“Do you have any questions for the pharmacist?”
Every visit to your local pharmacy includes an opportunity to discuss your prescription with a pharmacist. If you use a mail-order pharmacy, each order is delivered with contact information if you want to reach out to your pharmacist.
Pharmacists are medication experts. They do much more than count pills and label bottles. For every prescription, your pharmacist must verify that the prescriber’s information is complete, that the new medication will not interact with your other medicines, that the dosage is appropriate, and that you understand how to properly take the medication. However, most people decline the offer to talk to their pharmacist. Instead, in today’s culture, most people think if they need a question answered, they will “just Google it.”
The problem with Googling your medical questions is that your search results will yield a mix of reliable and unreliable information that lacks context.
For example, let’s imagine that your doctor has prescribed escitalopram (Lexapro), a popular selective serotonin reuptake inhibitor (SSRI), for your anxiety disorder. Before starting the medication, you decide to do a little Google research first. The search “Lexapro side effects” serves up a list of common side effects right on on the Google homepage.
Without having to click any further, you skim the list and feel alarmed to see “anxiety” within the top five most common side effects. You question why your doctor would prescribe a medication for your anxiety that has anxiety listed as a side effect. You decide not to take it.
However, if you had discussed your side effect question with your pharmacist, he or she would have explained that SSRIs, such as escitalopram, do not work immediately. Over the first two to four weeks, SSRIs gradually increase your brain’s level of serotonin, which is a chemical that promotes positive mood and calmness.
Before the medication helps serotonin build up its effectiveness, your anxiety symptoms may continue or worsen over the first week or two. For this reason, a benzodiazepine is often prescribed as needed for anxiety during the initiation phase of SSRI treatment. But once the SSRI begins working, most people experience a significant reduction in their anxiety symptoms and no longer feel the need to take benzodiazepines as often. Now that you understand how the medication works, you have the all-important context around the “anxiety” side effect found in your Google search.
If you continue to scroll through the Google search results about escitalopram, you will view links to various websites that provide extensive lists of side effects, many of them very serious and scary-sounding. All potential side effects, also known as adverse effects, are legally required to be disclosed by pharmaceutical manufacturers.
Adverse effects generally fall into two categories: “common but mild” and “rare but serious.” Keep in mind that the vast majority of people do not typically experience serious side effects from SSRIs. Side effects from most SSRIs are usually temporary or in the “common but mild” category. Remember that your doctor will only prescribe medication if he or she deems that the benefits outweigh the risks.
Best Advice for SSRIs: Start Low, Go Slow
The most frequently prescribed medications for anxiety disorders include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs).
Examples of popular SSRIs include:
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
Examples of popular SNRIs include:
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
What can you really expect when starting an SSRI? Is there anything you can do to prevent or minimize side effects?
The best advice for minimizing side effects from all SSRIs and SNRIs is to start low and go slow. Start by taking only half the dose each day and wait at least seven days before increasing to the full dose. This gives your body plenty of time to get used to the new medication, significantly reducing common initial side effects. These may include nausea, trouble sleeping, sleepiness, dizziness, and loss of appetite.
Most of these side effects are mild, and if they occur, they usually go away on their own within two weeks. By starting with half-doses for the first week, you may substantially avoid these initial SSRI/SNRI side effects.
Technical note: SSRI/SNRI tablet products (e.g., escitalopram, sertraline) can be safely split in half. For capsule products (e.g., fluoxetine, duloxetine), you will need two separate prescriptions: one for a short-term supply of the lower strength capsule and one for a long-term supply of the regular strength capsule.
Taking your SSRI or another antidepressant consistently is essential. You should take your dose around the same time each day to keep a consistent medicine level in your body. This consistency reduces headache side effects.
Let’s Talk About Sex: Sexual Side Effects of Anxiety Medications
“Sexual side effects” are likely to catch your eye as you skim the Google search results, and will likely prompt more Google searches to answer your questions on this sensitive subject. Changes in sexual desire, performance, and satisfaction often occur as part of depression or anxiety disorders, but they can also be a side effect of antidepressant medications.
Reliable estimates of the incidence and severity of sexual side effects are difficult to obtain, because people may be embarrassed or reluctant to discuss them with their healthcare providers.
This section will discuss the details of the potential sexual side effects of SSRIs/SNRIs. This section is not comprehensive of all important prescribing information and does not take the place of consulting with your healthcare provider.
Sexual Side Effects of SSRIs
The most common sexual side effect of SSRIs in males is delayed ejaculation. Men with delayed ejaculation may be unable to ejaculate or may only be able to ejaculate with great effort after prolonged intercourse (for example, 30 to 45 minutes).
Decreased libido is a reduction in sex drive or less desire for sex. Decreased libido has been frequently reported in males and females as a result of taking SSRIs or SNRIs. Keep in mind that many other factors may contribute to low sex drive, such as depression or anxiety itself, low testosterone levels, lack of physical exercise, substance abuse, or relationship problems.
Other sexual dysfunction side effects reported from SSRIs include vaginal dryness, difficulty reaching orgasm, and erectile dysfunction. Erectile dysfunction (ED) occurs when a male cannot get or keep an erection firm enough for sexual intercourse.
Out of the SSRIs, paroxetine (Paxil) has the highest risk of causing delayed ejaculation. Interestingly, this may actually be a perceived benefit for some men, and paroxetine is sometimes prescribed off-label for men who suffer from premature ejaculation.
When selecting an SSRI, it is recommended to first try escitalopram (Lexapro), sertraline (Zoloft), or fluoxetine (Prozac) as they cause relatively less sexual problems.
Paroxetine (Paxil) should be the last-choice SSRI since it causes the most sexual dysfunction, among other undesirable side effects.
Cymbalta (duloxetine) is an SNRI that interestingly does not seem to cause sexual problems in females, but may cause delayed ejaculation or low libido in males.
What to Do if You Experience Sexual Side Effects
If SSRI-related sexual dysfunction does not go away on its own within a few weeks, do not
suddenly stop taking your SSRI. You should consider the following options with your healthcare provider:
- Lowering the dose of your medication can reduce the risk of sexual side effects. Always talk with your doctor first before changing your dose.
- Timing the dose is less likely to help ejaculation and erectile problems, but it is possible to increase libido by timing your SSRI dose after the time of day you typically have sex. This is less likely to help for fluoxetine (Prozac) due to its long half-life.
- Switching to another medication that may cause less sexual side effects. Other antidepressant medications that may cause less sexual side effects include:
- Bupropion (Wellbutrin)
- Mirtazapine (Remeron)
- Vilazodone (Viibryd)
- Vortioxetine (Trintellix)
- Adding on another anxiety medication that has been proven to relieve sexual side effects, such as:
- Bupropion (Wellbutrin)
- Buspirone (Buspar)
- Adding on a medication to treat ED can be very useful for males, and some studies also show effectiveness for improving arousal in females. Examples:
- Sildenafil (Viagra)
- Tadalafil (Cialis)
- Vardenafil (Levitra)
- Saffron extract, an herbal supplement, may be effective at improving vaginal lubrication and erectile function. Saffron has no known drug interactions and is worth trying to improve sexual satisfaction.
Do not hesitate to communicate with your doctor or pharmacist about your anxiety medications. Your healthcare team is ready and willing to help you find an effective medication treatment(s) that will minimize side effects and keep your anxiety under control.