Which antidepressants are known to increase libido in women?

Bupropion is the Antidepressant Most Likely to Increase or Preserve Libido in Women

Bupropion is the only antidepressant with evidence demonstrating actual enhancement of sexual function, including increased libido, in depressed women. 1, 2

Evidence for Bupropion's Pro-Sexual Effects

The strongest evidence comes from direct comparative studies showing that 77% of bupropion-treated patients reported at least one aspect of heightened sexual functioning beyond their pre-illness baseline 2. Specifically in women, bupropion treatment resulted in:

• 41% improvement in desire
• 52% improvement in arousal/lubrication
• 48% improvement in ease/satisfaction of orgasm

Additionally, 86% of bupropion-treated patients had no adverse sexual effects, compared to only 27% of SSRI-treated patients 2.

Why Bupropion Works Differently

Bupropion's mechanism differs fundamentally from SSRIs and SNRIs. It acts primarily on dopamine and norepinephrine pathways rather than serotonin, avoiding the 5-HT2 receptor stimulation that causes sexual dysfunction with most antidepressants 3, 2. The American College of Physicians guidelines confirm that bupropion had a significantly lower rate of sexual adverse events than fluoxetine or sertraline 1.

Alternative: Mirtazapine

Mirtazapine represents a second option, though with more modest effects than bupropion. In depressed women, mirtazapine improved:

• Desire by 41%
• Arousal/lubrication by 52%
• Ease/satisfaction of orgasm by 48%

However, this study had a 50% dropout rate before six weeks, limiting confidence in these findings 3. Mirtazapine blocks 5-HT2 and 5-HT3 receptors, theoretically avoiding SSRI-related sexual dysfunction 3, 4.

Antidepressants to Avoid

Paroxetine has the highest rates of sexual dysfunction among all antidepressants and should be specifically avoided when sexual function is a concern 1. All SSRIs (fluoxetine, sertraline, paroxetine, citalopram, escitalopram) and SNRIs (venlafaxine, duloxetine) significantly decrease libido, arousal, and orgasm function below pre-illness levels 2, 4.

Clinical Approach

When prescribing for a woman with depression where libido is a concern:

1. First-line: Bupropion - the only antidepressant with evidence of actually enhancing sexual function
2. Second-line: Mirtazapine - may preserve or improve sexual function, though evidence is weaker
3. Avoid: All SSRIs and SNRIs - these reliably worsen sexual function, with paroxetine being the worst offender

Important Caveats

• Bupropion carries a slightly increased seizure risk and should be avoided in patients with seizure disorders or eating disorders 1
• The sexual benefits of bupropion occur alongside effective antidepressant action - this is not simply a stimulant effect 2
• SSRI-induced sexual dysfunction is substantially underreported unless patients are specifically asked about various aspects of sexual function 2, 4
• Recent evidence suggests some patients may experience persistent post-SSRI sexual dysfunction (PSSD) even after discontinuation, making initial antidepressant selection particularly important 4