The low frequency of reported sexual dysfunction in Asian patients with schizophrenia (2001-2009): low occurrence or ignored side effect?

Prevalence of sexual dysfunction in Chinese patients with schizophrenia: a systematic review and meta-analysis

Background

There may be a higher risk of sexual dysfunction in the schizophrenia population. China has made significant contributions to the global community of patients with schizophrenia. Currently, there is no estimation of the prevalence of sexual dysfunction in Chinese patients with schizophrenia.

Aim

We conducted a meta-analysis to pool the evaluated prevalence of sexual dysfunction in Chinese patients with schizophrenia.

Methods

We systematically searched PubMed, Web of Science, Embase, PsycINFO, China National Knowledge Infrastructure, China Science and Technology Journal Database, Wanfang Medical Network, and Huayi Academic Literature Database from inception to September 2023. Meta-analysis was conducted with R version 4.3.1.

Outcomes

To examine the pooled prevalence of sexual dysfunctions among Chinese patients with schizophrenia.

Results

In our meta-analysis, we included 16 studies with 5417 participants, among whom 1727 experienced sexual dysfunction. The results of the meta-analysis reveal that the prevalence of sexual dysfunction in Chinese patients with schizophrenia is 50.43% (95% CI, 37.86%-62.95%). Subgroup analysis results indicate that various factors-including the specific type of dysfunction, duration of illness, assessment tools, mean ages, study region, gender, research setting, marital status, publication years, and type of antipsychotics-all have a particular impact on the occurrence rate of sexual dysfunction in Chinese patients with schizophrenia. Female patients had a slightly higher prevalence of sexual dysfunction than male patients (65.22% vs 54.84%).

Clinical Implications

The findings of this study can be used in high-quality nursing care for the schizophrenia population, particularly for the care of specific sexual dysfunction nursing.

Strengths and Limitations

This meta-analysis is the first to evaluate the prevalence of sexual dysfunction in China among patients with schizophrenia. The limited number of studies is the most important limitation.

Conclusions

The pooled prevalence of sexual dysfunction in Chinese patients with schizophrenia is relatively high, and the prevention and intervention of individual sexual dysfunctions in schizophrenia are advised.

Sexual Dysfunction in Schizophrenia: A Systematic Review and Meta-Analysis

Importance

In individuals with schizophrenia, antipsychotic-induced dysfunctions are frequent but often underexplored in clinical practice.

Objective

To synthetize the data of observational studies exploring the prevalence of sexual dysfunction in individuals with schizophrenia-spectrum disorders as well as associated factors.

Data Sources

A systematic literature search without language or time restrictions was conducted in Google, Google Scholar, PubMed/MEDLINE, Science Direct, and Université Sorbonne Paris Cité for studies published up to June 8, 2022.

Study Selection

All observational studies reporting a prevalence of sexual dysfunction in schizophrenia-spectrum disorder were included.

Data Extraction and Synthesis

The MOOSE guidelines with independent extraction by 2 observers and random-effects models were used.

Main Outcomes and Measures

The prevalence of sexual dysfunction and each specific dysfunction.

Results

A total of 72 of 1119 studies from 33 countries on 6 continents published from inception to June 2022 were included with a total of 21 076 participants with schizophrenia. The pooled global prevalence of sexual dysfunctions was 56.4% (95% CI, 50.5-62.2), with a prevalence of 55.7% (95% CI, 48.1-63.1) for men and 60.0% (95% CI, 48.0-70.8) for women. The most frequent sexual dysfunction was erectile dysfunction in men (44%; 95% CI, 33.5-55.2), followed by loss of libido in men (41%; 95% CI, 30.7-51.4), ejaculation dysfunction in men (39%; 95% CI, 26.8-51.8), orgasm dysfunction in women (28%; 95% CI, 18.4-40.2), and amenorrhea in women (25%; 95% CI, 17.3-35.0). Factors associated with heterogeneity were study design, time and location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and the use of antidepressants and anxiolytics. Sexual dysfunctions were more frequent in schizophrenia vs schizoaffective disorders, and erectile disorders were less frequent in individuals with longer illness duration. Antidepressant and mood stabilizer prescriptions were associated with lower rates of erection disorders (β, -6.30; 95% CI, -10.82 to -1.78); P = .006 and -13.21; 95% CI, -17.59 to -8.83; P < .001, respectively) and ejaculation disorders (β, -6.10; 95% CI, -10.68 to -1.53; P = .009 and β, -11.57; 95% CI, -16.34 to -6.80; P < .001, respectively). No obvious improvements in the rates of sexual dysfunction at other times were found, and there were conflicting results regarding antipsychotic classes.

Conclusions and Relevance

This systematic review and meta-analysis found a high prevalence of sexual dysfunction among individuals with schizophrenia, with considerable heterogeneity in associated factors. The findings also suggest that some dysfunctions may be explained by schizophrenia. The association between lower rates of dysfunction and antidepressant use suggests that treating comorbid depression could be an effective strategy to improve sexual health. A lack of data on metabolic parameters and physical health in general was also noted, while these issues are frequent in the care of schizophrenia.

Frequency of sexual dysfunction in outpatients with severe mental illness in Greece

Introduction

Patients with psychosis can develop sexual dysfunction, which may be related to the disease itself, psychosocial factors, somatic comorbidities, and the use of psychotropic medication.

Objective

We aimed to investigate the type and frequency of sexual dysfunction in patients diagnosed with schizophrenia or bipolar disorder in order to assess the side effects of antipsychotics in sexual function.

Methods

This is a multicenter, cross-sectional study, involving patients diagnosed with schizophrenia (79.3%) or bipolar disorder (20.7%) treated in the Department of Psychiatry and Community Mental Health Centers from November 2018 to December 2019. Patients were enrolled in the study after signed informed consent. Demographic and clinical data were collected from patients through a semi-structured interview. The Antipsychotics and Sexual Functioning Questionnaire (ASFQ) was administered to assess sexual function.

Results

A total of 87 outpatients on antipsychotics were recruited in the study. The mean age was 43.6 years, while the mean duration of the disease was 16.9 years. Overall, only 9.1% of patients spontaneously reported sexual dysfunction. Patients treated with oral first-generation antipsychotics had more difficulties in achieving orgasm and decreased erection capacity. In contrast, patients treated with oral second-generation antipsychotics had decreased ejaculation capacity. Patients on antipsychotic combination therapy were associated with higher rates of sexual anhedonia.

Discussion

These results suggest that sexual dysfunction is a side effect of antipsychotic treatment, which was spontaneously rarely reported by patients. It seems essential to obtain a psychosexual clinical history before initiating antipsychotic treatment to evaluate following changes and adopt an individualized strategy to manage sexual dysfunction induced by antipsychotics.

Analysis of the trends of polypharmacy and high-dose prescriptions in Japan

INTRODUCTION

After extensive research, this study explored whether high-dose prescriptions and polypharmacy remain more frequent in Japan than elsewhere. If confirmed, we aimed to identify the factors that contributed to this unique trend.

METHODS

The psychotropic drug prescription patterns for patients with schizophrenia in Japan were reviewed. This was based on a large sample collected from surveys of the Research on Asian Psychotropic Prescription Patterns, an international collaborative research project conducted by Asian psychiatrists to monitor prescriptions of psychotropic drugs for people with mental disorders, in 2001, 2004, 2008, and 2016.

RESULTS

The 2016 Research on Asian Psychotropic Prescription Patterns survey revealed that Japan continued to demonstrate the highest rate of polypharmacy and the highest dosages of psychotropic prescription drugs for patients with schizophrenia among the 15 countries and areas that participated in the survey.

DISCUSSION

The Research on Asian Psychotropic Prescription Patterns surveys demonstrated that science plays a limited role in the decision-making process for prescriptions of psychotropic medications. Such prescriptions are influenced by a wide range of factors, such as the national mental health policy, prescription-financing systems, the history of psychiatry in each country, and the prevailing culture. Hospital-based national mental health policies and mental health financing systems have been the primary obstacles to reducing polypharmacy in Japan.

Sexual Dysfunction in Chronically Medicated Male Inpatients With Schizophrenia: Prevalence, Risk Factors, Clinical Manifestations, and Response to Sexual Arousal

BACKGROUND

Sexual dysfunction is a common symptom in patients with schizophrenia, especially in chronically medicated patients. However, the relationship between sexual dysfunction and emotional response to sexual arousal in male patients with schizophrenia remains unclear. This study aimed to assess the incidence, risk factors of sexual dysfunction in males, and their clinical correlations to sexual arousal in male patients with schizophrenia in China.

METHODS

A total of 162 male patients, aged 18-50 years, with schizophrenia were recruited from a psychiatric hospital in Ganzhou. The clinical symptoms were assessed by the Positive and Negative Syndrome Scale (PANSS). The Arizona Sexual Experience Scale was utilized to evaluate sexual dysfunction. Erotic images were selected from International Affective Picture System (IAPS). Sixty-eight out of the 162 subjects completed the erotic pictures reactivity task.

RESULTS

Overall, 48 (29.6%) patients were measured as having global sexual dysfunction, 72 (44.4%) patients as having strength of sex drive dysfunction, 51 (31.5%) patients as having sexual arousal dysfunction, 55 (34.0%) patients as having penile erection dysfunction, 60 (37.0%) patients as having reached orgasm dysfunction, and 60 (37.0%) patients as having satisfaction with orgasm dysfunction. The sexual dysfunction patients had significantly higher scores on the negative symptoms of the PANSS. The only important predictor of sexual dysfunction was the severity of PANSS negative factor. The sense of pleasure and arousal post viewing erotic images in the sexual dysfunction group were lower compared to the non-sexual dysfunction group. The sense of pleasure and approach motivation were significantly negatively correlated with the severity of sexual dysfunction.

CONCLUSIONS

This study shows that nearly one-third of young and middle-aged chronically medicated male inpatients with schizophrenia suffer from sexual dysfunction. The negative factor of the PANSS can be regarded as the risk factor of sexual dysfunction. Schizophrenia patients with sexual dysfunction experienced lower pleasure and higher avoidance motivation than non-sexual dysfunction patients when exposed to erotic stimuli.

Sexual dysfunctions in schizophrenia: Beyond antipsychotics. A systematic review

BACKGROUND

Sexual dysfunctions (SD) in schizophrenia are frequent with strong impact on adherence and quality of life. Current recommendations stipulate to switch to prolactin-sparing antipsychotic in case of SD.

OBJECTIVES

To synthetize in a systematic review data on the SD prevalence and the associated risk factors in schizophrenia (SZ).

METHODS

Medline, Google Scholar, PsychInfo, and Cochrane were explored, without any year or language restriction.

RESULTS

Overall, 89 studies and 25,490 participants were included in the present review. SZ subjects aged 18-70 reported high SD frequency [30%-82%] (men [33%- 85%]; women [25%- 85%]). For SZ men erectile dysfunction [31%-95%] was the most frequent SD vs. loss of libido for women [31%-100%]. The following risk factors were associated with increased SD: 1. Illness severity (including psychotic symptomatology, early age at SZ onset, negative symptomatology, and continuous illness course), 2. Depressive symptomatology 3. Antipsychotics (especially first generation antipsychotics, risperidone and antipsychotic polytherapy). Switching to prolactin-sparing antipsychotics has shown effectiveness in some studies (especially aripiprazole). Antidepressants were not found to be associated with SD in SZ subjects.

CONCLUSION

The prevalence of SD is high in SZ subjects. In addition to the current guidelines, the present review suggests that treating depressive symptoms may be a major intervention to improve SD in SZ subjects. Sociodemographic variables, physical illnesses, metabolic syndrome and peripheral inflammation have been poorly or never explored and should be included in future studies.

Sexual dysfunction in Chinese rural patients with schizophrenia

BACKGROUND

Sexual dysfunction is common in patients with schizophrenia, however it is poorly studied in China, especially in primary health care institutions in rural areas. We investigated the prevalence of sexual dysfunction and its correlates including quality of life (QoL), in schizophrenia patients treated in primary care in a rural area in China.

METHOD

By using a random numbers table, 21 small town primary care service centers (from 63 totally) were selected in the study. Data of 720 community-dwelling patients with schizophrenia in rural area with diagnoses according to DSM -IV or ICD-10 were collected by interviews. Data on socio-demographic and clinical characteristics including sexual dysfunction and quality of life (QoL) were collected using a standardized protocol and data collection procedure. Data were analyzed using chi-square tests, t-tests, U-tests, ANCOVA and multiple logistic regression as appropriate by SPSS 21.0.The level of significance was set at 0.05 (two-tailed).

RESULTS

In this sample, sexual dysfunction was found in 71.3% of the whole sample, 82.7% of female patients and 64.5% of male patients. Multiple logistic regression analysis showed that older age (OR = 1.06, P<0.001, 95%CI: 1.04-1.09) and higher Brief Psychotic Rating Scale (negative domain) score (OR = 1.16, P = 0.01, 95%CI: 1.02-1.31) were significantly associated with sexual dysfunction. Contrary to previous findings, sexual dysfunction was not associated with quality of life after controlling for confounding variables.

CONCLUSIONS

More than 2/3 of schizophrenia patients living in a rural area complained of sexual dysfunction, which was associated with older age and more negative psychotic symptoms. Primary care physicians should pay attention to sexual dysfunction during the assessment and treatment of patients with schizophrenia in rural areas in China.

Chinese version of the Psychotropic-related Sexual Dysfunction Questionnaire (PRSexDQ -SALSEX): Validity and reliability for schizophrenic patients taking antipsychotics

This study was designed to examine the validity and reliability of the Chinese version of the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX) in patients with schizophrenia taking antipsychotics. It was conducted in a sample of 135 patients aged between 18 and 50 years old and diagnosed with schizophrenia. Demographic data and clinical features were assessed with PRSexDQ, the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression (CGI), and the Udvalg for Kliniske Undersøgelser (UKU) Side Effects Rating Scale. The internal consistency of the Chinese version of PRSexDQ using Cronbach's α was 0.902. The test-retest and inter rater reliability was both high with p<0.001. PRSexDQ was correlated with corresponding items in the UKU Side Effects Rating Scale (Items 4.12-4.16), and showed good sensitivity, specificity, positive and negative predictive value. It could also clearly detect differences in SD rates of three monotherapy groups: patients treated with risperidone had the highest scores, followed by patients treated with olanzapine, whereas patients treated with aripiprazole had the lowest scores. The Chinese version of PRSexDQ is a reliable and valid instrument to assess patients with schizophrenia. Assessed by PRSexDQ, 53.2% of total subjects in our study reported symptoms of SD.

Sexual dysfunction among women with Schizophrenia-A cross sectional study from India

Sexual dysfunction among women usually has a multifactorial etiology and is also difficult to study in cultures where open discussions about sexuality are not common. Not much is known about sexual function in women with schizophrenia even though it may have a significant impact on their quality of life and maybe influenced by several factors.

AIMS AND OBJECTIVES

This study aimed to assess the frequency and nature of sexual dysfunction in women with schizophrenia and study its association with marital quality, illness, treatment, and socio-demographic factors.

METHODOLOGY

This was a cross sectional, hospital-based study conducted among 63 women with schizophrenia attending the outpatient services of a tertiary care psychiatric hospital. Sexual dysfunction was assessed using the Female Sexual Function Index (FSFI). Side effects of medications, psychopathology, and marital quality were assessed using standard scales.

RESULTS

Among the 63 women assessed, 44 (70%) reported sexual dysfunction. Impaired desire was reported by all women, impaired arousal by 58 (92.1%), poor lubrication by 30 (47.6%), impaired orgasm by 48(76.2%) poor satisfaction by 44(69.8%) and pain by 23(36.5%). Poor Marital quality ('p' value-0.001), higher scores on general psychopathology of the Positive and Negative symptoms scale of schizophrenia (PANSS) ('p' value-0.049) and side effects such as weight gain, menstrual disturbances, galactorrohea and dry vagina were significantly associated with Female Sexual Dysfunction (FSD) in univariate analysis. However, multivariate analysis found marital quality alone to be significantly related to FSD.

Hyperprolactinemia, prolactin-related side effects and quality of life in Chinese psychiatric patients

PURPOSE

To examine the frequency of hyperprolactinemia and the socio-demographic, clinical, and quality of life (QOL) correlates. The frequency of prolactin-related side effects and associated subjective experiences were also examined.

METHODS

A cohort of 1364 psychiatric inpatients were consecutively recruited and evaluated. Basic socio-demographic and clinical data were collected. Psychopathology, prolactin-related side effects were measured using standardized instruments. QOL was assessed using the Medical Outcomes Study Short Form 12.

RESULTS

The frequency of hyperprolactinemia was 61.3% in the whole sample; 61.6% in female and 60.8% in male patients. There was no significant association between hyperprolactinemia and any QOL domain. In the whole sample, 15.1% of patients reported moderately severe breast symptoms and lactation, and 53.9% reported moderate or severe discomfort. Nearly a third of female patients (30.4%) reported at least moderate menstrual changes and 50.2% moderate or severe discomfort, while 24.2% of male patients reported at least moderate erectile dysfunction and 52.6% moderate or severe discomfort. Multiple logistic regression analysis revealed that patients with hyperprolactinemia were less likely to be married, diagnosed with mood disorders, or treated with clozapine, aripiprazole, or antidepressants but more likely to receive risperidone.

CONCLUSIONS

Effective measures to lower the frequency of hyperprolactinemia and the related side effects should be considered in Chinese psychiatric facilities.

Sexual dysfunction and its impact on quality of life in Chinese patients with schizophrenia treated in primary care

PURPOSE

Sexual dysfunction in schizophrenia patients is common. In China, maintenance treatment for clinically stable patients with schizophrenia is usually provided by primary care physicians. Illness- or treatment-related sexual dysfunction in this patient population has been never studied. This study describes the prevalence and correlates of sexual dysfunction and its impact on quality of life (QOL) in patients with schizophrenia treated in primary care in China.

METHOD

A total of 607 patients with schizophrenia treated in 22 randomly selected primary care services in China formed the study sample. Patients' socio-demographic and clinical characteristics including sexual function and QOL were recorded using a standardized protocol and data collection.

RESULTS

Sexual dysfunction was present in 69.9% of all patients; 60.7% in males and 80.6% in females. Multiple logistic regression analysis revealed that female gender, being single, older age and use of first-generation antipsychotics were independently and significantly associated with more sexual dysfunction accounting for 23.5% of its variance (P<0.001). Unexpectedly, sexual dysfunction was not associated with lower QOL.

CONCLUSIONS

High rate of sexual dysfunction was reported in the majority of patients with schizophrenia treated in primary care in China. Given its negative impact on social adjustment, QOL and treatment adherence, efforts should be made to address sexual dysfunction in this patient population.

Management of sexual dysfunction due to antipsychotic drug therapy

BACKGROUND

Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, retrograde ejaculation, sexual arousal, or overall sexual satisfaction. These are major aspects of tolerability and can highly affect patients' compliance.

OBJECTIVES

To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy.

SEARCH METHODS

An updated search was performed in the Cochrane Schizophrenia Group's Trials Register (3 May 2012) and the references of all identified studies for further trials.

SELECTION CRITERIA

We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated random effects risk ratios (RR) with 95% confidence intervals (CI), for crossover trials we calculated Odds Ratios (OR) with 95% CI. For continuous data, we calculated mean differences (MD) on the basis of a random-effects model. We analysed cross-over trials under consideration of correlation of paired measures.

MAIN RESULTS

Currently this review includes four pioneering studies (total n = 138 , duration two weeks to four months), two of which are cross-over trials. One trial reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n = 32, MD 3.20 95% CI 1.83 to 4.57), a greater mean duration of erections (n = 32, MD 1.18 95% CI 0.52 to 1.84) and frequency of satisfactory intercourse (n = 32, MD 2.84 95% CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n = 10, MD change on Aizenberg's sexual functioning scale -0.40 95% CI -3.95 to 3.15). No evidence was found for switching to quetiapine from risperidone to improve sexual functioning (n = 36, MD -2.02 95% CI -5.79 to 1.75). One trial reported significant improvement in sexual functioning when participants switched from risperidone or an typical antipsychotic to olanzapine (n = 54, MD -0.80 95% CI -1.55 to -0.05).

AUTHORS' CONCLUSIONS

We are not confident that cross-over studies are appropriate for this participant group as they are best for conditions that are stable and for interventions with no physiological and psychological carry-over. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Switching to olanzapine may improve sexual functioning in men and women, but the trial assessing this was a small, open label trial. Further well designed randomised control trials that are blinded and well conducted and reported, which investigate the effects of dose reduction, drug holidays, symptomatic therapy and switching antipsychotic on sexual function in people with antipsychotic-induced sexual dysfunction are urgently needed.