Prevalence of anxiety and depressive symptoms in men with erectile dysfunction

Erectile dysfunction (ED) is defined as the consistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance, over a 3-month period. ED is a common sexual disorder with a prevalence rate of 40% among 40-yearold men, increasing to 70% among 70-year-olds. There is a high correlation of depression and anger symptoms in patients suffering from ED. The relationship between ED and depressive illness is still unclear, with general acceptance that the aetiology of ED is in most cases multifactorial in origin with a strongly related organic component.

articles Erectile dysfunction (ED) is defined as the consistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance, over a 3-month period. 1 ED is a common sexual disorder with a prevalence rate of 40% among 40-yearold men, increasing to 70% among 70-year-olds. 2,3There is a high correlation of depression and anger symptoms in patients suffering from ED. 2 The relationship between ED and depressive illness is still unclear, with general acceptance that the aetiology of ED is in most cases multifactorial in origin with a strongly related organic component. 1e Massachusetts Male Aging Study 3 showed a significant association between ED and age, diabetes mellitus, heart disease and hypertension.The same study showed that patients with depression have a 1.82 times higher chance of developing moderate to severe ED than patients not suffering from depression. 3,4The triad of ED, cardiovascular disease and depression are likely to increase the morbidity and mortality rate in such patients. 5Four models of cause-and-effect association have been proposed to explain the complex relationship between depression and ED: 6 Model 1.The primary illness is that of depression, with ED a symptom of the depressive disorder.Methods.An obser vational analytical study was undertaken of 100 consecutive male patients of all ages presenting with ED (with a score less than 20 on the 5-item intensity scale for ED).Age, race, marital and employment status were noted as well as social habits including smoking and alcohol use.The presence of known medical conditions and surgical procedures was ascertained.All current prescription medication was recorded.Panic disorder, obsessive-compulsive disorder, generalised anxiety disorder and social phobia were rated using the Mini International Neuropsychiatric Interview, while the Antidepressant-induced sexual dysfunction may lead to premature discontinuation of treatment, raising the risk of relapse and recurrence of major depression.
There is also a high prevalence of anxiety in patients with ED, 8 and performance anxiety has been emphasised as a major cause of psychogenic ED, 9 with the effects on sexual arousal in men having been shown to be mediated largely by cognitive factors. 9Two studies reported that approximately one-third of men with ED have a co-morbid psychiatric disorder, 6 predominantly affective disorder.
Even when the full diagnostic criteria are not met, there are high levels of anxiety and depressive symptoms. 6Thus ED should be considered a multifactorial condition requiring a multidisciplinary approach and management.
The aim of the present study was to determine the prevalence of anxiety and depressive symptoms in men presenting with ED at the Men's Clinic International in Bloemfontein.Further aims were to determine the relationship, if any, between the severity of ED and mood/anxiety symptoms.We also hope to increase awareness of the co-morbidity of anxiety/mood symptoms and ED.

Material and methods
The study was an observational analytical study of 100 consecutive male patients of all ages presenting to the Men's The interviewer recorded all current prescription medication, noting the subject's stated reason for use of each.The above procedures are routine during the assessment of patients at the clinic and only the psychiatric rating scales were additional.Following assessment and diagnosis the patient was started on the relevant therapy.
Baseline depressive symptomatology was measured using the 17-item Hamilton Rating Scale for Depression (HAM-D). 12The HAM-D was developed as a measure of treatment outcome, but it is commonly used as a screening scale.The HAM-D is a 17- Panic disorder, obsessive-compulsive disorder, generalised anxiety disorder and social phobia were rated using the Mini International Neuropsychiatric Interview (MINI). 13During the research it was observed that the questions asked on the MINI rating scales were too direct for some of the clients and falsepositive answers were obtained.Non-direct questions were adopted and if a positive answer was obtained more direct questions from the MINI rating scale were asked to confirm the answer.
Results were summarised as frequencies and percentages (categorical variables) and means, standard deviations or percentiles (numerical variables).Associations were assessed by risk differences with 95% confidence intervals (CIs).

Results
Selected characteristics of the respondents are listed in Table I.
Table II

Smoking currently 46
Current alcohol use 70 articles agoraphobia, 9 for generalised anxiety disorder 7 and for social phobia.In total, 21 patients had an anxiety disorder.The presence of an anxiety disorder tended to correlate with moderate to severe ED, but not with mild ED.
Under medical conditions 41% of participants suffered from hypertension, 17% from diabetes mellitus, 10% from hypercholesterolaemia and 5% from cardiovascular disease.
Only 2% of patients reported being treated for a psychiatric condition.The majority of these respondents were receiving medication for the relevant conditions.With regard to surgery, 2 respondents had coronary artery bypass grafts, 2 had stents inserted and 3 respondents had had prostatectomy performed in the past.

Discussion
The results of this study suggest that men suffering from ED are likely to have a co-morbid psychiatric disorder (42%, 95% CI: 32.2 -52.3%).Numerous studies have shown a high correlation between depression and ED, 1,2 and this study supports these findings, with 33% of the participants having depressive symptoms on the HAM-D.This is higher than the 15% lifetime prevalence of major depressive disorder occurring in men. 14One of the difficulties experienced in this study was to find South African general population figures for depression and anxiety disorders for comparison, and therefore lifetime prevalence was used.The probability of depression seems to increase with the degree of ED.The co-morbidity of ED and depressive symptoms is also important as it affects compliance with treatment.Patients with ED and depressive symptoms are more likely to discontinue treatment for ED than patients with ED and no depressive symptoms. 1enty-one participants (21%, 95% CI: 13.5 -30.3%) were diagnosed with an anxiety disorder, which is slightly higher than the lifetime prevalence of anxiety disorder in men (19.2%). 15en subdivided into the specific anxiety disorders none of the individual anxiety disorders was higher than the lifetime prevalence.
Anxiety disorders were only diagnosed in participants with moderate to severe ED.Twelve respondents had both depressive symptoms and an anxiety disorder, showing that 36% of patients with depressive symptoms had a co-morbid anxiety disorder.In this study, the majority of men presenting with ED were between the ages of 30 and 59 years.
Although  As previously mentioned, the MINI rating scale was problematic as the questions were direct and respondents gave numerous false-positive answers.To prevent a false diagnosis, non-directive questions were asked to confirm positive answers obtained from the MINI.Should the present study be repeated, alternative anxiety rating scales could be used.
, MB ChB, MMed (Psych) Departments of Psychiatry and Biostatistics, University of the Free State, Bloemfontein Objectives.To determine the prevalence of anxiety and depressive symptoms in men presenting to a sexual dysfunction clinic in Bloemfontein with erectile dysfunction (ED); to determine the relationship, if any, between age and mood/anxiety symptoms in such patients; and to make clinicians aware of the co-morbidity of anxiety/mood symptoms and ED.
to determine what comes first (ED, depression or medical condition), the treating physician should screen ED patients for affective and anxiety disorders.The physician should also assess patients with affective and anxiety disorders for ED.Ideally the assessment of ED should occur before the commencement of psychotropic medication.Patients should also be screened routinely for medical conditions, namely hypertension, diabetes mellitus, hypercholesterolaemia and cardiac conditions.The treatment regimen for medical and psychiatric conditions should be altered to avoid side-effects of certain medications compounding the problem of ED.
shows the severity of ED, risk factors for ED and co- had mild depressive symptoms (Fig.2).Thirteen respondents had moderate to severe depressive symptoms and no other psychiatric disorder.Twelve respondents had both depressive symptoms and an anxiety disorder.None of the patients with cardiovascular disease scored more than 17 on the HAMD.Eight patients fulfilled the criteria for panic disorder withoutVolume 11No. 2 September 2005 SAJP

Table III
compares the respondents with mild (N = 7), moderate (N = 36) and severe (N = 57) ED in terms of age, race and marital status.The majority of the participants suffering from severe ED were evenly spread from the ages of 30 to 69 years.Moderate ED was mainly reported in the 40 -59-year age groups.Almost 60% of the participants with mild ED were aged between 40 and 49 years.Table IV compares the severity of ED with risk factors and comorbid psychiatric diagnosis.Participants suffering from moderate to severe ED were more likely to have medical conditions, most notably hypertension.Two-thirds of those Volume 11 No. 2 September 2005 SAJP

Table II . Severity and risk factors for erectile dysfunction and co-morbid psychiatric diagnosis (N = 100)
10EF = International Index of Erectile Function.10

Table IV . Comparison of the severity of erectile dysfunction and risk factors
As this study has shown, depressive and anxiety disorders and concomitant medical conditions are common in men presenting with ED.As ED is a multifactorial condition, and we are unable conditions.Participants diagnosed with moderate to severe ED were more likely to have an accompanying medical condition, most notably hypertension.The majority of the hypertensive sufferers were on antihypertensive medication, which is known to add to the problem of ED. 61 articles Volume 11 No. 2 September 2005 SAJP