Evaluation of sexual dysfunction and quality of life in patients with severe mental illness: A cross-sectional study from a tertiary care center in Chhattisgarh.

BACKGROUND: Sexual dysfunctions (SDs) are common and lead to psychological distress and impair quality of life (QOL). However, little attention has been paid to explore SD in severe mental illnesses (SMIs). Hence, this study aimed to evaluate the occurrence of SD and its impact on the QOL in persons suffering from schizophrenia, bipolar disorder, and depression and compare it with healthy controls.
MATERIALS AND METHODS: In this cross-sectional study, 79 clinically stable patients and 50 healthy controls underwent evaluation for SD on the Arizona Sexual Experience Scale, and their QOL was measured using the WHO QOL-BREF scale. Chi-square test was used for the categorical variables, whereas comparison of continuous variables was done by t-test with post hoc corrections.
RESULTS: Compared to healthy controls, patients with depression had significantly higher rates of SD in the domain of obtaining penile erection (P = 0.019), ability to reach orgasm (P = 0.03), and satisfaction from orgasm (P = 0.01). Patients with schizophrenia had higher rates of problems in achieving arousal (P < 0.01), penile erection (P = 0.03), and satisfaction from orgasm (P = 0.03), whereas those with bipolar disorder only differed significantly on the domain of ability to reach orgasm (P = 0.03). However, patients fared better than the controls on various domains of QOL (except social domain).
CONCLUSION: A significant number of patients with SMI suffer from SD. Hence, it should be made a routine practice to evaluate and address the problem of SDs in patients with SMI. Copyright:

A healthy sexual function has been suggested as a fundamental quality of life (QOL) issue rather than just a lifestyle. An adequate sexual expression serves an important part in human relations and enhances the QOL in various domains of physical, psychological, and social well-being.[1] Sexual dysfunction (SD) is common and often very distressing but very scarcely evaluated. Moreover, these impact the sufferer and the partner alike in the form of unhappiness, frustration, problems in intimate relationships to loss of self-esteem, and dysfunction in social and occupational spheres.[1] SD in various forms such as poor sexual desire, erectile dysfunction, and lack of orgasm has been observed more often in persons suffering from severe and chronic mental illnesses as compared to healthy populations and equally seen in men and women.[2] It is partly attributed to the nature of mental illness and partly to the utilization of various psychotropic medications. The attribution of SD in various major psychiatric disorders may differ, and in some of mental illnesses, even hypersexuality may be a reason of distress. For example, persons suffering from schizophrenia may have SD (like reduced sexual drive or interest) in view of the negative symptoms[3] which may also be observed in patients with depression, and it may further be worsened by the use of psychotropic medications.[45] Sexual function may be affected in disorders such as mania and bipolar disorder and personality disorders or substance use disorders.[67] Furthermore, these illnesses may impact various other domains of intimate relationships, QOL, and compliance/adherence to medications and even lead to discontinuation of treatment. Lately, there has been increased interest in evaluation of the impact of various psychotropic medications and SD in various psychiatric disorders. However, very few studies have explored and compared the occurrence of SD in severe mental illnesses (SMIs), which may/may not be related to the use of medication. Moreover, the research in this aspect is very scarce from our country. Hence, this study was undertaken with an aim to explore the occurrence of SD and resultant impact on the QOL in persons suffering from schizophrenia, bipolar disorder, and depression and compare it with healthy controls. It was hypothesized that the occurrence of SD will be more in persons suffering from SMI as compared to the healthy controls, and this in turn will affect their QOL negatively.

MATERIALS AND METHODS

This study was carried out at the outpatient department of psychiatry at a tertiary care hospital in Chhattisgarh. The inclusion criteria for this study were male patients diagnosed with schizophrenia, bipolar affective disorder (BPAD), and depression (F20–28, F31, F32, and F33) according to the ICD-10 International Statistical Classification of Diseases and Related Health Problems- 10th revision diagnostic criteria. The patients were required to be married, in the age range of 20–60 years, in a heterosexual relationship, clinically stable (determined by subjective report of no symptoms, rather than objective evaluation on clinical rating scales) for at least past 3 months, and without any change of medication in past 1 month. The patients who were suffering from hypertension, diabetes mellitus, hypo/hyperthyroidism, or dyslipidemia and were taking treatment for it were not excluded, and the control of blood pressure, diabetes, thyroid, and lipid profile was ensured by reviewing their medical records. However, the patients were excluded if they had a comorbid substance abuse disorder (other than tobacco use), intellectual disability, organic mental illness, and a severe and chronic neurological illness or have been taking medication/s for an already existing SD. A control sample was drawn from the male caregivers who accompanied the patients (un-/related) who fulfilled the inclusion and exclusion criteria. The controls were supposed to be in the age range of 20–60 years, married, in a heterosexual relationship, without any substance dependence (except tobacco use), and with adequate control of hypertension, diabetes mellitus, hypo/hyperthyroidism, and hyperlipidemia. However, we did not include the female caregivers and those who had a chronic and severe neurological disorder, with a diagnosable psychiatric disorder (including intellectual disability).

A purposive sampling method was used with a target of thirty patients each with schizophrenia, BPAD, and depression. A control group of thirty male members who were married and accompanied the patients were also approached to participate in this study. The study was approved by the Institute Ethics Committee (IEC), and all the participants provided a written informed consent.

Study instruments

The Arizona Sexual Experience Scale (ASEX)[8] – a self-report questionnaire, was used in this study for evaluation of sexual functioning. The scale measures the quality of sexual functioning using five questions which evaluate sexual drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and the satisfaction from orgasm. The scale is 6-point Likert scale with higher scores representing higher SD. A total ASEX score of 19 and more or a score of 5 or more on any one item or score of 4 and more on any three items of this scale represents clinical SD. The scale has excellent internal consistency and test–retest reliability, and it has been translated to vernacular language (i.e., Hindi). However, the translated tool has not been validated

The World Health Organisation Quality of Life (WHO QOL BREF) scale – It is the short form of 100-item scale and comprises 26 items which assess the QOL in four domains of physical health, psychological status, social relationship, and environmental condition. Scoring of each question was done according to 5-point Likert style from 1 to 5. There is one item which explores about the satisfaction with one's sex life (item 21). The scoring of the instrument was done according the WHO manual for WHO QOL-BREF (available at http://www.who.int/mental_health/media/en/76.pdf). This tool is available in various languages including Hindi version (WHOQOL Group, 1998).[9]

Statistical analysis

The data were analyzed using SPSS IBM Statistical Package for the Social Sciences for Windows, Version 14, Chicago: SPSS Inc., U.S. Chi-square test was used for the categorical variables, whereas the continuous variables were analyzed using mean and standard deviation. Pairwise Chi-square test and Kruskal–Wallis test were utilized for analyzing the significant difference between various groups. The comparison of the continuous variables among different groups was done by t-test with post hoc corrections using Bonferroni correction. A two-tailed P value was utilized for various statistical analyses, and P < 0.05 was considered to be statistically significant.

RESULTS

We recruited thirty patients each, who were suffering from schizophrenia, bipolar disorder, and depression. Although the protocol purported to include thirty healthy male participants who accompanied the index patients to serve as a control group, we could recruit 52 controls at the end of study. However, 11 patients suffering from schizophrenia did not fill the study scales accurately, and two forms of the controls were considered void. Hence, the final sample was that of 30 patients each who suffered from bipolar disorder and depression, 19 persons with schizophrenia, and 50 healthy controls.

The mean age of the patient group was more than the control group (34.02 vs. 26.98 years; P < 0.001), as was the mean years of education (11.84 vs. 10.18 years; P = 0.005). As shown in Figure 1, antidepressant medications were the most frequently prescribed medications (n = 49; 62.02%), followed by mood stabilizers (n = 33; 41.77%), antipsychotics (n = 30; 37.97%), and benzodiazepines (n = 13; 16.67%). Furthermore, nearly two-thirds of the patients received at least two types of psychotropic medication (n = 49; 62.02%) and nearly one-fourth of the participants even received a third psychotropic medicine (n = 21; 26.58%). Figure 2 shows the breakup of the primary psychotropic medicine prescribed to the study patients. Among the antidepressants, paroxetine was most commonly prescribed, whereas valproate sodium or divalproex sodium was the often prescribed mood stabilizer. Trifluoperazine and olanzapine were the two most commonly prescribed antipsychotic agents.

Figure 1

The frequency of various psychotropic medications prescribed to the study patients

Figure 2

The breakup of the primary psychotropic medicine prescribed to the study patients

As shown in Table 1, the mean scores on the ASEX instrument were higher for the patients in comparison to the controls on all the items. Furthermore, the rates of SD in the patient group were significantly more than that of the control group by utilizing various criteria for ASEX. However, interestingly, on the WHO QOL-BREF scale, the patient group outperformed the control group on the measures of physical health, psychological status, and the items of environmental conditions. However, no significant difference was observed in the domain of social relations and on the one item that explored about the sexual satisfaction in the study participants, i.e., the item 21 of WHO QOL-BREF (How satisfied are you with your sex life?).

Table 1

Comparison of the sociodemographic and clinical variables in the patient and control groups

Variable	Mean (SD)/n (%)		P
	Cases (n=79)	Controls (n=50)
Age (years)	34.02 (10.08)	26.98 (3.61)	<0.001
Education (years)	11.84 (3.34)	10.18 (3.60)	0.005
ASEX item 1	3.35 (1.24)	2.36 (0.98)	<0.001
ASEX item 2	3.11 (1.30)	2.30 (1.09)	<0.001
ASEX item 3	3.03 (1.17)	2.22 (1.03)	<0.001
ASEX item 4	3.06 (1.25)	2.14 (0.94)	<0.001
ASEX item 5	3.05 (1.19)	1.19 (0.70)	<0.001
ASEX total	15.62 (4.67)	11.24 (4.25)	<0.001
ASEX score 5 or more on one item	30 (37.97%)	3 (6%)	<0.001
ASEX score 4 or more on three items	21 (26.58%)	6 (12%)	0.047
Total ASEX score >19	19 (24.05%)	5 (10%)	0.046
QOL
Domain 1 (physical health)	24.86 (2.83)	20.72 (3.04)	<0.001
Domain 2 (psychological status)	24.72 (3.62)	18.96 (3.05)	<0.001
Domain 3 (social relationship)	10.34 (2.41)	10.38 (2.23)	0.928
Domain 4 (environmental condition)	29.32 (5.10)	25.42 (4.64)	<0.001
QOL item 21	3.70 (1.194)	3.58 (0.90)	0.527

QOL – Quality of life; SD – Sexual dysfunctions; ASEX – Arizona Sexual Experience Scale

Further comparison of the sociodemographics and measures of SD and QOL among various patient groups and the controls has been shown in Table 2. The patients with depression were significantly older than the controls, whereas patients suffering from schizophrenia had higher years of education in comparison to the controls. On the ASEX scale, the mean scores on various items, i.e., sexual drive, arousal, penile erection, ability to reach orgasm, and the satisfaction from orgasm were significantly higher for various patient groups when compared to the controls. However, no significant difference was observed for ability to reach orgasm in the patients with schizophrenia and the controls. Furthermore, utilizing the criteria score of 5 or more on any item of ASEX scale, the rates of SD were significantly higher in patients with bipolar disorder, schizophrenia, and depression in comparison to the control group. However, when the other criteria of SD, namely the score of 4 or more on three items of ASEX or a total score of >19, were used, then only significant difference persisted between patients with depression and controls. The controls scored significantly poorly on the domains of physical health, psychological status, and environmental conditions as measured on the WHO-QOL-BREF scale. However, no significant difference was observed between the various patient groups and the controls on the domain of social relationships and the item that explored the sexual satisfaction (i.e., item 21).

Table 2

Comparison of the sociodemographic and clinical variables in the different patient and control groups

Variable	Mean (SD)/n (%)				P	Post hoc test/pairwise Chi-square test (P)
	BPAD patients (n=30)/I	Schizophrenia patients (n=19)/II	Depression patients (n=30)/III	Controls (n=50)/IV
Age (years)	31.67 (9.74)	32.11 (9.52)	37.53 (10.06)	26.98 (3.61)	<0.001	III>IV
Education (years)	11.13 (3.35)	12.77 (2.88)	12.00 (2.64)	10.18 (3.60)	0.014	II>IV
ASEX item 1	3.36 (1.18)	3.38 (1.46)	3.32 (1.19)	2.36 (0.98)	<0.001	IV<I, IV<II, IV<III
ASEX item 2	2.76 (1.00)	3.50 (1.54)	3.22 (1.35)	2.30 (1.09)	0.001	IV<I, IV<II, IV<III
ASEX item 3	2.83 (1.11)	3.00 (1.13)	3.25 (1.23)	2.22 (1.03)	0.001	IV<I, IV<II, IV<III
ASEX item 4	3.03 (1.09)	2.50 (1.04)	3.41 (1.40)	2.14 (0.94)	<0.001	IV<I, IV<III
ASEX item 5	2.73 (0.98)	3.16 (1.29)	3.29 (1.29)	1.19 (0.70)	<0.001	IV<I, IV<II, IV<III
ASEX total	14.73 (4.08)	15.55 (4.78)	16.51 (5.11)	11.24 (4.25)	<0.001	IV<I, IV<II, IV<III
ASEX score 5 or more on on e item	9 (30%)	9 (50%)	12 (40%)	3 (6%)	<0.001	I>IV (<0.01), II>IV (<0.001), III>IV (<0.001)
ASEX score 4 or more on three items	6 (20%)	5 (27.77%)	10 (33.33%)	6 (12%)	0.149	III>IV (0.02)
Total ASEX score >19	5 (16.67%)	5 (27.77%)	9 (30%)	5 (10%)	0.125	III>IV (0.01)
QOL
Domain 1	24.76 (2.55)	24.66 (3.41)	25.06 (3.03)	20.72 (3.04)	<0.001	I>IV, II>IV, III>IV
Domain 2	24.26 (3.41)	25.33 (4.01)	24.80 (3.79)	18.96 (3.05)	<0.001	I>IV, II>IV, III>IV
Domain 3	9.80 (2.45)	10.94 (2.79)	10.51 (2.07)	10.38 (2.23)	0.396	N.S.
Domain 4	29.10 (4.90)	29.44 (5.60)	29.48 (5.15)	25.42 (4.64)	<0.001	I>IV, III>IV
QOL item 21	3.67 (1.24)	3.67 (1.41)	3.77 (1.17)	3.58 (0.90)	0.904	Not significant

QOL – Quality of life; SD – Sexual dysfunctions; ASEX – Arizona Sexual Experience Scale; BPAD – Bipolar affective disorder

The frequency of SD in various domains of sexual drive, arousal, achieving penile erection, ability to reach orgasm, and satisfaction from orgasm did not differ much in the patient group [Table 3]. However, none of the controls had SD in the domains of reaching and having a satisfactory orgasm. While comparing with the control group, patients with depression had significantly higher rates of SD in the domains of obtaining penile erection, ability to reach orgasm, and satisfaction from orgasm. Similarly, patients with schizophrenia had higher rates of problems in achieving arousal, penile erection, and satisfaction from orgasm. Patients with bipolar disorder only differed significantly on the domain of ability to reach orgasm in comparison to the normal controls.

Table 3

The rates of sexual dysfunction in various domains as measured on Arizona Sexual Experience Scale

Variable	BPAD patients (n=30),n (%)/I	Schizophrenia patients (n=19), n (%)/II	Depression patients (n=30), n (%)/III	Controls (n=50), n (%)/IV	Pair-wise Chi-square test
ASEX item 1 (drive)	4 (13.34)	4 (21.05)	4 (13.34)	2 (4)	Not significant
ASEX item 2 (arousal)	1 (3.34)	6 (31.57)	6 (20)	2 (4)	II>IV (0.008)
ASEX item 3 (penile erection)	2 (6.67)	4 (21.05)	6 (20)	1 (2)	II>IV (0.03)III>IV (0.019)
ASEX item 4 (ability to reach orgasm)	4 (13.34)	1 (5.26)	5 (16.67)	0	I>IV (0.03)III>IV (0.01)
ASEX item 5 (satisfaction from orgasm)	1 (3.34)	3 (15.78)	5 (16.67)	0	II>IV (0.03)III>IV (0.01)

ASEX – Arizona Sexual Experience Scale; BPAD – Bipolar affective disorder

DISCUSSION

This study was undertaken on the premise that a married male person who is in heterosexual relationship and is suffering from a SMI such as schizophrenia, bipolar disorder, and depression will tend to have SD in comparison to the normal controls and a resultant poor QOL too. Structured clinical scales were used to elicit the SD and QOL among the study groups, and for the first time, the three commonly observed SMIs were compared with normal controls. The cases when clubbed in one group and compared with the normal controls were significantly older and scored higher on various items of ASEX as well as had significantly higher rates of SD. However, on WHO-QOL-BREF, the patient group scored better on the domains of physical health, psychological status, and environmental conditions. However, no difference was observed for social relationships and the item which evaluated the sexual satisfaction. Nearly, two-thirds of the patients received antidepressants, and an equal number of patients received more than one psychotropic medication. When the different groups of illnesses were compared with the controls, the patients with depressive disorders were significantly older than the controls, whereas those with schizophrenia fared better than controls with respect to years of education. Moreover, most of the differences for SD and QOL remained significant with the patient groups reporting higher sexual problems and interestingly still a better QOL as compared to controls.

In one of the largest epidemiological surveys till date, Laumann et al.[2] reported that sexual complaints were voiced by 43% of females and 30% of males. However, higher prevalence rates of up to 40%–68% in adult women and 8%–30% in adult men were reported from other research.[10] Furthermore, the rates are supposed to be much higher in patients suffering from mental illnesses. The rates are much higher in patients with depression with estimates up to 80%–90% with predominant complaints of reduced sexual desire.[11] In addition, the patients with depression also report problems in achieving adequate erection, arousal, and orgasm.[12] Similarly, the patients with bipolar disorder who were on mood stabilisers (lithium mainly), the rates of SD ranged between 25% and 50%[131415]. Consonant to these findings, an earlier Indian study found the rate of SD in patients with bipolar disorder to be 33%.[16] However, the evidence is lacking with respect to a traditional notion of mania associated with hypersexuality. The rates of SD in patients with schizophrenia receiving an antipsychotic medication have been reported ranging from 30% to more than 90%.[1718192021] In the index study, depending on the criteria of ASEX used, the rates of SD ranged from 24 to 38% in the cases, whereas it was in the range of 6%–12% in the controls. Further, the rates were lowest for bipolar disorder group (16.67%–30%) and highest for the schizophrenia group (27.77% to up to 50%), whereas for depressive disorder group, it was in between 30% and 40%. One of the major factors which influence such a range of reported SD is the method of assessment. Some of the studies have utilized semi-structured questionnaires, whereas others have used clinical questions only. Uçok et al.[22] used ASEX to evaluate SD in 827 stable patients of schizophrenia who were receiving atypical or conventional antipsychotic or even a combination of both. The rate of SD in their cohort was reported to be 52.6% with predominant complaints being low sexual desire or problems in achieving an orgasm. The total score of ASEX for male patients in their cohort and the rates of SD are comparable with the index study. The rates are also comparable with some recent studies[2123] but less when compared to few others.[242526] In a Scottish survey of SD in patients with schizophrenia and community controls, significant differences in reporting of sexual desire, achieving and maintaining an adequate penile erection, early ejaculation, and less satisfaction with orgasm were reported in the former group.[27] In a recent study from Nigeria,[23] the most common problems reported by persons suffering from schizophrenia were inability to achieve orgasm followed by satisfaction with orgasm. However, in the index study, lack of sexual drive and arousal were the most common problems observed in persons with schizophrenia and were significantly more than the control group.

Despite the fluctuation in the levels of sexual drive in various phases, largely the patients with bipolar disorder are dissatisfied with their sexual life.[2829] However, they tend to have a more stable sexual life when compared to schizophrenia.[30] Further, indulgence in risky sexual behavior is an additional problem for male patients in comparison to females. Very few studies have been undertaken with regard to SD in this population.[3715] In a previous study from India,[16] which utilized ASEX to estimate the rates of SD in bipolar disorder patients, the rates of SD reported were 35.3% in male patients who were stable on lithium. The reduction in sexual drive was the most common SD when a cutoff score of 5 or more was utilized for each domain of ASEX. When we utilized the same criterion, the rates of SD in the bipolar disorder group were 30%; however, a reduction in sexual drive and inability to achieve an orgasm were equally observed.

Depression in itself is associated with sexual difficulties, and also, the patients with SD tend to suffer from depression. Moreover, the use of certain antidepressants may lead to SD. It has been seen that depressive symptoms may exert its effect on all aspects of sexual response cycle.[12] Accordingly, for Indian studies in depressive disorder which have utilized ASEX, the rates of SD in one study were found to be 23% with reduced desire being the most common problem,[31] whereas in another study, the rates of SD reported were up to 71.66% in both genders, and in males, it was present in two-third of patients with reduced sexual desire being the most common symptom.[32] However, in the present study, the rate of SD was in between 30% and 40%, and the problems in arousal and achievement of adequate penile erection were most reported problems.

The evidence for relationship between SD and QOL among various SMIs is sparse and contradictory too. With respect to schizophrenia, studies have shown either an association of SD and poor QOL[333435] or no difference between those with/without associated SD.[1826] The information for impact of SD on patients suffering from bipolar disorder is scant. Although distress, dissatisfaction and poor dyadic adjustment have been reported in patients with bipolar disorder who suffer from SD.[1629] However, only one study which evaluated QOL in association with bipolar disorder in female patients had reported poor perception of QOL (measured on WHOQOL-BREF) in association with SD.[36] Akin to the limited research on this topic in patients with bipolar disorder, only a few studies have evaluated impact of SD in patients with depression on their QOL.[313237] The WHO QOL-BREF scale was used in a North Indian study,[31] whereas the other from East India[32] utilized the QOL Enjoyment and Satisfaction Questionnaire-Short Form (QLES-Q-SF). Both the studies have reported that QOL is significantly impaired in patients with depression with SD as compared to those without SD. In the present study, we recruited a healthy control group for such a comparison and found that the QOL was significantly poor in the control group as compared to cases except for the social relations and the rating on item 21 of WHO QOL-BREF. Moreover, the difference still persisted when comparison was done for various groups of disorders and the control group. The finding is in contrast to most of earlier research except that no difference was found for QOL and SD associated with schizophrenia in a Chinese study.[18] Such a result may be attributed to the recruitment of an accompanying caregiver/acquaintance who was significantly younger than the patient group and probably was burdened with care of the person with mental illness in addition to other family responsibilities.

There is ample amount of research that psychotropic medications in the form of certain antidepressants, antipsychotics, and mood stabilizers, especially lithium, are associated with SD.[38] However, evidence is sparse for benzodiazepines and certain mood stabilizers. In the index study, although details pertaining to prescribed psychotropics were collected, nearly two-third of patients were on at least two medications, and an antidepressant was the most commonly prescribed drug. We did not attempt to delineate the effect of psychotropic medication on various aspects of SD in the study participants in the current study.

In the present study, an effort was made to analyze and compare the rates of SD in persons with SMIs and healthy control population. The selection of only married men, without any comorbid substance dependence, and a healthy control population are some of the advantages in this study. However, the study is limited by its sample size (we did not utilize standard method of sample size calculation), non-measurement of various socio-demographic parameters, and non-utlization of rating scales for psychopathology, and the Hindi version of ASEX scale has not been validated. In addition, a significant number of forms filled by patients with schizophrenia were not included in the analysis due to deficiencies which might have skewed the results. The exclusion of the female patients was also a limitation as was the non-involvement of the sexual partner of the patients. Also, we did not evaluate the dyadic relationship in the study participants. The control group, though related to the patient group, was not matched for their age and education and hence could have influenced certain analysis. The measurement of hormonal parameters could have also added to the evidence. Hence, future studies must attempt to address these limitations.

CONCLUSION

A significant number of patients with SMI suffer from SD. This may manifest in various domains of sexual response cycle which may differ for different mental illness. Hence, it should be made a routine practice to evaluate and address the problem of sexual dysfunction in patients with SMIs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.