Buspirone Has the Lowest Risk of Sexual Dysfunction for Anxiolytic Treatment
For adults requiring anxiolytic therapy who want to avoid sexual dysfunction, buspirone is the clear first-line choice, as it not only lacks sexual side effects but may actually improve sexual function. 1, 2
Evidence-Based Medication Selection
Buspirone: The Optimal Choice
- Buspirone normalized sexual function in 8 of 10 patients (80%) with generalized anxiety disorder after 4 weeks of treatment, with 9 of these patients having reported decreased sexual function before treatment. 2
- Buspirone offers a distinct clinical advantage over other anxiolytics, which are typically associated with impairment of sexual function. 2
- In patients already experiencing SSRI-induced sexual dysfunction, approximately 58% reported improvement when buspirone was added, compared to only 30% with placebo—demonstrating that buspirone can actually reverse sexual dysfunction rather than cause it. 3
- The improvement in sexual function with buspirone occurs rapidly, typically within the first week of treatment, with no further improvement needed during continued therapy. 3
SSRIs: Avoid for Anxiolytic Use When Sexual Function Matters
- Paroxetine has the highest rate of sexual dysfunction at 70.7%, significantly worse than all other antidepressants, and should be completely avoided when sexual function is a concern. 1, 4
- Fluoxetine and sertraline both cause significant sexual dysfunction, with sertraline causing ejaculatory dysfunction in 14% of males and decreased libido in 6% of patients overall. 1, 5
- Sexual dysfunction from SSRIs is dose-dependent, with higher doses increasing both efficacy for anxiety and frequency of erectile dysfunction and decreased libido. 4
- Among SSRIs, if one must be used, escitalopram has lower rates of sexual dysfunction than paroxetine, fluoxetine, or sertraline. 1
Mirtazapine: A Secondary Alternative
- Mirtazapine has lower rates of sexual dysfunction than SSRIs and was independently associated with favorable sexual outcomes in longitudinal studies. 1, 5
- However, mirtazapine causes significant sedation and weight gain, which may limit tolerability despite its favorable sexual side effect profile. 1
Clinical Decision Algorithm
Step 1: Start with Buspirone
- Initiate buspirone at 20-60 mg/day (mean effective dose approximately 48.5 mg/day) for generalized anxiety disorder. 3
- Expect improvement in sexual function within the first week if any baseline dysfunction exists. 3
- Monitor for therapeutic response within 1-2 weeks. 1
Step 2: If Buspirone is Contraindicated or Ineffective
- Consider mirtazapine 15-30 mg/day as the next option, counseling patients about sedation and weight gain. 1
- Avoid SSRIs entirely if sexual function is a priority, as they uniformly cause sexual dysfunction at rates far exceeding buspirone. 1, 4
Step 3: If an SSRI Must Be Used
- Choose escitalopram over other SSRIs due to lower sexual dysfunction rates. 1
- Never use paroxetine when sexual function is a concern—its 70.7% sexual dysfunction rate makes it the worst choice. 1, 4
Critical Caveats and Pitfalls
Underreporting of Sexual Dysfunction
- Sexual dysfunction rates are vastly underreported in clinical trials, meaning real-world incidence is likely higher than published figures for all medications except buspirone. 1, 4
- Proactively ask patients about sexual function at baseline and follow-up visits, as patients may be reluctant to volunteer this information. 1
Buspirone Limitations
- Buspirone should not be used in agitated patients or those with seizure disorders. 4
- Buspirone has less established efficacy for anxiety disorders compared to SSRIs, so the trade-off between sexual function preservation and anxiolytic efficacy must be considered. 1
Gender Differences
- The beneficial effect of buspirone on sexual function was more pronounced in women than in men when used to reverse SSRI-induced dysfunction. 3
- Men may be more likely than women to experience impaired sexual outcomes with SSRIs overall. 5