Peggy J. Kleinplatz, Ph.D. is a Certified Sex Therapist and has been seeing patients for sexual problems for over 30 years. She has published 5 books and over 50 peer-reviewed articles on sexuality and sex therapy. The opinions expressed below are her own and she is not speaking on behalf of the University of Ottawa.
June 10, 2020.
Dear Ms. Grey,
Thank you for asking about my clinical experiences with patients in sex therapy who have been prescribed SSRIs or SNRIs. I have been seeing couples in sex therapy since the release of the first SSRI, Prozac (fluoxetine) in 1988. These classes of drugs have been prescribed for the most common psychological complaints, depression or depression with anxiety for decades.
Although SSRIs/SNRIs are prescribed widely, few of the patients referred to me have been warned about their sexual side effects. The adverse impacts may include effects on arousal (subjectively or physiologically or both, for example, erectile dysfunction), sexual response, including delayed, diminished or absent orgasm, or sexual desire. Some drugs affect only one aspect while patients report that others affect all three, that is, desire, arousal and sexual response. By contrast, Wellbutrin (bupropion), an atypical antidepressant, does not normally cause sexual side effects.
The effects of these drugs on sexuality have been so well known in medical circles that beginning in the early 1990s, Paxil (paroxetine) began to be prescribed off-label (that is, prescribed for a purpose not originally approved by regulators such as Health Canada or the US FDA) for treatment of premature ejaculation. The side effect of markedly delayed or absent orgasm, so unwelcome to most patients, had by then been widely recognized enough that it was being used to slow men down who worried about ejaculating too rapidly. (Please see References below.)
What is worrisome to most of the individuals and couples I see is sexual dysfunction that appears unexpectedly. Most of the people who are referred to me and who have been prescribed an SSRI/SNRI have not been told what to anticipate. What otherwise depressed individuals have often described is at least finding refuge in their sexuality during difficult times; however, within approximately 6 weeks of beginning their SSRI/SNRI treatment, this source of solace, too, has disappeared. Sometimes, depression is associated with sexual dysfunction. But for those who were sexually fulfilled despite depression, this sudden loss is quite demoralizing.
Some patients go online rather than consulting their family physicians and make the connection between the timing of their prescription and the new symptoms. If so, they may discontinue their medications abruptly. The sudden withdrawal of SSRIs/SNRIs results in what pharmaceutical companies refer to as SSRI discontinuation syndrome. Rather than their previous depression, they may now experience agitated depression, thereby being at higher risk of suicide or acts of violence towards others. Furthermore, quick withdrawal of SSRIs/SNRIs is not only unlikely to restore previous sexual functioning but patients report that their sexual dysfunction is prolonged, even after discontinuation.
From what they report, the more quickly they go off the medications, the more enduring the sexual side effects. This is especially infuriating to those who had no history of sexual difficulties prior to beginning SSRIs/SNRIs. Obviously, they now wish to stop drug treatment immediately, only to learn that this strategy is going to backfire. I counsel them to return to their prescribing physicians and an experienced pharmacist to supervise a gradual and tapered weaning (generally months rather than the 2 weeks they usually report) instead of risking prolonging symptoms by undertaking this process alone.
It can be utterly devastating to existing sexual relationships when one of the partners suddenly feels neutered, as your patient representatives have described. It can also make it hard to even find the strength to seek out new partners, when individuals feel defective. They recall the aliveness they had previously experienced and wonder if it will ever return. Fortunately, it usually does. But as you and your colleagues have documented, for some the process is unending. Although Post-SSRI/SNRI Sexual Dysfunction (PSSD) is recognized in Europe, it has been less so in North America. More research is required to comprehend the spectrum of responses of the SSRI/SNRIs on human sexuality and the duration of such effects.
I hope your efforts to publicize this condition will encourage prescribers to take the time to insure informed consent before recommending SSRIs/SNRIs. Such a conversation would ensure that patients also have a plan as to how to handle possible adverse sexual consequences and a plan for weaning before beginning a trial of these medications.
Wishing you every success.
Sincerely,
Peggy J. Kleinplatz, Ph.D.
Professor/ Professeure Titulaire
Dept. of Family Medicine and
School of Epidemiology and Public Health
Faculty of Medicine
Director of Sex and Couples Therapy Training
University of Ottawa
(613) 563-0846
See also: Bala, A., Nguyen, H.M.T., Hellstrom, W.J.G. (2018). Post-SSRI Sexual Dysfunction: A literature review. Sex Med Rev;6:29-34. doi: 10.1016/j.sxmr.2017.07.002.
Fava, G.A., Gatti, A., Belaise, C., Guidi, J., Offidani, E. (2015). Withdrawal symptoms after Selective Serotonin Reuptake Inhibitor discontinuation: A systematic review. Psychother Psychosom. 84(2):72‐81. doi:10.1159/000370338
Kaplan, P.M. (1994) The use of serotonergic uptake inhibitors in the treatment of premature ejaculation. Journal of Sex & Marital Therapy, 20:4, 321-324, DOI: 10.1080/00926239408404382
Montejo-González A.L., Llorca, G., Izquierdo, J.A., Ledesma, A., Bousoño, M., et al., (1997) Selective serotonin reuptake inhibitor-induced sexual dysfunction: clinical and research considerations. Journal of Sex & Marital Therapy, 23(3):176-94. doi: 10.1080/00926239708403923. PMID: 9292833 Review.
Waldinger, M.D., Olivier B. (1998). SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. Int Clin Psychopharmacol. Jul;13 Suppl 6:S27-33 doi: 10.1097/00004850-199807006-00006. PMID: 9728672
Waldinger, M.D., Hengeveld, M.W., Zwinderman, A.H., Olivier, B. (1998). Effect of SSRI antidepressants on ejaculation: a double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine, and sertraline J. Clin Psychopharmacol. 18(4):274–281. doi: 10.1097/00004714-199808000-00004.