From the Guidelines
Bupropion has the least sexual side effects among the selective serotonin reuptake inhibitors (SSRIs), with a significantly lower rate of sexual adverse events compared to fluoxetine and sertraline. According to the study by the American College of Physicians 1, bupropion is associated with a lower rate of sexual adverse events than fluoxetine and sertraline, whereas paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, and sertraline.
Some key points to consider when prescribing SSRIs include:
- Bupropion's reduced sexual side effect profile makes it a good option for patients who are concerned about sexual dysfunction
- Other SSRIs with relatively lower rates of sexual dysfunction include escitalopram (Lexapro) and sertraline (Zoloft) 1
- If sexual side effects occur with any SSRI, potential management strategies include dose reduction, drug holidays (temporarily stopping medication), switching to a different antidepressant, or adding medications like bupropion that may counteract sexual dysfunction
- Physicians and patients should discuss adverse event profiles before selecting a medication 1
It's essential to weigh the benefits and risks of each medication and consider individual patient factors when making treatment decisions. Always discuss any side effects with your healthcare provider before making medication changes.
From the FDA Drug Label
Male and Female Sexual Dysfunction with SSRIs ... Table 5 Adverse EventSertraline Hydrochloride TabletsPlacebo Ejaculation Failure1(Primarily Delayed Ejaculation) 14% 1% Decreased Libido26%1%
Table 6 Incidence of Sexual Adverse Events in Controlled Clinical Trials PAXILPlacebo n (males)14461042 Decreased Libido6-15%0-5% Ejaculatory Disturbance13-28%0-2% Impotence2-9%0-3%
Comparison of Sexual Side Effects
- Paroxetine (PAXIL):
- Decreased Libido: 6-15%
- Ejaculatory Disturbance: 13-28%
- Impotence: 2-9%
- Sertraline:
- Ejaculation Failure: 14%
- Decreased Libido: 26%
Based on the provided data, sertraline may have a lower incidence of ejaculatory disturbance (14% vs 13-28%) but a higher incidence of decreased libido (26% vs 6-15%) compared to paroxetine. However, it is essential to note that the ranges for paroxetine are broad, and the actual incidence may vary.
Given the available information, paroxetine might be considered to have the least sexual side effects, particularly in terms of decreased libido. However, this conclusion is drawn with caution, as the evidence is not entirely clear-cut, and individual patient responses may vary. 2 3
From the Research
Sexual Side Effects of 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 mechanism of sexual dysfunction is thought to be through serotoninergic inhibition of the sexual response 5.
- Among the SSRIs, escitalopram and fluvoxamine are reported to have the lowest degree of sexual dysfunction, while sertraline, citalopram, and paroxetine have a higher frequency of sexual side effects 5.
Comparison of SSRIs
- A study comparing vortioxetine and escitalopram found that vortioxetine showed significantly greater improvements in sexual functioning, as measured by the Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14) 6.
- The study suggests that switching to vortioxetine may be beneficial for patients experiencing sexual dysfunction during antidepressant therapy with SSRIs 6.
- Another review suggests that management strategies for SSRI-induced sexual dysfunction include dose reduction, change of medication, and add-on treatment 5.
Individual SSRIs
- Escitalopram has been reported to have a lower degree of sexual dysfunction compared to other SSRIs, such as sertraline, citalopram, and paroxetine 5.
- Vortioxetine has been shown to have a lower rate of sexual dysfunction compared to escitalopram in a clinical trial 6.
- Fluvoxamine has also been reported to have a lower degree of sexual dysfunction compared to other SSRIs 5.