Which Selective Serotonin Reuptake Inhibitor (SSRI) has the lowest sexual side effect?

SSRI with Lowest Sexual Side Effects

Among SSRIs specifically, escitalopram and fluvoxamine cause the lowest rates of sexual dysfunction, though bupropion (not an SSRI) has significantly lower sexual side effects than any SSRI and should be considered first-line when sexual function is a concern. 1, 2, 3

Evidence-Based Ranking of SSRIs by Sexual Dysfunction Risk

Lowest Risk SSRIs

• Escitalopram causes sexual dysfunction in approximately 14% of males (ejaculation disorder) and 6% of females (anorgasmia), making it one of the better-tolerated SSRIs 4, 3
• Fluvoxamine yields the lowest degree of sexual dysfunction within the SSRI group alongside escitalopram 3
• Citalopram has intermediate rates of sexual dysfunction, lower than paroxetine but higher than escitalopram 2

Moderate Risk SSRIs

• Sertraline causes sexual dysfunction in 14% of males (primarily ejaculatory failure) and 6% decreased libido across both sexes, placing it in the moderate range 1, 5
• Fluoxetine has intermediate rates, with significantly lower sexual dysfunction than paroxetine 1, 2

Highest Risk SSRI

• Paroxetine consistently shows the highest rates of sexual dysfunction among all SSRIs at 70.7%, with significantly higher rates than fluoxetine, fluvoxamine, nefazodone, or sertraline 1, 2, 6
• Over 70% of patients treated with paroxetine experience sexual side effects 3

Clinical Decision Algorithm

When Sexual Function is a Primary Concern

1. First-line: Consider bupropion (not an SSRI) with 8-10% sexual dysfunction rate—significantly lower than any SSRI 1, 2

   • Contraindicated in patients with seizure disorders or high agitation 2

2. If SSRI required: Start with escitalopram 10-20 mg daily 2, 4, 3

   • Alternative: Fluvoxamine 3
   • Second alternative: Citalopram 2

3. Avoid paroxetine entirely when sexual function is a concern 1, 2, 6

For Patients Already on SSRIs with Sexual Dysfunction

• Switch to escitalopram or vortioxetine (multimodal antidepressant) for improvement in sexual function while maintaining antidepressant efficacy 7, 8
• Direct switching is safe and effective without requiring washout periods 8

Important Clinical Caveats

Underreporting Problem

• Sexual dysfunction rates are vastly underreported in clinical trials—actual rates are likely higher than published figures 1, 2
• Physicians consistently underestimate the prevalence of antidepressant-associated sexual dysfunction 9
• Routinely inquire about sexual side effects at every visit, as patients are reluctant to volunteer this information 4, 5

Dose-Related Effects

• Sexual side effects are strongly dose-related with SSRIs 6
• Escitalopram 20 mg daily shows approximately twice the sexual dysfunction rate compared to 10 mg daily 4
• Consider dose reduction to minimum effective level before switching medications 6

Specific Sexual Dysfunction Patterns by Sex

Males experience: 4, 5

• Delayed or absent ejaculation (most common)
• Decreased libido
• Erectile dysfunction

Females experience: 4

• Delayed or absent orgasm
• Decreased libido
• Decreased arousal

Management Strategies Beyond Switching

• Reduce dose to minimum effective level for depression control 6
• Never abruptly discontinue—gradual taper required to prevent withdrawal syndrome (dizziness, nausea, electric shock-like sensations) 6, 4
• Consider adding treatments for sexual dysfunction rather than switching if antidepressant response is excellent 2