I've had the most success with Buproprion (immed release) 50mg prn and Sildenafil 20-60mg prn (generic, b/c it's cheaper since most carriers still make you jump through hoops to get it approved). Mostly sildenafil more than anything else.
I've also used Adderall 5-10mg and Ritalin 5-10mg with varying success. Problem with them, and with Buproprion to a lesser degree is we tend to have sex in the evening and these agents can obviously be disruptive to sleep.
I've never had much success with Artane or Periactin. Some studies out there showing Yohimbine was successful, but I've never suggested/prescribed it.
Alternatively, especially if it's short acting antidepressant, you can try a drug holiday or delaying taking the medication until after sex. Also a method met with varying success, and also a spontaneity killer.
The most common approach of course would likely be to try a different antidepressant. Sometimes even changes in timing of administration can make a significant difference in perceived adverse effects.
Generally, most men I've treated respond with Sildenafil. If the antidepressant therapy has been effective and nothing has helped with anorgasmia or dec. libido, often the pt will rather deal with the adverse effect and stay on the medication. I just make sure to inform them of all the options, to not get discouraged, and to regularly bring up the topic of medication discontinuation.
There's a peculiar thing about the 'serotonergicity" of these medications. I've had patients that didn't achieve a therapeutic response with low-moderate doses of Zoloft or Effexor but developed anorgasmia with higher doses of either though they achieved a therapeutic response. But I've switched some of these very same patients to low dose Paxil to be taken qHS, achieved a therapeutic response, and not induced anorgasmia.
Again, explain your reasoning and that just because something is listed as a possible adverse effect doesn't mean that they'll necessarily develop it and to not get discouraged. I typically reassure patients by telling them it's par for the course to end up trying 3-4 agents before finding the best fit.
