What are the types of sexual dysfunction associated with antidepressant treatment, listed from most common to least common, in patients taking medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)?

Types of Antidepressant-Induced Sexual Dysfunction: Ranked by Frequency

The most common types of sexual dysfunction caused by SSRIs and SNRIs, ranked from most to least frequent, are: (1) delayed or absent orgasm/ejaculation, (2) decreased libido, (3) erectile dysfunction in men, and (4) arousal difficulties including vaginal dryness in women. 1, 2, 3, 4

Ranking of Sexual Dysfunction Types by Frequency

1. Delayed or Absent Orgasm/Ejaculation (Most Common)

• Ejaculatory delay or failure is the most frequently reported sexual side effect across all SSRIs and SNRIs, occurring in 14% of male patients taking sertraline in controlled trials, though actual rates are likely higher due to underreporting 2, 4
• Among SSRIs, paroxetine provides the strongest ejaculation delay (8.8-fold increase over baseline) and is specifically used therapeutically for premature ejaculation at doses of 20 mg daily 1
• Delayed or absent orgasm affects both men and women and is the hallmark sexual side effect of serotonergic antidepressants 3, 5, 4

2. Decreased Libido (Second Most Common)

• Decreased libido occurs in approximately 6% of patients (both male and female combined) taking sertraline in controlled trials, making it the second most common sexual dysfunction 2
• The American College of Physicians reports that decreased libido affects 23-50% of men and 33-90% of women with depression, though distinguishing medication effects from illness effects is challenging 1, 6
• Men experience significantly greater drug-related impairment in drive/desire (38-50%) compared to women (26-32%) across SSRIs and SNRIs 7

3. Erectile Dysfunction in Men (Third Most Common)

• Erectile dysfunction is reported less frequently than orgasmic dysfunction or decreased libido in SSRI trials 2, 4
• Sexual side effects of SSRIs are strongly dose-related, with higher doses increasing the frequency of erectile dysfunction 1, 4
• Paroxetine causes significantly more impotence than fluvoxamine, fluoxetine, or sertraline 5

4. Arousal Difficulties (Least Common Among Reported Types)

• Disorders of sexual arousal in women, usually presenting as excessive vaginal dryness, are less commonly reported than other sexual dysfunctions 6
• The specific association of arousal difficulties to SSRI use has not been consistently demonstrated in studies, unlike orgasmic dysfunction 4
• Arousal problems may be confounded by the underlying depressive disorder itself 4, 7

Comparative Risk Among Specific Antidepressants

Highest Risk Agents

• Paroxetine has the highest overall sexual dysfunction rate at 70.7%, significantly higher than all other SSRIs 1, 3, 5
• Citalopram follows with 72.7% sexual dysfunction rate 3
• Venlafaxine (SNRI) causes sexual dysfunction in 67.3% of patients 3

Moderate Risk Agents

• Sertraline causes sexual dysfunction in 62.9% of patients overall, with 14% ejaculatory failure in males and 6% decreased libido in both sexes 2, 3
• Fluvoxamine causes sexual dysfunction in 62.3% of patients 3
• Fluoxetine causes sexual dysfunction in 57.7% of patients 3

Lowest Risk Agents

• Bupropion has the lowest sexual dysfunction rate at 8-10% and should be considered first-line when sexual function is a major concern 1, 8
• Mirtazapine causes sexual dysfunction in only 24.4% of patients, though it causes sedation and weight gain 1, 3
• Nefazodone causes sexual dysfunction in only 8% of patients 3

Critical Clinical Considerations

Underreporting Is Universal

• Sexual dysfunction rates are vastly underreported in clinical trials, with actual rates likely much higher than published figures 1
• When physicians directly ask about sexual side effects, the incidence is 58%, compared to only 14% when spontaneously reported by patients 5
• Routine inquiry about sexual side effects is essential, as patients and physicians are often reluctant to discuss them 2, 4

Gender Differences

• Men have higher frequency of sexual dysfunction (62.4%) compared to women (56.9%), but women experience higher severity of symptoms 3
• Men experience more ejaculatory and erectile problems, while women experience more arousal difficulties (vaginal dryness) 6, 7

Timing and Persistence

• Most sexual adverse effects emerge within the first few weeks of treatment 1
• In 81.4% of patients, sexual dysfunction shows no improvement even after 6 months of continued treatment 5
• Only 5.8% of patients experience complete resolution of dysfunction within 6 months while continuing the medication 5

Impact on Treatment Adherence

• About 40% of patients show low tolerance of their sexual dysfunction, contributing to the 40% who either refuse to begin or discontinue antidepressant treatment within 12 months 1, 3, 5
• Sexual dysfunction is among the most serious reasons for treatment discontinuation 6