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IMPROVEMENT IN SEXUAL DYSFUNCTION FOLLOWING ANTIDEPRESSANT TREATMENT IN DEPRESSED FEMALES
*Dr. Abhivant Niteen N. 1, Dr. Sawant Neena S.2,
Introduction: Depression is associated with sexual dysfunction. As the depression improves sexual dysfunction also improves. There are not many studies on female sexuality. Aims and objectives: To find out the changes in sexual functioning in depressed females after treatment with anti-depressant drugs. Method: 41 female patients diagnosed to have depression were included in study. Becks Depression Inventory and Female Sexual Functioning Index scales were applied at the beginning and after 6 weeks to assess the improvement in sexual dysfunction and depression. Results: When scores were compared after 6 weeks of antidepressant treatment then a highly significant difference was seen on all the scores of BDI ( p< 0.000***) and FSFI (p< 0.01**). On the various domains of FSFI a highly significant difference was seen on the domains of Arousal (p< 0.03**), Lubrication (p< 0.051**), Orgasm (p< 0.028**) and Satisfaction (p< 0.06**). Conclusions: This study showed significant improvement in sexual dysfunction and different aspects of sexual dysfunctions after treatment with antidepressants for 6 weeks.
Keywords: Female sexual dysfunction, Depression, SSRI, FSFI.
The issue of sexual health, once regarded as taboo subject, has been widely debated recently. Reliable estimates of incidence and severity of sexual dysfunctions in females is difficult to obtain as the patients are often unwilling to raise the issue of sexual health with health professionals and both the patient and the physician may be reluctant to discuss it. Female sexual dysfunction is multifactorial and multidimensional condition combining biological, psychological and interpersonal determinants . Although sexual dysfunctions are not life threatening, they have major impact on personal relationships, physical health and quality of life. There are several studies on male sexual dysfunctions in India  but literature on the prevalence of sexual dysfunction among women is particularly scant [3, 4].
The prospective Zurich cohort study shows that the prevalence of sexual problems in depressed subjects is approximately twice that in controls . A number of investigators have reported various sexual dysfunctions associated with depression [1, 6, 7, 8].Female sexual function is also regulated by a variety of neurotransmitters and hormones. Estrogen, testosterone and progesterone promote sexual desire; dopamine promotes desire and arousal, and norepinephrine promotes arousal [9, 10]. Prolactin inhibits arousal, and oxytocin promotes orgasm .
Hence a need was felt to look into the aspects of female sexual dysfunctions and it’s relation to underlying depression and drug therapy. Increased awareness of this problem in medical community will lead to further research in female sexual dysfunctions and improved treatment.
AIMS AND OBJECTIVE
To find out the changes in sexual functioning in depressed females after treatment with anti-depressant drugs.
MATERIAL AND METHODS
This study was a prospective (6 week) study conducted in a psychiatry outpatient department of a general municipal hospital. The sample consisted of 52 female patients who were diagnosed to have depression as per Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text revision, criteria after satisfying inclusion and exclusion criteria.
1) Females diagnosed to have depression as per Diagnostic and
Statistical Manual of Mental Disorders, 4th edition, Text revision
2) Those who were willing to participate in the study.
3) Language compatibility.
1) Females less than 18 years of age.
2) Those with past history of depression or any psychiatric illness.
3)Those who were on any other psychotropic medications.
4) Sexual dysfunction prior to depression.
52 female patients were screened of which 3 patients refused the consent and so had to be dropped out of the study. 49 female patients gave consent and so were enrolled in the study protocol. Of the 49 patients, 8 patients dropped out of the follow-up period over 6 weeks. At the end of 6 weeks, 41 patients were available for analysis.
All patients were explained about the nature of study and it’s applications and informed consent was obtained from patients. A proforma was designed to enquire into the socio-demographic details, details of psychopathology, presence of sexual dysfunctions and questions pertaining to aims and objectives of study. All the patients were interviewed in presence of female co-investigator or another lady doctor or a nurse and were interviewed in drug naïve state and then they were started on any of the Selective Serotonin Reuptake Inhibitor medications viz Sertraline, Escitalopram for underlying depression. All the patients were administered Beck’s Depression Inventory and Female Sexual Functioning Index Scale in the drug naïve state and all the scales were again administered at the end of 6 weeks of anti-depressant medication to gauge the improvement in mood and sexual functioning.
1) BECK’S DEPRESSION INVENTORY: Developed by A. Beck  is a rating to measure the severity of depression in which individuals rate their own symptoms of depression. This is a 21 item scale which evaluates the key symptoms of depression including mood, pessimism, sense of failure, self dissatisfaction, self accusation, self dislike, guilt, punishment, suicidal ideas, crying, irritability, social withdrawal, indecisiveness, body image changes, insomnia, fatigability, loss of appetite, weight loss, somatic pre-occupation and loss of libido. Individuals are asked to rate themselves on a 0 to 3 spectrum [0=least, 3=most] with a score range of 0 to 63. Total score is a sum of all items.
2) FEMALE SEXUAL FUNCTIONING INDEX : The Female Sexual Functioning Index is a 19 item questionnaire. It is a brief, multidimensional, self report instrument to assess the key dimensions of sexual function in females. It assesses six domains of sexual function including 1) Desire 2) Physical arousal-sensation
- Physical arousal-lubrication 4) Orgasm 5) Satisfaction and 6) Pain.
All the scales were translated in Marathi and Hindi and were validated by the departmental staff before administration.
All analyses were done with SPSS statistical version 11 at 5% significance. The changes in tools (Beck’s Depression Inventory, Female Sexual Functioning Index) were analyzed pre and post treatment using the paired‘t’ test.
The mean age of this sample (n=49) was 28.9 years (+_ 3.03 yrs) with range of 23- 39 years and majority (81.6%) patients were from 25-31 years age group. Majority (63.26%) of patients had completed their secondary education and 94% were home makers with hardly 6% of them doing some job. As expected, about two-third (67.34%) were Hindus. The mean duration of depression was 2 years with standard deviation of 1.8 years with range being from 3 months to 7 years.
When all the patients were assessed for improvement in their depression and areas of sexual functioning after a 6 week treatment with SSRI’s viz. Escitalopram (optimum dose 10 to 15 mg) and Sertraline (100mg), then a highly significant difference was seen on all the scores of BDI ( p< 0.000***) and FSFI. (p< 0.01**).
On the various domains of FSFI a highly significant difference was seen on the domains of Arousal (p< 0.03**), Lubrication (p< 0.051**), Orgasm (p< 0.028**) and Satisfaction (p< 0.06**). Desire and pain domains did not show any significant changes.
Depressive disorders are among the most prevalent psychiatric disorders . Depression is characterized by loss of interest, reduction in energy, lowered self-esteem and inability to experience pleasure, irritability and social withdrawal which may impair the ability to form and maintain intimate relationships. This constellation of symptoms may be expected to produce difficulties in sexual relationships, and depression has long been associated with sexual problems . A number of investigators have reported association between sexual dysfunctions and depression [1, 6, 7, 8].
Depression is also associated with various neurotransmitter changes which may also contribute to sexual dysfunction in depression [10, 16, 17].
Our study showed that as depression improves, sexual functioning also improves which has been corroborated by Piazza  who had studied depressed women with greater sexual dysfunction at baseline and improvement in sexual functioning with treatment with SSRI’s in areas of improvement in sex drive, physiologic and psychological arousal.
SSRI’s due to their antidepressant action improve the depression which may consequently reduce the various faulty cognitions associated with depression and enhance the person’s self esteem and energy. Also as the depression improves the various biological changes associated with it also improves which may also contribute to the reduction in sexual dysfunction. In short, with reversal of biological and psychological changes sexual dysfunction improves with SSRI treatment.
There are also various studies which have linked SSRI’s with sexual dysfunction and have been discussed in critical reviews [19, 20] but Montgomery and colleagues  have also pointed out numerous obstacles to establishing the exact prevalence of antidepressant-related sexual dysfunction. Sex is more than a physical act. It also includes emotional and psychological dimensions. Studies have also shown that besides antidepressants many other factors influence the incidence and prevalence of sexual dysfunction in patients with depression. These include factors such as, depression itself, cultural and social factors and physical and psychiatric co-morbidities .
Given the scarcity of evidence-based treatments, the management of sexual dysfunction is still an art rather than a science. Even a seemingly clear-cut case of medication-associated sexual dysfunction should not be treated in a vacuum or in a strictly biological sense. The overall treatment should always take into consideration psychological factors and normal fluctuation of sexual functioning.
ACKNOWLEDGEMENTS: We sincerely acknowledge the support and guidance of Dr. Shubhangi Parkar, Professor and Head, Department of Psychiatry, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai. 400012
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