Depression, antidepressants and ED: the link in both directions

The short version: depression and erectile dysfunction (ED) often travel together, and the link runs both ways. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, part of the NIH) lists depression among the mental health issues that “can either cause ED or make it worse” (NIDDK, Symptoms & Causes of ED). Research also points the other way, with men who have ED more likely to be depressed. A third thread runs through the middle: several antidepressant labels list ED as a possible side effect. This guide covers each direction, what the labels actually say, why stopping a medicine on your own is risky, and how clinicians approach both problems at once.

Can depression cause ED?

Depression can contribute to ED, according to the NIH, which names “anxiety, depression, or stress” alongside feeling isolated, low self-esteem and negative body image as issues that “can either cause ED or make it worse” (NIDDK, Symptoms & Causes of ED). Population studies back up the link. In the Massachusetts Male Aging Study, a survey of men aged 40 to 70, ED was associated with depressive symptoms even after the researchers accounted for age, health status, medication use, hormones and lifestyle (odds ratio 1.82) (Araujo et al., Psychosomatic Medicine, 1998).

A 2018 systematic review pooled 48 studies on depression as an exposure and found it was linked to higher odds of ED (pooled odds ratio 1.39), though the studies varied a lot in design (Liu et al., Journal of Sexual Medicine, 2018). These are associations, not proof that depression is the cause for any one man. ED also has many physical causes, including diabetes, heart and blood vessel disease and hormone problems, which is why the full picture needs a clinician (NIDDK).

Can ED lead to depression?

The evidence suggests ED and depression are linked in this direction too. The same 2018 review pooled 6 studies that looked at ED as the exposure and found men with ED had higher odds of depression (pooled odds ratio 2.92), with fairly consistent results across those studies (Liu et al., 2018). The authors are careful to say their method “was unable to determine the direction of causality,” and their practical conclusion is that men reporting ED should be screened for depression, and men with depression should be asked about ED.

A clinical trial adds a hint about how the two interact. In 152 men with ED and mild to moderate depressive symptoms, men whose ED responded to treatment saw their depression scores fall much more than men whose ED did not respond: 76% of responders had at least a 50% drop on a depression rating scale, against 14% of nonresponders (Seidman et al., American Journal of Psychiatry, 2001). That trial was in men with milder depressive illness, so it does not mean treating ED replaces treating depression.

Which antidepressant labels list sexual side effects?

Antidepressants are the first medicine group on the NIH list of drugs that can cause ED (NIDDK), and the FDA labels give detail for specific drugs. The labels for sertraline (an SSRI) and venlafaxine (an SNRI) each have a dedicated sexual dysfunction warning, while the bupropion label lists impotence only in its postmarketing reports. The table summarizes what each label says for men.

Sources: ZOLOFT prescribing information, DailyMed; EFFEXOR XR prescribing information, DailyMed; WELLBUTRIN XL prescribing information, DailyMed.

A 2022 review of the research puts rough numbers on the classes. It reports that SSRIs are associated with treatment-emergent sexual dysfunction in about 70% of patients, SNRIs and tricyclics in 40 to 45%, and antidepressants without serotonin reuptake effects at rates similar to placebo, under 10% (Winter et al., Expert Opinion on Drug Safety, 2022). Those are averages across studies, not a prediction for you, and which medicine fits your depression is a decision for your prescriber.

Is it the depression or the antidepressant?

Often it is hard to tell, and the labels say so directly. The sertraline label notes that “changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder” but “may also be a consequence of SSRI treatment,” and it asks prescribers to take a detailed history, “including timing of symptom onset,” because sexual symptoms “may have other causes, including the underlying psychiatric disorder” (ZOLOFT prescribing information).

The 2022 review estimates that sexual dysfunction is a symptom of depression itself in about 70% of people presenting with major depressive disorder, and notes that treating depression to remission reduces sexual dysfunction that comes from the depression (Winter et al., 2022). Physical causes can sit alongside both. Useful things to note before an appointment are when the erection changes began, whether they came before or after starting a medicine, and whether desire, erections or ejaculation changed. Our guide to telling ED from performance anxiety covers other clues clinicians use, such as how suddenly it started.

Why not stop an antidepressant on your own?

Stopping suddenly can cause discontinuation symptoms. The NIH says plainly: “Do not stop taking any medicines on your own. Talk with your health care professional first” (NIDDK, Treatment for ED). The sertraline label describes symptoms after stopping serotonergic antidepressants, “particularly after abrupt discontinuation,” including nausea, sweating, irritability, dizziness, electric shock sensations, anxiety and confusion, and its Medication Guide says, “Do not stop ZOLOFT without first talking to your healthcare provider” (ZOLOFT prescribing information). The venlafaxine label likewise tells prescribers to advise patients “not to abruptly stop taking Effexor XR without talking first with their healthcare provider” (EFFEXOR XR prescribing information).

There is also good reason to speak up rather than quietly put up with it. The labels expect the conversation: the sertraline label asks prescribers to “discuss potential management strategies,” and its patient guide says, “There may be treatments your healthcare provider can suggest.” The NIH notes a clinician may suggest a different dose or switching to another medicine (NIDDK, Treatment for ED). Our page on medicines that can affect erections covers other drug groups on the NIH list.

How are depression and ED treated together?

Clinicians usually look at both at once, because each can affect the other. The American Urological Association (AUA) guideline recommends that men with ED get “a thorough medical, sexual, and psychosocial history,” and its Statement 6 says that for men being treated for ED, “referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship” (AUA Erectile Dysfunction Guideline). The NIH adds that counseling may be suggested when mental health or emotional issues are affecting ED, and that a partner may be invited to sessions (NIDDK, Treatment for ED).

Strategies the 2022 review describes for antidepressant-related sexual problems include checking sexual function before and during treatment, addressing other factors such as medical or psychiatric conditions, substance use or relationship difficulties, switching to an antidepressant with fewer sexual effects, adding a treatment for the side effect, or lowering the dose (Winter et al., 2022). ED medicines have been tested in this setting. In a randomized trial of 90 men whose major depression was in remission and who had sexual dysfunction linked to serotonergic antidepressants, 54.5% of men on sildenafil were much or very much improved versus 4.4% on placebo, and depression scores stayed in remission in both groups (Nurnberg et al., JAMA, 2003). Whether any ED medicine suits you depends on your health and other medicines, and is for a prescriber to judge; our guide on how ED medications work explains the class. If low desire is part of the picture, our page on ED and low testosterone covers that hormone side.

When should you talk to a clinician?

Talk to a clinician if erection problems keep happening, if they began after starting or changing an antidepressant, or if you have been feeling low for more than a short spell. The AUA guideline says men should be counseled that ED is a risk marker for heart and blood vessel disease and other health conditions that may warrant evaluation (AUA guideline). Our guides on when to see a doctor about ED and how ED is diagnosed explain what that visit involves.

Sources

Every clinical statement on this page traces to one of these sources:

• NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases, NIH), Symptoms & Causes of Erectile Dysfunction, last reviewed October 2024. Depression, anxiety and stress as issues that can cause ED or make it worse; antidepressants on the medicines list: niddk.nih.gov, ED symptoms and causes
• NIDDK, Treatment for Erectile Dysfunction, last reviewed October 2024. Counseling, medication review, a different dose or a different medicine, and “Do not stop taking any medicines on your own”: niddk.nih.gov, ED treatment
• American Urological Association, Erectile Dysfunction (ED) Guideline. Statement 1 (medical, sexual and psychosocial history), Statement 3 (ED as a risk marker) and Statement 6 (referral to a mental health professional): auanet.org, ED guideline
• Liu Q, et al. Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis (Journal of Sexual Medicine, 2018). 49 publications; pooled odds ratios 1.39 (depression to ED) and 2.92 (ED to depression); direction of causality not determined: pubmed.ncbi.nlm.nih.gov/29960891
• Araujo AB, et al. The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging Study (Psychosomatic Medicine, 1998). Odds ratio 1.82 after adjustment: pubmed.ncbi.nlm.nih.gov/9710291
• Winter J, et al. Sexual dysfunction with major depressive disorder and antidepressant treatments: impact, assessment, and management (Expert Opinion on Drug Safety, 2022). Rates by antidepressant class and management strategies: pubmed.ncbi.nlm.nih.gov/35255754
• Seidman SN, et al. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate (American Journal of Psychiatry, 2001). 152 men; depression scores and ED treatment response: pubmed.ncbi.nlm.nih.gov/11578994
• Nurnberg HG, et al. Treatment of antidepressant-associated sexual dysfunction with sildenafil: a randomized controlled trial (JAMA, 2003). 90 men with depression in remission: pubmed.ncbi.nlm.nih.gov/12503977
• ZOLOFT (sertraline) prescribing information and Medication Guide, DailyMed. Sections 5.5 Discontinuation Syndrome, 5.11 Sexual Dysfunction and 6.1 (Tables 3 and 4, male sexual adverse reactions): dailymed.nlm.nih.gov, ZOLOFT label
• EFFEXOR XR (venlafaxine) prescribing information, DailyMed (Viatris). Section 5.13 Sexual Dysfunction, male sexual adverse reactions table, and patient counseling on discontinuation: dailymed.nlm.nih.gov, EFFEXOR XR label
• WELLBUTRIN XL (bupropion) prescribing information, DailyMed (Bausch Health). Section 6.1 (decreased libido in immediate-release trials) and 6.2 Postmarketing Experience (impotence): dailymed.nlm.nih.gov, WELLBUTRIN XL label
• National Institute of Mental Health, Depression, last reviewed December 2024. Overview and the 988 Suicide & Crisis Lifeline: nimh.nih.gov, depression