Review Question - QID 107294

This patient likely has selective serotonin re-uptake inhibitor (SSRI) induced sexual dysfunction. Bupropion can be prescribed as a stand-alone or add-on therapy to improve sexual side effects.

Use of SSRIs, tricyclic antidepressants or monoamine oxidase inhibitors are known to lead to sexual dysfunction. In patients who require long-term treatment of these drugs, the sexual side effects (delayed ejaculation, anorgasmia, decreased libido) can be debilitating. Bupropion is a norepinephrine and dopamine re-uptake inhibitor, which improves sexual functioning in those taking SSRIs. Other anti-depressants that have minimal sexual side effects or may improve SSRI induced sexual dysfunction include: buspirone, vilazodone and mirtazapine.

Smucny et al. discuss the antidepressants with the lowest risk of sexual side effects. Buproprion and nefazodone have a lower incidence of sexual dysfunction as compared to SSRIs. Nefazodone is not commonly used in the United States. Between different SSRIs (including citalopram, sertraline, paroxetine, fluoxetine and fluvoxamine) there has not been compelling evidence to suggest a significant difference in adverse sexual events.

Bijlsma et al. discuss the mechanism of anti-depressant induced sexual dysfunction. SSRIs are hypothesized to impact sexual functioning via several mechanisms. Increased serotonin activity in the spinal cord is thought to decrease sexual reflexes. Serotonin is also thought to inhibit the effects of dopamine in the hypothalamus and mesolimbic tracts of the brain. Dopaminergic activity is important in positive sexual functioning. Additionally, mirtazepine (due to antagonism of 5HT2C), vilazodone (due to 5HT1A partial agonism) and buspirone (5HT1A agonism) have lesser sexual side effects.

Incorrect Answers:
Answer 1: Paroxetine is a soothing SSRI known to induce sexual side effects
Answer 2: Venlafaxine is a serotonin and norepinephrine re-uptake inhibitor known to cause sexual side effects, sometimes within a week of starting.
Answer 3: Aripiprazole has been approved as an adjunct for MDD. While it may improve sexual functioning, these effects have not been sufficiently validated.
Answer 5: Cyproheptadine is a serotonin 5-HT2 receptor antagonist, which may be beneficial in treating SSRI induced sexual side effects. It is not standard of care for MDD.