Sexual Health, Lack of Libido

Treatment of SSRI-Induced Sexual Dysfunction: Many strategies have been suggested in regards to managing SSRI-induced sexual dysfunction including: (1) awaiting spontaneous remission of sexual dysfunction, (2) reduction of dose, (3) ?drug holiday?, (4) addition of a pharmacologic antidote, (5) switching antidepressants, and (6) starting with an antidepressant with fewer or no sexual side effects. Whichever strategy is used, the treatment must be individualized.

Spontaneous Remission of Sexual Side Effects: Some patients report that sexual side effects improve over time. [13] In this limited data, it seems as though improvement of sexual side effects occurs when the initial complaints are mild and associated with delayed orgasm, rather than desire or arousal disorders. In a series of 156 patients with SSRI-related sexual side effects, only 19% reported moderate-to-complete improvement of side effects at 4 to 6 months. [14] Evidence from a number of studies suggests that treatment for an episode of depression must last a minimum of 3 months after acute stabilization, and should probably last 6 to 9 months. [15] Chronic major depressive disorder usually has an onset in early to midlife, and the full syndrome of major depression persists for 2 years or longer. The basic principles of treatment of chronic depression involve longer treatment and higher doses than are usually necessary for an acute event of depression. [16] In light of the small percentage of spontaneous remission of sexual side effects and the necessity of antidepressant therapy from a minimum of 6 to 9 months up to a lifetime, different strategies may prove more effective in maintaining sexual health.
Decreased Dosage Regimens: If waiting is unacceptable or ineffective, decreasing the daily dosage may significantly reduce or resolve the sexual side effects. [17] SSRIs have a flat dose-response curve and this effect may allow enough room to decrease the dosage enough to eliminate the side effects, but still maintain the antidepressant efficacy. It has been shown that a fluoxetine dose of 5-10 mg/day can be as effective as the more usual dose of 20 mg/day in improving depressive symptoms. If this strategy is implemented, the treating physician must be alert to any signs of recurrent depression and promptly resume a higher dose if necessary. If the patient's complaint is delayed orgasm or anorgasmia, the patient can be instructed to time intercourse either soon before or after taking their SSRI dosage. This timing allows for the serum drug level to be at its nadir during intercourse, hopefully decreasing sexual side effects.

Drug Holidays: A drug holiday is taking a 2-day break from medication in order to lessen sexual side effects and plan intercourse during this period of time. This idea first appeared when patients informed their physicians that they had tried stopping their medication for a day or 2 and that this resulted in an improvement of sexual functioning without a worsening of depressive symptoms. [5] Due to this finding, a study was performed to determine whether drug holidays were effective strategies for treating SSRI-induced sexual dysfunction. [18] Thirty patients were studied while taking fluoxetine, paroxetine, and sertraline (10 patients in each arm). All 30 patients had reported normal sexual functioning prior to starting the SSRI and only had sexual dysfunction secondary to SSRIs. Patients took their doses Sunday through Thursday and skipped their doses Friday and Saturday. Each of the 30 patients performed the drug holiday four times. Improved sexual function for at least 2 of the 4 weekends was noted by the patients who were taking sertraline and paroxetine, the 2 SSRIs with relatively short half-lives. The patients on fluoxetine did not note improved sexual function, probably secondary to the longer half-life of this particular drug. All three groups denied worsening of depressive symptoms.