What to prescribe for Post-SSRI Sexual Dysfunction (PSSD) after a Selective Serotonin Reuptake Inhibitor (SSRI) overdose?

Management of Post-SSRI Sexual Dysfunction (PSSD) After SSRI Overdose

For patients with Post-SSRI Sexual Dysfunction (PSSD) following an SSRI overdose, bupropion or vortioxetine are recommended as first-line pharmacological treatments due to their positive effects on the brain dopamine/serotonin ratio and demonstrated improvement in sexual function. 1

Understanding PSSD

PSSD is characterized by persistent sexual dysfunction that continues after discontinuation of SSRI medications, including:

• Loss or decreased libido 2
• Erectile dysfunction 2
• Genital anesthesia 3
• Anorgasmia 2
• Orgasmic/ejaculatory anhedonia 3

PSSD can also include non-sexual symptoms such as anhedonia, apathy, and blunted affect, significantly impacting quality of life 3.

First-Line Treatment Options

Pharmacological Approaches

• Vortioxetine (5-20 mg daily): Shows significant improvement in all International Index of Erectile Function domains in PSSD patients 1

• Bupropion (150-300 mg daily): Positively affects the brain dopamine/serotonin ratio and has the least risk of sexual dysfunction among antidepressants 1, 4

• Moclobemide: Has lower risk of sexual dysfunction compared to SSRIs and SNRIs 4

• Agomelatine: Associated with minimal sexual dysfunction risk 4

Nutraceutical Approaches

• L-citrulline-based supplements: Case reports show improvement in sexual function after 3-month treatment 5

• Other commonly used aphrodisiacs: May be considered as adjunctive therapy 5

Second-Line Treatment Options

• Pelvic muscle vibration therapy: Has shown positive results in case studies 1

• Alpha-1 adrenoreceptor antagonists: May be considered for patients who have failed first-line therapy 6

• Topical anesthetics (lidocaine/prilocaine): While typically used for premature ejaculation, may help with certain PSSD symptoms 6

Important Considerations and Precautions

• Avoid restarting SSRIs or SNRIs: These medications may worsen the condition 3

• Avoid serotonergic drugs: Particularly important to prevent serotonin syndrome 6

• Monitor for suicidal ideation: Especially in patients under 24 years of age and those with comorbid depression 6

• Avoid MAOIs: These can interact with residual serotonergic agents and precipitate serotonin syndrome 6

• Screen for bipolar disorder: Treatment with certain antidepressants should be avoided in patients with history of bipolar depression due to risk of mania 6

Diagnostic Approach

• Rule out other causes of sexual dysfunction including:

  • Ongoing depression 4
  • Hormonal imbalances 3
  • Other medications 3
  • Underlying medical conditions 3

• Confirm temporal relationship between SSRI use/overdose and onset of sexual dysfunction symptoms 4

Treatment Algorithm

1. Initial assessment: Confirm PSSD diagnosis by excluding other causes of sexual dysfunction 3

2. First-line treatment: Start with either vortioxetine or bupropion 1, 4

   • Begin vortioxetine at 5 mg daily, titrating up to 10-20 mg as needed
   • OR begin bupropion at 150 mg daily, increasing to 300 mg if needed after 1-2 weeks

3. Add nutraceuticals: Consider adding L-citrulline-based supplements if response is inadequate 5

4. Second-line options: If no improvement after 8-12 weeks, consider:

   • Switching to moclobemide or agomelatine 4
   • Adding pelvic muscle vibration therapy 1
   • Trial of alpha-1 adrenoreceptor antagonists 6

5. Ongoing monitoring: Regularly assess sexual function, mood, and quality of life 4

Prognosis

• PSSD can persist for extended periods, with documented cases lasting up to 23 years 2
• Treatment response is variable and often incomplete 2, 1
• Psychological support is essential due to significant impact on quality of life 2