Better Alternative to Lexapro (Escitalopram) for Managing Sexual Side Effects
Bupropion is the preferred alternative to escitalopram when sexual dysfunction is a concern, with significantly lower rates of sexual side effects (8-10%) compared to all SSRIs including escitalopram. 1
Primary Recommendation: Switch to Bupropion
The American College of Physicians recommends bupropion as first-line therapy when depression requires treatment and sexual function is a major concern, due to its substantially lower sexual dysfunction rates compared to any SSRI 1
In direct comparison trials, bupropion SR demonstrated sexual dysfunction rates of only 15% in men and 7% in women, versus 63% in men and 41% in women taking sertraline (another SSRI) 2
Bupropion has been shown to be equally effective as SSRIs for treating depression while maintaining this favorable sexual side effect profile 3
Critical Safety Considerations When Switching
Bupropion should NOT be used in patients with seizure disorders or eating disorders due to increased seizure risk 1
Bupropion should be avoided in highly agitated patients 1
When switching from escitalopram, gradual tapering is required to prevent SSRI withdrawal syndrome (dizziness, nausea, headache, flu-like symptoms) 4
Alternative SSRI Options (If Bupropion is Contraindicated)
If bupropion cannot be used, among SSRIs, escitalopram and fluvoxamine cause the lowest rates of sexual dysfunction, though exact rates are not specified and all SSRIs carry significant sexual side effect risk 1
Paroxetine should be avoided entirely as it has the highest sexual dysfunction rate among all SSRIs at 70.7% 1
Sertraline causes moderate sexual dysfunction (14% in males, 6% in females) 1
The FDA label for sertraline confirms ejaculatory failure occurs in 17% of men on sertraline versus <1% on placebo 5
Dosing Strategy for Bupropion
Bupropion SR 150 mg twice daily (300 mg total daily) appears most effective based on available evidence 6
Lower doses (150 mg once daily) have not demonstrated consistent benefit for sexual dysfunction 7
Bupropion is available in three formulations: immediate release (IR) three times daily, sustained release (SR) twice daily, and extended release (XR) once daily—all are bioequivalent for systemic exposure 3
Additional Considerations
Sexual side effects from SSRIs typically emerge within the first few weeks of treatment and are dose-dependent 4
Escitalopram-induced sexual dysfunction affects multiple domains including desire, arousal, orgasm, and satisfaction 5
Mirtazapine represents another alternative with lower sexual dysfunction rates than SSRIs, though it causes sedation and weight gain 1