Evidence-Based Reviews

Sex and antidepressants: When to switch drugs or try an antidote

Current Psychiatry. 2004 November;3(11):53-66

References

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Measures of arousal, orgasm, and global sexual functioning did not differ significantly between the two groups. Bupropion added to SSRI treatment was well-tolerated; most-commonly reported side effects were irritability (12%), dry mouth (12%), and headache (15%).

Other ED treatments. Two additional phosphodiesterase-5 inhibitors have become available in the past year. Like sildenafil, tadalafil and vardenafil are indicated for treating ED. They may be useful as alternatives for patients who do not respond to or tolerate sildenafil, although no published studies have examined their use in antidepressant-induced sexual dysfunction.

Recommendation. Based on the evidence, it seems reasonable to start with bupropion or sildenafil when considering an antidote for sexual side effects caused by SSRIs or other medications with strong serotonergic effects. Determining which agent would be “first-line” depends on patient factors, as summarized in Table 1^30,31For example:

Bupropion has been reported to augment SSRIs’ antidepressant effects³² and thus may provide added benefit in patients with residual depressive symptoms.
Bupropion is more effective than sildenafil for improving sexual desire and thus would be preferred for patients in whom this sexual dysfunction symptom is prominent.
Sildenafil appears to be more effective than bupropion for improving overall sexual satisfaction for men experiencing substantial erectile dysfunction.

Table 4

Bupropion vs. sildenafil as antidote therapy for antidepressant sexual side effects

Bupropion
Possible advantages
May reduce residual depressive symptoms, if present³²
Appears to improve sexual desire¹⁵
Possible disadvantages
Daily dosing may increase side-effect risk, but less effective when taken as needed³⁰
Less-clear benefits for arousal and orgasm-related symptoms
Sildenafil
Possible advantages
Can be taken as needed as opposed to daily³¹
Benefits for arousal and orgasm-related symptoms demonstrated in men³¹
Possible disadvantages
Benefit less-proven for women than for men
Reduced sexual spontaneity
Unclear benefits for sexual desire³¹
Contraindicated in patients taking organic nitrates because of potentiation of hypotensive effects. Caution advised in patients with: history of MI, stroke, or life-threatening arrhythmia in past 6 months blood pressure <90/50 or >170/110 cardiac failure or unstable angina retinitis pigmentosa
Source: Prepared from references 15 and 30-32.

Related resources

Worthington JJ 3rd, Peters PM. Treatment of antidepressant-induced sexual dysfunction. Drugs Today (Barc) 2003;39(11):887-96.
Montgomery SA, Baldwin DS, Riley A. Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction. J Affect Disord 2002;69(1-3):119-40.

Drug brand names

Amantadine • Symmetrel
Bethanechol • Duvoid, Urecholine, Urabeth
Bupropion SR • Wellbutrin SR
Buspirone • Buspar
Citalopram • Celexa
Clomipramine • Anafranil
Cyproheptadine • Periactin
Fluoxetine • Prozac
Granisetron • Kytril
Methyphenidate • Ritalin
Mianserin • Bolvidon, Norval
Mirtazapine • Remeron
Nefazodone • Serzone
Paroxetine • Paxil
Pramipexole • Mirapex
Ropinirole • Requip
Sertraline • Zoloft
Sildenafil • Viagra
Tadalafil • Cialis
Vardenafil • Levitra
Venlafaxine • Effexor

Disclosure

Dr. Nelson receives research support from Eli Lilly and Co. and Forest Laboratories and is a speaker for Pfizer Inc. and Wyeth Pharmaceuticals.