Sexual dysfunctions in schizophrenia: Professionals and patients perspectives.

BACKGROUND: Sexual dysfunction (SD) is not commonly reported by persons with schizophrenia unless an enquiry is made by a doctor or staff during routine clinical visits.
MATERIALS AND METHODS: A cross-sectional study was carried out to determine reporting of drug-induced sexual side-effects and the attitude of the treating team in clarifying or detecting this issue.
RESULTS: A vast majority of professionals (73.2%) did not enquire about SDs in routine clinical setting and admitted that they lack expertise based on the Attitude Survey Questionnaire. More than one-third of the patients (35.3%) attributed sexual side-effects to medications. Many patients (91.7%) reported good to fair tolerance to sexual side-effects according to the Psychotropic Related Sexual Dysfunction Questionnaire.
CONCLUSION: The treating team plays a crucial role. Sexual side-effects are often under-reported and need to be addressed by the treating physician.

INTRODUCTION

Sexual dysfunctions (SDs), such as erectile dysfunction, decreased libido or disturbances in ejaculation/orgasm are more frequent in both men and women suffering from schizophrenia.[12] Professionals believed people with schizophrenia were unable to manage their sexual life and were reluctant to discuss sexual issues with them. Psychiatrists have an important role in effectively addressing this problem.[2] Patients are more likely to open up when physicians raise this issue.[3] Clinicians should routinely enquire about SD in their patients, but it is unclear what the training experiences and attitudes of psychiatrists are? There is a paucity of studies looking at psychiatrist's perception in dealing with patient's SD in India. Keeping this in mind, this study was conceived to assess SD in schizophrenia and treating team's attitude to enquire these symptoms during routine clinical practice.

MATERIALS AND METHODS

Setting

This study was conducted at the outpatient clinical services of Schizophrenia Research Foundation (SCARF), Chennai, India.

Sample

One hundred and thirty-six consenting patients (18-60 years) diagnosed with schizophrenia (International Classification of Diseases 10 criteria) receiving antipsychotic treatment for at least 3 months prior to entering the study were randomly selected for interview by the investigators in a cross-sectional study.

Measurements

A semi-structured proforma was designed to collect the demographic data and illness-related variables. The Psychotropic Related Sexual Dysfunction Questionnaire (PRSexDQ-Salsex) used for the purpose of the study consists of It has 2 introductory items (A and B) and other 5 items pertaining to SD. It explores the different aspect of SD after the onset of any psychotropic treatment and the tolerability after these sexual changes for patients as well. The item A is a screening item to assess whether the patient has any sort of SD since the beginning of the treatment. The second item B assesses whether the patient has spontaneously reported any SD to the rater. The next 5 items (items 1-5) assess five-dimensions of SD according to either severity or frequency: Total store: 0 (no SD) to 15 (severe SD) based on scores of items 1-5 and classified as mild: 0-5, moderate: 6-10 severe: 11-15.[3] The questionnaire is designed such that higher scores indicate greater dysfunction. This questionnaire has been shown to have adequate feasibility and psychometric properties. The attitude and awareness of mental health professionals have been recorded using a 14-item Self-Report Attitude Survey Questionnaire.

Ethics

Institutional Ethics Committee clearance was obtained prior to the study.

Data analysis

The data were analyzed using SPSS 16 version, SPSS Inc Chicago, 2007.

RESULTS

Sociodemographic variables

Both sexes were nearly equally represented. Sixty-nine males (39.5 ± 9.7 years) and 67 females (40.1 ± 9 years) were recruited. Married women (55.2%) and single men (55.1%) were part of the study. The mean duration of illness and treatment did not show any statistically significant difference across the different levels of dysfunction. About 60.4% of the patients have expressed mild SD. Forty-eight patients comprising of 29 males (42%) and 19 females (28.4%) reported of experiencing SD after taking the antipsychotic drug treatment. Few male patients (13.8%) expressed a desire to discontinue treatment due to the sexual side-effects of the drugs. Table 1 indicates findings based on PRSexDQ-Salsex in women who reported severe decrease in libido and decreased vaginal lubrication. In contrast, men were found to have moderate decrease in libido. Both sexes had fair sexual tolerance and very few reported of delay in ejaculation or anorgasmia.

Table 1

Distribution of SDs reported by patients on PRSexDQ-Salsex (n=48)

Professionals perspectives

Fifty-five professionals were approached directly or via E-mails to participate in this study. Forty-one respondents (11 males and 30 females) comprised of psychiatrists (14), psychologists (9), social workers (9), occupational therapists (3) and nurses (6). Fourteen professionals did not respond to the questionnaire. Therefore, Table 2 depicts the knowledge, attitudes and emotions expressed by the 41 professionals in dealing with patients SDs. Based on the self-report, professionals were found to experience a range of emotions – concern (63.4%), sympathetic (34.1%), helpless (34.1%) and caring (22%). Treatment options professionals preferred were drug holiday, giving phosphodiesterase inhibitors, dose reduction, and psychosexual education and shifting to atypical or using Ayurveda products.

Table 2

Professionals (n=41) responses on the attitude survey questionnaire

DISCUSSION

Sexual dysfunctions reported by patients may wax and wane depending on the patient's illness, drugs received and attitude of the treating team.[12] The two-thirds of psychiatrists who were interviewed did not routinely enquire about SD in their patients, and only one-third felt competent in assessing SD, despite majority agreeing that good sexual function is important to patients.[3] Improving clinician's awareness of the importance of SD in patients might improve adherence and subsequent treatment outcomes.[1] In our study, men more often reported of SD on enquiry. This is in agreement with published reports.[45] Both sexes reported that lack of interest, single status, physical illness or SD in the spouse and spiritual involvement as reasons for the inactive sexual functioning.[6] In our study, female patients may have under-reported the incidence of SD that is a universal finding.[789] Women interviewed felt shy and reluctant to discuss SD or matters related to intimacy. Other factors perceived by women were increasing age, physical weakness, attainment of menopause, hysterectomy, children, living in a joint family and lack of room and privacy, experiencing hallucinations with sexual content and depression. The Intimacy and Mental Illness study shows that persons with mental illness are less likely to experience sexual intimacy than the general population.[10] Our study is in complete agreement with this finding as majority of men with schizophrenia were single and did not have a sexual partner. The negative symptom paradigm of anhedonia, limited social initiative, social anxiety, and deficits in social perception, SDs, can be the source of their demoralization and discouragement in seeking sex with appropriate partners. Remitted patients in our study also reported of SD. Both sexes considered treatment discontinuation as the best solution for SD due to side effects of the drugs and the impairment on quality of life.[11121314] Patients reporting of greater tolerance to side effects in our study could be because many patients consider discussing sex as taboo and therefore accept the dysfunction. Under-reporting by patients is evident if the treating doctor does not directly enquire about the SD. The majority of professionals in our sample agreed that they did not enquire about the sexual health of the patients regularly, and this was in keeping with the findings from Britain[315] Most of the professionals admitted that they feel incompetent or reluctant and avoid enquiring about SD. The major limitations are that this study was cross-sectional, and patients were already on two or more drugs so the causal effect of individual class or combination of drugs cannot be commented. A prospective study to determine the perceived distress in both professionals and patients attitude towards possible antipsychotic-induced SDs can pave the way for effective treatment solutions and outcome.

CONCLUSION

The treating team must take a proactive role and sensitively address possible SDs reported by both genders during routine out-patient visits.