dysfunction in a group of 51 depressed patients using the Beck
Rating Scale for Depression and an un-validated 0–7 scale
assessing sexual dysfunction and showed that depressed patients
were more likely to have altered libido than controls, but showed
no relationship between depression and the physical aspects of
sexual function.
Several other studies have similarly linked sexual function and
depression, primarily identifying correlations between the psy-
chological aspects of sexual function, such as sexual desire and
depression, without Fnding a relationship between the physical
aspects of sexual function including the ability to have and
maintain an erection, have an orgasm or ejaculate and depressive
symptoms.
14,16,17
Despite the above insights, few studies have
examined
the
relationship
between
sexual
function
and
depressive symptoms using validated metrics.
2,8,16,19,20
In light of
the dearth of objective data evaluating the intersection between
the physical and psychological aspects of sexual function and
depression, we evaluated this relationship using validated
questionnaires.
MATERIALS AND METHODS
Patient selection and data collection
A retrospective review of 186 men presenting to our urology clinic
between May and November 2011 was performed. After obtaining
institutional review board approval, we obtained demographic informa-
tion, including age, body mass index (BMI) and comorbidities. Each patient
was asked to complete validated questionnaires evaluating depressive
symptoms (Patient Health Questionnaire (PHQ-9)), sexual function (Inter-
national Index of Erectile ±unction (IIE±)) and hypogonadism (both the
quantitative Androgen Decline in the Aging Male (qADAM) and the
ADAM). Each of the above questionnaires were completed once by each
patient, and serum hormone levels, including total testosterone (TT), free T
and estradiol were recorded for each patient at the time of questionnaire
completion. We utilized the qADAM questionnaire preferentially to assess
hypogonadal symptoms as it uses a 1–5 Likert scale that permits
quantitation of the severity of hypogonadal symptoms, rather than simply
a binary assessment as is the case with the ADAM, potentially providing
increased sensitivity over the ADAM in evaluation of hypogonadal
symptoms.
21
The qADAM questionnaire is composed of the same 10
questions as the validated ADAM questionnaire. However, the qADAM
questionnaire uses scalar rather than binary responses, permitting
evaluation of the severity of hypogonadal symptoms. Although not
validated, the qADAM questionnaire correlates with serum T levels as well
as other validated instruments of sexual function and hormonal status
including the Expanded Prostate Cancer Index Composite and Sexual
Health in Men questionnaires.
21
The IIE± questionnaire is comprised of 15
questions (see Table 2), various combinations of which comprise its
domains. The domains of the IIE± questionnaire and their corresponding
questions include: (A) erectile function (questions 1, 2, 3, 4, 5 and 15); (B)
orgasmic function (questions 9 and 10); (C) sexual desire (questions 11 and
12); (D) intercourse satisfaction (questions 6, 7 and 8); and (E) overall
satisfaction (questions 13 and 14).
Data analysi
s
Spearman’s rank correlation analysis was performed to assess the
relationships between depressive symptoms and sexual function, as well
as between depressive and hypogonadal symptoms, using comparisons
between PHQ-9 and IIE± total scores as well as between PHQ-9 and
qADAM total scores, respectively. We also assessed the correlations
between PHQ-9 total score and individual IIE± and qADAM question scores,
as well as between PHQ-9 total score and the domains of the IIE±. We also
grouped men according to a PHQ-9 score cutoff of 10 and performed
Spearman’s rank correlation analysis within these groups as above. A PHQ-
9 score
X
10 correlates with symptoms of at least mild depression. ±inally,
to assess which patients were likely to have more severe depressive
symptoms, we used PHQ-9 questionnaire data to group patients using
DSM-IV diagnostic criteria for major depressive disorder (MDD): Fve or
more depressive symptoms (depressed mood, anhedonia, change in
appetite, feelings of worthlessness or guilt, insomnia or hypersomnia,
diminished concentration, psychomotor agitation or retardation, loss of
energy, suicidal thoughts) having been present during the same 2-week
period and representing a change from previous functioning, with at least
one of the symptoms being depressed mood or loss of interest or
pleasure.
22
We then compared IIE± domain and qADAM scores between
these groups.
Data were analyzed using Microsoft Excel (Microsoft, Redmond, WA,
USA) and SPSS (IBM Corp, Somers, NY, USA). Statistical analyses included
Spearman’s rank correlation to perform comparisons between question-
naire responses as above. Analysis of variance was used to compare
numeric variables that were not related to questionnaires, and
w
2
analysis
to compare categorical variables. Statistical signiFcance was considered at
a
P
-value
p
0.01.
RESULTS
Between May and November 2011, 186 men receiving treatment
at our clinic were included in the study. ±or all subjects,
mean
±
s.d. subject age was 52.6
±
12.7 years and baseline serum
hormone
levels
were:
TT
429.8
±
239.2 ng dl
±
1
,
free
T
9.72
±
7.5 pg ml
±
1
and estradiol 34.4
±
22.8 pg ml
±
1
(Table 1). A
PHQ-9 score of
X
10 correlates with mild depression or worse, and
in our cohort 30 of 186 (16.1%) men met this criterion, a rate
similar to that previously observed in men in the general
population.
23,24
The relationship between depression and sexual function
SigniFcant negative correlations were observed between total
PHQ-9 score and several domains of the IIE±, including sexual
desire
(
r
¼±
0.210,
P
¼
0.006),
intercourse
satisfaction
(
r
¼±
0.293,
P
o
0.0001) and overall satisfaction (
r
¼±
0.413,
P
o
0.0001) (Table 2). A negative correlation approaching sig-
niFcance was observed between PHQ-9 scores and the erectile
function domain of the IIE± (
r
¼±
0.128,
P
¼
0.089). In addition,
each individual question of the sexual desire (questions 11 and
12), intercourse satisfaction (questions 6, 7 and 8) and overall
satisfaction (questions 13 and 14) domains of the IIE± showed
signiFcant negative correlation with the PHQ-9 score as well, as
did one question of the erectile function domain (question 5). Men
with a PHQ-9 score
X
10 had lower IIE± sex life satisfaction
question scores (2.9
±
1.3 (PHQ-9
o
10) vs 2.3
±
1.0 (PHQ-9
X
10),
P
¼
0.009) than men with PHQ-9 score
X
10 (Table 3). In addition, a
signiFcant difference in IIE± overall satisfaction domain was
observed between groups (6.1
±
2.7 (PHQ
o
10) versus 4.6
±
2.1
(PHQ
X
10),
P
¼
0.008). These data suggest that men with more
signiFcant depressive symptoms are more likely to have sexual
dysfunction affecting the psychological domains of the IIE±, but
also with an impact on the physical aspects of sexuality, including
how often one is able to have an erection and the ability to
maintain an erection.
The relationship between depression and hypogonadal symptoms
We also evaluated the relationship between depressive and
hypogonadal symptoms, as hypogonadism is associated with
decreased libido, worsened erectile function and depressive
symptoms.
10,15,25–27
Towards this goal, we correlated PHQ-9
scores with qADAM scores and observed strong negative
correlations between total PHQ-9 score and individual qADAM
questions 1–5, 7 and 9 (Table 4). ±urthermore, all individual PHQ-9
questions evidenced strong negative correlations with total
qADAM score (
P
o
0.0001 for each PHQ-9 question (Table 5))
and men with a PHQ-9 score of
X
10 had lower mean qADAM
scores than men with PHQ-9
o
10 (19.1
±
4.9 versus 26.0
±
4.9,
respectively,
P
o
0.0001) (Table 3). Taken together, these data are
in line with prior Fndings showing a relationship between
depressive symptoms and hypogonadal symptoms.
12,13,27
It is
important to note that we used qADAM scores to assess severity
of hypogonadal symptoms. However, within our cohort, ADAM
positivity was associated with lower mean qADAM score (Mean
Depression and sexual dysfunction in men
AW Pastuszak
et al
195
&
2013 Macmillan Publishers Limited
International Journal of Impotence Research (2013), 194 – 199