Archives of Mental Health

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 23  |  Issue : 1  |  Page : 1--6

Prevalence of sexual dysfunction in the patients suffering from depression: A cross-sectional study


Prosenjit Ghosh1, Gulshan Narula2, Anweshan Ghosh2,  
1 Assistant Professor, Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam, India
2 PGT, Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam, India

Correspondence Address:
Dr. Prosenjit Ghosh
Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam
India

Abstract

Background: A significant number of patients suffering from depression experience various sexual dysfunctions like decreased sexual interest, erectile disorders, premature ejaculation and anorgasmia. The evaluation of the prevalence of sexual dysfunction in depression is complicated by the fact that both medications as well as the depressive state itself may affect sexual desire and arousal. This study aimed to assess the prevalence of sexual dysfunction in cases of depression, and to check the correlation of severity of depression with severity of sexual dysfunction. Methods: This study was a cross-sectional non-interventional hospital based study. Diagnosis of depressive disorder was made according to ICD-10. The severity of depression was assessed using Beck Depression Inventory (BDI-II) and the severity of sexual dysfunction was assessed using Arizona Sexual Experience scale (ASEX). The data obtained was analysed using SPSS Version 23. Results: A total of 100 depressed patients diagnosed as per the International Classification of diseases 10 criteria were recruited after their informed consent. Majority of the participants were young lower middle class female; most of the participants were married (50%), homemakers by profession (34%), belonging to a semiurban area (43%). 50% of them (n=50) reported having sexual dysfunction. The mean BDI-II total score was 17.08±4.206. The mean ASEX total score was 28.28±11.312. The BDI-II score was found to be significantly correlated with the ASEX total score (r=0.686, p<0.001). Conclusion: A significant correlation was found between severity of depression and severity of sexual dysfunction.



How to cite this article:
Ghosh P, Narula G, Ghosh A. Prevalence of sexual dysfunction in the patients suffering from depression: A cross-sectional study.Arch Ment Health 2022;23:1-6


How to cite this URL:
Ghosh P, Narula G, Ghosh A. Prevalence of sexual dysfunction in the patients suffering from depression: A cross-sectional study. Arch Ment Health [serial online] 2022 [cited 2022 Jun 26 ];23:1-6
Available from: https://www.amhonline.org/text.asp?2022/23/1/1/339120


Full Text



 Introduction



Sexual dysfunction (SD) is quite common in the community population. Large epidemiological community survey from the United States reports 30% of men suffering from some form of SD, with premature ejaculation (21%) being the most common.[1]

The prevalence of SDs is higher in persons with mental disorders, particularly those treated with psychotropic medications. For instance, SD has been reported in as many as 30%–60% of patients with schizophrenia treated with antipsychotic medications,[2] up to 78% of individuals with depression treated with antidepressants,[3],[4],[5] and up to 80% in patients suffering from anxiety disorders.[6],[7]

An evaluation of a SD in psychiatric patients should take into consideration primary sexual functioning, the psychiatric disorders, physical diseases, and the various medications. SD may be comorbid with, and often a first sign of many physical illnesses and contributes significantly to reduction in quality of life. Awareness of the prevalence and of the hypothesized mechanisms of SDs in psychiatric patients would improve the attitude of the treating physicians toward sexual difficulties in those patients and result in increased compliance with treatment on the patients' part.

About 10% of the population suffers from depressive episodes with a severe impairment in the quality of life and functioning. Decreased libido commonly accompanies an episode of major depression. Casper et al.,[8] in the classic study on a sample of moderate to severe hospitalized drug-free patients with major affective disorder, found that the majority of these patients (72% of unipolar depressed and 77% of bipolar depressed) experienced loss of sexual interest. Increasing severity of depression and anxiety was associated with loss of libido. Age and cognitive impairment also showed a strong correlation with the reduction in sexual interest. Depressed persons may also experience diminished ability to maintain sexual arousal or achieve orgasm. In males with severe depression, the rate of ED might reach 90%.[9] Assessment of nocturnal penile tumescence has been used as a measure of erectile capacity. Thase et al.[10] studied a sample of 34 male outpatients with major depression and an age-matched group of 28 healthy controls. Diminution of penile rigidity was found in approximately 40% of the depressed outpatients in addition to a reduction in the duration (in minutes) of sleep-related tumescence (nocturnal penile tumescence time) when compared to the healthy controls.[11] These findings were replicated in a second sample of 51 depressed male outpatients.[11] Thus, it seems that depression in men is associated with a potentially reversible decrease in erectile capacity which may be associated with significant SD.

Depression is widely treated with antidepressants. The treatment is usually prolonged, for a period of months to years and demands cooperation from the patient. Selective serotonin reuptake inhibitors (SSRIs) replaced gradually tricyclic antidepressants (TCAs). SSRIs have less side effects than TCAs, mainly due to lack of the anticholinergic side effects. However, one of the salient side effects of SSRIs is impairment of sexual function. The most prominent effect is inhibition of orgasm, but also impairment in desire and arousal, and as a consequence, the feeling of satisfaction from sexual function is negatively affected.[3]

The evaluation of the prevalence of SD in depression is complicated by the fact that both medications and the depressive state itself may affect sexual desire and arousal.

There are various studies that have glanced into SD in depression. However, studies of the prevalence of SD in patients with depression in North East, India, are rare.

Aims and objectives

To assess the prevalence of SD in cases of depressionTo check the correlation of severity of depression with severity of SD.

 Materials And Methods



The study was a cross-sectional noninterventional hospital-based study conducted for a period of 1 year. A case in the present study was defined as “any sexually active patient attending the outpatient Department of Psychiatry of Silchar Medical College and Hospital and fulfilling the diagnostic criteria for depressive disorder or recurrent depressive disorder according to International Classification of Diseases-10 (ICD-10).” The sample size for the patient group was decided as per universal sampling. A total of 145 depressed patients who attended the outpatient department from December 2019 to November 2020 were screened. Only those patients diagnosed as having depression as per the ICD-10 criteria by the consultant psychiatrist, who were sexually active and willing to participate in the study were enrolled in the study after obtaining informed consent. Patients with secondary depression, debilitating physical illnesses, intellectual disability, severe cognitive impairment, and severe depressive episode with psychotic symptoms or active suicidal ideas were excluded from the study. The patient sample size was therefore 100 patients satisfying the inclusion and exclusion criteria. A standardized pro forma for entering the sociodemographic variables was utilized for collecting data from these patients, which was designed and standardized in the Department of Psychiatry. Beck's Depression Inventory was used for assessing the severity of depression, and Arizona Sexual Experience Scale (ASEX) was used to assess the presence or absence and severity of SD. ASEX was administered by same sex interviewers – the authors, who are male, of the study in the case of male patients, and by the clinical psychologist of the Department of Psychiatry, Silchar medical college, who is female, in the case of female participants. For all cases, privacy of interview and confidentiality were strictly maintained.

Description of tools

A standard pro forma describing the sociodemographic variables was used which was designed and standardized in the Department of PsychiatryDiagnosis of depressive disorder was carried out in accordance with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)

ICD-10 classification of mental and behavioral disorders criteria – these criteria were used to diagnose depressive episode and recurrent depressive disorder and their subtypes. Patients with a diagnosis of depressive episode (F32) or recurrent depressive disorder (F33) were selected.

Beck Depression Inventory (BDI-II) to assess severity of depression created by Beck et al. is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression[12]

The BDI-II was a 1996 revision of the BDI, developed in response to the American Psychiatric Association's publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, which changed many of the diagnostic criteria for major depressive disorder

Like the BDI, the BDI-II also contains 21 questions, each answer being scored on a scale value of 0–3. Higher total scores indicate more severe depressive symptoms. The standardized cutoffs used differ from the original:

0–13: minimal depression14–19: mild depression20–28: moderate depression29–63: severe depression.

One measure of an instrument's usefulness is to see how closely it agrees with another similar instrument that has been validated against information from a clinical interview by a trained clinician. In this respect, the BDI-II is positively correlated with the Hamilton depression rating scale with a Pearson r = 0.71, showing good agreement. The test was also shown to have a high 1-week test–retest reliability (Pearson r = 0.93), suggesting that it was not overly sensitive to daily variations in mood. The test also has high internal consistency (α =0.91). As the primary language of the participants was Bengali, the BDI-II scale was translated into Bengali and back translated into English, for determining the linguistic validity of the translated version.

ASEX to assess the SD

The ASEX is a brief 5-item questionnaire designed to measure sexual functioning in the following domains: sexual drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm over the past week.[13] Items are rated on a 6-point scale ranging from 1 (hyperfunction) through to 6 (hypofunction), providing a total score range between 5 and 30. A total score >18, or a score ≥5 (very difficult) on any single item or any three items with individual scores ≥4 is indicative of clinically significant SD.

Analysis of data

The analysis was done by descriptive and inferential statistics with P < 0.05 considered as significant. Pearson correlation analysis was done to find the correlation between BDI and ASEX scores. Data were analysed using SPSS version 23.0.

 Results



[Table 1] describes the sociodemographic variables of the participants of the study. The whole sample (n = 100) had a mean ± SD, age of 36.92 ± 14.40 years. About 53% of the participants were female, majority belonged to a semiurban background (43%), most of them were married (50%), and majority belonged to a lower-middle socioeconomic status (33%).{Table 1}

Twenty-seven per cent of the participants had mild depression, while 37% had moderate depression and 36% had severe depression [Table 2].{Table 2}

Female participants [Figure 1] reported a 50.9% prevalence of sexual dysfunction (n = 27) while male reported a slightly lower (48.9%) prevalence of sexual dysfunction (n = 23).{Figure 1}

The mean BDI score was 28.28 ± 11.312, with a higher mean score for males (31.40 ± 12.496) than females (25.51 ± 9.425). The mean ASEX total score was 17.28 ± 4.495 for males and 16.91 ± 3.967 for female participants.

On Pearson correlation test, total BDI scores correlated positively with total ASEX scores significantly (r = 0.686, P < 0.001)

 Discussion



The present study aimed to assess the prevalence of sexual dysfunctions in patients with depression.

In the present study, the sample population (n=100) had a mean age of 36.92±14.40 years. In our study, we found that 62.5% of the participants in the age group 49-65 years and 57.1% of the participants in the age group 29-38 years had comorbid sexual dysfunction in depression. This is in line with the studies by Song et al. and Chen et al. which suggested that advancing age was a risk factor for sexual dysfunction in patients with depression.[14],[15] 53% of the subjects were female, majority belonged to a semi urban background (43%), most of them were married (50%), and majority belonged to a lower middle socioeconomic status (33%). This is most likely representative of a sample population of the catchment area of the present study.

We have found that Mild and Moderate Depression is more in Females whereas Severe Depression is more common in Males [Figure 2]. Both Mean BDI-II score and mean ASEX scores were slightly higher in males compared to females [Table 3]. In the present study, a significant percentage of patients with depressive disorder reported having sexual dysfunction (50%). This was similar to the findings of the prospective Zurich Cohort[16] which showed that the prevalence of sexual problems in patients with depression to be 50%. However, both Thakurta et al.[17] and Kendurkar and Kaur[18] reported a higher prevalence of sexual dysfunction in patients with depression in their studies (71.66% and 76%, respectively). We found that Female participants reported a slightly higher prevalence of sexual dysfunction (50.9%) while male reported a slightly lower (48.9%) prevalence of sexual dysfunction [Table 4]. Lower rates of dysfunction in males (48.9% vs. 66.7%) and females (50.9% vs. 75%) were observed compared with the study by Thakurta et al.[17] The variations in prevalence can be due to differences in the inclusion criteria and techniques of assessment.{Figure 2}{Table 3}{Table 4}

A strong correlation was found [Figure 3] and [Table 3] and [Table 5] between total BDI scores and total ASEX scores (r=0.686, P<0.001). This was similar to the findings by Thakurdesai and Sawant, 2018[19] and Thakurta et al., 2012.[17] However, Kennedy and Rizvi[20] did not find any association between the two. Depression and sexual functioning have a bidirectional relationship. Due to low mood, anhedonia, fatigue, and impaired social functioning in depression, as well as treatment in the form of antidepressants themselves, there can be increased incidence of sexual dysfunctions. Often, problems in sexual functioning themselves can lead to depressive features.{Figure 3}{Table 5}

Significance

Sexual Dysfunction is a part of Depressive Symptomatology and every patient should be encouraged to discuss about their sexual functioning and satisfaction level. At times Antidepressant drugs may also cause Sexual Dysfunction. Clinicians must be aware of this facts and try to avoid those drugs known to cause sexual dysfunction.

 Conclusion



It was found in this study that there is a significant prevalence of sexual dysfunctions in patients with depressive disorders, the prevalence being slightly high for females compared to males. Depression was found to correlate with sexual functioning and more severe the depression, the greater the intensity of problems in sexual functioning. Thus, mental health-care professionals must inquire regarding sexual functioning sensitively. As patients do not spontaneously report sexual issues, inquiring for sexual history as a part of thorough assessment becomes important. Addressing sexual problems would make management more comprehensive.

Our study has few limitations. The sample size was small and reflected a selection bias of the patient group seen at a tertiary care hospital. There was no control group, and confounding factors such as treatment with varying antidepressants on a small section of the study population were also not accounted for.

Limitations

Our study has few limitations. The sample size was small and reflected a selection bias of the patient group seen at a tertiary care hospital. There was no control group, and confounding factors such as treatment with varying antidepressants on a small section of the study populationwere also not accounted for.

Ethical approval

The study was approved by the Institutional Ethics Committee of Silchar Medical College and Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999;281:537-44.
2Peuskens J, Sienaert P, De Hert M. Sexual dysfunction: The unspoken side effect of antipsychotics. Eur Psychiatry 1998;13:23s-30s.
3Rosen RC, Lane RM, Menza M. Effects of SSRIs on sexual function: A critical review. J Clin Psychopharmacol 1999;19:67-85.
4Clayton AH, Pradko JF, Croft HA, Montano CB, Leadbetter RA, Bolden-Watson C, et al. Prevalence of sexual dysfunction among newer antidepressants. J Clin Psychiatry 2002;63:357-66.
5Osvath P, Fekete S, Voros V, Vitrai J. Sexual dysfunction among patients treated with antidepressants – A Hungarian retrospective study. Eur Psychiatry 2003;18:412-4.
6Kaplan HS. Anxiety and sexual dysfunction. J Clin Psychiatry 1988;49 Suppl: 21-5.
7Letourneau EJ, Schewe PA, Frueh BC. Preliminary evaluation of sexual problems in combat veterans with PTSD. J Trauma Stress 1997;10:125-32.
8Casper RC, Redmond DE Jr., Katz MM, Schaffer CB, Davis JM, Koslow SH. Somatic symptoms in primary affective disorder. Presence and relationship to the classification of depression. Arch Gen Psychiatry 1985;42:1098-104.
9Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: Results of the massachusetts male aging study. J Urol 1994;151:54-61.
10Thase ME, Reynolds CF 3rd, Jennings JR, Frank E, Howell JR, Houck PR, et al. Nocturnal penile tumescence is diminished in depressed men. Biol Psychiatry 1988;24:33-46.
11Thase ME, Reynolds CF, Jennings JR, Frank E, Garamoni GL, Nofzinger EA, et al. Diminished nocturnal penile tumescence in depression: A replication study. Biol Psychiatry 1992;31:1136-42.
12Beck AT, Steer RA, Brown GK. Manual for the beck depression inventory-II. Vol. 1. San Antonio, TX: Psychological Corporation; 1996. p. 82.
13McGahuey CA, Gelenberg AJ, Laukes CA, Moreno FA, Delgado PL, McKnight KM, et al. The arizona sexual experience scale (ASEX): Reliability and validity. J Sex Marital Ther 2000;26:25-40.
14Song SH, Jeon H, Kim SW, Paick JS, Son H. The prevalence and risk factors of female sexual dysfunction in young korean women: An internet-based survey. J Sex Med 2008;5:1694-701.
15Chen KC, Yeh TL, Lee IH, Chen PS, Huang HC, Yang YK, et al. Age, gender, depression, and sexual dysfunction in Taiwan. J Sex Med 2009;6:3056-62.
16Angst J. Sexual problems in healthy and depressed persons. Int Clin Psychopharmacol 1998;13 Suppl 6:S1-4.
17Thakurta RG, Singh OP, Bhattacharya A, Mallick AK, Ray P, Sen S, et al. Nature of sexual dysfunctions in major depressive disorder and its impact on quality of life. Indian J Psychol Med 2012;34:365-70.
18Kendurkar A, Kaur B. Major depressive disorder, obsessive-compulsive disorder, and generalized anxiety disorder: Do the sexual dysfunctions differ? Prim Care Companion J Clin Psychiatry 2008;10:299-305.
19Thakurdesai A, Sawant N. A prospective study on sexual dysfunctions in depressed males and the response to treatment. Indian J Psychiatry 2018;60:472-7.
20Kennedy SH, Rizvi S. Sexual dysfunction, depression, and the impact of antidepressants. J Clin Psychopharmacol 2009;29:157-64.