From the Guidelines
Bupropion (Wellbutrin) is often considered the best option for avoiding decreased libido, though it's technically not an SSRI but rather a norepinephrine-dopamine reuptake inhibitor (NDRI). Among actual SSRIs, escitalopram (Lexapro) and sertraline (Zoloft) may have somewhat lower rates of sexual side effects compared to others like paroxetine (Paxil), which tends to cause more sexual dysfunction, as noted in studies 1. Typical starting doses are 10mg daily for escitalopram or 50mg daily for sertraline, which can be adjusted based on response. If sexual side effects occur with an SSRI, several strategies may help:
- taking the medication after sexual activity,
- temporary drug holidays (only under medical supervision),
- dose reduction if symptoms are well-controlled,
- or adding bupropion (starting at 150mg daily) as an adjunct therapy, as suggested by guidelines 1. Sexual side effects happen because SSRIs increase serotonin, which can inhibit dopamine and norepinephrine pathways involved in sexual function. Bupropion works differently by increasing dopamine and norepinephrine without affecting serotonin, which is why it rarely causes sexual problems and may even enhance sexual function in some people, as reported in studies 1. It's essential to discuss adverse event profiles with patients before selecting a medication, considering the potential for sexual dysfunction and other side effects, as recommended by the American College of Physicians 1.
From the FDA Drug Label
Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences Table 5 below displays the incidence of sexual side effects reported by at least 2% of patients taking sertraline in placebo-controlled trials Table 5 Adverse EventSertraline Hydrochloride TabletsPlacebo Ejaculation Failure1(Primarily Delayed Ejaculation) 14% 1% Decreased Libido26%1% Prospective Evaluation of Treatment Emergent Sexual Dysfunction (TESD) Two, randomized, double-blind, active-controlled studies were conducted to prospectively compare the incidence of TESD between TRINTELLIX and SSRIs via a validated self-rated measure of sexual function, the Changes in Sexual Functioning Questionnaire Short Form (CSFQ-14). Effect of Switching from SSRI to TRINTELLIX on TESD The effect of TRINTELLIX on TESD induced by prior SSRI treatment in MDD patients whose depressive symptoms were adequately treated was evaluated in an eight-week, randomized, double-blind, active-controlled (escitalopram), flexible-dose study (Study 11) Improvement in TESD induced by prior SSRI treatment in subjects switched to TRINTELLIX was superior to the improvement observed in those subjects who switched to escitalopram
The best SSRI to avoid decreased libido is not explicitly stated in the provided drug labels. However, the labels suggest that vortioxetine (TRINTELLIX) may have a lower incidence of sexual dysfunction compared to some SSRIs, such as sertraline and escitalopram.
- Vortioxetine (TRINTELLIX): Studies have shown that switching from an SSRI to vortioxetine can improve treatment-emergent sexual dysfunction (TESD) 2.
- Sertraline: Has a reported incidence of decreased libido of 26% in placebo-controlled trials 3. It is essential to note that the incidence of sexual dysfunction can vary across different SSRIs, and the best choice for a patient will depend on individual factors and medical history.
From the Research
SSRI-Induced Sexual Dysfunction
- Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors (SSRIs), affecting up to 80% of patients 4, 5.
- The most commonly reported sexual side effects of SSRIs include delayed ejaculation, absent or delayed orgasm, decreased libido, and arousal difficulties 4, 5.
Comparison of SSRIs
- Paroxetine is associated with the highest rate of sexual dysfunction among SSRIs 6.
- Other SSRIs, such as fluoxetine, sertraline, and paroxetine, have been reported to have equal potentials in implicating female sexual side effects 7.
Alternatives to SSRIs
- Bupropion, mirtazapine, vilazodone, vortioxetine, and serotonin-norepinephrine reuptake inhibitors may be considered as alternative treatments to SSRIs, as they have been reported to have lower rates of sexual side effects 6, 7.
- Bupropion may also be added as an adjunctive medication to SSRIs to mitigate sexual side effects 6, 7.
Management of SSRI-Induced Sexual Dysfunction
- Strategies for managing SSRI-induced sexual dysfunction include waiting for tolerance to develop, dosage reduction, drug holidays, substitution with another antidepressant, and augmentation with other medications 4, 5.
- Some studies suggest that saffron may reduce some aspects of sexual dysfunction, excluding ability to reach orgasm 6.