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Clinical Interventions in Aging Dove Press

The correlation between emotional distress and aging males symptoms at a psychiatric outpatient clinic: sexual dysfunction as a distinguishing characteristic between andropause and anxiety/depression in aging men
Ching-Yen Chen, Chin-Pang Lee, [...], and Chun-Liang Chen Additional article information

Abstract
Background
Andropause and psychiatric disorders are associated with various symptoms in aging males and are part of the differential diagnosis of depression and anxiety. This study was designed to investigate the relationship between symptoms of aging, anxiety, and depression, and to determine if sexual dysfunction could be a differentiating characteristic in the psychiatric outpatient clinic.

Methods
One hundred seventy-six male psychiatric outpatients participated in the study and completed self-reported measures assessing symptoms of aging, depression, and anxiety. Symptoms of aging were assessed by the Aging Males Symptoms scale. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale. Erectile dysfunction was considered if a response to item 15 on the Aging Males Symptoms scale (impaired sexual potency) was rated with 4 or 5 points. Affective disturbance was assessed by the total scores of the Hospital Anxiety and Depression Scale.

Results
Age was correlated with less anxiety and more sexual symptoms. Anxiety and depression were associated with more severe symptoms of aging, and depression was associated

with more sexual symptoms than was anxiety. Impaired sexual potency was the only sexual symptom not significantly associated with depression and anxiety. Depression was associated with an interspousal age gap of 6 years. The point prevalence of erectile dysfunction was 28.4%, and age and affective disturbance were associated with the risk of erectile dysfunction.

Conclusion
Impaired sexual potency should raise the suspicion of androgen deficiency rather than depression and anxiety among middle-aged or older male psychiatric outpatients. Keywords: androgen deficiency, depression, anxiety, erectile dysfunction

Introduction
The term andropause has been used to describe syndromes in aging males including various clinical symptoms encompassing somatic, psychological, and sexual dimensions, as well as endocrine dysfunction, partly related to an age-related decline in androgen and even androgen deficiency.13 It is also associated with dysthymia4 and an increase in depressive symptoms.5,6 Exogenous testosterone replacement may be beneficial for treatment-resistant depression associated with androgen deficiency.6,7 Androgen deficiency is associated with premature death, erectile dysfunction (ED), metabolic syndrome, and cardiovascular disease.2 Symptoms of andropause and androgen deficiency overlap with common psychiatric disorders such as major depressive disorder (MDD).8 In one study conducted in a male climacteric clinic in Japan, patients with MDD had significantly more severe symptoms of aging as assessed by the Aging Males Symptoms (AMS) scale than did patients without MDD; the estimated prevalence of MDD approached 50%.9 Sato et al, in 2007, reported that the prevalence of MDD was 42% in an andrology clinic and recommended routine screening for MDD.10 Although the gold standard for the diagnosis of androgen deficiency is the measurement of serum free or bioavailable testosterone, such data are not available for every male suspected of suffering from decreased testicular function.11 In order to assess aging males symptoms, a valuable and easily applicable screening tool should be considered. In the present study, the AMS scale was selected as the screening questionnaire for several reasons. First, the validity and reliability of the AMS scale had been established in Taiwan.12 Second, the internal structure of the AMS scale across other countries has been sufficiently similar to conclude that the scale measures the same phenomenon in varying contexts.13 Third, the AMS scale was developed in response to the lack of a standardized scale14 such as the androgen deficiency in aging males questionnaire. Fourth, it can measure the severity of symptoms of aging over time in different dimensions as well as their impact on health-related quality of life (QoL).15

Due to the complex nature of the phenomenon and the limited number of studies in the male psychiatric population, we investigated the relationship between aging males symptoms and emotional distress by using the AMS scale and the Hospital Anxiety and Depression Scale (HADS), and examined whether sexual dysfunction could be a differentiating characteristic for symptoms of aging among middle-aged or older male psychiatric outpatients.

Methods
Population
The sample was previously recruited for validation of the Chinese version of the AMS scale, and a more detailed description has been published elsewhere.12 One hundred seventy-six Taiwanese men, 4080 years of age, attending the psychiatric outpatient service of Chang Gung Memorial Hospital at Linkou (a convenience sample) participated in the study. All participants reported neurotic symptoms such as anxiety, depression, insomnia, or somatic complaints. The participants had received general psychiatric evaluations during their initial visits and had no psychotic, bipolar, or cognitive disorders and no history of psychoactive substance abuse. The demographic data were obtained through clinical interviews (Table 1). The age groups were defined as middle-aged (40 49 years), pre-elderly (5064 years), and elderly (65 years). The interspousal age gap (IAG) was defined as the absolute age difference between the participants and their spouses. Three IAG groups were defined: age-matched (IAG = 02 years), moderate age gap (IAG = 35 years), and large age gap (IAG 6 years). Body mass index (BMI) groups were defined as normal (BMI < 24.0 kg/m2), overweight (BMI = 24.026.9 kg/m2), and obese (BMI > 27.0 kg/m2). Education groups were defined by years of education: primary school and under (06 years), high school (712 years), and college or university and above (>12 years).

Table 1 Demographic data and characteristics of the initial participant sample (n = 176)

Main outcome measures

Aging males symptoms scale This 17-item self-administered questionnaire is the best studied and validated questionnaire to help assess the severity of symptoms of aging males and the QoL in men

>40 years of age.13,16 The scale has been validated internationally with a standard translation of the Chinese version.12 Each item is rated on a five-point Likert scale, with a response of 5 representing extremely severe and 1 representing none. The total score (AMS-T) measures the overall severity of symptoms of aging and the QoL. The psychological score (AMS-PSY), the sum of items 68, 11, and 13, assesses the psychological dimension. The somatovegetative score (AMS-SOM), the sum of items 1 5, 9, and 10, assesses the somatic dimension. The sexual score (AMS-SEX), the sum of the remaining five items, assesses the sexual dimension. The AMS scale is moderately correlated with the Beck Depression Inventory9,17 and the HADS.12 With a cut-off value of 27,18 the AMS-T has a sensitivity of 29% and a specificity of 97% in predicting androgen deficiency.19 Erectile dysfunction (ED) is considered if a response to item 15 of the AMS scale (impaired sexual potency) is rated at 4 or 5.20

Hospital anxiety and depression scale

The HADS, a 14-item self-administered questionnaire comprised of a seven-item anxiety scale (HADS-A) and a seven-item depression scale (HADS-D) scored on a four-point Likert scale (03), is designed to provide a simple yet reliable screening tool for depression and anxiety in various clinical settings, with good internally consistent reliability for anxiety and depression (Cronbachs = 0.80 and 0.76, respectively),2123 and with good sensitivity and specificity (approximately 0.8) for identifying psychiatric cases.24,25 The total score (HADS-T) measures affective disturbance; anxiety is defined as a HADS-A 11; depression is defined as a HADS-D 11.23 Four severity grades of psychological distress are distinguished as follows: none (HADS-T < 8), little (HADS-T = 810), moderate (HADS-T = 1115), and severe (HADS-T 16).22 To determine the effect of anxiety and depression, control was defined as a HADS-A < 11 and a HADS-D < 11, anxiety as a HADS-A 11 and a HADS-D < 11, depression as a HADS-A < 11 and a HADS-D 11, and mixed anxiety and depression as both HADS-A 11 and HADS-D 11.

Statistical analysis
Statistical analyses were performed using R version 2.14.1 for Windows (R Foundation for Statistical Computing, Vienna, Austria).26 Students t-test was used to test for continuous variables by two groups. A one-way analysis of variance was used to test for differences among groups. A post hoc Tukey HSD test was used to discern subgroup differences. Fishers exact test was used to test for an association between two categorical variables. Kendalls correlation coefficients were derived with significance and multiplicity adjusted by Holms method. A stepwise multiple logistic regression analysis was used for ED. The independent variables were the HADS-T, age, the IAG, BMI, marriage, employment, and education. The P value was set at 0.05 for all statistical tests.

Results
The mean age of subjects was 54.3 years (standard deviation [SD] = 10.7). Table 1 shows the demographic characteristics of all 176 participants.

Correlation between age, BMI, HADS, and AMS

Age was negatively correlated with the HADS-A ( = 0.16), and positively correlated with the AMS-SEX ( = 0.22). BMI was not correlated with HADS or AMS. There were mostly weak-to-moderately positive correlations ( = 0.210.55) among responses to the HADS and AMS scales (Table 2).

Table 2 Kendall correlations between age, BMI, HADS, and AMS scale

Groups of depression and anxiety

Table 3 shows the results of the one-way analysis of variance among groups in terms of depression and anxiety. There were 103 (58.5%) controls, 18 (10.2%) subjects with depression, 26 (14.8%) with anxiety, and 29 (16.5%) with mixed anxiety and depression. There were significant differences in the IAG, AMS-SEX, and all sexual symptoms except impaired sexual potency among groups with depression and anxiety. A post hoc Tukey HSD test showed that the depression group had a significantly higher IAG than the control and anxiety groups. The group with anxiety only had a significantly higher score on item 12 (past peak) than did the control group, while the groups with depression and mixed anxiety and depression had significantly higher scores on items 12, 16 (fewer morning erections), and 17 (disturbed libido) than did the control group. The group with depression had a significantly higher score on item 14 (decrease in beard growth) than did the other 3 groups.

Table 3 Analysis of variance among groups with depression and anxiety

Erectile dysfunction

Fifty (28.4%) of the 176 participants had ED. There was significant positive association between age and ED (for every SD [10.7 years], the odds ratio for ED was 2.51 [95% confidence interval 1.584.00]). Subjects with ED were significantly older (61.0 11.0 years versus 51.7 9.4 years, t[174] = 5.635, P < 0.0001); had higher spousal ages (57.0 9.9 years versus 48.4 9.2 years, t[155] = 5.226, P < 0.0001); were less employed (40% versus 66.7%, P = 0.0020); and scored higher on the AMS-T (47.7 11.1 versus 36.8 9.7, t[174] = 6.419, P < 0.0001), AMS-PSY (13.4 4.8 versus 11.2 4.3, t[174] = 2.958, P = 0.0036), AMS-SOM (18.3 5.0 versus 15.7 4.5, t[174] = 3.333, P = 0.0011), and AMS-SEX (16.0 2.8 versus 9.9 3.0, t[174] = 12.523, P < 0.0001) compared with the 126 participants without ED. Subjects with ED had a trend towards a higher HADS-D than those without ED (8.8 5.4 versus 7.3 4.4, t[174] = 1.922, P = 0.0563). Subjects with ED were not significantly different from those without ED in terms of IAG, HADS scores, marital status, BMI, and education (Table 4). After adjusting for demographic factors including age, BMI, HADS-D, and employment, the results of multiple logistic regression analyses for ED are shown in Table 5.

Table 4 Comparisons between subjects with and without erectile dysfunction

Table 5 Logistic regression of erectile dysfunction

Discussion
In the present study, anxiety and depression were associated with more severe symptoms of aging and a poorer QoL, yet they exerted different effects on sexual symptoms. It is noteworthy that impaired sexual potency was the only sexual symptom not significantly associated with anxiety and depression. Anxiety was associated only with past peak, while depression was associated with all sexual symptoms except impaired sexual potency. The severity of both anxiety and depression was moderately correlated with past peak, while age was not, suggesting that this symptom was related more to psychological health than to aging. The other four sexual symptoms were weakly correlated with severity of depression but not with anxiety, suggesting that depression may play a more

important role in sexual dysfunction than does anxiety. There was a weak negative correlation between age and severity of anxiety, and no correlation between age and severity of depression, which is in contrast to a previous report of a weak negative correlation between age and anxiety, and a curvilinear relationship between age and depression.27 Age was positively correlated with the severity of sexual symptoms, impaired sexual potency, and fewer morning erections, but was not correlated with past peak and disturbed libido, paralleling the findings associated with age-related sexual dysfunction. A large interspousal age gap was associated with depression and its severity, but not with anxiety. Such an age gap may place more of a psychological burden on men based on differences in sexual function, age identity,28 health status, and social life. In one study of men with symptomatic benign prostatic hyperplasia, IAG was associated with increased symptoms and burden on the partner.29 Erectile dysfunction has a multifaceted relationship with psychological, neurologic, hormonal, and vascular problems,2 and is linked to metabolic syndrome and cardiovascular diseases.30 The prevalence of ED in Asian countries is estimated to be 7%15% (4049 years of age) and 39%49% (6070 years of age).31 Several studies have shown a high prevalence of ED among psychiatric patients.32,33 Age is one of the important risk factors for ED. Other risk factors include less than good overall health, diabetes mellitus, cardiovascular disease, genitourinary disease, psychiatric disorders, other chronic conditions, smoking, and hormonal factors.30 Schneider et al reported that significantly more individuals in clinical samples had ED than did a general population sample (28.9%30.8% versus 15%), and subjects with ED were older, had lower testosterone levels, and more anxiety than those without ED.20 The point prevalence of ED in our sample was 28.4%, and subjects with ED were significantly older, more likely to be unemployed, and had significantly higher AMS scores than did those without ED. The response to the HADS was not significantly different between subjects with and without ED. As shown in our logistic regression model, there was only a trend towards an association between ED and depression but not for anxiety. The present cross-sectional study is one of the few papers to investigate relationships between symptoms of aging and emotional distress among male psychiatric outpatients with neurotic complaints, but it does have several methodological limitations. First, we did not have detailed medical and lifestyle assessments of the participants, and not all participants underwent blood tests for testosterone levels due to some economic and technical constraints. Second, we did not record potential confounding factors such as income, marriage duration, partner relationship, and psychosocial stressors, all of which may contribute to depression and anxiety. Third, self-administered questionnaires do not necessarily infer any specific diagnosis, and they are confounded by the current state of mind and personality traits. Nevertheless, they are efficient tools and provide some insight in phenomenological investigation. In addition, the AMS scale was not specific for the diagnosis of androgen deficiency, and we did not use a validated assessment of ED. Furthermore, the results may not be applied to the community at large due to the small sample size and hospital-based population.

Conclusion
Anxiety, depression, and ED were associated with more severe symptoms of aging and a poorer QoL in males. Impaired sexual potency was related more to aging than to emotional problems. A high prevalence of ED highlighted the importance of routine screening in male psychiatric outpatients who present with symptoms of aging. Mental health clinicians should be aware of the relationship between symptoms of aging and psychological health, and request further investigation when warranted.

Acknowledgments
All of the participants are acknowledged with appreciation.

Footnotes
Disclosure The authors report no conflicts of interest in this work.

Article information
Clin Interv Aging. 2013; 8: 635640. Published online 2013 June 4. doi: 10.2147/CIA.S45190 PMCID: PMC3677807 Ching-Yen Chen,1,4,5 Chin-Pang Lee,1,4 Yu Chen,2,4,5 Jun-Ran Jiang,3,4,5 Chun-Lin Chu,1,4,5 and Chun-Liang Chen3,4,5 1 Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taiwan 2 Department of Urology, Chang Gung Memorial Hospital at Linkou, Taiwan 3 Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital at Linkou, Taiwan 4 Mens Health Center, Chang Gung Memorial Hospital at Linkou, Taiwan 5 School of Medicine, Chang Gung University, Taoyuan, Taiwan Correspondence: Ching-Yen Chen, Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, No 5, Fusing St, Gueishan, Taoyuan 333, Taiwan, Tel +886 33281200 ext 2439, Fax +886 33280267, Email psycychen/at/yahoo.com.tw Copyright 2013 Chen et al, publisher and licensee Dove Medical Press Ltd This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Articles from Clinical Interventions in Aging are provided here courtesy of Dove Press

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BMC Research Notes BioMed Central

Demographic and clinical correlates of sexual dysfunction among Nigerian male

outpatients on conventional antipsychotic medications

Aina Kikelomo Oyekanmi, Adegoke Oloruntoba Adelufosi, [...], and Timothy Olaolu Adebowale Additional article information

Abstract
Background
In psychotic disorders, early intervention with antipsychotic medications increases the likelihood of favourable long-term course. However, the pharmacologic management especially with conventional antipsychotic medications is complicated by a high rate of adverse effects including sexual dysfunction. This study aims to determine the demographic and clinical factors associated with sexual dysfunction among male psychiatric outpatients on conventional antipsychotic medications in South-western Nigeria.

Methods
Two hundred and seventy five consecutive male outpatients with psychotic disorders on conventional antipsychotic medications were interviewed. Data was collected on demographic characteristics, illness-related and medication-related variables. Illness severity was assessed with the Brief psychiatric rating scale. The International Index of Erectile Function questionnaire was used to assess for sexual dysfunctions.

Results
A total of 111 (40.4%) respondents had one or more forms of sexual dysfunction. Sexual desire dysfunction was present in 47 (17.1%) of respondents, erectile dysfunction in 95 (34.5%), orgasmic dysfunctions in 51 (18.5%), intercourse dissatisfaction in 72 (26.2%) and overall dissatisfaction in 64 (23.3%). Sexual dysfunction was significantly associated with employment status, age, marital status, haloperidol use, medication dosage, and presence of psychopathology. Unemployment was the only significant independent correlate of sexual dysfunction, with unemployed respondents twice more likely to have sexual dysfunction compared with those employed (Wald = 3.865, Odds Ratio = 2.033, 95% confidence interval = 1.002 - 4.124, p = 0.049).

Conclusions

The high prevalence of sexual dysfunction found in this study suggests a need among clinicians for increased awareness and recognition of the sexual side effects in patients taking conventional antipsychotic medications. This knowledge should guide conventional antipsychotic medication prescription in the at-risk population to improve treatment adherence. Keywords: Sexual dysfunction, Conventional antipsychotics, Schizophrenia

Background
Sexual dysfunction is commonly associated with the pharmacologic management of psychotic illnesses especially conventional antipsychotic medications [1-3]. This is further complicated by the effects of major psychotic illness itself on sexual functioning, among which are reduced libido, decreased sexual performance and satisfaction [4]. Previous studies showed that sexual dysfunction occurred in as many as 60% of outpatients with schizophrenia [5-7]. Sexual adverse effects have been reported in up to 4550% of patients taking conventional antipsychotics and are more likely to be disturbing to men than women [8-10]. Other authors reported that more than 50% of males on conventional antipsychotics experienced sexual dysfunction [11]. Commonly experienced sexual side effects in males are poor penile erection, ejaculatory and orgasmic disturbance [12,13]. Despite this high rate, complaints about sexual dysfunction are largely unexplored or ignored by clinicians, or attracted only vague reassurances resulting in poor medication adherence and quality of life [2,14,15]. There is a paucity of studies on sexual dysfunction in Nigeria [16]. Many of the available studies were conducted among medical outpatient clinic attendees and community samples, with findings which cannot be generalized to patients in specific diagnostic groups like schizophrenia and other psychotic disorders [17,18]. A recent study by Mosaku & Ukpong [19] conducted among outpatients attending a psychiatric clinic in Southwest Nigeria reported a prevalence of 86.5% for erectile dysfunction, with varying prevalences reported for other forms of sexual dysfunctions. However, aside patients with schizophrenia, the study included patients diagnosed with other mental illnesses such as depression, bipolar affective disorder, and psychoactive substance dependence, who may actually have differing patterns and prevalences of sexual dysfunction. To the best knowledge of the authors, no Nigerian studies have reported the prevalence and correlates of sexual dysfunction among patients in a specific diagnostic group like those with schizophrenia and delusional disorders. The aim of this study was to determine the prevalence of sexual dysfunction, associated socio-demographic and clinical factors among male patients with psychotic disorders on conventional antipsychotic, in Southwestern Nigeria.

Methods

Study design and setting

This was a descriptive cross sectional survey of sexual dysfunction among male outpatients with schizophrenia on conventional antipsychotic medications for at least six months. The study was carried out at the out-patient clinic of the Neuropsychiatric Hospital Aro, Abeokuta, Nigeria between August 2005 and February 2006. The annual report of the medical records department of the hospital showed that 3,270 patients with a diagnosis of schizophrenia attended the outpatient clinic in 2004 (Unpublished data, medical records department). The hospital has a total capacity of 526 beds and attends to all patients that come to the hospital through referrals and those brought by relatives. It has an Emergency/Assessment Unit that provides a 24-hour first-contact and Emergency services, 7 days of the week while outpatient clinics are run for follow-up consultations on Mondays, Tuesdays, Thursdays and Fridays after the first contact or following discharge from the in-patient care.

Participants
Participants were consecutive male outpatient between the ages of 1860 years. Only subjects meeting the ICD-10 criteria for schizophrenia and delusional disorders (F20 F29) based on information from patients` case notes were included in the study. Patients with clinical history/record of conditions and medications that may contribute to sexual dysfunctions viz Diabetes, hypertension, cerebrovascular disorder e.g. stroke, gonadal injury, endocrine disorder/medications, alcohol dependence, antidepressant medication were excluded from the study (all patients undergo routine laboratory screening including fasting/random blood sugar and full physical examination at presentation and regular intervals for any concomitant physical illness at the study center; body weight and BP checks are also carried out at every visit).

Instruments
The following instruments were administered: 1. A questionnaire drawn up by the researchers (AKO and TOA) to elicit information on socio-demographic characteristics of respondents and their clinical characteristics, such as illness and medication history. 2. Brief Psychiatric Rating Scale (BPRS) - The BPRS is a widely used instrument developed by Overall & Gorham to measure psychotic symptoms and psychopathology profiles [20]. It is a semi-structured interview schedule originally comprising 16 items. Each item is scored on a 7-point scale and produces sub scores (profiles) for affective, psychotic and negative symptoms. The 16 items of the original scale was used in this study to measure current psychopathological profile of the subjects. The BPRS has been used by previous researchers in Nigeria [21] 3. The International Index of Erectile Function (IIEF) questionnaire - This is a self administered questionnaire that evaluates male sexual functions. The IIEF was developed

by an International panel of experts through an extensive review of the literature and existing questionnaires in addition to detailed interview of men with sexual dysfunction and their partners [22]. The IIEF instrument consists of 15 questions (Q), rated on a scale of 15, with 0 indicating no sexual activity or no attempt. It has 5 domains: Erectile dysfunction (Q1 5, 15), Orgasmic Function (Q9, 10), Sexual Desire (Q11, 12), Intercourse Satisfaction (Q6 8), and Overall Satisfaction (Q13, 14), each addressing a unique dimension of sexual function. Total IIEF questionnaire score ranged from 030, with higher scores indicating better sexual functioning. Responses to each question are based on a mans experience over the past 4 weeks. The IIEF has been used by previous authors in Nigeria [19] and in their study, a reliability coefficient (cronbachs alpha) of 0.921 was obtained. All the questionnaires were translated to Yoruba (the predominant language in the locality of the study) through the process of back translation.

Procedure
Consecutive male outpatient clinic attenders between the ages of 1860 who were married and/or who had a regular sexual partner and who had fulfilled the ICD-10 criteria for schizophrenia, and delusional disorders (F20 F29) at one time or the other based on information from patients` case notes, and were currently on conventional antipsychotic medications for at least six months (including those that still had active or residual symptoms but not acutely disturbed with gross excitement or disorientation) were included. The interviews were conducted by AKO and two trained research assistants (resident doctors in psychiatry) in the outpatient clinic consultation rooms after routine consultation, to ensure confidentiality. Assistance in completing the questionnaires was provided for the respondents where necessary.

Ethical considerations
Approval of the Research Ethical Committee of the Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria was obtained to carry out the study. This study complied with the Declaration of Helsinki protocol and informed verbal consent was obtained from the participants after a detailed explanation of the study.

Data analysis
Statistical Package for Social Sciences (SPSS) version 11.0 for Windows was used for data analysis. Most of the variables were grouped for ease of statistical analysis. Results were calculated as frequency (%) and mean. Group differences were determined using Chi-square (2) test for categorical variables and student t-test for continuous variables. Variables that were found to be significantly associated with any form of sexual dysfunction (independent variables) were then included in a logistic regression model with presence or absence of sexual dysfunction as the outcome (dependent variable). Level of significance was set at p < 0.05.

Results
Sociodemographic characteristics
Two hundred and seventy nine male outpatients who met the inclusion criteria were invited to participate in the study. There were 5 outright refusals, giving a response rate of 98.6%. The data of 275 male outpatients meeting the inclusion criteria for the study were analysed. Mean age was 39.5 9.4 years, and they were mainly between 30 and 39 years old (36.4%). Respondents were predominantly married (60.7%) and the majority of patients (86.9%) were employed. The patients were predominantly Christians (62.9%) Table Table11.

Table 1 Demographic, Clinical and Medication Related Characteristics of Respondents

Clinical characteristics and medication related variables

The majority of patients (87.6%) had a diagnosis of schizophrenia. The mean age at onset of illness was 27.4 7.4 years. The majority of respondents (42.5%) had their onset of illness between 15 and 25 years. The mean (SD) BPRS score was 0.40 (1.2). The mean duration of conventional antipsychotic medication use was 8.4 2.1 years. One hundred and thirty one patients (47.6%) had been using medications for more than 35 years. Majority of the patients (55.3%) were taking more than two conventional antipsychotic at the time of the study. The mean chlorpromazine equivalent daily medication dose taken by the patients was 462 mg, with the majority (61.8%) being maintained on less than 500 mg chlorpromazine equivalent daily dose (Table (Table11).

Prevalence of sexual dysfunction

One or more forms of sexual dysfunction existed among 111 (40.4%) of the respondents. Sexual desire dysfunction was present in 47 (17.1%) of subjects, Erectile dysfunction in 95 (34.5%), Orgasmic Dysfunctions 51 (18.5%), Intercourse Dissatisfaction 72 (26.2%) and Overall Dissatisfaction 64 (23.3%).

Correlates of sexual dysfunction

The demographic, medication and illness related variables associated with one or more forms of sexual dysfunction were: Employment status (sexual desire dysfunction, orgasmic dysfunction, intercourse dissatisfaction and overall dissatisfaction), age group (orgasmic dysfunction), marital status (overall dissatisfaction), haloperidol use (erectile dysfunction, orgasmic dysfunction), medication dose (erectile dysfunction, orgasmic dysfunction, overall dissatisfaction), any psychopathology on the BPRS (overall dissatisfaction) Table Table22.

Table 2 Association between Specific Sexual dysfunctions and Sociodemographic, Illness-related and Medication-related Variables

Independent correlates of sexual dysfunction

Result of the logistic regression analysis showed unemployment as the only independent correlate of sexual dysfunction, with unemployed respondents twice as likely to have sexual dysfunction as those employed (Wald = 3.865, Odds ratio = 2.033, 95% confidence interval = 1.002 - 4.124, p = 0.049).

Discussion
This study examined the prevalence and correlates of sexual dysfunction among Nigerian men with psychotic illness attending a psychiatric outpatient clinic. Overall, about 40% of the respondents had at least one form of sexual dysfunction. This rate of sexual dysfunction is similar to that reported in other previous studies [8,10,18]. Considering the finding that the mean age (39.5 years) of the respondents fell within the reproductive age group, problems with their sexual functioning may be a significant source of concern for them with far reaching consequences if left untreated. Most of the patients (64.7%) in this study were taking more than one conventional antipsychotics, an observation also made in a study examining the prescribing habits for psychiatric in-patient admissions [23]. Other authors have found that despite extensive research and recommendations regarding the rational prescription of antipsychotic drugs, polypharmacy exists even among clinically stable patients [24]. This study reports an association between poly-pharmacy and sexual dysfunction which can be explained by the fact that increasing the number of medications result in increased

risk of adverse effects experienced by patients. Our finding is similar to what previous authors reported that combination of antipsychotics adds to the risks of developing medication side effects [25]. In addition, we found a significant relationship between medication dosages (chlorpromazine equivalents) and some forms of sexual dysfunction, similar to that reported by some authors [7]. Higher dosages of conventional antipsychotics are therefore associated with higher prevalence of sexual dysfunction since there will be more drugs to act at the various pathways leading to sexual dysfunction [8]. Among the conventional antipsychotics medications prescribed, only haloperidol showed a significant relationship with sexual dysfunction (erectile and orgasmic dysfunctions). This may be attributed to the high affinity of haloperidol for dopamine D2 receptor and inhibition of dopamine release, resulting in impaired libido and erection [26]. On the other hand, the sexual dysfunction observed may be a result of severe psychopathologies experienced by the patients [4], which then necessitated the use of a highly potent typical antipsychotic medication like haloperidol. Erectile dysfunction was the commonest type of sexual dysfunction reported by the respondents, a finding also reported in previous studies [19,27,28]. Poor penile erection interferes with subjective enjoyment of other stages of sexual intercourse and because it was the commonest sexual dysfunction reported by respondents, it may account for the high prevalence of intercourse dissatisfaction and overall dissatisfaction with sex observed in this sample. Inability to achieve good penile erection for optimal sexual satisfaction may be associated with feelings of inadequacy in the sufferer. In many societies, including Nigeria, individuals with poor or absent penile erection are often stigmatized, subjected to public ridicule and may be deserted by their spouse. Erectile dysfunction may result in poor treatment adherence and negatively impacts on patients quality of life [15]. Our study revealed a significant relationship between marital status and sexual dysfunction, specifically with overall dissatisfaction with sex. It may be that patients with medication induced sexual dysfunction were likely to be dissatisfied with their overall sexual functioning. For married men, the marriage setting provides an opportunity for a feedback from the spouse about sexual performance, which may result in subjective awareness of an existing sexual inadequacy, otherwise unnoticed by the patient. This raises a possibility that the relationship between marital status and sexual dysfunction seen in these patients may be psychogenic in origin, rather than organic. Unfortunately, the IEFF could not distinguish between organic and psychogenic sexual dysfunction, an important limitation of this study. However, other authors have also reported a significant association between marital status and sexual dysfunction among patients taking conventional antipsychotics in Nigeria [19] In this study, unemployed respondents were more likely to have sexual dysfunction than those who are employed. Previous studies have found an association between sexual dysfunction, depression and socioeconomic disadvantages like unemployment [8,29]. Unemployment may result in role reversal within a relationship, engendering feelings of shame and inadequacy in the male partner. Previous authors have reported that

unemployment in a person with mental illness is associated with public and selfstigmatization, a double jeopardy, which may negatively impact on self-worth and sexual performance or satisfaction [21]. This study has a number of limitations. First, it was cross-sectional in nature, so the direction of causality between sexual dysfunction and the sociodemographic and clinical variables could not be inferred from the findings. Second, there is a limitation regarding the generalizability of the result to other patients on conventional antipsychotics in Nigeria, as the study was conducted in just one centre. Third, the absence of a control group is also an important limitation to the generalizability of our results. However, to the best of our knowledge, it is the first to examine sexual dysfunction among specific group of psychiatric outpatients on conventional antipsychotics in Nigeria. It is also one of the few available studies on sexual dysfunction in a developing country setting where conventional antipsychotic medications are commonly prescribed for the treatment of psychotic illnesses [30].

Conclusions
Sexual dysfunction is common among outpatients with psychotic disorders on conventional antipsychotics. It is associated with demographic, illness and medication related variables. Unemployment was found to be the most important independent correlate of sexual dysfunction. Therefore, there is a need among clinicians for increased awareness and recognition of the sexual side effects of conventional medications on patients, especially those socially disadvantaged. This should guide antipsychotic medication prescription resulting possible improvement in treatment adherence and outcome.

Competing interests
The authors declare that they have no competing interests.

Authors contribution
OAK conceived the study and together with ATO designed the study. OAK executed the data collection. AOA and OA did the statistical analysis and drafted the first version of the manuscript. OAK and ATO participated in the interpretation of data. All authors read and approved the final manuscript.

Source of financial support

None.

Article information

BMC Res Notes. 2012; 5: 267. Published online 2012 June 7. doi: 10.1186/1756-0500-5-267 PMCID: PMC3426474 Aina Kikelomo Oyekanmi,1 Adegoke Oloruntoba Adelufosi, 2 Olukayode Abayomi,2 and Timothy Olaolu Adebowale1 1 Neuropsychiatric Hospital, Aro, P.O Box 2210, Sapon, Abeokuta, Ogun State, Nigeria 2 Ladoke Akintola University Teaching Hospital, Ogbomoso, Oyo State, Nigeria Corresponding author. Aina Kikelomo Oyekanmi: akoyekanmi/at/gmail.com; Adegoke Oloruntoba Adelufosi: ozotee/at/gmail.com; Olukayode Abayomi: abayomikay/at/gmail.com; Timothy Olaolu Adebowale: toadebo/at/yahoo.com Received March 28, 2012; Accepted May 28, 2012. Copyright 2012 Oyekanmi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from BMC Research Notes are provided here courtesy of BioMed Central

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effects of antipsychotics among callers to a United Kingdom National Mental Health Helpline. Int Clin Psychopharmacol. 2001;16(3):153162. doi: 10.1097/00004850-200105000-00004. [PubMed] [Cross Ref] 10. Knegtering H, Boks M, Blijd C, Castelein S, Van den Bosch RJ, Wiersma DA. Randomized open-label comparison of the impact of olanzapine versus risperidone on sexual functioning. J Sex Marital Ther. 2006;32:315326. doi: 10.1080/00926230600666378. [PubMed] [Cross Ref] 11. Ghadirian AM, Chouinard G, Annable L. Sexual dysfunction and plasma proclatinlevels in neuroleptic-treated schizophrenic outpatients. J Nerv Mental Disease. 1982;170:463467. doi: 10.1097/00005053-198208000-00004. [PubMed] [Cross Ref] 12. Segraves RT. Effects of psychotropic drugs on human erection and ejaculation. Arch Gen Psychiatry. 1989;46(3):275284. doi: 10.1001/archpsyc.1989.01810030081011. [PubMed] [Cross Ref] 13. Gitlin MJ. Psychotropic medications and their effects on sexual function: diagnosis, biology, and treatment approaches. J Clin Psychiatry. 1994;55:406 413. [PubMed] 14. Aviv A, Shelef A, Weizman A. An open-label trial of sildenafil addition in risperidone treated male schizophrenia patients with erectile dysfunction. J Clin Psychiatry. 2004;65(1):97103. doi: 10.4088/JCP.v65n0117. [PubMed] [Cross Ref] 15. Gopalakrishnan R, Jacob KS, Kuruvilla A, Vasantharaj B, John JK. Sildenafil in the treatment of antipsychotic induced erectile dysfunction: a randomized, doubleblind, placebo-controlled, flexible-dose, two-way crossover trial. Am J Psychiatry. 2006;163(3):494499. doi: 10.1176/appi.ajp.163.3.494. [PubMed] [Cross Ref] 16. Modebe O. Erectile failure among medical clinic patients. Afr J Med Science. 1990;19:259264. [PubMed] 17. Okulate G, Oladokun O, Dogunro AS. Erectile dysfunction: Prevalence and relationship with depression, alcohol abuse and Panic disorder. Gen Hosp Psychiatry. 2003;25(3):209213. doi: 10.1016/S0163-8343(03)00015-X. [PubMed] [Cross Ref] 18. Adegunloye OA, Makanjuola AB, Adelekan ML. Sexual dysfunction among secondary school teachers in Ilorin, Nigeria. J Sex Med. 2010;7:38353844. doi: 10.1111/j.1743-6109.2010.01764.x. [PubMed] [Cross Ref] 19. Mosaku KS, Ukpong DI. Erectile dysfunction in a sample of patients attending a psychiatric outpatient department. Int J Impotence Res. 2009;21:235239. doi: 10.1038/ijir.2009.16. [PubMed] [Cross Ref] 20. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Reports. 1962;10:799812. doi: 10.2466/pr0.1962.10.3.799. [Cross Ref] 21. Adewuya AO, Owoeye AO, Erinfolami AO, Ola BA. Correlates of self-stigma among outpatients with mental illness in Lagos, Nigeria. Int J Soc Psychiatry. 2011;57(4):418427. doi: 10.1177/0020764010363522. [PubMed] [Cross Ref] 22. Rosen RC, Riley A, Wagner G. et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology.

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Advances in Urology Hindawi Publishing Corporation

Sexual Dysfunction and Hyperprolactinemia in Male Psychotic Inpatients: A Cross-Sectional Study

Erik Johnsen, Rune Kroken, [...], and Hugo A. Jrgensen Additional article information

Abstract
Introduction. Sexual dysfunction (SD) and hyperprolactinemia are frequently reported in patients with psychotic disorders and have the potential for severe complications but investigations in males are particularly scarce. The primary aims were to determine the prevalence of SD and hyperprolactinemia in male patients and to investigate whether associations exist between SD and prolactin levels. Methods. Cross-sectional data were obtained at discharge from the hospital or 6 weeks after admittance for patients acutely admitted for psychosis and treated with a second-generation antipsychotic drug. Results. Half the patients reported diminished sexual desire and more than a third reported erectile and ejaculatory dysfunctions with no differences among the drugs. More than half the sample was hyperprolactinemic. No association was found between prolactin levels and SD. Conclusion. High rates of SD and hyperprolactinemia were found in male patients and should be a treatment target. SD and hyperprolactinemia were not correlated.

1. Introduction
Active psychosis affects most aspects of normal functioning and has been ranked the third most disabling disorder in the general population, and more disabling than paraplegia, blindness, or HIV infection [1]. The life-time prevalence of any psychotic disorder is about 3 in 100 persons [2]. In a substantial proportion of cases, the disorders are chronic and life long. The presence of psychosis will in most instances indicate the use of antipsychotic drugs. Both the nature of the disorders and antipsychotic drug treatment can profoundly affect sexual functioning. Main tolerability issues related to antipsychotic drug use have traditionally been the extrapyramidal syndrome (EPS) associated with the first-generation (typical) antipsychotics, and metabolic adverse effects associated mainly with the secondgeneration (atypical) agents [3, 4]. Sexual dysfunction (SD) has received far less attention, although these side effects have been reported among the most discomforting ones by patients with schizophrenia [5, 6]. SD is important also as it has negative impact on medication adherence. Antipsychotic-induced hyperprolactinemia is commonly regarded as a frequent cause of SD. As demonstrated in a review by Byerly et al. [7], the findings of different studies are conflicting, however, with regards to associations between hyperprolactinemia and sexual side effects. While differential propensities among second-generation antipsychotics (SGAs) in causing hyperprolactinemia are well documented [8], differences among the SGAs in causing SD are less investigated. Studies addressing male SD specifically in psychosis are particularly scarce. In one study, SD has been reported to affect almost half the sample of outpatients with schizophrenia and to adversely affect their quality of life [9]. Several research questions of clinical relevance thus remain unresolved, and studies in clinically relevant samples are called for.

The primary aims of the present study were to determine the prevalence of SD and hyperprolactinemia, and to investigate whether associations exist between SD and prolactin levels in male patients with psychosis. Secondary aims were to disclose whether differences exist among second-generation antipsychotics (SGA) with regards to SD.

2. Materials and Methods

The materials and methods used have been described in more detail in a previous publication [10]. The Bergen psychosis project (BPP) is a pragmatic, randomized trial comparing SGAs in the treatment of psychosis. The present study reports results from the BPP from the time of discharge or 6 weeks after admission if not discharged from hospital. To ensure a clinically relevant sample, the patient recruitment focused on all patients with psychosis acutely admitted to the emergency ward. Patients were recruited from March 2004 until February 2009. All patients were recruited from Haukeland University Hospital, Division of Psychiatry, with a catchment population of about 400,000. The BPP was approved by the Regional Committee for Medical Research Ethics, and the Norwegian Social Science Data Services. The BPP was publicly funded and has not received any financial or other support from the pharmaceutical industry. The Regional Committee for Medical Research Ethics allowed eligible patients to be included before informed consent was provided, thus entailing a clinically relevant representation in the study. Patients from 18 to 65 years of age were eligible for the study if they were acutely admitted to the emergency ward for symptoms of psychosis as determined by a score of 4 on one or more of the items delusions, hallucinatory behavior, grandiosity, suspiciousness/persecution, or unusual thought content from the Positive and Negative Syndrome Scale (PANSS) [11]. Eligible patients met the ICD-10 [12] diagnostic criteria for schizophrenia, schizoaffective disorder, acute and transient psychotic disorder, delusional disorder, drug-induced psychosis, bipolar disorder except manic psychosis, and major depressive disorder with psychotic features. The diagnoses were determined by the hospital's psychiatrists or specialists in clinical psychology. Patients were excluded from the study if they were unable to use oral antipsychotics because a depot formulation was indicated, were suffering from manic psychosis or for other behavioral or mental reasons related to the state of illness were unable to cooperate with assessments, did not understand spoken Norwegian, were candidates for electroconvulsive therapy as determined by the attending psychiatrists, or were medicated with clozapine, usually regarded as a final resort, on admittance. Patients with druginduced psychoses were included only when the condition did not resolve within a few days and when antipsychotic drug therapy was indicated. The patients were rated using the PANSS, the Calgary Depression Scale for Schizophrenia (CDSS) [13], the Clinical Drug and Alcohol Use Scales (CDUS/CAUS) [14], the Clinical Global ImpressionSeverity of Illness scale (CGI-S) [15], the Global Assessment of FunctioningSplit Version, Functions scale (GAF-F) [16], and a neurocognitive screening test (Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)) [17]. Patients were asked also to complete the patient-administered version of the UKU Side Effect Rating Scale (UKU-SERS Pat) [18].

The items reported here include diminished sexual desire; erectile dysfunction; and ejaculatory dysfunction. The patient-administered version of the interview was chosen to obtain more valid results as clinicians often underestimate SD [19]. The questions asked were have you experienced decreased sexual interest or decreased sexual desire?; have you experienced difficulty in reaching erection?; have you experienced difficulties in ejaculation? The patients were instructed to report symptoms that they attributed to their prescribed medications and use the last week as the time frame of reference. Each item was rated from 0 (not at all) to 3 with increasing severity of the SD symptom reported. A composite mean SD score was calculated based on the three UKUSERS Pat items, accepting up to two missing values. A blood sample was collected from the patients between 08 and 10 am, and serum level measurements of prolactin and antipsychotics were conducted. Drug doses were converted to mean Defined Daily Doses (DDDs) as developed by the World Health Organization Collaborating Centre for Drug Statistics Methodology [20]. The basic definition of the DDD unit is the assumed average maintenance dose per day for a drug used for its main indication in adults. Fifteen (23.1%) of the prolactin blood samples were analysed at Laboratory A by means of a noncompetitive immunofluorometric assay (DELFIA kit by Wallac Oy, Turku, Finland). Fifty (76.9%) of the samples were analyzed at Laboratory B using another immunoassay kit (Immulite 2000 by Siemens Medical Solutions Diagnostics, Berlin and Munich, Germany). The cutoff for hyperprolactinemia was set at 360 mIU/L. Screening for macroprolactinemia by polyethylenglycol (PEG) precipitation was performed if prolactin levels were above 1000 mIU/L at both laboratories to identify cases with pseudohyperprolactinemia caused by the biologically inert macroprolactin fraction. SPSS version 18.0 was used for statistical analyses. Mean serum prolactin levels at laboratories A and B were compared using an independent samples t-test. Chi square exact test was used for categorical data. To investigate the association between prolactin levels and symptoms registered on the rating scale, a bivariate analysis of correlation was performed using the Spearman correlation coefficient as normal distribution could not be assumed. Significance level was set at = 0.05.

3. Results and Discussion

3.1. Results
A total of 72 men were assessed. A total of 20 patients used risperidone, the corresponding figures were for olanzapine 26, quetiapine 9, ziprasidone 13, and aripiprazole 1. Three patients were not prescribed antipsychotics. The mean serum levels with standard deviations (sd) and reference levels in nanomoles per litre were for risperidone 79.5 (58.5) (30120), for olanzapine 107.3 (75.8) (30200), for quetiapine 522.8 (660.9) (100800), for ziprasidone 129.1 (107.2) (30200), and for aripiprazole 141 (-) (2001300). The mean doses in milligrams with sd were for risperidone 3.7 (1.3), for olanzapine 17.3 (6.4), for quetiapine 477.8 (204.8), for ziprasidone 98.3 (46.3); and

for aripiprazole 5 (-). There were no differences among the groups with regards to the use of concomitant medication. The clinical characteristics and demographics are displayed in Table 1. The majority had a diagnosis of schizophrenia (55.6%). A total of 33 (45.8%) patients had not used antipsychotic drugs before this admittance to hospital. With the exception of a higher CDSS sum score (6.9), in the risperidone group versus 2.8; 3.9; 3.6; 1.0; 3.5, in the olanzapine, quetiapine, ziprasidone, aripiprazole, and unmedicated groups, respectively (one-way anova, P = 0.033), there were no statistically significant differences among the drug groups. A total of 45.9% of the patients reported diminished sexual desire, whereas 35.9% and 36.1% reported erectile and ejaculatory dysfunction, respectively (Figure 1). There were no differences among the groups, or between the antipsychotic nave patients and those with prior antipsychotic drug use in this regard. The mean prolactin level was 627.9 mIU/L, range 59.03019.0. There was no significant difference among the laboratories with regards to mean prolactin levels (t-test: P = 0.25; mean difference 68.3; 95% CI 286.0422.6). The risperidone group had the highest mean prolactin level (1250.8 mIU/L) followed by olanzapine (483.0 mIU/L), ziprasidone (379.6 mIU/L), quetiapine (236.2 mIU/L), the unmedicated group (184.7 mIU/L), and aripiprazole (70.0 mIU/L, one-way anova: P < 0.001). A total of 56.3% of the patients had hyperprolactinemia, and there were significant differences among the groups following the same pattern as for the mean prolactin levels (chisquare: P < 0.001). A total of 18.5% had prolactin levels above 1080 mIU/L, the proportion being 57.9% in the risperidone group with significant differences among the groups (chisquare: P < 0.001). There was no association between prolactin level and the composite SD score (Spearman's correlation coefficient r = 0.141; P = 0.29, Figure 2). Also, there was no association between SD and the PANSS total and subscale scores; the CDSS, the CGI, the GAF-F, neurocognitive test score, or DDDs of the different drugs. For risperidone but not the other antipsychotics, there was a significant correlation between serum prolactin level and drug doses of risperidone in DDD equivalents (Spearman's correlation coefficient r = 0.598; P = 0.011).

Figure 1 Distribution of sexual dysfunction.

Figure 2 Sexual dysfunction and serum prolactin levels. Notes. Mean sexual dysfunction score = Composite mean sexual dysfunction score calculated based on the UKU-SERS Pat items Diminished sexual desire; Erectile dysfunction; and Ejaculatory dysfunction.

Table 1 Clinical and demographic characteristics.

3.2. Discussion
The sample was heterogeneous both with regards to diagnoses and stage of illness and about half the sample was antipsychotic drug nave at admittance which most likely represents patients with first-episode psychosis. The sample should accordingly be clinically relevant. The main findings of the present study were the very high rates of SD and hyperprolactinemia in patients treated with SGAs, and the lack of association between the two. About half the patients reported diminished sexual desire and more than a third reported erectile and ejaculatory dysfunction. The rate of SD is in correspondence with the findings of Olfson et al. [9] in their sample of male outpatients with schizophrenia. The mean age of the sample was more than 10 years older than in the BPP sample and seemed to be selected for the assessment of SD specifically, making the results of the more diagnostically and clinically heterogeneous BPP sample even more startling. SD is perceived by patients as among the more severe side effects of antipsychotics and is associated with poor drug adherence [5, 6]. Noncompliance is one leading cause of relapse and rehospitalisation in patients with schizophrenia, the latter representing the largest part of the schizophrenia treatment costs [21]. The proportions with SD are accordingly alarmingly high both in terms of individual suffering and economic burden to society. With regards to the secondary aim, no differences among the drug groups were found. Bobes et al. [22] found in their sample of 636 schizophrenia outpatients a lower risk of SD in quetiapine, treated patients compared to those treated with haloperidol, risperidone, or olanzapine. The different findings across the studies may be related to different samples, treatment settings, or an insufficient sample size in the BPP to detect actual differences among the drug groups.

More than half the sample was hyperprolactinemic, and about one fifth had prolactin levels more than 3 times the upper threshold, none of which were caused by the biologically inert macroprolactin fraction. There were differences among the drug groups, with risperidone-treated patients having the highest prolactin levels and the highest proportions with hyperprolactinemia. Hyperprolactinemia has received new attention lately as potential long-term complications have been pointed to, including osteoporosis and carcinogenic effects [7, 8]. No association was found in the present study between prolactin levels and SD. This is in line with previous findings from our research group [23]. In a recent study in schizophrenia patients switched to a second-generation antipsychotic drug, positive correlation between prolactin levels and diminished sexual desire was found for men [24]. Nakonezny et al. [25] found an association between serum prolactin level and SD for prolactin but not quetiapine in their 6-week randomized trial. Byerly et al. [7] report differing results among different studies regarding relationship between prolactin levels and SD in men, as only about half the studies reviewed found support for such a relationship. Data on SD in first-episode psychosis has been published from the EUFEST study, indicating influence from the psychotic disorder itself as well as from prolactin on at least some aspects of SD [26]. The primary strengths of the present study are the clinically relevant sample of consecutively recruited male psychotic patients, and the very comprehensive characterisation of the sample. The measurement of serum levels of the antipsychotics used adds special value to the study too. Some limitations should be mentioned, however. The cross-sectional design does not allow for analyses of causality. The sample size may have been too small to detect actual associations. We do not believe this to be the case, however, as significant correlations between hyperprolactinemia and SD were disclosed in even smaller samples of schizophrenia patients in the review by Byerly et al. [7]. We hypothesise that in a heterogeneous sample such as the BPP sample, the prolactin contribution is blurred among several other causes of SD.

4. Conclusions
Both SD and hyperprolactinemia were very prevalent in this sample of male psychotic patients. Based on our findings, the phenomena should be regarded as relatively independent entities with regards to planning appropriate actions. In some instances, reduction of the prolactin level may also resolve SD, whereas in other cases this may not suffice. Finally, prolactin levels should be measured irrespective of whether symptoms of SD are present or not to avoid potential long-term complications of silent hyperprolactinemia.

Acknowledgments
Funding of the project was initiated by the Research Council of Norway, followed by the Western Norway Regional Health Authority, and Haukeland University Hospital,

Haukeland University Hospital, Division of Psychiatry. The supporters had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. E. Johnsen has received honoraria for lectures given in meetings arranged by Bristol-Myers Squibb, Eli Lilly, and AstraZeneca, and for a contribution to an information brochure by Eli Lilly. E. Johnsen has been reimbursed by the Eli Lilly Company and the Janssen Cilag Company for attending conferences. R. Kroken has been reimbursed by the Eli Lilly Company, Janssen Cilag Company, Bristol-Myers Squibb, and AstraZeneca for attending conferences. E. M. Lberg has no competing interests to declare. E. Kjelby has been reimbursed by BristolMyers Squibb, Novartis, Lundbeck, Eli Lilly, and AstraZeneca pharmaceutical companies for attending conferences. H. A. Jrgensen has received honoraria for lectures given in meetings arranged by AstraZeneca and Eli Lilly.

Article information
Adv Urol. 2011; 2011: 686924. Published online 2011 November 30. doi: 10.1155/2011/686924 PMCID: PMC3235493 Erik Johnsen, 1, 2 * Rune Kroken, 1 Else-Marie Lberg, 1, 3 Eirik Kjelby, 1 and Hugo A. Jrgensen 2 1 Division of Psychiatry, Haukeland University Hospital, Sandviksleitet 1, 5035 Bergen, Norway 2 Department of Clinical Medicine, Psychiatry, University of Bergen, Sandviksleitet 1, 5035 Bergen, Norway 3 Institute Biological and Medical Psychology, University of Bergen, Sandviksleitet 1, 5035 Bergen, Norway *Erik Johnsen: Email: erij/at/helse-bergen.no Academic Editor: Hussein Ghanem Received June 25, 2011; Accepted September 14, 2011. Copyright 2011 Erik Johnsen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from Advances in Urology are provided here courtesy of Hindawi Publishing Corporation

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3. Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. The Lancet. 2009;373(9657):3141. [PubMed] 4. Crossley NA, Constante M, McGuire P, Power P. Efficacy of atypical v. typical antipsychotics in the treatment of early psychosis: meta-analysis. The British Journal of Psychiatry. 2010;196(6):434439. [PMC free article] [PubMed] 5. Perkins DO. Predictors of noncompliance in patients with schizophrenia. Journal of Clinical Psychiatry. 2002;63(12):11211128. [PubMed] 6. Lambert M, Conus P, Eide P, et al. Impact of present and past antipsychotic side effects on attitude toward typical antipsychotic treatment and adherence. European Psychiatry. 2004;19(7):415422. [PubMed] 7. Byerly M, Suppes T, Tran QV, Baker RA. Clinical implications of antipsychoticinduced hyperprolactinemia in patients with schizophrenia spectrum or bipolar spectrum disorders: recent developments and current perspectives. Journal of Clinical Psychopharmacology. 2007;27(6):639661. [PubMed] 8. Haddad PM, Wieck A. Antipsychotic-induced hyperprolactinaemia. Mechanisms, clinical features and management. Drugs. 2004;64(20):22912314. [PubMed] 9. Olfson M, Uttaro T, Carson WH, Tafesse E. Male sexual dysfunction and quality of life in schizophrenia. Journal of Clinical Psychiatry. 2005;66(3):531538. [PubMed] 10. Johnsen E, Kroken RA, Wentzel-Larsen T, Jrgensen HA. Effectiveness of secondgeneration antipsychotics: a naturalistic, randomized comparison of olanzapine, quetiapine, risperidone, and ziprasidone. BMC Psychiatry. 2010;10, article 26 [PMC free article] [PubMed] 11. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin. 1987;13(2):261276. [PubMed] 12. World Health Organization. International statistical classification of diseases and related health problems. 10th Revision, version for 2007. World Health Organization/German Institute of Medical Documentation and Information, 19942006 http://www.who.int/classifications/apps/icd/icd10online/ 13. Addington D, Addington J, Schissel B. A depression rating scale for schizophrenics. Schizophrenia Research. 1990;3(4):247251. [PubMed] 14. Drake RE, Rosenberg SD, Mueser KT. Assessing substance use disorder in persons with severe mental illness. New Directions for Mental Health Services. 1996;(70):317. [PubMed] 15. Guy W. EDDEU Assessment Manual for Psychopharmacology Revisited (DHHS publ NO ADM 91338) Rockville, Md, USA: US Department of Health and Human Services; 1976. 16. Karterud S, Pedersen G, Loevdahl H, Friis S. Global Assessment of Functioning Split Version (S-GAF): Background and Scoring Manual. Oslo, Norway: Ullevaal University Hospital, Department of Psychiatry; 1998. 17. Randolph C, Tierney MC, Mohr E, Chase TN. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): preliminary clinical validity. Journal of Clinical and Experimental Neuropsychology. 1998;20(3):310319. [PubMed] 18. Lindstrm E, Lewander T, Malm U, Malt UF, Lublin H, Ahlfors UG. Patient-rated versus clinician-rated side effects of drug treatment in schizophrenia. Clinical validation

of a self-rating version of the UKU Side Effect Rating Scale (UKU-SERS-Pat) Nordic Journal of Psychiatry, Supplement. 2001;55(supplement 44):569. [PubMed] 19. Dossenbach M, Hodge A, Anders M, et al. Prevalence of sexual dysfunction in patients with schizophrenia: international variation and underestimation. International Journal of Neuropsychopharmacology. 2005;8(2):195201. [PubMed] 20. Ronning M. The WHO collaborating centre for drug statistics methodology. Established 1982 http://www.whocc.no/atcddd/ 21. Obradovic M, Mrhar A, Kos M. Cost-effectiveness of antipsychotics for outpatients with chronic schizophrenia. International Journal of Clinical Practice. 2007;61(12):19791988. [PubMed] 22. Bobes J, Garca-Portilla MP, Rejas J, et al. Frequency of sexual dysfunction and other reproductive side-effects in patients with schizophrenia treated with risperidone, olanzapine, quetiapine, or haloperidol: the results of the EIRE study. Journal of Sex and Marital Therapy. 2003;29(2):125147. [PubMed] 23. Johnsen E, Kroken RA, Abaza M, Olberg H, Jrgensen HA. Antipsychotic-induced hyperprolactinemia: a cross-sectional survey. Journal of Clinical Psychopharmacology. 2008;28(6):686690. [PubMed] 24. Rettenbacher MA, Hofer A, Ebenbichler C, et al. Prolactin levels and sexual adverse effects in patients with schizophrenia during antipsychotic treatment. Journal of Clinical Psychopharmacology. 2010;30(6):711715. [PubMed] 25. Nakonezny PA, Byerly MJ, Rush AJ. The relationship between serum prolactin level and sexual functioning among male outpatients with schizophrenia or schizoaffective disorder: a randomized double-blind trial of risperidone vs. quetiapine. Journal of Sex and Marital Therapy. 2007;33(3):203216. [PubMed] 26. Malik P, Kemmler G, Hummer M, Riecher-Roessler A, Kahn RS, Fleischhacker WW. SD in first-episode schizophrenia patients. Results from Europeand First Episode Schizophrenia Trial. Journal of Clinical Psychopharmacology. 2011;31:274280. [PubMed]

Journal of Psychiatry & Neuroscience : JPN Canadian Medical Association

Psychopharmacology for the Clinician

Sakina J. Rizvi, PhD (candidate) and Sidney H. Kennedy, MD Additional article information

Management strategies for SSRI-induced sexual dysfunction

A 45-year old woman with major depressive disorder (MDD) and comorbid generalized anxiety disorder (GAD) reported a decrease in libido since her last depressive episode about 3 years ago. Despite being in remission for the last year and taking a 60 mg dose of paroxetine, she reported an overall decrease in sexual interest and activity. Sexual dysfunction occurs through several brain pathways involving increases in serotonin (5-HT), decreases in dopamine (DA) and inhibition of nitric oxide synthase.1 Increases in cortico-limbic 5-HT result in decreased sexual desire, ejaculation and orgasm.2 Consequently, it is not surprising that selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction occurs in 30%80% of patients3,4 and is a main cause of treatment discontinuation.5,6 Therefore, it is important to use strategies to alleviate treatment-emergent sexual dysfunction. The key to addressing sexual impairment is to systematically assess the domains of sexual function. There are several validated sexual side effect scales available to clinicians.79 The patient we describe received a score of 5 of 44 on the Sex Effects Scale9 (SexFX; a high score is good), as paroxetine is known for its adverse effects on sexual function (Box 1). Pharmacologic methods to reduce sexual dysfunction involve dose reduction, augmentation, or switching medication. Since dose reduction is the least disruptive strategy it should be considered first, particularly in a responder. When our patients dose was reduced to 40 mg, she remained in remission with reduced but persisting sexual dysfunction, particularly anorgasmia.

Box 1
Frequency of sexual dysfunction with antidepressant treatment * < 10% Agomelatine Bupropion Mirtazapine Moclobemide Reboxetine
*

10%30% > 30% Citalopram Fluoxetine Duloxetine Fluvoxamine Escitalopram Paroxetine Venlafaxine Sertraline Milnacipran

Modified with permission.10

Altering 5-HT receptor antagonism and agonism can have favourable sexual effects, but may cause other adverse events. Mirtazapine antagonizes 5-HT2 and 5-HT3 receptors and it has been successfully used as an add-on therapy for antidepressant-induced sexual dysfunction, albeit with a relatively high rate of weight gain.11,12 In addition, cyproheptidine, a 5-HT2A antagonist, has been found to relieve SSRI-induced anorgasmia,13,14 but its use is limited by sedation. Buspirone, a 5-HT1A agonist, may also alleviate SSRI-induced sexual dysfunction.15 Our patient was started on a 15 mg dose of mirtazapine, but it was discontinued owing to daytime sedation.

Sildenafil and tadalafil are phospho-diesterase inhibitors that increase nitric oxide, which in turn, helps to increase blood flow to genetalia. They have both demonstrated evidence for the reversal of SSRI-induced sexual side effects in men.1619 There is only preliminary evidence that these drugs improve sexual adverse events in women,20,21 and neither was prescribed to our patient. Evidence also suggests that DA release enhances sexual function.1 The strongest evidence supports 150300 mg of adjunctive bupropion XL for reversing SSRI-induced sexual dysfunction in men and women across the domains of desire, arousal and orgasm.22,23 These benefits occur irrespective of the SSRI used or duration of sexual dysfunction.24 There is also evidence to support drugs that have more pronounced effects on DA, including methylphenidate, dextroamphetamine, pramipexole or ropinerole.2527 However, caution should be exercised when using DA agonists, given reports of hypersexuality associated with pramipexole.28 Our patients regimen was augmented with 150 mg/day of bupropion XL, taken in the morning. She reported improved arousal and lubrication after 6 weeks, and her overall SexFX score improved to 13 (moderate impairment). Several antidepressants, including bupropion, moclobemide, mirtazapine, agomelatine and vilazodone,3,29 have little to no effect on sexual function compared with placebo when used as a monotherapy. Our patients paroxetine was discontinued and the bupropion was increased to 150 mg twice daily. This switch resulted in a return to normal sexual function (SexFX 29) over the course of 4 weeks. At 3 months, she was still in remission. For patients reluctant to add another medication to their regimen, nonpharmacotherapeutic options may be useful. Evidence suggests exercise can improve sexual function. A trial involving women treated with SSRIs found that exercise before viewing sexual stimuli significantly increased arousal.30 Open-label trials have suggested yoga improves sexual function.31,32 There is little support for neutraceuticals alleviating SSRI-induced sexual dysfunction.3335 In summary, pharmacologic methods have the strongest support in alleviating SSRIinduced sexual dysfunction. Of the augmentation strategies, bupropion has the most support in terms of efficacy and tolerability. There are several possible treatment strategies: reduce antidepressant dose, augment with an antidote, or switch medication. However, it is better to take the importance of sexual side effects into consideration when prescribing an initial antidepressant. It is also important to query sexual adverse events specifically to ensure that side effects are mitigated and to avoid treatment discontinuation.

Footnotes
The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided. The patient described in this column is a composite with characteristics of several real patients.

Psychopharmacology for the Clinician columns are usually based on a case report that illustrates a point of interest in clinical psychopharmacology. They are about 650 words long. Competing interests: S.J. Rizvi has received payment for travel expenses and course registration from St. Jude Medical and Eli Lilly. S.H. Kennedy is on the boards of Lundbeck, Pfizer, Servier, and St. Jude Medical and has consulted for Astra Zeneca, Eli Lilly, Janssen, Lundbeck, Pfizer, Servier and St. Jude Medical.

Article information
J Psychiatry Neurosci. 2013 September; 38(5): E27E28. doi: 10.1503/jpn.130076 PMCID: PMC3756120 Sakina J. Rizvi, PhD (candidate) Departments of Pharmaceutical Sciences and Neuroscience, University of Toronto, Department of Psychiatry, University Health Network, Toronto, Ont., Canada Sidney H. Kennedy, MD Department of Psychiatry, University Health Network, Department of Psychiatry, University of Toronto, Toronto, Ont., Canada Copyright 2013 Canadian Medical Association Articles from Journal of Psychiatry & Neuroscience : JPN are provided here courtesy of Canadian Medical Association

References
1. Keltner NL, McAfee KM, Taylor CL. Mechanisms and treatments of SSRI-induced sexual dysfunction. Perspect Psychiatr Care. 2002;38:1116. [PubMed] 2. Montejo AL, Llorca G, Izquierdo J, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. J Clin Psychiatry. 2001;62:1021. [PubMed] 3. Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol. 2009;29:25966. [PubMed] 4. Kennedy SH, Rizvi S. Sexual dysfunction, depression, and the impact of antidepressants. J Clin Psychopharmacol. 2009;29:15764. [PubMed] 5. Bull SA, Hunkeler EM, Lee JY. Discontinuing or switching serotonin reuptake inhibitors. Ann Pharmacother. 2002;36:57884. [PubMed] 6. Hu XH, Bull SA, Hunkeler EM. Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate. J Clin Psychiatry. 2004;65:95965. [PubMed] 7. McGahuey CA, Gelenberg AJ, Laukes CA, et al. The Arizona Sexual Experience Scale: reliability and validity. J Sex Marital Ther. 2000;26:2540. [PubMed] 8. Clayton AH, McGarvey EL, Clavet GJ. The Changes in Sexual Functioning Questionnaire (CSFQ): development, reliability, and validity. Psychopharmacol Bull. 1997;33:73145. [PubMed]

9. Kennedy SH, Rizvi SJ, Fulton K. The sex effects scale: pilot validation in a healthy population. Psychopharmacol Bull. 2010;43:1525. [PubMed] 10. Kennedy SH, Lam RW, Nutt DJ, et al. Treating depression effectively. Valley Stream, NY: Martin Dunitz; 2007. 11. Atmaca M, Korkmaz S, Topuz M, et al. Mirtazapine augmentation for selective serotonin reuptake inhibitor-induced sexual dysfunction: a retropective investigation. Psychiatry Investig. 2011;8:557. [PMC free article] [PubMed] 12. Ravindran LN, Eisfeld BS, Kennedy SH. Combining mirtazapine and duloxetine in treatment-resistant depression improves outcomes and sexual function. J Clin Psychopharmacol. 2008b;28:1078. [PubMed] 13. Aizenberg D, Zemishlany Z, Weizman A. Cyproheptadine treatment of sexual dysfunction induced serotonin reuptake inhibitors. Clin Neuropharmacol. 1995;4:3204. [PubMed] 14. Lauerma H. Successful treatment of citalopram-induced anorgasmia by cyproheptadine. Acta Psychiatr Scand. 1996;93:6970. [PubMed] 15. Landn M, Eriksson E, Agren H, et al. Effect of buspirone on sexual dysfunction in depressed patients treated with selective serotonin reuptake inhibitors. J Clin Psychopharmacol. 1999;19:26871. [PubMed] 16. Fava M, Nurnberg HG, Seidman SN, et al. Efficacy and safety of sildenafil in men with serotonergic antidepressant-associated erectile dysfunction: results from a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2006;67:2406. [PubMed] 17. Nurnberg HG, Hensley PL. Sildenafil citrate for the management of antidepressantassociated erectile dysfunction. J Clin Psychiatry. 2003;64(Suppl 10):205. [PubMed] 18. Evliyaoglu Y, Yelsel K, Kobaner M, et al. Efficacy and tolerability of tadalafil for treatment of erectile dysfunction in men taking serotonin reuptake inhibitors. Urology. 2011;77:113741. [PubMed] 19. Segraves RT, Lee J, Stevenson R, et al. Tadalafil for treatment of erectile dysfunction in men on antidepressants. J Clin Psychopharmacol. 2007;27:626. [PubMed] 20. Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction: a randomized controlled trial. JAMA. 2008;300:395404. [PubMed] 21. Ashton AK, Weinstein W. Tadalafil reversal of sexual dysfunction caused by serotonin enhancing medications in women. J Sex Marital Ther. 2006;32:13. [PubMed] 22. Zisook S, Rush AJ, Haight BR, et al. Use of bupropion in combination with serotonin reuptake inhibitors. Biol Psychiatry. 2006;59:20310. [PubMed] 23. Clayton AH, Warnock JK, Kornstein SG, et al. A placebo-controlled trial of bupropion SR as an antidote for selective serotonin reuptake inhibitor-induced sexual dysfunction. J Clin Psychiatry. 2004;65:627. [PubMed] 24. Safarinejad MR. The effects of the adjunctive bupropion on male sexual dysfunction induced by a selective serotonin reuptake inhibitor: a double-blind placebo-controlled and randomized study. BJU Int. 2010;106:8407. [PubMed] 25. Ravindran AV, Kennedy SH, ODonovan MC, et al. Osmotic-release oral system methylphenidate augmentation of antidepressant monotherapy in major depressive disorder: results of a double-blind, randomized, placebo-controlled trial. J Clin Psychiatry. 2008a;69:8794. [PubMed]

26. Balon R, Segraves RT. Survey of treatment practices for sexual dysfunction(s) associated with anti-depressants. J Sex Marital Ther. 2008;34:35365. [PubMed] 27. Worthington JJ, III, Simon NM, Korbly NB, et al. Anxiety Disorders Research Program. Ropinirole for antidepressant-induced sexual dysfunction. Int Clin Psychopharmacol. 2002;17:30710. [PubMed] 28. Aiken CB. Pramipexole in psychiatry: a systematic review of the literature. J Clin Psychiatry. 2007;68:12306. [PubMed] 29. Reinhold JA, Mandos LA, Lohoff FW, et al. Evidence for the use of vilazodone in the treatment of major depressive disorder. Expert Opin Pharmacother. 2012;13:221524. [PubMed] 30. Lorenz TA, Meston CM. Acute exercise improves physical sexual arousal in women taking antidepressants. Ann Behav Med. 2012;43:35261. [PMC free article] [PubMed] 31. Dhikav V, Karmarkar G, Gupta R, et al. Yoga in female sexual functions. J Sex Med. 2010a;7:96470. [PubMed] 32. Dhikav V, Karmarkar G, Verma M, et al. Yoga in male sexual functioning: a noncompararive pilot study. J Sex Med. 2010b;7:34606. [PubMed] 33. Jacobsen FM. Fluoxetine-induced sexual dysfunction and an open trial of yohimbine. J Clin Psychiatry. 1992;53:11922. [PubMed] 34. Michelson D, Kociban K, Tamura R, et al. Mirtazapine, yohimbine or olanzapine augmentation therapy for serotonin reuptake-associated female sexual dysfunction: a randomized, placebo controlled trial. J Psychiatr Res. 2002;36:14752. [PubMed] 35. Dording CM, Fisher L, Papakostas G, et al. A double-blind, randomized, pilot dosefinding study of maca root (L. meyenii) for the management of SSRI-induced sexual dysfunction. CNS Neurosci Ther. 2008;14:18291. [PubMed]

Indian Journal of Psychological Medicine Medknow Publications

Nature of Sexual Dysfunctions in Major Depressive Disorder and its Impact on Quality of Life
Rajarshi Guha Thakurta, Om Prakash Singh, [...], and Ranjan Das Additional article information

Abstract
Background:

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 wellbeing. Epidemiological and clinical studies show that depression is associated with impairments of sexual function and satisfaction, even in untreated patients. Most antidepressant drugs have adverse effects on sexual function, but accurate identification of the incidence of treatment-emergent dysfunction has proved troublesome. However, few investigators have reported the base rate for disturbances in sexual desire, arousal, and orgasm or ejaculation in patients with major depressive disorder (MDD) prior to antidepressant treatment. The purpose of this study is to define the frequency of sexual dysfunction (SD) in 60 patients with MDD and examine the relationship between SD and quality of life enjoyment and satisfaction variables.

Materials and Methods:

A consecutive series of 24 male and 36 female MDD patients diagnosed by SCID-DSM IV assessment completed a series of psychometric measures including a Sexual Function QuestionnaireArizona Sexual Experience Scale (ASEX) which asked about change in sexual interest and function as well as quality of life of life enjoyment using QLESQ-SF.

Results:
Over 33.33% of men and 42% of women reported decreased sexual interest. Reduced levels of arousal were more common in both men and women (8-22%) than ejaculatory or orgasm difficulties (1116%). In women, SDs were more than males. Quality of life was more impaired in sample with SDs than those without dysfunction showing significant impact of SD on quality of life.

Limitation and Conclusion:

Although limited by a relatively small sample of drug-free patients with MDD, and by the absence of a non-depressed comparison sample, these results emphasize the importance of factors beyond specific drug effects in the assessment of SD in drug naivedepressed patients. Keywords: Impairment, major depressive disorder, quality of life, sexual dysfunctions

INTRODUCTION
Sexual functioning is influenced by a number of factors, mental illness being one of them. Sexual dysfunctions (SDs) are characterized by disturbances in sexual desire and in the psychophysiological changes associated with the sexual response cycle in men and women.[1] Using the measure of disability-adjusted life years, it was determined that unipolar major depression was the fourth leading cause of disease burden in the world. It was also

projected that, in the year 2020, unipolar major depression would be the second leading cause of disease burden in the world.[2] Major depressive disorder (MDD) is characterized by loss of interest, reduction in energy, lowered self-esteem, inability to experience pleasure, this constellation of symptoms may be expected to produce difficulty in sexual relationship. Depressed patients have shown SD two to three times more than non-depressed individuals.[3] Quality of Life (QOL) is a multidimensional construct to include subjective well-being and life satisfaction. Subjects with affective disorders have significant QOL impairment although the degree of dysfunction varies.[4] SD in patients with MDD has mostly been studied independently or in gender-specific studies. These studies have reported significant dysfunction in different areas of sexual functioning. However, a majority of these studies are uncontrolled and provide limited evidence about the baseline rates of dysfunction across MDD. Furthermore, patients in affective disorders are usually prescribed antidepressant medications, which are known to cause substantial SD. Simply exemplifying the dysfunction caused by medications is imperfect unless the dysfunction caused by the disease is clearly demarcated. SD and QOL in MDD have mostly been studied independently or in gender-specific studies. Most studies have highlighted the role of drugs used in the class of affective disorders which cause substantial SDs.[5] In India, most of the studies have focused on male SD, very few have voiced the female SD.[6] Thus, limited data exist on SD and QOL in MDD in Indian Literature in rural or urban settings. The aim of the present study was to assess the sexual functioning in drug-free MDD subjects and to investigate the association with QOL domains.

MATERIALS AND METHODS

The present study was a single center, cross-sectional, single interview study that was approved by the institutional ethics board. All the first-time registered patients were screened with the Psychiatric Diagnostic Screening Questionnaire (PDSQ).[7] Subjects of either sex aged between 18 and 65 years fulfilling the criteria for MDD were included. All subjects were interviewed by using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Re-search Version, Patient Edition (SCID-I/P) and Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II).[8] A detailed history was obtained and a physical examination, consultation liaison (when required), and laboratory investigations (where indicated) were performed to rule out any physical comorbidity.

The selected cases fulfilling the selection criteria for MDD were rated for severity of illness with the 17-item Hamilton Rating Scale for Depression (HAM-D).[9] Sexual experience of subjects was assessed by using the Arizona Sexual Experience Scale (ASEX),[10] a self-rated instrument for both genders. The ASEX rates sexual experience in the areas of desire, excitement, penile erection/vaginal lubrication, orgasm, and satisfaction from orgasm on a scale of 1 to 6. SD is defined as having either a score of 5 or more on any item or a total score of 19 or more. The patients were then evaluated for impairment in QOL using QOL Enjoyment and Satisfaction Questionnaire-Short Form (QLES-Q-SF).[11] Higher scores on the QLES-Q are indicative of greater enjoyment or satisfaction. Scoring on all scales were administered by a psychiatrist and recorded. After screening 104 subjects, 60 subjects were included on giving written consent. The exclusion criteria for all subjects included having comorbid Axis I and Axis II disorders (excluding tobacco dependence) on SCID-I/P and SCID-II; psychotic symptoms; history of SD prior to present episode of illness; endocrinal disorders (thyroid dysfunctions, diabetes); local genital problems (vaginitis, pelvic infections); hypogonadism; cardiovascular disorders (angina, myocardial infarction); renal dysfunctions; neurologic disorders (stroke, spinal cord lesions, pelvic autonomic neuropathy); intake of any psychiatric medication in last 1 month; and pelvic and abdominal surgeries in past, known to be causing SDs (oophorectomy, operations for prolapse). The subjects were excluded if any of the above-mentioned physical disorders were present in last 3 months. The data was pooled and statistical analysis was done using SPSS version 20 (SPSS Inc., Chicago, ILL). Chi square tests, two sample t-tests, and correlation analysis using Pearson's correlation were performed where necessary. In all these analyses, two-tailed level of significance was set at P<0.05 and confidence interval (CI) at 95%.

RESULTS
Table 1 describes the demographic and clinical characteristics of the subjects participating in the study. The overall sample (n=60) had a meanSD age of 38.010.53 years. 60% of the subjects were female (n=36). Most of the subjects were from a rural background (n=48), while 20% were from urban areas. 88.3% of the subjects were married. The meanSD of duration of illness was 14.268.25 months.

Table 1 Socio-demographic characteristics of the sample On rating for severity of depression, the overall sample had HAM-D meanSD 19.353.96, with higher mean scores on HAM-D for females 19.974.10. Figure 1 depicts the distribution of severity across either gender, 29.5 % of male subjects (n=7) had moderate depression while 37.5% of them had severe depression. However, in female subjects, severe and very severe depression was rated in 33.3% of subjects (n=12) in each category.

Figure 1 Depicts the gender-wise distribution of severity of Ham-D scores SD was reported in 71.66% of the subjects (n=43). Table 2 depicts the gender wise distribution of SD across all the domains. In males, total dysfunction was present in 66.67% of the subjects, low desire 33.33% (n=8) was most frequently reported followed by difficulty in sustaining penile erection (n=7, 22.23%). Arousal and excitement problems were less reported. The meanSD ASEX scores in males was 18.713.67.

Table 2 Depicts distribution of ASEX severity scores among subjects Females reported higher rates of dysfunction spanning all domains with total dysfunction in 75% (n=27) of subjects. Figure 2 depicts the gender wise and domain wise distribution of SD. In female subjects, low desire 41.67% (n=15) was the most common reported

abnormality followed by arousal and excitement problems 22.2% (n=8). The meanSD ASEX scores in females was 18.783.12.

Figure 2 Depicts the gender-wise distribution of sexual dysfunction on ASEX items The overall sample had dysfunctions in the domains of desire 38.33% followed by dysfunctions in penile erection/vaginal lubrication 23.3%. To study the impact of depression on SD, a two sample t-test was done (t=14.12, P=0.000) showing that mean HAM-D scores were significantly higher in the SD group. Figure 3 shows the relationship between mean HAM-D and ASEX scores. On correlation analysis, HAM-D scores correlated significantly with all ASEX items except erection/lubrication (r=0.15, P=0.257). Total HAM-D scores correlated positively with total ASEX scores significantly (r=0.817, P<0.000).

Figure 3 Represents the relationship between mean HAM-D and ASEX (total) scores To study the relationship of SD on QOL raw scores on QLES-Q-SF were converted to % maximum scores. Subjects without dysfunction had meanSD (65.249.90) compared to subjects with SD (30.636.68) the difference being statistically significant (t = -13.265, df=22.0, P<0.001). The mean differences on all items of QLESQ-SF were significant statistically in between the groups, helping in assessing the impact of SD on all domains of QOL. A correlation matrix between HAM-D, ASEX (TOTAL), all items of QLES-Q, and total QLES-Q-SF revealed total score on HAM-D correlated positively and significantly with duration of illness (r=0.579, P<0.001), total ASEX scores (r=0.817, P<0.000), negatively with all domains of QOL scale and total scores (r=0.849, P<0.001). Similarly as depicted in Table 3, total ASEX scores correlated negatively with all items on QLES-Q-SF and total score (r=0.752, P<0.001).

Table 3 Shows the correlation matrix between the variables The scatter plot in Figure 4 shows the association between ASEX scores and QLES-Q-SF (%maximum).

Figure 4 Shows the scatter plot between ASEX and % maximum score QLES-Q

DISCUSSION
The present study aimed to assess the prevalence of SDs in drug-free depressed patients and to evaluate its impact on QOL. The results from the present study indicate high rates of SD in MDD patients, 71.66% which is comparable to the results of Casper et al.[12] who found in 132 patients with depressive disorders, loss of sexual interest, characterized by loss of libido, or decrease of sexual desire or potency, was reported by 72% of patients with unipolar depression.[12] Our findings are comparable to Kendurkar and Kaur[13] who in 50 drug naive-depressed patients from India reported 76% baseline rates of SD. The prospective Zurich cohort study shows that the prevalence of sexual problems in depressed subjects (including those with major depression, dysthymia, and recurrent brief depression) is approximately twice that in controls (50% versus 24%). This difference encompassed emotional problems, SD, and both decreased and increased libido. The data in this study are from a group of young people (28-35 years) and may not be applicable to older age groups.[14] Low sexual desire has frequently been reported with MDD as it was reported with the highest mean score in this study with 33.3% males and 41.67% females reporting dysfunctions in the area of desire which is comparable with the findings of Kennedy et al. [15] who assessed SD in a depressed sample of 67 men and 102 women who either had never taken antidepressant medication or had been antidepressant free for at least 2 weeks (5 weeks if they had been taking fluoxetine). They found that 42% of men and 50% of women reported a decrease in sexual drive, 36% of men and 38% of women had a

decreased interest in sexually explicit material, and 42% of men and 35% of women had a reduction in fantasizing about sex. In female subjects, 22.2% reported dysfunction in arousal which was comparable to previous self-reported measures in arousal in 914 women and found that arousal was significantly lower in women with recurrent MDD compared to women with no history of depressive disorder, even when controlling for current depression scores, psychotropic medication use, and comorbid anxiety or substance abuse.[16] Difficulty in erection was the second most common dysfunction in males. 29.16% preceeded by desire problems in this study which is comparable to the findings of Kendurkar[13] who reported 32% dysfunction in the domains of erection using the same rating instrument in Indian population. A study by Kennedy and co-workers showed similar rates of dysfunction with erection difficulties in 34% of male subjects.[16] Orgasmic dysfunctions were comparatively lower in this study population but corroborated with the findings of Kennedy and coworkers who found that 22% of depressed men reported delayed ejaculation and 12% had difficulty with premature ejaculation while 15% of depressed women reported difficulty in attaining orgasm. Comparing our results with that of Kendurkar et al.[13] we reported lower rates of dysfunction in males (74% vs 66.7%) and comparable rates in female subjects (78% vs 75%), which could be due to the higher male representation in the previous studies. The most important finding of this cross-sectional study is the strong correlation between HAM-D scores and all individual items of ASEX scale which is not comparable to results previously documented.[17] This study found a significant correlation between ASEX and QLESQ-SF in all domains which were negatively correlated, quantifying the strength of impairment in all domains of QOL, enjoyment, and satisfaction. The strong negative association between severity of depression and QOL domains are consistent with previous work demonstrating a monotonic gradient between MDD and QOL.[18] The finding that subjects with SD have statistically significant impairment in all domains of QOL compared to subjects without sexual complaints suggests it is likely that depressive symptoms and sexual problems are linked in a cyclic fashion with one contributing to the other. Concerning SD alone, there is little agreement about its causes, except that it is multiply determined, and that the relationships between SD and mood are complex and multidirectional.[1921] There are certain inherent limitations with this study, firstly the absence of a control healthy group, secondly the small sample size, and thirdly the cross-sectional nature of this study limits the possibility to explore the cause and effect relationship between SD

and psychiatric diagnosis. Lastly, since the data were collected from a specific population, the degree to which they represent the general population cannot be commented upon. The robust nature of this study lies in documenting the baseline prevalence and types of SDs in both genders in MDD without highlighting the role of medication-induced dysfunctions. Also by excluding subjects with onset of SD prior to current episode and those with known physical conditions known to cause SDs an attempt was made to obtain more unambiguous data.

CONCLUSION
This study highlights the high rates of sexual dysfunctions in drug-free outpatients of MDD, involving all phases of sexual cycle with females having greater dysfunction rates. The greater impairment in quality of life in subjects with sexual dysfunction suggests that although various factors contribute to sexual dysfunctions, early recognition of sexual dysfunctions and appropriate treatment of depressed patients with sexual complaints will prevent progression from milder to more severe disorders. Moreover, early recognition of SD will lead to better choice of antidepressant medication and treatment plan with a favorable side effect profile and use of pharmacologic antidotes wherever necessary to improve the overall quality of life in MDD.

Footnotes
Source of Support: Nil Conflict of Interest: None.

Article information
Indian J Psychol Med. 2012 Oct-Dec; 34(4): 365370. doi: 10.4103/0253-7176.108222 PMCID: PMC3662135 Rajarshi Guha Thakurta, Om Prakash Singh,1 Amit Bhattacharya, Asim Kumar Mallick, Paramita Ray, Sreyashi Sen,2 and Ranjan Das Department of Psychiatry, BMCH, Kolkata, West Bengal, India 1 Department of Psychiatry, NRS Medical College and Hospital, Kolkata, West Bengal, India 2 Department of Psychiatry, Anaesthesiology, IPGMER Hospital, Kolkata, West Bengal, India Address for correspondence: Dr. Om Prakash Singh, Department of Psychiatry, NRS Medical College, Kolkata - 700 014, West Bengal, India. E-mail: hodpsybmc/at/gmail.com Copyright : Indian Journal of Psychological Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from Indian Journal of Psychological Medicine are provided here courtesy of Medknow Publications

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1. Laumann EO, Park A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281:53744. [PubMed] 2. Murray CJ, Lopez AD. Boston, MA: Harvard University Press; 1996. The global burden of disease and global health statistics. 3. Baldwin DS. Depression and sexual function. J Psychopharmacol. 1996;10(Suppl 1):S304. 4. Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry. 2005;162:11718. [PubMed] 5. Balon R. Mood, anxiety, and physical illness: Body and mind, or mind and body? Depress Anxiety. 2006;23:37787. [PubMed] 6. Prakash O, Rao TS. Sexuality research in India. Indian J Psychiatry. 2010;52(Suppl 1):S2603. [PMC free article] [PubMed] 7. Zimmerman M, Mattia JI. A self-report scale to help make psychiatric diagnoses: The psychiatric diagnostic screening questionnaire. Arch Gen Psychiatry. 2001;58:78794. [PubMed] 8. 4th ed. Washington, DC: American Psychiatric Association; 1994. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders; pp. 493 522. 9. Hamilton M. A Rating scale for Depression. J Neurol Neurosug. 1960;23:5661. [PMC free article] [PubMed] 10. McGahuey CA, Gelemberg AJ, Laukes CA, Moreno FA, Delgado PI, McKnight KM, et al. The Arizona Sexual Experience Scale (ASEX): Reliability and validity. J Sex Marital Ther. 2000;26:2540. [PubMed] 11. Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure. Psychopharmacol Bull. 1993;29:3216. [PubMed] 12. Casper RC, Redmond E, Katz MM, Schaffer CB, Davis JM, Koslow SH. Somatic symptoms in primary affective disorders: Presence and relationship to the classification of depression. Arch Gen Psychiatry. 1985;42:1098104. [PubMed] 13. Kendurkar 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;19:299305. [PMC free article] [PubMed] 14. Angst J. Sexual problems in healthy and depressed patients. Int Clin Psychopharmacol. 1998;13(Suppl 6):S13. [PubMed] 15. Kennedy SH, Dickens SE, Eisfeld BS, Bagby RM. Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord. 1999;56:2018. [PubMed]

16. Cyranowski JM, Bromberger J, Youk A, Matthews K, Kravitz DO, Powell LH. Lifetime depression history and sexual function in women at midlife. Arch Sex Behav. 2004;33:53948. [PubMed] 17. Nicolosi A, Moreira Jr ED, Villa M, Glasser D. A population study of the association between sexual function, sexual satisfaction and depressive symptoms in men. J Affect Disord. 2004;82:23543. [PubMed] 18. Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. J Affect Disord. 1997;45:1930. [PubMed] 19. Wincze JP, Carey MP. New York: The Guilford Press; 2001. Sexual dysfunction: A guide for assessment and treatment. 2nd ed. 20. Weiner DN, Rosen RC. Sexual dysfunctions and disorders. In: Millon T, Blaney PH, Davis RD, editors. Oxford Textbook of Psychopathology. New York: Oxford University Press; 1999. pp. 41043. 21. Werneke U, Northey S, Bhugra D. Antidepressants and sexual dysfunction. Acta Psychiatr Scand. 2006;114:38497. [PubMed]

Clinics Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo

Female sexual dysfunction in patients with substance-related disorders

Alessandra Diehl, Rosiane Lopes da Silva, and Ronaldo Laranjeira Additional article information

Abstract
OBJECTIVE:
To estimate the prevalence of female sexual dysfunction symptoms and the associated risk factors in a sample of patients with substance-related disorders admitted to a specialized in-patient care unit.

METHODS:
This study used a cross-section design, with eight months of data collection, conducted with substance-dependent women using structured questionnaires to collect sociodemographic data and identify their drug of choice. The Drug Abuse Screening Test,

Short Alcohol Dependence Data questionnaire, Fagerstrm Test for Nicotine Dependence, and Arizona Sexual Experience Scale were also administered.

RESULTS:
The sample consisted of 105 women who had a mean age of 34.8 years (SD = 12.1, range = 18-65) and were predominantly heterosexual (74.3%), single (47.6%), Caucasian (50.5%), catholic (36.2%), and educated only to the level of primary education (40%), with a monthly family income of up to one minimum salary (37.5%). In 42.9% of the patients, crack was the drug of choice; 47.6% of the sample qualified for the Drug Abuse Screening Test (substantial problems related to drugs), 43.8% exhibited Short Alcohol Dependence Data (moderate or severe dependency), 47.6% exhibited Fagerstrm Test for Nicotine Dependence (high or very high nicotine dependence). The prevalence of sexual dysfunction symptoms was 34.2% (95% CI = [25.3, 44.1]), and a high level of nicotine dependence and low income increased the chances of having sexual dysfunction by 2.72fold and 2.54 fold, respectively. An association was also observed between female sexual dysfunction symptoms and schooling and levels of drug dependence.

CONCLUSIONS:
Female sexual dysfunction symptoms were common among this sample and primarily associated with high levels of nicotine use. Keywords: Sexual Dysfunction, Substance-Related Disorders, Women, Crack/Cocaine, Tobacco Use Disorder

INTRODUCTION
Female sexual dysfunction (FSD) is a common disorder in societies worldwide, but it is also a complex multifactor phenomenon that encompasses emotional intimacy and relationship satisfaction, along with other psychosocial factors across all cultures, all sexual orientations and various socio-economic statuses, with a great potential to affect relationships negatively and impair quality of life (1-3). Epidemiological studies in the United States have estimated that FSD affected 43% of women in the general population over the past 12 months (4). In the United Kingdom, 5.8% of women have reported recent sexual dysfunction, and 15.5% have reported lifelong sexual dysfunction (1), whereas in Latin America, the rate of FSD for middle aged women it is approximately 58% (5). Some studies on this issue have indicated that among women with any sexual difficulty, an average of 64% (range = 16-75%) experienced difficulty with desire, 35% (range = 16-48%) experienced difficulty achieving orgasm, 31% (range = 12-64%) experienced difficulty becoming aroused, and 26% (range = 7-58%) experienced sexual pain (1,4,6). Unfortunately, this condition remains a largely under-explored field in medicine, despite (a) sexual dysfunction being more prevalent in women than in men and (b) the evolution

of nonlinear models due to understanding the intricacy of female sexual function that recognize the importance of both nonbiological and biological factors (1),. Some of the psychological factors associated with FSD include the unconscious avoidance of sex and pleasure, fear, structured rigid families, the demands of a relationship, and an excessive need to satisfy the partner. In addition, the guilt that comes from experiencing pleasure can be internalized as a potential risk and danger, which in turn leads to both insecurity and a repression of the body and possible pleasure that it can experience (4,7). Alcohol consumption, tobacco smoking, and illicit drug abuse/dependence have long been associated with sexual dysfunction (10-12). Among chronic heroin and morphine users, for example, a review study noted decreases in sexual intercourse frequency, masturbation, and the quality and frequency of orgasm (13). These effects occur because opioids inhibit the hypothalamic-pituitary-gonadal axis and increase prolactin levels, which affect both the male and female sexual response (13). Animal and in vitro studies examining the effects of cannabis abuse on sexual function have identified potential links between chronic cannabis smoking and inhibited orgasms (13-15). Chronic cocaine abuse is also associated with hyperprolactinemia and sexual dysfunction symptoms, such as diminished libido and difficulty reaching orgasm (11,12). In alcohol-dependent women, the most common forms of sexual dysfunction observed include dyspareunia, high rates of genitourinary health problems, and low vaginal lubrication, revealing problems with sexual arousal (13,16). Other factors that may predict symptoms of sexual dysfunction in this population include a history of sexual abuse, psychiatric comorbidities (such as depression, anxiety, and eating disorders) that commonly co-occur with dependence to alcohol and other drugs in women, various specific symptoms associated with the abuse of psychoactive substances (such as "crashing" after cocaine use), and insomnia problems (3,10,16). Furthermore, research on the relationship between FSD symptoms and drug abuse (especially for other drugs, such as crack) has been neglected to an even greater extent (11,13). Nevertheless, identifying the magnitude of this problem and managing the sexual health issues among this population may have a significant impact on the prevention of relapse. Managing this problem is especially important because the use of psychoactive substances may be involved in the relief of symptoms related to sexual dysfunction or result from a search for anesthesia feelings in response to the frustration of not achieving sexual pleasure (17). The scarcity of data on the prevalence of sexual dysfunction symptoms in women, especially among crack users, justifies the expansion of scientific evidence in this area (6,13). Our hypothesis is that FSD occurs more frequently in addict patients than the general population and is largely associated with alcohol, crack, and polydrug abuse.

The objective of this study was to evaluate the prevalence of sexual dysfunction and the associated risk factors among a sample of substance-dependent women admitted to an inpatient care service.

METHODS
This study was approved by the Federal University of So Paulo Ethics Committees (protocol number 1193/09), and all of the subjects signed an informed consent form. The patients did not receive any financial reward or compensation for participating in this study. The study used a cross-sectional design and was conducted at the public inpatient care center of the Alcohol and Drugs Research Unit of the Federal University of So Paulo, which specializes in the treatment of disorders related to substance use, is dedicated exclusively to women, and is located within a tertiary psychiatric hospital near Sao Paulo, Brazil. This unit has 28 beds for women over the age of 18 years, with an average occupancy of 15 beds per month. The average duration of treatment for each patient is approximately 45 days and includes individual and group activities with a multidisciplinary staff that employs a combination of pharmacological treatment and several psychosocial approaches, such as relapse prevention, 12-step program facilitation, motivational interviewing, cognitive behavioral therapy, harm reduction, and complementary therapies, such as physical activity and dance (18).

Procedures
During the eight months of data collection between February 2011 and October 2011, a psychologist and a nurse, both with expertise in addiction and previous training, administered a questionnaire developed by the authors to 105 women who had been diagnosed with substance-related disorder and who were older than 18 years of age. All of the patients had a confirmed clinical diagnosis of dependence according to the diagnosis criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (19) up to the first week of admission to this setting. The interview duration was 40 minutes on average. No refusals were recorded.

Main outcomes measures

Socio-demographic data: The following socio-demographic data were collected: age, sexual orientation, educational level, ethnicity, marital status, monthly income, employment status, and religious affiliation. Drug of choice: The term "drug of choice" refers to the preferred drug of the substance abuser, and this information is often important to the clinical status of the patient because substance users often meet diagnostic criteria for dependence on multiple drugs. Certain characteristics, such as age, race, and marital status, have been shown to vary between individuals according to their drug of choice preferences. These data are not collected on a scale, but each patient is asked a simple question: What is your drug of choice? (20).

Short Alcohol Dependence Data (SADD) questionnaire: This instrument is a 15-item self-report questionnaire used to provide a measure of the severity of alcohol dependence within a continuum ranging from a mild drinking problem to severe alcohol dependence; it evaluates the behavioral and subjective aspects of alcohol dependence, with an adequate construct validity and high correlation with other instruments. The Brazilian version of the SADD and original English version were highly correlated. The coefficient of internal consistency was 0.79 (21). Drug Abuse Screening Test (DAST-20): This survey comprises 20 questions relating to drug use during the last year. The questions pertain specifically to abuse, dependence, withdrawal (signs and symptoms), social impairment, familial relationships, legal implications, medical problems, and previous treatment. The problem severity was classified on a scale from 0 to 20 and scored as follows: 0 = no problem; from 1 to 5 = mild; 6 to 10 = moderate; 11 to 15 = substantial; and 16 to 20 = severe. This scale has been used in several studies and validated in other countries with good results in concurrent and discriminate validity, but it has yet to be validated in Brazil (22). Fagerstrm Test for Nicotine Dependence (FTND): This questionnaire is a screening instrument that has been extensively translated and used in many countries, including Brazil, to assess physical nicotine dependence. The instrument consists of six items that are easily understood and can be rapidly applied. The scores obtained on the test permit the classification of nicotine dependence into five levels: very low (0 to 2 points); low (3 to 4 points); moderate (5 points); high (6 to 7 points); and very high (8 to 10 points). The reliability index of this instrument is excellent (0.87), and Cronbach's alpha coefficient ranged from 0.55 to 0.74, indicating that the FTND has moderate internal consistency. The FTND showed satisfactory sensitivity (0.75) and specificity (0.80) (23). Arizona Sexual Experience Scale (ASEX): This instrument is a scale designed to measure five specific items as the core elements of sexual function: sexual drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction from orgasm. The instrument measures these items with five questions in a relatively nonintrusive bimodal fashion using a six-point Likert scale that ranges from hyperfunction (1) to hypofunction (6). The scores range from 5 to 30, and scores higher than or equal to 19 indicate sexual dysfunction. The ASEX was designed to be either self- or clinically administered and can be used in either heterosexual or homosexual populations, regardless of whether the subject has a sexual partner. Questions addressing the frequency/preference of sexual activity were considered unrelated to sexual dysfunction. Cronbach's alpha analysis indicated that the ASEX demonstrated excellent internal consistency and scale reliability (alpha = 0.9055). The ASEX also demonstrated strong test-retest reliability (for patients, r = 0.801, p<0.01; for controls, r = 0.892, p<0.01). The sensitivity and specificity of the ASEX in terms of the identification of sexual dysfunction were 82% and 90%, respectively (24). The main rationale for using the ASEX scale instead of wellestablished measures for sexual dysfunction in women, such as the Female Sexual Function Index or Female Sexual Distress Scale, was that the ASEX scale is shorter than those mentioned and more easily incorporated into the protocols of our service, which already includes many other instruments and also provides inpatient care for men with substance-related disorders (6,7,18).

Data analyses
For the descriptive analysis, we evaluated the absolute and relative frequencies of the categorical variables and summary measures: means, quartiles, minimums, maximums and standard deviations of the numeric variables. To investigate the association between the characteristics of the categorical variables of the sample with sexual dysfunction symptoms, we used the 2 test or Fisher exact test if the sample was insufficient (25). The use of categorical variables in the SADD, DAST-20, FTND, and ASEX scales was adopted owing to their nonlinear functional relationship with the variable of interest and because the cut-off points are already well accepted in the literature (18,25). To compare the means of the numerical variables between the two groups, we used the Student t test for independent samples. To make comparisons between the averages of more than two groups, we used an analysis of variance (ANOVA) after confirming the assumption of observed data normality using the Kolmogorov-Smirnov test (25). Initially, all of the variables were included in the model. Then, the variables that were not significant at the 5% level were excluded one by one in order of significance (reverse method). Furthermore, the Hosmer-Lemeshow test was used to evaluate the suitability of model adjustment means in the final model. The sensitivity and specificity were calculated from the odds of sexual dysfunction final model, which was estimated using the ROC curve (25). In this study, two pseudo R2 (coefficient of determination) values were obtained. The first was Cox-Snell, and the second was Nagelkerke. Logistic regression does not have an R2 value that allows a linear regression to explain the variation of the model. Therefore, an attempt must be made to obtain a statistically similar value; various pseudo R2 values have been proposed. It is important to note that the R2 assumes nonnegative values (greater than or equal to zero) but never reaches a value of one (in a linear regression, the R2 takes values between zero and one, and one indicates a perfect fit of the model). Therefore, because the pseudo R2 shares the same interpretation as the R2 (part of the variability of the dependent variable the outcome explained by the regressors explanatory variables), its value must be assessed with caution (25). Finally, for the joint assessment of the effects of characteristics on sexual dysfunction symptoms, logistic regression was used. For all of the statistical tests, a significance level of 5% was used (25).

RESULTS
Socio-demographic data
The sample consisted of 105 women, with a mean age of 34.8 years (SD = 12.1), an age range of 18-65 years (t = -1.41, p = 0.16) and a median age of 31 years (second quartile). The women were predominantly heterosexual (74.3%, n = 78), single (47.6%, n = 50),

Caucasian (50.5%, n = 53), and catholic (36.2%, n = 38). They also had a monthly income of up to one minimum wage, and 37.5% (n = 39) had an elementary education, which equates to an average of approximately six to seven years of study. According to Table 1, the only association observed was between education and sexual dysfunction symptoms 61.1% (n = 22) of the women with sexual dysfunction symptoms had not completed elementary school, whereas 29% (n = 20) of the women with no sexual dysfunction symptoms had not completed elementary school.

Table 1 Sociodemographic data and sexual dysfunction symptoms (N = 105). The average age of the women with sexual dysfunction symptoms (n = 36) was 37.1 years (SD = 12.0), and the average age of those without sexual dysfunction symptoms (n = 69) was 33.6 years (SD = 12.1). There were no detectable differences between the mean ages for sexual dysfunction symptoms (t = -1.41, p = 0.16).

Prevalence of sexual dysfunction symptoms

In this sample, the prevalence of sexual dysfunction symptoms was 34.2% (95% CI = [25.3, 44.1]) according to the ASEX.

Affective sex orientation

The subjects were predominantly heterosexual (74.3%, n = 78), followed by bisexual (17.1%, n = 18), and homosexual (8.6%, n = 9). The proportion of exclusively homosexual women was too small in our sample to conduct any meaningful comparative analysis in terms of the prevalence of FSD symptoms in homosexual versus heterosexual women.

Characteristics related to substance abuse/dependence

In 42.9% (n = 45) of the subjects, crack was the drug of choice, followed by alcohol in 30% (n = 32) of subjects. In addition, 47.6% of this sample presents a substantial level of problems related to drugs according to the DAST-20; 43.8% (n = 46) have a moderate or severe dependence on alcohol according to SADD, and 47.6% (n = 60) have a high or very high level of nicotine dependence according to FTND (Table 2). There were no

differences in the mean levels between the ASEX, SADD (p = 0.50), DAST-20 (p = 0.67), and FTND (p = 0.27).

Table 2 Dependence level and sexual dysfunction symptoms (N = 105)

Risk factors
Table 3 presents the final logistic regression model. The coefficients associated with the incomplete high school and high school levels of education were similar (p = 0.78); therefore, these two categories were combined to increase the regression model degrees of freedom due to sample size. The same occurred with the levels of DAST-20; the coefficients associated with the low, moderate, substantial and severe levels were similar (p = 0.71).

Table 3 Risk factors associated with female sexual dysfunction. The variable salary and DAST-20, although not significant at the 5% level, were maintained in the sample because they were marginally significant. It can be observed in this table that women who have had secondary education (complete or incomplete) have an 80% reduced chance of presenting dysfunction symptoms compared with women with lower levels of education. However, women with a high level of nicotine dependence increased their chance of presenting sexual dysfunction symptoms by 2.72 compared with women of other levels of drug dependence. The Hosmer-Lemeshow test (p = 0.48) indicated a good adequacy of fit to the model. From the final model, it is possible to use the characteristics of women in terms of education, FTND, DAST-20, and salary to estimate the probability of having FSD symptoms.

Using the ROC curve, we obtained a cut-off of 0.31 in probability, which was associated with a sensitivity of 82.9% and specificity of 68.1%. Hence, if all of the women with a probability greater than 0.31 are classified as having sexual dysfunction symptoms, the model classifies 82.9% of women who truly have positive sexual dysfunction symptoms. In addition, among the women who do not have sexual dysfunction symptoms, 68.1% are properly classified as not having sexual dysfunction symptoms. In this study, two pseudo R2 were obtained. The first was Cox-Snell and had a value of 0.21, and the second was Nagelkerke and had a value of 0.29.

DISCUSSION
Socio-demographic factors, such as age, marital status, income, and education, have been strongly predictive of sexual dysfunction symptoms in women (3,4). In this sample, a significant association between sexual dysfunction symptoms and socio-demographic characteristics was observed only for schooling, which is in agreement with other international studies showing that levels of sexual dysfunction are higher in women with low levels of education (3,4). In addition to education, another finding that stands out and concurs with other international studies refers to the 2.54 fold increased chance of sexual dysfunction symptoms in women with low income. Women who subsist on a low income comprise a high-risk vulnerable population with limited access to social and health services. In general, this population is also more vulnerable to poverty and higher levels of sexual crime and violence than most other populations investigated in sexual function studies (3). For women addicted to alcohol and drugs, these vulnerabilities may be heightened because the consumption of drugs, especially crack, has been associated with various types of violence and the exchange of sex for drugs in women (18). The prevalence of 34.2% FSD symptoms in this sample of women with substance-related disorder was common and comparable to other studies reported worldwide, which have reported prevalence rates of FSD symptoms of 12-63% (3,6,10), even in a sample of women with severe psychoactive substance dependence, as determined by the DAST-20, SADD, and FTND scales. Consequently, we expected to find higher sexual dysfunction symptom prevalence rates than in the general population. Another finding that is in accordance with the current scientific evidence is the association between severe nicotine dependence and sexual dysfunction symptoms, which was almost threefold the odds ratio compared with women of other nicotine dependence levels in our sample (10). Scientific evidence has suggested that long-term cigarette smoking is an independent risk factor for sexual dysfunction in men (26,27). However, the results of the limited data investigating this relationship in women are diverse, and some of the evidence supports the suggestion that nicotine may be the primary pharmacological agent responsible for genital hemodynamic disturbance, thereby facilitating a cascade of vascular and biochemical events that may obstruct normal sexual arousal responses in women.

Controlled experimental studies examining the acute and chronic effects of isolated nicotine intake on female physiological sexual responses are necessary to help clarify the potential role of tobacco in the development and/or maintenance of sexual dysfunction in women (26,27). Although FSD has been investigated in groups of women with various health problems, such as polycystic ovary syndrome, diabetes, HIV, and breast cancer (28-30), women with substance-related disorder represent a unique underserved and vulnerable population that continues to suffer from low detection rates and limited access to treatment (18). The strong point of this study is on the recruitment of this special group of women because little focus has been given to the link between these two issuessexual dysfunction symptoms and alcohol and drug dependenceusing validated questionnaires as the assessment measures, especially in Brazil and other Latin American countries, where very few studies have been conducted on this association at alcohol and drug dependence services (31). This study is limited by its cross-sectional design and the relatively small sample size. Only associations, not causal relationships, can be inferred from cross-sectional studies. A longitudinal study design would allow causality related to the onset of substance use and reported sexual dysfunction symptoms. Beyond that issue, because the recruitment took place at a tertiary service, this sample of women may not be representative of the community because it can be assumed that only the most serious patients receive this type of treatment (18). This sample bias may therefore limit the external validity of these findings. Another limitation is that psychiatric comorbidities, detox periods, the use of medication, and other medical conditions that might cause sexual dysfunction symptoms were not investigated or controlled; therefore, they might be potential confounding factors (3-5). Another limitation that should be noted is that the authors have chosen not to examine the individual sexual functions affected and the various explanatory variables, as there are known differences in the etiology of various symptoms of sexual dysfunction, such as those affecting the phases of desire and arousal (3,7). However, future studies may focus on this topic, expanding the scientific evidence on this theme. The clinical implications of the findings of this study indicate that addressing sexual dysfunction should be part of the recovery process of the recovering addict and should not be marginalized or made invisible in most rehabilitation centers (32). When sexual health and sexual dysfunction are not directly addressed in alcohol and drug treatment centers, they may contribute to treatment failure with relapses and consequently, substantial losses in the life quality of the addict (32). Many patients come to treatment with feelings of guilt and shame related to their sexual behavior when using, which can contribute to relapse and noncompliance if the issue is not addressed (32).

For example, alcohol-dependent women with vaginismus can relapse and use alcohol to cope with their sexual dysfunction, as may other women who use alcohol to achieve sexual excitement or relaxation during sex (32). Therefore, recovery offers an excellent opportunity to identify, prevent, and manage sexual dysfunction symptoms in women with problems related to alcohol and other drugs (31,32). Future substance abuse population-based and longitudinal studies should be conducted to extend the scientific evidence, including the research on sexual dysfunction and sexual health. It is especially important to study crack smokers because this drug has become a public health problem in many low to middle income countries (33). In conclusion, FSD symptoms in this sample were common and primarily associated with high levels of nicotine dependence.

ACKNOWLEDGMENTS
For their attention and cooperation in the performance of this project, the inpatient care staff of the Alcohol and Drugs Research Unit of Federal University of So Paulo has our sincere gratitude and appreciation.

Footnotes
No potential conflict of interest was reported.

Article information
Clinics (Sao Paulo). 2013 February; 68(2): 205211. doi: 10.6061/clinics/2013(02)OA14 PMCID: PMC3584261 Alessandra Diehl, Rosiane Lopes da Silva, and Ronaldo Laranjeira Federal University of So Paulo (UNIFESP)/Psychiatry Department/Alcohol and Drug Research Unit (UNIAD)/National Institute of Alcohol and Drugs Policy (INPAD), So Paulo/SP, Brazil. Contributed by Silva RL contributed to the data collection and preparation of the database. Diehl A contributed data analysis and preparation of the article by writing the same. Laranjeira R contributed overseeing the study, selecting papers on the topic and review the article after it has been finalized. E-mail: alediehl/at/terra.com.br Tel.: Phone: 55 11 5579-5643 Received September 30, 2012; Revised October 8, 2012; Accepted October 26, 2012. Copyright 2013 Hospital das Clnicas da FMUSP This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from Clinics are provided here courtesy of Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo

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Depression Research and Treatment Hindawi Publishing Corporation

Reduced Treatment-Emergent Sexual Dysfunction as a Potential Target in the Development of New Antidepressants
David S. Baldwin, M. Carlotta Palazzo, and Vasilios G. Masdrakis Additional article information

Abstract
Pleasurable sexual activity is an essential component of many human relationships, providing a sense of physical, psychological, and social well-being. Epidemiological and clinical studies show that depressive symptoms and depressive illness are associated with impairments in sexual function and satisfaction, both in untreated and treated patients. The findings of randomized placebo-controlled trials demonstrate that most of the currently available antidepressant drugs are associated with the development or worsening of sexual dysfunction, in a substantial proportion of patients. Sexual difficulties during antidepressant treatment often resolve as depression lifts but can endure over long periods and may reduce self-esteem and affect mood and relationships adversely. Sexual dysfunction during antidepressant treatment is typically associated with many possible causes, but the risk and type of dysfunction vary with differing compounds and should be considered when making decisions about the relative merits and drawbacks of differing antidepressants. A range of interventions can be considered when managing patients with sexual dysfunction associated with antidepressants, including the prescription of phosphodiesterase-5 inhibitors, but none of these approaches can be considered ideal. As treatment-emergent sexual dysfunction is less frequent with certain drugs, presumably related to differences in their pharmacological properties, and because current management approaches are less than ideal, a reduced burden of treatment-emergent sexual dysfunction represents a tolerability target in the development of novel antidepressants.

1. Introduction
Systematic reviews of the epidemiology of sexual difficulties, dysfunction, and dissatisfaction indicate that sexual problems are common in men and women in all societies and more frequent in older individuals and among those with chronic medical conditions, including depression [1, 2]. For example, the Global Survey of Sexual Attitudes and Behavior, of over 27,000 men and women aged 4080 years, found early

ejaculation (i.e., rapid or premature ejaculation) to be the most common sexual dysfunction, affecting 14% of men, with erectile difficulties having a prevalence of 10% all sexual dysfunctions in men being more prevalent in older groups [3]. The Men's Attitudes to Life Events and Sexuality Study, of similar size but among men aged 2075 years, found the prevalence of erectile dysfunction to be 16%, the proportion being higher in older men and individuals with cardiovascular disease, hypertension, or depression [4]. The Women's International Study of Health and Sexuality, in over 4,500 women aged 2070 years, found hypoactive sexual desire disorder to have a prevalence range of 1646%, in pre-menopausal to surgically postmenopausal women [5]. There is a close and two-way relationship between the presence of depressive symptoms and reports of sexual difficulties and dissatisfaction. Recognizing the nature and strength of this association, a recent international consensus statement on sexual dysfunction in patients with chronic illness recommends screening for depression [6]. The longitudinal epidemiological Zurich Study found the prevalence of sexual problems in depressed individuals (including those with major depression, dysthymia, and recurrent brief depression) to be approximately twice that in controls (50% versus 24%) [7]. Sexual problems may be more frequent in those with recurrent depression, as the United States Study of Women's Health Across the Nation found that only those with recurrent episodes were significantly more likely to report problems in sexual arousal, physical pleasure, and emotional satisfaction, when compared to controls [8]. Given its effects on mood, energy, capacity for pleasure, self-confidence, and selfesteem, it should be anticipated that depression would lower sexual interest and satisfaction; and this is the case, more markedly so in younger patients [9]. Depressive symptoms commonly coexist with anxiety symptoms, which are also associated with reports of sexual difficulties [10, 11] and often with obsessive-compulsive symptoms, known to be associated with loss of sexual pleasure and sexual dissatisfaction [12, 13]. But depression exerts adverse effects on the full range of the sexual response, including the ability to achieve and maintain penile erection or attain adequate vaginal moistening and to achieve ejaculation or orgasm [14]. Most antidepressant drugs can exert untoward effects on sexual function and satisfaction, but when considering the relative risks for and management of sexual dysfunction associated with antidepressant treatment, the adverse effects of depression itselfand of any coexisting physical illness or concomitant medicationcan be easy to overlook.

2. Relative Incidence of Sexual Dysfunction during Antidepressant Treatment

Accurate identification of the incidence of treatment-emergent sexual dysfunction (including both the worsening of preexisting problems and the development of new sexual difficulties in previously untroubled patients) during antidepressant treatment has proved troublesome. Two international studies of the prevalence of sexual dysfunction in depressed patients prescribed either a selective serotonin reuptake inhibitor or serotoninnoradrenaline reuptake inhibitor, which take account of the presence of self-reported

sexual problems prior to starting antidepressant and of the presence of concomitant medication sometimes implicated in causing sexual difficulties, suggest that 2765% of female and 2657% of male patients experience either a worsening of preexisting difficulties or the emergence of new sexual difficulties in the early stages of treatment, the differences in prevalence partly reflecting variations in case ascertainment and local clinical practice [15, 16]. Elucidation of the relative incidence of treatment-emergent sexual dysfunction with differing antidepressants has also proved difficult. Ideally, studies should be prospective, randomized, double-blind, and placebo-controlled in a defined diagnostic group, with an assessment of sexual function at baseline, and direct comparisons between drugs, prescribed at doses of equivalent efficacy. In addition, sexual dysfunction should be assessed with a reliable, valid and sensitive rating scale, rather than relying on reports or open questions which could be interpreted variably by different patients. Only a small proportion of investigations of treatment-emergent sexual dysfunction have met these rigorous criteria, but a series of meta-analyses together provide reasonable evidence that antidepressants differ in their propensity for worsening sexual function. An early meta-analysis of studies with differing methodologies (including open-label, double-blind, cross-sectional, and retrospective investigations) indicates that treatmentemergent sexual dysfunction is no more common with agomelatine, amineptine, bupropion, moclobemide, mirtazapine, or nefazodone than it is with placebo, in contrast to the situation with other antidepressants [17] (Table 1): all other antidepressants were significantly more likely than placebo to be associated with sexual dysfunction, as a unitary category, and nearly all of these were significantly more likely to be associated with dysfunction in each stage of the normal sexual response. A meta-analysis of randomized controlled trials of the efficacy and tolerability of acute treatment of major depressive episodes with second-generation antidepressants indicates that bupropion is associated with a significantly lower rate of treatment-emergent sexual dysfunction than is seen with escitalopram, fluoxetine, paroxetine, or sertraline [18]: this is probably due to the nonserotonergic but predominantly noradrenergic-dopaminergic mechanism of action of bupropion [19]. A systematic review of the relative efficacy and tolerability of mirtazapine and comparator antidepressants in the acute treatment of major depression suggests that mirtazapine is significantly less likely than other antidepressants to cause adverse sexual effects [20], which is probably related to its antagonist effects at both the alpha-2 adrenergic receptor and the 5-HT2C receptor [21]. Randomized controlled trials with agomelatine suggest it has fewer adverse effects on sexual functioning than some other antidepressants, which is more probably due to its antagonist effects on the 5-HT2C receptor, rather than the agonist effects at melatonin receptors [2224].

Table 1 Estimated proportion and relative likelihood of treatment-emergent sexual dysfunction (derived from Serretti and Chiesa [17]).

3. Assessing Sexual Functioning in Depressed Patients

There are many risk factors for developing sexual dysfunction during antidepressant treatment (including male gender, older age, lower academic achievement, lack of fulltime employment, physical ill-health, multiple drug treatment, and troubled interpersonal relationships), but only some of these are amenable to intervention. Interindividual variations in pharmacokinetics may be important, as the poor metabolizer status for cytochrome P450 2D6 contributes to sexual dysfunction with paroxetine [25, 26], as does genetic variation in P-glycoprotein which affects its blood-brain barrier transfer [27]. Both patients and health professionals may find it embarrassing to mention and discuss sexual symptoms, consultation [28] and recognition rates in primary care are low [29], and recent reviews demonstrate that relying on the spontaneous reporting of adverse events can lead to a substantial underestimation of the prevalence of sexual problems [30, 31]. Comprehensive assessment of a depressed patient reporting sexual difficulties whilst undergoing antidepressant treatment can be a protracted process: although use of scales cannot fully substitute for a sensitive but comprehensive interview, the assessment can be facilitated by employing screening or severity questionnaires [32]. An early review suggested that few sexual functioning scales and questionnaires had sufficiently robust psychometric properties, but the Arizona Sexual Experiences Scale, the Changes in Sexual Functioning Questionnaire, the Psychotropic-Related Sexual Dysfunction Questionnaire, and the Sex Effects Scale all have adequate properties (including validity, reliability, and sensitivity to change) and so can be used to monitor sexual function and satisfaction prior to and during antidepressant treatment [32].

4. Improvement in Sexual Function during Antidepressant Treatment

Not all the sexual effects of antidepressants are unwanted in all patients. For example, many men troubled by persistent premature ejaculation can derive benefits from treatment with either clomipramine or selective serotonin reuptake inhibitors, on either a daily or as required basis [33], and a systematic review of randomized placebocontrolled trials with trazodone indicates that when prescribed at a higher dosage (150 200 mg per day), it is efficacious in reducing the psychogenic erectile dysfunction [34].

Whilst a substantial proportion of patients experience treatment-emergent sexual dysfunction whilst taking antidepressants [15, 16], the reduction of depressive symptoms through successful antidepressant treatment can also be accompanied by reported improvements in sexual desire and satisfaction [35, 36]. Whilst it is thought that treatment-emergent sexual dysfunction is a cause of nonadherence to antidepressants, the proportion of patients that stop treatment because of sexual problems is not established [37], and neither is the time-course of sexual dysfunction in patients who persist with antidepressant treatment [38].

5. Management of Sexual Dysfunction in Depression

The international studies demonstrate that the presence of sexual dysfunction associated with antidepressant treatment can significantly reduce self-esteem and quality of life, and also impose burdens on interpersonal relationships over and above those associated with depression [15, 16, 39]. Many approaches for managing patients troubled by sexual dysfunction associated with antidepressant drugs have been proposed, but the number of randomised placebo-controlled trials is limited, there is an absence of randomised controlled data evaluating the effect of psychological interventions [40], and none of the current approaches can be considered ideal. If patients are concerned to preserve sexual functioning, choosing an antidepressant from the list of those regarded as having fewer adverse effects on sexual functioning (Table 1) is reasonable, when other considerations allow; however some of these antidepressants have other side effects, only limited availability, or questionable efficacy. Sexual side effects of at least some antidepressants may be dose-related, and a reduction in daily dosage is a commonly adopted first-line approach to management [41] (Table 2), but this approach may contribute to a relapse of symptoms and should be contemplated only for patients who have achieved a full symptomatic remission and who have successfully completed the continuation treatment. Regular brief interruptions of treatment (drug holidays) have previously been proposed as potentially useful for some antidepressants [42], but only a proportion of patients describe improvements in sexual function (and only with some antidepressants), depressive symptoms tend to worsen, and discontinuation symptoms can be troublesome [43], together making this approach to management potentially hazardous and consequently rather uncommon [41].

Table 2 Commonly adopted strategies for managing sexual dysfunction associated with antidepressant drugs. Questionnaire survey, US psychiatrists, expertise in managing

sexual dysfunction [41]. Percentages indicate the proportion of physicians using that strategy ... Many adjuvant compounds have been advocated for relieving sexual dysfunction associated with antidepressant drug treatment, though relatively few compounds have been subjected to rigorous evaluation. Randomised placebo-controlled trials indicate probable efficacy for bupropion [40], olanzapine [40], testosterone gel [44], and the phosphodiesterase-5 inhibitors sildenafil (both in male and female patients [45, 46]) and tadalafil [47]. Comparative studies are rare, though a placebo-controlled study found no evidence of efficacy for augmentation with mirtazapine, olanzapine, or yohimbine in female patients [48]. Augmentation of antidepressant treatment with aripiprazole is associated with improvements in sexual interest and satisfaction in female depressed patients, independent of the improvement in depressive symptoms [49]. Though switching from one antidepressant drug to another seems reasonable and is a commonly adopted practice [41]; placebo-controlled evidence of efficacy for this approach rests on a study of switching from sertraline to nefazodone [40]: furthermore switching away from one drug to another may lead to discontinuation symptoms, and the replacement drug may prove less effective in controlling depressive symptoms.

6. The Role of Phosphodiesterase-5 Inhibitors

Nitric oxide is involved in the physiology of the sexual response, in both men and women. In men, nitric oxide in the corpus cavernosum of the penis binds to guanylate cyclase receptors, which results in increased levels of cyclic guanosine monophosphate (cGMP), leading to smooth muscle relaxation (vasodilation) of the intimal cushions of the helicine arteries, which in turn leads to vasodilation, increased flow of blood into the spongy tissue of the penis, and resulting in erection. Sildenafil, tadalafil and vardenafil are potent and selective inhibitors of cGMP-specific phosphodiesterase type 5 (PDE5), which is responsible for degradation of cGMP in the corpus cavernosum. The molecular structure of sildenafil is similar to that of cGMP and acts as a competitive binding agent of PDE5 in the corpus cavernosum, resulting in more cGMP and facilitation of erection [50]. In women, the role of nitric oxide and its interplay with estrogen are less well understood, but phosphodiesterase type 5 inhibitor enhancement of nitric oxide-cGMP in nonadrenergic-noncholinergic signaling for women seems similar to men, and the release of nitric oxide results in vasodilatation in clitoral and vaginal tissues [51]. As noted above, a series of randomised placebo-controlled trials have demonstrated that PDE-5 inhibitors are efficacious in resolving sexual dysfunction associated with antidepressants [4547]. In addition, studies of men with erectile dysfunction and depressive symptoms (but not undergoing antidepressant treatment) indicate that prescription of PDE-5 inhibitors is often accompanied by a reduction in depressive symptom severity, an enhancement of quality of life, and an improvement in interpersonal relationships [52, 53]. Furthermore, investigations in animal models indicate that nitric oxide activity is an important vulnerability factor in the Flinders rat depressive phenotype [54], that passage of PDE-5 inhibitors across the blood-brain barrier is possible [55], that sildenafil has antidepressant-like effects after central

muscarinic receptor blockade [56], and that administration of sildenafil can lead to a reversal of reduced social interactive behavior [55]. Given these observations, it could be argued that the advent of treatment with PDE-5 inhibitors is a game-changer in the management of patients with sexual dysfunction associated with antidepressants. However like other potential treatment approaches, PDE-5 inhibitors are not ideal, having side effects such as headache, dyspepsia, and visual disturbances and needing to be used cautiously in patients with cardiovascular disease, which is a common comorbidity with depression.

7. Refined Approaches to Pharmacotherapy

It seems possible that a growing understanding of the influence of genetic polymorphisms may see the adoption of laboratory approaches to identifying patient subgroups at increased risk of developing sexual side effects of antidepressant treatment. The genomewide association study associated with the STAR*D programme in the United States shows that ten single nucleotide polymorphisms (SNPs) may mediate the effects of bupropion on sexual side effects [57], and another genome-wide association study in Japan indicates that 11 SNPs are associated with sexual dysfunction associated with the antidepressants fluvoxamine, milnacipran, and paroxetine [58]. Smaller studies suggest that sexual dysfunction associated with selective serotonin reuptake inhibitors may be influenced by both the GG [59] and the AA [60] genotype of the 5-HT2A receptor 1438 G/A polymorphism. Future management options may be extended through the development of new antidepressant treatments with a lower risk of causing sexual problems. These could include compounds with effects on the 5-HT1A receptor, or with noradrenaline reuptake inhibitor properties or even complementary approaches, such as the use of S-adenosyl-lmethionine (SAMe) [61], Maca root (Peruvian Ginseng) [62], or saffron [63]. At present, the evidence relating to the effects of drugs acting on the 5-HT1A receptor is intriguing: the partial agonist buspirone has been used to reduce sexual dysfunction associated with selective serotonin reuptake inhibitors [64, 65], and the partial agonist gepirone improves sexual functioning in depressed men, independent of antidepressant or anxiolytic effects [66]. The novel antidepressant drug vilazodone, which has both selective serotonin reuptake inhibitor and 5-HT1A partial agonist properties, appears to have a low incidence of adverse effects on sexual functioning [67, 68], as does the multimodal compound LuAA21004 (vortioxetine), whose pharmacological properties include full agonism at the 5-HT1A receptor [69]. However, the experimental 5-HT1A full agonist VML-670 was not efficacious in reversing sexual dysfunction associated with fluoxetine or paroxetine [70], and preclinical studies suggest that selective 5-HT1A antagonists can both prevent and reverse fluoxetine-induced sexual dysfunction in rats [71]. Although the antidepressant efficacy of the selective noradrenaline reuptake inhibitor is limited [72], randomised controlled trials indicate that it probably has fewer adverse effects on sexual function than selective serotonin reuptake inhibitors [35, 73, 74]. These findings could encourage the further development of compounds with noradrenaline reuptake inhibitory properties as part of their mechanism of action: a proof-of-concept

placebo-controlled study with the novel triple reuptake inhibitor amitifadine suggests that it has a low propensity to worsen sexual function in depressed patients [75], though the novel noradrenaline reuptake inhibitor LY22166884 was associated with significantly more sexual adverse events than placebo in a recent large placebo-controlled trial [7]. Whilst these findings suggest a prospect for novel antidepressant treatments, less likely to be associated with sexual adverse effects than many of the current medications, patient management currently rests on making the best use of the available treatments. This involves careful but sensitive enquiries to establish whether sexual difficulties are present, on choosing antidepressants with a lower likelihood of worsening sexual dysfunction, when other considerations allow; on judiciously reducing antidepressant dosage, when this is feasible; and on gaining greater familiarity with the potential benefits and drawbacks of phosphodiesterase-5 inhibitors and other adjuvant treatments.

Conflict of Interests
D. S. Baldwin has received research grants (funding to the University of Southampton) from Bristol-Myers Squibb, Cephalon, Eli Lilly Ltd, GlaxoSmithKline, H. Lundbeck A/S, Pierre Fabre, Pfizer Ltd, Roche, and Vernalis Ltd. He has served on advisory boards hosted by Astra-Zeneca, Bristol-Myers Squibb, Eli Lilly Ltd, GlaxoSmithKline, Grnenthal, H. Lundbeck A/S, Pierre Fabre, and Pfizer Ltd. He is a past President of Depression Alliance and a current Medical Patron of Anxiety UK. M. C. Palazzo and V. G. Masdrakis report no conflict of interest.

Acknowledgments
This paper is based upon a talk given by D. S. Baldwin in the National Institute of Mental Health in Angoda, Sri Lanka, in May 2012.

Article information
Depress Res Treat. 2013; 2013: 256841. Published online 2013 February 4. doi: 10.1155/2013/256841 PMCID: PMC3575662 David S. Baldwin, 1 , 2 ,* M. Carlotta Palazzo, 3 and Vasilios G. Masdrakis 4 1 Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO14 3DT, UK 2 Department of Psychiatry, University of Cape Town, Cape Town, South Africa 3 Department of Pathophysiology and Transplantation, University of Milan and Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy 4 First Department of Psychiatry, Eginition Hospital, Athens University Medical School, 11528 Athens, Greece *David S. Baldwin: Email: dsb1/at/soton.ac.uk Academic Editor: Charles B. Nemeroff Received October 1, 2012; Revised December 18, 2012; Accepted January 3, 2013.

Copyright 2013 David S. Baldwin et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from Depression Research and Treatment are provided here courtesy of Hindawi Publishing Corporation

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History of the Human Sciences SAGE Publications

Contested psychiatric ontology and feminist critique

Female Sexual Dysfunction and the Diagnostic and Statistical Manual Katherine Angel Additional article information

Abstract
In this article I discuss the emergence of Female Sexual Dysfunction (FSD) within American psychiatry and beyond in the postwar period, setting out what I believe to be important and suggestive questions neglected in existing scholarship. Tracing the nomenclature within successive editions of the American Psychiatric Associations Diagnostic and Statistical Manual (DSM), I consider the reification of the term FSD, and the activism and scholarship that the rise of the category has occasioned. I suggest that analysis of FSD benefits from scrutiny of a wider range of sources (especially since the popular and scientific cross-pollinate). I explore the multiplicity of FSD that emerges when one examines this wider range, but I also underscore a reinscribing of anxieties

about psychogenic aetiologies. I then argue that what makes the FSD case additionally interesting, over and above other conditions with a contested status, is the historically complex relationship between psychiatry and feminism that is at work in contemporary debates. I suggest that existing literature on FSD has not yet posed some of the most important and salient questions at stake in writing about womens sexual problems in this period, and can only do this when the relationship between second-wave feminism, post-feminism, psychiatry and psychoanalysis becomes part of the terrain to be analysed, rather than the medium through which analysis is conducted. Keywords: American Psychiatric Association, Diagnostic and Statistical Manual, Female Sexual Dysfunction, feminism and post-feminism, psychiatric ontologies

Introduction
Female Sexual Dysfunction (FSD) is a term that has gained in medical, psychiatric and media prominence in recent decades, especially in the last 15 years. It is not in itself a diagnostic category, but has gained a currency that can sometimes suggest otherwise. Female sexual problems are currently classified in the American Psychiatric Associations 4th edition of the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2000), in a section on Sexual Dysfunctions (separate both from the paraphilias and from gender identity disorders), and assembling diagnoses relating to desire, arousal, orgasm and pain (see table 1). The DSMs rise has been much criticized, and while the growing discussions of FSD are praised by researchers and scientists as an index of a long-overdue attention to womens sexuality a triumph of feminism (Basson et al., 2001; Berman and Berman, 2001) critics have underscored the link between this renewed medical attention and pharmaceutical interests in launching a compound comparable to Viagra for Erectile Dysfunction (Tiefer, 2008; Kaschak and Tiefer, 2001; Loe, 2004).

Table 1. DSM-IV, 1994. The FSD debate plays itself out in the public and popular domains as well as in the medical, psychiatric and sexological realms. Existing historical scholarship on female sexuality in the postwar period focuses primarily on sexology (e.g. Gerhard, 2001; Irvine, 1990). In this article, I suggest that analysis of FSD benefits both from scrutiny of a wider range of sources (especially since the popular and scientific cross-pollinate), and from an approach from the history of psychiatry, in particular one that probes debates about the

ontology and aetiology of sexual disorders, and the relationship between feminism and psychiatry in the postwar period. I suggest that existing literature on FSD has not yet posed some of the most important and salient questions at stake in writing about womens sexual problems in this period, and can only do this when the relationship between 'second-wave' feminism, 'post-feminism', psychiatry and psychoanalysis becomes part of the terrain to be analysed, rather than the medium through which analysis is conducted. I begin by outlining a brief sketch of female sexual problems in the 20th century, and their rendering in the first two postwar DSMs. I then give an account of the emergence of DSM-III in 1980, and the classifications of sexual disorders in this manual. I then discuss both the reification of FSD as a term, in relation to Viagras emergence in the late 1990s, and the recent activism and scholarship around FSD. I explore the multiplicity of FSD that emerges when one examines a wider range of sources, but also underscore a reinscribing of anxieties about psychogenic aetiologies. I then argue that what makes the FSD case additionally interesting, over and above other conditions with a contested status, is the historically complex relationship between psychiatry and feminism that is at work in contemporary debates. I conclude with some thoughts about post-feminism and the historiographical challenges raised by FSD.

Sexual problems and the DSM

Womens sexual problems have been written about prolifically during the 20th century, in sexological, gynecological, psychiatric and psychoanalytic literature, as well as marital advice material (e.g. Ellis, 18971928; Krafft-Ebing, 1899; Hitschmann and Bergler, 1936; Stekel, 1936; Stopes, 1918; Wright, 1955[1930]; Van de Velde, 1928[1926]; Gray, 1923; see Lunbeck, 1994; Downing, 2004; Irvine, 1990; Maines, 1999; Cook, 2004; Cryle, 2009; Angel, 2010). Psychiatry has been salient in these discussions due to the mutually entangled development of psychiatry, sexology and criminology in the last quarter of the 19th century (Foucault, 1979; Bland and Doan, 1998; Davidson, 2001). A forensic rationale fostered a focus in late 19th- and early 20th-century sexology on sexual behaviours and identities, with the reification of classifications such as homosexuality, sadism, masochism and fetishism. Frigidity and its flip-side, nymphomania were much invoked preoccupations in the first half of the 20th century, enduring until the 1960s at least; other concepts throughout the century have included sexual anaesthesia, sexual inhibition, anorgasmia, or preorgasmia, and, from the 1970s, sexual dysfunction. Frigidity especially has been a semantically shifting term variously meaning womens natural lack of desire, their unnatural failure to experience a normal desire, their failure to become aroused, failure to reach orgasm, or failure to reach vaginal orgasm (Loewenfeld, 1899; Acton, 1862, quoted in Ellis, 1908: 1578; Hitschmann and Bergler, 1936; Stekel, 1936; Huhner, 1937). A vast literature has documented the neo-Freudian linking of a range of social and psychological ills to a clitoral, rather than a vaginal, sexuality, where the outlining of norms for female sexuality has functioned as a way of defining norms of femininity and heterosexuality (e.g. in Abraham, 1920; Bonaparte, 1953; Deutsch, 1944 5; see Buhle, 1998; Lunbeck, 1994; Irvine, 1990; Maines, 1999; Downing, 2004).

In the postwar period, the American Psychiatric Association (APA) and its DSM loom increasingly large in psychiatry and in matters sexual. In its 1st edition in 1952 (an attempt to consolidate the many local variations to the American Medico-Psychological Associations existing nomenclature and a proliferation of military nomenclatures), problems such as impotence and frigidity are an instance of Psychophysiological autonomic and visceral disorders (under a larger group of Disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain), of which a psychophysiological genito-urinary reaction is an instance. We are told that these include some types of menstrual disturbance, dysuria, and so forth, in which emotional factors play a causative role (American Psychiatric Association, 1952: 30). (See table 2.)

Table 2. DSM-I, 1952. These disorders represent the visceral expression of affect that is often prevented from being conscious. Symptoms are due to a chronic and exaggerated state of the normal physiological expression of emotion, with the feeling, or subjective part, repressed. Such long continued visceral states may eventually lead to structural change (American Psychiatric Association, 1952: 29). In the 1968 DSM-II (see table 3), we see a slight variation of this; psychophysiological disorders include genito-urinary disorders such as disturbances in menstruation and micturition, dyspareunia, and impotence in which emotional factors play a causative role (American Psychiatric Association, 1968: 47). These psychophysiological disorders are characterized by physical symptoms that are caused by emotional factors and involve a single organ system, usually under autonomic nervous system innervation. The physiological changes involved are those that normally accompany certain emotional states, but in these disorders the changes are more intense and sustained. The individual may not be consciously aware of his emotional state. (American Psychiatric Association, 1968: 46)

Table 3. DSM-II, 1968.

Little detail is given, then, of the specific kinds of disorders included in these categories (in DSM-I, readers are told that each diagnosis of psychophysiologic autonomic and visceral disorders will be amplified with the specific symptomatic manifestations, e.g. anorexia, loss of weight, dysmenorrhea, hypertensions, and so forth (American Psychiatric Association, 1952: 29), and the kinds of disorders enumerated are not meant to be comprehensive. An aetiological process is posited, and it is the process rather than its specific manifestations that is salient. In their focus on unconscious, repressed emotions, the manuals terminology reflects the importance within American psychiatry, between the 1930s and 1960s, of an American-inflected psychoanalysis (Hale, 1995); in their emphasis on physiological changes that accompany certain emotions, and eventually, if sustained for long enough, lead to structural damage, they reflect the influence of a psychosomatic medicine much shaped by Franz Alexander (Alexander, 1932, 1950; Brown, 2000; Greco, 1998). Moreover, the manuals, in their emphasis on mental illness as on a continuum with health, also voice the influence of Adolf Meyers psychobiology, in which environmental factors interacted with certain predisposing factors in an individual to determine his or her capacity to adapt to that environment (Meyer, 1952). The DSM-III of 1980, however, ushers in significant changes in classification, marking an important shift in psychiatrys 20th-century history.

DSM-III
The DSM-III of 1980 emerged out of a period of intense controversy and questioning in the psychiatric profession and beyond. Psychoanalysis was at the core of American psychiatry by the 1950s, but increasingly competing with other emerging forms of psychotherapy, and increasingly challenged by a critique of its scientific validity made by academic psychologists, behaviourists and philosophers who questioned the very possibility of its generating verifiable predictions and testable theories (see Eysenck, 1959; Eysenck, 1965(a), 1965(b); Popper, 1963; Hook, 1959; Fisher and Greenberg, 1977; Freedheim, 1992; Luborsky, 1975; Wallerstein, 1966; see Hale, 1995: ch. 17). In addition, insurers were becoming unwilling to fund long psychoanalytic treatments whose efficacy was under question (Mayes and Horwitz, 2005). And the critique of psychoanalysis overlapped with some strands of the anti-psychiatry movement, which challenged what it saw as diagnostic promiscuity and abusive and authoritarian relationships to the patient with some critiques focusing particularly on the gender biases at work in psychoanalysis1 (Szasz, 1962; Laing, 1960, 1964; Scheff, 1966; Goffman, 1961; Becker, 1963; Sulloway, 1979; Roazen, 1976; Brome, 1967; Medawar, 1975; Gelfman, 1969; Fliegel, 1973; Gilman, 1971, 1977; Friedan, 1963; Chesler, 1972; Millett, 1970; see Grob, 1991; Hale, 1995; Shorter, 1997; Healy, 2002, 1997; Dain, 1989; Nye, 2003; Osborne, 1992; Appignanesi and Forrester, 2000; Tomes, 1994). This scientific and cultural dissatisfaction was reflected in professional concern over diagnostic confusion and classificatory unreliability, with stark disparities in diagnostic trends causing embarrassment (see Stengel, 1959; Kramer, 1969; Kendell et al., 1971; WHO, 1973). In the late 1970s at the APA, Robert Spitzer, trained in both medicine and psychoanalysis, was appointed to the new task force to revise the DSM. He and his collaborators were committed to several axioms about psychiatry and mental illness that

overturned the key assumptions of previous DSMs; namely, that there is a boundary between the normal and the sick; that there are discrete mental illnesses; and that the focus of psychiatric physicians should be particularly on the biological aspects of mental illness (Klerman, 1978: 104, see Bayer and Spitzer, 1985). The DSM-III sought to remove aetiological assumptions (of a psychoanalytic kind, emphasizing neurosis and defences) that it argued were unsupported. Disorders were discrete, and operationalized reliably by sets of symptom criteria (Rogler, 1997); an effect, argues Healy, of the rise of the randomized, placebo-controlled trial to test new medications required by the FDA provably to target clearly definable illness (see Healy, 1997, 2002; Pignarre, 2004). Highly controversial at the time for its excision of psychoanalytic conceptions, the DSMIII has consistently provoked controversy since, though latterly focused on the DSMs expansion and its role in providing a rationale for pharmaceutical products (Mayes and Horwitz, 2005; Horwitz and Wakefield, 2007; Kirk and Kutchins, 1992; Kutchins and Kirk, 1997; Angell, 2011; Watters, 2010; Lane, 2007; Lakoff, 2005; Moynihan and Mintzes, 2010). For good or for ill, the DSM is now connective tissue for biomedical psychiatry, binding together measurement tools, diagnosis, treatment, research, drug assessment, epidemiology, insurance, and the law (Lakoff, 2005: 13).

The DSM-III and sexual dysfunctions

DSM-III yielded an increasingly detailed and differentiated classification of disorders, subsumed under a new splitting of diagnostic areas (e.g. Neurotic Disorders were dispensed with, but symptomatic remnants were distributed into the affective, anxiety, somatoform and dissociative disorders) (see Rogler, 1997). The manual reorganizes the two categories of sexual problems that existed in DSM-I and DSM-II; instead of entirely separate categories and chapters for Sexual Deviations and Psychophysiological Genito-urinary Disorders, in DSM-III we have an overarching chapter on Psychosexual Disorders. (See table 4.)

Table 4. DSM-III, 1980. This is broken down into gender identity disorders, paraphilias and psychosexual dysfunctions (with the latter using gender as a defining principle). The revised DSM-III-R of 1987 changed Psychosexual Dysfunctions to Sexual Dysfunctions, and lists the various disorders under the overarching categories of Sexual Desire Disorders, Sexual Arousal Disorders, Orgasm Disorders and Sexual Pain Disorders, among other changes (see table 5). DSM-IV (1994) remains much the same, except that Inhibited female orgasm becomes Female orgasmic disorder. (See table 1.)2

Table 5. DSM-III-R, 1987. The classification, since DSM-III, is much indebted to the work of Masters and Johnson, whose Human Sexual Response and Human Sexual Inadequacy were published in 1966 and 1970 respectively. Masters and Johnson were not the first to approach sexual problems with a form of behavioural conditioning, or to emphasize the clitoris in female sexual pleasure (Rachman, 1961; Lazarus, 1963; Kinsey et al., 1953; see also Downing, 2004). But their detailed physiological studies heralded the professionalization of a behaviouristically inflected sex therapy. Concerned to draw a near-total equivalence between male and female sexual function,3 they outlined a four-stage Human Sexual Response Cycle (excitement, plateau, orgasm, resolution), and three female sexual disorders: dyspareunia, vaginismus and orgasmic dysfunction (primary and secondary) (Masters and Johnson, 1966, 1970). (The problems for men were premature ejaculation, ejaculatory incompetence and primary and secondary impotence.) Masters and Johnsons ideas and nomenclature were mediated through Helen Singer Kaplan, who was a member of the Sexual Disorders Committee for DSM-III, and a sex therapist and psychoanalyst who sought to combine behaviourist and psychoanalytic models in her work. She modified their nomenclature into a three-stage model of desire, excitement and orgasm, incorporated into the document (American Psychiatric Association, 1980; Tiefer, 2004: 512). Together with psychoanalyst Harold Lief, who also served on the DSM-III Sexual Disorders Committee, she ensured that problems of desire, as well as those of arousal and orgasm, were foregrounded (see Kaplan, 1977 and 1979; Lief, 1977). APA archival material, however, also reveals that psychoanalyst Robert Stoller, with whom Spitzer kept up a detailed correspondence, similarly (and earlier) suggested abandoning Masters and Johnsons distinction between the excitement and plateau phases: There is one issue with which I am out of step as compared to other colleagues in sex research. I am not sure there is good reason to separate out an excitement phase from a plateau phase. I do not believe that what is called plateau is anything other than excitement. It is as if we were to divide excitement into a number of non-distinguishable episodes; such distinctions have no real function. (Stoller, 1977) This renewed emphasis on desire problems of which had been a significant component of the neo-Freudian writings on frigidity undid an emphasis on the mechanics of arousal and orgasm in Masters and Johnson. Kaplans categories of inhibited desire, excitement and orgasm reinscribed a psychoanalytic affinity, with the concept of

inhibition containing within it the psychoanalytic connotations of symptoms resulting from the defences mounted against anxiety. So while criticisms of the DSMs FSD nomenclature have tended to focus on their allegedly uncritical adoption of a flawed and mechanistic Masters and Johnson model (Tiefer, 2004), and criticisms of the methods and rationale of the DSM-III revolution have underlined Spitzers ruthless eviction of psychoanalysis from the manual (and the profession) (Kutchins and Kirk, 1997), it appears that, at least for the Sexual Disorders, this narrative of eviction does not hold up so well, suggesting that a vision of the move to DSM-III as involving a stark and wholesale shift away from psychoanalytic concepts is in need of some refinement.

Female Sexual Dysfunction and Erectile Dysfunction

In Masters and Johnsons books, the term female sexual dysfunction operated simply as a generic description rather than as a specific diagnosis; it signified any problem with sexual function as identified in the human sexual response cycle. But the term Female Sexual Dysfunction becomes more prominent after their publications, however. It begins to appear in medical and scientific journals as a phrase only from 1977 onwards; half a dozen results appear in the 1970s, and the same number in the 1980s a period when the term frigidity is waning in frequency. Occurrences of FSD from the 1990s onwards jump to being in the 500s. And yet there is in fact no such term FSD in the DSMs; the chapter headings are Psychosexual Disorders (DSM-III) or Sexual Disorders (DSMIII-R), under which the various subtypes appear. This jump in FSD discourse occurs around the time of Viagras licensing for Erectile Dysfunction (ED) in 1998. Viagras apparently phenomenal success, and its astounding sales, put a premium on finding a similar drug for women. Pharmaceutical companies rushed to test Viagra in women and sought to develop other compounds (Loe, 2004; Hartley, 2003, 2006). What we see, from the 1990s onwards, is a significant slippage between FSD as a generic umbrella term where the general type of dysfunctions is sexual, and the female works as a qualifier to FSD figuring as a condition in itself, a slippage enabled by the use of the singular term dysfunction. An example is a 1999 article by Jennifer and Laura Berman and Irwin Goldstein (prominent and prolific authors the former in scientific and popular texts on ED and FSD), which opens thus: Female sexual dysfunction is age-related, progressive, and highly prevalent, affecting 30% to 50% of women (Berman et al., 1999a: 385). While they go on to specify particular areas of diagnosis such as vaginal lubrication, pain and discomfort with intercourse, decreased arousal, and difficulty achieving orgasm, they also state that our knowledge and understanding of the anatomy and physiology of the female sexual response and the pathophysiology of female sexual dysfunction is limited. And yet, some of the diversity of sexual problems having been roll-called, the slippage to the phrase pathophysiology of female sexual dysfunction assumes that the pathway to these diverse phenomena is one and the same, though it remains to be clearly elucidated. In other words, it casts female sexual dysfunction as a condition in itself. This pattern is much repeated elsewhere, and articles frequently use the term FSD in the title, but quickly move in the text to specifying disorders under

consideration (ODonohue et al., 1997; Sarwer and Durlak, 1996). A recent example is Figueroa-Haas (2012), who uses Female Sexual Dysfunction in the title, and writes the following: Female sexual dysfunction (FSD) occurs when a woman is unable to fully experience pleasure during sexual activity. This dysfunction can affect a womans quality of life and lead to personal distress and interpersonal impairments. It is defined as disorders of sexual desire, arousal, orgasm, and sexual pain. An estimated 40% of women are affected by sexual dysfunction and 1 in 4 is unable to achieve orgasm. (Figueroa-Haas, 2012: 156) In this particularly confused example, FSD is cast as a disorder in itself, offering a definition of FSD as disorders of desire, arousal and so on whereas these categories are not definitions of a disorder, but the diagnostic categories subsumed under a generic term for them. Moreover, it emphasizes pleasure, which potentially brackets out desire problems. What we are seeing here is FSD being used as an analogue a counterpart to ED, as in an article entitled Lifestyle/Dietary Recommendations for Erectile Dysfunction and Female Sexual Dysfunction (Esposito and Giugliano, 2011). But ED is one diagnostic category applicable to men in the Sexual Disorders section of the DSM, while FSD is not its equivalent it is a generic umbrella term for diagnoses that vary significantly. This reification of FSD both reflects and bolsters the desire to see FSD as a discrete, bounded diagnostic category amenable to a technology that would target it in the allegedly specific way Viagra did for ED a desire that nonetheless has yielded little in the way of concrete results.4

Activism and scholarship

The rise of FSD and pharmaceutical efforts around it has provoked considerable controversy as well as activism. New York sexologist Leonore Tiefer founded the New View Campaign, challenging the medicalisation of sex (see Kaschak and Tiefer, 2001), after the increase, post-Viagra, in the marketing of FSD, having previously written about ED (Tiefer, 1994, 2004). The campaign sees Viagra as reinforcing a mechanical view of sexuality, rendering penetration and orgasm the pinnacle of sexual activity, and expressing hetero-normative ideals of sexual behaviour. It argues that FSD discourse reduces sexuality to the purely biological as malfunctions of vascular, hormonal, or cerebral systems to be fixed by pharmacological intervention, suggesting instead that female sexual problems especially are highly contextual the result of social, cultural and political factors (lack of communication between partners; exhaustion due to inequalities in child-rearing and housework; anxieties about body image; violence from sexual partners; and misunderstandings of female anatomy; [see http://www.newviewcampaign.org/manifesto.asp]). The campaign has received growing press coverage in the last few years (Vernon, 2010; Sample, 2009; Independent, 2010a; Laurence, 2010; Independent, 2010b).

The campaign is also interlinked with a growing scholarship on FSD, the DSM and pharmaceutical developments for sexual problems (much coming from social science, qualitative research and science studies), part of a larger movement challenging the medicalization of problems seen as social, political, contextual and relational in nature (Cacchioni, 2007; see Potts, 2000; Potts et al., 2004; Potts et al., 2003 for material on masculinity and Viagra; Ramage, 2006a, 2006b; Fishman, 2004; Nicolson and Burr, 2003; Kaschak and Tiefer, 2001; Potts, 2008). Polemical and general audience works are also interlinked with the campaign (Drew, 2003; Moynihan and Cassels, 2005; Moynihan and Mintzes, 2010). Many of these works owe much in spirit to the discourses of anti-medicalization that have been such a prominent part of debates about medicine and psychiatry since the 1960s. And they owe much to a component of second-wave feminism, suspicious of psychiatric expertise and professional expansion of authority over womens health, bodies and minds (e.g. Towards a Feminist Sex Therapy, in Tiefer, 2004). That the existing scholarship takes its impetus largely from activist concerns has some important methodological consequences. It necessitates and explains a focus on the DSM and on pharmaceutical developments. But in consequence, it narrowly construes the FSD landscape, glossing over resources such as womens magazines and self-help books, for instance, which speak in an emotional, psychological and behavioural register. Moreover, it also glosses over the multiplicity at work in medical texts themselves.

Multiplicity
Take, for example, the pages of Cosmopolitan. Sex psychotherapist Rachel Morris responds to a letter about libido problems: A lack of desire can be due to many things, hormone imbalance included, but usually its down to a psychological or emotional block. There are so many reasons to freak out about sex what if Im no good? What if I dont orgasm? It could be that you let negative thoughts freeze desire before it starts. Adding pressure will only make it worse, and stress, depression and anxiety are libido killers. Sexuality cant be forced it has a life of its own. Talk to your GP and ask for psychosexual counselling. (Cosmopolitan, May 2001: 36) Similarly, Jennifer and Laura Berman, authors of the best-selling For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life (Berman is also the author of The Passion Prescription: Ten Weeks to Your Best Sex Ever!), and prolific in medical journals also, advocate a significantly medical and pharmacological framework for sexual problems, especially the virtues of Viagra and testosterone; but they too see fantasy, imagination and thoughts as key to helping yourself with your sexual problems. In these texts, emotional, behavioural and cognitive habits are on a par with medical drugs, pornography and sex toys; factors key to enhancing pleasure and overcoming sexual problems. Likewise, health information websites such as Netdoctor identify a range of factors in sexual problems (Webber and

Delvin, 2011), and a representative article in the American Family Physician lists, as possible causes of sexual problems: medicines; diabetes; high blood pressure; alcohol; vaginal infections; menopause; depression, an unhappy relationship or abuse (now or in the past); the stresses of everyday life, or being bored by a long-standing sexual routine ( American Family Physician, 2000: 1412). The ontology of sexual problems we see in a range of resources is, I think, more cacophonous and multiple than a focus on pharmacological reductionism suggests. It is perhaps an index of a late 20th- and early 21st-century surveillance medicine in which multiple symptoms and signs become risk factors for future outcomes (Armstrong, 1995; Rose, 2007). And yet, while a great many things hormones and emotional blocks, as Cosmopolitan tells us are relevant to sexual problems, they are not all equal. A kind of ontological hierarchy is asserted in a range of texts, with those construed as psychosomatic, psychological, or psychodynamic as partaking of the unscientific psychiatry which DSM-III overturned figuring as morally and scientifically fraught. A 2001 Consensus Report written by prominent urologists and psychiatrists, for example, proposes a nomenclature that would cover both psychogenic and organically based disorders (unlike the DSM, which it describes as narrowly psychiatric, not intended to be used for classification of organic causes of female sexual dysfunctions; Basson et al., 2001: 92). This is a curious reading of the DSM, given the latters insistence on its own nature as providing a medical nomenclature, and as aetiologically neutral (American Psychiatric Association, 1994: xviixviii). But it reveals thereby the ambivalence with which the past of psychiatry with its aetiologies that so prioritized psychogenic factors in causing symptoms is experienced. Location in the DSM is problematic, signalling a discomfort with psychiatric theorizing that also sustains the claim that female sexuality, unlike male sexuality, has not, historically, been the subject of medical scrutiny (Basson et al., 2001: 834) a claim that overlooks the location of female sexual problems within sexological, psychiatric and psychoanalytic work in the 20th century. As such, it reflects a contemporary discomfort with the psychodynamic past of psychiatry that necessitates defining it, retrospectively, as non-medical. Psychiatry, its own medical protestations notwithstanding, is experienced as a troubling fringe discipline with a troubling past: female sexual problems should be removed from the realm of primarily psychiatric disorders into the mainstream of research and treatment (Rosenthal, 2001: 203; emphasis added). The fraught status of the psychogenic aetiologies associated with a psychiatry that has been left behind is also evident in responses to a British Medical Journal article in 2003 written by Ray Moynihan that described the making of FSD by researchers with close ties to drug companies (Moynihan, 2003: 45). Outraged responses ensued. A nurse therapist wrote that FSD is not a new, pharmaceutically manufactured condition and that it is ignorant in the extreme to think that she is only treating social disorders (Astbury-Ward, 2003). Sexual dysfunction is not, a patient wrote, a fabrication of womens imagination or of corporate Americas financial imagination (Dionne, 2003). Another patient wrote that a woman is effectively silenced by the constant response that it is psychological (i.e. that she is imagining it) (Lewis, 2003). Similarly, Jennifer and

Laura Berman a urologist and psychiatrist team write that they are shocked to hear of doctors telling patients that their sexual problems are emotional, relational, or due to fatigue from child rearing or their busy jobs: We hope that this book will serve as an antidote to what women have heard for decades. The problem is not just in your head. You are not crazy. We are beginning to recognize female sexual dysfunction as a medical problem. (Berman and Berman, 2001: xxi) In the wake of Viagra, much-cited articles state that the context of female sexuality is highly important, but their priority remains to frame FSD as medical rather than psychiatric or psychological, as in Berman et al. (1999a: 389), which states that not all female sexual complaints are psychological, and that there are possible therapeutic options. This article, and others, frames the psychological as secondary matter, which rhetorically functions as a concession in the article; they also echo an aspect of the Viagra/ED debate, in which Viagras apparent success was invoked (though this is not logically compelling) as proof that ED is physical, not psychological (Berman et al., 2000; Park et al., 1997; Korenman, 1998; Goldenberg, 1998; Berman et al., 1999a; Berman et al., 1999b; see Loe, 2004; Hartley, 2003). We are seeing here the slippery power of terms with deep ontological and moral reverberations. Claims about what influences diagnostic categories, aetiological narratives and symptoms themselves are repeatedly interpreted as claims about the reality of symptoms. Describing a condition as psychological is interpreted as meaning that it is non-physical; what is not physical is thought to be not real. So saying that something is psychological is equated with saying it is unreal, imaginary, or fake. Psychosomatic illness, in popular usage, tends to connote deception, if not of others then at least of oneself, raising sensitive questions about wilful motivation and individual culpability (Lawrie, 2000; Stone et al., 2004).

Psychiatry and feminism

The fraught ontologies in the FSD landscape are, to be sure, not dissimilar from controversies regarding other conditions, Chronic Fatigue Syndrome most notably, where bitter and tail-chasing debates ensue about the reality of conditions (Prins et al., 2006). The ontological discomforts I outline here, however, are overlain with something else the historically uncomfortable relationship between feminism, psychiatry and psychoanalysis, which adds a complex dimension to this landscape. The fact that FSD scholarship tends to be activist-related explains another phenomenon in the existing literature: a failure to scrutinize, as an object in landscape, the feminism that sustains the critique of it. Feminist critics were vocal in the criticisms of psychiatry, and especially of psychoanalysis, from the 1960s, underscoring gender biases and the violences these were seen to enable (e.g. Friedan, 1963; Chesler, 1972; Millett, 1970; also, in the 1980s, Masson, 1985, 1989). The figure of Freud looms large in these works; Millett described him as beyond question the strongest individual counterrevolutionary force in the ideology of sexual politics; and Anne Koedt framed the myth of vaginal

orgasms (1973) as his most pernicious legacy (a legacy repeatedly invoked elsewhere; see Maines, 1999, and a criticism by Lunbeck, 2002). Existing scholarship on female sexuality, psychiatry, medicine and sexology is emphatic in its recognition of the feminist stakes in understandings of female sexual problems (Cook, 2004; Irvine, 1990; Gerhard, 2001). To Irvine, for example, the measure of sexology, and its history, is the extent to which it is compatible with feminism (even if the nature of that feminism is not explicitly articulated or spelt out in the book). Indeed, the fields of womens history, feminist critique and the history of medicine themselves have a thoroughly intertwined, and immensely fruitful, history (Tomes, 1994). While feminist critiques of FSD emphasize the social, psychological and contextual factors involved in sexual problems, they sidestep the thorny question of psychodynamic understandings of symptoms, or of any potential role of the unconscious in forming symptoms. They articulate a complex position via the nature and causes of sexual problems, but do so under the shadow of the sins of the fathers the abuses perpetrated in the name of psychiatric and especially psychoanalytic conceptions of sexuality.5 As such, it reveals its own historically contingent identity as part of a particular strand of AngloAmerican second-wave feminism, evincing an antipathy towards the psychological discourses of sexuality associated with Freud rather than as part of feminisms that have wrought sympathetic if critical engagement with psychoanalysis (Mitchell, 1974; Chodorow, 1989; Cixous, 1976[1975]; Irigaray, 1977). And while feminist critique of psychoanalysis emerged with good reason, it cannot simply be assumed, theoretically and methodologically, by scholarship that attempts to illuminate the postwar trajectory of female sexual problems within psychiatry and culture given that the rejection of psychoanalysis by both feminist and psychiatric discourses is such a pivotal phenomenon in that landscape.6 In seeking to understand the FSD landscape, I suggest, it is helpful to widen the lens of criticism from discerning the norms of sexuality and gender expressed in explicitly medico-pharmaceutical discourse vital though that is to also scrutinizing feminism itself as a category that is discursively managed across a range of realms: medical texts, popular texts, and indeed feminist texts themselves. Debates about female sexual problems in the postwar period are characterized by ambivalences towards the past, and indeed towards the very act of looking back at the past. Medical, feminist and popular texts evince discomfort with harking back to the past of psychiatric theorizing which, in psychodynamic psychiatry, involved precisely a commitment to the importance of the past in creating symptoms. Moreover, scholarship on these matters embodies a reluctance to look back, inclusively, at the history of feminism itself: at its complex relationship to psychiatry and its past, and how that shapes the modes in which critique is articulated. Angela McRobbie has described a post-feminist sexual contract, in which, under the guise of an equality assumed to have been achieved, young women are attributed with political, economic and sexual capacity. Young women are able to come forward as high-achieving, economically powerful figures on condition that feminism fades

away, and that they abandon the critique of hegemonic masculinity and sexism associated with feminism (McRobbie, 2007: 720, 729). She implies that the rejecting and the historicizing of feminism are essentially interwoven (McRobbie, 2009: 16). We are required to look back at feminism as something unnecessary, old and worn, and the dismantling of feminist politics is, she argues, inextricably linked to the contemporaneous dismantling of feminism within the academy (ibid.: 13). What relationship, then, does this historical activity of including feminism as a component in the landscape to be analysed bear to a post-feminist stance that has been diagnosed as a symptom of a contemporary rejection of feminism? How should one look back, historically and critically, at the feminisms of the postwar period? It is my view that an adequate analysis of the landscape requires, in addition to a critical relationship to rejections of feminism, a critical relationship to modes of rejecting the activity of looking back at the past. FSD scholarship provides us, I think, with an opportunity as yet not taken up to rethink the relationships between second-wave feminism, postfeminism, psychoanalysis, medicine and psychiatry. It provides an opportunity not only to think about the intertwined legacies of psychiatry and feminism, but also to listen to complex discourses about history itself; about what is past, and what is present. It is, in other words, an opportunity to ask, and to find out, what kind of scholarship this particular moment in psychiatry, feminism and their historiography is challenging us to write.

Biographical note
Katherine Angel is a Postdoctoral Fellow in the History of Medicine at Warwick University. She holds a PhD from the History and Philosophy of Science Department at Cambridge, and has held research posts there, at UCL and at Kings College London. She has published on FSD, clinical waste and interwar psychiatry.

Notes
1.

The catch-all term antipsychiatry needs to be used with caution; as Colin Jones has underlined, it encompasses a very varied phenomenon made up of sometimes conflicting positions, among which are a content-based critique of psychiatry, a gestural politics of carnivalesque inversion and symbolic performance and the exploration of new paradigms of knowledge about what it is to be human; see Jones (1998).
2.

DSM-V is, at the time of writing, being prepared, due to be published in 2013; it appears to be significantly reordering the sexual classifications, in particular collapsing desire and arousal problems into a category of Sexual Interest/Arousal Disorder in women, and combining Dsypareunia and Vaginismus into Genito-Pelvic Pain/Penetration Disorder; accessed 21 July 2011 @: http://www.dsm5.org/Pages/Default.aspx
3.

A commitment to equivalence has persisted into later DSMs, and has been the target of critique (Tiefer, 2004). It is also being rethought in current revisions for DSM-V, through

the work of Rosemary Basson, and Lori Brotto, who both suggest that female sexual response is more responsive and receptive, and less spontaneous, than male desire (Basson, 2002; Brotto, 2010).
4.

Initial attempts to develop vasocongestive targeting arousal problems proved disappointing; efforts have since focused on central pathways and the desire centres of the brain, with testosterone and serotonin receptor antagonists candidates (e.g. flibanserin). The latter garnered much media attention, but was rejected by the FDA, which has not yet approved a pharmacological agent for FSD, though the European Medicines Agency has licensed Intrinsa, a testosterone patch for post-menopausal women with Hypoactive Sexual Desire Disorder (HSDD).
5.

The critique features prominently in Moynihan and Mintzess recent popular book, making use of the tremendously fruitful language of construction, but in ways that slip between questioning the validity of the FSD category, and indeed of the very task of classification an epistemological point and questioning whether someone has symptoms that the diagnosis claims to describe questioning whether there is anything there to (mis)describe an ontological point. This obfuscation in the use of the term is where interested parties pharmaceutical companies, practitioners invested in the dissemination of FSD and treatments for it have immense leeway to accuse FSD critics of disregard for women. See Angel (2012).
6.

Downing (2004) stands out somewhat in that it uses critical and queer theory to approach FSD.

Article information
Hist Human Sci. 2012 October; 25(4): 324. doi: 10.1177/0952695112456949 PMCID: PMC3549574 Katherine Angel University of Warwick, UK Katherine Angel, Centre for the History of Medicine, University of Warwick, Humanities Building, 448 Gibbet Hill Road, Coventry CV4 7AL, UK Email: k.angel/at/warwick.ac.uk Copyright The Author(s) 2012 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Articles from SAGE Choice are provided here courtesy of SAGE Publications

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Aging and Disease JKL International LLC

An Update on Female Sexual Function and Dysfunction in Old Age and Its Relevance to Old Age Psychiatry
Alison Wood, Ross Runciman, [...], and Ross McManus Additional article information

Abstract
Numerous studies have now demonstrated that many older women retain an interest in their sexual lives. Yet, how many old age psychiatrists commonly check with older women about whether the depression they are treating, or the SSRIs (Selective Serotonin Re-uptake Inhibitors) they have prescribed, have adversely affected their patients sexual lives? We consider the latest evidence regarding cultural, social and medical influences on older womens sexual lives and some specific issues which affect lesbian and transsexual people. We examine how mental illness and psychotropic medication in particular can adversely affect older womens sexual functioning and at how difficult it often proves to be for women to seek help. We also focus on why doctors and in particular psychiatrists may not take a sexual history, look for sexual side effects or refer

for appropriate treatment, especially when interviewing older women patients. Most published information about psychiatric training and sexual issues focuses on the younger male patient. We therefore aimed to provide a broad-ranging review of the literature regarding female sexual functioning in old age, the difficulties that can arise and the role that old age psychiatrists have an opportunity to fulfil, in this often neglected aspect of their patients treatment. From our review it was clear that, in the light of the increasing cultural acceptability of discussions regarding sexuality and older women, the training of student doctors and trainee psychiatrists needs to reflect this change so that old age psychiatrists can enhance the quality of their patient care. Keywords: Female, old age, sexuality, chronic disease, help-seeking, psychiatry Sexuality in our later years is now positioned as a key element of successful aging. Hinchliff et al [1]. Increasingly organizations such as the AARP (American Association of Retired Persons) are publicizing the cultural acceptability of ongoing physical closeness and contributing to gathering data reflective of this trend [2]. For example, on their website articles such as Are You Savvy About Sex After 50? Take our quiz and then compare scores with your partner to see who comes out on top are easy to find. Numerous studies have now demonstrated that many older women retain an interest in their sexual lives. They are likely to feel better physically and mentally for doing so Brody and Costa [3]. Yet, how many old age psychiatrists commonly check with older women about whether the depression they are treating or the SSRIs (Selective Serotonin Re-uptake Inhibitors) they have prescribed have adversely affected their patients sexual lives? Most published information about psychiatric training and sexual issues focuses on the younger male patient as, in England, have the practical examinations of psychiatric competence with regard to sexual side effects of medication. We aim to examine the latest data on female sexual functioning in old age, the difficulties that can arise and the role that old age psychiatrists have an opportunity to fulfil in this often neglected aspect of their patients care. We will examine the latest evidence regarding cultural, medical and social influences on older womens sexual lives including some which specifically affect lesbian and transsexual people. We will look at how mental illness and psychotropic medication in particular can adversely affect older womens sexual functioning and at how difficult it often proves to be for women to seek help. We question why doctors and in particular psychiatrists may not take a sexual history, look for side effects or refer for appropriate treatment, especially when interviewing older women patients.

Method
We made this a selective review, due to the breadth of aspects covered. Multiple searches were conducted, mainly via Athens Login to the National Library for health in the UK.

The following databases were accessed BNI, CINAHIL, EMBASE, MEDLINE, PUBMED, PSYCHINFO. Search terms included female, women, old age, elderly and geriatric, sex, sexuality and sexual, lesbian and transsexual, psychiatry and nursing home. Relevant additional studies and websites known to the authors were included. Most research cited has been published since the year 2000 and much of it in the last two years. Some smaller studies have been included in areas where there is a dearth of larger studies to draw upon.

Are older women bothered about sex?

Nicolosi et al [4] as part of the Global Study of Sexual Attitudes and Behaviors (GSSAB), aimed to study the sexual activity and the prevalence of sexual dysfunctions and related help seeking behaviour, among people in Europe aged 4080 years. This was a large scale study both men and women were interviewed by telephone in 2001 and 2002. They came from Sweden, the United Kingdom, Belgium, Germany, Austria, France, Spain and Italy. Altogether 5023 women took part. Overall 21% of the women aged 7080 had had sexual intercourse within the preceding 12 months and 25% of those sexually active women aged 7080 had sexual intercourse more than once a week. Women aged 4080 were asked, as part of the same study, whether satisfactory sex was essential to the maintenance of a relationship. 77% agreed that it was. Only 18% agreed that Older people no longer want sex. There have been two recent large-scale studies in the United States which investigated the prevalence of sexual activity in the over-70s. According to the American Association of Retired Persons survey in 2009[5](www.aarp.org/home-family/sex-intimacy), the percentage of women over seventy having vaginal intercourse even once within the previous six months was 13.3%. Whereas the National Survey of Sexual Health and Behaviour, also conducted in 2009 and published by Hernbenick et al [6] 21.6% of women over seventy reported having vaginal intercourse within the previous year. These studies also indicated that masturbation was undertaken by 3340% of women over seventy, showing ongoing sexual interest in this age-group. In Sweden Beckman et al [7] found that Swedes over seventy appeared to be more sexually active and more sexually satisfied than they had been 30 years previously and that 56% of married women over seventy remained sexually active. It is also worth pointing out that what counts as sexual activity can change, as women get older. Older people often redefine their sexuality. Hinchliff [1] noted other activities engaged in as a couple may be viewed as sexual. Penetrative sex may be less of a focus for men and women. Having a positive attitude to sex appears to be an important factor when it comes to older people engaging in sexual activity DeLamater (2012) [8]. This point is emphasised by some studies looking into physical difficulties of various kinds, which have shown that having a physical disability which affects a womans sexual life does not necessarily have as much impact as how the woman feels about that physical disability. Lowenstein

et al [9] who studied 380 women with Pelvic Organ Prolapse (POP) and concluded that Sexual function is related to a womans self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a womans perception of her body image than to actual topographical changes from POP. Similarly Hinchliff et al, 2011[1] noted the discrepancy in some studies between the levels of women with clinically significant sexual dysfunction and the lower proportions of women within the same studies, who identified themselves as having a sexual problem.

The impact of aging on female sexuality

The foremost change in discussing the medical effects of aging in women with regards to sexuality is perhaps that of the menopause as DeLamater (2012) [8] indicates. This period of transition as Avis et al [10] discuss, rather than being a singular event, lasts on average 3.8 years and is preceded by the climacteric or peri-menopause which begins at the mean age of 47.5 years. It is during this climacteric period, when there is a gradual decline in the functioning of the ovaries, that symptoms begin to appear, consisting mainly of vaginal dryness and vaginal atrophy as Howard et al [11] discovered in their research of women aged 40 to 79. However, in their study of middle aged and older women in Australia, vaginal dryness was reported as completely absent in 35.8% of women and always present in only 11.5%. Furthermore, only 14.6% of women experience dyspareunia 50% or more of the time. Interestingly, they also found that the overall incidence of both dyspareunia and of dryness did not vary significantly in their age group of 40 to 79. However Leiblum et al [12] in their international study of 6,725 women from 11 countries including the UK, Germany, Japan, Canada, Spain, and Brazil found that the incidence of vaginal dryness varied significantly between different countries. In Italy vaginal dryness was reported by 5.8% of women, by contrast in Brazil 19.7% of women complained of the same problem. A similar picture emerged with reports of dyspareunia, which was experienced by 3.6% of women in Australia but 18.6% of women in Brazil; this contrast also casts some doubt over the value of extrapolating the results of Howard et als [10] study internationally. In addition, this detailed research found that there was significantly more vaginal dryness in the UK, Australia, Canada, Italy, Spain, Argentina, and Thailand in the 5065 year old age group compared with the 1843 year age group. Lastly, the researchers highlighted an important contrast in health beliefs in these two age groups; internationally, the majority of women under 50 attributed vaginal dryness to inadequate sexual arousal whereas the over 50 age group blamed this on their age or the menopause. Crucially, this also illustrates the importance of how the individual woman perceives biological aging and may explain, to a certain extent, the varied views of attitudes towards sex post-menopausally as discussed by DeLamater (2012) [8]. Also there is little evidence that sexual desire declines directly as a result of the menopause as Hinchliff et al [1] discovered in their qualitative study of the sexual experiences of women over the age 50. It is also worth noting that there is little consistent evidence to show that the menopause causes depression as Eden et al [13] discuss in their review article; furthermore Avis et als [10] study of 2565 women aged 4555 years in Massachusetts

highlighted that previous depression is the most likely factor to predict depression at menopause, supported also by Guthrie et als [14] study of 438 Melbourne women. Clearly a complex biopsychosocial model is necessary to explain how the menopause effects female sexual functioning. Although obviously not universal like the menopause, diabetes mellitus type II in the older woman is increasingly common internationally and the incidence increases with age as Whitehouse [15] indicates. In her literature review she highlighted two main consequences of diabetes; firstly, the direct effect of the disease on the physiology of the body and secondly, the psychological effects of diabetes. Firstly, hyperglycaemia which can commonly occur in poorly controlled diabetes and indeed before it is diagnosed is thought to reduce the hydration of the mucus membranes which include vaginal tissues therefore resulting in vaginal dryness and associated dyspareunia. In addition the increased incidence of urinary tract infections in women with diabetes can cause further vaginal discomfort. Additionally, diabetes causes significant pathological changes to vascular structures leading to potential damage to the blood supply to the vagina. This can result in reduced lubrication and diminished circulation to the clitoris, inhibiting engorgement during sexual arousal. Secondly, the psychological effects of diabetes such as increased perceived tiredness, embarrassment about the disease as well as reported loss of desire all serve to indirectly reduce sexual function. There is a disagreement in the literature about whether type I or type II diabetes effects sexual functioning the most, with no conclusive answer. This lack of clarity could be accounted for by the lack of research. Enzlin et al [16] are scathing both about the scarcity and quality of research about diabetes and its effect on the diabetic women, whilst they corroborate Whitehouse [15] citing the combination of decreased or slow vaginal lubrication with reduced sexual arousal. However they suggest that problems with achieving orgasm are not more common in diabetic women. Urinary incontinence and pelvic organ prolapse are also more common in the older woman. Unsurprisingly urinary incontinence results in significant psychological distress in many women, with the fear of urine leakage during intercourse uppermost in their minds, accompanied with increased feelings of guilt and disgust about sex as Melin et al [17] explored. They also found that the fear of incontinence led to women avoiding sexual contact. Interestingly in Tannebaum et als [18] study 2361 women with a mean age of 71 in Canada found that the women with urinary incontinence werent less likely to be sexually active, however the severe incontinence did correlate with less intercourse. Here, overall, they found age (younger) and marital (married) status to be better predictors of regular sexual activity. Closely related to urinary incontinence in effect is pelvic organ prolapse on womens perception of their sexuality; a subject which Sublett [19] highlights is often unvisited by health care professionals and yet despite the scarcity of research on this subject, there may be a considerable impact on sexual function. A common risk factor for diabetes mellitus type II, urinary incontinence and pelvic organ prolapse is obesity, a commonly known growing epidemic. Beyond the direct pathological links between these conditions and obesity it is important to consider the

relationship between obesity and sexual function directly, on which there is little research as Zabelina et al [20] discuss. In their study of 9991 overweight and obese men and women they used the Impact of Weight on Quality of Life-Lite (IWQOL-Lite), a measure of weight-related quality of life tool, to explore sexual function. Interestingly the results showed that at all age groups, the overweight and obese women had less self-esteem, encountered more public distress at their perceived image and had a less active sex life than the men. They found that the frequency of sexual activity in the women took a sharp dive after the age of 25 and then levelled out, in contrast to the more gradual decline for the men. However, self-esteem increased every decade in women peaking aged 70 along with a consistent decline in public distress as they got older. This research did not compare obese or overweight individuals with those of a more healthy weight but the aforementioned study by Melin et al [17] usefully contrasts obese and non-obese women, finding the former group experiencing less sexual excitement, lower sexual activity and less satisfaction with their sexual lives. Yet dyspareunia and ability to achieve orgasm were not significantly different when obese women were compared with non-obese women. Obesity therefore clearly impacts on sexual function in women of all ages. There has, thus far, been very little research into the impact of obesity on the sexual functioning specifically of older women. Although certain chronic illnesses have been discussed, the older woman may encounter a variety of debilitating conditions. Encouragingly however, Howard et als [11] Australian study which compared women with breast cancer, osteoarthritis and hypertension to healthy women of the same age, found little difference in their sexual function and satisfaction. Despite these findings the authors suggest that advances in medical care for the older women, would very probably lead to increases in sexual functioning in the future. Their findings were supported by Lindau et als [21] study of 6037 US American women where they found that men tended to have their sexual functioning impaired much more by chronic illness than their female counterparts at all ages. Good health was associated strongly with a good quality frequent sex in their study, however the exact causality and nature of this relationship is unknown.

Cultural and social influences on aging female sexuality

Hinchliff et al [1] highlighted some of the barriers to older people expressing their sexuality; old bodies sit in stark contrast to contemporary images of sexuality, which portray a youthful physical appearance and noting that because sex has traditionally been linked to the natural order (reproduction), later-life sexuality has been viewed as a perversion. However attitudes are changing. Hinchliff et al [1] noted that Sexuality in our later years is now positioned as a key element of successful aging. The apparent health benefits of continuing sexual activities into old age are also becoming more noticed Based upon a broad range of methods, samples, and measures, the research findings are remarkably consistent in demonstrating that one sexual activity (PVI {penile-vaginal intercourse} and the orgasmic response to it) is associated with, and in some cases, causes processes associated with better psychological and physical functioning. Brody [22] concluded

after his 2010 review of the literature on health and sexual activity. Psychiatrists will be particularly interested in the study, previously conducted by Brody and Costa [3] of a large representative sample of the Swedish population. They found that PVI frequency was a significant predictor of both mens and womens greater satisfaction with their mental health. Age did not confound these results. Women tend to live longer than men. Thus one clear factor limiting the sexual lives of heterosexual older women is lack of a partner. This was highlighted in an unusual study in Germany where Beutel et al [23] examined sexual desire and sexual activity, but included all ages. Their overall sample included 201 women and 101 men over seventy and even some people in their nineties. In the over-seventies the major factor determining sexual activity levels was whether someone had a partner. DeLamater et al [8] also noted after his review that relationship or marital status is perhaps the major influence on the frequency of heterosexual sexual activity in later life. Additionally he highlighted the frequent presence of cultural norms limiting sexual activity to persons in committed relationships. The sexual and general health of a womans partner also naturally affects their sexual lives. A male partner may also be experiencing the effects of aging, The effects of social, cultural, medical and pharmaceutical factors on the sexual functioning of men is however beyond the scope of this article. As women get older they or their partners may not be able to continue without residential or nursing home care. Unfortunately this may make continuation of their sexual life very difficult due to staff attitudes and lack of privacy. Their only privacy is between the sheets by Bauer et al [24] in Australia demonstrated a lack of individual rooms and how difficult it was for residents to have privacy from other residents or from staff. Staff felt that their need for access was more important than residents privacy. Staff and nursing home managers need to work toward developing a home environment that is supportive of residents sexuality rights, that permits sexuality expression and promotes a culture where all people concerned are comfortable with sexuality issues, Roach [25] in 2004 concluded after looking qualitatively at staff attitudes in Western Australia.

Why do older women commonly not seek help for sexual difficulties?
Women often do not seek help for sexual problems Nicolosi et al [4] (GSSAB) found that 32% of their sample of 5023 women in Europe reported a sexual dysfunction. 11% had lubrication difficulties, 13% had an inability to reach orgasm and 18% had lack of sexual interest. This study found that of men and women who reported a sexual dysfunction, overall, 74% had not sought medical help. The authors did not report these results by gender because the results were almost identical for men and women. This study also asked respondents, who had not sought help for their sexual dysfunction why they had not done so. Their results highlighted four main reasons. About 76% of respondents said that they did not feel that they had a problem, 71% felt that it was not a medical issue,

39% felt embarrassed and 26% had concerns about affordability or access to medical care. Interestingly though, 59% of women agreed with the statement I am in favour of the use of medical treatments to help older people enjoy sexual activity. Hinchliff et al, 2011[1] extensively reviewed the help-seeking behaviour of people over 50, with respect to their sexual functioning. Qualitative studies highlighted common beliefs that sexual difficulties were a normal part of old age and that the sexual difficulties were not causing much distress; people were comfortable the way they were. Difficulties were left to see whether they would resolve by themselves and were often not considered to be serious. It was common to feel that sexual functioning was recreational and as so, not so much a medical issue to discuss with a doctor. Some patients felt that the doctor might be uncomfortable with the subject of sex themselves and some older people even feared that a younger doctor may appear to disapprove of sexual activity in an older person. Many older women suffer with chronic diseases which may impact upon their sexual functioning. Kedde et al [26] in the Netherlands sought to investigate help-seeking behavior concerning sexual problems among people with a disease or an impairment and to determine factors and reasons that deter people from seeking professional sexological help. Shame shyness and anxiety prohibited people and many were unsure which health professional to approach and doubtful that they would receive useful help. Unfortunately, when Kedde et al [26] enquired, it turned out that two thirds of those who had sought help judged the consultation they received negatively so peoples doubts appeared to be well-founded. There is some research available regarding attitudes of doctors which illustrates that doctors themselves often subliminally or overtly discourage their patients from consulting them about sexual functioning. Hinchliff et al [1] found that doctors were more likely to broach the subject of sexual functioning with younger patients than older patients in their review. They also found that cultural factors can influence attitudes of both doctors and patients, creating barriers to open communication, noting that there are noticeably behaviours in different countries. It was established in 2001 that Psychiatrists, even Old Age Psychiatrists, are not immune from this as Bouman et al [27] illustrated in their study entitled Are Psychiatrists Guilty of Ageism when it comes to taking a Sexual History? They aimed to examine the attitudes and perceived clinical practice of psychiatrists with regard to taking a sexual history and management of sexual dysfunction in their patients by comparing responses of old age and general psychiatrists. They sent their questionnaire to 144 consultants in old age psychiatry and general adult psychiatry. The questionnaire contained one out of two possible two case vignettes. One described an 83 year old man with no previous psychiatric history and without any cognitive impairment, complaining of low mood for two months and the other described a 40 year old man with the same complaint. Questions then covered whether the consultant would take the various elements of a sexual history and if not, why not. They were then asked what their management would

be if a sexual difficulty was identified. Their results showed, from 61% replies, that both groups of consultants were more likely to ask the younger man about sexual function and to refer the younger man for appropriate treatment. These authors postulated that factors which may have influenced the lack of history taking were that patients dont tend to raise the subject themselves, Psychiatrists may have difficulties disconnecting from their own personal belief system regarding aged sexuality or they may just lack awareness of physiological, pharmacological and psychosocial bases of sexual problems as well as of aged sexuality. Similarly, with respect to treatment referral, their results showed that a Psychiatrist would typically refer a middle-aged patient with sexual dysfunction for sexual therapy but that an elderly man with the same problems would be referred to a community psychiatric nurse, who is not trained in sexual therapy. The authors concluded that taking a sexual history is often omitted in the psychiatric assessment of elderly men and that elderly men with sexual dysfunction do not receive appropriate referral and treatment. Bouman et al [27] reached the conclusion that Human sexuality and particularly aged sexuality is an area that requires more attention in psychiatric training. This study also begs the question; what would the respondents have answered, had the patient been female? Rele and Wylie in 2007 [28] looked at the Management of psychosexual and relationship problems in general mental health services by psychiatry trainees. They sent a completely anonymous questionnaire to all psychiatry trainees in one region of the United Kingdom, regarding their perception of their competency in dealing with sexual dysfunction and relationship problems; the need to discuss potential sexual side-effects before and after starting psychotropic medication and the importance of a readily available psychosexual disorder clinic. The questionnaire also tried to establish the extent of their training on psychosexual issues and sexual medicine. 81% of trainees reported feeling inadequacy whilst dealing with psychosexual disorders during their training in psychiatry. Only 30% reported asking patients about potential sexual side-effects when on psychotropic medication. The authors concluded that training for undergraduates needed to focus on sexual health more fully and that trainees should be supervised and assessed so that they could demonstrate competence in this area of the curriculum. Schindel et al [29] recently completed a larger scale study of US and Canadian Medical students. They received over 2000 self-selected replies to a wide-ranging survey which examined not only their attitudes towards discussing sexuality with their patients but also the students own sexual preferences and levels of sexual activity. They found that the most powerful association of lack of comfort in dealing with patients sexuality was a perception of inadequate human sexuality training in medical school. This was the case irrespective of their personal sexual choices and experiences These authors therefore highlighted the importance of ensuring a quality human sexuality curriculum at medical schools throughout the United States and Canada.

Issues specifically affecting older lesbian women

Although there is limited research available in this area, studies indicate that Lesbian women have specific concerns as they enter old age.

In their small-scale qualitative study of lesbians in New York, Howell and Beth [30] found that Middle-aged lesbians expressed concern regarding who would care for them when they were old. What would they do when they could no longer use coping skills that they learned as young people facing homophobia? Some expressed hope that homosexual communities that supported them through their coming out processes would also meet this need. However, they were concerned that lesbian-friendly services were already difficult to find, even in New York City where many gay and lesbian service organizations exist. Similarly, Smith et al [31], who examined the views of Gay, Lesbian, Bisexual and Transsexual (GLBT) people in California noted that Not a single participant thought that nursing homes were very GLBT-friendly and over half (52.6%) thought nursing homes were not GLBT-friendly. Almost as many (47.4%) thought that assisted living services were not GLBT-friendly. Equal percentages (36.8%) thought that senior centers and accessible transportation were not GLBT-friendly. About a quarter thought that in-home care personnel would not be GLBT-friendly. Neville et al [32], did a larger-scale survey, undertaken in New Zealand, entitled Lavender retirement: a questionnaire survey of lesbian, gay and bisexual peoples accommodation plans for old age Of women (n=1001), 476 (47.6%) chose living with family/partner, 395 (39.5%) chose living in their own house, flat or apartment, 78 (7.8%) chose other and only52 (5.2%) chose a general retirement facility. They also found that, when women were asked what they would prefer if they were unable to live on their own,1007 women respondents to this question, 593(58.9%) preferred an LGB-friendly retirement facility, 201 (20.0%) preferred to be cared for in her own home by public services, 122 (12.1%) preferred a general retirement facility, and 91 (9.0%) preferred some other accommodation option. They advocated ensuring nursing curricula covers topics such as sexuality, gender, discrimination, as well as relationships, friendships and lifestyle patterns of Lesbian, Gay and Bisexual people.

Old age in the transsexual community

People have usually been part of the transsexual community for many years before entering old age but some people request gender reassignment when older as described by Docter [33] and previously by Lothstein [34]. Psychiatrists in old age therefore need to be aware that a strong desire to change gender can present in old age and know the appropriate referral procedure in their area. For people within the transsexual community, aging can be a daunting prospect. Smith et al [31] in California collected some qualitative data from the LGBT community, which illustrates some perceived unmet needs. Their respondents suggestions included; Have more gay friendly people that provide services, Begin to educate the organizations that cater to senior citizens about the need to be accepting of GLBT persons, More training for people involved in social services, nonbiased. These comments appear to indicate a worry that as an elderly LGBT person, one might find oneself vulnerable to prejudice from professionals. Several people also expressed a preference for specialised services;

Open GLBT specific centers geared for senior GLBT persons to congregate More community activities for older gays/homosexual people and their partners Start an LGBTQ [lesbian, gay, bisexual, transgender, or queer] housing project, like they have in other cities. Jonson et al [35] in their 2012 Swedish study deftly illustrated how sexuality can adapt during aging for the LGBT community. Turning vinegar into wine: Humorous selfpresentations among older LGBTQ, looked at self advertising in two Internet dating forums. Self depreciating humour about old age, being overweight, impotence and other age-related changes were in fact part of a repertoire that displayed marketable characteristics such as humor, self-distance and honesty among advertisers.

Direct effects of mental illness on female sexual functioning

Depression and anxiety are more common in older women and they are directly associated with increased anorgasmia and lack of pleasure according to Moreira et al [36]. Ching et al [37] in their unusual study of 73 unmedicated patients with depression alongside 116 healthy volunteers revealed that depressed women in all age groups had poorer sexual functioning than the control group. They also found that increased age was associated with poorer sexual functioning in the depressed group, whereas in the control group, sexual satisfaction continued to increase to the age 40, before starting to decline. Fabre et al [38] studied 1184 women, using the Hamiliton Depression Rating Scale and the Derogatis Inventory of Sexual Function tool. Here they found that a higher the depression score correlated with a lower the level of sexual functioning. However, this relationship between depression and sexual dysfunction is highly complex. Indeed there is evidence that penile-vaginal intercourse, crucially including ejaculation, leads to stimulation of hormones in women that can be psycho-protective, such as seminal prostaglandins, as Brody [39] discusses. The length of exposure to seminal fluid is also key, with women who void urine shortly after sex having a higher incidence with depression than those that dont. This potentially leads to vicious circle in depressed women, whereby reduced libido from their mental illness engenders less sexual activity, which in turn reduces exposure to seminal fluid via penile-vaginal intercourse. This research does not directly discuss older women; however their increased incidence of depression together with the tendency for older women to engage in less frequent penilevaginal intercourse makes these findings worthy of note. There is again a great paucity of contemporary research on the effect on female sexual functioning of other mental illness across any age groups, let alone in older women. However, over 25 years ago, some interesting research was conducted by Raboch [40] on Czechoslovakian women which found there to be no difference in orgasmic response in bipolar patients, compared with a control group. However, he found those women with schizophrenia and neurotic disorders had much lower rates of coital orgasm than the controls with no mental illness. There is clearly an on-going need for research into the

relationship between mental illness, especially those other than depression and sexual dysfunction in the older woman.

The dilemmas faced by dementia sufferers and their carers

Dementia is a pervasive disease of increasing prevalence, especially in Western societies, as peoples life expectancy has increased. Although quality of life maintaining treatments are increasingly available there is a steady progression towards widespread loss of mental faculties. This is often devastating for sufferers and partners, who are often redesignated as carers. When verbal communication is impaired, sometimes non-verbal communication and physical closeness can provide an intermittent window of comfort. However as the sufferers capacity to consent declines, couples can find themselves in a minefield, surrounded by well-meaning professionals. The Alzheimers Society: Sex and Dementia leaflet [41] (www.alzheimers.org.uk/site/scripts/documents_info.php? documentID=129) outlines common changes that can occur in the context of dementia. These are a greater or lesser interest in sex, an increase or decrease in sexual performance, changes in sexual manners for example, appearing less sensitive to the others person needs or appearing sexually aggressive and changes in levels of inhibitions. This publication also provides some practical guidance for couples negotiating through these sometimes ethically challenging areas. The English National Institute for Clinical Excellence (NICE) recommends At the time of diagnosis and when indicated subsequently, the impact of dementia on relationships, including sexual relationships, should be assessed in a sensitive manner There is even hope after dementia leads to care outside ones own home. Intimacy, Sexuality and Sexual Behaviour in Dementia: How to Develop Practice Guidelines and Policy for Long Term Care Facilities [42] has been developed in Canada. This pragmatic approach aims to challenge the pervasive belief in society that sex is for the cognitively intact.

The effects of prescription medications on sexuality in the elderly

As the population ages the need for multiple drug therapies grows. Whilst many women in older age wish to continue their sexual relationships, the medicines they are prescribed can make this difficult and sometimes impossible. Additionally the medicines prescribed for their sexual partner can impair their sexual performance and as a result damage their relationship. The potential for newly prescribed drugs to cause sexual impairment is easily overlooked at the counselling phase. Many prescribers may be unaware of their patients difficulties as a consequence of reluctance by the patient to talk about them. Direct questioning from the prescriber is usually required to open this dialogue. It is important that they are aware

which medicines have the potential to impair sexuality in order to ask appropriate questions of those patients recently started on such drugs. In order to predict the potential for a medicine to impair sexual function an appreciation of the normal mechanisms involved in sexual function is required. The central nervous system (CNS), parasympathetic system and the sympathetic system are all involved in normal sexual function.

Sexual interest or libidomediated primarily by CNS Arousal mediated by CNS and parasympathetic system Plateau Orgasm/ejaculation mediated by CNS and sympathetic system Resolution

Many neurotransmitters, neuropeptides and hormones are involved in normal sexual reactions.

Psychotropic medication which may affect sexual functioning of women and men:
Antidepressants
Mixed anxiety & depression is a common mental disorder. For example, approximately 812% of the British population experience depression in any year according to the The Office for National Statistics Psychiatric Morbidity report [43]. Of these, half only experience symptoms for 18 months. However the poor, the long-term sick and the unemployed, three states often attributable to the elderly, are likely to be affected for a longer duration than the general population. Sexual dysfunction is a known cause of depression but the relationship is complex. Unfortunately it is also a symptom of depression and can be an adverse effect of treatment with antidepressant medicines Seidman [44]. These confounding issues imply that there is a requirement to establish an understanding of the patients baseline sexual functioning before they were depressed and before they subsequently commence treatment with antidepressants. Sexual dysfunction in men and women has been reported with nearly all antidepressant medication with reported incidence varying from 40% according to the Better Or Worse: A Longitudinal Study Of The Mental Health Of Adults In Great Britain report [45] to 59.1% according to Rothschild [46]. Delayed orgasm can be attributed to the anticholinergic effects of tricyclic antidepressants while decreased libido is a result of their dopamine antagonist properties. Females not requiring antidepressants may still experience the results of tricyclic antidepressant sexual adverse effects such as erectile dysfunction and impaired

ejaculation in their male partner. Beaumont [47] highlights that elderly patients are especially vulnerable to many of the side-effects of tricyclic antidepressants. The selective serotonin reuptake inhibitors (SSRIs) are increasingly common drugs prescribed for depression, yet they also carry a risk of worsening sexual function. Montejo et al [48] observed that delayed orgasm is seen with the SSRIs along with decreased libido, anorgasmia, and decreased vaginal lubrication. Citalopram and paroxetine were shown to be relatively likely to have had an effect in the Montejo et al study [48]. The sexual adverse effects of SSRIs are thought to be caused by increasing synaptic concentrations of serotonin stimulating 5HT2 and 5HT3 receptors resulting in decreased levels of dopamine activity, according to Michael et al [49]. Specific resources should therefore be directed towards the education of prescribers to help identify those patients most at risk and monitor for treatment emergent sexual side effects. As with the tricyclic antidepressants, females whose male partners are taking an SSRI may still experience sexual adverse effects as a result of erectile dysfunction. Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, was identified in one study by Montejo et al [48], which compared several antidepressants, as having a relatively high incidence of sexual dysfunction (67.3%). Effects may include decreased libido, delayed orgasm, anorgasmia, decreased vaginal lubrication and in men, erectile dysfunction. Mirtazapine is a selective 5HT2 and 5HT3 antagonist, which may explain the relatively low frequency and intensity of sexual dysfunction (24.4%)[48] as compared to some SSRIs. As a consequence of its low frequency and intensity of sexual dysfunction, mirtazapine may be considered a viable choice as an alternative antidepressant for women experiencing sexual dysfunction. It remains unclear what effects trazadone has on sexual function; Rattya et al [50] reported increased libido. Duloxetines effect on sexual function was assessed in 4 randomised double blind placebo and paroxetine controlled trials in patients with major depression in a study by Delgarno et al [51]. It was found to have a higher rate of treatment-emergent sexual dysfunction (46.4%) than placebo (28.8%) but significantly lower rate than paroxetine (64.1%). Like the tricyclic and SSRI antidepressants the non-reversible MAOIs may produce sexual dysfunction, which is suggested to be as a result of their serotonergic stimulating action. Physiological effects are similar to those of the tricyclic antidepressants. Rothschild [46] suggests the alternative of moclobemide, a reversible MAOI with a lower reported incidence of sexual dysfunction and which may even have a stimulating effect on sexual function.

Anti-epileptics

Epilepsy can affect reproductive function and sexuality. This is likely to be because many patients report low satisfaction with sexual relationships in the context of feeling stigmatized by having the condition according to Harden [52]. Changes in sex hormone levels in patients with epilepsy may be attributable to the condition, the antiepileptic drugs or to both. Findings in women with epilepsy include abnormal levels of prolactin, luteinizing hormone, estradiol, sex hormone binding globulin, and dehydroepiandrosterone. The hepatic enzyme-inducing anti-epileptic drugs; phenobarbital, phenytoin, carbamazepine, and oxcarbazepine increase hepatic synthesis of sex hormone binding globulin and the metabolism of sex hormones. Lambert [53] reports that lamotrigine, which does not induce hepatic enzymes, appears not to affect sexual function.

Anti-parkinsons drugs
The physical manifestations of Parkinsons disease (PD) impair the ability to perform sexual activity successfully. In addition, the effects of PD also produce a range of symptoms that can impair sexuality. In both genders loss of libido is common while in men erectile dysfunction and delayed ejaculation is seen also. In women vaginal tightness and dissatisfaction in sexual intercourse has been noted. Sakakibara et al [54] discuss that treatment of PD using dopaminergic drugs improves sexual functioning to some extent however pathological hypersexuality may occur which they attribute to the dopamine dysregulation syndrome in this disorder.

Antipsychotics
Stimmel et al [55] highlight that sexual dysfunction can occur in patients with schizophrenia but that it is more likely still to affect individuals who are taking antipsychotics. Advanced age is one of the factors influencing the degree of sexual dysfunction. Also relevant are the class of antipsychotic, higher levels of depression and concomitant disease/drug therapy according to Stimmel et al [55]. The most common sexual side effect of antipsychotics is reduced libido affecting 30% to 60% of those taking older antipsychotics affected and up to 43% of those taking newer atypical antipsychotics in the Stimmel et al review [55]. This is apparently related to dopamine antagonism and the increased prolactin levels caused by dopamine blockade. Risperidone has been found to cause elevations in prolactin levels relatively frequently. Olanzapine and clozapine are respectively less likely to cause this and quetiepine less likely still [55]. The older conventional antipsychotic drugs such as chlorpromazine, haloperidol and fluphenazine are potent dopamine blockers. These may cause up to 60% of patients to experience sexual adverse effects [55]. Hanssens et al [56], in their trial comparing aripiprazole with standard care (olanzapine, quetiapine or risperidone), found that both groups experienced improvements in sexual function when compared with baseline assessments. However at 8 weeks the aripiprazole group reported significantly greater improvement compared with the standard care group.

Although baseline mean serum prolactin levels were similar in the two treatment groups, at Week 26, mean decreases in serum prolactin were 34.2 mg/dL in the aripiprazole group, compared with 13.3 mg/dL in the standard care group. The study concluded that aripiprazole has the potential to reduce sexual dysfunction, which in turn might improve patient compliance.

Benzodiazepines
Benzodiazepines such as diazepam and temazepam are often used at relatively high doses for the treatment of anxiety and panic disorders. Together with the drowsiness you would expect they have been found to cause reduced libido and ejaculatory difficulty in the Hanssens et al trial [56].

Old Age Psychiatry and sexual functioning

So, what has sexual functioning got to do with psychiatry, anyway? The effects of mental illness on female sexuality and sexual functioning have already been addressed. Also we have examined the role of psychotropic medication on sexual functioning. Therefore surely, sexual functioning and any changes to it are the business of the psychiatrist. In addition, we have established that training in this area at the undergraduate and postgraduate level in Psychiatry appears to be insufficient which impairs communication with patients. Nnaji et al [57] looked specifically at sexual dysfunction in schizophrenia and found As regards training in the management of sexual dysfunction in schizophrenia, 62 psychiatrists (81.6%) had not had any; 60 respondents (78.9%) agreed they would want training, with 19 (26.3%) agreeing strongly that this was required. Although awareness of sexual dysfunction has been rising over recent years amongst psychiatrists, this awareness still tends to be focused on the needs of younger men, just as it was for Bouman [27]. Yet we have a responsibility. Stevenson [58] in Canada in 2004 asserted For an area of life and health that is so fundamental and pervasive, professional ignorance or inattention to possible sexual problems does not meet current standards of psychiatric practice. and it may be argued that it is indefensible not to take a good screening sexual history from each patient.

Conclusions
The prospect of a good sexual life for older women appears to be improving. The internet is providing more resources for older women to seek and find information and sexual aids. Information can be found via the AARP [5] website and the Sexual Advice Association (www.sda.uk.net), which also provides a helpline in the United Kingdom. It additionally provides specific information about how to approach your General Practitioner about a sexual difficulty. As pointed out by Hinchliff et al [1] the internet also enables people who are not able to travel easily, to obtain items to assist their sexual

functioning by post and anonymously. Finding partners can be facilitated by websites as highlighted by Jonson et al [35]. The authors were unable to find any specific research investigating the attitudes or practice of Psychiatrists regarding the sexual health of their older women patients despite the known effects of mental illness and psychotropic medication on female sexual functioning and the increasing awareness that many older women treasure their sexual lives. Psychiatrists have a unique opportunity to address this topic with their patients. Usually the psychiatrist has more time with their patient than, for example, their general practitioner. The psychiatrist is also routinely overcoming psychological barriers to ask difficult questions. If psychiatrists can address the myriad of psychotic symptoms and suicidal ideation with their older female patients, is it really so difficult to enquire about and appropriately address changes in sexual functioning? Training in both medical school and for psychiatric trainees appears to be fundamental to overcoming the identified barriers to this aspect of patient care.

Article information
Aging Dis. 2012 October; 3(5): 373384. Published online 2012 August 25. PMCID: PMC3501393 Alison Wood,1,* Ross Runciman,2 Kevan R. Wylie,3 and Ross McManus4 1 Old Age Psychiatry, Sheffield Health and Social Care Trust, Eastglade Centre, Sheffield, UK 2 Rotherham Hospital, Rotherham, UK 3 Porterbrook Clinic, Sheffield, UK 4 Pharmacy Department, Royal Hallamshire Hospital, Sheffield, UK * Correspondence should be addressed to: Alison Wood. Old Age Psychiatry, Sheffield Health and Social Care Trust, Eastglade Centre, Sheffield, UK. E-mail: alison.wood/at/shsc.nhs.uk Received July 20, 2012; Revised August 10, 2012; Accepted August 10, 2012. Copyright notice Articles from Aging and Disease are provided here courtesy of JKL International LLC

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