[dr. bob]

Dr. Bob's
Psychopharmacology Tips

SSRI sexual dysfunction

Date: Wed, 15 Mar 1995 01:10:41 EST
From: MWKR59A@prodigy.com (Dr Frederick C Goggans)
Subject: Adding buspirone for SSRI sexual dysfunction

I have had good experience withe use of buspirone to reverse SSRI effects on libido and orgasm and find this method to be more useful than other approaches touted in the literature.

Date: Wed, 12 Apr 1995 22:47:16 +0059 (EDT)
From: scole@world.std.com (Stanley Cole)
Subject: Adding bupropion for SSRI sexual dysfunction

I haven't had much luck with buspirone reversing sexual dysfunction (I am having better luck with bupropion).

Date: Sun, 16 Apr 1995 11:30:20 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRI retarded ejaculation

On Sun, 16 Apr 1995 paznes01@MCRCR6.MED.NYU.EDU wrote:

He responded very well to Prozac. Unfortunately he developed intolerable retarded ejaculation.
Bupropion would be a good choice as it seldom causes sexual dysfunction. Trazodone can seldom be given in doses high enough to be effective without being too sedating. If the bupropion does not help, you might consider restarting the Prozac and co-administering buspirone 10-20 mg tid. Buspirone has been reported to protect some men from the sexual side effects of the SSRIs.

If the buspirone fails, some other medications that may help sexual function are amantadine and cyproheptadine.

Date: Sun, 16 Apr 1995 16:34:08 -0700 (PDT)
From: "Kristin E. Zethren" <zethren@chaph.usc.edu>
Subject: SSRI retarded ejaculation

I have found a number of strategies useful with this type of problem but no one panacea. Sometimes, adding 75 mg of bupropion can make a difference. There has been some success for some of my patients with cyproheptadine 2-4 mg about an hour before sex although most of my colleagues have not been impressed. There is the danger of the anti-serotonin effect with this drug but I have never encountered it. The sedation might also be a problem (since about half the people using antihistamines become sedated). Of course, sedation would be a big problem with trazodone, especially for those of us who favor morning sex.

From: "Richard Rubin, MD" <rdoc@mindspring.com>
Date: Mon, 17 Apr 1995 00:28:32 -0500
Subject: SSRI retarded ejaculation

Although I haven't had a report from any patients yet, I've heard that nefazodone (Serzone) is similar to bupropion in absence of sexual side effects.

Date: Mon, 17 Apr 1995 07:08:56 -0400 (EDT)
From: Charles B. Nemeroff <cnemero@emory.edu>
Subject: SSRI retarded ejaculation

Either treat the sexual dysfunction secondary to SSRIs with one of the anecdotal treatments, e.g. buspirone 10-20 mg po tid, amantidine, or cyproheptidine, or switch to venlafaxine (in my experience less sexual dysfunction) or bupropion.

Date: Sat, 13 May 1995 08:49:20 -0400 (EDT)
From: Bill Boyer <wboyer@emory.edu>
Subject: Adding methylphenidate for SSRI sexual dysfunction

Dr. John Feighner (creater of the Feighner criteria, which led to the RDC and then to DSM-III and IV) states that he has successfully treated SSRI-associated sexual dysfunction in 3 individuals with methylphenidate (Ritalin), 10-30 mg/day.

This fits conceptually with reports of the efficacy of amantadine, another dopamine agonist, and with the idea that SSRI-associated apathy (including lowered libido) may be related to dopamine down-regulation.

From: Kevin Miller <MillerKB@wpogate.slu.edu>
Date: Fri, 19 May 1995 03:20:36 -0400
Subject: SSRI decreased libido in women

I've had fairly good (75%, small n) luck with cyproheptadine, 2-4 mg several hours before sex or 2-4 mg TID regularly, for sexual dysfunction/loss of interest with SSRIs. One also can try adding small doses of bupropion to the SSRI for both depression and loss of sexual interest.

Date: Sun, 4 Jun 1995 01:43:54 -0500
From: talmadge@Onramp.NET (John M. Talmadge, M.D.)
Subject: SSRI anorgasmia

Some of us have had success with telling patients to skip the dose the day of expected sexual acitivity, and that works pretty well with venlafaxine (Effexor) (not a true SSRI, but...) in my experience.

I have also noticed that just switching SSRIs can often alleviate the problem. I seem to be seeing that on the Prozac-Zoloft-Paxil axis I can just move a patient from one to another and often clear things up. I'll bet that is a buggy solution and that my "n" is not large enough to justify any conclusions, but as long as it works I guess I'll keep going with it.

I have also been disappointed that trying to switch my patients to Wellbutrin, now touted for its lack of sexual side effects, doesn't seem to help many of them.

In the really problematic cases, I urge them to give a TCA a trial, because despite some of the other side effects those are still very reliable medications. I just don't like having that lethal overdose potential and I prefer the rapid onset of action the SSRIs seem to demonstrate.

Date: Sun, 4 Jun 1995 10:47:38 -0400
From: Aminadav_Zakai@brown.edu (Aminadav Zakai)
Subject: SSRI anorgasmia

My 2 cents' worth:

Date: Sun, 4 Jun 1995 11:59:23 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRI anorgasmia

There are a few more psychopharmacologic interventions that are often useful:

Date: Sun, 4 Jun 1995 13:00:55 -0700 (PDT)
From: Thomas Lewis <tblewis@itsa.ucsf.EDU>
Subject: Adding yohimbine for SSRI anorgasmia

I've also had good luck adding yohimbine, 5.4 mg bid to tid.

Date: Sun, 4 Jun 1995 13:42:34 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Adding yohimbine for SSRI anorgasmia

Yohimbine is often effective but may precipitate manic episodes in pholks with bipolar disorder.

From: Fluox@aol.com (Ron Winchel, MD)
Date: Mon, 5 Jun 1995 04:43:29 -0400
Subject: Adding buspirone for SSRI anorgasmia

Try adding buspirone (Buspar). Michael Norden recently reported benefits. I have been doing the same for about a year with substantial benefits about 1/2 the time.

I use 5 mg bid upped qweek by 5 bid to 20-30 bid total. Usually it takes a couple of weeks to get effects. If the patient is on high dose SSRIs, be careful. One of my patients had a mild serotonin syndrome-like event on Buspar 60/d and Paxil 60/day.

It is also helpful to be more specific about the sexual side effects. Decreased libido and ejaculatory latency are different phenomena and the latter may respond better to Buspar addition. In addition, many (maybe most) men on SSRIs report decreased masturbation frequency. But this does not necessarily indicate sexual dysfunction -- since on closer questioning, many of these same men report intact erotic responsiveness to external sexual stimuli.

From: ORRP@aol.com
Date: Thu, 8 Jun 1995 01:37:25 -0400
Subject: SSRI anorgasmia

One thing to consider is whether you can lower the dose of the SSRI. That was helpful for three of my female patients. Another female patient did well with cyproheptadine (Periactin) though it cut down on spontaneity.

From: M112961F@aol.com (Michael Friedman, M.D.)
Date: Sat, 17 Jun 1995 09:40:45 -0400
Subject: SSRI sexual dysfunction

My experience with SSRIs is that they [can] cause decreased libido as well as anorgasmia. Personally, I believe that the problems are rather difficult to treat. I have had little success with adding Periactin, Buspar or Wellbutrin. I have found that more often than not I am forced to lower the SSRI or stop it completely when the patient complains about these side effects.

Date: 18 Jun 95 11:33:33 EDT
From: "Furey A. Lerro" <71544.3434@compuserve.com>
Subject: SSRI decreased libido

I have found that loss of sex drive in depressed patients often occurs separately from the symptom of diminished libido that is part of depression. The majority of my patients do not prefer to stop the medication for fear of return of symptoms. I've had some success in lowering the dosage of the SSRI, but have found various remedies for the problem, e.g., yohimbine and amantadine, not to be helpful. Switching to trazodone, bupropion, and most recently nefazodone has been quite successful.

Date: Thu, 13 Jul 1995 22:09:04 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRI decreased libido in women

On Thu, 13 Jul 1995 Hottod@aol.com wrote:

Can anyone shed light on management of diminished libido in female patients on SSRIs? Are there any differential strategies across gender? Lowering dosage and trying cyproheptadine are two that come to mind. What about buspirone and bupropion in females vs. males?
While cyproheptadine is often useful in reversing the anorgasmia in both men and women taking SSRIs, it does not usually have any effect on desire.

Buspirone, bupropion, and amantadine seem to do the best at restoring desire in both sexes.

Date: Thu, 13 Jul 1995 22:33:08 -0500
From: gsdavids@niagara.com (George Davidson)
Subject: SSRIs and decreased libido in women

In extensive practical but not academic experience, lowering the dose is effective only when you get close to zero, cyproheptadine may work for anoragasmia (I haven't had any success with it) but not for libido, buspirone doesn't seem to work for anyone I've tried it on (small n, scared off by ineffectiveness or side effects), and you can't use bupropion in Canada.

If I have a good response to SSRI, but sexual problems become a nuisance, I have so far had 100% success switching to nefazadone or moclobemide.

Date: 15 Jul 95 09:04:01 EDT
From: "Furey A. Lerro" <71544.3434@compuserve.com>
Subject: SSRIs and decreased libido in women

I can echo Dr. George Davidson's comments regarding buspirone being unhelpful along with the SSRI. Bupropion has been the best alternative medication. I've also been able to switch a couple of women to trazodone with very good success. Additionally, returning to the tricyclics is often worth considering. Dr. Susan McElroy's article on treating antidepressant side effects in suppl. 2 of vol. 56 of the Journal of Clinical Psychiatry this year is excellent and gives many good references in this area.

From: PMBrig@aol.com (Peter M. Brigham, MD)
Date: Fri, 21 Jul 1995 09:22:23 -0400
Subject: Increased sexual function on buspirone

On Jul 20, 1995, JGMD@mindlink.bc.ca (Jane Garland) wrote:

no one has mentioned the paradoxical occurrence of increased libido and increased frequency and intensity of orgasms which one of my patients had on fluoxetine at 20 mg. She was being treated for OCD, [which] responded well. She also enjoyed the sexual side effects.
I haven't seen this with SSRIs, but I have a patient on fluoxetine 20 mg for an atypical anxiety disorder who complained bitterly of anorgasmia, so I added buspirone 10 mg tid and she got her sexual responsiveness back. She also had some bruxism, which didn't improve on the buspirone, so she discontinued the fluoxetine on her own, but kept the buspirone on board, since it had benefitted her anxiety level. She told me last week she wanted to continue the buspirone, since in addition to lowering [her] anxiety it actually heightened her sexual response -- "it makes everything more intense." She said her libido was unchanged, but when she did have intercourse it was more pleasurable.

Date: Sat, 11 Nov 1995 17:10:30 -0500
From: wbrown@mail.aqua.net (Walter A. Brown MD)
Subject: SSRIs and decreased libido

I have heard that for folks with sexual dysfunction on paroxetine or sertraline (not fluoxetine) that using the med four days a week but not on Friday-Saturday-Sunday will preserve remission of depression and at the same time allow unimpaired libido on weekends.

--Jaime Smith

According to an article in the Oct 1995 Am J Psychiatry (A Rothschild, 1514) it works in half the patients who try it without exacerbation of depression.

Date: Tue, 14 Nov 1995 22:41:52 -0800 (PST)
From: "J. Wynn" <jdwynn@u.washington.edu>
Subject: Bupropion for SSRI sexual dysfunction

Interestingly it seems that bupropion was touted early on as a curative for low libido in and of itself, i.e., before marketing it as an antidepressant took off it was discussed by sexologists as a potentially useful item. I have tried it twice with no luck.

From: "Richard Rubin, MD" <rdoc@mindspring.com>
Date: Tue, 12 Dec 1995 17:20:14 -6
Subject: Bupropion for paroxetine sexual dysfunction

I've tried bupropion 75 mg at 6:00 p.m. in 4 patients who were complaining of problems with decreased libido as a side effect of paroxetine. Three of them reported no more side effects when using the bupropion. They were the women. The one man continued to complain that he was unable to achieve orgasm.

Date: Thu, 16 Nov 1995 08:00:47 -0800 (PST)
From: Thomas Lewis <tblewis@itsa.ucsf.EDU>
Subject: SSRI anorgasmia

For what it's worth, I have a female patient, 40-ish, on 40 mg of paroxetine for major depression, who fortuitously discovered that her dense anorgasmia is relieved for a period of several hours after aerobic exercise (e.g., running).

Date: Sun, 19 Nov 95 17:49:21 PST
From: "Jim Ellison" <jellison@interserv.com>
Subject: Bupropion for SSRI sexual dysfunction

Clinicians are adding bupropion to SSRIs [to diminish the loss of libido they sometimes cause], but I'd be more inclined simply to switch to bupropion if possible (not always possible!). Walker et al (J Clin Psychiatry 54: 459-465, 1993) found such a switch helpful for patients with fluoxetine-induced loss of libido, and Gardner and Johnston (J Clin Psychopharmacol 5: 24-29, 1985) used such a substitution to restore libido and erectile function to the majority of a group of patients on a TCA, tranylcypromine, or trazodone. Adding the bupropion makes sense in some ways, but one might be concerned about additive side effects or a synergistically lowered seizure threshold.

Date: Sun, 19 Nov 1995 18:02:15 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Bupropion for SSRI sexual dysfunction

While I have occasionally had great success adding bupropion to an SSRI when the sexual side effects were unacceptable, more often than not, the depression improves a bit but the sexual problems remain unchanged.

Date: Mon, 20 Nov 1995 20:02:04 -0800 (PST)
From: Peter Forster <forster@itsa.ucsf.EDU>
Subject: Bupropion for SSRI sexual dysfunction

I have tried adding bupropion to SSRIs with both men and women with good results in about 80%. Usually I think about switching to bupropion, but often I don't because of the very positive response to the SSRI. In those where adding a second agent doesn't help, I sometimes can get a response by decreasing the SSRI (which I always try without the bupropion augmentation, first), and find that a lower SSRI dose may be effective with combined therapy. I have also heard of similar stories from 4 of my colleagues.

Date: Mon, 11 Dec 1995 22:43:14 +0001 (EST)
From: scole@world.std.com (Stanley Cole)
Subject: Bupropion for SSRI sexual dysfunction

I've used bupropion 75 mg BID (occasionally 75 mg qd will do it, especially if it is taken in the afternoon) with both fluoxetine and sertraline. About 80% of people had about an 80% improvement in libido and delayed orgasm with it. I have tried all the other remedies for this will rare success (amantadine can help).

Date: Mon, 11 Dec 1995 19:00:41 -0800 (PST)
From: "J. Wynn" <jdwynn@u.washington.edu>
Subject: Bupropion vs. bromocriptine for SSRI impotence

I've added bupropion, in doses up to 325 mg/d, to Paxil, Zoloft and Prozac, with little benefit. I recently added bromocriptine to venlafaxine for the same problem with prominent apathy, with very nice results. I've also been disappointed with cyproheptadine, buspirone and yohimbine, though not in a large patient sample.

Bromocriptine is very expensive.

Date: Tue, 13 Feb 1996 22:55:46 -0800
From: jgmd@mindlink.bc.ca (Jane Garland)
Subject: SSRI sexual dysfunction

At recently attended conferences on SSRIs and sexual dysfunction, the audience was asked to raise their hands depending on the frequency with which they had seen this problem in private practice. The % ran between 30 and 50 -- much higher than originally reported. This fits with my experience also. I think that the under-reporting previously was based on the fact that severely depressed patients aren't that concerned initially about sexual dysfunction. It is only later as they begin to get out of the pit that it becomes an issue. I think psychiatrists probably also attributed the sexual dysfunction to the depressed state. The earlier studies were of shorter duration than what we see when treating patients for years.

--L.James Grold M.D.

I agree, at least 30%, more likely 50%, will have at least some complaint of delayed or absent orgasm. But many patients will put up with this, despite mentioning it as a problem, because it is better than being depressed. Adolescents and spouses get impatient, however. Of interest is that some of those patients with "reverse" symptoms on fluoxetine (weight gain, lethargy, somnolence) have "complained" of increased libido as a problem, suggesting something about that norfluoxetine metabolite implicated in reverse symptoms.

My patients have had the same sexual symptoms on nefazodone as on SSRIs, which was disappointing after initial marketing hype on this.

Date: Fri, 3 May 1996 01:17:10 -0300
From: Ivan Luiz de Vasconcellos Figueira <ilvf@Montreal.com.br>
Subject: Increased sexual function on fluoxetine

I have a woman in her late 20s on fluoxetine 20 mg/day for 2 weeks for depression (of a mild to moderate severity). She felt it as odd that her sexual arousal was improved more than she would have thought from her small improvement in mood.

--Jonathan Pulman

I think it's more than just improvement in depression -- increase in libido with fluoxetine is seen as well in some patients with eating disorder (not that they don't get depressed, too). J Clin Psychopharm reported a couple of patients on fenfluramine for bulimia with libido increased to the point of obsessive pursuit of sexual experience, which was very unpleasant for them -- not just improvement of mood. I've seen (and read about) sexual obsessions with Prozac treatment, too -- though I believe that to be very rare, much more so than the opposite effect.

--Jim Ellison

Some authors (1, 2) reported beneficial sexual effects associated with fluoxetine. Garcia-Campayo et al (3) described a case of orgasm as a side-effect of fluoxetine. However, I've never seen such a case. Patients with social phobia or panic disorder on fluoxetine who have had a normal sexual life before the drug frequently complain about sexual problems induced by fluoxetine. In my experience sexual side-effects are the principals obstacles in the long term treatment of anxiety disorder patients using SSRIs.

1. Power-Smith P. Beneficial sexual side-effects from fluoxetine. Br J Psychiatry, Feb 1994, 164 (2): 249-50. Comment: Br J Psychiatry, Jun 1994, 164 (6): 854.

2. Smith DM, Levitte SS. Association of fluoxetine and return of sexual potency in three elderly men. J Clin Psychiatry (United States), Aug 1993, 54 (8): 317-9.

3. Garcia-Campayo J, Sanz-Carrillo C, Lobo A. Orgasmic sexual experiences as a side effect of fluoxetine: a case report. Acta Psychiatr Scand, Jan 1995, 91 (1): 69-70.

Date: Mon, 20 May 1996 16:19:50 -0400 (EDT)
From: Randi Rubovits-Seitz <rrs2623@gwis2.circ.gwu.edu>
Subject: Switching to nefazodone

A couple of people I switched to nefazodone, one each from Prozac and Paxil, to which they'd had otherwise excellent responses, reported some improvement in sexual function on nefazodone but were so much less happy with it as an antidepressant that they requested reinstitution of the SSRI.

Date: Mon, 20 May 1996 14:30:11 -0700
From: jgmd@mindlink.bc.ca (Jane Garland)
Subject: SSRI anorgasmia

Lots of my patients read the articles about nefazodone in our local press about a year ago because of local release and research. I switched over quite a number of patients over. To date, no or marginal improvement in anorgasmia and relapse of depression have been the result. I have been much more impressed with bupropion for reversal of anorgasmia. I have had a few patients with an antidepressant response (somewhat, not too impressive) to nefazodone (mostly anxious ones who did well on trazodone but got too sedated in the past), but not those I switched for anorgasmia. I am not opposed to trying a few more, however, in case one of them reverses, as this side effect is disabling, but nefazodone has been quite disappointing overall. Perhaps a clearer profile of potential responders will emerge.

From: bojrab@iquest.net (Christopher D. Bojrab, M.D.)
Date: Thu, 27 Jun 1996 22:38:33 -0400
Subject: SSRI anorgasmia

Before trying any of these approaches, I believe that one should make sure that the depression has resolved to the point where the patient could realistically expect the return of his or her normal libido.

P.S. My personal "small n" favorite is bupropion 75-100 mg QPM, which I have had the most reliable luck with, especially in women.

From: LJGROLD@aol.com (L.James Grold M.D.)
Date: Thu, 11 Jul 1996 11:30:15 -0400
Subject: SSRI sexual dysfunction

My experience with yohimbine is that it rarely has worked, however, a patient of mine found yohimbine chewing gum at a health food store. He chewed 10-15 pieces and had according to him an incredible sexual time with his girlfriend.

Date: Thu, 11 Jul 1996 10:46:37 -0700 (PDT)
From: Denis Franklin <denis@itsa.ucsf.edu>
Subject: SSRI sexual dysfunction

Success [of yohimbine] in SSRI induced hypo-orgasmia has been reported to me by a couple of patients.

I recommended use of 0.5 to 1 tab (5.4 mg each) an hour or so ahead of the event. Yohimbine does also produce insomnia, so one has to arrange the timing and titrate the dose to accommodate the circumstances. The insomnia can actually be an additional benefit to the romantic, bonding aspects of the relationship, and the man's status in the eyes of the woman, because he can't roll over and go to sleep immediately after orgasm.

From: CWangTSA@aol.com
Date: Fri, 8 Nov 1996 23:27:36 -0500
Subject: Ginkgo biloba for SSRI sexual dysfunction

I read about a pilot study by psychiatrist Alan Jay Cohen at the University of California at San Francisco. It suggests that ginkgo biloba, an ancient Chinese herbal medicine, may be an antidote to diminished libido or delayed orgasm. Cohen presecribed a patent-protected formulation of ginkgo-tree leaf extracts, two 60 mg capsules qid, to 37 men and women, all of whom experienced diminished libido and delayed orgasm as a result of Prozac, Zoloft, and Paxil. (The subjects had tried switching to other antidepressants, taking sexually activating prescription drugs before bedtime, or avoiding medication on weekends, all to no avail.) After taking the ginkgo biloba 86 percent reported substantial improvement in their sexual function, with virtually no side effects. Cohen says that ginkgo biloba seems to restore blood flow to the genitalia, which is often blocked by serotonin-enhancing drugs.

Date: Fri, 8 Nov 1996 20:55:18 -0800 (PST)
From: Camilla Cracchiolo <camilla@PrimeNet.Com>
Subject: Ginkgo biloba for SSRI sexual dysfunction

Very interesting, especially in light of ginkgo's vasodilating effects.

Two fast comments:

  1. Since Traditional Chinese Medicine uses the seed and not the leaf, the traditional indications for gingko don't neccessarily apply to this work.

  2. I don't see any mention of a placebo control group.

Date: Sat, 9 Nov 1996 04:42:43 -0800
From: "Jim Ellison" <jellison@interserv.com>
Subject: Ginkgo biloba for SSRI sexual dysfunction

I spoke with Dr. Cohen in the course of preparing a talk on this topic and after reading his New Research Abstract (NR 715) in the 1996 APA syllabus. He is a UCSF psychiatrist and has had excellent results with ginkgo -- but his studies are not controlled and must be seen in that light. The mechanism claimed for ginkgo is enhanced vascular flow, but that too should be considered tentative.

Date: Sat, 30 Nov 1996 14:10:34 -0800 (PST)
From: Camilla Cracchiolo <camilla@PrimeNet.Com>
Subject: Ginkgo for SSRI sexual dysfunction

I mentioned using ginkgo to treat SSRI related sexual dysfunction to my personal physician, who responded that she had been prescribing ginkgo to treat male erectile difficulties for the past 3 years and found that it works fairly well. She originally enountered the idea in the Journal of Urology. Unfortunately, she didn't have the reference at hand.

From: rdb@icu.com (Richard David Brand, MD)
Subject: Bupropion for SSRI sexual dysfunction
Date: Sun, 13 Apr 1997 00:17:40 -0400

Bupropion 75 mg QAM has worked for about half the SSRI related sexual dysfunction patients I've treated (n about 12-20).

Date: Wed, 14 May 1997 00:02:00 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Relative SSRI sexual dysfunction

How does fluvoxamine compare to the other SSRIs with respect to sexual dysfunction?
I have not seen any meaningful differences between the SSRIs with regard to sexual dysfunction. But we use very little fluvoxamine.

--Larry Ereshefsky

Many psychopharmacologists who prescribe a lot of SSRIs have noted that the incidence of sexual side effects with fluvoxamine is higher than that of the other SSRIs. I am unaware of any good data on the topic.

From: jefferson_jeff_w@ssmhcs.com
Date: Wed, 14 May 97 15:15:33 CST
Subject: Relative SSRI sexual dysfunction

The lore that fluvoxamine has a lower incidence comes from Nemeroff et al. Depression 3: 163-169, l995. In a double-blind comparison, "Significantly more patients reported sexual dysfunction in the sertraline (28%) than in the fluvoxamine (10%) group." It was not clear if sexual function was evaluated by specific questioning. The party line from Solvay to me in a letter dated 2/7/97 was, "Reaching definitive comparative conclusions regarding SSRIs and incident rates of side effects is difficult... Overall, SSRIs cause significantly less sexual dysfunction than tricyclic antidepressants."

Date: Thu, 29 May 1997 09:17:11 -0400
From: Jim Ellison MD <jellison@interserv.com>
Subject: Nefazodone for SSRI sexual dysfunction

A recent letter to the editor cited use of nefazodone with sertraline. The purpose was to block 5HT2 postsynaptic receptors and reduce sexual dysfunction:

Reynolds RD. Sertraline-induced anorgasmia treated with intermittent nefazodone [letter]. Journal of Clinical Psychiatry. 58 (2): 89, 1997 Feb.

Date: Thu, 10 Jul 1997 10:10:38 -0700 (PDT)
From: "J. Wynn" <jdwynn@u.washington.edu>
Subject: SSRI sexual dysfunction

Reference for SSRI-induced sexual side effects being even more common than most of us realize:

Modell JG, Katholi CR, Modell JD, DePalma RL. Comparative sexual side effects of bupropion, fluoxetine, paroxetine, and sertraline. Clinical Pharmacology & Therapeutics. 61 (4): 476-87, 1997 Apr.

Of patients given an SSRI, 73% reported at least one type of sexual dysfunction and 27% reported no problems.

Date: Wed, 23 Jul 1997 22:17:35 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Ginkgo for SSRI sexual dysfunction

Ginkgo has been mentioned on this list a number of times as a possible treatment for patients with antidepressant-induced sexual dysfunction.

The July issue of Clinical Psychiatry News (p. 5) contains a report on a presentation by Alan J. Cohen, MD, at the recent San Diego annual meeting of the APA. Dr. Cohen reported that 60-120 mg twice a day of ginkgo led to relief of antidepressant-induced sexual side effects in 30 of 33 women and 23 of 30 men. Side effects of ginkgo were reported to have been minimal.

Erectile failure, anorgasmia, and decreased libido were the symptoms reported to have responded. Ginkgo was tried for 6 weeks before being considered to have failed. (6 weeks is possibly long enough for some patients to have developed tolerance to the sexual side effects of their antidepressants.)

Dr. Cohen utilized ginkgo in an uncontrolled manner. A placebo-controlled, double-blind study is now being organized.

From: Cmindell@aol.com
Date: Thu, 24 Jul 1997 17:40:47 -0400 (EDT)
Subject: Ginkgo for SSRI sexual dysfunction

I've tried ginkgo with one man, in his late 50s, after some months on sertraline with decreased sexual interest, some difficulty in getting an erection, and prolonged ejaculation. He was taking one aspirin a day, and after I checked with an internist who knew about ginkgo, who didn't think the potential interference with platelet aggregation would be much of an issue, he started at 60 mg qd. At 60 mg bid the above side effects diminished significantly. (Bupropion hadnn't helped, nor had stopping the medication for up to 2 days prior to sex.) He stayed on the ginkgo for about 8 weeks, until we tapered him off the sertraline. He had no side effects from the ginkgo.

From: TomRusk@aol.com
Date: Fri, 25 Jul 1997 08:41:43 -0400 (EDT)
Subject: SSRI sexual dysfunction

I haven't seen people develop tolerance to the sexual side-effects of SSRIs and venlafaxine.

Date: Fri, 25 Jul 1997 16:22:46 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: SSRI sexual dysfunction

I have seen a few people in whom tolerance to the sexual side-effects of SSRIs seemed to develop... or maybe their compliance decreased and they failed to report that.

Date: Fri, 25 Jul 1997 23:37:04 -0400
From: William Braden <braden@brown.edu>
Subject: SSRI sexual dysfunction

Yes, some patients do lose the sexual side-effects (after 2 to 6 months).

Date: Sat, 26 Jul 1997 06:57:45
From: "Richard David Brand, MD" <rdb@icu.com>
Subject: SSRI sexual dysfunction

Several patients of mine have regained sexual normal sexual activity after 3-6 months on venlafaxine.

Subject: Ginkgo for SSRI sexual dysfunction
Date: Mon, 1 Dec 97 19:50:51 -0000
From: Geoff Hyde <geoffhyde@empnet.com>

Ginkgo Biloba for Drug-induced Sexual Dysfunction

Alan J. Cohen, M.D., Department of Psychiatry, University of CA at SF; Barbara D. Bartlik, M.D.

In an open trial, ginkgo biloba, an herb derived from the bark of the Chinese ginkgo tree, noted for its cerebral enhancing effects, was found to be 84% effective in treating antidepressant-induced sexual dysfunction due predominantly to selective serotonin reuptake inhibitors (SSRIs) (N = 63). Women (N = 33) were more responsive to the sexually enhancing effects of ginkgo biloba than men (N = 30), with relative success rates of 91% versus 76%. Ginkgo biloba generally had a positive effect upon all four phases of the sexual response cycle: desire, excitement (erection and lubrication), orgasm, and resolution (afterglow). This study originated from the observation that geriatric patients on ginkgo biloba for memory enhancement noted improved erections. Patients exhibited sexual dysfunction secondary to a variety of antidepressant medications including SSRIs, SNRIs, MAOIs, and tricyclics. Dosages of ginkgo biloba extract ranged from 60 mg qd to l80 mg bid (average 200 mg/d). The common side effects were gastrointestinal disturbances, headache, and general CNS activation.

  1. Cohen A. Treatment of antidepressant-induced sexual dysfunction: a new scientific study shows benefits of gingko biloba. Healthwatch. 5 (1), 1996 Jan.
  2. Kleijnen J, Knipschild P. Ginkgo biloba. Lancet. 340 (8828): 1136-9, 1992 Nov 7. Comment: 1992 Dec 12; 340 (8833): 1474.

From: docohen@webtv.net (alan cohen)
Date: Tue, 2 Dec 1997 23:09:01 -0800
Subject: Ginkgo for SSRI sexual dysfunction

Please see my Brief Report on Long Term Safety and Efficacy of Ginkgo Biloba Extract in the Treatment of Antidepressant-Induced Sexual Dysfunction.

Date: Tue, 20 Jan 1998 23:28:41 -0500 (EST)
From: Charles S Berlin <cberlin+@pitt.edu>
Subject: Granisetron for SSRI sexual dysfunction

Although only a single open use case report, there was a fascinating letter in the November Journal of Clinical Psychiatry. Drs. Nelson, Keck, and McElroy note the theoretically inviting view that granisetron, a 5HT3 antagonist (and sexual stimulant in rats), might counteract SSRI induced sexual side effects (which they believe stem from SSRI activity at 5HT2 and 5HT3 receptors).

They thus had one of their patients take this medication 1 hour before sex: "On three out of three trials Ms. A noticed a complete recovery of sexual interest and ability to achieve orgasm."

This is tantalizing enough to warrant further exploration. Unfortunately, there is at least one drawback: this medication (available as Kytril, labelled for chemotherapy-related nausea control) costs an eye-popping $50/pill! (My consulting pharmacist quipped, "It would have to be a heck of an encounter to justify that!" when she looked up the price.) I'm sure insurance companies would balk at this very quickly...

Nelson EB, Keck PE Jr, McElroy SL. Resolution of fluoxetine-induced sexual dysfunction with the 5-HT3 antagonist granisetron. Journal of Clinical Psychiatry. 58 (11): 496-7, 1997 Nov.

Date: Wed, 28 Jan 1998 23:15:21 -0600
From: michelle & evan peterson <dovetail@mc.net>
Subject: Yohimbine for SSRI sexual dysfunction

Charles S Berlin wrote:

While yohimbine is often mentioned as potentially helpful for SSRI sexual side effects, my own clinical experience with this, and reading the anecdotal reports of others, is that the results in actual use overall seem to be somewhat disappointing.
Yohimbine evidently increases peripheral blood flow, and its reputation for improving male sexual performance came from observations of vasocongestion of genitals in animals that ate it.

From: tgarton@ix.netcom.com (Theresa Garton,MD)
Date: Sat, 28 Feb 1998 11:04:17 -0800
Subject: SSRI sexual dysfunction

I add bupropion, at a low dose of 75 mg daily, for symptoms of decreased interest in sex or delayed orgasm in patients who are also using SSRIs. I have good luck with this specific use. I will admit though, that this is not infrequently the first step in switching from an SSRI to single drug therapy with buproprion.

For inability to acheive erection, I would also consider other etiologies. A thorough history, exam, etc., would probably be in order for that symptom unless the patient was clearly attributing his lack of erections to a nonexistant interest in sexual activity.

From: M. Kirsten Miller, M.D., M.P.H. <KMillerx@aol.com>
Date: Sun, 5 Apr 1998 23:20:01 EDT
Subject: Mirtazapine for SSRI sexual dysfunction

I've used Remeron (mirtazapine) fairly often for SSRI induced sexual dysfunction -- with or without Wellbutrin.

Date: Mon, 20 Apr 1998 21:18:12 -0400
From: "Marianna C. Glenday" <MC_Glenday@compuserve.com>
Subject: Urologic workup before initiating treatment

With impotence presumed to because by SSRIs there are a number of reasons to do a urologic workup before initiating treatment.

There may be another primary or co-morbid cause of the impotence that would have been subclinical until the addition of the SSRI, and some of these causes can be major health problems such as undiagnosed diabetes, vascular disease and even alcoholism. The depression may also be the result of such a comorbid illness and all three of the problmes found to be from a common pathology.

From: Ron Podell <ConEmo@aol.com>
Date: Mon, 4 May 1998 04:04:37 EDT
Subject: SSRI sexual dysfunction

Granisetron is anecdotally reported to help orgastic dysfunction -- inhibited or delayed ejaculation in men and orgastic dysfunction in women.

Erectile dysfunction in SSRI users is an interesting problem. Does the man have any history of erectile dysfunction prior to the SSRI? If so, then a work up with nocturnal penile tumescence testing (for example, with the Rigiscan) is something that could be done to see if there are any organic factors present. If there are, Viagra is a very legitimate choice. If not, the erectile dysfunction is probably secondary to decreased desire or orgastic dysfunction. If the patient has orgastic dysfunction then ginkgo biloba and granisetron may be a good combination.

Viagra does enhance response to sexual stimulation in normals, but who cares unless you are getting older and want 95% rigidity instead of 80%? Rigidity matters, but only if it's less than 60-65% or you are dating much younger women and worry about it.

From: "Fier, Eric" <FierEL@MSX.UPMC.EDU>
Subject: SSRI sexual dysfunction
Date: Mon, 18 May 1998 15:48:08 -0400

How much buproprion for a man on Prozac to assist with sexual impairment?
75-150 mg of the regular or the SR preparation, usually dosed daily; in some cases, used PRN 1 hour before sex:

Ashton AK, Rosen RC. Bupropion as an antidote for serotonin reuptake inhibitor-induced sexual dysfunction. Journal of Clinical Psychiatry. 59 (3): 112-5, 1998 Mar.

You may also consider adding nefazadone 50-100 qHS or mirtazapine 7.5-15 qHS.

Has Viagra been tried for this?
Initial studies of sildenafil citrate looked at > 3000 patients with erectile dysfunction secondary to assorted etiologies; success rate of 70-80% reportedly included patients with antidepressant-induced impotence. No specifics yet on this cohort. Dose 50 mg initially; may try 75 or 100 mg if no improvement.

Date: Tue, 19 May 1998 23:51:01 -0400
From: "Howard Rudominer, M.D." <hrudmd@home.com>
Subject: SSRI sexual dysfunction

I have had to use as much as 300 mg of buproprion SR to see results on occasion. I would stay away from the regular preparation because of the increased risk of seizures. I see no reason to use it over the SR form unless the patient had an idiosyncratic reaction to it.

The problem with mirtazapine is that it may work to reverse the sexual dysfunction, but not without the cost of marked weight gain.

Nefazadone does not have as favorable a side effect profile as buproprion SR.

I have had some success with ginkgo biloba 120 mg bid.

Date: Thu, 21 May 1998 22:37:09 -0400
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Sildenafil for SSRI sexual dysfunction

One of my female patients with Prozac-induced anorgasmia tried 100 mg of her husband's Viagra and reported that it made it much easier for her to reach orgasm.

Date: Thu, 21 May 1998 20:15:31 -0700 (PDT)
From: Ronald Shlensky <3004rs@west.net>
Subject: Sildenafil for SSRI sexual dysfunction

What has made Viagra so attractive is not that it is the only remedy for erectile dysfunction, as potency problems are called medically. There are half a dozen other effective treatments. But unlike the others, Viagra is a pill, making it a far simpler and more discreet remedy than its rivals, which include drugs injected or inserted into the penis and devices implanted and inflated.

But in the wave of enthusiasm surrounding this drug over the last two months, many physicians and their patients have ignored its limitations and side effects -- those already known and those that may become apparent after millions of men have used it.

"Whenever a new drug is introduced, pharmaceutical companies always tout it as extraordinarily effective and without side effects," said Dr. Robert Kolodny, medical director of the Behavioral Medicine Institute in New Canaan, Conn., and a former associate of the pioneering sex researchers, Dr. William Masters and Virginia Johnson.

"In every case, a year or two later when the drug becomes widely used, new side effects emerge that were not previously seen," Dr. Kolodny said. "This is uncharted territory. There may be interactions between Viagra and other drugs men are taking. Men may use it at higher doses than it was designed to be used. And it will undoubtedly be used by a wide range of people, not all of whom are suitable or adequately screened medically beforehand."

Dr. Kolodny noted that some women are already taking Viagra, even though no data have shown its effectiveness or hazards for women. Likewise with adolescents, who may take it because of a medical problem that causes impotence or simply as a recreational drug in hopes of enhancing their virility.

Because most men with potency problems are in the later decades of life, some Viagra users no doubt will be in very poor health, suffering from diabetes, heart disease, arthritis and other ailments. Will their hearts stand the physical demands of sexual intercourse? How will Viagra interact with other medicines they may be taking?

Men who are rendered impotent by drugs for high blood pressure or depression are likely to constitute a large share of Viagra users, but until large numbers use the potency enhancer, its possible adverse interactions with their medicines will not be fully known.

What is known so far about Viagra, also known as sildenafil, is that it cannot safely be taken by anyone using nitrate medications and, according to a report last week in The New England Journal of Medicine, about a third of men experience one or more minor side effects, including headaches, flushing, indigestion, stuffy nose and temporary changes in visual perception of color or brightness. But in tests of Viagra in hundreds of men, few dropped out because of such effects.

"Whether the promise of sildenafil will be realized after many more men have been treated and the drug has been taken repeatedly for prolonged periods remains to be seen," Dr. Robert D. Utiger cautioned in an editorial in the same issue of the journal.

--NY Times

From: Ron Podell <ConEmo@AOL.COM>
Date: Fri, 22 May 1998 00:49:50 EDT
Subject: Sildenafil for SSRI sexual dysfunction

Viagra helps with the excitement phase of the sexual response. It does nothing for desire -- except what it might contribute psychologically to a person who now believes he can have sexual relations. The orgastic problem with SSRIs is a threshold problem. The hill one has to climb to reach orgasm is higher. The increased excitement phase response due to Viagra has helped some of my patients climb the hill all the way to the top and over. The only question is whether that will continue. But it does not directly affect desire or orgastic phases.

From: Henry F. Crabbe <Pmchfc@aol.com>
Date: Tue, 26 May 1998 03:46:07 EDT
Subject: Sildenafil for SSRI sexual dysfunction

My experience is similiar. Viagra 50 mg reversed anorgasmia in a female patient treated with Prozac.

Date: Tue, 26 May 1998 14:11:48 -0700 (PDT)
From: Denis Franklin <denis@itsa.ucsf.edu>
Subject: Sildenafil for SSRI sexual dysfunction

I, too, had a female patient who overcame anorgasmia by taking her husband's sildenafil... and giving it to her boyfriend.   :-)

Date: Sun, 07 Jun 1998 07:12:35 -0400
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Sildenafil for SSRI sexual dysfunction

While I believe that it is too soon to prescribe sildenafil (Viagra) for antidepressant-induced sexual difficulties, about a dozen of my male and female patients have obtained it by various means and have tried it out. The success rate seems to be about 75% in both men and women, and the side effects seem to be minimal, so far.

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