How to manage sexual side effects of Selective Serotonin Reuptake Inhibitors (SSRI)?

Management of Sexual Side Effects of SSRIs

Switching to bupropion is the most effective strategy for managing SSRI-induced sexual dysfunction while maintaining antidepressant efficacy. 1

Understanding SSRI-Induced Sexual Dysfunction

Sexual dysfunction is a common and distressing side effect of SSRIs, affecting up to 70-80% of patients taking medications like sertraline, citalopram, or paroxetine 2. These side effects include:

• Delayed or absent orgasm/ejaculation (most common)
• Decreased libido
• Erectile dysfunction or decreased arousal
• Retrograde ejaculation

Sexual side effects are strongly dose-related and vary among different SSRIs based on their pharmacological properties 3.

Management Algorithm

First-Line Approaches:

1. Dose reduction

   • Consider lowering the SSRI dose if clinically appropriate
   • Most sexual side effects are dose-dependent 3
   • Monitor for return of depressive symptoms

2. Medication switch

   • Bupropion SR: Shows 46-75% response rate for treating SSRI-induced sexual dysfunction 1

     • Most improvement occurs within first 2 weeks at low doses (100-200 mg/day)
     • Effective for all categories of sexual side effects

   • Alternative antidepressants with lower sexual side effect profiles:

     • Mirtazapine
     • Moclobemide
     • Agomelatine
     • Reboxetine 4

3. Drug holidays

   • Brief (1-2 day) planned breaks from medication
   • Only suitable for SSRIs with shorter half-lives
   • Not recommended for patients with severe depression or suicidal ideation

Second-Line Approaches:

1. Augmentation strategies

   • Add medications that may counteract sexual side effects:
     • 5-HT2 antagonists
     • 5-HT3 antagonists
     • Alpha-2 adrenergic receptor antagonists
     • Dopamine receptor agonists
     • PDE5 inhibitors (sildenafil, tadalafil) 3

2. Timing adjustments

   • Taking medication after sexual activity
   • Scheduling sexual activity when drug levels are lowest

Special Considerations

Monitoring

• Actively assess sexual function at baseline, during treatment, and after treatment cessation 4
• Use standardized questionnaires to track changes in sexual function

Post-SSRI Sexual Dysfunction (PSSD)

• Rare but serious condition where sexual dysfunction persists after discontinuation of SSRIs 2
• Consider this possibility in patients whose sexual dysfunction began during SSRI treatment and persists after discontinuation

Cautions

• Avoid sudden cessation of SSRIs as this may precipitate withdrawal syndrome 5
• When switching medications, follow appropriate cross-titration protocols
• Monitor for serotonin syndrome if combining serotonergic medications 5

Practical Implementation

1. Discuss sexual side effects openly with patients before initiating treatment
2. Reassess sexual function at each follow-up visit
3. For patients already experiencing sexual dysfunction:
   • First try dose reduction if clinically appropriate
   • If ineffective, consider switching to bupropion or another antidepressant with lower sexual side effect profile
   • Consider augmentation strategies only if switching is not feasible

By addressing sexual side effects proactively, you can improve medication adherence and quality of life for patients taking SSRIs.