What alternative medication can be used for a patient experiencing sexual dysfunction on a Selective Serotonin Reuptake Inhibitor (SSRI)?

Managing SSRI-Induced Sexual Dysfunction

For patients experiencing sexual dysfunction on SSRIs, bupropion is the recommended alternative medication due to its significantly lower rate of sexual adverse events compared to SSRIs while maintaining antidepressant efficacy. 1

Understanding SSRI-Related Sexual Dysfunction

Sexual dysfunction is one of the most common reasons patients discontinue SSRI therapy, which can negatively impact treatment adherence and overall mental health outcomes. Sexual side effects from SSRIs may include:

• Decreased libido
• Erectile dysfunction
• Delayed orgasm or anorgasmia
• Decreased arousal
• Decreased satisfaction

Evidence-Based Medication Alternatives

First-Line Alternative:

Bupropion

• Has significantly lower rates of sexual adverse events (only 7-15%) compared to SSRIs (41-63%) 1, 2
• Maintains comparable antidepressant efficacy to SSRIs 1
• Acts through norepinephrine and dopamine reuptake inhibition rather than serotonergic mechanisms 3
• Neuroimaging studies show bupropion preserves normal activation in brain regions associated with sexual arousal and motivation 3

Other Potential Alternatives (in order of preference):

1. Mirtazapine

   • Lower risk of sexual dysfunction than SSRIs 4
   • May cause sedation and weight gain

2. Vortioxetine

   • Demonstrated improvement in SSRI-induced sexual dysfunction in clinical trials 5
   • In Study 11, patients switched from SSRIs to vortioxetine showed greater improvement in sexual function than those switched to escitalopram 5

3. SNRIs

   • Still have significant sexual side effects but may be better tolerated than SSRIs in some patients 6

Implementation Algorithm

1. Confirm SSRI as the cause:

   • Ensure sexual dysfunction developed after starting SSRI
   • Rule out other causes (relationship issues, other medications, medical conditions)

2. Switch to bupropion:

   • Starting dose: 150 mg sustained-release once daily
   • May increase to 150 mg twice daily if needed for depression control
   • Monitor for improvement in sexual function over 2-4 weeks

3. If bupropion is ineffective or contraindicated:

   • Consider vortioxetine (starting at 10 mg daily)
   • Alternative: mirtazapine (starting at 15 mg at bedtime)

Important Considerations and Caveats

• Cross-titration approach: When switching from an SSRI to bupropion, gradually taper the SSRI while starting bupropion to minimize discontinuation symptoms

• Monitoring: Assess both sexual function and depressive symptoms regularly during the transition

• Contraindications for bupropion: History of seizure disorder, eating disorders, or recent alcohol withdrawal

• Post-SSRI sexual dysfunction: Be aware that some patients may experience persistent sexual dysfunction even after SSRI discontinuation 4

• Paroxetine caution: Among SSRIs, paroxetine has the highest rates of sexual dysfunction and should be particularly avoided in patients concerned about sexual side effects 1, 6