What are the treatment options for selective serotonin reuptake inhibitor (SSRI)-induced decrease in libido?

Treatment Options for SSRI-Induced Decrease in Libido

Bupropion is the first-line treatment for SSRI-induced decrease in libido due to its efficacy in improving sexual function without compromising antidepressant effects. 1, 2, 3

Understanding SSRI-Related Sexual Dysfunction

Sexual dysfunction is a common adverse effect of SSRIs, affecting approximately 50% or more of patients taking these medications 1. This side effect significantly impacts quality of life and is a leading cause of medication non-adherence.

Types of SSRI-induced sexual dysfunction include:

• Decreased libido
• Delayed orgasm or anorgasmia
• Erectile dysfunction in men
• Lubrication difficulties in women

Treatment Algorithm

First-Line Options:

1. Add Bupropion

   • Dosage: Start at 100-200 mg/day, may increase to 300 mg/day 3
   • Mechanism: Dopaminergic and noradrenergic effects counteract serotonergic sexual side effects
   • Evidence: Response rates of 46% for women and 75% for men with most improvement occurring within first 2 weeks 3
   • Caution: Monitor for drug interactions as bupropion inhibits CYP2D6, which may affect SSRI metabolism 4

2. Switch to an Antidepressant with Lower Sexual Side Effect Profile

   • Options include:
     • Bupropion
     • Mirtazapine
     • Moclobemide (where available)
     • Reboxetine (where available)
     • Agomelatine (where available)
   • These medications have demonstrated lower rates of sexual dysfunction compared to SSRIs and SNRIs 2

Second-Line Options:

1. Dose Reduction of Current SSRI

   • Lower the dose to the minimum effective dose that maintains antidepressant efficacy
   • May partially improve sexual function while preserving therapeutic benefit 5

2. Drug Holidays

   • Temporarily discontinuing the SSRI for 1-2 days before planned sexual activity
   • Most applicable for SSRIs with shorter half-lives
   • Not recommended for fluoxetine due to its long half-life
   • Caution: Risk of discontinuation symptoms and mood destabilization 5

3. Specific Interventions Based on Type of Sexual Dysfunction

   • For erectile dysfunction: Consider adding phosphodiesterase-5 inhibitors 5
   • For lubrication difficulties: Consider vaginal lubricants 5

Important Considerations

• Medication Selection: When choosing between SSRIs, note that paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, or sertraline 6

• Monitoring: Sexual function should be actively assessed at baseline, at regular intervals during treatment, and after treatment cessation 2

• Post-SSRI Sexual Dysfunction: Be aware that sexual dysfunction may persist after discontinuation of SSRIs in rare cases 2

• Drug Interactions: When adding bupropion, be cautious of potential interactions with other medications metabolized by CYP2D6 4

• Tamoxifen Considerations: For patients on tamoxifen, avoid strong CYP2D6 inhibitors like paroxetine or fluoxetine; consider citalopram or venlafaxine which have less impact on tamoxifen metabolism 6

Special Populations

• Breast Cancer Patients: For those experiencing hot flashes and sexual dysfunction, venlafaxine may improve libido while treating vasomotor symptoms 6

• Men with Premature Ejaculation: SSRIs are actually used therapeutically for this condition, so switching to non-SSRI antidepressants may be particularly beneficial for these patients 6

By following this treatment algorithm and considering individual patient factors, SSRI-induced decrease in libido can be effectively managed while maintaining the therapeutic benefits of antidepressant treatment.