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32 Int J Res Med. 2017; 5(4); 32-37 e ISSN:2320-2742 p ISSN: 2320-2734

Sexual Dysfunction In Drug Free Patients Suffering From

Depression

Chirag K. Barot1*, Sunil Kumar Ahuja2, Prashant M. Mangla3

1

Assistant Professor, 2,3Resident doctor, Department of Psychiatry, Medical College, Baroda.

INTRODUCTION

Sexual function is our physiological capacity for desire, arousal and orgasm. Regardless of what factors enter into sexual interest and performance, normal sexual function requires the integrity of the genitalia, the reliable co-ordination of blood flow, the activation of various smooth and skeletal muscles and the stimulation of local secretions. This is linked with cognitive processes attending to the sexual meaning of what is happening. Problem anywhere in the entire sequence may lead to sexual problems. Many factors influence the reported incidence of sexual dysfunction. First, the method of enquiry; for example, in a prospective study of depressed out-patients, the incidence of sexual dysfunction was 14% when relying on spontaneous reporting, but 58% when patients were questioned directly by doctors1. Second, the expectations people have of their sexual performance and their willingness to discuss problems varies widely between different cultures2. Third, many terms used to define sexual

*Corresponding Author:

Chirag K. Barot

Department of Psychiatry Medical College Baroda, Vadodara

Email: gladiatorjahaan@gmail.com

dysfunction are subjective and dependent on ideas of what is normal. Finally, temporal trends can occur as increased awareness of sexual matters and availability of medical treatments increase the number who perceive themselves as suffering from sexual dysfunction3. Adequate sexual expression is an essential part of many human relationships, and may enhance quality of life and provide a sense of physical, psychological and social well-being. Sexual dysfunctions are highly prevalent, affecting about 43% of women and 31% of men4. Hypoactive sexual desire disorder has been reported in approximately 30% of women and 15% of men in population-based studies, and is associated with a wide variety of medical and psychologic causes. Sexual arousal disorders, including erectile dysfunction in men and female sexual arousal disorder in women, are found in 10% to 20% of men and women, and is strongly age related in men. Orgasmic disorder is relatively common in women, affecting about 10% to 15% in community-based studies. In contrast, premature ejaculation is the most common sexual complaint of men, with a reporting rate of approximately 30% in most studies 5. Sexual impairment appears to be a frequent and underestimated problem in psychiatric patients with a high prevalence across all diagnoses, particularly in depression6-8. Sexual

ORIGINAL ARTICLE

ABSTRACT

BACKGROUND: Normal sexual behavior brings pleasure to oneself and one’s partner, involves stimulation of

primary sex organs, is devoid of inappropriate feelings of guilt or anxiety and is not compulsive. Sexual dysfunction is influenced by a number of factors, mental illness being one of them. Impairment in sexual dysfunction is frequent and underestimated in patients with mental disorders, particularly in those with mood disorders. Although it is important to study and document the effects antidepressant medication on sexual functioning, it is equally important to establish a baseline level of sexual interest and sexual function in patients who suffer from major depressive disorder prior to the initiation of treatment with antidepressant medication.

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33 Int J Res Med. 2017; 5(4); 32-37 e ISSN:2320-2742 p ISSN: 2320-2734

dysfunction is reported to be two to three times as likely in a depressed population as in a normal population6, 9. Prevalence rates of sexual dysfunctions ranging from 36% to 78% have been reported in drug-naïve depressed patients and depressed mood plays a role in the etiology of sexual dysfunction7, 8, 10-12. The rate of sexual dysfunction in depressed women has been estimated as high as 70-80%10, 11. In women, sexual desire was found to be the sexual sphere predominantly affected by depressive illness, while in male patients both sexual desire and erectile function tend to be impaired. Loss of libido has been reported in various studies to affect from 25 to 75% of patients with unipolar depression and its prevalence appears to be correlated with the severity of depression. Significantly higher liftetime prevalence rates of affective disorders were found in patients with hypoactive sexual desire disorder (HSDD) with respect to matched controls; further, the onset of the depressive disorder almost always coincided with or preceded the HSDD onset13. Disorders of arousal also appear to be relatively common in both men and women with major depression, of whom about 25% may experience problems with erection or lubrication. The scant available data regarding orgasmic difficulties in patients with depression who have not yet taken antidepressant medication suggest that these sexual dysfunctions are more common than in the general population

14-16

. Sexual dysfunction in depression is common. It is unclear whether these symptoms reflect path physiological involvement of hypothalamic or neuroendocrine function or simply indicate another manifestation of anhedonia. The former explanation is suggested by observation that reduced libido may be the most persistent depressive symptom during treatment continuing even after mood, hedonia and self-esteem have returned to baseline. Disturbances in sexual function contribute to the strain that mood disorders place upon marital relationship17. Epidemiological and clinical studies show that depression is associated with impairments of sexual function and satisfaction, even in untreated

patients. In a study, the rate of sexual dysfunction in MDD (76%) had been found to be nearly 3 times higher than those in healthy subjects (30%). Subjects with MDD experienced the highest frequency of low desire (54%) and low sexual excitement (42%) 18. According to a review article, the incidence of moderate to complete erectile dysfunction is estimated to be nearly 90%, 60%, and 25% in men with severe, moderate, and minimal depression respectivelyn. Another review article concluded that low sexual desire has been reported in 25% to 75% of patients with depression who are not taking medication, and its prevalence appears to be related to the severity of depression. Some patients with depression experience increased sexual desire, which may be associated with unrecognized hypomania or mixed states. Disorders of arousal are relatively common in patients with erection or lubrication. Although attention has been focused on anorgasmia due to antidepressant medications, the prevalence of orgasmic dysfunction may be higher than average in patients with depression before treatment20.

AIMS AND OBJECTIVES

1.To study the sexual dysfunction in drug naïve / drug free patients suffering from depression.

2.To compare the sexual dysfunction between patients suffering from depression and healthy controls.

MATERIALS AND METHODS

The study sample was taken from the outpatient department and inpatients of Department of Psychiatry, S.S.G. Hospital, and H.M.H., Vadodara and consisted of 60 patients suffering from Depression as per DSM-IV-TR criteria. The study was carried out between January 2010 to September 2011.

Inclusion Criteria :

Patients coming to OPD for consultation and diagnosed as Depression according to DSM-IV-TR.

Patients who gave informed consent for study.

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34 Int J Res Med. 2017; 5(4); 32-37 e ISSN:2320-2742 p ISSN: 2320-2734

examination during the preceding 3 months).

 Were anti-depressant free for a minimum of 2 weeks prior to treatment (5 weeks in case of Fluoxetine).

Exclusion Criteria :

 Patients with exposure to any psychotropic medication in previous month.

 Patients on any drugs that affect sexual function.

 Patients having psychotic symptoms or history of other psychiatric illness.  Patients who were pregnant or within 2

months of postpartum period.

Hamilton’s Depression Rating Scale (Ham-D17): Severity of illness was assessed using Hamilton’s depression rating scale. The HAM-D was developed in the early 1960s to monitor the severity of major depression, with a focus on somatic symptomatology. Items on HAM-D are scored from 0 to 2 or from 0 to 4, with total score ranging from 0 to 50. Scores of 7 or less may be considered normal, 8 to 13 mild, 14 to 18 moderate, 19 to 22 severe, and 23 and above very severe21.

Arizona Sexual Experiencing Scale (Asex): The ASEX was developed in the University of Arizona for assessing sexual dysfunctions. It can be used for heterosexual and homosexual populations, as well as for those without sexual partners. 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. Items are rated on a 6-point scale ranging from 1 (hyperfunction) through 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 sexual dysfunction22.

Statistical Analysis Of Data : Data thus collected was entered in the master chart and was analyzed using MedCalc –

version 11.1.0.0. Appropriate statistical tests were performed.

RESULTS AND DISCUSSION

Demographic Profile of the Study Population :

Age wise distribution: Mean age of patients with Depression was 38.96 (SD=13.53) years and mean age of control group was 38.5 (SD=12.89) years.

Sex wise distribution: in patients with Depression 53.3% were male. Similarly in control group 55.5% were male. Education level: in the study group,

6.6% of the subjects were illiterate, 68.3% were educated up to secondary level, 18.3% up to higher secondary level and 6.6% up to graduation level; whereas in the control group, 3.7% were illiterate, 68.5% were educated up to secondary level, 22.2% up to higher secondary level and 5.5% up to graduation level.

Marital status: in the study group, 63.3% were married and 36.6% were unmarried, divorced/separated and widow; whereas in the control group 68.5% subjects were married and 31.4% were unmarried, divorced/separated and widow.

Study of sexual dysfunction in patients

with depression, based on their

Demographic profile:

Table 1: Comparison of sexual

dysfunction in patients with depression based on marital status and gender

Demographic profile

No. of patients

(N)

Sexual dysfunction

n (%)

Chi-square

value P value

Marital status

Married 38 27 (71.05) 1.02 0.31

Unmarried/wid

ow/separated

22 12 (54.5)

Gender

Male 32 17 (53.1) 32.05 0.07

Female 28 22 (78.5)

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35 Int J Res Med. 2017; 5(4); 32-37 e ISSN:2320-2742 p ISSN: 2320-2734

Table 2: Marital status and gender wise comparison of mean ASEX total score of patients with depression

Demographic profile

Patients with depression

(N=60)

ASEX total score (mean

± SD)

P value

Marital status

Married 38 20.84 ± 4.075 0.99 Unmarried/wido

w/separated

22 18.90 ± 4.72

Gender

Male 32 18.15 ± 3.90 0.0002 Female 28 22.35 ± 3.83

Mann-Whitney test was applied. At 95% confidence level for the median and two tailed probability (P=0.99) indicates that the difference of mean ASEX total score

between married &

unmarried/widow/separated population was statistically not significant. On gender wise comparison, difference in mean ASEX total score was found to be significant (P=0.0002).

Sexual dysfunction in patients with depression and control:

Table 3: comparison of sexual

dysfunction between controls and

patients with depression ASEX item Patients with

Depression N=60, n (%)

Control N=54, n (%)

P value

Desire 33 (55) 5 (9.2) <0.0001 Excitement 26 (43.3) 3 (5.55) <0.0001 Penile erection/vaginal

lubrication

24 (40) 12 (22.2) 0.06

Orgasm 21 (35) 7 (12.9) 0.01 Orgasm satisfaction 25 (41.6) 7 (12.9) 0.001

Total score ≥ 18 39 (65) 11 (20.3) <0.0001 Sexual dysfunction 39 (65) 16 (29.6) 0.0003

Male subjects 32 30

Desire 14 (43.7) 02 (6.6) 0.002 Excitement 09 (28.1) 01 (3.3) 0.021 Penile erection 08 (25) 06 (20) 0.867 Orgasm 04 (12.5) 03 (10) 0.927 Orgasm satisfaction 08 (25) 03 (10) 0.225 Total score ≥ 18 17 (53.1) 05 (16.6) 0.006 Sexual dysfunction 17 (53.1) 07 (23.3) 0.031

Female subjects 28 24

Desire 19 (67.8) 03 (12.5) <0.0001 Excitement 17 (60.7) 02 (8.3) 0.0003 Vaginal lubrication 16 (57.1) 06 (25) 0.03

Orgasm 17 (60.7) 04 (16.6) 0.003 Orgasm satisfaction 17 (60.7) 04 (16.6) 0.003 Total score ≥ 18 22 (78.5) 06 (25) 0.0003 Sexual dysfunction 22 (78.5) 09 (37.5) 0.0064

Among healthy individuals, sexual dysfunction was reported by 29.6% of subjects (23.3% of males and 37.5% of females). Most female controls reported difficulty in vaginal lubrication (25%) followed by difficulty in achieving orgasm (16.6%) and low orgasm satisfaction

(16.6%), while among male controls maximally reported complaint was difficulty in penile erection (20%). Difficulty in attaining sexual excitement was the least prevalent sexual dysfunction among healthy subjects. Among patients with depression, sexual dysfunction was reported by 65% of subjects. Most commonly reported sexual dysfunction was low desire (55%), followed by difficulty in attaining sexual excitement (43.3%). Male patients with depression had maximal complaints of low desire (43.7%). Similarly, in female patients with depression low desire (67.8%) was most frequently reported, followed by around similar frequency in other phases of sexual dysfunction. When compared with controls, sexual dysfunction was more in patients with depression in all phases of sexual response cycle. On applying chi-square test, P value < 0.05 was obtained, which indicates the difference in sexual dysfunction between patients suffering from depression and control group, was statistically significant in almost all items if ASEX across both gender.

These findings are similar to other reported studies {15, 18}.

Table 4: Comparison of Mean ± SD ASEX scores of the subjects

ASEX item Control (N=54)

Patients with Depression

(N=60)

P value

Desire 2.83 ± 0.99 4.25 ± 1.026 <0.0001 Excitement 2.79 ± 8.8 3.86 ± 11.89 <0.0001

Penile erection/vaginal

lubrication

3.11 ± 1.18 3.98 ±1.008 0.0001

Orgasm 3.01 ± 1.02 3.93 ± 0.91 <0.0001 Orgasm

satisfaction

3.09 ± 1.023 4.08 ± 0.89 <0.0001

Total score 14.83 ± 4.67 20.13 ± 4.38 <0.0001

Male subjects 30 32 <0.0001

Desire 2.66 ± 0.94 3.96 ± 1.04 <0.0001 Excitement 2.66 ± 0.82 3.40 ± 1.19 <0.0001 Penile erection 3.06 ± 1.18 3.62 ± 0.099 0.02

Orgasm 2.73 ± 0.92 3.40 ± 0.70 0.04 Orgasm

satisfaction

2.86 ± 0.97 3.75 ± 0.82 0.0008

Total score 14 ± 4.59 18.18 ± 3.94 0.0005

Female subjects 24 28 0.0006

Desire 3.04 ± 1.041 4.57 ± 0.92 <0.0001 Excitement 2.95 ± 0.95 4.39 ± 0.95 <0.0001

Vaginal lubrication

3.16 ± 1.20 4.39 ± 0.87 0.0006

Orgasm 3.37 ± 1.055 4.53 ± 0.74 0.0002 Orgasm

satisfaction

3.37 ± 1.055 4.46 ± 0.83 0.0006

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36 Int J Res Med. 2017; 5(4); 32-37 e ISSN:2320-2742 p ISSN: 2320-2734

Subjects with Depression scored significantly higher in all ASEX items. In Mann-Whitney test this difference in scores was found to be significant across both genders. These findings are similar to

another previously conducted cross-sectional study which found that subjects with depression scored significantly higher in all ASEX items and difference was statistically significant {15}.

Relationship between age and ASEX score:

Table 5: Association of ASEX item score with age in patients suffering from depression and in control group

ASEX item Age of Control group Age of Patients with Depression

Correlation coefficient Regression Correlation coefficient Regression

R P R2 P R P R2 P

Desire 0.76 <0.0001 0.68 <0.001 0.37 0.003 0.14 0.003 Excitement 0.81 <0.0001 0.75 <0.001 0.27 0.033 0.09 0.018 Penile erection/vaginal

lubrication

0.86 <0.0001 0.75 <0.001 0.43 0.0007 0.21 <0.001

Orgasm 0.72 <0.0001 0.55 <0.001 0.20 0.11 0.09 0.018 Orgasm satisfaction 0.70 <0.0001 0.53 <0.001 0.41 0.0014 0.21 <0.001

Total score 0.83 <0.0001 0.77 <0.001 0.39 0.002 0.19 <0.001 ASEX total score in males 0.91 <0.0001 0.87 <0.001 0.33 0.05 0.15 0.02 ASEX total score in females 0.88 <0.0001 0.83 <0.001 0.67 0.0004 0.44 <0.001

To find the relation between age and sexual dysfunction, Spearmen correlation coefficient was applied. In control group, Rank correlation (R>0.50) and P value <0.0001 was obtained, which indicates moderate to very good relation between age and sexual dysfunction. Whereas in patients suffering from depression, fair linear relation was found (R=<0.50) except in females where moderate relation was found between age and ASEX total score (R=>0.50).

SUMMARY AND CONCLUSIONS In this study, a total of 60 patients [drug naïve or antidepressant free for a minimum of 2 weeks prior to treatment (5 weeks in case of Fluoxetine) suffering from depression were assessed for sexual dysfunction and compared with controls [healthy controls were taken from relative of patient]. Assessment included a semi-structured questionnaire consisting of demographic profile, assessment of severity of illness using HAM-D17 rating scale, and Arizona Sexual Experiencing Scale for assessment of sexual dysfunction.

The salient findings of the study are as follows:

 Healthy subjects reported considerable sexual dysfunction despite being physically and psychiatrically well.  Depression affects all the phases of

sexual functioning.

 Patients with depression have more sexual dysfunction than controls in all

phases of sexual functioning cycle, across both genders.

In control group, there was moderate to very good relation between increasing age and sexual dysfunction in all phases of sexual functioning whereas in patients suffering from depression fair degree of linear relation was found.

Finally, sexual dysfunction occurs in significant amount in patients with depression. This dysfunction must be explored in detail for proper management of patient.

REFERENCES

1. Montejo-Gonzalez AL, L. G. (1997). SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. J Sex Marital Ther, 23, 176-94.

2. Bhugra D, D. S. (1993). Sexual dysfunction across cultures. Int Rev Psychiatry, 5, 243-52.

3. Baldwin, D. S. (2001). British Medical Bulletin, 57, 81-99.

4. Laumann EO, P. A. (1999). Sexual dysfunction in the United States: prevalence and predictors. JAMA, 281, 537-44.

5. Rosen R. (2000). Curr Psychiatry Rep, 2(3), 189-195.

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7. Cohen S, K. K. (2007). Sexual impairment in psychiatric inpatients:

Focus on depression.

Pharmacopsychiatry, 40, 58-63.

8. Perlman CM, M. L. T. (2007). Prevalence and predictors of sexual dysfunction in psychiatric inpatients. Psychosomatics, 48, 309-18.

9. Corona G, R. V. (2008). Association between psychiatric symptoms and erectile dysfunction. J Sex Med, 5, 458-68.

10.Phillips RL Jr, S. J. (2000). Depression and sexual desire. Am Fam Physician, 62, 782-6.

11.Bonierbale M, L. C. (2003). The ELIXIR study: Evaluation of sexual dysfunction in 4,557 depressed patients in France. Curr Med Res Opin, 19, 114-24.

12.Osvath P, F. S. (2003). Sexual dysfunction among patients treated with antidepressant. Eur Psychiatry, 4, 412-4.

13.Schreiner-Engel P, S. R. (1986). Lifetime psychopathology in individuals with low sexual desire. Journal of Nervous and Mental Disease, 174, 646-51.

14.Mathew RJ, W. M. (1982). Sexual dysfunctions in depression. Arch Sex Behav, 11, 323-8.

15.Casper RC, R. E. (1985). Somatic symptoms in primary affective disorders: presence and relationship to the classification of depression. Arch Gen Psychiatry, 42, 1098-104.

16.Angst, J. (1998). Sexual problems in healthy and depressed persons. Int Clin Psychopharmacol, 13 (6 suppl), S1-4. 17.Eugene H Rubin, C.F. (2005).

Blackwell’s neurology and psychiatry access series.

18.Arvind Kendurkar, M. a. (2008). Major Depressive Disorder, Obsessive Compulsive Disorder, and Generalized Anxiety Disorder : Do the Sexual Dysfunctions Differ? Prim Care Companion J Clin Psychiatry, 10(4), 299-305.

19.Sabsigh, R. (2001). Sexual Dysfunction and Depression: Etiology, Prevalence and Treatment. Current Urology Reports, 2, 463-467.

20.Katherine Williams, M. a. (2006). CNS Spectr, 8 (suppl 9), 19-23.

21.Sadock, B. J., & Sadock, V. A., & Ruiz, P. (2009). Kalpan & Sadock’s

Comprehensive Textbook of

Psychiatry, 9th Edition. Lippincott Williams & Wilkins.

22.McGahuey CA, G. A. (2000). The Arizona Sexual Experience Scale (ASEX): reliability and validity. J Sex

Figure

Table 1: Comparison of sexual dysfunction in patients with depression based on marital status and gender

References

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