SSRIs, Sex, and Viagra

abstract & commentary

Synopsis: Ashton and Bennett report the successful use of sildenafil (Viagra) to treat two men with sexual dysfunction secondary to the use of selective serotonin reuptake inhibitors (SSRIs).

Source: Ashton AK, Bennett RG. J Clin Psychiatry 1999; 60(3):194-195.

Because sildenafil (viagra) is indicated for the treatment of male sexual erectile dysfunction of various etiologies, Ashton and Bennett initiated sildenafil in two men with sexual dysfunction secondary to the use of selective serotonin reuptake inhibitor antidepressants. Their first patient was a 20-year-old male with major depression, obsessive compulsive disorder, and panic disorder who had achieved a good response to fluoxetine (Prozac) after failing several other treatments. Without prior sexual dysfunction, he developed erectile dysfunction and anorgasmia in association with fluoxetine treatment. The addition of bupropion (Wellbutrin) at a dose of 300 mg/d was ineffective (the addition of bupropion is one of the more common strategies used to attenuate SSRI-induced sexual dysfunction). Subsequent treatment with sildenafil 100 mg prior to sexual activity was highly effective. Side effects were those typically seen with sildenafil monotherapy. Their second patient was a 46-year-old man with major depression and attention deficit disorder who was well controlled on sertraline (Zoloft) and methylphenidate (Ritalin). This gentleman also failed to respond to other antidepressants, but experienced erectile dysfunction and delayed ejaculation in association with sertraline. The addition of bupropion 100 mg/d was ineffective. The addition of sildenafil 50 mg prior to sexual activity improved both erectile function and delayed ejaculation, without side effects.

Comment by Lauren B. Marangell, MD

The incidence of sexual dysfunction with SSRIs may be as high as 50%. The simplest solution is to use the lowest effective SSRI dose, but in many patients the lowest effective dose also causes some degree of decreased libido, delayed ejaculation, or anorgasmia. A variety of antidotes have been used with modest success, although controlled data are lacking for most. In some cases the addition of bupropion (Wellbutrin), which has more dopaminergic effects, may help increase libido. The usual augmenting dose is bupropion SR 150 mg each morning. Other agents with dopaminergic effects, such as amantadine or psychostimulants, may also be of some benefit. The addition of daily buspirone (BuSpar) in doses of at least 30 mg/d may also be helpful, particularly for patients who also have residual anxiety. Cyproheptadine (Periactin) has been used in doses of 4-8 mg prior to sexual activity, but resulting sedation is problematic. Although it is reasonable to be hesitant about initiating treatment based on only a few cases, SSRI-induced sexual dysfunction is a significant problem, especially since many patients require long-term treatment. Novel approaches are necessary because treatments to date are only modestly effective. In this context, the use of sildenafil appears reasonable, providing that routine precautions are taken, such as not prescribing in patients who are taking nitrates. Although sildenafil has not been systematically studied in women, some clinicians are beginning to use this medication to treat women with SSRI-induced sexual dysfunction with some success. Use in women should include proper documentation that the patient was advised that this use is off-label and that there are minimal data in women at this time. Finally, antidepressants less likely to cause treatment-emergent sexual dysfunction are nefazodone (Serzone), bupropion (Wellbutrin), and mirtazepine (Remeron). (Dr. Marangell is Director, Clinical Psychopharmacology, Moods Disorders Research, Assistant Professor of Psychiatry, Baylor College of Medicine, Houston, Texas.)

All of the following have been used to treat SSRI-induced sexual dysfunction except:

a. bupropion (Wellbutrin).

b. cyproheptadine (Periactin).

c. buspirone (BuSpar).

d. alprazolam (Xanax).

e. sildenafil (Viagra).