We all know that SSRIs are known to cause sexual side effects including lowered libido, erectile issues or orgasm problems.
Often our patients come in to see us, are started on an antidepressant that’s helpful for their depression or anxiety but then they report lowered libido or other forms of sexual dysfunction. Or maybe they don’t even tell us why the medication isn’t working so they just stop taking it or maybe they report side effects but are vague with providing details.
It’s no secret that certain psychotropic medications can cause sexual dysfunction. But not enough of us know how to effectively treat it. Sure, there’s bupropion (Wellbutrin), the poster child for antidepressants that’s known to have less of an effect on sexual functioning, but that’s about it.
Let’s talk about other ways to treat antidepressant-induced sexual dysfunction.
Treating antidepressant-induced sexual dysfunction
Bupropion (Wellbutrin SR, Wellbutrin XL)
Let’s start by talking about the antidepressant most well known to help prevent sexual side effects – that’s bupropion (aka Wellbutrin).
Bupropion, regardless of its form (extended release or immediate release) is a great medication to use as adjunct treatment for antidepressant treatment. For example, let’s say your patient is prescribed citalopram and experiencing sexual side effects. One alternative is adding bupropion to help address this side effect. Just make sure to educate your patient about serotonin syndrome and monitor for its emergence when you combine multiple serotonergic agents.
You can use the mnemonic “SHIVERS” to remember signs of serotonin syndrome. Immediate action needs to be taken for patients exhibiting these clinical features – Shivering. Hyperreflexia and myoclonus. Increased temperature. Vital sign abnormalities. Encephalopathy. Restlessness. Sweating.
Some contraindications for prescribing bupropion include patients with a history of seizures and patients with eating disorders such as anorexia nervosa who are at increased risk for seizures. Bupropion is known to lower seizure threshold so keep this in mind when considering it for your patients.
Mirtazapine (Remeron)
Another medication to consider for treating antidepressant-induced sexual dysfunction is mirtazapine (Remeron). As far as categorization, mirtazapine is classified as an atypical antidepressant and specifically a “tetracyclic antidepressant.
With this medication, you just want to be mindful of some of its side effects which include weight gain (which can be significant for some patient)) as well as sedation. It’s a great adjunct antidepressant for treatment of depression and has an added bonus of helping with insomnia and low appetite for patients struggling with that.
Vilazodone (Viibryd)
Vilazodone is considered a serotonin partial agonist reuptake inhibitor (SPARI) and has fewer sexual side effects than SSRIs. One of the primary side effects to know about this medication is that patients might experience moderate to severe nausea. Make sure to educate your patients about this side effect and ensure they take the medication with food to help with tolerability.
Vortioxetine (Trintellix)
Vortioxetine is a “multimodal” antidepressant and has effects on several receptor sites. For patients experiencing sexual side effects, this is another good alternative. Side effects with this medication are similar to side effects of SSRIs. You know the ones – nausea, vomiting, diarrhea or constipation, dry mouth, and headaches.
Now that we’ve talked about antidepressants least likely to cause sexual side effects, let’s touch on some of the most likely culprits for sexual dysfunction.
At the top of the list includes: SSRIs, SNRIs, and MAOIs (hopefully you’re not prescribing a ton of those).
Treating antipsychotic-induced sexual dysfunction
Most of us know about sexual dysfunction related to antidepressants, but fewer of us know about antipsychotic- induced sexual dysfunction. Antipsychotics are a commonly prescribed class of medications, so an understanding of how to treat this not uncommon side effect is key.
Now, it’s likely that sexual side effects aren’t going to be at the top of the list of considerations when treating patients requiring antipsychotics but it should be. Side effects such as lowered libido are reasons some patients might choose to stop medications, whether they tell us or not.
So, for antipsychotics, one option for reducing sexual side effects includes considering antipsychotic agents that are partial agonists instead of full agonists – medications like cariprazine and aripiprazole. Both cariprazine and aripiprazole are partial agonists which help improve sexual dysfunction by partially blocking dopamine instead of fully blocking it.
For those who want the nitty gritty..
Hyperprolactinemia is a major cause of sexual dysfunction. But how? Dopamine acts on the pituitary gland as an inhibitor of prolactin secretion. So blockade of dopamine D2 receptors by certain antipsychotics like typical antipsychotics and risperidone can cause hyperprolactinemia and thus sexual dysfunction among other side effects.
Antipsychotics associated with lower rates of sexual dysfunction (due to their prolactin-sparing nature) include aripiprazole, olanzapine, clozapine, and quetiapine.
Strategies for treating sexual dysfunction
1. Wait to see if sexual side effects get better over time. For some patients, symptoms improve within several weeks. You don’t need to necessarily jump to stopping a medication when a patient reports sexual side effects because in some cases, symptoms can improve with a bit of time.
2. Adjust the dose of the antidepressant or antipsychotic. Side effects can be dose dependent – higher doses can cause greater side effects so one alternative, particularly before stopping medications, is to decrease the dose to see if symptoms improve.
3. Switch to another antidepressant or antipsychotic. If lowering the dose is ineffective or symptoms don’t improve with time, switching to another antidepressant or antipsychotic can improve sexual side effects.
4. Augment with a second medication. Sometimes, adding a second medication, such as bupropion, can ease sexual side effects caused by the agent your patient is taking.
5. Add a medication to improve sexual function. Adding a medication to treat sexual dysfunction could help. For psychiatric providers, you’ll llikely be referring your patients your fellow primary care providers. Medication options include sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra, Staxyn). It should be noted that these medications are approved to treat sexual issues in men (not fair really, but at least half the population is covered!).
Phew! That’s a lot of information. What are the boiler points?
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- SSRIs and SNRIs are known to cause sexual dysfunction. Strategies to deal with this annoying side effect include waiting, lowering doses, switching agents or augmenting with other medications.
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- Antidepressants with fewer sexual side effects include bupropion, mirtazapine, vilazodone, and vortioxetine.
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- Antipsychotics are also known to cause sexual side effects. Consider antipsychotics that are partial agonists instead of full agonists such as cariprazine or aripiprazole to help reduce sexual dysfunction.
Armed with this information, you’re in good shape to address sexual side effects for your patients with mental health needs. For those of you who want to delve deeper and become ninjas at effectively treating your patients’ mental health, check out the Mental Disorders Crash Course.
