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{{Short description|Medical condition}}
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'''Post-SSRI sexual dysfunction (PSSD)'''<ref name= Jannini2022>{{cite journal |vauthors=Jannini TB, Lorenzo GD, Bianciardi E, et al |title=Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs) |journal=Curr Neuropharmacol |volume=20 |issue=4 |pages=693–712 |date=2022 |pmid=33998993 |pmc=9878961 |doi=10.2174/1570159X19666210517150418 |type= Review}}</ref><ref name= Tarchi2023>{{cite journal |vauthors=Tarchi L, Merola GP, Baccaredda-Boy O, et al |title=Selective serotonin reuptake inhibitors, post-treatment sexual dysfunction and persistent genital arousal disorder: A systematic review |journal=Pharmacoepidemiol Drug Saf |volume= |issue= |pages= |date=June 2023 |pmid=37294623 |doi=10.1002/pds.5653 |s2cid=259126886 |url=https://onlinelibrary.wiley.com/doi/10.1002/pds.5653|type=Review|hdl=2158/1317239 |hdl-access=free }}</ref> refers to a set of symptoms reported by some people who have taken [[selective serotonin reuptake inhibitor]]s (SSRIs) or other [[Serotonin reuptake inhibitor|serotonin reuptake-inhibiting]] (SRI) drugs, in which sexual dysfunction symptoms persist for at least three months<ref name= "Healy_2022"/><ref name="Chinchilla Alfaro_2022" /> after ceasing to take the drug.
Post-SSRI sexual dysfunction (PSSD)<ref name= Jannini2022>{{cite journal |vauthors=Jannini TB, Lorenzo GD, Bianciardi E, et al |title=Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs) |journal=Curr Neuropharmacol |volume=20 |issue=4 |pages=693–712 |date=2022 |pmid=33998993 |pmc=9878961 |doi=10.2174/1570159X19666210517150418 |type= Review}}</ref><ref name= Tarchi2023>{{cite journal |vauthors=Tarchi L, Merola GP, Baccaredda-Boy O, et al |title=Selective serotonin reuptake inhibitors, post-treatment sexual dysfunction and persistent genital arousal disorder: A systematic review |journal=Pharmacoepidemiol Drug Saf |volume= |issue= |pages= |date=June 2023 |pmid=37294623 |doi=10.1002/pds.5653 |s2cid=259126886 |url=https://onlinelibrary.wiley.com/doi/10.1002/pds.5653|type=Review|hdl=2158/1317239 |hdl-access=free }}</ref> refers to a set of symptoms reported by some people who have taken SSRIs or other [[Serotonin reuptake inhibitor|serotonin reuptake-inhibiting]] (SRI) drugs, in which sexual dysfunction symptoms persist for at least three months<ref name= "Healy_2022"/><ref name="Chinchilla Alfaro_2022" /><ref name=Marks2023>{{cite journal |vauthors=Marks S |title=A clinical review of antidepressants, their sexual side-effects, post-SSRI sexual dysfunction, and serotonin syndrome |journal=Br J Nurs |volume=32 |issue=14 |pages=678–682 |date=July 2023 |pmid=37495413 |doi=10.12968/bjon.2023.32.14.678 |s2cid=260202178 }}</ref> after ceasing to take the drug. The status of PSSD as a legitimate and distinct pathology is contentious; several researchers have proposed that it should be recognized as a separate phenomenon from more common SSRI side effects.<ref name="Bala_2018_2" /> The reported symptoms include reduced [[Libido|sexual desire]] or [[Human sexual response cycle|arousal]], [[erectile dysfunction]] in males or loss of [[vaginal lubrication]] in females, difficulty having an [[orgasm]] or loss of pleasurable sensation associated with orgasm, and a reduction or loss of sensitivity in the genitals or other [[erogenous zone]]s. Additional non-sexual symptoms are also commonly described, including [[Reduced affect display|emotional numbing]], [[anhedonia]], [[depersonalization]] or [[derealization]], and [[Cognitive deficit|cognitive impairment]].<ref name="Healy_2022" /><ref name="Peleg_2022" /> The duration of PSSD symptoms appears to vary among patients, with some cases resolving in months and others in years or decades; one analysis of patient reports submitted between 1992 and 2021 in the [[Netherlands]] listed a case which had reportedly persisted for 23 years.<ref name="Chinchilla Alfaro_2022">{{cite journal | vauthors = Chinchilla Alfaro K, van Hunsel F, Ekhart C | title = Persistent sexual dysfunction after SSRI withdrawal: a scoping review and presentation of 86 cases from the Netherlands | journal = Expert Opinion on Drug Safety | volume = 21 | issue = 4 | pages = 553–561 | date = April 2022 | pmid = 34791958 | doi = 10.1080/14740338.2022.2007883 | s2cid = 244347777 |type= Review}}</ref> The symptoms of PSSD are largely shared with [[Finasteride|post-finasteride syndrome (PFS)]] and [[Isotretinoin|post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS)]], two other poorly-understood conditions which have been suggested to share a common etiology with PSSD despite being associated with different types of medication.<ref name="Giatti_2018">{{cite journal | vauthors = Giatti S, Diviccaro S, Panzica G, Melcangi RC | title = Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin? | journal = Endocrine | volume = 61 | issue = 2 | pages = 180–193 | date = August 2018 | pmid = 29675596 | doi = 10.1007/s12020-018-1593-5 | s2cid = 4974636 |type= Review}}</ref>


First reported in the medical literature in 2006,<ref name="Healy_2022"/> PSSD remains poorly understood; its biological mechanism, risk factors and frequency of occurrence are unknown. The reported symptoms include reduced [[Libido|sexual desire]] or [[Human sexual response cycle|arousal]], [[erectile dysfunction]] in males or loss of [[vaginal lubrication]] in females, difficulty having an [[orgasm]] or loss of pleasurable sensation associated with orgasm, and a reduction or loss of sensitivity in the genitals or other [[erogenous zone]]s. Additional non-sexual symptoms are also commonly described, including [[Reduced affect display|emotional numbing]], [[anhedonia]], [[depersonalization]] or [[derealization]], and [[Cognitive deficit|cognitive impairment]].<ref name="Healy_2022" /><ref name="Peleg_2022" /> It is considered a distinct clinical pathology from [[antidepressant discontinuation syndrome]], [[post-acute-withdrawal syndrome|post-acute withdrawal syndrome]], and [[major depressive disorder]].<ref name="Peleg_2022" /><ref name="Bala_2018_2">{{cite journal |vauthors=Bala A, Nguyen HM, Hellstrom WJ |date=January 2018 |title=Post-SSRI Sexual Dysfunction: A Literature Review |journal=Sexual Medicine Reviews |volume=6 |issue=1 |pages=29–34 |doi=10.1016/j.sxmr.2017.07.002 |pmid=28778697 |quote=There is still no definitive treatment for PSSD. Low-power laser irradiation and phototherapy have shown some promising results. |type= Review}}</ref>
Diagnostic criteria for PSSD were proposed in 2022,<ref name="Healy_2022">{{cite journal | vauthors = Healy D, Bahrick A, Bak M, Barbato A, Calabrò RS, Chubak BM, Cosci F, Csoka AB, D'Avanzo B, Diviccaro S, Giatti S, Goldstein I, Graf H, Hellstrom WJ, Irwig MS, Jannini EA, Janssen PK, Khera M, Kumar MT, Le Noury J, Lew-Starowicz M, Linden DE, Lüning C, Mangin D, Melcangi RC, Rodríguez OW, Panicker JN, Patacchini A, Pearlman AM, Pukall CF, Raj S, Reisman Y, Rubin RS, Schreiber R, Shipko S, Vašečková B, Waraich A | display-authors = 6 | title = Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin | journal = The International Journal of Risk & Safety in Medicine | volume = 33 | issue = 1 | pages = 65–76 | date = 1 January 2022 | pmid = 34719438 | pmc = 8925105 | doi = 10.3233/JRS-210023 }}</ref> but as of 2023, there is no agreement on standards for diagnosis.<ref name= Tarchi2023/> It is considered a distinct clinical pathology from [[antidepressant discontinuation syndrome]], [[post-acute-withdrawal syndrome|post-acute withdrawal syndrome]], and [[major depressive disorder]].<ref name="Peleg_2022" /><ref name="Bala_2018_2">{{cite journal |vauthors=Bala A, Nguyen HM, Hellstrom WJ |date=January 2018 |title=Post-SSRI Sexual Dysfunction: A Literature Review |journal=Sexual Medicine Reviews |volume=6 |issue=1 |pages=29–34 |doi=10.1016/j.sxmr.2017.07.002 |pmid=28778697 |quote=There is still no definitive treatment for PSSD. Low-power laser irradiation and phototherapy have shown some promising results. |type= Review}}</ref> PSSD must be distinguished from sexual dysfunction associated with [[major depressive disorder|depression]]<ref name= "Peleg_2022"/> and [[persistent genital arousal disorder]].<ref name= Tarchi2023/> There are limited treatment options for PSSD as of 2023 and no evidence that any individual approach is effective.<ref name= Tarchi2023/> The mechanism by which SRIs may induce PSSD is unclear;<ref name="Peleg_2022">{{cite journal |vauthors=Peleg LC, Rabinovitch D, Lavie Y, et al |title=Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors |journal=Sex Med Rev |volume=10 |issue=1 |pages=91–98 |date=January 2022 |pmid=34627736 |doi=10.1016/j.sxmr.2021.07.001 |s2cid=238580777 |type=Review}}</ref> neurobiological and cognitive factors may combine to cause PSSD.<ref name= Tarchi2023/> As of 2023, prevalence is unknown.<ref name= Tarchi2023/> A 2020 review stated that PSSD is rare, underreported, and "increasingly identified in online communities".<ref name=Rothmore2020>{{cite journal |vauthors=Rothmore J |title=Antidepressant-induced sexual dysfunction |journal=Med J Aust |volume=212 |issue=7 |pages=329–334 |date=April 2020 |pmid=32172535 |doi=10.5694/mja2.50522 |s2cid=212728659 |type= Review}}</ref>

There are limited treatment options for PSSD as of 2023.<ref name= Tarchi2023/> The mechanism by which SRIs may induce PSSD is unknown.<ref name="Peleg_2022">{{cite journal |vauthors=Peleg LC, Rabinovitch D, Lavie Y, et al |title=Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors |journal=Sex Med Rev |volume=10 |issue=1 |pages=91–98 |date=January 2022 |pmid=34627736 |doi=10.1016/j.sxmr.2021.07.001 |s2cid=238580777 |type=Review}}</ref>

The status of PSSD as a legitimate and distinct pathology is contentious; several researchers have proposed that it should be recognized as a separate phenomenon from more common SSRI side effects.<ref name="Bala_2018_2" />


Reports of PSSD have occurred with almost every SSRI ([[dapoxetine]] is an exception).<ref name= Tarchi2023/> In 2019, the [[European Medicines Agency#Pharmacovigilance Risk Assessment Committee|Pharmacovigilance Risk Assessment Committee]] of the [[European Medicines Agency]] (EMA) recommended that packaging leaflets of selected SSRIs and [[SNRIs]] should be amended to include information regarding a possible risk of persistent sexual dysfunction.<ref>{{cite book |url= https://www.ema.europa.eu/en/documents/prac-recommendation/prac-recommendations-signals-adopted-13-16-may-2019-prac-meeting_en.pdf |publisher= [[European Medicines Agency]] |date = 11 June 2019 |title= PRAC recommendations on signals: Adopted at the 13-16 May 2019 PRAC meeting |page = 5 |access-date= 19 July 2023}}</ref> Following on the EMA assessment, a safety review by [[Health Canada]] "could neither confirm nor rule out a causal link{{nbs}}... which was long lasting in rare cases", but recommended that "healthcare professionals inform patients about the potential risk of long-lasting sexual dysfunction despite discontinuation of treatment".<ref name= HealthCanada>{{cite journal |title= SSRIs, SNRIs: risk of persistent sexual dysfunction |journal = Reactions Weekly |publisher= Springer |volume= 1838 |issue = 5 |date= 16 January 2021 |page = 5 |doi= 10.1007/s40278-021-89324-7|s2cid = 231669986 }}</ref> A 2023 review stated that ongoing sexual dysfunction after SSRI discontinuation was possible, but that cause and effect were undetermined.<ref name= Tarchi2023/> The 2023 review cautioned that reports of sexual dysfunction cannot be generalized to wider practice as they are subject to a "high risk of bias", but agreed with the EMA assessment that cautionary labeling on SSRIs was warranted.<ref name= Tarchi2023/>
Reports of PSSD have occurred with almost every SSRI ([[dapoxetine]] is an exception).<ref name= Tarchi2023/> In 2019, the [[European Medicines Agency#Pharmacovigilance Risk Assessment Committee|Pharmacovigilance Risk Assessment Committee]] of the [[European Medicines Agency]] (EMA) recommended that packaging leaflets of selected SSRIs and [[SNRIs]] should be amended to include information regarding a possible risk of persistent sexual dysfunction.<ref>{{cite book |url= https://www.ema.europa.eu/en/documents/prac-recommendation/prac-recommendations-signals-adopted-13-16-may-2019-prac-meeting_en.pdf |publisher= [[European Medicines Agency]] |date = 11 June 2019 |title= PRAC recommendations on signals: Adopted at the 13-16 May 2019 PRAC meeting |page = 5 |access-date= 19 July 2023}}</ref> Following on the EMA assessment, a safety review by [[Health Canada]] "could neither confirm nor rule out a causal link{{nbs}}... which was long lasting in rare cases", but recommended that "healthcare professionals inform patients about the potential risk of long-lasting sexual dysfunction despite discontinuation of treatment".<ref name= HealthCanada>{{cite journal |title= SSRIs, SNRIs: risk of persistent sexual dysfunction |journal = Reactions Weekly |publisher= Springer |volume= 1838 |issue = 5 |date= 16 January 2021 |page = 5 |doi= 10.1007/s40278-021-89324-7|s2cid = 231669986 }}</ref> A 2023 review stated that ongoing sexual dysfunction after SSRI discontinuation was possible, but that cause and effect were undetermined.<ref name= Tarchi2023/> The 2023 review cautioned that reports of sexual dysfunction cannot be generalized to wider practice as they are subject to a "high risk of bias", but agreed with the EMA assessment that cautionary labeling on SSRIs was warranted.<ref name= Tarchi2023/>

According to a 2018 [[literature review]], "Common PSSD symptoms include genital anesthesia, pleasure-less or weak orgasm, decreased sex drive, erectile dysfunction, and premature ejaculation."<ref name="Bala_2018_2" /> A 2022 review stated that many case reports describe additional non-sexual symptoms such as "anhedonia, apathy, and blunted affect".<ref name="Peleg_2022" />

The symptoms of PSSD are largely shared with [[Finasteride|post-finasteride syndrome (PFS)]] and [[Isotretinoin|post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS)]], two other poorly-understood conditions which have been suggested to share a common etiology with PSSD despite being associated with different types of medication.<ref name="Giatti_2018">{{cite journal | vauthors = Giatti S, Diviccaro S, Panzica G, Melcangi RC | title = Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin? | journal = Endocrine | volume = 61 | issue = 2 | pages = 180–193 | date = August 2018 | pmid = 29675596 | doi = 10.1007/s12020-018-1593-5 | s2cid = 4974636 |type= Review}}</ref>

The duration of PSSD symptoms appears to vary among patients, with some cases resolving in months and others in years or decades; one analysis of patient reports submitted between 1992 and 2021 in the [[Netherlands]] listed a case which had reportedly persisted for 23 years.<ref name="Chinchilla Alfaro_2022">{{cite journal | vauthors = Chinchilla Alfaro K, van Hunsel F, Ekhart C | title = Persistent sexual dysfunction after SSRI withdrawal: a scoping review and presentation of 86 cases from the Netherlands | journal = Expert Opinion on Drug Safety | volume = 21 | issue = 4 | pages = 553–561 | date = April 2022 | pmid = 34791958 | doi = 10.1080/14740338.2022.2007883 | s2cid = 244347777 |type= Review}}</ref>

Diagnostic criteria were proposed in 2022,<ref name="Healy_2022">{{cite journal | vauthors = Healy D, Bahrick A, Bak M, Barbato A, Calabrò RS, Chubak BM, Cosci F, Csoka AB, D'Avanzo B, Diviccaro S, Giatti S, Goldstein I, Graf H, Hellstrom WJ, Irwig MS, Jannini EA, Janssen PK, Khera M, Kumar MT, Le Noury J, Lew-Starowicz M, Linden DE, Lüning C, Mangin D, Melcangi RC, Rodríguez OW, Panicker JN, Patacchini A, Pearlman AM, Pukall CF, Raj S, Reisman Y, Rubin RS, Schreiber R, Shipko S, Vašečková B, Waraich A | display-authors = 6 | title = Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin | journal = The International Journal of Risk & Safety in Medicine | volume = 33 | issue = 1 | pages = 65–76 | date = 1 January 2022 | pmid = 34719438 | pmc = 8925105 | doi = 10.3233/JRS-210023 }}</ref> but as of 2023, there is no agreement on standards for diagnosis.<ref name= Tarchi2023/>

PSSD must be distinguished from sexual dysfunction associated with [[major depressive disorder|depression]]<ref name= "Peleg_2022"/> and [[persistent genital arousal disorder]].<ref name= Tarchi2023/>

There is no standard treatment as of 2023, and no evidence that any individual approach is effective.<ref name= Tarchi2023/>

As of 2023, prevalence is unknown.<ref name= Tarchi2023/> A 2020 review stated that PSSD is rare, underreported, and "increasingly identified in online communities".<ref name=Rothmore2020>{{cite journal |vauthors=Rothmore J |title=Antidepressant-induced sexual dysfunction |journal=Med J Aust |volume=212 |issue=7 |pages=329–334 |date=April 2020 |pmid=32172535 |doi=10.5694/mja2.50522 |s2cid=212728659 |type= Review}}</ref> Cases have been reported after only a few, or even single doses of an SRI.<ref name="Bala_2018_2" />

The biological mechanism underlying the reported symptoms of PSSD is unclear.<ref name="Peleg_2022"/> Hypotheses include serotonergic neurotoxicity, serotonin concentrations in the brain lowering [[testosterone]],<ref name="Rothmore2020" /> changes to other neurotransmitters or hormones involved in sexual function, and a genetic predisposition with [[epigenetic]] factors.<ref name="Peleg_2022" /> Neurobiological and cognitive factors may combine to cause PSSD.<ref name= Tarchi2023/>

== References ==
{{reflist}}

== Further reading ==
* {{cite journal |vauthors=Marks S |title=A clinical review of antidepressants, their sexual side-effects, post-SSRI sexual dysfunction, and serotonin syndrome |journal=Br J Nurs |volume=32 |issue=14 |pages=678–682 |date=July 2023 |pmid=37495413 |doi=10.12968/bjon.2023.32.14.678 |s2cid=260202178 }}

Revision as of 18:47, 15 August 2023

Post-SSRI sexual dysfunction (PSSD)[1][2] refers to a set of symptoms reported by some people who have taken SSRIs or other serotonin reuptake-inhibiting (SRI) drugs, in which sexual dysfunction symptoms persist for at least three months[3][4][5] after ceasing to take the drug. The status of PSSD as a legitimate and distinct pathology is contentious; several researchers have proposed that it should be recognized as a separate phenomenon from more common SSRI side effects.[6] The reported symptoms include reduced sexual desire or arousal, erectile dysfunction in males or loss of vaginal lubrication in females, difficulty having an orgasm or loss of pleasurable sensation associated with orgasm, and a reduction or loss of sensitivity in the genitals or other erogenous zones. Additional non-sexual symptoms are also commonly described, including emotional numbing, anhedonia, depersonalization or derealization, and cognitive impairment.[3][7] The duration of PSSD symptoms appears to vary among patients, with some cases resolving in months and others in years or decades; one analysis of patient reports submitted between 1992 and 2021 in the Netherlands listed a case which had reportedly persisted for 23 years.[4] The symptoms of PSSD are largely shared with post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction/post-Accutane syndrome (PRSD/PAS), two other poorly-understood conditions which have been suggested to share a common etiology with PSSD despite being associated with different types of medication.[8]

Diagnostic criteria for PSSD were proposed in 2022,[3] but as of 2023, there is no agreement on standards for diagnosis.[2] It is considered a distinct clinical pathology from antidepressant discontinuation syndrome, post-acute withdrawal syndrome, and major depressive disorder.[7][6] PSSD must be distinguished from sexual dysfunction associated with depression[7] and persistent genital arousal disorder.[2] There are limited treatment options for PSSD as of 2023 and no evidence that any individual approach is effective.[2] The mechanism by which SRIs may induce PSSD is unclear;[7] neurobiological and cognitive factors may combine to cause PSSD.[2] As of 2023, prevalence is unknown.[2] A 2020 review stated that PSSD is rare, underreported, and "increasingly identified in online communities".[9]

Reports of PSSD have occurred with almost every SSRI (dapoxetine is an exception).[2] In 2019, the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency (EMA) recommended that packaging leaflets of selected SSRIs and SNRIs should be amended to include information regarding a possible risk of persistent sexual dysfunction.[10] Following on the EMA assessment, a safety review by Health Canada "could neither confirm nor rule out a causal link ... which was long lasting in rare cases", but recommended that "healthcare professionals inform patients about the potential risk of long-lasting sexual dysfunction despite discontinuation of treatment".[11] A 2023 review stated that ongoing sexual dysfunction after SSRI discontinuation was possible, but that cause and effect were undetermined.[2] The 2023 review cautioned that reports of sexual dysfunction cannot be generalized to wider practice as they are subject to a "high risk of bias", but agreed with the EMA assessment that cautionary labeling on SSRIs was warranted.[2]

  1. ^ Jannini TB, Lorenzo GD, Bianciardi E, et al. (2022). "Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)". Curr Neuropharmacol (Review). 20 (4): 693–712. doi:10.2174/1570159X19666210517150418. PMC 9878961. PMID 33998993.
  2. ^ a b c d e f g h i Tarchi L, Merola GP, Baccaredda-Boy O, et al. (June 2023). "Selective serotonin reuptake inhibitors, post-treatment sexual dysfunction and persistent genital arousal disorder: A systematic review". Pharmacoepidemiol Drug Saf (Review). doi:10.1002/pds.5653. hdl:2158/1317239. PMID 37294623. S2CID 259126886.
  3. ^ a b c Healy D, Bahrick A, Bak M, Barbato A, Calabrò RS, Chubak BM, et al. (1 January 2022). "Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin". The International Journal of Risk & Safety in Medicine. 33 (1): 65–76. doi:10.3233/JRS-210023. PMC 8925105. PMID 34719438.
  4. ^ a b Chinchilla Alfaro K, van Hunsel F, Ekhart C (April 2022). "Persistent sexual dysfunction after SSRI withdrawal: a scoping review and presentation of 86 cases from the Netherlands". Expert Opinion on Drug Safety (Review). 21 (4): 553–561. doi:10.1080/14740338.2022.2007883. PMID 34791958. S2CID 244347777.
  5. ^ Marks S (July 2023). "A clinical review of antidepressants, their sexual side-effects, post-SSRI sexual dysfunction, and serotonin syndrome". Br J Nurs. 32 (14): 678–682. doi:10.12968/bjon.2023.32.14.678. PMID 37495413. S2CID 260202178.
  6. ^ a b Bala A, Nguyen HM, Hellstrom WJ (January 2018). "Post-SSRI Sexual Dysfunction: A Literature Review". Sexual Medicine Reviews (Review). 6 (1): 29–34. doi:10.1016/j.sxmr.2017.07.002. PMID 28778697. There is still no definitive treatment for PSSD. Low-power laser irradiation and phototherapy have shown some promising results.
  7. ^ a b c d Peleg LC, Rabinovitch D, Lavie Y, et al. (January 2022). "Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors". Sex Med Rev (Review). 10 (1): 91–98. doi:10.1016/j.sxmr.2021.07.001. PMID 34627736. S2CID 238580777.
  8. ^ Giatti S, Diviccaro S, Panzica G, Melcangi RC (August 2018). "Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin?". Endocrine (Review). 61 (2): 180–193. doi:10.1007/s12020-018-1593-5. PMID 29675596. S2CID 4974636.
  9. ^ Rothmore J (April 2020). "Antidepressant-induced sexual dysfunction". Med J Aust (Review). 212 (7): 329–334. doi:10.5694/mja2.50522. PMID 32172535. S2CID 212728659.
  10. ^ PRAC recommendations on signals: Adopted at the 13-16 May 2019 PRAC meeting (PDF). European Medicines Agency. 11 June 2019. p. 5. Retrieved 19 July 2023.
  11. ^ "SSRIs, SNRIs: risk of persistent sexual dysfunction". Reactions Weekly. 1838 (5). Springer: 5. 16 January 2021. doi:10.1007/s40278-021-89324-7. S2CID 231669986.
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