International Journal of Impotence Research (2009) 21, 235–239 & 2009 Nature Publishing Group All rights reserved 0955-9930/09 $32.00 www.nature.com/ijir
ORIGINAL ARTICLE
Erectile dysfunction in a sample of patients attending a psychiatric outpatient department KS Mosaku and DI Ukpong Department of Mental Health, Obafemi Awolowo University, Ile-Ife, Osun, Nigeria
To assess the prevalence of erectile dysfunction among a sample of patients attending a psychiatric clinic, we administered the International Index of Erectile Function on 108 male patients attending the clinic. We also obtained sociodemographic and clinical variables from the patients. The mean age of the patients studied was 39.6 (s.d. ¼ 11.6), with a mean duration of illness of 10.24 (s.d. ¼ 8.2) years. There were 46.8% schizophrenics; other diagnoses include bipolar affective disorder, recurrent depressive disorder and substance use disorder. The prevalence of erectile dysfunction was 83%. Age, marital status, current medications and the presence of comorbid medical conditions were significantly associated with erectile dysfunction; however, only age and marital status significantly predicted erectile dysfunction. We concluded that erectile dysfunction is highly prevalent among patients attending the psychiatric clinic, as such inquiries about sexual function should be routinely carried out by clinicians. International Journal of Impotence Research (2009) 21, 235–239; doi:10.1038/ijir.2009.16; published online 11 June 2009 Keywords: psychiatric; erectile dysfunction; schizophrenia; age; marital status
Introduction Sexual health and function are important determinants of the quality of life. Erectile dysfunction is defined as the inability to achieve or maintain an erection sufficient for sexual activity.1 The effect of erectile dysfunction on patients and their partners can be devastating. A cross-sectional, populationbased, nationally representative survey in a general community setting estimated the overall prevalence of erectile dysfunction as 22% in the United States of America.2 Studies in the United Kingdom, Japan and Denmark reported prevalence rates of 32, 26 and 19%, respectively.3 Erectile dysfunction, although essentially a vascular disease, is often associated with other vascular diseases such as diabetes, hypertension, coronary artery diseases, atherosclerosis and hyperlipidemia. For all the above conditions, endothelial dysfunction is recognized as the common denominator;
Correspondence: Dr KS Mosaku, Department of Mental Health, Obafemi Awolowo University, Off Ibadan Road, Ile-Ife, Osun 220005, Nigeria. E-mail:
[email protected] Received 2 February 2009; revised 27 March 2009; accepted 27 March 2009; published online 11 June 2009
thus, a patient with erectile dysfunction has a vascular problem until proven otherwise.4–6 However, erectile dysfunction may also result from neurological conditions, such as multiple sclerosis, alcoholic neuropathy, spinal cord injury and Parkinson’s disease.1 Common psychiatric conditions that may cause erectile dysfunction include anxiety, major depressive disorder, drugs and alcohol dependence.1 Psychological factors that have been implicated in the etiology of erectile dysfunction include obsessive personality trait, developmental factors such as early sexual experiences and sexual trauma in childhood, poor body image, low self esteem and confidence.7 Erectile dysfunction may also occur as an adverse effect of many commonly prescribed drugs, such as antipsychotics8 and antihypertensives.9 In the United States, it was reported that sexual dysfunction is highly prevalent in men. A report by the Massachusetts Male Aging Study (MMAS),10 which is a community-based survey of men aged 40–70 years, showed that 52% of the respondents reported some erectile difficulty. Complete erectile dysfunction, which was defined as the total inability to obtain or maintain an erection during sexual stimulation, and the absence of nocturnal erections, occurred in 10% of the respondents, whereas lesser degrees of mild and moderate erectile dysfunction occurred in 17 and 25%, respectively.
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Although a rarely studied or discussed issue in our society, a recent community study in Nigeria by Fatusi et al.11 reported a prevalence rate of 43.8% for erectile dysfunction. They also reported that the prevalence increases with age, ranging from 38.5% for age 31–40 years to 63.9% for age 61–70 years. Similarly, a comparative prevalence study of erectile dysfunction in three countries found the ageadjusted prevalence rates among patients attending primary care clinics to be 57.4% in Nigeria, 63.6% in Egypt and 80.8% in Pakistan.12 Psychiatric disorders, especially depression, have reportedly affected the sexual functions of sufferers, and drugs used, both antipsychotics and antidepressants, have been implicated in the high occurrence of sexual dysfunction in the mentally ill.8 This study assesses the prevalence of this condition and associated factors among a sample of patients attending the psychiatric outpatient clinic of a tertiary institution.
Methods The study was conducted among patients attending the psychiatric unit of the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife. The hospital is a tertiary institution with two psychiatric units, with a total bed space of 24, manned by five consultant psychiatrists and one clinical psychologist. Working with the psychiatrists are seven resident doctors; there are also 25 specialist nurses and four social workers attached to the unit. The units have four clinic days, with an average attendance of four new cases per clinic and an average of 50 follow-up patients per clinic. Clearance for the study was obtained from the hospital’s ethical committee. Each respondent included gave a written consent after the objective of the study was explained to them.
Procedure The goal was to include all male patients attending the psychiatric outpatient during the period of the study. Patients who had been on treatment for more than 3 months and those who met the International Classification of Diseases 10th edition diagnostic criteria for specific conditions were included. Acutely ill patients, those with disturbing psychotic symptoms and those who had been on treatment for o3 months were excluded, to allow time for all the patients interviewed to be stable enough to complete the questionnaires. Patients who met the inclusion criteria and who consented to participate in the study were interviewed; seven (6.4%) patients refused to participate in the study, whereas five (4.6%) questionnaires could not be interpreted because they were not International Journal of Impotence Research
completely filled. A total of 96 (89%) questionnaires were included in the analysis. Sociodemographic and clinical information were obtained from them. Each respondent completed the questionnaire on erectile dysfunction. Assistance was given where necessary. Questionnaires Sociodemographic questionnaire: A questionnaire was prepared to obtain sociodemographic variables such as age, marital status, educational level and so on of the respondents. This questionnaire was also used to obtain clinical variables, such as diagnosis, duration of illness, current medication and so on. International Index of Erectile Function: This is a self-administered multidimensional scale for the assessment of erectile dysfunction.13 It has 15 questions that ask about the effect of erection problems on sexual life during the previous 4 weeks. The questions are rated on a scale of 1–5, with 0 indicating no sexual activity, no intercourse or no attempt. The total International Index of Erectile Function (IIEF) score ranged from 0–30; higher scores indicate better sexual functioning. The instrument is organized into the following five domains: erectile function maximum score of 30, erectile dysfunction was defined as score o26; orgasmic function with a maximum score of 10; sexual desire with a maximum score of 10; intercourse satisfaction with a maximum score of 15 and overall satisfaction with a maximum score of 15. The instrument has been used in Nigeria,11 and in this study, a reliability coefficient (cronbach’s alpha) of 0.9201 was obtained. The Yoruba translation of the questionnaire, which was prepared by the backtranslation method, was administered to respondents who could not understand the English version but could read and understand the Yoruba language. Statistics The results were analyzed using the Statistical Package for Social Sciences (SPSS Version 10, Spss Inc., Chicago, Illinois, USA). Descriptive statistics was used, and Chi-squared test (w2) was used to test association between variables where appropriate. Inferential statistics was also used to identify significant predictive variables.
Results The mean age of respondents was 39.6 (s.d ¼ 11.6) years, with a mean duration of illness of 10.2 (s.d. ¼ 8.2) years and mean episodes of illness of 3.7 (s.d ¼ 2.7). Among the respondents, 64.2% were married and 60 (62%) had tertiary education. Distribution by diagnosis showed that 45 (46.8%)
Erectile Dysfunction and the mentally ill KS Mosaku and DI Ukpong
are schizophrenic, 26 (27.2%) have bipolar affective disorder, 15 (15.6%) are depressed and 10 (10.4%) are dependent on psychoactive substances, mainly cannabis. An analysis of the current treatment showed that 65 (67%) are using conventional antipsychotics and 6 (6.2%) are on atypical antipsychotics. An overall erectile dysfunction prevalence of 86.5% on the basis of the erectile function domain of the IIEF was obtained; 32.5% had severe erectile dysfunction (erectile function domain score 0–10), out of which 52% were in the age range of 46–65 years, whereas only 13% were below 30 years of age. Moderate dysfunction (11–21) was present in 21.9% of the respondents, whereas 32.3% had mild dysfunction (22–25). The severity of erectile dysfunction, however, increased with the patients’ age. Variables that were significantly associated with erectile dysfunction in this population are age (w2 ¼ 9.12, P ¼ 0.01), marital status (w2 ¼ 14.67 P ¼ 0.001), current medication (w2 ¼ 8.46, P ¼ 0.04) and the presence of comorbid medical conditions (w2 ¼ 9.84, P ¼ 0.002). The mean scores for the different domains on the IIEF are 13.3 (s.d. ¼ 8.6) in the erectile function domain, 4.7 (s.d. ¼ 3.4) in the orgasmic function domain, 5.9 (s.d. ¼ 2.4) in the sexual desire domain, 6.1 (s.d. ¼ 5.1) in the intercourse satisfaction domain and 4.9 (s.d. ¼ 2.4) in the overall sexual satisfaction domain. An analysis of the association between the other domains on the IIEF and other variables, such as age, marital status, ICD 10 diagnosis, current medication, comorbid medical conditions and duration of illness, showed that age was significantly associated with orgasmic function (w2 ¼ 15.9, df ¼ 4, P ¼ 0.003), sexual desire (w2 ¼ 26.78, df ¼ 4, P ¼ 0.0001) and intercourse satisfaction (w2 ¼ 33.95, df ¼ 4, P ¼ 0.001). Marital status was significantly associated with sexual desire (w2 ¼ 33.73, df ¼ 4, P ¼ 0.001), whereas among the single patients interviewed, 20 (67%) had erectile dysfunction compared with 59 (95%) among the married patients. Duration of illness was significantly associated with orgasmic function (w2 ¼ 28.8, df ¼ 4, P ¼ 0001), sexual desire (w2 ¼ 17.41, df ¼ 4, P ¼ 0.002) and overall satisfaction (w2 ¼ 13.96, df ¼ 4, P ¼ 0.001). There were no other significant associations. Regression analysis with erectile function scores as a dependent variable showed that age (P ¼ 0.001) and marital status (P ¼ 0.01) significantly predicted the occurrence of erectile dysfunction in patients, whereas the duration of illness, type of medication and comorbid conditions did not significantly predict its occurrence.
Discussion Erectile dysfunction is a relatively common condition as shown by studies from different part of the
world.2,3,10,14 Its etiology is multi-factorial, ranging from disease entities such as hypertension,6,9 diabetes15 and depression8 to drugs used in the treatment of various conditions such as antihypertensives16,17 and antipsychotics.16 In this study, we found a prevalence rate of 86.5%. This is high when compared with the findings in a community study by Fatusi et al.,11 who reported an erectile dysfunction rate of 43.8% in their study. Compared with the general population, the prevalence rate reported in this study is significantly higher; this is not surprising, considering the fact that these patients’ conditions and medication may predispose them to developing erectile dysfunction. Sexual dysfunction in the mentally ill is said to be related to the disease itself, to psychosocial factors, medical health and to the use of psychotropic medications.18,19 However, it is instructive to note that only 12% of the patients with erectile dysfunction reported this complaint, either with or without being prompted. Knegtering et al.20 reported in their study that spontaneous reports underestimate the prevalence of sexual dysfunction in patients treated with psychotropic medications. This lack of information on the part of patients may be secondary to the low level of knowledge about erectile dysfunction in the general population and the taboo associated with discussing sexual problems outside the bedroom in our community. We also noted in this study, as in other studies on erectile dysfunction,11,21 that severity increases with age, with the elderly being more affected by this condition. The mean score in all domains of the IIEF questionnaire also reduced with age. Factors that were significantly associated with erectile dysfunction in this study included the patients’ age, marital status, current medication and the presence of other medical conditions such as hypertension and diabetes. Erectile dysfunction being primarily a vascular condition is worsened by the presence of diseases that affect the vessels, such as hypertension and diabetes. Drugs used in treating these conditions have also been implicated in erectile dysfunction. Marital status was also significantly associated with erectile dysfunction in our study, with more married patients complaining about this condition than unmarried patients. This could be a reflection of the fact that a spouse may complain about lack of sexual satisfaction to their mate, who might otherwise not have been bothered about the problem. The occurrence of erectile dysfunction among unmarried patients in this study was also high (67%). Lee et al.22 in their study had suggested that impotency in unmarried patients is mainly psychogenic. However, the etiology of erectile dysfunction in our group of patient needs further exploration. Another factor that was significantly associated with erectile dysfunction is the patient’s current
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medication. Most of the patients interviewed are on conventional neuroleptics (phenothiazines and butyrophenones); both groups of medications are recognized as having some effect on erectile function and sexual satisfaction, because of the effect they have on the anterior pituitary and the hypothalamus.10,23 The duration of the patients’ illness, which is also an indication of the duration of medication use, is also significantly associated with orgasmic functions, sexual desires and overall sexual satisfaction. Thus, the duration of antipsychotics use may, in part, explain the high prevalence of sexual dysfunction found in this study. However, it was noticed that a specific diagnosis of the respondents was not significantly associated with erectile dysfunction. Although depression has been associated with sexual problems,8 the patients used in this study are relatively stable patients who had been on treatment for some time and who do not have active symptoms. Among the patients studied, age and marital status were the variables that significantly predicted the occurrence of erectile dysfunction. The Massachusetts Male Aging Study,10 an epidemiological community-based study among healthy men in the United States, reported that age is an important variable in erectile dysfunction; other studies among healthy individuals also reported similar findings.3,11,24 A study by Naya et al.,15 among patients on renal dialysis, reported that aging was an important predictor of erectile dysfunction among these patients. Thus, aging in the presence of other known risk factors for erectile dysfunction, such as the use of antipsychotics and antidepressants, increases the possibility of the occurrence of erectile dysfunction. Thus, with the high level of prevalence of erectile dysfunction found in this study, and the relationship between satisfaction with sexual function and quality of life, it becomes important that patients should be asked questions about their sexual functioning. Many barriers such as the influence of culture in doctor–patient relationship, gender and age differences between the doctor and the patient affect the clinician while asking information on patients’ sexual life. Another factor is the inadequate consultation time due to patient load. Although on the part of the patient, reluctance and embarrassment prevent them from complaining, there is also societal attitude toward discussing sexual matters, as well as the cost of treatment.25 There is, therefore, a need for vigilance and awareness on the part of the clinician who should also be familiar with various treatment options now available, as this will give them more confidence to ask questions on patients’ sexual functioning. Thus, continuous education of both the clinician and patients is needed. A major limitation of this study is the fact that dosage of current medication was not taken into consideration in the assessment of patients, espe-
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cially in light of the fact that erectile dysfunction is said to be dose related.22 Another limitation of this study is that it did not assess for other organic etiological factors of erectile dysfunction.
Conflict of interest Authors declare no conflict of interest.
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