Premature Ejaculation Associated with Citalopram Withdrawal

David E Adson and Michael Kotlyar

OBJECTIVE: To report a case of premature ejaculation occurring subsequent to citalopram discontinuation.

CASE SUMMARY: A 43-year-old white man being treated for depression with citalopram wished to discontinue treatment. Four or 5
days after stopping citalopram he reported that, during sexual intercourse, his genitals seemed to be extremely sensitive and
orgasm was achieved within approximately 1 minute. These symptoms continued over the next 3–4 weeks and remitted after
citalopram was restarted. Several subsequent attempts to discontinue citalopram resulted in a return of these symptoms despite
using a slow tapering regimen. An objective causality assessment revealed a probable relationship between drug withdrawal and
the observed symptoms.
DISCUSSION: The ability of selective serotonin-reuptake inhibitors (SSRIs) to delay ejaculation has been well documented; however,
discontinuation of these agents generally results in a return to baseline function. Although discontinuation of SSRI therapy has been
associated with a number of withdrawal symptoms, this is the first report (MEDLINE, September 2003), to our knowledge, of the
emergence of sexual adverse effects in someone with no previous history of these symptoms.
CONCLUSIONS: Premature ejaculation is a possible withdrawal effect after SSRI discontinuation. Since patients are usually reluctant
to spontaneously report sexual adverse effects, it is important to specifically inquire about them both when starting and stopping
treatment with an SSRI.
KEY WORDS: citalopram, premature ejaculation, withdrawal syndrome.

Ann Pharmacother 2003;37:1804-6.

Published Online, 5 Nov 2003, www.theannals.com, DOI 10.1345/aph.1D214

ecause of their tolerability, efficacy, and favorable ad-
B verse effect profile, the selective serotonin-reuptake in-
hibitors (SSRIs) continue to be first-line agents in the treat-
ment of depressive disorders.1 Given that treatment with
these agents is generally well tolerated, much attention has
been paid to the sexual adverse effects associated with
SSRI treatment.2 These adverse effects most commonly in-
clude delayed ejaculation and absent or delayed orgasm
and, less frequently, decreased libido and erectile dysfunc-
tion.2 The reported incidence of these symptoms varies de-
pending on the methodology used to collect this informa-
tion. Studies relying on spontaneous reports from patients
reveal relatively low rates of sexual dysfunction with these
agents, whereas when patients are systematically queried
regarding sexual adverse effects, rates of up to 73% have
been reported.2-4
Upon abrupt discontinuation of SSRI therapy, a number
of withdrawal symptoms have been reported. These can
include sensory disturbances (e.g., parasthesia, sensations
Author information provided at the end of the text.
Dr Adson has received honoraria or research support from As-
traZeneca, Bristol Myers Squibb, Eli Lilly, Forest Labs, and Pfizer.
Kotlyar has received speaking honoraria from Forest Labs.
of electric shock), gastrointestinal complaints, dizziness,
flu-like symptoms, and sleep disturbances.5 Withdrawal
symptoms typically begin within 24–72 hours and are nor-
mally short-lived, although reactions of greater severity
and longer duration have been reported.5,6 Any sexual ad-
verse effects associated with antidepressant use, however,
typically improve after antidepressant discontinuation.2
We report a case of a man who, upon discontinuation
from citalopram treatment, experienced hypersensitivity of
the genitals and premature ejaculation. These symptoms
were of sufficient severity that antidepressant therapy was
reinitiated to alleviate these symptoms.
Case Report
A married 43-year-old white man was seen in consultation for a long-
standing history of mild depression and irritability. Marital problems
stemming from these symptoms led his wife to suggest that he seek psy-
chiatric consultation. Psychotherapy had previously been tried; however,
the patient perceived only limited benefit and was hesitant to again seek
this option. Pharmacotherapy with sertraline and paroxetine had been
previously attempted but discontinued due to adverse effects (restless-
ness after starting sertraline, sedation with paroxetine). Citalopram 20
mg/d was initiated and continued for approximately 1 year. Although citalo-
pram was generally well tolerated and effective in treating the patient’s pre-
senting problem, he reported some decrease in libido and orgasmic delay.
These symptoms led him to request that citalopram be discontinued. The
dose was decreased to 10 mg/d for 1 month and then discontinued.

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Four or 5 days after stopping the citalopram, the patient noticed that,
during sexual intercourse, his genitals seemed to be extremely sensitive
and orgasm was achieved within approximately 1 minute. Premature
ejaculation continued over the next 3– 4 weeks and was a source of sig-
nificant frustration for both him and his wife. Citalopram 10 mg/d was
restarted, leading to resolution of these symptoms. Several additional at-
tempts to discontinue citalopram were made over the following months.
Despite attempting a slower taper (dose was decreased to 5 mg/d for 2
wk prior to discontinuation), a recurrence of premature ejaculation and
hypersensitivity of his genitals led to citalopram being restarted after
each discontinuation attempt, with the longest duration of citalopram
withdrawal being approximately 2 months. Intermittent use of the an-
tidepressant at the 10-mg/d dose resulted in a recurrence of his depressed
mood and irritability. Accordingly, he elected to go back on citalopram at
20 mg/d, which led to a remission of his depression.
Once escitalopram became available, the patient was switched to this
agent in the hope that less sexual dysfunction would be seen; however,
symptoms of insomnia and recurrence of the decreased libido led to its
discontinuation after 1 month and the resumption of citalopram treat-
ment. When last seen in follow-up (~3 y after citalopram treatment was
first started), he reported that he continued having symptoms of de-
creased libido and mild orgasmic delay; however, he found these adverse
effects preferable to a recurrence of depressed mood or premature ejacu-
lation and did not wish to change his therapy.
Discussion
To our knowledge, this is the first reported case (MED-
LINE, September 2003) of premature ejaculation occur-
ring upon discontinuation of an SSRI in a patient with no
history of premature ejaculation. The ability of SSRIs to
delay ejaculation has been well documented, and these
agents have been shown to be effective for treatment of
premature ejaculation, although citalopram may have less
of an effect on ejaculatory delay than some of the other
SSRIs.7,8 Discontinuation of SSRIs, however, generally re-
sults in a return to baseline function.9,10 The temporal asso-
ciation between cessation of drug therapy and the emer-
gence of premature ejaculation suggests that drug discon-
tinuation was the causative factor. The emergence of
symptoms 4 –5 days after drug discontinuation is consis-
tent with the amount of time necessary for most of the
drug to be eliminated, given its average half-life of approx-
imately 36 hours.11 That restarting the drug eliminated
symptoms and subsequent attempts to discontinue treat-
ment caused a return of symptoms further support the be-
lief that these symptoms were caused by withdrawal of
citalopram treatment. Use of the Naranjo probability scale
indicated a probable relationship between drug withdrawal
and the observed symptoms.12
The mechanism by which serotonergic antidepressants
cause sexual dysfunction is unclear, with some proposed
mechanisms implicating alterations in either serotonergic,
dopaminergic, or anticholinergic function.2,4,8 The 5-HT2
receptor has been suggested as playing an important role in
mediating the effects of SSRIs on sexual function, in part
because antidepressants that block this receptor (e.g., mir-
tazapine, nefazodone) are less likely to cause sexual dys-
function.13-15 It is unclear why citalopram withdrawal led to
premature ejaculation, although the longevity of this effect
after drug discontinuation suggests that changes in receptor
function or density may have occurred during citalopram
treatment. A limitation of this case report is that citalopram
www.theannals.com The Annals of Pharmacotherapy
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Case Reports
was not discontinued for longer than 6 –8 weeks; there-
fore, it is not known whether these symptoms would have
subsided had citalopram been discontinued for a longer pe-
riod of time. However, after several unsuccessful attempts
to discontinue therapy, it is possible that during subsequent
attempts, psychological factors may have contributed to a
recurrence of symptoms despite the slower tapering regi-
men being attempted.
This case report demonstrates that premature ejaculation
is a possible persistent withdrawal effect after SSRI discon-
tinuation. Although there have not been previous reports of
this effect, patients are generally reluctant to spontaneously
report sexual adverse effects. If such an effect resolves rela-
tively quickly, it is likely that it would not be reported. The
duration of this adverse effect (at least 3 wk after initially
discontinuing citalopram) may be what led this patient to
report it.
Summary
Sexual adverse effects, such as delayed ejaculation or
decreased libido, are commonly reported during SSRI
treatment. Although a number of withdrawal symptoms
have been reported upon abrupt discontinuation of SSRI
therapy, generally any sexual adverse effects associated
with antidepressant use resolve after the drug’s discontinu-
ation. This case suggests that premature ejaculation may
be an additional symptom that occurs in some patients
upon SSRI discontinuation. Due to the reluctance of pa-
tients to spontaneously report sexual adverse effects, it is
possible that other cases have occurred. It is therefore impor-
tant when discontinuing antidepressant therapy to follow up
with patients to ascertain whether any withdrawal symptoms
(specifically sexual adverse effects) are being experienced.
David E Adson MD, Assistant Professor, Department of Psychia-
try, School of Medicine, University of Minnesota, Minneapolis, MN
Michael Kotlyar PharmD, Assistant Professor, Department of Ex-
perimental and Clinical Pharmacology, College of Pharmacy and De-
partment of Psychiatry, School of Medicine, University of Minnesota
Reprints: David E Adson MD, Department of Psychiatry, School of
Medicine, University of Minnesota, Fairview-University Medical Cen-
ter, F282/2A West, 2450 Riverside Ave., Minneapolis, MN 55454-
1495, FAX 612/273-9779, adson001@umn.edu
References
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ZM. Antidepressant-induced sexual dysfunction. Ann Pharmacother
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4. Montejo AL, Llorca G, Izquierdo JA, Rico-Villademoros F. Incidence of
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EXTRACTO
OBJETIVO: Informar sobre un caso de eyaculación prematura que ocurrió
después de suspender el uso del citalopram.
RESUMEN DEL CASO: Un hombre, que recibía terapia con citalopram para
la depresión, quiso suspender el tratamiento. Cuatro a 5 días después de
suspender el citalopram, informó que durante la relación sexual
desarrolló sensibilidad extrema en los genitales y alcanzó el orgasmo en
aproximadamente 1 minuto. Estos síntomas continuaron durante las
próximas 3 a 4 semanas y desaparecieron luego de reiniciar el
citalopram. Subsiguientemente, al intentar suspender el citalopram
varias veces, los síntomas reaparecieron, a pesar de que la dosis se
disminuyó lentamente. Una evaluación de causa objetiva indicó una
relación probable entre el retiro del medicamento y los síntomas
observados.
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DISCUSIÓN: La capacidad de los SSRIs para retardar la eyaculación está
bien documentada; sin embargo, por lo general, cuando se suspenden los
inhibidores de la recaptación de serotonina, se recupera la función de
base inicial. Aunque la suspensión de la terapia con los SSRI ha estado
relacionada con una serie de síntomas, que sepamos este es el primer
informe de efectos colaterales sexuales en una persona sin historia
previa de estos síntomas.
CONCLUSIONES: La eyaculación prematura es un efecto posible del retiro
de los SSRIs. Debido a que los pacientes, por lo regular, no informan
espontáneamente los efectos colaterales sexuales, es importante
preguntar sobre estos, de manera específica, al comenzar y al suspender
el tratamiento con los SSRIs.
Rafaela Mena
RÉSUMÉ
OBJECTIF: Rapporter le cas d’un patient souffrant d’éjaculation précoce
secondaire à l’arrêt du citalopram.
RÉSUMÉ: Un homme recevant du citalopram pour une dépression
demanda à cesser son traitement. Quatre ou 5 jours plus tard, il rapporta
que ses organes génitaux étaient extrêmement sensibles durant les
relations sexuelles et qu’il atteignait l’orgasme en environ 1 minute. Ses
symptômes ont persistés pendant 3 ou 4 semaines jusqu’à ce que le
citalopram soit réintroduit. Plusieurs essais subséquents pour cesser le
citalopram ont résulté en la réapparition des symptômes et ce, même
avec une réduction graduelle des doses. Une évaluation de la causalité
révéla une relation probable entre les symptômes et l’arrêt du
médicament.
DISCUSSION: L’action des inhibiteurs sélectifs de la sérotonine (ISS) sur
l’éjaculation est bien documentée. Cependant, l’arrêt de ces
médicaments entraîne généralement le retour à une situation similaire à
celle qui prévalait avant le traitement. Bien que l’arrêt des ISS ait été
associé à un certain nombre de symptômes de retrait, ce cas est le
premier, à notre connaissance, touchant la fonction sexuelle chez
quelqu’un n’ayant jamais souffert de tels ennuis par le passé.
CONCLUSIONS: L’éjaculation précoce est un symptôme possible à l’arrêt
des ISS. Puisque les patients ont en général de la difficulté à rapporter de
façon spontanée des effets sur la fonction sexuelle, il est important de
questionner ceux-ci lorsqu’un traitement au ISS est soit institué, soit
cessé.
Suzanne Laplante
www.theannals.com