06. Sexual Side Effects of Antipsychotics, Mood Stabilizers, and Benzodiazepines

In this section, we’ll discuss sexual side effects of other psychotropics like antipsychotics and mood stabilizers.

Among antipsychotic medications with lower rates of sexual dysfunction, we see D2 antagonist, partial agonist effects and/or 5-HT2 antagonism as mechanisms of action. These would include aripiprazole, quetiapine, brexpiprazole, ziprasidone, lurasidone, olanzapine and lumateperone.

5-HT1A agonists like aripiprazole, brexpiprazole, cariprazine, lurasidone and lumateperone also were associated with lower rates of sexual dysfunction.

Other negative effects of antipsychotics related to postsynaptic dopamine blockade and elevated prolactin like risperidone and paliperidone, alpha-1 receptor antagonism like priapism, and perhaps cholinergic antagonism that is affecting arousal, or persistent psychosis also seem to be associated with sexual dysfunction.

If we look at decreasing impact on sexual function, we can see that thioridazine, one of the older typical antipsychotics, has the highest identified rate at 60% and then through risperidone, probably cariprazine following next, haloperidol, olanzapine, ziprasidone, quetiapine and now most recently even less than quetiapine was seen with lurasidone, aripiprazole, and lumateperone.

So antipsychotics may cause sexual dysfunction through cholinergic receptor antagonism and alpha-adrenergic receptor antagonism.

When we look at mood stabilizers, less sexual dysfunction has been seen with lamotrigine, but lithium, valproate, carbamazepine have some sexual dysfunction associated with their use. Outcomes with benzodiazepines are inconclusive. Perhaps, there’s a gender difference negatively impacting sexual functioning in women more than men.

Our key points here are: Antipsychotic medications with lower rates of sexual dysfunction are those with D2 antagonist, partial agonist effects and/or 5-HT2 antagonism and these include aripiprazole, quetiapine, brexpiprazole, ziprasidone, lurasidone, olanzapine and lumateperone.

Less sexual dysfunction may be seen with aripiprazole, brexpiprazole, cariprazine, lurasidone and lumateperone through the 5-HT1A agonism effects. Conversely, antipsychotics may cause sexual dysfunction through elevation of prolactin such as with risperidone and paliperidone, alpha-1 receptor antagonism potentially priapism, cholinergic receptor antagonism and/or alpha-adrenergic receptor antagonism.

Mood stabilizers may contribute to sexual dysfunction – lithium, valproate and carbamazepine. Less sexual dysfunction is seen with lamotrigine. Benzodiazepines may impact women and men differently or may be due to dosing with chronic daily use associated with sexual dysfunction versus acute occasional administration.