From the Guidelines
Among SSRIs, bupropion is associated with a lower rate of sexual adverse events than fluoxetine or sertraline, whereas paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline 1. When considering SSRIs with the least sexual dysfunction side effects, it's essential to weigh the benefits and risks of each medication.
- Bupropion may be a preferable option for patients concerned about sexual side effects, as it has been shown to have a lower rate of sexual adverse events compared to fluoxetine or sertraline 1.
- Paroxetine, on the other hand, has higher rates of sexual dysfunction and may not be the best choice for patients with concerns about sexual side effects.
- Other SSRIs, such as fluoxetine, fluvoxamine, nefazodone, or sertraline, may have varying degrees of sexual dysfunction, but the evidence suggests that bupropion may be a better option for minimizing these side effects 1. It's crucial to note that individual responses to medications can vary, and some patients may still experience sexual dysfunction with bupropion or other SSRIs.
- Strategies like dose reduction, drug holidays, or adding medications like bupropion may help alleviate sexual side effects, but it's essential to consult with a healthcare provider before making any changes to medication regimens.
- The American College of Physicians recommends regular assessment of patient status, therapeutic response, and adverse effects of antidepressant therapy, beginning within 1 to 2 weeks of initiation of therapy 1.
From the FDA Drug Label
Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance, and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that SSRIs can cause such untoward sexual experiences. Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence.
The available data does not allow for a direct comparison of the sexual dysfunction side effects of different SSRIs.
- Citalopram: The reported incidence of decreased libido and anorgasmia was 1.3% and 1.1% in female patients, and abnormal ejaculation (mostly ejaculatory delay) was 6.1%, libido decreased was 3.8%, and impotence was 2.8% in male patients 2.
- Escitalopram: The incidence of ejaculation disorder was 12% and 14% in males, libido decreased was 6% and 3% in females and males, and anorgasmia was 3% in females 3 and 3. It is not possible to determine which SSRI has the least sexual dysfunction side effects based on the provided information.
From the Research
Sexual Dysfunction Associated with SSRIs
- Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors (SSRIs), with estimates of incidence varying from a small percentage to more than 80% 4.
- The most commonly associated sexual side effects of SSRIs are delayed ejaculation, absent or delayed orgasm, sexual desire (libido) difficulties, and arousal difficulties 4.
SSRIs with Lower Risk of Sexual Dysfunction
- Vortioxetine has been shown to have a lower risk of sexual dysfunction compared to other SSRIs, such as paroxetine and escitalopram 5, 6.
- Vilazodone may have a smaller adverse impact on sexual function in adults with major depressive disorder (MDD) compared to other SSRIs 7.
- Bupropion, mirtazapine, and serotonin-norepinephrine reuptake inhibitors may be potential alternatives to SSRI treatment with a lower risk of sexual dysfunction 8.
Comparison of SSRIs
- Vortioxetine has been compared to escitalopram and paroxetine in studies, showing significantly greater improvements in sexual functioning 5, 6.
- Paroxetine has been associated with the greatest rate of sexual dysfunction among SSRIs 8.
- Vilazodone has been shown to have a small adverse impact on sexual function, but the difference in sexual dysfunction at the end of treatment was not statistically significant compared to placebo 7.