Managing Sexual Dysfunction in a Patient on Vraylar (Cariprazine)
Do not add Cymbalta (duloxetine) to treat decreased libido in your patient on Vraylar—SSRIs and SNRIs like duloxetine are well-known to cause or worsen sexual dysfunction, including decreased libido, and would likely compound the problem rather than solve it. 1
Why Cymbalta Is Contraindicated
- SSRIs and SNRIs consistently cause sexual side effects, including decreased libido, delayed ejaculation, and anorgasmia, which is why they are used therapeutically for premature ejaculation 1
- Duloxetine (Cymbalta), as an SNRI, shares the same serotonergic mechanism that produces sexual dysfunction seen with SSRIs 1
- Adding duloxetine would create a dual burden of sexual side effects from both cariprazine and the SNRI 1
Understanding the Problem with Vraylar
- Cariprazine is a dopamine D3/D2 partial agonist, and while it has a favorable side effect profile compared to many antipsychotics, sexual dysfunction can still occur 2, 3
- The D3 receptor involvement affects motivation and reward processing, which can impact sexual drive 4
- At the 1.5 mg daily dose your patient is taking, side effects are generally milder than at higher doses 3
Recommended Management Approach
First: Assess and Optimize Current Treatment
- Verify the sexual dysfunction is truly from cariprazine by reviewing the timeline of symptom onset relative to medication initiation 2
- Consider whether the underlying psychiatric condition (bipolar disorder or schizophrenia) itself is contributing to decreased libido 3
- Evaluate for other contributing factors: relationship issues, stress, comorbid depression, other medications, or medical conditions 1, 5
Second: Consider Dose Adjustment
- Attempt dose reduction of cariprazine if clinically stable, as lower doses (1.5 mg) generally have fewer side effects than higher doses (3.0 mg) 3
- Monitor closely for psychiatric symptom recurrence during any dose adjustment 2, 3
Third: If Additional Treatment Is Needed
Do not add antidepressants for libido enhancement—this is pharmacologically counterproductive 1
Instead, consider:
- Switching to a different antipsychotic with lower sexual side effect burden if psychiatric symptoms allow 1
- Psychosexual therapy, which shows 50-80% success rates and can address both psychological and relationship factors contributing to sexual dysfunction 1
- Addressing comorbid conditions: If depression is present and contributing to low libido, treat the depression with careful medication selection, but recognize that most antidepressants worsen sexual function 5
Critical Pitfall to Avoid
The most common error is reflexively adding an antidepressant when a patient reports low mood or decreased libido while on an antipsychotic. SSRIs and SNRIs will reliably worsen sexual function through their serotonergic effects, creating a compounding problem rather than a solution 1, 6. This is precisely why sertraline, paroxetine, and other SSRIs are used therapeutically to delay ejaculation in premature ejaculation—they suppress sexual function 1, 6.