From the Guidelines
For a patient experiencing loss of libido as a side effect of escitalopram for depression, the next best step would be to consider switching to bupropion (Wellbutrin), which is less likely to cause sexual dysfunction and may even improve sexual function. This recommendation is based on the evidence from the American College of Physicians, which suggests that bupropion has a lower rate of sexual adverse events compared to other antidepressants such as fluoxetine and sertraline 1.
Key Considerations
- Typical starting dose of bupropion is 150 mg once daily of the extended-release formulation, which can be increased to 300 mg daily if needed after several weeks.
- Alternatively, adding bupropion (150 mg daily) to the current escitalopram regimen could be tried if the patient is otherwise responding well to escitalopram.
- Other options include switching to mirtazapine (starting at 15 mg at bedtime) or vortioxetine (starting at 10 mg daily), both of which have lower rates of sexual side effects.
- Sexual side effects are common with SSRIs like escitalopram, affecting 30-50% of patients, and are a leading cause of medication discontinuation.
Monitoring and Follow-up
It's essential to discuss these options with the patient, emphasizing that improvement in sexual function typically occurs within 1-2 weeks after medication adjustment, and to monitor for both depression symptoms and side effects after making any change. Regular follow-up appointments should be scheduled to assess the patient's response to the new treatment and adjust as needed.
Evidence Summary
The American College of Physicians recommends that clinicians select between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient 1. The evidence suggests that bupropion is a suitable alternative for patients experiencing sexual side effects with escitalopram, due to its lower risk of sexual dysfunction.
From the FDA Drug Label
Taking selective serotonin reuptake inhibitors (SSRIs), including Escitalopram tablets, may cause sexual problems Symptoms in males may include: • Delayed ejaculation or inability to have an ejaculation • Decreased sex drive • Problems getting or keeping an erection Symptoms in females may include: • Decreased sex drive • Delayed orgasm or inability to have an orgasm Talk to your healthcare provider if you develop any changes in your sexual function or if you have any questions or concerns about sexual problems during treatment with Escitalopram tablets. There may be treatments your healthcare provider can suggest.
The next best step is to talk to the healthcare provider about the loss of libido, as they may suggest alternative treatments or adjustments to the current treatment plan 2.
From the Research
Next Best Step for Patient with Depression and Lost Libido
The patient has started on escitalopram but is experiencing lost libido, a common side effect of selective serotonin reuptake inhibitors (SSRIs) 3.
- The first consideration is that sexual dysfunction is prevalent in patients with major depressive disorder (MDD) and is also associated with second-generation antidepressants (SGADs) that are commonly used to treat the condition 4.
- One option is to switch to an antidepressant with a lower risk of sexual dysfunction, such as bupropion, which has been shown to have a lower impact on sexual functioning compared to other antidepressants 5, 3, 4.
- Another option is to add a medication that can help alleviate sexual dysfunction, such as buspirone, which has been shown to improve SSRI-associated sexual dysfunction in some patients 6.
- It is also important to note that sexual function can improve as depressive symptoms decrease during treatment with escitalopram, so it may be worth continuing with the current treatment and monitoring the patient's symptoms 7.
Considerations for Treatment
- When considering treatment options, it is essential to discuss the patient's preferences and weigh the potential benefits and risks of each treatment 4.
- The patient's treatment plan should be individualized, taking into account their specific needs and circumstances.
- Regular follow-up appointments should be scheduled to monitor the patient's symptoms and adjust the treatment plan as needed.