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David Baxter

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Antidepressants: Which cause the fewest sexual side effects?
By Mayo Clinic Staff
Dec 6, 2007

My psychiatrist is recommending that I take an antidepressant for my depression. But I'm worried about the sexual side effects. What can be done to prevent or minimize such side effects? ~ Jane / Kentucky

Mayo Clinic psychiatrist Daniel Hall-Flavin, M.D., and colleagues answer select questions from readers.

Answer
Sexual dysfunction is a common side effect of antidepressants. So your concern is understandable. The risk and severity of sexual side effects depends on the individual and the specific type and dose of antidepressant. People taking antidepressants may experience reduced sexual desire, erectile dysfunction and difficulty achieving orgasm or ejaculation.

Selective serotonin reuptake inhibitors (SSRIs) all have a high rate of sexual side effects, including delayed orgasm or ejaculation and inability to achieve orgasm. However, some research suggests that paroxetine (Paxil) is more likely to cause sexual dysfunction than are other SSRIs.

Tricyclic antidepressants have a lower rate of sexual dysfunction than SSRIs do. Some research suggests that clomipramine (Anafranil) and amoxapine have a higher incidence of sexual dysfunction than do other tricyclic antidepressants.

The antidepressants with the lowest incidence of sexual side effects include bupropion (Wellbutrin), nefazodone, mirtazapine (Remeron) and duloxetine (Cymbalta), according to a 2007 overview of research.

Exactly how antidepressants interfere with sexual desire and function remains the subject of ongoing debate and investigation. Unproven theories abound. For example, some blame the sedating effect of certain antidepressants for dampening sexual desire. Others speculate that antidepressants cause chemical changes in the parts of the brain that regulate sexual desire and function. Complicating all of this is the effect of depression itself in decreasing sexual desire and function.

It's impossible to predict which individuals are most likely to develop sexual side effects while taking an antidepressant. In some cases, sexual side effects may improve once your body adjusts to the medication. But in others, sexual side effects may last for the duration of treatment. If you experience sexual side effects while taking an antidepressant, consider these strategies:

  • Talk to your doctor about the possibility of changing your dose.
  • Consider taking a medication that requires only a once-a-day dose, and schedule sexual activity before taking that dose.
  • Talk to your doctor about adding or switching to an antidepressant that may counteract sexual side effects, such as bupropion (Wellbutrin) or mirtazapine (Remeron). The anti-anxiety drug buspirone (Buspar) also may reverse antidepressant-induced sexual dysfunction.
  • Talk to your doctor about taking a medication intended to directly treat sexual dysfunction.
How well these strategies might work depends on the specific drug and your individual circumstances. If sexual side effects are troublesome, talk to your doctor before discontinuing your medication or trying unproven remedies.
 
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Sexual dysfunction is a common side effect of antidepressants.
one can also consider that it's a common symptom of depression, and anti-depressants might in fact help in that area as well (because when you feel better, you become more yourself again).
 

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That's an excellent observation. Indeed, I know some clients, especially female clients, who have reported increased libido and/or decreased sexual dysfunction AFTER starting antidepressant medications.
 

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When someone is being treated for the illness of depression, I wonder if giving this much emphasis to the potential of sexual side effects when there are much more serious aspects of the illness that need to be mitigated.

The article cites paroxetine (Paxil) as having the greatest potential for sexual side effects. In fact the product monograph indicates that less than 7% of men might experience delayed ejaculation:

Primarily ejaculatory delay. In a trial of fixed doses of
paroxetine, the incidence of ejaculatory disturbance in males
with 20 mg/day of paroxetine was 6.5% (3/46) versus 0% (0/23)
in the placebo group.
Placebo: male, n=206; female, n=215.
Paroxetine: male, n=201; female, n=220.

Suggesting that one consider a tricyclic anti depressant rather than an SSRI strictly on the basis of sexual side effects is similarly misleading.

The improvement in overall effectiveness and tolerability of the more recent SSRI/SNRI medications should, in this layman's view outweigh any concern about the relatively small chance for sexual side effects.
 

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While I agree with some of your points, Steve, the makers of Paxil have been accused on more than one occasion of hiding trials data unfavorable to their product. I would also say that, based on experience with clients, Paxil is one of the worst for sexual side effects as well as weight gain, and far and away the worst for discontinuation effects.

In truth, from what I have seen, I cringe when I hear a client has been prescribed Paxil. Yes, I have seen a few who do well on this medication but for most of my clients who have taken it it has been a bit of a nightmare.
 

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I didn't want to imply I was defending Paxil in particular, and sadly, there have been incidents where manufacturers have been accused of influencing the conclusion of trial data.

What I wanted to say was that if someone requires treatment for depression, their first consideration might not be whether and to what degree the medication proposed by the doctor might cause sexual side effects.

There are other more disturbing adverse reactions to anti depressants that one might want to discuss with the doctor such as nausea, dry mouth, headaches, somnolence and constipation.

Not that any one individual might experience some or any of these, but these are some of the side effects most frequently experienced by users of anti depressants, tricyclics more often than SSRI/SNRI's

The key, however is in the advice given in the article to speak to the doctor about strategies available to counteract this or any other side effect of a medication for depression.

Specialists (psychiatrists) and their colleagues, psycho-pharmacologists are skilled at counteracting adverse reactions by using compounds added on to the anti depressant.

For anyone interested, the U.S. product monograph for Paxil can be seen HERE

and far and away the worst for discontinuation effects

David, would you attribute the difficulties in discontinuation of Paxil to non compliance with instructions for tapering or in spite of correct tapering?

Of course, if a person is switched from Paxil or any other short acting SSRI or SNRI to another SSRI/SNRI, discontinuation withdrawl should not be an issue.
 

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Yes, I agree that there are other options. For example, some people find that decreasing the dose of the SSRI a bit and adding in Wellbutrin counteracts the side-effects, especially the sexual side effects.

As to the question about Paxil, my observations with clients is that, while some of them did either discontinue suddenly (for example, running oot of the prescription and not getting a refill), others followed good tapering advice and still went through hell. As I said, my observations have led me to hope fervently that nmy clients are not put on this particular medication, although as I said earlier I am aware that some people find it to be an effective medication and do not experience the nasty side-effects or discontinuation effects.
 

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I would just like to say good luck with all of those meds. I am so jaded at this point with them. I had tried the SSRIs and had SD with all of them. Then I tried remeron, did not have SD but had extreme problems with battling weight gain, then buspar was substituted for the remeron and the anxiety went up, so the remeron was added in combo with the buspar and then I had SD again (but admittedly not as bad as with SSRis) plus I still had anxiety. I basically have no faith in medications anymore although the one that does help is ativan. I have also had a psychiatrist mention cymbalta and say that her clinical experience differs from the claim that it does not cause sexual dysfunction and that in her experience with clients it does. In the past I have skipped doses to "schedule around this dysfunction" and it just doesn't seem very romantic. I am scheduled to go back in for a check up and I have pretty much given up all hope of finding anything that will be worth taking. I am now working on making peace with the anxiety.

Sorry if this sounds jaded but it is my truth.
 

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If you're taking these medications for anxiety rather than depression, many people do well with a lower dose than would be normally recommended for depression - and that can sometimes get around the side-effects as well.
 

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Thank you for the tip. I always go through the same cycle where I am started on a very low dose because I am so sensitive to medication, then before you know it, it gets raised and raised and raised because I'm still anxious until it's high. Then things get added and I'm still anxious. I must be one of those rare people who cannot handle the medication or am not willing to tolerate the sexual side effects (which have damaged relationships in the past) and/or weight gain as a young adult. It's too early for that for me. With the amount it helps, the tradeoff is not worth it.
 

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then before you know it, it gets raised and raised and raised because I'm still anxious until it's high. Then things get added and I'm still anxious.

If you know from past experience that you experience adverse effects with certain meds at specific doses or certain combinations of meds, it would help your physician immensely if your reported your experience.

Doctors want to provide you with quality of life as close to normal while treating your particular condition/disorder.

Your part of being a partner in your health care is to provide information to the doctor so changes and modifications can be made in compounds and or dosages.

Communication is the key to successful and (hopefully) trouble free therapy.

No one can promise a medication that will be 100% side effect free, except quacks and snake oil salesmen.

Prescription medications are intended to alter body or brain chemistry in order to correct the issue that was diagnosed.

Sometimes a compound will exert a so called, off target effect, which might cause adverse reactions. Your doctor needs to know about this, so changes in therapy can be considered.
 

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Thanks Steve. I definitely have told them my history. The doctors have all said that I will basically get those side effects with every med. My only options are to 1. deal with the side effects 2. trial and error every one with the unlikely event that one might cause less 3. or try buspar again which is what I'm trying now.

More or less, the doctor i'm at right now has no more ideas so she asks me what I want to do so I am trying buspar again and it's not really working. But I have never had anythign work for the anxiety except aitvan and remeron.

Seriously, if anyone has any suggestions about a relatively side effect free anxiety med that does not cause sexual dysfunction or weight gain I would love to hear it as I am going back in this week and I'm sure ask me for suggestions or ideas.
 

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Lorazepam or clonazepam - although a lot of physicians are still biased against the use of benzodiazepines.
 

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Thank you, I have an ongoing rx for lorazepam for 1mg everyday, down from taking 3x a day so I don't become too dependent on that. You are right about the biased. The reason I like this doctor is she is the only person who has ever let me had thsi medication on an onging basis.
 

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For certain types of anxiety disorders, I think there is abundant evidence that tranquilizers do a much better job than SSRIs - and they are generally well tolerated, at least at low the doses typically prescribed these days.

It really is an unwarranted prejudice based on old history with valium-librium, in my opinion.
 

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I was taking Bupropion SR Since January 1st 100mg twice a day. It Helped but notice it wasn't enough and I saw my family Dr today and he let me have 150mg twice day.
Last year I was on Celexa for a few months and it didn't help me and the sexual side effect was terrible. Now with the Bupropion Sr no problem. I hope the new dose make me less depress.

Sue
 

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