Which selective serotonin reuptake inhibitor (SSRI) has the least sexual side effects?

SSRI with Least Sexual Side Effects

Bupropion has significantly lower rates of sexual side effects compared to SSRIs and should be considered when sexual dysfunction is a concern. 1

Comparison of Sexual Side Effects Among SSRIs and Other Antidepressants

SSRIs and Sexual Dysfunction

• Sexual dysfunction is a common side effect of SSRIs, affecting approximately 58-73% of patients 2
• The incidence of sexual dysfunction varies among different SSRIs:
  • Paroxetine: 70.7% (highest among SSRIs) 2
  • Citalopram: 72.7% 2
  • Sertraline: 62.9% 2
  • Fluoxetine: 57.7% 2
  • Fluvoxamine: 62.3% 2

Types of Sexual Side Effects

• Common sexual side effects with SSRIs include:
  • Decreased libido (6-15% in males, 0-9% in females) 3
  • Ejaculatory disturbances (13-28% in males) 3
  • Orgasmic dysfunction (2-9% in females) 3
  • Impotence (2-9% in males) 3

Best Options for Minimizing Sexual Side Effects

Non-SSRI Antidepressants

• Bupropion has significantly lower rates of sexual adverse events compared to fluoxetine and sertraline 1
• Mirtazapine has lower sexual dysfunction rates (24.4%) compared to SSRIs 2
• Nefazodone has very low rates of sexual dysfunction (8%) 2

Among SSRIs

If an SSRI is specifically required:

• Fluoxetine has the lowest reported rate of sexual dysfunction among SSRIs (57.7%) 2
• Sertraline has lower rates of sexual dysfunction than paroxetine but higher rates of diarrhea 1, 4
• Paroxetine should be avoided when sexual function is a concern as it has the highest rates of sexual dysfunction among SSRIs 1, 3

Management Strategies for SSRI-Induced Sexual Dysfunction

Dose Adjustments

• Lower doses of SSRIs may reduce the incidence of sexual side effects 1
• For example, fluoxetine at doses as low as 5 mg/day may still provide clinical benefit with fewer side effects 1

Alternative Dosing Strategies

• Situational dosing (taking medication only before sexual activity) may be considered for some patients 1
• For example, sertraline 50 mg taken 4-8 hours before intercourse rather than daily dosing 1

Switching Medications

• Switching from an SSRI to bupropion may improve sexual function while maintaining antidepressant efficacy 1
• Newer antidepressants like vortioxetine have shown significantly less sexual dysfunction compared to paroxetine in healthy adults 5

Special Considerations

Gender Differences

• Men have a higher frequency of sexual dysfunction with SSRIs (62.4%) than women (56.9%), although women report higher severity 2
• Different phases of sexual response may be affected differently based on gender 1

Monitoring and Assessment

• Sexual side effects are often underreported unless specifically asked about 3, 2
• Regular assessment of sexual function should be conducted using validated questionnaires 6

Common Pitfalls

• Assuming sexual dysfunction is related to depression rather than medication
• Failing to discuss sexual side effects with patients before starting treatment
• Not recognizing that sexual dysfunction is a major cause of non-adherence to antidepressant therapy

In conclusion, when sexual side effects are a concern, bupropion is the best first-line option. If an SSRI is specifically required, fluoxetine appears to have the lowest rate of sexual side effects, while paroxetine should be avoided due to its high incidence of sexual dysfunction.