When Antidepressants Affect Your Sex Life: What You Can Do

I see many patients whose depression has improved a lot on medication, but who stay silent and don't dare tell their doctor: "Since I started the pills, I have no desire at all," or "I can't reach orgasm." Some quietly stop the medicine themselves until the depression comes back. I want to say that this is common, it is not your fault, and it can be managed.

Possible sexual side effects

• Lower sexual desire
• Difficulty getting an erection, or less vaginal lubrication in women
• Delayed ejaculation, no ejaculation, or not reaching orgasm
• Reduced sensation in the genitals

SSRIs (such as sertraline, fluoxetine, paroxetine and escitalopram) and SNRIs (such as venlafaxine and duloxetine) commonly cause sexual side effects. Many studies, including a meta-analysis by Serretti and Chiesa (2009), report rates from roughly a quarter to more than half of users, depending on the drug, the dose and how people are asked.

Remember that depression itself can also lower desire, so sometimes we need to work out whether the problem comes from the illness or the medicine. Read more in Depression or low testosterone: how to tell them apart.

Why the medicine does this

SSRIs and SNRIs raise serotonin levels in the brain, which helps stabilise mood. But high serotonin reduces the activity of dopamine and noradrenaline, which drive sexual desire and response. Serotonin also directly slows the ejaculation reflex, which is why some of these medicines are also used to treat premature ejaculation.

1. 1SSRI / SNRIRaise serotonin levels in the brain
2. 2Mood steadierThis is the aim of treatment
3. 3Dopamine fallsThe driver of desire and sexual response
4. 4Sexual effectsLower desire, harder erections, delayed ejaculation

Options for managing it (together with your prescribing doctor)

1. Wait for a while. Some side effects ease on their own in the first 1–3 months, but many people don't improve by themselves.
2. Adjust the dose to the lowest that still controls your symptoms.
3. Switch to a medicine with fewer sexual side effects, such as bupropion, mirtazapine or vortioxetine, depending on what suits you.
4. Add a helper medicine, such as a PDE5 inhibitor for erection problems, which a Cochrane review found can help these men, or add bupropion in some cases. See Tadalafil vs sildenafil.
5. Adjust timing. With some medicines, a doctor may suggest taking the dose at a time well away from when you usually have sex, but don't try "weekend drug holidays" on your own.
6. Look after other factors too, such as exercise, enough sleep, less alcohol and talking with your partner.

Wait and see

• Some ease on their own in the first 1-3 months

Adjust the dose

• Lowest dose that still controls symptoms

Switch medicine

• One with fewer sexual side effects

Add a medicine

• E.g. PDE5 inhibitors for erection problems

Other factors

• Exercise, enough sleep, talk with partner

Never stop antidepressants on your own. If you have thoughts of self-harm, call 1323 (mental-health hotline) or 1669 (emergency).

If sexual function doesn't return after stopping

There are reports of a condition called PSSD (post-SSRI sexual dysfunction), where sexual problems persist after the medicine is stopped. In 2019 the European Medicines Agency (EMA) required this warning to be added to the product information for SSRIs and SNRIs. The condition is still poorly understood and uncommon, but if you have it, you deserve a serious assessment, not to be told it's all in your head.

How to talk to your doctor so it helps

• Say plainly when the symptoms started, compared with when you started the medicine
• Say how much this matters to you and whether it affects whether you keep taking the medicine
• Bring a list of all your medicines and supplements
• If you have a partner, you can bring them along; sometimes it makes planning together easier

The doctor who prescribes your antidepressant (a psychiatrist or family physician) should know about this, because adjusting the medicine means considering both the depression and the side effects together.

When to see a doctor, and how the clinic can help

Seek advice when sexual side effects affect your happiness or relationship, make you want to stop the medicine, or when you have erection or delayed ejaculation problems and aren't sure of the cause. Read more in Delayed or absent ejaculation: what causes it and Erectile dysfunction (ED).

At Dr. Kris Clinic we assess whether the problem comes from the medicine, the illness or other factors such as hormones or the relationship, work together with the doctor who prescribes your antidepressant, and consider additional treatment safely, because good mental health should come with a balanced sex life. Consultations are available in English, in Surat Thani or online. Read about lower desire in all genders in Low sexual desire (HSDD).