Sexual Dysfunction in Depression

Sex Disabil(2009)27:165–172
DOI10.1007/s11195-009-9121-4
B R I E F
C O M M U N I C A T I O N
Sexual Dysfunction in Depression:Gynecological
and Psychiatric Interactions
Andre´Barciela VerasÆArabella RassiÆLivia Mitsue Gomes YukizakiÆ
Fla´via Schueler FrancoÆLuisa Duarte NovoÆAlexandre Martins Valenc¸aÆAntonio Egı´dio Nardi
Published online:18May2009
ÓSpringer Science+Business Media,LLC2009
Abstract A sample of outpatient women(n=56)in treatment for depression were sequentially evaluated using the Arizona Sexual Experience Scale(ASEX),Rey Auditory-Verbal Learning Test,Hamilton Depression Rating Scale and a semi-structured ques-tionnaire.A larger number of abortions in the sample patients with sexual dysfunction(SD) were observed and also a correlation between a higher number of abortions and a higher intensity of the majority of the ASEX symptoms.The SD sample showed the lowest verbal memory performance,indicated by the smaller average recall of number of words immediately after submission to a list of distracting words(SD:6.7versus Preserved Sexual Function—PSF:9.3P=0.001)and registered30min after the test(SD:6.6versus PSF:9.6P=0.002).The immediate recall of a larger number of words was associated with better performance of all ASEX functions.
Keywords Sexual dysfunctionÁAbortionÁVerbal memoryÁDepressionÁ
Brazil
Introduction
The high incidence of sexual dysfunction among patients receiving treatment for depres-sion and anxiety disorders suggests an area of major subject study.The estimated incidence A.B.Veras(&)ÁA.Rassi
Psychiatric Institute,Federal University of Rio de Janeiro(UFRJ),Av.Venceslau Bra´s,71,
CEP Campus da Praia Vermelha,Botafogo,Rio de Janeiro,RJ22290-140,Brazil
e-mail:barcielaveras@;barciela@.br
L.M.G.YukizakiÁF.S.FrancoÁL.D.Novo
UFRJ,Rio de Janeiro,RJ,Brazil
A.M.Valenc¸a
School of Medicine,Universidade Federal Fluminense,UFF,Rio de Janeiro,RJ,Brazil
A.E.Nardi
School of Medicine,Psychiatric Institute,UFRJ,Rio de Janeiro,RJ,Brazil
of sexual dysfunction among women with mental disorders,especially depression,was identified as40–50%[1],in this respect being less affected than men.The decrease in sexual drive(libido)was the most common symptom found among this group of women and this complaint seems necessarily multifactorial[2].
Amongst these numerous factors,some studies point out a relationship between gyno-obstretic events,sexual function and depression.For example:(I)The triad depression, memory impairment and sexual dysfunction has been the subject of research involving the role of androgens in women,more recently being defined as the Female Androgen Defi-ciency Syndrome[3]because of the apparent role of these hormones in vital functions, especially during menopause.Obstetrics has a promising(II)role of in the study of sexual dysfunction,but long term research will necessary.Bianchi-Demicheli et al.[4],assessing two female sample groups who had undertaken aspiration induced abortion,identified sexual dysfunction in a third of the women3–6months later.The same author[5]also noted that persistent sexual dissatisfaction was related to a decline in the partner satis-faction,fatigue,feelings of guilt,lower frequency of intercourse and anxiety related to intercourse,showing the importance of psychological factors in the complaints.(III)Out of the symptoms of menopause the ones related to vasomotor are most closely linked to hormonal variations.Hormonal oscillations have also been listed as contributing to the symptoms of depression and sexual dysfunction[6].Reed et al.[7],found that symptoms of depression,sleep disturbances and night sweats may be important factors associated with diminished libido in late menopausal transition and early post menopause. Statement of Purpose
Gynecological history markers are,normally,not taken into consideration in psychiatric outpatient care.Nevertheless,psychiatrists more frequently hear complaints about sexual dysfunction in this ambience.A simultaneous analysis of the variables—gynecological and psychiatric—that potentially play a role in sexual dysfunction can help clarify other potential factors that influence the sexual function in clinical practice.The intention of this preliminary study is to investigate the influence of a select number of important gyneco-logical history markers together with the clinical characteristics of depression on the sexual function of women.
Methodology
Participants
Fifty-six(n=56)outpatient women in treatment at the research center for depression and anxiety disorders at the Psychiatric Institute of the Federal University of Rio de Janeiro. Procedure
All the patients were sequentially evaluated by the researchers as they awaited their regular appointment.Treatment stage was not considered since the objective was to typify the general female population under treatment at the Institute.The patients seeking treatment for depression as the main diagnostic,according to DSM-IV criteria,with or without associated anxiety disorders,were sent to care after screening undertaken by a senior
psychiatrist.Women with personality disorder,drug abuse or substance abuse and psy-chotic disorders or bipolar disorder according to DSM-IV criteria were set apart and sent to the proper outpatient clinics for care.
The women patient sample was thus in regular treatment,most patients taking anti-depressants(n=47)and/or anxiolytics.No changes in medication dosages where made for purposes of the study.All the participating patients were duly made aware of the study and signed the study consent document.The protocol was approved by the institution’s Research Ethics Committee.
Materials
While the research sample patients awaited further evaluations,undertaken by trained researchers supervised by a qualified psychiatrist,they were asked tofill in the Arizona Sexual Experience Scale(ASEX)[8].The researchers,blind to the results of the Arizona Scale,requested patient information related to demographic data,psychiatric history and gynecological history by means of a semi-structured questionnaire.Next the sample patients were submitted to the Rey Auditory-Verbal Learning Test(RAVLT)[9]translated to Portuguese and to the Hamilton Depression Rating Scale(HAM-D)[10].
The adoption of a self-filing scale like ASEX had the purpose of reducing the possibility of the patient minimizing sexual dysfunction issues through some restraining factor via a researcher.The latter aspect we consider to be important for our study since a large number of researchers were used.The sample patients were also informed that their identity would not be disclosed since the questionnaires were controlled numerically and then accessed by a sole researcher,bound to data protection,at the time of compiling the results.ASEX was considered to be the most appropriate research instrument for the study since it is amply used in surveys of patients with depression,showing adequate sensibility and internal consistency.ASEX is also one of the few instruments for use in sexual dysfunction research,translated and validated in Portuguese.
A score higher than or equal to19in the Arizona Scale represents patients with sexual dysfunction,according to the original validation study[8]and a Brazilian clinical sample [11].The ASEX is a5-item scale with severity levels from normal[1]to total absence[6]. For example,how easily are you sexually aroused?(1)extremely easily,(2)very easily,(3) quite easily,(4)with some difficulty,(5)not easily at all and(6)never aroused.Symptom score higher than three were considered an isolated dysfunctional symptom.After iden-tifying the prevalence of sexual dysfunction in the whole sample,the group with dys-function was compared with the one with no sexual dysfunction.Furthermore to achieve greater clarity,sample patients with ASEX scores near the cut-off—from16to21—were removed.Thus,thefinal sexual dysfunction group(SD)consisted of27women and the sample with no sexual dysfunction(Preserved Sexual Function—PSF),23women. Statistical Analysis
Average and standard deviation(SD)were adopted to evaluate the descriptive data. Fisher’s Exact test and the Chi-square test were used to compare categorical variables,and the t-student was employed to compare continuous averages between the two samples.The Spearman correlation index was used for the relationship between the intensity of the sexual dysfunction symptoms and the other variables in the total sample.A Bonferroni
correction was considered so that the errors of the Type1for all the comparatives reached a maximum limit of5%.A P-value less or equal to0,002was considered significant. Results
The group of sample women patients with sexual dysfunction(SD)and with preserved sexual function(PSF)showed no significant differences in their demographic data (Table1).However,according to the Arizona Scale approximately half the women eval-uated(51.7%;n=29)presented compromised sexual function.Most of the sample patients showed compromised libido(62.5%),a reduction of excitability(57.1%),diffi-culty to achieve orgasm(55.3%),poor vaginal lubrication(42.8%)and inadequate orgasm satisfaction(33.9%).Sixty-one percent of the patients showed two or more dysfunctional symptoms.
The intensity of the symptoms of depression was different between the sample groups, for the HAM-D scale,the average was18.1(±8.9)in the SD group and13.0(±8.4)for the PSF group(P=0.044)(Table2).
The performance level in the Rey Auditory-Verbal Learning Test(RAVLT)was sig-nificantly lower among the SD sample patients,indicated by a smaller average word recall immediately after a list of distracting words(SD: 6.7±2.4versus PSF:9.3±3.1, P=0.001;effect size:0.195)and30min after the test(SD:6.6±2.6versus PSF: 9.6±3.2,P=0.002;effect size:0.217)(Table2).
Regarding the gynecological historical data,a tendency of higher incidence of abortion in the SD sample was noted when compared to the PSF group(Table3).The average number of abortions in SD sample was1.1,while for the PSF sample the average was0.3 (P=0.004).
The correlation between the5symptoms of the Arizona Scale and the data obtained in the study using the total sample(n=56)were analyzed.Each symptom was influenced differently,it was found,that is,few variables alone actually affected the sexual function entirely(Table4).
Table1Comparison of demographic data between the sexual dysfunction group(SD)and the preserved sexual function group(PSF)
SD(n=27)PSF(n=23)P
Average age(SD)49.7(7.1)45.6(11.5)NS Race NS Caucasian(%)64.060.8
Afro-descendent(%)36.039.1
Education—years of study average(SD)9.0(5.0)11.1(5.4)NS Exercising—hours/week average(SD) 1.2(2.2) 1.4(3.3)NS Income—minimum wages average(SD) 5.6(7.9) 5.7(6.4)NS Partner(%)51.860.8NS Work activity(%)60.859.2.5NS Smoking(%)22.226.8NS Alcohol consumption(%)11.121.7NS
Table2Comparison of clinical data between the sexual dysfunction group(SD)and the preserved sexual function group(PSF)
SD(n=27)PSF(n=23)P
Number of depressive recurrences average(SD) 1.6(3.8) 1.5(2.4)NS Period of follow-up(months)average(SD)19.9(28.1)21.0(35.6)NS Time afterfirst diagnosis(months)average(SD)67.2(65.9)79.0(102.2)NS Use of SSRI(%)29.625.0NS Use of TCA(%)44.460.0NS No use of antidepressants(%)18.510.0NS Use of benzodiazepines(%)59.255.0NS HAM—D average(SD)18.1(8.9)13.0(8.4).044 Immediate memory average(SD) 6.7(2.4)9.3(3.1).001 Short-term memory average(SD) 6.6(2.6)9.6(3.2).002
SSRI selective serotonin reuptake inhibitor,TCA tricyclic antidepressant,HAM-D Hamilton depression rating scale
Table3Comparison of gynecological history data between the sexual dysfunction group(SD)and the preserved sexual function group(PSF)
SD(n=27)PSF(n=23)P
Menarche—average(SD)12.5(1.8)12.7(2.6)NS Pregnancies—average(SD) 2.9(1.7) 1.7(1.4).014 Abortions—average(SD) 1.1(1.1)0.3(0.5).004 Births—average(SD) 1.7(1.1) 1.3(1.1)NS Daily hotflushes(%)40.717.3NS Hormone replacement therapy(%)18.58.6NS Contraception(%) 3.721.7NS Stage of menopause NS Pre-menopause(%)25.943.4
Post-menopause(%)55.547.8
Perimenopause(%)18.58.6
Table4Correlations with at least two Arizona scale symptoms among all patients(n=56)
Libido Excitement Lubrication Orgasms Satisfaction
CC/P CC/P CC/P CC/P CC/P
Oral contraception-.275/.040-.314/.018 Daily hotflashes.336/.011.288/.031 Abortions.448/.000.372/.004.359/.006 HAM-D.362/.006.296/.027 Immediate memory-.288/.031-.296/.027-.304/.022-.323/.015-.364/.005 Short-term memory-.296/.038-.403/.004
Only the statistically significant correlations are shown(P\0.05)
CC correlation coefficient,HAM-D Hamilton depression rating scale
Discussion
The most significant piece of information from the study was the relationship between sexual dysfunction and worse RAVLT performance.Lower immediate recall and30-min recall ability among patients with sexual dysfunction and the relationship of immediate memory with all the symptoms of the Arizona Scale must also be considered.The Female Androgen Deficiency Syndrome[3]—depression,memory impairment and sexual dys-function—is a possibility identified in our sample.No hormone analysis was performed and since low concentration of testosterone is an important factor in the diagnosis[12]of patients carrying the latter syndrome,however,this cannot be categorically stated.Another limitation to this conclusion might be the possibility of a worse RAVLT performance being due to a greater intensity of depressive symptoms verified among SD sample patients. Furthermore,ideally multiple measurements of verbal memory would be required before making claims about neuropsychological functioning.In this respect,a double-blind, placebo-controlled study made by Shah et al.[13]established the role of testosterone in the performance of cognitive tests.While attention,working memory,psychomotor perfor-mance and executive function were not influenced,simple concentration,visual and verbal memory—impaired among our patients—recent and delayed,were significantly improved with the administration of testosterone.New studies to identify the Female Androgen Deficiency Syndrome in female outpatients undergoing psychiatric treatment so that more accuracy can be established regarding the motivators of sexual dysfunction in this popu-lation are necessary.The identification of this subgroup of patients would be beneficial to sexual dysfunction therapy.
The majority of studies that go into the connection between cognition and sexual function refer to testosterone effects in the bio-psychological functions.Although positive data about these effects on sexual function and cognition exist,some results remain controversial[14,15].In addition,data obtained in studies using male samples can not be entirely extrapolated to females since there are relevant differences in brain effects of testosterone comparing men and women[16].Another important aspect is the sexual difference in the performance of neuropsychological tests.For example:Women are more likely than men to have better performance in verbal memory tests[17–19].Although testosterone might play a role as a linking factor between sexuality and cognition[20], other elements have to be considered.Among them,the role of mood regarding libido and cognitive performance and the link of a satisfactory sexual act and its secondary effects on the brain function through endogen opiates.
Another interestingfinding was the relationship between sexual dysfunction and abortion.Patients with sexual dysfunction showed a higher number of abortions and,in the whole sample,a higher number of abortions were associated with the reduction in libido, orgasms and orgasm satisfaction.Age at the time of the abortion was not researched,in the clinical interviews frequent references to recent abortion or abortion as a motivator for seeking treatment were not observed.The study sample consisted of women between45 and49years of age on average,with increased chance that any reported abortions would have occurred some years ago.Therefore,one speculates that thefindings reflect a long-term persisting sexual dysfunction caused by abortion.Some of the explanations for this association are the persisting psychic conflicts caused by abortion and their influence on sexuality,or the interactions between early pregnancy interruption with the hypothalamus-hypophysis-ovary axis and testosterone levels[21,22].However,a greater incidence of abortions can be brought on by sexual dysfunction or by depression.A possible expla-nation for the latter would be that some women with reduced libido may feel a desire to
initiate sexual intercourse as soon as they feel stimulated,leading to a lower usage of preservatives.Feelings of depression also increase the intercourse risk as a result of the woman’s intention to improve her mood[23]through intercourse.Higher exposure to intercourse just mentioned would have an influence as much on the number of abortions as on the number of births.Proportionally the latter was not supported in the female study samples evaluated.The number of abortions had more influence on the study sample than on the literature data frequently discussed for this population.The abortion data,which is part of the gynecological history,is not sufficiently considered in the ambience of psy-chiatric care.For this reason,in our clinical environment,the history of abortions emerged as a new element to be researched and approached in view of the complaints and intentions to seek treatment on the part of women with sexual dysfunction.We did not evaluate whether the abortions were induced or spontaneous or when they occurred in the patient’s life.The accurate identification of the latter seems important and should be taken into consideration in further studies.
Conclusions
In this study the existence of new variables(verbal memory and abortion)that showed a potential link with sexual dysfunction in women in treatment for depression,were iden-tified.The better understanding of the connection between sexual function and memory,or sexual function and abortion can bring new clinical prospects for the treatment of sexual dysfunction in women with this condition.Thus,the identified relationships merit further research.
Limitations
The small sample size,naturally,limited the generalizability of the studyfindings.The greater symptoms of depression in the SD sample patients could be partly responsible for the differences found.Future replication,using different methodologies,is recommended before solid conclusions can be made.
Acknowledgments This study was sponsored by CNPq(402846/2005-2).The authors Livia Mitsue Go-mes Yukizaki and Fla´via Schueler Franco were sponsored by PIBIC/UFRJ Scholarship.The author Luisa Duarte Novo was sponsored by CNPq Scholarship.
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