Selective serotonin reuptake inhibitors (SSRIs) are being approved by the FDA for management of depression and anxiety disorders. but, they have been used, as well, in the frame of an experimental approach, in other psychiatric problems, like addiction, autism, personality disorders, etc. One of the said off-label approaches includes prescription of SSRIs for sex addiction or sexual promiscuity in female patients, except in bipolar cases, whose excessive or chaotic sexual behavior could be ascribed to impulsiveness, personality trait, intellectual deficit or psychotic disinhibition. In such cases, some psychiatrists may sometimes rely on sexual side effects of SSRIs for decreasing libido and complete or partial control of the said problematic behavior. 

Selective serotonin reuptake inhibitors (SSRIs) are being approved by the FDA for management of depression and anxiety disorders. But, they have been used, as well, in the frame of an experimental approach, in other psychiatric problems, like addiction, autism, personality disorders, etc. One of the said off-label approaches includes prescription of SSRIs for sex addiction or sexual promiscuity in female patients, except in bipolar cases, whose excessive or chaotic sexual behavior could be ascribed to impulsiveness, personality trait, intellectual deficit or psychotic disinhibition. In such cases, some psychiatrists may sometimes rely on sexual side effects of SSRIs for decreasing libido and complete or partial control of the said problematic behavior. In general, as is known, around half of patients who have been prescribed SSRIs may show sexual side effects, which is proportionally more in comparison with tricyclic antidepressants (TCAs) or monoamine oxidase inhibitors (MAOIs), and comparatively less in competition with serotonin norepinephrine reuptake inhibitors (SNRIs). But, it seems that such a side effect, which, in addition to other sexual side effects, like anorgasmia, may include declining of libido and drug-induced hypo-sexuality or asexuality in men, may present paradoxically in women, and result in more or additional sexual presentations. Whether such an increment is factitious and due to medication or real and due to intervening psychopathology, is not usually measurable, though antidepressant-induced side effects, like paradoxical suicide, which may occur in the initial weeks after commencement of antidepressant treatment, is an enduring threat by antidepressant, antipsychotic and anticonvulsive medications, which are frequently valuable, too, for control of self-mutilation or aggressiveness. Anyhow, it seems that some side effects may differ based on demographic characteristics, like gender or age. For example, a 28-year-old woman, who had been diagnosed as suffering from moderate major depressive disorder a few months ago, had been prescribed sertraline, 50 milligrams per day. Since her depression had responded positively in a few weeks, she was recommended to continue that dosage, as maintenance, for another few months for prevention of relapse. After two months, one of her relatives reported an extramarital affair between her and another man, which had not been perceived before. In response to the psychiatrist’s query, she replied that, since, from the beginning of her marriage, around four years ago, she could not respond appropriately to her husband’s sensual desires, which were not nonconforming, as well. A problem, which, in addition to preventing them from having another baby, was disturbing for her husband, had become worse after the initiation of her depression. Accordingly, she thought that maybe, by finding a new boyfriend, she could help herself to become happier and more motivated, than before, to have a better sexual relationship with her husband. So, due to hazard of additional stresses, divorce or her spouse’s retaliation, she was advised to stop, immediately, the said prohibited relationship, which was ostensibly sexless, as well, and referred to a counselor for supplementary care. As another example, a 32-year-old woman with a diagnosis of mild major depressive disorder was prescribed citalopram, 40 milligrams per day, which was helpful in a few weeks, in management of her annoyance, insomnia and sadness. After a few weeks of maintenance treatment, and during one of her monthly visits, her husband, who was escorting her, too, complained that, in the last few days, his wife had started to amuse herself with another guy; a correlation which was seemingly sexless and for just eating ice-cream or drinking non-alcoholic beverages. As said by him, since he was older than her and he knew that she was never in love with him, he had permitted her, willfully and warily, after the birth of their second child, to do so, if she liked, to avoid potential hatred and separation, though she never did that. Nowadays, after beginning of the said treatment, she attempted that virtually, which was agonizing for him. Thus, after talking with them, in separate sessions, she was asked to stop the said affair, which could hurt her more mercilessly than before, and then she had been referred to a marital therapist for further probe and management. Likewise, a traditional couple had been referred for psychiatric evaluation and counseling. They had a long history of familial conflict, though they had shared conservative sociocultural values, and had two teenaged children, who were involved actively in the personal struggles of their parents. Anyhow, after the initial interview, a mild major depressive disorder had been diagnosed in the wife, who was 43 years old, and had been prescribed fluoxetine, 20 milligrams per day, which was promptly helpful for her bad temper, pessimism and gloom. During the maintenance period, the monthly visit was accompanied with simple counseling for finding appropriate problem-solving strategies for different conflictual issues, which, maybe, could have been amplified by her husband’s obsessive-compulsive traits. After three months, when everything seemed to be fine, suddenly, her husband complained that, according to their children, his wife had recently found a boyfriend, and, above all, they were dating openly, which was unbelievable and in opposition to their customary life-style. The said incident was so shocking that their children asked him to divorce her and to punish their mother. In response to a therapist’s query regarding the said affair, she replied that she did not know essentially what had happened. One day while she was out shopping, an unknown man had offered her riding, which she accepted thoughtlessly and repeated it a few times. According to her, there were no affection or erotic feelings, and they were merely driving and talking. Then she asked her therapist whether such a sexless act was really a wrongdoing. Finally, she accepted that since her naughtiness had outraged her family, she promised to put an end to her odd behavior. As is evident from the above cases, all of them were relatively young middle-class housewives and moms, who had started an unusual extramarital affair, just after initiation of SSRIs, which was apparently, sexless, insensitive, and for seeking amusement, and could be stopped immediately, though there was not enough following, as well. Moreover, there was, very nearly, no defiance or secrecy. Nonetheless, the first patient had projected her primary enticement to her psychiatrist and had stated that it was, according to his advice, for the acquirement of additional glee; an accusation which was absolutely incorrect. The last patient, as well, had indicated that her psychiatrist was aware regarding her affair; a claim which was, again, totally untrue. Therefore, even in the case of disinhibition, most of them have tried to get a partner or permission for their wrongdoings. Though according to statistics, extramarital relationships among married women are not rare, such a history in neither of them is exposable. Likewise, no previous history of felonious act, aggressiveness, rape, adultery or psychiatric disorder, including antisocial, histrionic or borderline personality trait or disorder was evident or available. Though, forensically, and in the frame of their own sociocultural values, such a disloyalty could be like a great misdemeanor, which could end in their extermination or excessive suffering, they had implemented that so bluntly, and had spoken regarding that so pliably, that it seemed that, maybe, they are a little muddled, though their cognitive assessment was not uncharacteristic. Also, incentives like drinking, eating, shopping or amusement, could not explain their bad behavior fittingly. So, in comparison with their past history, their present situation seemed to be aroused by a new cause, which included the prescription of SSRIs. On the other hand, emblematically or clinically, it could be taken as the alternative pole of a process which includes paradoxical suicide or hypomania and mania, as the known side effects of antidepressant medications, though it demands more proof and follow up. Anyhow, if the said behavior could be acknowledged as a possible side effect of SSRIs, firstly, its sociocultural or criminal consequences may be diminished a bit by ascribing it to adverse effects of antidepressant medications, and secondly, it may demand alternative therapeutic strategies and procedures, like psychotherapy, or medications, like third generation antidepressant preparations. Though evidence-based medicine may not support unsubstantiated testimony or inferences, primary preventive may not ignore topsy-turvy, but sensitive, comments (1 – 6).