| First Line Antidepressant | Class | Choose when: | Sexual Dysfunction | Comments |
|---|---|---|---|---|
| Escitalopram (LEXAPRO) | SSRI | Depression with anxious distress | Yes | Start 10 mg once daily (AM or PM). Usual maintenance dose is 10 to 20 mg. FDA max is 20 mg, but can go up to 60 mg for OCD (Stahl 2016). Always superior to citalopram (Celexa) |
| Sertraline (ZOLOFT) | SSRI | Depression with anxious distress | Yes | Start 50 mg once daily (AM or PM). FDA max is 200 mg, but can go up to 400 mg for OCD (Stahl, 2016). More likely to cause nausea and diarrhea than Lexapro. |
| Bupropion (WELLBUTRIN) | NDRI | Depression with fatigue and oversleeping; comorbid ADHD or tobacco use disorder | No | For XL formulation, start 150 mg AM; Max is 450 mg. For SR formulation, start 100 mg BID; Max 200 mg BID. The IR formulation (TID) is not recommended due to risk of Seizure. |
| Mirtazapine (REMERON) | NaSSA | Depression with insomnia and loss of appetite | No | Start 15 mg HS. FDA max is 45 mg, although 60 mg is safe. Higher doses are less sedating - use lower dose for insomina |
| Venlafaxine | SNRI | Depression with fibromyalgia/chronic pain | Yes | Sucks to come off of |
Sexual Dysfunction
Serotonergic medications commonly decrease sexual desire,
disrupt the sexual pleasure response, and increase latency to
orgasm. Here are some drugs ranked (approximately) from worst
to best in regard to sexual dysfunction:
Negative Sexual Side Effects / Sexual Dysfunction
Paroxetine (Paxil) - the worst, > 70% of patients
Sertraline (Zoloft) > 60% - “so soft”
Escitalopram (Lexapro) and citalopram (Celexa) ~ 60%
Fluoxetine (Prozac) ~ 60%
Venlafaxine (Effexor) ~ 60%
Fluvoxamine (Luvox) - least among the SSRIs but still > 50%
Duloxetine (Cymbalta) - least among the SNRIs
Vortioxetine (Trintellix) - minimal at 10 mg (44% at > 10 mg)
Vilazodone (Viibryd) - slightly more than placebo
Placebo - up to 30% sexual dysfunction
Positive Sexual Side Effects / Increased Sexual Function
Trazodone - possible enhancement (and risk of priapism)
Nortriptyline and Desipramine (TCAs without serotonergic effects)
Nefazodone (Serzone) - possible enhancement
Mirtazapine (Remeron) - possible enhancement
Bupropion (Wellbutrin) - enhances sexual functioning (female > male)
Buspirone (BuSpar) - enhances sexual functioning (female > male)
Antidepressant Combinations
Reasonable combos (although not necessarily effective):
► Antidepressant + lithium
► Antidepressant (excluding nefazodone)
► Quetiapine (Seroquel)
► Escitalopram or sertraline
► Aripiprazole (Abilify) or risperidone (Risperdal)
► SSRI + buspirone (Buspar)
► Trazodone + other antidepressant (excluding nefazodone)
► Trazodone + doxepin for sleep
► Fluoxetine + olanzapine (Zyprexa)
► SSRI + bupropion (Wellbutrin)
► Nortriptyline + escitalopram or sertraline
► SNRI + mirtazapine (Remeron) - “California Rocket Fuel”
► MAOI + TCA without serotonergic activity—nortriptyline, desipramine, maprotiline, trimipramine =“Non-Disparaged MAOI Tagalongs”
“Bad” combinations
► 2 SSRIs
► 2 SNRIs
► SSRI + SNRI
► 2 TCAs
► SNRI + TCA
► Fluoxetine or paroxetine (strong 2D6 inhibitors) with 2D6 substrates (including all TCAs)
► Bupropion + noradrenergic TCA or SNRI
► Antidepressant + St John’s wort
► SSRI or SNRI + tramadol (Ultram)
► Mirtazapine + clonidine or guanfacine
► Atomoxetine + SNRI, bupropion, fluoxetine or paroxetine
Dangerous combinations
► MAOI + other antidepressants, excluding those without
serotonergic effects (trazodone, bupropion, nortriptyline,
desipramine, maprotiline, trimipramine)