SSRI-induced sexual dysfunction

learn how to start a private practice
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
W

Way2Swanky

Full Member
10+ Year Member
15+ Year Member
Joined
Aug 23, 2008
Messages
28
Reaction score
0
Hey all, was hoping to get a few opinions on what to do for a particular patient:

Pt is a 30 yo male who presented 6 months ago with symptoms of GAD. Was titrated up on Paxil to 30 mg daily with full resolution of anxiety, but was now completely anorgasmic. Wellbutrin was added at 150 mg daily. After two months the sexual issues have improved but pt is still having difficulty with orgasm and is contemplating stopping the Paxil if this isn't resolved.

What to do? Up the dosage of Wellbutrin until normal orgasmic function returns? Switch from Paxil- if so, to what? Literature says Wellbutrin itself may be effective at anxiety control, although my preceptor disagrees. What about Buspar? Wellbutrin+Buspar?

Any advice appreciated!
Members don't see this ad.
 
Assuming that you're reasonably confident that this is a sexual side effect of the medication....

The data as far as I'm aware shows Zoloft & Paxil to have some superiority in treating anxiety disorders vs the other SSRIs.

However Paxil also is one of the dirtiest SSRIs available (other one is Prozac) in terms of how much stress it puts on the liver & the incidence of side effects. It was one of the few antidepressants I've prescribed where I saw a sizeable & memorable portion of the patients actively complaining about the side effects of the medication to the point where they were very unhappy with it. Aside from my own anectdotal experience, the data backs this up as well in comparison to other antidepressants.

I'd consider crossing the person from Paxil to another SSRI or try an SNRI. Which one? That's going to have to depend on several factors that you'll have to consider based on the patient.

The Mayoclinic website suggests that a 2007 study suggests that Cymbalta had the least amount of sexual side effects of all the SSRIs & SNRIs. While that's great and I think the Mayoclinic is a trustable source, they don't reference the source of their data (K&S often times does the same thing which I find frustrating).

But there's several other factors to consider--price of the medication, the patient's medical history in general, etc.

Another factor to consider is that Sildenafil or another cGMP phodiesterase inhibitor may also relieve the person's sexual side effects without having to take them off what is successfully working.

Only other factor I can think of is some couples I've seen with this problem try an option where the person with the anorgasmia can reach orgasm through masturbation but not through intercourse. The person with the anorgasmia could masturbate to the point of almost reaching climax, then have sex with their partner--requiring less work for the partner to reach orgasm.

I'd present the following options 1-live with the side effects 2-try another SSRI or SNRI, 3 try a cGMP PDE inhibitor, 4-if there's a couple suffering & not just one person, ask if there's any techniques they can think of to better reach orgasm, or a combination, discuss it with the patient and allow the patient to make an informed decision.
 
Last edited:
Thanks for your reply. My preceptor mentioned that some patients benefit from phosphodiesterase-5 inhibitors, but concedes that he doesn't understand how this class of meds should at all be effective for orgasmic dysfunction or desire. In any case, desire in this case is not a problem. It is an isolated anorgasmia. And yes, this has never been a problem before the Paxil.

What is your opinion of Buspar? Doesn't seem to have any adverse effects and no taper. Worthwhile option?
 
Members don't see this ad :)
Buspar may not be as helpful as the anti-depressants for anxiety though it has basically the same mechanism of action. Whatever you decide, if you want to switch him off the paxil you need to taper very slowly. Look up serotonin-discontinuation syndrome, it happens more often when paxil is discontinued even with a taper, the usual suggestion is 50% reduction in dose every three days to a week while starting the new medication at starting dose.

Some people require a protracted taper of paxil. You said he was on the medication for six months? Now may be a good time to see if he needs to be on the medication. Often times after six months to one year I try to taper people off the medication (in cases with monotherapy, no repeat depressive episodes, no suicidal thoughts) and see how they do. He may not need it anymore.
 
Last edited:
You could consider drug holidays - no more than 1-2 days per week. Given the relatively short half-life of Paxil, this might actually be something that would work in terms of predicting the occurrance of sex. By the same token, you run the risk of SSRI withdrawal, which itself can be a mood-killer.
 
My preceptor mentioned that some patients benefit from phosphodiesterase-5 inhibitors, but concedes that he doesn't understand how this class of meds should at all be effective for orgasmic dysfunction or desire
Click to expand...

Seems like your preceptor is wise & humble (in a good way). Yes the mechanism of the phosphodiesterase inhibition explains how it works in erectile dysfunction, but then what is the mechanism of this class of meds helping with orgasmic dysfunction? Does it truly do that? (there are studies indicating it does--but the amount of studies is still in the area where it should be debated).

As for a Paxil holiday--now someone can teach the attending--would the sexual side effects go away with a holiday? Or would this be the type of thing where you'd have to be off the med for several days, maybe even weeks? I've never seen any documentation from a trusted source mention this effect.

As you acknowledge Strangelove, there are risks with a holiday--and Paxil (& Effexor) are the only meds I've seen out of hundreds, maybe even thousands of patients on antidepressants complain of abrupt discontinuation syndrome from just a few hours of stopping the medication even when tapered to the lowest of dosages.

Paxil CR may help. Its essentially the same medication, but extended release forms of a medication sometimes have been seen to have lesser side effects (though not by much).
 
I appreciate everyone's input! I hadn't considered a drug "holiday". Will definitely do a lit search on that.
 
My solution re: Paxil is just to not use it. I don't think I've started one person on it in 6-7 years unless they were re-entering treatment and swore up and down that it had worked just great for them.
 
Paxil is just to not use it. I don't think I've started one person on it in 6-7 years unless they were re-entering treatment and swore up and down that it had worked just great for them.
Click to expand...

Agree. Paxil has the most amount of side effects of the SSRIs, its dirty, and its the SSRI most likely to cause discontinuation syndrome.

For that reason, if I got a depressed patient, and given that ll SSRIs (heck all antidepressants) are equally efficacious on the first try--why try the one with the most amount of baggage? If price is a concern, Citalopram & Fluoxetine are also available.

It does however show some superiority in treating anxiety disorders, however Sertraline was also up there and is cleaner. My own non-evidence based opinion is Paroxetine may have had superiority due to its anti-histaminic properties.

But in any case Paxil is low on my list of using SSRIs. I've rather go through most of the other SSRIs before I consider using it. Only times I had a person on it was someone who already was on it and didn't want to change it.

Only time I'd use Paroxetine first line is if it were to treat premature ejaculation because it is so good at causing sexual side effects--or in this case its anorgasmic effect is what the patient wants.
 
Funny that you mention sertraline, since that's now the plan of action, along with continued bupropion. The saga continues. Will he, or won't he, come again? Only time will tell.

By the by, what IS the story on buspirone? I swear I see shrinks start to roll their eyes whenever the name is mentioned...

whopper said:
Agree. Paxil has the most amount of side effects of the SSRIs, its dirty, and its the SSRI most likely to cause discontinuation syndrome.

For that reason, if I got a depressed patient, and given that ll SSRIs (heck all antidepressants) are equally efficacious on the first try--why try the one with the most amount of baggage? If price is a concern, Citalopram & Fluoxetine are also available.

It does however show some superiority in treating anxiety disorders, however Sertraline was also up there and is cleaner. My own non-evidence based opinion is Paroxetine may have had superiority due to its anti-histaminic properties.

But in any case Paxil is low on my list of using SSRIs. I've rather go through most of the other SSRIs before I consider using it. Only times I had a person on it was someone who already was on it and didn't want to change it.

Only time I'd use Paroxetine first line is if it were to treat premature ejaculation because it is so good at causing sexual side effects--or in this case its anorgasmic effect is what the patient wants.
Click to expand...
 
Way2Swanky said:
Funny that you mention sertraline, since that's now the plan of action, along with continued bupropion. The saga continues. Will he, or won't he, come again? Only time will tell.

By the by, what IS the story on buspirone? I swear I see shrinks start to roll their eyes whenever the name is mentioned...
Click to expand...

Good plan.

Isn't it Buspar that is called an expensive placebo. Oh...nevenr mind....:D

Seriously, I have seen it work well for a small subset of patients but remember to dose it high.
 
I tend to use it as an augmentation agent, not a first line itself.

Only patient I've seen where the person swore by it, well she really didn't meet enough criteria for an Axis I. She was one of those stereotype explosive anger crabby types, she was put on Buspar and she calmed down quite a bit. I wasn't her doctor. She was a co-worker on the inpatient unit and told me she was put on Buspar, and I did notice a beneficial change.

But in this case, it can help because Buspar in some cases reversed sexual side effects, and since it can augment the effect of an SSRI, the dosage of SSRI needed to effectively treat the disorder might not have to be as high without it--decreasing the odds of side effects.
 
whopper said:
...It does however show some superiority in treating anxiety disorders, however Sertraline was also up there and is cleaner. My own non-evidence based opinion is Paroxetine may have had superiority due to its anti-histaminic properties. ....
Click to expand...

Just wondering if you've got a couple of cites for the superiority in anxiety d/o, because I've been preaching to my med students that there's no significant difference between SSRIs. Personally I use a lot of citalopram in my practice, but that may just be my non-evidence-based bias (as well as desire to save money).
 
Members don't see this ad :)
whopper said:
Only patient I've seen where the person swore by it, well she really didn't meet enough criteria for an Axis I. She was one of those stereotype explosive anger crabby types, she was put on Buspar and she calmed down quite a bit. I wasn't her doctor. She was a co-worker on the inpatient unit and told me she was put on Buspar, and I did notice a beneficial change.

.
Click to expand...

You could have probably achieved the same effect with Topamax or Neurontin. I've tried Topamax on a patient like you described with added "mood swings" and it helped a lot. Also helped her lose some weight which she loves.

BTW why do you think Buspar got away without a blackbox warning?
 
Ah nuts....
My source was my board exam notes, and those notes often times do cite the source. I don't have them on me at this moment--and I thought I did, so now I'm actually getting paranoid because I can't find them. Not good to be missing an entire class of disorders!

I have heard other doctors say similar about the Sertraline & Paroxetine superiority, but I never saw a printed source until I got my BeattheBoards notes.

However they may be in my office, so I'll check there tomorrow, and ask the wife if she's seen them.

My understanding up until I got those notes was that all antidepressants show equal efficacy in treating depression. However I have never seen a cross comparison in terms of treating anxiety until those notes.

Personally I use a lot of citalopram in my practice
Click to expand...
As do I, even with anxiety disorders. There still is a lot of data that all SSRIs do treat anxiety disorders, and since citalopram is cheap & clean why not? And while I do not have my notes on me this moment, I doubt the "superiority" was based on a controlled comparison study on the order of CATIE. Out of the other $4 meds, Fluoxetine though effective can sometimes worsen anxiety because of its stimulatory side effects, and Paxil has all the baggage mentioned above.

The pharmacologic logarithm I tend to employ with patients with an anxiety DO
1-SSRI (usually Citalopram or Sertraline as first line, though I do leave it up to the patient after a discussion) with good dosage of an omega 3 fatty acid supplement, with taper up along the guidelines of STAR*D. At the same time employ a CBT triple column diary.
2-wait 4-6 weeks--no response taper up more
3-if at max dose & still no effect ask the person if they want to try a different SSRI, or SNRI or try Buspirone augmentation.

Price considerations--Buspirone augmentation (and that too is a $4 med) is a very good choice based on STAR*D results and its cheap. Why not?

BTW why do you think Buspar got away without a blackbox warning?
Click to expand...
Are you referring to the suicidality warning?
 
Last edited:
I'd first use a different SSRI and see if the patient has the same side effects... if so then I would move on to an SNRI and if similar effects somehow I would move on to a Topomax or another anticonvulsant.
 
Don't know other than that antidepressants appeared to be targeted, and Buspirone is for anxiety. The entire black box warning thing appeared to have a lot of politics mired into it.

Don't know other than that antidepressants appeared to be targeted, and Buspirone is for anxiety. The entire black box warning thing appeared to have a lot of politics mired into it.

Okay--did find those notes...
Panic Disorder--Paroxetine, Fluoxetine & Sertraline are 1st line over other SSRIs because they have more data backing them up & FDA approvals. (my own experience-though this is based on evidenced based data as well, fluoxetine-is a stimulant and can provoke anxiety for that reason, Paxil has so many side effects, and for that reason I still consider other SSRIs as first line. I give the data to the patient & let the patient decide).

Social Anxiety-first line tx: an SSRI, but Sertraline & Paroxetine should get higher standing because they have FDA approval, Venlafaxine however also has an FDA approval & can be considered first line.

OCD-again, mention of FDA approved meds (Fluvoxamine, Fluoxetine, Paroxetine & Sertraline) over others because of FDA approval

PTSD: Sertraline & Paroxetine--again because of FDA approval

I should clarify, and apologize (brain remembered it differently)--as we know simply because one medication has an FDA approval does not make it superior. It does reduce liability, & does sell it to the patient better.

So now I'm a bit bugged, because I have heard doctors say Paroxetine & Sertraline are superior in anxiety disorders-and that is what may have caused the malleable interpretation in my brain (no excuse-we're scientists aren't we?).

So I'm doing some looking around and found this...
http://www.medscape.com/viewarticle/458647_17
Slide 11
In this study, Paroxetine was put head to head against Citalopram--and Citalopram did just as well.
The mean outcome measured is the Panic Associated Severity of Symptoms scale and that has 3 major subcategories: panic attacks, anticipatory anxiety, and agoraphobia. There is no significant difference in terms of responsiveness with citalopram vs paroxetine. So both were highly effective in this study with response rates as high as 80%.
Click to expand...

Interestingly--Escitalopram showed some superiority over Citalopram...
Slide 12
. Here again you see a nice effect at week 8 and 10 for both escitalopram and citalopram. Here escitalopram, which is more selective and also it has fewer side effects in terms of profile than citalopram, is showing an earlier advantage in the treatment of panic disorder at week 4.
Click to expand...
However I don't see the dosages in that slide. One would expect that Escitalopram should be at 1/2 the dose vs Citalopram to give an equivalent comparison.

Anyways, I'm going to look at this presentation a bit further since it presents a very good cross comparison of SSRIs vs other SSRIs and other treatments.

So I guess the bottom line OPD is any SSRI works in anxiety disorders, though some have FDA approval for some anxiety disorders, some don't The amount of studies showing superiority between the SSRIs in anxiety disorders are few and without large numbers.

Now the following is anectdotal, but I have heard Escitalopram did try to go for an FDA approval on Panic Disorder but it failed. Anyone here about that? I don't got any verification.
 
Last edited:
Paxil and its permutations are problematic per weight gain, discontinuation effect (making a drug holiday a dicey idea in my view), significant sexual dysfunction, and sedation, just to mention the high-points.

Like oldpsychdoc, I rarely use it, unless I inherited a patient on it and who is not showing S.E. (or tried everything else without success.

I would not use any norepinephrine compounds for anxiety, at least not immediately. I've seen enough patients get worsening of symptoms, or have increased irritability or moodiness (also a great way to "unmask" a bipolar patient :().

Buspar does occasionally work. I have started a few patients on it and always ended up stopping it. That aside, I have about 8-10 patients who swear by it, having much better anxiety control than with previous medications. And by all means, if it works, don't muck with it.

In your case, I would go with Citalopram or Lexapro, at lower than normal dose, which works fine for anxiety without depression, 10 mg Citalopram or 5 mg Lexapro. BTW, Celexa is still available through the assistance program, but I do find some improvement in going from Citalopram to Lexapro at comparable dosing, so on programs, i tend to go with Lexapro. Also then (per less S.E., can easier push the dose if OCD dosing is necessary. But also a few doing better on Citalopram than Lexapro. Every patient is different. Every psychotropic med has always in at least one of my patients always had the exact opposite effect of what "the book" says it should.

In general, though, I chose the SSRI more on avoiding S.E., than on effect. They all seem equally effective, tolerability is always the main issue.
 
whopper said:
....Anyways, I'm going to look at this presentation a bit further since it presents a very good cross comparison of SSRIs vs other SSRIs and other treatments.

So I guess the bottom line OPD is any SSRI works in anxiety disorders, though some have FDA approval for some anxiety disorders, some don't The amount of studies showing superiority between the SSRIs in anxiety disorders are few and without large numbers.

Now the following is anectdotal, but I have heard Escitalopram did try to go for an FDA approval on Panic Disorder but it failed. Anyone here about that? I don't got any verification.
Click to expand...

Make sure your slides aren't Forest propaganda...:rolleyes:

I'm skeptical of the "FDA approval" issue in this realm, simply because most of the time it just means that the manufacturer bothered to put in an application...ala "Zoloft for Everything"

I don't know about who's applied for what application lately...but it wouldn't surprise me if escitalopram made panic d/o a bit worse at first. In the Great Lexapro Push of 1993 I switched a lot of Celexa patients to Lexapro, and there was a definite subset (mostly anxious middle-aged somatic types) who got too activated. Sometimes it's nice to have that R- entantiomer around as a buffer, I guess!
 
whopper said:
...The pharmacologic logarithm I tend to employ with patients with an anxiety DO
1-SSRI (usually Citalopram or Sertraline as first line, though I do leave it up to the patient after a discussion) with good dosage of an omega 3 fatty acid supplement, with taper up along the guidelines of STAR*D. At the same time employ a CBT triple column diary.
2-wait 4-6 weeks--no response taper up more
3-if at max dose & still no effect ask the person if they want to try a different SSRI, or SNRI or try Buspirone augmentation.
...
Click to expand...

Wait a minute...:confused:
What about my BENZOOOOOOOOHS????? :scared:

:D
 
Benzos, well that too is part of the logarithm--which I only give out if the patient I feel will be a good candidate for them.

because most of the time it just means that the manufacturer bothered to put in an application
Click to expand...

Of course..which is why Prozac seems to have an approval for everything, even most of the anxiety disorders even though its activating properties can worsen anxiety, and several SSRIs don't have that quality. Prozac was the first SSRI, was the only SSRI for some time and its parent company I'm sure wanted to extend its patent.

In fact the entire FDA warnings, approvals, cautions, etc need so much overhaul. Geodon was not the worst QT prolongation offender in CATIE, hardly anyone I know makes sure patients get an opthamologist referral when taking Seroquel, Welbutrin's seizure data is highly questionable......yet they're still there and they're stuck.
 
OldPsychDoc said:
I'm skeptical of the "FDA approval" issue in this realm, simply because most of the time it just means that the manufacturer bothered to put in an application..
Click to expand...
Which is what happened to Luvox. Shotty bid dosing, nobody used it, so they bothered with the OCD data even though it by no means is spectacularly differentiated or stellar regarding OCD.

BTW, anybody ever bothered with the extended-release luvox ever? I have personally never used it.
 
Regnvejr said:
Which is what happened to Luvox. Shotty bid dosing, nobody used it, so they bothered with the OCD data even though it by no means is spectacularly differentiated or stellar regarding OCD.

BTW, anybody ever bothered with the extended-release luvox ever? I have personally never used it.
Click to expand...

I have one patient on it. I started her on it when she came to see me for the intake evaluation. She was on Celexa 20mg for anxiety and un-diagnosed OCD for the last two months without significant improvement in symptoms. She presented with obsessions and compulsions (checks her front door five times each morning, a few days a week can't leave work until 8pm since she needs to keep checking that "everything is done"). I started her on Luvox CR 100mg QHS and I asked her to stop the celexa.

There's probably some GAD in the differential and mood d/o nos. I'm going to see her again next week (30 days from initial appointment), so far so good.
 
whopper said:
Interestingly--Escitalopram showed some superiority over Citalopram...
Slide 12

However I don't see the dosages in that slide. One would expect that Escitalopram should be at 1/2 the dose vs Citalopram to give an equivalent comparison.
Click to expand...

Would it necessarily be 1/2? I've been told by some of my attendings that the R enantiomer somehow interferes with the S, such that the dose equivalent isn't always 1/2. I've heard anecdotal reports of people being switched from Lex to twice the dose of celexa, and decompensating until the dose was raised a little more. Anyone else heard anything like this? Any basis in reality?
 
Way2Swanky said:
Hey all, was hoping to get a few opinions on what to do for a particular patient:

Pt is a 30 yo male who presented 6 months ago with symptoms of GAD. Was titrated up on Paxil to 30 mg daily with full resolution of anxiety, but was now completely anorgasmic. Wellbutrin was added at 150 mg daily. After two months the sexual issues have improved but pt is still having difficulty with orgasm and is contemplating stopping the Paxil if this isn't resolved.

What to do? Up the dosage of Wellbutrin until normal orgasmic function returns? Switch from Paxil- if so, to what? Literature says Wellbutrin itself may be effective at anxiety control, although my preceptor disagrees. What about Buspar? Wellbutrin+Buspar?

Any advice appreciated!
Click to expand...

Have you considered low dose trazodone augmentation?
An open label study showed benefit, which they theorize was due to 5HT-2A antagonism (2A being responsible for sexual side effects).
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Pubmed ID 18978492
 
such that the dose equivalent isn't always 1/2.
Click to expand...

Never heard the above, though I wouldn't be surprised.

I've had my own wierd stories with the 2 meds myself, and I wonder if they were as true as the patients told me. E.g. Celexa or Lexapro would work on them but not the other (or maybe the patient didn't give one of them a long enough try--switched to the other, and the other worked?), or one was allergic to one & not the other.
 
I'm under the impression that Luvox is the best of the SSRIs in terms of suicidality curbing.
 
whopper said:
Never heard the above, though I wouldn't be surprised.

I've had my own wierd stories with the 2 meds myself, and I wonder if they were as true as the patients told me. E.g. Celexa or Lexapro would work on them but not the other (or maybe the patient didn't give one of them a long enough try--switched to the other, and the other worked?), or one was allergic to one & not the other.
Click to expand...
I've had same experience, rash on Celexa recurring with re-challenge, now fine on Lexapro. Another one not tolerating Lexapro, but OK on Celexa. Weird if we listen to the reps rather than the patients :eek: It's always the S.E.'s that get us.

Memory from long ago-last day of pharmacology, instructor letting a few reps visit, bringing mugs etc. Instructor clarified: "yes, they are nice, they bring you samples and goodies. But if you ever change and treatment based only on what those guys tell you, then you will rot in Hell forever."
 
Are there treatment algorithms available somewhere for the big d/o's? I know there are practice guidelines and algorithms for kids, but what about adults?
 
You must log in or register to reply here.
Next unread thread

Similar threads

Stagg737
Cyproheptadine for sexual side effects
Replies
15
Views
4K
jettavr6
J
B
SSRI/SNRI + Coumadin? Your Thoughts
Replies
5
Views
1K
Sushirolls
Sushirolls
I
Why are anticholinergics used more often than Amantadine, for drug-induced Parkinsonism?
Replies
10
Views
667
deleted1100659
D
mistafab
Psychiatry in sexual medicine?
Replies
16
Views
3K
splik
splik
C
How fast does SSRI/addition of anti-psychotic adjuvant work in OCD?
Replies
24
Views
2K
caxoo
C
Top