Antidepressants and Sexual Side Effects

Sexual side effects are among the most common reasons men stop taking antidepressants, and among the least often discussed before starting them. This article covers what the rates are, why the drugs cause them, and what the options are.

Stopping an antidepressant abruptly, or without medical advice, carries real risk, including discontinuation symptoms and relapse of the condition being treated. Everything below is intended to support a conversation with a prescriber rather than replace one.

How common they are

Montejo and the Spanish Working Group followed 1,022 outpatients prospectively, using a questionnaire designed specifically to detect psychotropic-related sexual dysfunction. Incidence with SSRIs and venlafaxine ranged from 58% to 73%, considerably higher than with agents acting through different mechanisms, including mirtazapine, moclobemide and nefazodone.

Incidence is underestimated unless a specific questionnaire is used. Men do not volunteer this, and if nobody asks, it does not appear in the notes. Other estimates put the figure lower, in the 30% to 50% range, and the spread between studies largely reflects how the question was asked.

If you are experiencing this, you are not unusual, and your prescriber probably does not know unless you say so.

What the drugs do

Serotonin is the mechanism. Increased serotonergic activity, particularly through postsynaptic 5-HT2 receptor stimulation, suppresses sexual response across desire, arousal, erection, and orgasm. Delayed or absent orgasm is often the most prominent effect, and reduced desire frequently precedes any erectile difficulty. Montejo's group noted that erectile dysfunction was significantly less frequent than orgasm problems, which suggests it arises through a different pathway.

Paroxetine is associated with higher rates than others in its class. It blocks D2 receptors, which are involved in sexual function, and inhibits nitric oxide synthesis, which is the signaling pathway an erection depends on.

Depression as a confounder

Depression itself causes sexual dysfunction. Reduced desire is a core symptom, and erectile difficulty is common in untreated depression. Some of what is attributed to medication belongs to the illness.

Timing helps separate them. Sexual difficulty that predates the medication, or that tracks with mood, points toward the depression. Difficulty that began within weeks of starting or changing a drug, particularly delayed orgasm in a man whose mood has improved, points toward the medication.

The pattern of erections during sleep helps here too. Where nocturnal erections continue while daytime erections fail, the cause is more likely to be psychological or medication-related than vascular, a distinction covered in our article on sleep apnea and nocturnal erections.

What can be done

These are the approaches a prescriber will consider. Which is appropriate depends on the diagnosis, the history, and how well the current drug is working.

Wait. Some sexual side effects settle over the first months. That is a reason for patience, not for enduring them for a year.

Dose reduction. Sometimes effective, with an obvious risk to the treatment effect.

Switching. Antidepressants differ substantially here. Agents acting through mechanisms other than serotonin reuptake, including bupropion, mirtazapine and agomelatine, are associated with markedly lower rates.

Adding bupropion. Adding bupropion alongside an SSRI has been studied as a way to reverse the side effects, with trial evidence of improvement in libido and sexual frequency compared with placebo. Evidence beyond that is largely open-label.

Treating the erectile problem directly. PDE5 inhibitors can be used alongside an antidepressant.

Symptoms persisting after stopping

Most sexual side effects resolve after the medication is stopped. A small number of people report symptoms that persist, a phenomenon recognized by the European Medicines Agency in 2019 and termed post-SSRI sexual dysfunction.

Ben-Sheetrit and colleagues attempted to quantify it in a 19-year retrospective cohort drawn from the largest health fund in Israel, restricted to men aged 21 to 49 without medical or psychiatric comorbidities or other causes of erectile dysfunction. Serotonergic antidepressants were associated with roughly a threefold increase in the likelihood of being prescribed a PDE5 inhibitor. The estimated risk of persistent dysfunction was 1 in 216 treated patients, or 0.46%.

Measuring this is difficult, the mechanism is unknown, and there is no established treatment. It is uncommon, it should not deter treatment of a serious illness, and it is a fair thing to ask about before starting.

Where a device fits

Antidepressant-related difficulty is usually a problem of desire and arousal rather than of blood retention, and a mechanical device does nothing for either. Xialla slows venous outflow to hold blood in the erectile tissue, and it requires an erection to be achievable to begin with.

Where it may be relevant is in men who have a separate, physical retention problem alongside the medication effect, which is common enough with age and vascular risk factors. Sorting out which is which is the job of the assessment, not of the device.

Do not stop or change a prescribed antidepressant without speaking to the doctor who prescribed it.

Related reading

• Sleep Apnea, Nocturnal Erections, and What They Reveal About Erectile Dysfunction
• Venous Leak and Erectile Dysfunction Explained
• Vasculogenic ED: Arterial vs Venous Causes
• 8 Treatment Types for ED

References

• Montejo AL, Llorca G, Izquierdo JA, Rico-Villademoros F. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Journal of Clinical Psychiatry. 2001;62(Suppl 3):10–21. https://pubmed.ncbi.nlm.nih.gov/11229449/
• Ben-Sheetrit J, et al. Estimating the risk of irreversible post-SSRI sexual dysfunction (PSSD) due to serotonergic antidepressants. Annals of General Psychiatry. 2023;22:15. https://doi.org/10.1186/s12991-023-00447-0

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