A 25-year-old woman on escitalopram for depression develops bruxism and difficulty achieving orgasm. To address the sexual side effect while maintaining antidepressant efficacy, the most evidence-based pharmacological adjunct is:

• A Switch to paroxetine for better sexual tolerability
• B Add lorazepam for muscle relaxation addressing both bruxism and anorgasmia
• C Add lithium to augment the SSRI and reduce side effects
• D Add buspirone 10 mg BD, which partially reverses SSRI-induced sexual dysfunction via 5-HT1A partial agonism and dopamine D3 agonism ✓

Explanation

SSRI-induced sexual dysfunction (including delayed orgasm and anorgasmia) affects approximately 30–60% of patients and is mediated by 5-HT2 receptor-mediated inhibition of dopaminergic function in the mesolimbic pathway. Buspirone (5-HT1A partial agonist, weak D3 agonist) is an evidence-based adjunct that reduces this side effect while preserving antidepressant efficacy. Other evidence-based options include sildenafil (phosphodiesterase-5 inhibitor, effective in both sexes) and adding bupropion. Paroxetine has the highest rate of SSRI sexual dysfunction among SSRIs due to its anticholinergic and potent serotonergic profile.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.