Starting Dose of Bupropion for SSRI-Induced Sexual Dysfunction
Start bupropion sustained-release at 150 mg twice daily (300 mg total daily dose) for patients experiencing sexual dysfunction on sertraline 50 mg.
Rationale for Dosing
The evidence strongly supports using bupropion SR 150 mg twice daily as the effective dose for treating SSRI-induced sexual dysfunction:
The most robust evidence comes from a large randomized controlled trial (218 women) demonstrating that bupropion SR 150 mg twice daily significantly improved all domains of sexual function compared to placebo, with the highest improvements in sexual desire (86.4% increase) and lubrication (69.2% increase) 1.
Bupropion has a significantly lower rate of sexual adverse events than sertraline, making it an ideal adjunctive agent 2, 3.
Why Lower Doses Are Inadequate
Do not start with 150 mg once daily - this dose has been shown to be ineffective:
A placebo-controlled trial found no significant differences between bupropion SR 150 mg once daily and placebo for SSRI-induced sexual dysfunction 4.
Another study using 150 mg once daily similarly showed no benefit over placebo 5.
When lower doses (100-200 mg/day) showed benefit in open-label studies, most improvement occurred within 2 weeks, but these findings were not replicated in controlled trials at the 150 mg once-daily dose 6.
Dosing Algorithm
Initial dosing strategy:
Start bupropion SR 150 mg twice daily (morning and early afternoon to avoid insomnia) as adjunctive therapy to the existing sertraline 50 mg 1.
Continue the sertraline at its current dose - do not discontinue or reduce it, as this maintains depression control 1, 7.
Assess response after 2 weeks, though full benefit may take up to 12 weeks 1, 6.
Important Safety Considerations
Screen for seizure risk factors before initiating bupropion:
Bupropion may be associated with an increased risk for seizures 2.
Contraindications include history of seizure disorder, eating disorders, or abrupt discontinuation of alcohol or sedatives.
Monitor for psychiatric symptoms:
While studies showed no worsening of depression with bupropion augmentation, continue monitoring mood symptoms 7.
The combination maintains antidepressant efficacy while addressing sexual side effects 1.
Common side effects to counsel patients about:
Anxiety and tremor led to discontinuation in 15% of patients in one study 8.
Insomnia can occur - advise taking the second dose no later than early afternoon.
Alternative Considerations
If bupropion SR 150 mg twice daily is not tolerated or contraindicated:
For men with erectile dysfunction specifically, consider adding sildenafil (which showed benefit in improving erectile function with mean improvements of approximately 1 point on International Index of Erectile Function scales, equivalent to frequency improvement from "sometimes" to "most times") 7.
Switching antidepressants is an alternative strategy, though the evidence base is limited for currently available agents 7.