Romantic Love and SSRIs

 

A paper came out this week that examined the relationship between selective serotonin reuptake inhibitors) SSRIs and romantic love. The lead author is a PhD candidate in anthropology with an interest in romantic love.  At first glance, the paper seems to run counter to a lot of sensational papers on the sexual side effects and possible persistent sexual side effects of SSRIs, because it found no differences between romantic love as assessed by a standardized scale and SSRI use. 

That is contrary to well-known sexual sides effects of these medications and the more recent controversy that SSRIs may cause persistent sexual dysfunction as either PSSD (Post SSRI Sexual Dysfunction) or PGAD (Persistent Genital Arousal Disorder). I have written about this controversy in the past and have not seen any useful advance in that literature.  Since that writing my information has been posted somewhere and I continue to get emails from people requesting my assistance in either assessing or treating PSSD.  I am no longer treating patients and therefore must decline. I am interested in researching this topic but do not have the resources on my own and my suggestions to various research entities have not produced any results.

This study looked at an N of 810 adults (48% women) from an original study of 1,556 adults from 33 countries who were defined as being in romantic love (Romantic Love Survey (RLS)).  The Passionate Love Scale (PLS-30) was used to identify romantic love.  The PLS-30 is a 30-point scale of descriptors of romantic love. Each item is rated on a scale of 1 (not true) to 9 (definitely true).  The scale is available at the above link.  This is an example of a typical item:

3. sometimes my body trembles with excitement at the sight of ____________

               not at all true 1 2 3 4 5 6 7 8 9 definitely true

 

By my inspection the 30 items of this scale are all cognitive and emotional features of love.  There are no items specific to sex or sexual fantasy.  The maximum scale score is 270 and participants in the RLS had to score a 130 or above and be in love for 23 months or less.  The authors of the scale suggest that a score of 106 -135 on the shortened version (15 items and a max score of 135) means – “Wildly, even recklessly, in love.”

The authors cite previous data suggesting the 2-year timeframe is necessary for romantic love and they removed 2 cases of high scorers because they were at the 4-year mark.  They deemed that 4 years of romantic love was improbable.

In their analysis the independent variable was SSRI use and they examined biological sex, mental health problems, intensity of romantic love, obsessive thinking, commitment, and frequency of sex as the dependent variables.  No specific details were given about the antidepressants – it was an SSRI or not binary.  At the time of the study only 9% of the sample (76 subjects out of 810) were taking SSRIs. Obsessive thinking was measured by a single question using a Likert rating.  Commitment was measured by adopting an item from another change and changing the rating form 5 points to 9 points.  Frequency of sex was open to interpretation.  The question was “How often do you have sex on a weekly basis?” and a 50-point scale was used.  The mapping of responses to that scale is unclear from the description in this paper.  Mental health problems were measured with the Assessment of Quality of Life 4D (AQOL-4D) and distilled down to 1 question that looked at a anxiety, depression, or a combination ( “I do/do not feel anxious, worried or depressed). Any endorsement of these symptoms was considered a positive score of 1.

Binary logistic regression was done to see if any of the variables of interest predicted SSRI use and none was noted.  The authors confirm that none of their hypotheses about SSRI use correlating with less intense romantic love, less obsessive thinking, less commitment, and less frequency of sex were confirmed.  They conclude: “The results from this study demonstrate SSRIs use is not significantly associated with features of romantic love in our sample of young adults experiencing romantic love.”

I note that there was some reaction to this paper on social media.  Some were surprised by the results and some saw the result as a call for celebration. There are some people who claim that SSRIs have damaged their capacity for sex irreparably and the sexual side effects of the medication are well known.

The authors are more measured in their assessment of results. They comment on the discrepancy between their results and the literature on sexual side effects and consider several explanations.  The first has to do with selection bias.  Some people on SSRIs may have met exclusion criteria due to sexual side effects and for that reason would have been excluded from study.  Their demographic of young college age students may have been limiting. Is it possible that youthful vigor can counter known SSRI side effects? Specific drug, dosing and duration were also not specified.   

Any observational study like this one can be confounded by many factors.  As the authors mentioned selection bias can be primary. The original selection criteria may have selected out any persons with sexual dysfunction on or off SSRIs.  Interestingly the same phenomenon may occur in psychiatric practice.  Any psychiatrist who has been in practice for more than a few years has patients being seen on a long-term basis who are probably satisfied with treatment. Any medication being used may be well tolerated with few side effects.  Psychiatrists in that setting who routinely inquire about sexual side effects and relationship problems are not likely to hear about any.  The opposite selection bias occurs in some studies of these problems where subjects are recruited based on side effects.  In either scenario the true prevalence is likely to be over or underestimated.  

The authors advance several neurobiological explanations about brain substrates and serotonin that are highly speculative. Several discuss the importance of the serotonin system and its up-regulation in romantic love.  Serotonin is a very importance neurotransmitter in the human brain. Unfortunately, measuring it in vivo over time is very difficult.  Methods for accurate measurement in pre-clinical setting have only recently become available (4) and one of the interesting findings is that serotonin can be increased in the extracellular space by several medications – so that any serotonin-based mechanisms are not specific to SSRIs. I tried to capture the basic findings from this paper in the graphic at the top of this post.  The striking finding from Hashemi Lab is that antidepressants that purportedly have different up front mechanisms all increase extracellular serotonin. The discussion of serotonin is clouded by a lack of precision.  Terms like up regulated, down regulated, increase, and decrease are all meaningless unless it is relative to a specific location or structure.   This finding needs to be incorporated into any discussion of how brain structures are involved.  Any interested reader can find the referenced studies to see if that is happening.  In my experience it is not.

In terms of the study design, metrics for anxiety, depression, and sexual side effects would provide additional comparisons.  Many psychopharmacological investigations use the Arizona Sexual Experience Scale (ASEX) to measure the sexual side effects of medications in a more detailed way.  The ASEX is a 5-item list that assesses sex drive, sexual arousal, erections/vaginal lubrication, orgasm ease and orgasm intensity using a 6-point scale.  It would also allow for the study of dissociations of romantic love from sexual behavior – as an example asexual adolescent crushes on one end of the spectrum and sexual behavior in the absence of romantic love on the other.  

In the end this study is reassuring that at least some people can take SSRI medications and it does not affect their love-life. But large questions linger at this point. The authors call for additional research. but it would also benefit from consultation with psychopharmacology researchers for additional design elements.  One interesting consideration is whether there is any dissociation of adverse effects between romantic love and sex and whether romantic love may be protective.  Like all complex human behavior precise mechanisms require more precise phenotypes and methodologies. 

Romantic love is no different.

 

George Dawson, MD, DFAPA

 

References:

1:  Bode A, Kowal M, Aghedu FC, Kavanagh PS. SSRI is not associated with the intensity of romantic love, obsessive thinking about a loved one, commitment, or sexual frequency in a sample of young adults experiencing romantic love. J Affect Disord. 2025 Jan 21:S0165-0327(25)00100-4. doi: 10.1016/j.jad.2025.01.103. Epub ahead of print. PMID: 39848471.

2:  Bode A, Kavanagh PS. Romantic Love and Behavioral Activation System Sensitivity to a Loved One. Behav Sci (Basel). 2023 Nov 10;13(11):921. doi: 10.3390/bs13110921. PMID: 37998668; PMCID: PMC10669312.

3:  McGahuey CA, Gelenberg AJ, Laukes CA, Moreno FA, Delgado PL, McKnight KM, Manber R. The Arizona Sexual Experience Scale (ASEX): reliability and validity. J Sex Marital Ther. 2000 Jan-Mar;26(1):25-40. doi: 10.1080/009262300278623. PMID: 10693114.

4:  Witt CE, Mena S, Holmes J, Hersey M, Buchanan AM, Parke B, Saylor R, Honan LE, Berger SN, Lumbreras S, Nijhout FH, Reed MC, Best J, Fadel J, Schloss P, Lau T, Hashemi P. Serotonin is a common thread linking different classes of antidepressants. Cell Chem Biol. 2023 Dec 21;30(12):1557-1570.e6. doi: 10.1016/j.chembiol.2023.10.009. Epub 2023 Nov 21. PMID: 37992715.5:  (Open Access)