amount of pain pills they are taking.

You mention prescribing LDN for certain subtypes of depression/anxiety. What subtypes are you referring to?

In my opinion, depression is not a single disorder. It is rather a generic name that was chosen to describe a number of diverse conditions, just because they share a few common symptoms. There were many attempts in academic psychiatry to separate the clearly heterogeneous group of disorders collectively called “depression” into subtypes. Unfortunately, for a long time, this work had no impetus, as most of the medications that came to market during the last 20-30 years were inspired by the same theory - that depression is related to the imbalance in one or more principal neurotransmitters in the brain – serotonin, norepinephrine and dopamine. In my view, in the nearest future, we will see that new medications will seek approval to treat specific symptoms of depression, such as sadness, racing thoughts, obsessive ruminations and changes in energy, rather than for the generic indication “depression”.

Which subtypes of depression are more responsive to LDN?

Although not always, patients whose depression comes with tiredness, inability to feel any excitement, no motivation, no enthusiasm, slowed movements and thinking, decreased appetite, etc. are more likely to respond to LDN. This is compared to patients who describe their depression as “painful”, who feel discontent, antsy, and/or pessimistic. There are no strict rules; some of the depression types can overlap in their symptoms. I also want to add that it is very uncommon for LDN to worsen depression.

Although not always, patients whose depression comes with tiredness, inability to feel any excitement, no motivation, no enthusiasm, slowed movements and thinking, decreased appetite, etc. are more likely to respond to LDN.
What effects did you see LDN providing?

Since the majority of my patients are already taking at least a few, if not more, medications, I do not have a luxury to stop all their medications suddenly and switch them only to LDN. I usually start by adding LDN, along with making some other changes to the cocktail of their medications. I can only say that the result of adding LDN is sometimes spectacular and sometimes there is no obvious change.

In your experience, who can benefit from LDN?

LDN works on opioid receptors. Everybody who has opioid receptors can benefit from LDN. Although at this point there are no recommendations to take LDN prophylactically, knowing how much LDN can do, and how many autoimmune conditions remain undetected for long time, a trial of LDN is probably warranted for most of the cases of “vague symptoms”, for the cases of incomplete resolution of an illness, etc.

What do you advise your patients about the timing of taking their LDN?

In psychiatry, we frequently adjust dosages and schedules. Of course, I am aware of the traditional way to take low dose naltrexone before bed and I always recommend that patients start taking it this way. If, however, we do not get a desirable result – and, in the case of psychiatry, the patient, not the lab value is the best judge of the result - the dosage can be changed or the timing can be changed. I have patients who take LDN once a day and others who sip an LDN solution throughout the day. In some cases of addiction, or if my goal is to modify an unwanted behavior, I might instruct the patient to take naltrexone every time they think they might find themselves engaged in the behavior they want to extinguish.

Have you observed long-term effects of LDN yet?

As far as I understand, there is no official information related to the long term use of LDN. A lot of patients feel that they “returned back to step one” when they stopped taking LDN. Because of this, especially taking in consideration practically negligible side effects, the risk-benefit ratio of LDN is clearly supporting long-term use. Even when I treat illnesses with episodic courses, such as depression, I still recommend that patients continue taking LDN because of the high risk of recurrence. On the other hand, I had patients who felt strongly about stopping all medications as soon as they improved; it made no sense, but they had strong philosophical disagreement with taking any medications in general. In their cases, I just made sure that they have a strategic supply of LDN which can be started when the next episode begins. Unfortunately, this kind of patient is not always able to catch the first signs of the illness and start the treatment before it becomes severe.

...especially taking in consideration practically negligible side effects, the risk-benefit ratio of LDN is clearly supporting long-term use.
Do you think there is a risk of receptors becoming adjusted to LDN and creating the potential for either tolerance or addiction to it?

Some of my patients who say, “If I forget to take my LDN, I feel it” wonder the same. They feel they are “missing something”, and they might become more irritable, tired, have difficulty concentrating, and complain of “brain fog”. This makes sense because LDN works on the opioid receptors, after all. At the same time, I do not know a case when a patient could not stop LDN or had unbearable withdrawal, even after a prolonged use. Based on what I understand now, this “dependence” on LDN does not look like dependence to opioids or benzodiazepines (Xanax®, Ativan®, Valium®, etc.). It looks more like dependence to coffee. Some people who drink coffee every day and stop abruptly also complain of withdrawals – they have no energy, no concentration, they start having headaches, etc. These symptoms, however, are more of a nuisance than a tragedy. As a rule, they subside in a few days. Based on what I know now and what I read, I would not stop LDN because of the fear of dependence.

...I do not know a case when a patient could not stop LDN or had unbearable withdrawal, even after a prolonged use.
Have you seen any side effects from LDN?

The patients I treat are probably more vulnerable to vivid dreams and their dreams might become unpleasant. Additionally, after a couple of surprises, I do not forget to tell my female patients to be more careful about pregnancy precautions, because they might become unexpectedly more fertile.

What kind of research on LDN for sexual dysfunction are you interested in?

There is a tight connection between autoimmune conditions and hormone imbalance; there is even an opinion that autoimmune conditions are caused by hormone imbalance. Sexual dysfunctions (not only disorders of performance, but also disorders of desire and satisfaction) are only a small part of the consequences of the hormone imbalance. My most recent project is focusing on post-coital dysphoria or “post-sex blues”. Basically, it describes a phenomenon when people become dysphoric (tearful, depressed, or, possibly, argumentative) after they have an orgasm, even though they had satisfying sex with a person they loved. The phenomenon is most likely related to the skyrocketing and then sudden dropping of the dopamine level. The mechanism is somewhat similar to the crash following cocaine use. A few years ago, I came up with the idea of using LDN prior to sex to normalize this dopamine/endorphin response. In essence, taking LDN prior to sex can fix the problem, and the only question left is the timing and the amount of LDN.

In essence, taking LDN prior to sex can fix the problem, and the only question left is the timing and the amount of LDN.
What dose and timing do you recommend for this kind of sexual dysfunction condition?

In practice, I recommend LDN as a part of a stimulant-vitamin-drug combination. At this point, I need a little more data to announce the magic combination, dose and timing. I would like to invite the readers, whether you are on LDN currently or not, openly or anonymously, to share your experience about using LDN for this condition.

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