What is the best Selective Serotonin Reuptake Inhibitor (SSRI) to minimize sexual dysfunction, specifically decreased libido, in the treatment of generalized anxiety disorder?

From the Guidelines

Bupropion (Wellbutrin) is often considered the best option for treating generalized anxiety while minimizing sexual side effects, though it's technically not an SSRI but an NDRI (norepinephrine-dopamine reuptake inhibitor). Among true SSRIs, escitalopram (Lexapro) and sertraline (Zoloft) may have less impact on libido compared to others in the class, as suggested by studies such as 1. Typical starting doses are 5-10mg daily for escitalopram or 25-50mg daily for sertraline, gradually increasing as needed. Sexual side effects from SSRIs occur because they increase serotonin levels, which can inhibit dopamine and norepinephrine pathways involved in sexual function. Some patients find that taking the medication in the morning rather than evening helps minimize sexual side effects. Additionally, discussing this concern with your doctor is important as they might consider combination strategies, such as adding bupropion to an SSRI regimen specifically to counteract sexual side effects, as noted in 1. Remember that medication response varies significantly between individuals, so what works with minimal side effects for one person may not work the same for another. Key points to consider include:

• Bupropion has a lower rate of sexual adverse events compared to fluoxetine and sertraline, as reported in 1.
• Paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, and sertraline, according to 1.
• The American College of Physicians recommends discussing adverse event profiles before selecting a medication, as stated in 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%

The best SSRI to avoid decreased libido for generalized anxiety is not explicitly stated in the provided drug label. However, based on the information provided for sertraline, Decreased Libido was reported by 26% of patients taking sertraline, which is a significant incidence.

• Other SSRIs are not compared in the label.
• The label does not provide a direct comparison of sexual side effects among different SSRIs.
• Therefore, no conclusion can be drawn about the best SSRI to avoid decreased libido for generalized anxiety based on this information alone 2.

From the Research

SSRI Options for Generalized Anxiety with Minimal Libido Decrease

• There is no direct evidence comparing SSRIs for generalized anxiety with minimal libido decrease. However, studies suggest that vilazodone may have a limited adverse impact on sexual functioning 3.
• Vilazodone has been shown to reduce core symptoms of generalized anxiety disorder (GAD) with minimal effects on sexual functioning, including libido 3.
• Other studies suggest that SSRIs can have varying effects on sexual functioning, including libido, and that the impact may be dose-related and vary among individuals 4, 5.
• Buspirone, a non-SSRI anxiolytic, has been shown to have a positive effect on sexual function in patients with generalized anxiety disorder, with 8 out of 10 patients experiencing normalized sexual function after 4 weeks of treatment 6.

Management of SSRI-Induced Sexual Dysfunction

• Strategies for managing SSRI-induced sexual dysfunction include waiting for tolerance to develop, dosage reduction, drug holidays, substitution of another antidepressant, and augmentation with other medications 4, 5.
• The effects of SSRIs on sexual functioning seem to be complex and multifactorial, involving serotonin and dopamine reuptake mechanisms, induction of prolactin release, anticholinergic effects, and inhibition of nitric oxide synthetase 4.