Depression can affect the sex drive. Here’s how to cope.

Q: My mood isn’t great, I am tired all the time, and I just want to be left alone. I’m not ever in the mood for sex either. It’s affecting my marriage. I may be depressed, but I am concerned about taking antidepressants. Won’t that kill my libido even more?

A: One of my patients, a man in his mid-40s, recently asked me this question. I had diagnosed him with depression and discussed treatment options, including talk therapy, self-care, and a low dose of an antidepressant medication.

It’s a common question my patients ask. Antidepressant medications such as Lexapro or Prozac can help with symptoms of depression such as sleep problems, racing thoughts, or poor self-esteem. However, these medications come with a risk of sexual side effects, though not everyone experiences them.

If you are experiencing depression, and considering treatment, know that it is possible to save your mood without killing your sex life. Here’s how.

While antidepressants can negatively affect your sex life, a decreased interest in sex is also a common symptom of depression. In one study, 67% of depressed women and 75% of depressed men said that feeling depressed caused them to lose interest in sex before they even started taking an antidepressant.

This may be associated with poor body image, fatigue, or anhedonia (the inability to feel pleasure) — all traits that are common in depression and can play a role in how “in the mood” you are for sex. Major depressive disorders may also cause an imbalance in hormones (for instance, cortisol and testosterone) and neurotransmitters (such as dopamine) that can affect sexual desire and performance.

Not everyone who takes an antidepressant experiences sexual side effects — figures vary widely, ranging from 25% to 73%, or more. In my clinical experience, about half of my patients who are taking antidepressants describe these symptoms. This makes the decision to start an antidepressant as much of an art as it is a science. The good news is that sexual side effects — even if they are caused by an antidepressant — are usually a problem that is easy to manage.

The terms “sexual side effects” or “sexual dysfunction” are often used interchangeably and can be vague and somewhat frustrating ways to describe being unhappy with your sexual experience. To clarify the relationship between depression and sex, consider that the sexual response cycle consists of four distinct stages:

- Excitement (desire or libido)

- Arousal (physical changes)

- Orgasm (a climax)

- Resolution (the body’s return to its pre-aroused state)

Depression can affect any, or all, of these stages, but so can antidepressants. When thinking about sexual dysfunction, especially if you are discussing your concerns with a psychiatrist, be specific about which stages of your sexual response cycle are being affected.

Depression can cause both premature and delayed ejaculation in men, for example, and the two conditions are treated very differently. In women, depression may cause problems with desire or the ability to achieve orgasm, which would require a personalized treatment plan as well.

Since conditions that affect physical health, such as low testosterone in men and menopause in women, can also contribute to sexual dysfunction in specific ways, providing your primary-care doctor with as much detail as possible helps them develop an optimal treatment plan for you. They may direct you to an endocrinologist for low testosterone or to a gynecologist for menopause issues.

Unfortunately, almost all antidepressants get a bad rap for negatively affecting people’s sex lives. However, some antidepressants can make both depression and sex better. For example, depression that’s causing premature ejaculation in men may be reversed by Prozac, which might delay the ejaculation reflex. Similarly, Wellbutrin may improve sexual desire in women.

Trazodone may be great for helping some depressed men who are also dealing with erectile dysfunction. Remeron, an antidepressant that can help with poor appetite and insomnia, has been found to potentially improve all four stages of the sexual response in depressed women.

Finally, patients who are prescribed Viibryd, a relatively new antidepressant, have reported fewer undesirable sexual side effects.

A common dilemma some of my patients face is that as soon as they find an antidepressant that works well, they notice problems with one or more stages of their sex response cycle. It can place them in a dilemma of feeling like they have to choose between saving their mood and saving their sex life.

However, even if an antidepressant leads to problems with sex, there are several effective strategies a psychiatrist may recommend:

- Lowering the dose of your antidepressant

- Switching to a different antidepressant with fewer sexual side effects

- Adding a low dose of another antidepressant to offset sexual side effects

In a few rare cases, paradoxically, raising the antidepressant dose can help, especially if sexual side effects attributed to the antidepressant are because of inadequately treated depression.

My patient, with my assistance, decided to take Wellbutrin. Over the next couple of months, his mood began to improve, and he noticed more energy and motivation. Thankfully, the only sexual side effect he described was a better sex life with his wife.

If you are experiencing problems with depression and sex, a good psychiatrist can help you determine if your symptoms are related to depression or caused by another health concern such as hypothyroidism or low testosterone.

Being open about what you’re going through can help get your mood — and your sex life — back on track.

Gregory Scott Brown is a psychiatrist, mental health writer, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression, and Revitalizing Your Life.”