Psychosomatics 48:309-318, July-August
doi: 10.1176/appi.psy.48.4.309
© 2007 Academy of Psychosomatic Medicine
Prevalence and Predictors of Sexual Dysfunction in Psychiatric Inpatients
Christopher M. Perlman, M.Sc.,
Lynn Martin, Ph.D.,
John P. Hirdes, Ph.D.,
Nancy Curtin-Telegdi, M.A.,
Edgardo Pérez, M.D., and
Terry Rabinowitz, M.D.
Received November 11, 2005; revised January 27, 2006; accepted April 25, 2006. From the Dept. of Health Studies and Gerontology; Univ. of Waterloo; Waterloo, Ontario; Homewood Research Institute; Guelph, Ontario; Homewood Health Centre; Guelph, Ontario; Dept. of Psychiatry and Family Practice, Univ. of Vermont College of Medicine, Burlington, VT; Psychiatric Consultation Service, Burlington, VT. Send correspondence and reprint requests to John P. Hirdes, Ph.D., Professor, Dept. of Health Studies and Gerontology, Univ. of Waterloo, 200 University Avenue West, Waterloo, ON Canada, N2L 3G1. e-mail: hirdes{at}uwaterloo.ca
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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The authors examined the prevalence and predictors of sexual dysfunction in a sample of 3,717 psychiatric inpatients assessed with the Minimum Data Set–Mental Health Version 1 (MDS–MH 1.0). Sexual dysfunction was found to be less prevalent in inpatient psychiatry (17%) than is typically reported in community settings. Severe depression symptoms, use of antidepressants, and cardiopulmonary conditions emerged as powerful predictors of sexual dysfunction. More research is needed on the assessment and treatment of sexual dysfunction in psychiatric inpatients, particularly focusing on attitudes of assessors, patients, and interactions between medical, psychiatric, and medication characteristics.
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INTRODUCTION
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Sexual dysfunction refers to a disturbance in the psycho-physiological processes involved in the sexual-response cycle of both men and women.1 Common conditions include loss of desire, dyspareunia, vaginismus, anorgasmia, premature ejaculation, and erectile dysfunction. Sexual dysfunction is common in the general population, affecting an estimated 43% of women and 31% of men.2 Its prevalence is higher in persons with mental illness, particularly those treated with psychotropic medications. For instance, sexual dysfunction has been reported in as many as 78% of individuals with depression,3 30% to 54% of patients with schizophrenia treated with antipsychotic medications,4 and 10% to 50% of patients treated with antidepressant medications.5 Gauging of an accurate rate of sexual dysfunction in psychiatric patients is hampered by the variety of factors that may influence sexual dysfunction in this population. However, given its overall adverse effect on quality of life,5 we need a better understanding of factors contributing to sexual dysfunction in persons with mental illness.
A variety of risk factors for sexual dysfunction have been identified in the general population in the United States. Lauman et al.2 found that demographics (e.g., age), health, and lifestyle factors (e.g., poor physical health), social status indicators (e.g., loss of income), and characteristics of the sexual experience (e.g., previous sexual abuse) predict sexual dysfunction in both men and women.
In psychiatric patients, common factors associated with sexual dysfunction include illness symptoms and psychotropic medications. Most research examining the relationship between illness and sexual dysfunction has focused on depression and schizophrenia. Depression is associated with a number of sexual problems, including decreased libido, erectile dysfunction, and anorgasmia, even after we control for medication use.5,6 Social problems (e.g., lack of personal relationships) and negative symptoms (e.g., anhedonia) have been shown to be related to sexual dysfunction in persons with schizophrenia.7 Furthermore, Osvath and colleagues3 found that most patients with sexual dysfunction identified their mental illness as the primary cause of their sexual dysfunction.
Psychotropic medications have been consistently shown to affect sexual functioning. For instance, the antidepressants8,9 and antipsychotics4,10 negatively affect both the physical (e.g., erectile function) and psychological (e.g., libido) components of sexual functioning. Selective serotonin reuptake inhibitors (SSRIs) are the drug class most commonly associated with sexual dysfunction in both men and women, being widely prescribed for depression and anxiety.1 As many as 36% to 65% of persons receiving SSRI treatment have sexual dysfunction, with higher SSRI doses generally associated with higher rates of sexual dysfunction.12 These findings present a concern for medication compliance because many patients stop or consider stopping these medications as a consequence of sexual dysfunction, often without discussing their symptoms with their prescriber.8,13
Although Clayton and colleagues12 found that a variety of demographic and medication factors predicted sexual dysfunction in a large sample of primary-care patients with depression, few studies have examined factors other than specific medication use or psychiatric symptoms as predictors of sexual dysfunction in psychiatric inpatients. Therefore, our study examined personal, clinical, and treatment-related characteristics as predictors of sexual dysfunction among persons in inpatient psychiatric settings.
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METHOD
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Sample
Data from the 2000–2001 pilot implementation of the Minimum Data Set for Mental Health, Version 1 (MDS–MH 1.0) were available for a sample of psychiatric inpatients in the Canadian provinces of Ontario, Manitoba, and Alberta. A total of 3,717 adults (age 18 years or older) receiving inpatient treatment across 34 psychiatric facilities or units were included in this study.
Instruments
The MDS–MH 1.0 was developed by a six-country research team led by Ontario’s Joint Planning and Policy Commission (JPPC) and interRAI, a 26-country, not-for-profit research network (www.interrai.org).14 The team, including four of the authors (JPH, EP, TR, and NC-T) was composed of researchers, psychiatrists, physicians, social workers, nurses, and policy decision-makers, who deliberated to build consensus on the inclusion, wording, and coding of each item on the MDS–MH 1.0. The MDS–MH 1.0 collects information useful for care planning, outcome assessment, quality measurement, and resource utilization.15 Interrater reliability for almost all items exceed the cutoff for adequate reliability (i.e., weighted   0.40),16 with most items showing at least 70% agreement between raters.17 The value for the Sexual Dysfunction item was 0.40, with 72% agreement. An updated version of the MDS–MH 1.0, the Resident Assessment Instrument for Mental Health, Version 2, or RAI–MH 2.0) was mandated for use for all Ontario inpatient psychiatry beds beginning in October 2005.
Participating clinical staff members (e.g., nurses) from each facility received 2 full days of training from the research team’s clinical educator. Assessors received instruction on the intent and definition of each item in the MDS–MH 1.0, as well as on how to obtain and code the information; specific details on training specific to the item on sexual dysfunction is described below. Everyone who attended the training sent their first assessment to the clinical educator for review. The clinical educator provided both individual and general feedback (i.e., on any common clinical or coding issues) on the assessments. Staff incorporated the use of the MDS–MH 1.0 into regular assessment practices (e.g., completion of the MDS–MH 1.0 as a component of a standard admission assessment) for the duration of the study.
Dependent Variable: Sexual Dysfunction
In the MDS–MH 1.0, sexual dysfunction is a dichotomous variable, coded as Yes if "the patient reports persistent difficulty with sexual functioning during the past 30 days (e.g., loss of interest or drive, impaired erection or ejaculation, inhibited female orgasm)" or No if he or she has not. Although this is the specific wording of the item on the MDS–MH 1.0 form, assessors were encouraged not to simply read the item word-for-word to patients. In training, staff were reminded of the sensitivity that patients may have to discussing sexual dysfunction and were encouraged to use discretion in approaching this subject (e.g., making sure the discussion is held in private) in order to ensure comfort for patients and encourage confidentiality. Specifically, it was suggested that staff might want to approach the topic of sexual dysfunction within the context of discussing health conditions, pointing out that sexual functioning may be related to overall health. The MDS–MH 1.0 Manual, which is given to all participating staff, reinforces this message and provides further assessment examples.18
The MDS–MH 1.0 sexual dysfunction item includes criteria similar to those of DSM–IV for defining sexual dysfunction as both psychological factors (e.g., loss of interest) and physiological factors (e.g., erectile dysfunction).1 Other studies have used similar criteria for operationalizing sexual dysfunction, including the 30-day reference period of the MDS–MH 1.0 sexual dysfunction item.19,20
Independent Variables
A variety of personal, clinical, and treatment-related variables available in the MDS–MH 1.0 are considered in the model to predict sexual dysfunction. Personal characteristics include age, sex, years of formal education, marital status (No partner, including widowed, separated, divorced or Married or with partner), and loss of income in the past 2 years. To facilitate interpretation, three categories were created for both age and years of education. Age was divided into groups: 18–34 years, 35–64 years, and 65 years or older; years of education was grouped into the following categories: 0–9 years, 10–13 years, and 14 years or more.
Clinical characteristics include medical, functional, and psychological variables. The medical characteristics considered were self-rated health, medical diagnoses, and pain. The medical diagnoses were grouped as follows: cardiopulmonary (e.g., congestive heart failure, asthma), neurological (e.g., stroke, traumatic brain injury), musculoskeletal (e.g., fibromyalgia), gastrointestinal (e.g., liver disease), infections (e.g., HIV), as well as other conditions (e.g., diabetes, cancer, thyroid disorder). Pain was measured with the Pain Scale (PS) embedded in the MDS–MH 1.0. This scale measures both the frequency and intensity of pain on a scale from 0 (no pain) to 3 (intense daily pain).21
Functional characteristics included the patient’s cognitive status and self-care skills. Cognitive status was assessed with the embedded Cognitive Performance Scale (CPS).22 Based on items evaluating memory, decision-making, expression, and self-performance in eating, a predictive algorithm is used to compute a 7-point scale ranging from 0 (cognitively intact) to 6 (very severe cognitive impairment). The CPS was reported to be highly correlated with the Folstein Mini-Mental State Exam (MMSE).23 The embedded Activities of Daily Living Hierarchy Scale (ADL Hierarchy) was used to measure self-care performance. This scale classifies ADLs according to the stages at which they can no longer be performed, thus reflecting the disablement process.24 The 7-point ADL Hierarchy ranges from total independence (0) to total dependence (6) in ADLs.
A number of psychological factors were considered in relation to sexual dysfunction. A history of sexual, physical, or emotional abuse, as well as the presence of risk of harm to self (i.e., admitted as a danger to self; considered performing or performed a self-injurious act in the last 30 days; intent of any self-injurious act was to kill self; or others express concern that the patient is at risk of harm to self) were examined. Also, the presence of various psychiatric diagnoses (i.e., specific disorders of childhood or adolescence, cognitive disorders, substance-related disorders, schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, eating disorders, adjustment disorders, and personality disorders) and psychological symptoms (depression, psychosis, and social withdrawal) were considered. Depressive symptoms were assessed with the Depression Rating Scale (DRS) embedded in the MDS–MH 1.0, a 14-point scale based on the presence of seven symptoms (negative statements, persistent anger, expressions of unrealistic fears, repetitive health complaints, repetitive anxious complaints, facial expression, and crying or tearfulness) over the previous 3 days. DRS scores may vary between 0 and 14, where a score 3 indicates possible depression warranting further investigation.25 Psychotic symptoms were measured with a Positive Symptoms Scale (PSS), a summated scale based on the frequency of hallucinations, command hallucinations, delusions, and abnormal thought processes over the last 3 days. Items are rated from 0 (symptom not present) to 2 (symptom present daily in the last 3 days). Therefore, the PSS score ranges from 0 to 8, with higher scores indicating a greater frequency of positive symptoms. The PSS has good internal consistency in the current sample (Cronbach  =0.70). Negative symptoms were measured using the Negative Symptoms Scale (NSS), a summated scale based on the frequency of anhedonia, withdrawal from activities of interest or long-standing social relations, lack of motivation, and reduced social interaction over the last 3 days. The NSS is scored in the same manner as the PSS, with scores ranging from 0 to 8. Good internal consistency was found for the NSS in the current sample (Cronbach =0.85).
We also examined medication use. The MDS–MH 1.0 assesses whether patients had taken any of the following medications in the 7 days before assessment: neuroleptics/antipsychotics, anxiolytics, antidepressants, mood stabilizers, hypnotics/sedatives, psychostimulants, anti-Parkinson drugs, anticonvulsants, analgesics, antacids, antibiotics, anticoagulants, antihypertensives, asthma therapies, cardiac drugs, cough/cold medications, diabetes drugs, diuretics, hormone therapy, laxatives, thyroid drugs, oral contraceptives, and herbal/homeopathic remedies. Also, we recorded the total number of medications taken in the previous 7 days.
Statistical Analysis
Descriptive statistics (frequency, means) were used to profile the characteristics of the entire patient sample; chi-square analyses and independent t-tests were used to compare individual characteristics of patients with sexual dysfunction versus those with no sexual dysfunction.
Multiple logistic-regression was used to identify the adjusted risk factors for sexual dysfunction in psychiatric inpatients. Bivariate regression modeling between all independent variables and sexual dysfunction was first used to determine which variables should be included in the full predictive model. Variables significant at the p<0.05 level were considered for the multivariate model. Independent variables were randomly entered and removed from the model to check for multicolinearity. Goodness of fit was analyzed by evaluating the c statistic, which ranges from 0.5 to 1; a value of 1 indicates a perfect model fit to the data, whereas values close to 0.5 indicate that the model is no better than what could be achieved by chance.
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RESULTS
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Demographics
Overall, the sample largely consisted of single men, age 18 to 34 years, with an average of less than 14 years of formal education. The most common psychiatric conditions were mood disorders (41%), substance-related disorders (26%), and schizophrenia or other psychoses (25%). Antipsychotic, anxiolytic, and antidepressant medications were the most commonly used (51%, 48%, and 47%, respectively). Sixty-eight percent of patients with a mood disorder had taken antidepressant medications, and 87% of those with schizophrenia/other psychoses had taken antipsychotic medications in the 7 days before the assessment.
Sexual dysfunction was identified in 17% of the sample. Table 1 shows descriptive statistics for a variety of characteristics for patients with and without sexual dysfunction. As compared with patients with no sexual dysfunction, those with sexual dysfunction were more often female ( 2[1]=30.41; p<0.0001), under 35 years old (2[2]=97.05; p<0.0001), married/with a partner (2[1]=208.17; p<0.0001), had more years of formal education (2[2]=94.97; p<0.0001), had a mood disorder (2[1]=115.20; p<0.0001), anxiety (2[1]=78.65; p<0.0001), eating (2[1]=41.73; p<0.0001), or personality (2[1]=29.91; p<0.0001) disorder, and had a cardiopulmonary condition (2[1]=9.11; p<0.05). A smaller proportion of patients with sexual dysfunction had schizophrenia/other psychoses (2[1] =84.54; p<0.0001), a neurological (2[1]=5.54; p<0.05) or cognitive disorder (2[1]=24.61; p<0.0001). Also, patients with sexual dysfunction scored significantly higher on the DRS (t[180] = –7.91; p<0.0001) and NSS (t[180] = –8.81; p<0.0001) and significantly lower on the PSS (t[1,054]=8.03; p<0.0001), CPS (t[1,145]=8.40; p<0.0001), and ADL Hierarchy (t[1,681]=9.25; p<0.0001).
The mean number of medications taken by patients with sexual dysfunction was 3.7, and the mean number of medications taken by patients without sexual dysfunction was 3.4 (t[3,715]=0.06; p=0.95). However, as shown in Table 2, a greater proportion of patients with sexual dysfunction had taken anxiolytic (2[1]=7.65; p<0.05), antidepressant (2[1]=180.21; p<0.0001), hypnotic/sedative (2[1]=34.79; p<0.0001), analgesic (2[1]=6.16; p<0.05), asthma (2[1]=6.20; p<0.05), or hormone therapy (2[1]=20.89; p<0.0001) medications. A smaller percentage of patients with sexual dysfunction had taken antipsychotic (2[1]=77.41; p<0.0001), antiparkinson (2[1]=34.79; p<0.0001), or laxative (2[1]=21.03; p<0.0001) drugs.
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TABLE 2. Medication Use in the 7 Days Before Assessment for Patients With and Without Sexual Dysfunction, Percent (N)
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Predictors of Sexual Dysfunction
Table 3 presents the final logistic-regression model for predicting reported sexual dysfunction in psychiatric inpatients (c statistic=0.80). Sexual dysfunction was predicted by 14 variables, including personal, clinical, and treatment-related characteristics. All individual variable results are reported for this model under the assumption that all other variables in the model are held constant.
For personal variables, patients age 35 to 64 years were 1.39 times more likely to have sexual dysfunction, as compared with those 18 to 34 years of age. However, those age 65 years or older were less likely (odds ratio [OR]: 0.22) to be assessed as having sexual dysfunction than those age 18 to 34 years. Patients who had more formal years of education and were married had greater odds of having sexual dysfunction than those with fewer years of education or who were without a partner. Last, patients who had had a significant loss of income within the last 2 years were more likely to have sexual dysfunction than those with no loss of income.
Six psychological variables were related to sexual dysfunction. Patients with a history of sexual, physical, or emotional abuse were 1.61 times more likely to have sexual dysfunction than those with no history of abuse. Risk of self-harm (OR: 1.52) and symptoms of depression (DRS 3; OR: 1.54) were associated with an increase in the odds of sexual dysfunction. Patients with a provisional diagnosis of schizophrenia/other psychoses were less likely to have reported sexual dysfunction (OR: 0.70).
Two medical conditions were associated with reported sexual dysfunction. Patients who had poor self-rated health were 1.63 times more likely to have reported sexual dysfunction than those who did not rate their health as poor. Patients with cardiopulmonary conditions were 1.27 times more likely to have reported sexual dysfunction than those without such a diagnosis.
Of the 23 medications assessed, only 2 significantly contributed to the prediction of sexual dysfunction, holding all other variables constant. Patients who had taken antidepressant medications were almost twice as likely to have reported sexual dysfunction (OR: 1.96), whereas those who had taken antipsychotic medications were less likely to report sexual dysfunction (OR: 0.74).
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DISCUSSION
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The purpose of this study was to explore the prevalence and predictors of sexual dysfunction in a sample of psychiatric inpatients. The prevalence of sexual dysfunction in this sample was 17%, which is much lower than has been reported in other samples.2,3 Higher prevalence found in previous research may be due to the time over which sexual dysfunction was measured. For instance, Lauman et al.2 assessed the presence of sexual dysfunction in the 12 months, versus 30 days, before the assessment used in this study. This prevalence estimate also suggests the difficulty in assessing sexual functioning, because of the sensitive nature of this issue. In the absence of a strong therapeutic relationship, both patients and clinicians may feel uncomfortable discussing sexual dysfunction openly, particularly if patients do not fully understand how this issue might relate to their condition or their medication.
This study found that a mixture of personal, clinical, and treatment-related variables were predictive of sexual dysfunction. In terms of personal characteristics, patients with more years of education were more likely to have reported sexual dysfunction. This could be a reflection of their having investigated (e.g., used the Internet or scientific journals) the medications they are taking, or the sexual dysfunction itself, realizing that it is a pertinent health condition that should be reported. Finding that patients age 65 years or older are less likely to have sexual dysfunction is surprising, given that older adults with depression living in the community are more likely to have sexual dysfunction.10 This, coupled with our bivariate results indicating a lower proportion of patients with neurological or cognitive disorders having sexual dysfunction, may indicate that assessors are less likely to initiate an in-depth examination of sexual dysfunction in patients whom they presume to not be affected by such conditions (e.g., cognitively-impaired elderly persons). Although the literature reveals that single or divorced community-dwelling adults are more likely to have sexual dysfunction,2 the present study found that sexual dysfunction was three times more prevalent among married individuals. It may be that the sexual dysfunction is contributing to relationship problems in married couples, who are thus more inclined to report it in hopes of decreasing stress in their relationship. Also, it may be that single individuals are not necessarily aware of their sexual dysfunction if, in fact, there is one, if they have been sexually inactive in the 30 days before assessment. Furthermore, the assessment of unmarried individuals is more likely to focus on sexual activity, versus actual sexual functioning. Moreover, upon discovering that the patient has not had a sexual partner in the last 30 days, assessors may assume that sexual dysfunction is not present or pertinent. This could be harmful for patients, however, as the inability to satisfy one’s own sexual needs through masturbation because of sexual dysfunction may cause increased distress and further hinder recovery. As such, sexual dysfunction should be assessed in all patients, regardless of age, marital status, or presence of a sexual partner. Finally, the present study confirms the work of Lauman and colleagues2 in finding that loss of income is related to increased risk of sexual dysfunction. Loss of income could greatly increase the level of stress, which may, in turn, lead to sexual dysfunction.
Medical conditions have been previously identified as predictors of sexual dysfunction.2 As such, it is not surprising that individuals with poor self-rated health and cardiopulmonary disease were more likely to have sexual dysfunction. Cardiopulmonary conditions often co-occur with depression,26,27 and Roose6 has shown that sexual dysfunction in men is often the consequence of this comorbidity. Although treatment for sexual dysfunction in patients with cardiopulmonary disorders should be considered, caution must be used in treating sexual dysfunction, particularly for patients with comorbid depression28 (i.e., sexual activity should not be promoted until high-risk conditions such as congestive heart failure are stabilized).
In terms of psychological and treatment characteristics, history of abuse, self-injurious behavior, and symptoms of depression, all significantly predicted an increased risk for sexual dysfunction. The finding that history of abuse significantly predicted sexual dysfunction was not surprising; it has been reported previously.2,29 It is possible that sexual contact triggers feelings of fear and trauma similar to those of the abusive event. Findings indicating an increased risk of sexual dysfunction in patients at risk of harm to self may be a reflection of the severity of the patient’s illness. Therefore, our findings suggest that as illness severity increases, so does the risk of conditions such as sexual dysfunction. Furthermore, these patients are likely prescribed higher doses of medications such as SSRIs, further increasing their risk for sexual dysfunction. The results pertaining to the increased risk of sexual dysfunction with antidepressant medication use are consistent with those previously reported and support the compounding risk for sexual dysfunction among patients with more severe symptoms. Also, antidepressants were the only medications, psychotropic or otherwise, to be predictive of sexual dysfunction in the multivariate model. Although nonpsychotropic medications such as antihypertensives (e.g., alpha-blockers) are suspected to have sexual side effects,30 it may be that their impact on sexual functioning is not as severe or direct as that of antidepressants.
The finding that patients with schizophrenia/other psychoses were less likely to have sexual dysfunction was surprising. It may be that the symptoms of these disorders (e.g., hallucinations, paranoia), cause individuals with schizophrenia to be less aware that sexual dysfunction exists, or less likely to report such problems when they are recognized. Results for patients with schizophrenia may also be related to the negative relationship between antipsychotic medication use and sexual dysfunction. Such a relationship may be a function of a change in the type of antipsychotic medications taken. Although most antipsychotic medications are associated with impaired sexual functioning,4,5,31 the use of atypical antipsychotics (e.g., olanzapine, risperidone) may reduce the risk of sexual dysfunction10,32 because they do not increase prolactin levels, whereas typical antipsychotics, with dopamine antagonist activity, may affect prolactin. Furthermore, the effect of antipsychotics on sexual dysfunction may be dose-dependent (where higher doses are associated with increased risk of sexual dysfunction).33 Therefore, a shift in prescribing patterns to atypical antipsychotics, with reduced doses, may partially explain the findings in this study.
There are several limitations of this research. First, although similar in content to other scales measuring sexual dysfunction, the MDS–MH 1.0 sexual dysfunction item has not been formally validated against other sexual dysfunction scales. Although other scales do exist, none have received wide-scale psychometric testing among large samples and often focus more on the sexual experience, as opposed to specific sexual dysfunction.19 Therefore, a next step for research on sexual dysfunction would be to develop or further psychometrically evaluate sexual dysfunction scales so that a gold standard instrument can be established. Such an instrument could be used for in-depth assessment into the nature of sexual dysfunction, possibly after the identification of general sexual dysfunction that uses assessment systems such as the RAI–MH. Second, several findings discussed here suggest a possible systematic assessment bias (e.g., low prevalence rate, age effect predicting sexual dysfunction). Such a bias may have stemmed from varying levels of comfort or experience of assessors in discussing sexual dysfunction with patients. Inconsistencies in assessment are not uncommon in the literature and have been identified as possibly affecting international variation in rates of sexual dysfunction.20 Because comprehensive assessment is a large component of establishing needs of psychiatric inpatients, and as the recognition of sexual dysfunction as a health concern increases, improvement in training for clinical assessors is needed to increase understanding of sexual dysfunction and enhance comfort levels with its assessment. Such improvement in training may also improve the consistency of sexual dysfunction assessment. As noted, the sexual dysfunction item falls within the range of adequate reliability, but at the lower end of this range. Although the content of the item is sound, the stability of the information yielded may largely depend on the standardization of assessment on the part of assessor. Therefore, further training for assessors may also improve the reliability of the assessment of sexual dysfunction. Third, the data did not include any variables related to whether patients had been offered or were receiving treatment for sexual dysfunction. Therefore, this study is unable to gauge rates of treated versus untreated sexual dysfunction. Fourth, the specific types of medications being used were unknown (e.g., typical versus atypical antipsychotics). As discussed, atypical antipsychotics may produce different effects on sexual functioning as compared with typical antipsychotics. Fifth, the cross-sectional nature of the data means it was not possible to establish a temporal order between the variables of interest. For example, it may be that depression is both a cause and a consequence of sexual dysfunction. Therefore, conclusions can only be made about the association between independent variables and sexual dysfunction. Last, the degree to which the sample is fully representative of psychiatric inpatients is not known. These data were collected as part of a pilot implementation of the MDS–MH 1.0 in psychiatric hospitals/units in Ontario, Manitoba, and Alberta, and are based on entire units from volunteer hospitals in those provinces. As such, the sample may not be fully representative of psychiatric inpatients in general or of all the patients in the participating facilities.
With the understanding of what factors place psychiatric inpatients at greater risk for sexual dysfunction, more work is needed to explore how sexual dysfunction can be sensitively and effectively assessed and treated in this population. Such explorations could use case–control studies to examine the effects of pharmacological treatments of sexual dysfunction on psychotropic medication compliance and compare such results to psychotherapeutic treatments of sexual dysfunction. However, before examining specific treatments for sexual dysfunction, research is needed to explore how to effectively measure sexual dysfunction in patients with psychiatric conditions. For example, it needs to be determined which patients are most and least willing to discuss issues around sexual functioning, as well as what barriers prevent mental health professionals from addressing this issue, and what are the most effective methods of measuring sexual dysfunction (i.e., face-to-face interviews versus self-report).
The present study also has implications for the use of the RAI–MH in identifying sexual dysfunction and building sexual-dysfunction treatment into care planning. The RAI–MH is an ideal assessment system for identifying psychiatric patients who have the potential for developing sexual dysfunction, given that it contains a variety of patient information. Since it has been provincially mandated through the Ontario Mental Health Reporting System (www.cihi.ca), all inpatient facilities with mental health units will be completing RAI–MH assessments at various times through an admission. Therefore, care-planning for sexual dysfunction can be built in when risk factors for sexual dysfunction, as identified in this study and others, are triggered. Such triggers should be used in the development of a sexual-dysfunction Clinical Assessment Protocol (CAP) for mental health. Currently, the MDS–MH system includes a wide variety of CAPs (formerly referred to as Mental Health Assessment Protocols, or MHAPs) for other problems, describing patients’ strengths, weaknesses, needs, and problems. However, no CAP exists for sexual dysfunction. The development of a Sexual Dysfunction CAP would create a greater opportunity to identify and treat sexual dysfunction in psychiatric inpatients.
Despite the relatively low prevalence estimate found here, sexual dysfunction remains a complex issue for psychiatric inpatients. Most important, this study has shown that many factors beyond what has typically been studied play a role in affecting sexual dysfunction. As such, sexual dysfunction should be assessed as part of optimal psychiatric care, regardless of age, marital status, diagnosis, functional ability, or medications taken or not taken. Open communication and trust needs to be established between clinicians and patients so that sexual functioning can be addressed appropriately. Beyond direct discussions about sexual functioning, clinicians need to be aware of cues that patients may present indicating a possible problem with sexual functioning (e.g., statements about problems with personal relationships). The development of a Sexual Dysfunction CAP will assist clinicians in identifying such cues and lead to improved identification and treatment of sexual dysfunction in inpatient psychiatry. Properly identifying and treating sexual dysfunction may have positive implications for the recovery of patients and treatment compliance to maintain this recovery.
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ABSTRACT
INTRODUCTION
