From the Guidelines
Paroxetine (Paxil) is generally considered to have the worst sexual side effects among antidepressants, with higher rates of sexual dysfunction compared to other selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, fluvoxamine, nefazodone, or sertraline. This is due to its strong serotonergic effects and anticholinergic properties, which can interfere with sexual function, leading to decreased libido, delayed orgasm, anorgasmia, and erectile dysfunction in approximately 70-80% of patients 1. Other SSRIs like sertraline (Zoloft), fluoxetine (Prozac), and citalopram (Celexa) also commonly cause sexual side effects, but typically to a lesser degree. If sexual side effects are a concern, alternatives with lower rates of sexual dysfunction include bupropion (Wellbutrin), mirtazapine (Remeron), or vortioxetine (Trintellix). Patients experiencing sexual side effects should discuss them with their healthcare provider, as strategies such as dose adjustment, timing medication away from sexual activity, or switching medications may help manage these effects while maintaining effective depression treatment.
Some key points to consider:
- Bupropion has a significantly lower rate of sexual adverse events than fluoxetine or sertraline 1
- Paroxetine has higher rates of sexual dysfunction than other SSRIs 1
- Alternatives with lower rates of sexual dysfunction include bupropion, mirtazapine, or vortioxetine
- Patients should discuss sexual side effects with their healthcare provider to manage these effects while maintaining effective depression treatment.
From the FDA Drug Label
Male and Female Sexual Dysfunction With SSRIs ... In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences. Table 6 Incidence of Sexual Adverse Events in Controlled Clinical Trials PAXIL Placebo n (males) 1446 1042 Decreased Libido 6-15% 0-5% Ejaculatory Disturbance 13-28% 0-2% Impotence 2-9% 0-3%
Table 5 Adverse Event Sertraline Hydrochloride Tablets Placebo Ejaculation Failure 1(Primarily Delayed Ejaculation) 14% 1% Decreased Libido 2 6% 1%
Comparison of Sexual Side Effects
- Paroxetine (PAXIL):
- Decreased libido: 6-15%
- Ejaculatory disturbance: 13-28%
- Impotence: 2-9%
- Sertraline:
- Ejaculation failure (primarily delayed ejaculation): 14%
- Decreased libido: 6%
Based on the provided data, paroxetine (PAXIL) appears to have a higher incidence of sexual side effects, particularly ejaculatory disturbance (13-28% vs 14% for sertraline) 2. However, it is essential to note that the incidence of sexual side effects can vary depending on the population and study design. Therefore, a conservative clinical decision would be to consider both medications as potentially causing significant sexual side effects, and careful consideration should be given to the individual patient's needs and medical history. 3
From the Research
Antidepressants with Worst Sexual Side Effects
- The selective serotonin reuptake inhibitors (SSRIs) are reported to have a high frequency of sexual side effects, with paroxetine being associated with the greatest rate of sexual dysfunction among the SSRIs 4.
- More than 70% of patients treated with sertraline, citalopram, or paroxetine experience sexual side effects 5.
- Other SSRIs such as fluoxetine, fluvoxamine, and venlafaxine XR also have a high propensity to cause sexual side effects, although the incidence rates may vary 6, 7.
Comparison of Sexual Side Effects among Antidepressants
- A study comparing the side effects of nine antidepressants found that bupropion SR had the most favorable overall side-effect profile, while fluvoxamine had the least favorable 6.
- Another study concluded that the risk of sexual dysfunction is greatest with SSRIs and serotonin and noradrenaline reuptake inhibitors (SNRIs), less with tricyclic antidepressants (except clomipramine) and mirtazapine, and least with moclobemide, agomelatine, reboxetine, and bupropion 7.
Management of Antidepressant-Induced Sexual Dysfunction
- Management strategies for antidepressant-induced sexual dysfunction include dose reduction, change of medication, and add-on treatment 5.
- Some studies suggest that adding bupropion as an adjunctive medication may help alleviate sexual side effects in patients responding to SSRIs but experiencing unwanted sexual side effects 4.