Which of the following medications: Zoloft (sertraline), Lamictal (lamotrigine), propranolol, Abilify (aripiprazole), or caffeine is most likely to cause increased libido?

Medication Effects on Libido and Sexual Behavior

Direct Answer

Among the medications listed, Abilify (aripiprazole) is the most likely culprit for causing increased libido and changes in typical sexual behavior patterns. 1, 2

Mechanism and Evidence

Aripiprazole (Abilify) - Primary Suspect

Aripiprazole uniquely acts as a partial agonist at dopamine D2 and D3 receptors, which can enhance mesolimbic dopaminergic activity and trigger compulsive sexual behaviors. 2

• The FDA label explicitly warns about pathological gambling and other compulsive behaviors, including intense sexual urges that patients may be unable to control 1
• Post-marketing reports document patients experiencing compulsive sexual urges, hypersexuality, and even changes in sexual orientation while on aripiprazole 1, 2
• A 2016 case report documented a patient who developed both gambling addiction and hypersexuality with a complete change in sexual orientation (heterosexual to homosexual with sadomasochistic practices) on 15mg aripiprazole, with all symptoms resolving within two weeks of discontinuation 2
• Conversely, switching TO aripiprazole FROM other antipsychotics actually improved sexual function in most patients, with significant improvements in libido, erectile function, and ejaculatory function by week 12 3

The key distinction: aripiprazole can paradoxically either improve sexual dysfunction (when switching from prolactin-elevating antipsychotics) OR cause pathological hypersexuality through dopaminergic enhancement. 2, 3

Other Medications - Less Likely Causes

Zoloft (Sertraline) - Opposite Effect

• SSRIs like sertraline typically DECREASE libido and cause delayed or absent orgasm, not increased sexual drive 4, 5
• Sexual dysfunction occurs in 30-80% of SSRI users, primarily manifesting as reduced desire and delayed ejaculation 5
• Sertraline at doses of 25-200mg daily is specifically used to TREAT premature ejaculation by reducing sexual responsiveness 4

Lamictal (Lamotrigine) - Neutral to Positive

• Lamotrigine may actually IMPROVE sexual function rather than cause hypersexuality 6
• Among newer antiepileptic drugs, lamotrigine is associated with improved sexual function, not pathological increases 6

Propranolol - Decreases Function

• Beta-blockers like propranolol are associated with erectile dysfunction and decreased libido, not increased sexual drive 4
• The JNC-7 guidelines note that high-dose thiazide diuretics (often combined with propranolol) increase reports of erectile problems 4

Caffeine - Minimal Direct Effect

• No guideline or research evidence links caffeine to pathological increases in libido or changes in sexual orientation
• Any effects would be indirect through general CNS stimulation

Clinical Recognition and Management

Warning Signs to Monitor

Patients on aripiprazole should be specifically questioned about:

• Development of new or intense sexual urges that feel uncontrollable 1
• Compulsive sexual behaviors or changes in sexual patterns 1, 2
• Concurrent gambling urges, compulsive shopping, or binge eating (these often cluster together) 1

Critical Pitfall

Patients often do not recognize these behaviors as abnormal or medication-related, making direct questioning essential. 1

Management Algorithm

1. If compulsive sexual behaviors emerge on aripiprazole:

   • Consider dose reduction first 1
   • If behaviors persist or are severe, discontinue aripiprazole and switch to an alternative antipsychotic (such as amisulpride, as demonstrated in the case report) 2
   • Symptoms typically resolve within 2 weeks of discontinuation 2

2. Risk factors for developing these behaviors include:

   • Young age 2
   • Male sex 2
   • Previous gambling habits 2
   • Tobacco use 2

Bottom Line

The incongruent sexuality and higher-than-average libido described in your question strongly suggests aripiprazole as the causative agent. 1, 2 The other medications listed either decrease sexual function (Zoloft, propranolol) or have neutral to mildly positive effects (Lamictal), while caffeine lacks evidence for causing pathological sexual changes. The dopaminergic agonist properties unique to aripiprazole among antipsychotics explain its capacity to trigger reward-system-mediated compulsive behaviors including hypersexuality and altered sexual preferences. 2