Do Antidepressants Cause Sexual Side Effects?

Antidepressants are likely to cause different side effects and leave everyone concerned. The major misconception that revolves around antidepressants is one has to take the medicine for an entire life, thus having to suffer from its side effects.

Sexual dysfunction is one of the bothersome side effects caused by the majority of antidepressants. However, the rate of its occurrence varies in the population. That is why a thorough assessment is necessary to figure out if the sexual dysfunction is depression-induced or associated with lifestyle or chronic illness.

Introduction

What are antidepressants?

Antidepressants are medicines used to treat depressive states, generally moderate to severe depression as the name itself indicates. Apart from depression, they are also commonly prescribed for obsessive-compulsive disorder (OCD), generalised anxiety disorder and post-traumatic stress disorder (PTSD). They are also prescribed in patients with long-term chronic pain.1 The exact working mechanism of antidepressants remains unknown. It is assumed that they stabilise mood by increasing neurotransmitter levels (molecules used by the brain cells to communicate) such as serotonin and noradrenaline (norepinephrine). 

Importance of addressing antidepressant sexual side effects

Sexual dysfunction remains one of the top side effects linked with antidepressant therapy. Approximately 40% of patients prescribed antidepressants show one or the other form of sexual dysfunction ranging from reduction in sexual desire to absence of orgasm.2 This ultimately affects the quality of life and antidepressant treatment adherence, thus causing a maximal chance of relapse of symptoms.   

Types of antidepressants

SSRIs (Selective serotonin reuptake inhibitors)

Common SSRIs

Commonly prescribed SSRIs are Fluoxetine, Paroxetine, Sertraline, Escitalopram, Citalopram, etc. They are first-line drugs in treating depression. 

Mechanism of action

SSRIs help to compensate for deficient serotonin in the brain3, a neurotransmitter responsible for mood regulation. Serotonin is also called a “feel good” chemical.

Prevalence of sexual side effects

The overall frequency of sexual side effects in patients taking SSRIs varies from 25%-73%.4-7 The highest prevalence of sexual side effects is observed in citalopram (72.7%) followed by paroxetine (70.7%), sertraline (62.9%), fluvoxamine (62.3%), and fluoxetine (57.7).8 

SNRIs (Serotonin-norepinephrine reuptake inhibitors)

Common SNRIs

The commonly prescribed SNRIs are Venlafaxine, Desvenlafaxine, Milnacipran, and Duloxetine.

Mechanism of action

Like SSRIs, SNRIs also regulate serotonin levels in the brain along with norepinephrine (noradrenaline).9 Norepinephrine is responsible for regulating arousal, attention, cognitive function and stress reactions.10  

Sexual side effects comparison with SSRIs

No accurate results have been found showing a crystal clear difference in the prevalence of the side effect between SSRIs and SNRIs. Collectively, the appearance of sexual dysfunction among SSRIs and SSRIs takers ranges from 58%-70%.11

Other classes of antidepressants

Tricyclic antidepressants (TCAs)

The commonly available TCAs are Imipramine, Desipramine, Amitriptyline, Nortriptyline, Doxepin, etc. TCAs maintain levels of serotonin and norepinephrine in the central nervous system, thus alleviating depression.12 Alongside, it also helps to fight against other neurotransmitter acetylcholine, which is responsible for depressed mood.12 TCAs have complex mechanisms associated with TCAs and are shown to have the highest prevalence of sexual-related side effects in 90% of the population taking the medicine, with clomipramine showing the highest.13 Amitriptyline and Doxepin are found to show a lower incidence of sexual dysfunction.13

MAOIs (Monoamine oxidase inhibitors)

This class includes drugs such as Isocarboxazid, Phenelzine, Tranylcypromine, Selegiline, Rasagiline, Moclobemide, etc. These drugs suppress monoamine oxidase enzymes responsible for metabolising happy neurotransmitters like serotonin, norepinephrine, dopamine, and tyramine. The drugs thus prevent the breakdown of these neurotransmitters, stabilising your mood.14 They are prescribed for depression along with other conditions such as panic disorder, social phobia, and depression with atypical features such as overreacting and oversleeping.15 The sexual dysfunction is associated with MAOIs but not more than 40%.8,13,16 Moclobemide has proven to show a much lower incidence of sexual side effects as compared to others.17

Atypical antidepressants

Atypical antidepressants cover Bupropion, Mirtazapine, Nefazodone, Trazodone, and Agomelatine. They have several mechanisms of action. Overall, they help compensate for deficient neurotransmitters such as dopamine, serotonin, and norepinephrine in the brain and thus alleviate depression.18 Contrary to other antidepressants, atypical antidepressants like mirtazapine, bupropion and nefazodone are effective in improving sexual dysfunction and are as effective as SSRIs in treating depression.19

Sexual side effects:

Sexual side effects can have a great impact on people’s quality of life, self-esteem, and relationships. They can ultimately lead to non-compliance with treatment, thus leading patients to get into that circle of mood depression. The mechanism of sexual dysfunction is rarely understood. However, serotonin is considered to be the major neurotransmitter which upon elevation affects other neurotransmitters like dopamine and hormones like testosterone responsible for sexual arousal.20 The range of side effects varies from loss of desire to impotence and absence of orgasm. 

The risk of sexual side effects from antidepressants is simplified below:21

Class DrugsRisk
SSRIs- Citalopram 
- Escitalopram 
- Fluoxetine 
- Fluvoxamine 
- Paroxetine 
- Sertraline
All SSRIs have a high risk. Limited evidence suggests that paroxetine and escitalopram may have the highest risk in this group
SNRIs- Desvenlafaxine 
- Duloxetine 
- Venlafaxine
SNRIs have a high risk. Insufficient evidence to compare the risk between individual SNRIs, and between SNRIs and SSRIs. Duloxetine has been suggested to have a lower risk compared with venlafaxine, but further evidence is needed to clarify this
TCAs- Clomipramine 
- Amitriptyline 
- Dosulepin (dothiepin) 
- Doxepin 
- Imipramine 
- Nortriptyline
Clomipramine has a high risk (similar to SSRIs) 

Medium risk with other TCAs; however, very few studies have evaluated risk with TCAs and how the incidence compares with SSRIs. Results to date have been inconsistent
MAOIs- Moclobemide
- Phenelzine 
- Tranylcypromine
Low risk; comparable to placebo. Data is limited.
These are associated with SD, but the incidence compared with SSRIs is unclear due to a lack of trials. Limited data suggest phenelzine has a greater risk than tranylcypromine
Others- Agomelatine 
- Bupropion 
- Mirtazapine
- Reboxetine 
- Vortioxetine
Low risk; comparable to placebo in trials 
Low risk; comparable to placebo in trials
Low to medium risk; less than SSRIs 
Low risk; comparable to placebo 
Medium to high risk; less than duloxetine at doses of 5–10 mg, but not different to duloxetine at higher doses. Data are limited
MAOI = monoamine oxidase inhibitor; SNRI = serotonin and noradrenaline reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.

Common sexual side effects

The side effects vary from person to person and with the medicine being prescribed. Some of the common sexual side effects are:

Impact on quality of life and treatment adherence

Sex is often described as joy and satisfaction crucial in personal growth and the key to establishing bonds in interpersonal relationships.22 Any sort of imbalance in sexual aspects can thus impact one’s self-esteem and relationship equation and thus slowly affect other areas of life. If the dysfunction is associated with precipitating factors like medicines, it is likely that one is less likely to adhere to the medicine prescribed. It is one of the distressing side effects of antidepressants and one of the top reasons for patients not sticking to the therapy for a prescribed length of time.21

Challenges in discussing sexual side effects with healthcare providers:

Talking about sex and sexual health is considered taboo in so many societal settings. Sexual side effects make a person suffer in numerous aspects of life. There are so many instances when healthcare professionals are not equipped with the skills to communicate sensitive topics like these to make communication comfortable for patients. 

The lack of knowledge and training and several organisational regulations might be a factor where discussions like these might not be feasible for people with sexual side effects.22 Another matter of concern is, that unpleasant sexual experiences can also result in depression.13,23,24 That is why, healthcare professionals be very careful about dealing with such cases if it is sexual dysfunction associated with depression or antidepressant-induced sexual side effects. 

Managing sexual side effects

Though managing the sexual side effects associated with antidepressants completely is impossible, at least interventions need to be done to remove them partially. Some of the most common ways of clinically managing the conditions are as follows.

Dose adjustments

The incidence of sexual side effects varies greatly from individual to individual, with some showing side effects in low doses while others show no adverse effects even at high doses.6, 25 For those showing sexual dysfunction, reduction of dose to a minimum effective dose can be considered without compromising their mental health status.11 However, reduction of dose is not an immediate remedy and thus patience is key.

Switching antidepressants

Shifting from the medicine likely to show sexual dysfunction to others can be a game changer. For instance, replacing SSRIs with non-SSRIs can be considered. Switching sertraline to nefazodone has shown promising results in alleviating sexual side effects without altering depression recovery.26 Nefazodone, bupropion, trazodone and mirtazapine are some drugs with minimal or no side effects and may be used as the first line.11,27 Your psychiatrist can help you find the best alternative to improve your sexual health. However, stopping and swapping has to be done carefully to avoid serious drug-drug interactions like serotonin syndrome in transition.27

Adding adjunct medications

Some medicines taken along with antidepressants can improve the sexual side effects. 

  1. Adding another antidepressant

Bupropion has promising results in improving sexual side effects when given together with SSRIs. 

  1. Adding sildenafil (Viagra)

Sildenafil is found to be quite effective in treating erectile dysfunction in men,26, 28 along with delayed orgasm and inadequate lubrication in women.29 However, the addition of a regimen should be done after a thorough assessment of a patient because side effects of sildenafil can be even more debilitating than sexual side effects.11

  1. Adding herbal supplement: Ginkgo biloba

Ginkgo biloba has proven to show positive results in all phases of the sexual response cycle: desire, excitement, orgasm and resolution when used in conjunction with antidepressants.30

Non-pharmacological interventions

While non-pharmacological approaches alone cannot help to improve the sexual dysfunction associated with antidepressants, when carried out along with the regimen, they can be a great support in healing mental illness along with the side effects and consequences that have to follow, including sexual dysfunction.

Psychotherapy

Psychotherapy, more prominently cognitive behavioural therapy (CBT) can help patients to understand the depressive illness first. CBT cannot heal the sexual dysfunction associated with antidepressants but helps patients get psychological and social support, thus helping them stick to the regimen.11

Lifestyle changes

Depression and sexual dysfunction are closely related.31 Substance abuse, a sedentary lifestyle, and an unhealthy diet are common among depressive people, which can further precipitate sex-related problems. That is why changing life patterns with activity-filled days and a nutritious diet can improve sexual problems to a significant extent as this uplifts mood and morals and also yields great benefits in reducing the burden of sexual dysfunction.32 

Summary

Antidepressants and sexual dysfunction are closely related. Antidepressants induced sexual side effects can be more disturbing to already depressed individuals, thus breaking compliance to the treatment, which can exacerbate the mental illness. That is why thorough assessment before and after the initiation of therapy is important, and necessary interventions should be carried out. Myths regarding antidepressants should be clarified with open communication. For any related problems, unhesitantly visit your doctor (psychiatrist).

Frequently asked questions:

Do the sexual side effects of antidepressants go away?

For most people, sexual-related side effects subside as the body adjusts to the medicine. That is why patients need to have realistic expectations that it takes time for the medicine to work for the primary cause along with resolving side effects. If the problem continues for a prolonged time, visit your doctor.

Which antidepressant has the least sexual side effects?

Atypical antidepressants like bupropion, mirtazapine, trazodone, and nefazodone have been shown to cause minimal or no sexual side effects. For proper effectiveness of the medicine for a particular mental condition, you should see your doctor first and discuss.

Can you take Viagra with antidepressants?

No, you cannot take Viagra with antidepressants on your own as it can cause serious drug-drug interaction. This should only be taken after a proper physical assessment done by your doctor.

Why can’t I climax on antidepressants?

Certain antidepressants like SSRIs (Selective serotonin Reuptake Inhibitors), and SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are likely to cause delayed orgasm or loss of orgasm (anorgasmia). In most cases, the problem resolves as your body adjusts to the dose. If this has been a disturbing factor in your sexual health, you should see your doctor and can switch to other antidepressants with minimal side effects.

References:

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Gaurav Rayamajhi

Doctor of Pharmacy - PharmD, Bahauddin Zakariya University

Gaurav, an experienced pharmacist in a hospital setting, possesses a strong passion for communication, which has naturally drawn him towards medical writing and video presentation. His primary goal in the field of medical writing is to illuminate complex medical knowledge in the most accessible manner possible for the general public.

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