Antidepressant-Associated Sexual Dysfunction

Prevalence and Risk

• Most antidepressants, particularly SSRIs, are associated with sexual dysfunction rather than increased libido, with a notable association found in the literature, according to the American College of Physicians and the American Academy of Family Physicians 1, 2
• Antidepressants have high rates of sexual dysfunction, with 63% of patients on second-generation antidepressants experiencing at least one adverse effect 2
• Sexual side effects are often underreported by patients, and absolute rates are likely higher than documented in clinical trials, according to the American College of Physicians 1

Hierarchy of Sexual Side Effects

• The hierarchy of sexual side effects among antidepressants is as follows:

  Antidepressant	Risk Level
  Paroxetine	Highest risk
  Sertraline, fluoxetine	Moderate risk
  Fluvoxamine, mirtazapine	Lower risk
  Bupropion	Lowest risk

• Specific antidepressants have the following rates of sexual dysfunction:

Management of Sexual Side Effects

• The American College of Physicians recommends dose adjustment, situational dosing, or switching to an alternative agent (such as vortioxetine or bupropion) to manage sexual side effects, with lower doses of SSRIs (e.g., fluoxetine 5 mg/day) or situational dosing (e.g., sertraline 50 mg 4-8 hours before intercourse) also considered 1, 3
• Bupropion has significantly lower rates of sexual adverse events compared to SSRIs and should be considered when sexual dysfunction is a concern, with switching from an SSRI to bupropion potentially improving sexual function while maintaining antidepressant efficacy 1
• Paroxetine should be avoided when sexual function is a concern due to its high rates of sexual dysfunction among SSRIs 1

Assessment and Monitoring

• Assess baseline sexual function before starting treatment and regularly monitor for changes in sexual function throughout treatment, as a logical approach to patient care
• Be aware that different phases of sexual response may be affected differently based on gender, according to the American College of Physicians 1
• Mirtazapine may be considered as an alternative for patients concerned about sexual side effects when initiating antidepressant therapy, due to its lower risk profile compared to other antidepressants.