TLDR: It is common for folks who take antidepressants to experience changes in their sexual functioning; however, research in this area is severely limited. It is important to learn how to describe your ‘normal’ experience with sexual function and how you personally define sex in order to have productive discussions with your healthcare provider about antidepressant treatment and sexual function.
Antidepressants & sexual function: Is there a connection?
It is important to understand that there is no one-size-fits-all definition of sexual function (4). Everyone has different definitions of sex and experiences with sexual functioning. It is important that you identify your normal. If you need a place to start, here are some potential prompts to think about:
How do you personally define sex?
Libido (aka ‘sex drive’): how much do you desire sexual activity?
Arousal: how does your mind and your body prepare for sex?
Includes physiologic responses (i.e. vaginal lubrication, erection) as well as mental responses (i.e. feeling 'turned on').
Orgasms: think about if/how frequently they occur, how they feel when they happen, if/how often ejaculation occurs etc.
Feelings: what kind of things do you usually like versus dislike?
Learning how to describe your normal sexual function can help inform conversations you have with healthcare professionals. It can feel awkward to talk about sex with healthcare professionals, but it is important to have these conversations.
Conversations about sexual function should happen with a physician before you begin taking antidepressants, at regular intervals while you’re taking them, and when/if you come off of the treatment. Journaling your sexual experiences, functioning, and feelings can help guide these discussions and give you a better idea of what helps versus what kills ‘the mood’.
Changes to sexual function are common in folks taking antidepressants, especially those that alter serotonin levels (5). The most common classes of antidepressants associated with altered sexual function are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and bupropion (10). Despite their name, antidepressants are also used to treat other conditions such as anxiety, pain, and insomnia.
Concerns about antidepressants and sexual functioning are not new. Amytriptyline, one of the first antidepressants, was described in the 1960s by psychiatrist Frank Ayd as causing loss of libido in patients taking the medication (1). Looking at antidepressants in general, the clinical data suggests that roughly 5% of patients have changes to sexual functioning. However, patient survey data suggests that this number is between 50-70% (3).
The large discrepancy between clinical trials and survey data, in part, has to do with the way scientific research defines ‘sexual functioning.’ In clinical research, sex is simplified into three categories - desire, arousal, and orgasm - which are all described by physical measures (2). Below are some of the physiological responses that may describe these phases (14):
Desire: (also known as sex drive or libido)
Feelings of ‘butterflies’ in your abdominal region
Face flushes
Genitals begin to self-lubricate
Increased heart rate and breathing
Arousal: excitement
Similar feeling to the ‘desire’ phase - but more intense
Increased blood flow to the genitalia
Muscle tension and spasms throughout the body
Breathing, heart rate, and blood pressure all increase
Orgasm
Breathing, heart rate, and blood pressure are at their peak
Muscle spasms in feet
Sudden, forceful release of sexual tension
Rhythmic contraction of genital muscles
Ejaculation
However, we know that sex is multidimensional, and sexual experiences cannot be adequately summed up by this (primarily physical) categorization. Sexual functioning is related to age, socioeconomic factors, religion; and a variety of biological, psychological, and medical factors (12).
Depression, anxiety, and sexual functioning are all linked in women (9). However, the relationship between psychiatric disorders and sexual functioning is poorly understood. Therefore, it becomes difficult for researchers to determine the cause-effect relationship between antidepressant-use and depression. To complicate it further, changes to sexual function are also linked to other medical conditions such as (but certainly not limited to) thyroid disease, type I and II diabetes, and female infertility (8, 11, 13).
Unfortunately, due to limited research on sex and its impact on mental health (and vice versa), there are limited treatment options for folks experiencing unwanted changes to sexual functioning. Studies have suggested that current pharmacological treatments for female ‘sexual dysfunction’ are only minimally superior to placebos (6).
One approach to combat changes to sexual function is by switching antidepressants (7). Different types of antidepressants have been shown to have different effects on various aspects of sexual functioning. For example, let’s look at two common antidepressants, Prozac and Zoloft. Prozac has been shown to be linked to decreased sexual desire, whereas Zoloft is more strongly linked to difficulty reaching orgasm. This stresses the importance of understanding your ‘normal’ sexual functioning. Being able to identify what aspects of sexual functioning have changed can inform your physician to help you choose a different antidepressant or try other strategies to restore normal functioning.
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