Antidepressant-Related Erectile Dysfunction: Management via Avoidance, Switching Antidepressants, Antidotes, and Adaptation

The ideal antidepressant would control depression with no adverse effect on sexual function. Erectile dysfunctionand other sexual dysfunction associated with antidepressant medication treatment are problems withmany antidepressants and can lead to patient dissatisfaction and decreased compliance with treatment. A computerizedMEDLINE search (English language, 1966-2003) was performed using the terms antidepressiveagents, erectile dysfunction, and sexual dysfunction. Emphasis was placed on studies with specific sexual function measurements taken before and after treatment and placebo control. Mixed mediator, nonserotonergicantidepressants that block postsynaptic serotonin type 2 receptors (nefazodone, mirtazapine) or thatprimarily increase dopamine or norepinephrine levels (bupropion) were thought to be good choices for avoidingantidepressant-associated sexual dysfunction or for switching patients in whom antidepressant-associatedsexual dysfunction emerged. Comparisons with serotonin reuptake inhibitors (SRIs) have revealed less desireand orgasm dysfunction with nonserotonergic bupropion, less orgasm dysfunction with nefazodone, and superioroverall satisfaction with sexual functioning with bupropion or nefazodone. However, most of thesestudies have design flaws that make evidence-based claims of efficacy difficult to substantiate. Agents proposedfor antidote use in antidepressant-associated sexual dysfunction have either not been studied in menor not proved efficacious in randomized placebo-controlled trials. Switching to and augmentation with bupropionor nefazodone have also not clearly shown efficacy in controlled trials and require care and monitoringto avoid SRI discontinuation symptoms and loss of antidepressant efficacy. Few proposed treatment options,apart from avoidance, have proved effective for antidepressant-associated sexual dysfunction, which can havenegative consequences on depression management.