Alternatives to SSRI's for Anxiety?

[StayOnTop]

I started a patient on Zoloft, just at 50 mg, but the sexual side effects have kicked in after a few months, and he wants to switch. Since so many of the SSRI's have major sexual side effects, is there anything else I can use for anxiety? I thought about Wellbutrin, but I haven't had much experience using it for anxiety.

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[DisorderedDoc417]

I started a patient on Zoloft, just at 50 mg, but the sexual side effects have kicked in after a few months, and he wants to switch. Since so many of the SSRI's have major sexual side effects, is there anything else I can use for anxiety? I thought about Wellbutrin, but I haven't had much experience using it for anxiety.

Does he/she feel better on just 50mg of Zoloft with respect to their anxiety? I can’t honestly say I’ve met someone who responded significantly at that low a dose. If not, sexual side effects are likely to get worse with further titration. Could consider another SSRI/SNRI. Of course the new kids on the block are supposed to have less side effects, but often tough to get coverage. Definitely avoid Paxil. I would also consider one of the alternative adjuncts, such as viagra unless contraindicated, as Wellbutrin may well make his anxiety even worse.

Always a good idea to make sure you further characterize the sexual side effects though too. Sometimes it’s something other than the med.

 

[StayOnTop]

Does he/she feel better on just 50mg of Zoloft with respect to their anxiety? I can’t honestly say I’ve met someone who responded significantly at that low a dose. If not, sexual side effects are likely to get worse with further titration. Could consider another SSRI/SNRI. Of course the new kids on the block are supposed to have less side effects, but often tough to get coverage. Definitely avoid Paxil. I would also consider one of the alternative adjuncts, such as viagra unless contraindicated, as Wellbutrin may well make his anxiety even worse.

Always a good idea to make sure you further characterize the sexual side effects though too. Sometimes it’s something other than the med.

Difficulty getting and maintaining an erection.

 

[splik]

wellbutrin is not indicated in the treatment of anxiety. the first line treatment for anxiety disorders is psychotherapy (e.g. CBT or even psychodynamic psychotherapy). It does sound odd if the sexual effects have "kicked in after a few month"s they would typically begin immediately (unless there has been a dose change) so that would make me wonder about whether there is anything else going on. consider checking TSH, PRL, 0800 testosterone and ruling out any covert substance abuse. If the antidepressant is working (as described about 50mg is homoeopathic for most patients with anxiety disorders) i would consider offering a 5-HT2A antagonist (for example adding trazodone or mirtazapine) to reverse the sexual dysfunction. This works sometimes. You could also consider adding wellbutrin to the SSRI (i.e. as well as not instead of) to reverse the effects. Another possibility is using low dose sildenafil.

Most all SSRIs and SNRIs are going to cause issues. citalopram and escitalopram might be a little cleaner than the other SSRIs in this respect. Mirtazapine does not cause this and can be helpful for anxiety. trazodone is a good one for geriatric anxiety. vilazodone has much less sexual dysfunction and has some data for anxiety. gabapentin and pregabalin are alternatives to antidepressants. TCAs and MAOIs can also have their place in the treatment of anxiety disorders, and while both are associated with sexual dysfunction, it occurs about half as often as with SSRIs.

 

[Crayola227]

Difficulty getting and maintaining an erection.

But over baseline?

I thought SSRI sexual function issues were more libido and orgasm?

In any case, definitely have to factor in age, smoking, drinking, diabetes, atherosclerosis, exercise, basically anything that can be no bueno for lil nerves & capillaries (as a general statement, even if it's a SE).

Even if you change meds for this, I always like to use ED as a jumping off point to push lifestyle interventions. Healthier life happier penis?

 

[tr]

Agree with others that this sounds suspiciously unlike SSRI induced sexual dysfunction, which would typically onset pretty quickly after starting the drug and consist of delayed ejaculation or anorgasmia, not erectile dysfunction. Look for another culprit here.

In general though, BuSpar is antianxiety and also can help mitigate SSRI induced sexual dysfunction (it's a 5HT2A partial agonist). Wellbutrin does not treat anxiety and may increase it actually. And also agree thst switch to Lexapro could be reasonable, Zoloft is relatively bad for sexual function as SSRIs go. Vilazodone is marketed as less problematic for sexual function but so far I have not found that to be the case, I switched a few people to it for this reason and it was never any better than whatever they started with.

And I must vehemently disagree with those who say does of Zoloft under 50 mg are unlikely to be useful. I'd say the majority of the patients I see benefit from 50 mg or less. But I treat a lot of pregnant women who have reason to seek the minimum effective dose. If you start people at 50 mg you will never discover the many individuals who would have benefited from 25, or even 12.5 (though men typically do need higher doses in my experience).

 

[WisNeuro]

Well, they could always try therapy

 

[Mass Effect]

And I must vehemently disagree with those who say does of Zoloft under 50 mg are unlikely to be useful. I'd say the majority of the patients I see benefit from 50 mg or less. But I treat a lot of pregnant women who have reason to seek the minimum effective dose. If you start people at 50 mg you will never discover the many individuals who would have benefited from 25, or even 12.5 (though men typically do need higher doses in my experience).

Pregnant women typically require a higher dose, not lower. If they're seeing benefit from 12.5 or even 25, dare I mention the placebo affect? In which case, you're still exposing the baby to the medication without getting the true benefit of it.

 

[hamstergang]

Pregnant women typically require a higher dose, not lower. If they're seeing benefit from 12.5 or even 25, dare I mention the placebo affect? In which case, you're still exposing the baby to the medication without getting the true benefit of it.

The patient experiences a reduction in symptoms -- how is that not the benefit you were hoping for? And you got to use a low dose, helping to minimize exposure to the fetus. Unless you have another placebo to prescribe, I'd say this is a good outcome.

Edit: many patients on SSRIs benefit due to placebo. We can't tell in most cases whether an individual patient is responding solely due to the placebo effect or not, or whether it's other factors that occurred concurrently with the medication. So if someone gets better quickly enough on a low dose, what are we to do but continue it? It could be the medication actively helping or it could not be; some people respond differently and we can't tell all these options apart.

 

[Mass Effect]

The patient experiences a reduction in symptoms -- how is that not the benefit you were hoping for? And you got to use a low dose, helping to minimize exposure to the fetus. Unless you have another placebo to prescribe, I'd say this is a good outcome.

Edit: many patients on SSRIs benefit due to placebo. We can't tell in most cases whether an individual patient is responding solely due to the placebo effect or not, or whether it's other factors that occurred concurrently with the medication. So if someone gets better quickly enough on a low dose, what are we to do but continue it? It could be the medication actively helping or it could not be; some people respond differently and we can't tell all these options apart.

The poster was suggesting this was not placebo and that a low dose like that works for even pregnant women. Exposing the baby to the med for placebo affect wouldn't be my choice.

 

[StayOnTop]

Does he/she feel better on just 50mg of Zoloft with respect to their anxiety? I can’t honestly say I’ve met someone who responded significantly at that low a dose. If not, sexual side effects are likely to get worse with further titration. Could consider another SSRI/SNRI. Of course the new kids on the block are supposed to have less side effects, but often tough to get coverage. Definitely avoid Paxil. I would also consider one of the alternative adjuncts, such as viagra unless contraindicated, as Wellbutrin may well make his anxiety even worse.

Always a good idea to make sure you further characterize the sexual side effects though too. Sometimes it’s something other than the med.

The patient does report feeling better, but I suspect this has more to do with things getting better in life versus anything else. Also, the patient doesn't have any comorbid health issues, and is a young man in his 20's. No substance use issues either.

I should also mention that patient did initially report some delayed orgasm, but he had not been sexually active for months until this past week.

 

[hamstergang]

The poster was suggesting this was not placebo and that a low dose like that works for even pregnant women. Exposing the baby to the med for placebo affect wouldn't be my choice.

So let's say you start a pregnant woman on Zoloft and she stops the titration at 25mg, reporting that she feels well. Do you then:
a) discontinue Zoloft as this is just placebo, but then you may bring about the anxiety again as you took away a placebo that was helping.

b) increase Zoloft to get it to a "real" dose, thereby exposing the fetus to more Zoloft without any further reduction in symptoms

c) leave the dose alone, allowing the mother to have reduced anxiety with only a small dose of Zoloft. Maybe placebo, maybe not -- how could you even know?

 

[Mass Effect]

So let's say you start a pregnant woman on Zoloft and she stops the titration at 25mg, reporting that she feels well. Do you then:
a) discontinue Zoloft as this is just placebo, but then you may bring about the anxiety again as you took away a placebo that was helping.

b) increase Zoloft to get it to a "real" dose, thereby exposing the fetus to more Zoloft without any further reduction in symptoms

c) leave the dose alone, allowing the mother to have reduced anxiety with only a small dose of Zoloft. Maybe placebo, maybe not -- how could you even know?

If I already started the medication, thereby exposing the baby to it, I would likely leave it alone. But I would not say she had a response to the medication. I just don't buy that 25 mg or 12.5 mg in a pregnant woman (particularly after the first trimester) is therapeutic.

 

[whopper]

Sertraline 50 mg is a low dosage. While people can respond to it, if not or not enough you should raise the dosage before nixing it.
Other than SSRIs: Magnesium supplements, meditation, Alpha Stim, Buspirone, B-Blockers Alpha Blockers (better for ADHD-related anxiety), L-Theanine, SAM-E, SNRIs, 5HTP, Tryptophan supplements, (edited in: Gabapentin, Pregablin, forgot to mention those too!), exercise.


Wellbutrin doesn't help anxiety, in fact it could make it worse. AN EXCEPTION is if the patient's anxiety is a byproduct of ADHD. I've seen several patients with ADHD take Wellbutrin and their anxiety is far far less among other effects not commonly mentioned in training. E.g. I've seen a lot of ADHD people take Wellbutrin and get drowsy on it.

I've seen some patients do very very well on Propranolol, but these are the minority. I had a guy who was treatment resistant to SSRIs and SNRIs and first dosage of Propranolol he noticed a significant reduction of anxiety first day. The biggest pain in the butt with this med for me is checking VS. This is a med that literally could be raised every single day with appropriate coverage of BP and HR and therapeutic dosage established within just days but many patients don't know how to do it themselves. One of my patients on it is a nurse and he was able to do daily adjustments and just called me on the phone the first week to get to the right dosage but he's a nurse so he knew how to do it mostly on his own.

Pindolol is a Beta Blocker that mimics the effect of Buspirone too, that is it's a 5HT1A blocker. Problem is it's expensive. Another issue with B-blockers is that no one to my knowledge did a head-to-head study to see if one is a better med for anxiety purposes vs the others. I stick with Propranolol only because it has the most amount of data for use with anxiety but again no one actually compared it to, say for example, Atenolol vs Metoprolol vs Nadolol etc. A pharmacist I used to work with told me it does cross the BBB most of out of the B-Blockers so that's an added reason.

There's emerging data the Peyote, CBD oil and microdosing of LSD could treat treatment-resistant anxiety but that's for people in a category far worse than the patient mentioned above not to mention more data needs to be obtained. I would, however, be open to investigating these treatments in very treatment resistant patients who are severe cases.

 

[tr]

Pregnant women typically require a higher dose, not lower.

This issue typically kicks in after mid-pregnancy when volume of distribution increases and liver enzyme activity ramps up. It's usually quite evident; women will say that they feel their medication is not working as well anymore. I typically titrate to clinical effect when this occurs.

If they're seeing benefit from 12.5 or even 25, dare I mention the placebo affect? In which case, you're still exposing the baby to the medication without getting the true benefit of it.

What is your basis for this claim?

We know that liver enzyme function alone can account for enormous variations in functional serum concentration; for example, this study
Impact of polymorphisms of cytochrome-P450 isoenzymes 2C9, 2C19 and 2D6 on plasma concentrations and clinical effects of antidepressants in a naturalistic clinical setting
found variability by a factor of ten in dose-corrected plasma concentration for sertraline. Thus an ultra-slow metabolizer would need a dose of 20 mg sertraline to see the same serum level as an ultra-rapid metabolizer given a dose of 200 mg.

Whyever would you then imagine that if there are people for whom 200 is effective, there would not also be people for whom 25 is effective? This isn't even taking into account differences in 5HT transporter distribution and affinity for the drug.

 

[NickNaylor]

Just because someone experiences sexual dysfunction with sertraline (assuming that's the etiology) doesn't, in my mind, mean that all antidepressants are off the table. Yes, sexual dysfunction is an exceedingly common side effect, but any individual patient isn't guaranteed to have the same side effects across all medications. If the sexual dysfunction is that problematic, I would suggest trying a different SSRI and seeing if there's any difference.

Depending on the situation, you could consider pregabalin. There's evidence that it's effective and social anxiety disorder, and if the sexual dysfunction is that problematic, you may have a better go with pregabalin.

This is, of course, assuming that psychotherapy is off the table. That would really be the ideal treatment.

And please, for the love of god, do not give bupropion.