sexual function and quality of life

1. EFFECT OF DEPRESSION ON SEXUAL FUNCTION AND
QUALITY OF LIFE IN A TERTIARY CARE CENTER, KOLKATA
Dr. Arnab Pathak1, Dr Sayanti Ghosh2, Dr Sabir Hannan1, Dr Taniya Kundu1,Sk Ashik Uzzaman 3,Dr.Sumit Mukherjee4,
1- Junior Resident, Dept of Psychiatry, RG Kar Medical College, Kolkata, West Bengal, India
2-Associate Professor, NRS Medical College, 3- Clinical Tutor , Dept of Psychiatry, Calcutta National Medical College, 4- Senior Resident, Calcutta Pavlov Hospital.
*
ABSTRACT
METHODOLOGY: This study is a cross-sectional, single interview study in a tertiary care centre with a sample size of 60.
Consenting patients attending Psychiatry OPD, R G Kar Medical College, aged between 18-60yrs and sexually active were
evaluated. Patients with sexual dysfunction prior to depressive episode or other significant medical or surgical illness were
excluded. A detailed history with demographic profile were taken. Patients diagnosed as Major Depressive Disorder(MDD) were
included in the study. All the subjects diagnosed with MDD were rated with BDI, Arizona Sexual Experience Scale(ASEX) and
WHOQOL–BREF.
RESULTS AND CONCLUSIONS: Study Population had 75% sexual dysfunction, BDI score has a positive correlation with ASEX score
(spearman’s rho correlation coefficient 0.259, P value 0.046). BDI score and ASEX score both have negative correlation with all
the domains of WHOQOL. Which implies that with increased severity of depression and sexual dysfunction affects physical health
, psychological , social relationship, environment .
The results from the present study indicate high rate (75.0% ) of Sexual Dysfunction in MDD patients, which is comparable to the
results of Kendurkar and Kaur[9], who in 50 drug naive-depressed patients from India reported 76% baseline rates of SD. and Thakurta
et al.[10] who found sexual dysfunction in 71.66% of subjects in drug naïve depression patient in a tertiary care hospital of Bengal.
Comparing our results with that of Kendurkar et al.[9] we reported similar rate of dysfunction in male (74% vs 75%) and female
subjects (78% vs 75%), In our study most frequently reported domain of sexual dysfunction is impairment in orgasm (76.7%, n=46)
both in male(87.5%,n=7) and female(75.0%,n=39) , this is not comparable or similar with previous study which could be due to low
sample size, reporting bias and very low male representation in the study sample. In this study we found complains of desire in female
was reported in 73.1%(n=38) and excitement in 59.6%,n=31 which is again comparable to the results of Kendurkar and Kaur[9] who
found low desire reported in 68.4% and low sexual excitement in 57.9% among females and findings of Kennedy et al.[11] They found
that 42% of men had decrease in sexual drive. There is strong correlation between BDI scores ASEX total score which is comparable to
results previously documented.[12]
The strong negative association between severity of depression and QOL domains are consistent with previous work demonstrating a
monotonic gradient between MDD and QOL.[13]
This study found a significant correlation between ASEX and 2 domains of WHOQOL , on the other hand 2nd , 3rd and 4th domain of
WHOQOL have statistically significant negative correlation with ASEX score which is similar to the results of O.P Singh et all [10].
There are certain inherent limitations with this study,
• The absence of a control healthy group,
• Secondly the small sample size,
• The cross-sectional nature of this study limits the possibility to explore the cause and effect relationship between SD and
psychiatric diagnosis,
• Since the data was 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.
INTRODUCTION
Depression is characterised by loss of interest, reduction in energy and inability to experience pleasure, resulting in irritability and social
withdrawal which may in turn impair the ability to form and maintain intimate relationships.[1] This constellation of symptoms may be
expected to produce difficulties in sexual relationships.
Sexual dysfunctions are characterized by disturbances in sexual desire and in the psychophysiological changes associated with the sexual
response cycle in men and women. [2] Adequate sexual expression is an essential part of many human relationships, and may enhance
quality of life and provide a sense of physical, psychological and social well-being. Epidemiological and clinical studies show that depression
is associated with impairments of sexual function and satisfaction.
The life quality, functional impairment, and symptoms of major depressive disorder (MDD) patients have been an intriguing issue in recent
years . Major depressive disorder symptoms will interfere with concentration, motivation, and cognitive function. Quality of Life (QOL) is a
multidimensional construct to include subjective well-being and life satisfaction.[3] Subjects with affective disorders have significant QOL
impairment although the degree of dysfunction varies.[4]
REFERENCES
1.Baldwin DS. Depression and sexual function. J Psychopharmacol1996; 10 (Suppl. 1): S30–4
2.Byerly M, Nakonezny P, Fisher R, Magouirk B, Rush A. An empirical evaluation of the Arizona sexual experience scale and a simple one-item screening test for
assessing antipsychotic-related sexual dysfunction in outpatients with schizophrenia and schizoaffective disorder. Schizophrenia Research. 2006;81(2-3):311-316.
3. Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry 2005;162:1171-8.
4.A. McGahuey, Alan J. Gelenberg, Cin C. The Arizona Sexual Experience Scale (ASEX): Reliability and Validity. Journal of Sex & Marital Therapy. 2000;26(1):25-40.
5.Richter P, Werner J, Heerlein A, Kraus A, Sauer H, On the Validity of the Beck Depression Inventory. Psychopathology 1998;31:160-168
6.Smarr, K. L. and Keefer, A. L. (2011), Measures of depression and depressive symptoms: Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies
Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Arthritis
Care Res, 63: S454–S466. doi:10.1002/acr.20556
7.Eaton, W. W., Smith, C., Ybarra, M., Muntaner, C., & Tien, A. (2004). Center for Epidemiologic Studies Depression Scale: Review and Revision (CESD and CESD-R). In
M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Instruments for adults (pp. 363-377). Mahwah, NJ:
Lawrence Erlbaum Associates.
8.T. (1998). Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychological Medicine, 28(3), 551-558.
9. 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;19:299-305.
10. Singh, O., Bhattacharya, A., Mallick, A., Ray, P., Sen, S., Das, R. and Thakurta, R. (2012). Nature of Sexual Dysfunctions in Major Depressive Disorder and its
Impact on Quality of Life. Indian Journal of Psychological Medicine, 34(4), p.365.
11.Kennedy SH, Dickens SE, Eisfeld BS, Bagby RM. Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord 1999;56:201-8.
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;42:1098-104.
13. 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;45:19-30.
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 mild to severe disorders.
Moreover, early recognition of SD will lead to better choice of antidepressants and treatment plan, with a favourable side
effect profile ,to improve the overall quality of life in MDD.
CONCLUSIONS
A
DISCUSSION
CEZIPS 2018
METHODOLOGY
RESULTS
Figure 1 shows that with increase in BDI score there is decrease in
each domain score of WHOQOL. This indicates that with increase in
severity of depression there is deterioration in all the domains that
is physical health, psychological , social relationship and
environment.. In Fig. 2 box plot and Fig.3 scatter plot it has been
shown that mean ASEX total increase with severity of depression.
Table -1. Demographic distribution according to sex,
residence, severity of depression. (n=60)
Table -2 Domain wise distribution of sexual dysfunction
according to sex. (Multiple response). (n=60)
In our sample, most of the subjects were female (86.66 % )and were from a rural (71.7%) background. The overall sample
mean BDI score is 30.13±10.57 and females have higher mean score than males. Sexual dysfunction was reported in 75% of
the subjects (n=45). Females reported same rate of dysfunction as of male that is 75% of the subjects were affected as
shown in table 1. Most frequently reported domain of sexual dysfunction is impairment in orgasm (76.7%, n=46) both in
male (87.5%,n=7) and female (75.0%,n=39). Second most frequently reported domain is desire in female(73.1%,n=38) and
satisfaction in male (87.5%, n=7) detailed domain wise distribution is shown in table 2.
FIGURE-1. Scatter plot showing correlation between BDI
score and WHOQOL domains scores
Fig.2. Boxplot showing ASEX total score across severity
categories of depression
Figure-3, Scatter plot showing correlation between
ASEX total score and BDI score .
In Bivariate Correlation BDI score has a positive correlation with ASEX score (spearman’s rho correlation coefficient 0.259, P
value 0.046). . BDI score and ASEX score both have negative correlation with all the domains of WHOQOL. Spearman’s rho
correlation coefficient and p value for Domain 1 , Domain 2, Domain 3 , Domain 4 respectively – 0.331(0.01), - 0.419(0.001) , -
0.499 (0.000) , -0.345 (0.007) suggest the increased severity of depression affects our psychological health and social
relationship strongly although all the domains are affected.
AIMS AND OBJECTIVE:
1. Correlation between severity of depression with quality of life and sexual dysfunction.
2. To find frequency of different domains of sexual dysfunction .
STUDY SETTING AND SUBJECT
This is an observational descriptive study with cross sectional design of sample size of 60. Serial patients who attended Psychiatry OPD , R G
Kar Medical College between October 2017 to December 2017 were assessed for inclusion and exclusion criteria for this study. Patients of
either sex given informed consent, aged within 18–65 years and sexually active within 2 weeks of visit , diagnosed as MDD according to DSM-
IV text revision (TR) were included in this study. To prevent sexual dysfunction from being confounded by other medical conditions, substance
abuse, or psychotic symptoms, the following exclusion criteria were established 1)Not taken any antidepressant or any other psychotropic
drugs previously. 2)Previous history of sexual dysfunction prior to depressive episode, 3)local genital problems (vaginitis, pelvic infections,
hypogonadism ) , endocrinal disorders (thyroid dysfunctions, diabetes) , cardiovascular disorders (angina, myocardial infarction), renal
dysfunctions, neurologic disorders (stroke, spinal cord lesions, pelvic autonomic neuropathy)
4) No previous or current other axis I or II psychiatric illness diagnosed by the Mini International Neuropsychiatric Interview, such as psychotic
disorders, substance dependence, substance abuse, bipolar disorder, etc.
PROCEDURE
A detailed history with demographic profile was taken and physical examination was done, consultation liaison (when required), and
laboratory investigations (where indicated) were performed to rule out any physical comorbidity. The selected cases were given SCID and
those fulfilling the selection criteria for MDD were rated for severity of illness with BDI . Sexual experience of subjects were assessed by
using the Arizona Sexual Experience Scale (ASEX), The patients were evaluated for impairment in QOL using WHOQOL –BREF.
INSTRUMENTS
1)The Arizona Sexual Experience Scale (ASEX) is a self-administered scale with five questions. It is designed to assess five major aspects of
sexual dysfunction such as drive or desire, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction from orgasm.
Items are measured on a 6-point scale (1 to 6), with higher scores reflecting impaired sexual function. Sexual dysfunction was defined as 1) a
total ASEX score of ≥ 19, 2) any one item with a score of ≥ 5, or 3) any three items with a score of ≥ 4.[2,4]
2)BDI- Becks Depression Inventory is a 4 point scale to evaluate severity of depression. It consist of 21 items with scoring 0(not at all) to
3(extreme form of each symptoms) for each item , score 1-16 is considered as low depression, 17-30 as moderate depression , and more
than 31 as significant depression.[5,6]
3) WHO-QoL 100 allows detailed assessment of each individual facet relating to quality of life. WHO-QoL BREF field trial version has been
developed to provide a short form for assessment of quality of life. It contains 26 questions with score 1-5 for each question. Form the raw
score 4 domain score is to be calculated. Each domain scores are comparable with each other . The 4 domains are as follows. DOMAIN 1:
PHYSICAL HEALTH; DOMAIN2: PSYCHOLOGICAL HEALTH ; DOMAIN3:SOCIAL RELATIONSHIP; DOMAIN4:ENVIRONMENTAL[7]
STATISTICAL METHODS
Data were entered in Microsoft Excel and analysed using SPSS 23.0 for Windows (SPSS Inc., Chicago, Illinois, U.S.A.). Categorical variables are
presented as proportions, continuous variables are presented as mean/median and standard deviation/inter quartile range as appropriate.
Spearman correlation is used for non-normally distributed continuous variables.