“I came in asking for antidepressants — but really it’s that I finish far too quickly in bed and it’s wrecking my confidence and relationship”

A young man presenting "for antidepressants to feel better" may be masking an embarrassing sexual concern — here PREMATURE EJACULATION (PE) — so the first skill is eliciting the HIDDEN AGENDA sensitively, creating safety and inviting the real issue rather than prescribing an antidepressant for "low mood" and missing it. PE (ISSM definition, international) is ejaculation that always or nearly always occurs within about 1 minute of penetration in LIFELONG PE, or after a bothersome reduction in latency, often to about 3 minutes or less, in ACQUIRED PE, with a lack of control and DISTRESS (EAU also describes variable and subjective PE, managed with reassurance); classify LIFELONG versus ACQUIRED, as acquired PE warrants seeking a cause (erectile dysfunction, performance anxiety/relationship factors, prostatitis, thyroid dysfunction, drugs). Screen the psychological and relationship context (anxiety, low mood — exploring/treating genuine depression — and partner impact), and crucially check for coexisting ERECTILE DYSFUNCTION, which commonly accompanies PE and should generally be treated first (rushing to ejaculate before losing the erection can drive PE), with basic checks such as TFTs where indicated, a face-to-face genital examination and blood pressure check, with consent and a chaperone offered, where indicated, and a proper depression assessment including self-harm risk (NICE NG222). Offer evidence-based treatment: behavioural/psychosexual techniques (stop-start and squeeze), self-help and partner involvement; topical anaesthetics (lidocaine with prilocaine spray, licensed for lifelong PE; creams such as EMLA off-label; wipe off excess to protect the partner); and pharmacotherapy — an SSRI delays ejaculation (dapoxetine on-demand, licensed for PE in men aged 18–64, 30 mg 1–3 hours before sex, no more than once in 24 hours, after an orthostatic check, without alcohol or another SSRI/serotonergic drug; or off-label daily SSRIs; BNF) — with psychosexual referral for refractory cases or significant relationship/psychological factors. The skill is the empathic hidden-agenda elicitation, classification, ED check and offering effective, destigmatised treatment (EAU 2024, international; ISSM 2014; BNF; NICE NG222; BSSM 2018).