This patient reports some improvement of his depression as well as new symptoms that are likely early side effects of the selective serotonin reuptake inhibitor (SSRI) fluoxetine (ie, nausea, anxiety, insomnia). Gastrointestinal and activating side effects are common at the start of SSRI treatment, and tolerance typically develops over several weeks. In contrast, SSRI-related sexual dysfunction often does not respond to watchful waiting.
Has the longest half life with active metabolites; therefore, it does not need to be tapered because of a low risk of SSRI discontinuation syndrome (a phenomenon characterized by headaches, dizziness, nausea, and malaise).
Is the most likely SSRI to cause GI disturbances.
Up to 50% of patients treated with selective serotonin reuptake inhibitors (SSRIs) may experience some degree of sexual dysfunction (eg, impaired orgasm, decreased libido, erectile dysfunction) as a side effect of treatment. The choice of management strategy should take into account the patient's response to antidepressants. In SSRI responders, such as this patient, augmentation with a second agent is preferred to switching to an alternate agent. In men with erectile dysfunction, augmentation with a phosphodiesterase-5 inhibitor (eg, sildenafil) is recommended. For women, augmentation with bupropion is typically suggested, although a phosphodiesterase-5 inhibitor is a reasonable option in those whose sexual dysfunction is limited to anorgasmia.
For patients with no response or only modest benefit from their SSRI, ==switching to a non-SSRI antidepressant== is recommended. Options include ==bupropion and mirtazapine==, as these antidepressants are associated with lower rates of adverse sexual effects compared with SSRIs. Serotonin-norepinephrine reuptake inhibitors such as venlafaxine have also been associated with sexual dysfunction, making bupropion a better option.