What are the next steps for a patient with pre-existing low libido who started taking sertraline (selective serotonin reuptake inhibitor) and is experiencing continued or worsened symptoms?

Management of Pre-Existing Low Libido in a Patient Starting Sertraline

Since the low libido preceded sertraline initiation, this is not SSRI-induced sexual dysfunction, and sertraline should be discontinued or switched to an antidepressant with minimal sexual side effects, specifically bupropion, as sertraline will predictably worsen the pre-existing sexual dysfunction. 1, 2

Critical Diagnostic Distinction

The temporal relationship is paramount here:

• Pre-existing low libido indicates an underlying sexual dysfunction that requires independent evaluation and treatment 3
• Sertraline causes sexual dysfunction (decreased libido, delayed orgasm, erectile dysfunction) in 58-73% of patients when directly questioned, making it contraindicated when sexual dysfunction already exists 4, 5
• The American Urological Association explicitly states that when erectile dysfunction or sexual dysfunction coexists with other conditions, the sexual dysfunction should be treated first or concomitantly 3

Immediate Management Steps

1. Discontinue or Switch Sertraline

• Taper sertraline gradually to prevent withdrawal syndrome (dizziness, nausea, headache, flu-like symptoms), never discontinue abruptly 6
• Switch to bupropion as the preferred alternative antidepressant, as 86% of bupropion-treated patients have no adverse sexual effects, and 77% report heightened sexual functioning (increased libido, arousal, and orgasm intensity) 2
• Bupropion is the only antidepressant consistently associated with prosexual effects rather than sexual dysfunction 1, 2

2. Evaluate the Pre-Existing Low Libido

Obtain morning total testosterone level (before 10 AM):

• If testosterone <300 ng/dL, testosterone replacement therapy may be indicated 3, 7
• Rule out hypogonadism, which commonly presents with decreased libido 3

Screen for concurrent erectile dysfunction:

• Many patients with erectile dysfunction develop secondary premature ejaculation or low libido due to performance anxiety 3
• If erectile dysfunction is present, treat it first with PDE5 inhibitors (sildenafil, tadalafil, vardenafil) as first-line therapy 3

Assess for psychological factors:

• Depression itself causes decreased libido independent of medication effects 5
• Relationship issues, stress, and interpersonal difficulties significantly impact sexual function 3, 5

Why Continuing Sertraline Is Problematic

• Sertraline causes dose-dependent sexual dysfunction, with higher doses increasing frequency of erectile dysfunction and decreased libido 1, 8
• Sexual side effects of SSRIs are strongly dose-related and may persist even after discontinuation in rare cases 9, 5
• Paroxetine shows the highest rates of sexual dysfunction among SSRIs, but sertraline still causes significant ejaculatory delay and decreased libido in the majority of patients 4, 2
• Only 24.5% of patients have good tolerance of SSRI-induced sexual dysfunction, and 81.4% show no improvement after 6 months of continued treatment 4

Alternative Antidepressant Strategy

If bupropion is contraindicated (seizure disorder, eating disorder, abrupt alcohol/benzodiazepine withdrawal):

• Consider mirtazapine or nefazodone, which have lower rates of sexual dysfunction than SSRIs 1
• Avoid all SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram) and SNRIs, as they uniformly cause sexual dysfunction 4, 5

Common Pitfalls to Avoid

• Do not reduce sertraline dose as a management strategy when sexual dysfunction preceded treatment—this only partially mitigates SSRI-induced worsening and does not address the underlying problem 1
• Do not add PDE5 inhibitors or other augmentation strategies for pre-existing low libido while continuing sertraline—this approach is only appropriate for SSRI-induced sexual dysfunction in patients who had normal function before starting the medication 3, 1
• Do not assume the low libido will improve with depression treatment if sertraline is continued—SSRIs worsen sexual function independent of mood improvement 4, 5
• Never combine sertraline with MAOIs (including linezolid) due to risk of potentially fatal serotonin syndrome 6