What is the best next medication choice for a 28-year-old female with generalized anxiety disorder who experienced sexual side effects with two selective serotonin reuptake inhibitor (SSRI) trials?

From the Guidelines

For a 28-year-old female with generalized anxiety disorder who has failed two SSRI trials due to sexual side effects, bupropion would be the best next choice among the options provided. Bupropion (commonly prescribed as Wellbutrin) is unique among antidepressants as it primarily affects dopamine and norepinephrine rather than serotonin, which helps explain its minimal sexual side effect profile, as noted in studies such as 1 and 1. It can be started at 150 mg daily for a week, then increased to 150 mg twice daily if tolerated. While bupropion is not FDA-approved specifically for anxiety and may occasionally worsen anxiety in some patients, it often works well for patients with mixed anxiety and depression, particularly when sexual dysfunction is a concern. The medication's noradrenergic effects can improve energy and focus while addressing depressive symptoms that often accompany anxiety.

Some key points to consider when prescribing bupropion include:

• Its unique mechanism of action, which is different from SSRIs and SNRIs, as discussed in 1
• The potential for improved energy and focus due to its noradrenergic effects
• The importance of monitoring for adverse effects, such as increased anxiety or agitation, as recommended in 1 and 1
• The consideration of alternative treatments, such as SNRIs like duloxetine, if bupropion is not effective or tolerated, as mentioned in 1

It's also important to note that duloxetine, an SNRI, would be a second consideration, but it still carries some risk of sexual side effects, as reported in 1 and 1. Both sertraline and fluvoxamine are SSRIs and would likely cause similar sexual side effects as the previously failed medications, making them less appropriate choices in this specific case. Overall, the choice of medication should be based on the individual patient's needs and medical history, as well as the potential benefits and risks of each medication, as emphasized in 1, 1, and 1.

From the FDA Drug Label

In these trials, duloxetine delayed-release capsules-treated male patients experienced significantly more sexual dysfunction, as measured by the total score on the ASEX and the ability to reach orgasm, than placebo-treated male patients (see Table 5) Duloxetine delayed-release capsules-treated female patients did not experience more sexual dysfunction than placebo-treated female patients as measured by ASEX total score.

The best next medication choice for a 28-year-old female with generalized anxiety disorder who experienced sexual side effects with two selective serotonin reuptake inhibitor (SSRI) trials is duloxetine, as it did not cause significant sexual dysfunction in female patients in clinical trials, as measured by the ASEX total score 2.

From the Research

Treatment Options for Generalized Anxiety Disorder

The patient in question has generalized anxiety disorder and has experienced sexual side effects with two selective serotonin reuptake inhibitor (SSRI) trials. Considering this, the next best medication choice could be:

• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine extended release, as they are also a first-line treatment for generalized anxiety disorder 3
• Bupropion, which has been studied as a potential treatment for SSRI-induced sexual dysfunction, although results are mixed 4, 5, 6
• Other classes of drugs, such as benzodiazepines, azapirones, antihistamines, alpha(2)delta Ca++ channel modulators, and atypical antipsychotics, which have been shown to be beneficial in patients with generalized anxiety disorder 7

Considerations for Treatment Selection

When selecting a treatment, clinicians should consider:

• Patient preference
• Current and prior treatments
• Medical and psychiatric comorbid illnesses
• Age, sex, and reproductive planning
• Cost and access to care 3
• The potential for sexual side effects and the need for adjunctive treatment to mitigate these effects 4, 5, 6

Adjunctive Treatment Options

If the patient experiences sexual side effects with their medication, adjunctive treatment with bupropion may be considered, as it has been shown to be effective in some cases 5, 6. However, the evidence is not consistent, and more research is needed to fully understand the effectiveness of bupropion for this purpose 4.