Selective Serotonin Reuptake Inhibitor-induced Sexual Dysfunction in a Young Male

Sexual dysfunction remains one of the most frequent yet under-discussed adverse effects of selective serotonin reuptake inhibitors (SSRIs). Although these agents are preferred for their safety and tolerability, treatment-emergent sexual difficulties may significantly affect adherence, particularly in younger individuals. We report a case of escitalopram-associated sexual dysfunction in a young male, underscoring the importance of routine inquiry and timely management.

A 27-year-old unmarried male employed in a private industrial setting presented with a three-month history of low mood, anhedonia, reduced energy, impaired concentration, and disturbed sleep. There was no past psychiatric illness, substance use, medical comorbidity, or endocrine disorder. Premorbid sexual functioning was reported as normal. Mental status examination was consistent with a moderate depressive episode as per International Classification of Diseases (ICD)-10 criteria.

Escitalopram was initiated at 10 mg/d and titrated to 20 mg/d after six weeks due to partial response. At eight weeks, depressive symptoms had substantially improved. However, the patient reported reduced libido, difficulty achieving and maintaining an erection, and delayed ejaculation. These symptoms had emerged approximately four weeks after starting escitalopram and were distressing. He denied prior sexual difficulties.

Physical and genital examinations were unremarkable. Laboratory investigations, including thyroid profile and serum testosterone levels, were within normal limits. No psychosocial stressors or performance anxiety were elicited. The temporal association with escitalopram initiation, absence of alternative etiologies, and subsequent course suggested antidepressant-induced sexual dysfunction. The Naranjo Adverse Drug Reaction Probability Scale yielded a score of seven, indicating a probable adverse drug reaction.

A trial of dose reduction to 10 mg/d over two weeks did not yield improvement. Escitalopram was tapered and discontinued, and bupropion sustained release was initiated at 150 mg/d and increased to 300 mg/d. Over the following month, libido and erectile function improved, and ejaculatory delay resolved. At the six-month follow-up, depressive symptoms remained in remission with restoration of baseline sexual functioning.

SSRIs are associated with sexual dysfunction in 30%–70% of treated patients, though rates vary depending on assessment methods.^1,2 Increased serotonergic activity, particularly via Serotonin (5-HT2) receptor stimulation, is thought to inhibit dopaminergic pathways involved in sexual desire and arousal. ³ Depression itself can impair sexual functioning; however, in this case, sexual symptoms appeared after mood improvement and resolved following medication change, supporting a drug-related etiology.

Management strategies include dose reduction, switching to an antidepressant with a lower sexual side-effect burden, augmentation, or use of phosphodiesterase-5 inhibitors in selected cases. ⁴ Bupropion, owing to its dopaminergic and noradrenergic action, has demonstrated benefit both as monotherapy and in reversing SSRI-induced sexual dysfunction. ⁵

In sociocultural settings where discussion of sexual health may be inhibited, patients often do not volunteer such concerns. Failure to proactively inquire may result in covert non-adherence and relapse. This case highlights the need for baseline assessment and periodic evaluation of sexual functioning in patients receiving SSRIs.