What are the percentages of sexual dysfunction associated with each selective serotonin reuptake inhibitor (SSRI), including paroxetine, sertraline, fluoxetine, escitalopram, and fluvoxamine, in patients taking these medications?

Sexual Dysfunction Rates by SSRI

Paroxetine has the highest sexual dysfunction rate at 70.7%, followed by citalopram (72.7%), fluvoxamine (62.3-62.9%), sertraline (62.9%), fluoxetine (57.7-62.9%), with escitalopram and fluvoxamine causing the lowest rates among SSRIs, though all SSRIs cause substantially more sexual dysfunction than bupropion (8-10%). 1, 2

Specific SSRI Sexual Dysfunction Percentages

Highest Risk SSRIs

• Paroxetine: 70.7% - consistently the worst offender across all studies, with significantly higher rates than all other SSRIs 1, 2
• Citalopram: 72.7% - nearly equivalent to paroxetine in one large prospective study 2

Moderate-High Risk SSRIs

• Sertraline: 62.9% - with specific breakdown showing 14% ejaculatory failure and 6% decreased libido when analyzed by sex 1, 2
• Fluvoxamine: 62.3-62.9% - falls in the moderate-high range 2, 3
• Fluoxetine: 57.7-62.9% - moderate-high rates with range depending on study methodology 4, 2

Lower Risk Within SSRIs (But Still Significant)

• Escitalopram and Fluvoxamine: Lowest among SSRIs - the American College of Physicians identifies these as causing the lowest rates within the SSRI class, though exact percentages are not specified and rates remain clinically significant 1, 3

Critical Context for These Numbers

These published rates vastly underestimate real-world sexual dysfunction because clinical trials rarely use direct inquiry or validated questionnaires, and patients don't spontaneously report sexual problems unless specifically asked 1, 5, 6

Dose-Response Relationship

Sexual dysfunction with SSRIs is strongly dose-related - higher doses increase both antidepressant efficacy and sexual side effects, particularly erectile dysfunction and decreased libido 1, 6

Sex Differences

Men experience higher frequency of sexual dysfunction (62.4%) compared to women (56.9%), though women report higher severity when dysfunction occurs 2

Patient Tolerance

Approximately 40% of patients show low tolerance of their sexual dysfunction, contributing to treatment discontinuation within 12 months 1, 2

Clinical Algorithm for SSRI Selection

When sexual function is a concern, avoid SSRIs entirely and start with bupropion (8-10% sexual dysfunction rate) as first-line therapy per American College of Physicians recommendations 1, 7

If an SSRI must be used (e.g., comorbid anxiety disorders where bupropion has less established efficacy):

1. First choice: Escitalopram or fluvoxamine (lowest SSRI rates) 1, 3
2. Second choice: Sertraline or citalopram (intermediate rates) 1
3. Avoid entirely: Paroxetine (70.7% rate - highest of all SSRIs) 1, 2

Important Bupropion Caveats

• Contraindicated in seizure disorders, eating disorders (bulimia/anorexia), or agitated patients 1, 7
• Increased seizure risk particularly above 300 mg/day or with predisposing factors 7
• Less effective for comorbid anxiety compared to SSRIs 7

Comparison to Non-SSRI Alternatives

For complete context on sexual dysfunction risk:

• Bupropion: 8-10% (significantly lower than any SSRI) 1, 7
• Nefazodone: 8% 2
• Mirtazapine: 24.4% (lower than SSRIs but causes sedation and weight gain) 1, 2
• Venlafaxine (SNRI): 67.3% (similar to SSRIs, not a better alternative) 2