Talking about sexuality with consumers of mental health services

Unheard voices: The sexual challenges of families of patients with bipolar disorder: A qualitative content analysis

OBJECTIVES

The aim of this study was to explore the voices of the family members of Bipolar Disorder (BD) patients about the challenges ahead of them.

METHODS

In this qualitative study, 22 participants shared their experiences of sexual challenges of patients with BD through in-depth, face-to-face, semi-structured interviews. Qualitative content analysis was used for data analysis.

RESULTS

An overarching theme entitled "Unheard voices" reflected this experience. It comprised four main categories include sexual promiscuity, a change in sexual patterns, sexual support, and sexual indifference. The results revealed that the families of patients with BD have to deal with sexual promiscuity and change in sexual patterns in their family, and the family system attempts to respond to these changes by sexual support mechanisms and sexual indifference.

CONCLUSIONS

Given the significant impact of healthy sexual behaviors on the quality of life of both the individual and the family, therapists and family support systems are advised to strengthen and educate families to support their patients' sexual health and needs and protect their sexual existence; they should also address the sexual challenges faced by these families as a diagnostic and therapeutic priority, and early sexual health interventions should be provided to these families.

[Sexual dysfunction on the background of antidepressant therapy]

The review is devoted to the problem of sexual dysfunction caused by taking antidepressants. Sexual dysfunction is widespread, but it is not reported, and its impact on the quality of life and compliance of patients is underestimated. Partly because of its bidirectional association with depression, sexual dysfunction is difficult to diagnose. Possible mechanisms and risk factors associated with sexual dysfunction in patients with depression are considered. The data on the frequency of sexual dysfunction with the use of various antidepressants are given. Therapeutic strategies for sexual dysfunction associated with taking antidepressants are described. The advantages of agomelatin as an antidepressant associated with a low risk of sexual side effects are emphasized.

Sexual dysfunction among males and females with bipolar disorder and healthy subjects: The burden of illness severity

OBJECTIVES

Sexual dysfunction has wide-ranging impacts on the person's functioning and quality of life, being associated with higher severity of psychiatric illnesses and poor therapeutic response. Given the paucity of data on this topic in bipolar disorder (BD), we investigated sexual functioning among males and females with BD and healthy controls (HCs) as well as whether illness severity markers and subthreshold mood symptoms were associated with sexual dysfunctions in BD patients.

METHODS

The study included 80 BD outpatients and 70 HCs. Sexual functioning was evaluated using the validated, gender-specific Changes in Sexual Functioning Questionnaire (CSFQ-14).

RESULTS

BD patients had a significantly poorer sexual functioning than HCs (p < 0.00001). The odds of sexual dysfunction doubled given a one-unit increase in the number of suicide attempts (adjusted OR = 2.01, 95% CI:1.23-3.55; p < 0.01) and increased by 60% for every additional hospitalization (p < 0.05). Greater illness duration was associated with arousal/orgasmic (p < 0.05) and overall sexual dysfunctions (p < 0.01). BD patients with more mixed or (hypo)manic episodes had a lower likelihood of libido loss and arousal/orgasmic disturbances (p < 0.01), respectively. Higher levels of subthreshold depressive symptoms increased by 20% the odds of sexual interest/frequency dysfunctions (p < 0.05), and up to 60% regarding orgasmic disturbances (p < 0.01).

CONCLUSIONS

Sexual functioning may be a useful proxy of illness severity as well as a relevant dimension to more deeply characterize BD patients. Further studies are warranted to replicate our findings, to evaluate temporal associations between sexual dysfunctions and illness severity across the BD mood and treatment spectrums and to explore neurobiological underpinnings of these associations.

Management Strategies for Antipsychotic-Related Sexual Dysfunction: A Clinical Approach

Antipsychotic medication can be often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) remains underestimated in clinical practice. However, psychotic patients consider sexual issues as important as first rank psychotic symptoms, and their disenchantment with TESD can lead to important patient distress and treatment drop-out. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antipsychotic with a low rate of TESD) to possible pharmacological interventions aimed at improving patients' tolerability when TESD is present. The suggested recommendations include the following: prescribing either aripiprazole or another dopaminergic agonist as a first option antipsychotic or switching to it whenever possible. Whenever this is not possible, adjunctive treatment with aripiprazole seems to also be beneficial for reducing TESD. Some antipsychotics, like olanzapine, quetiapine, or ziprasidone, have less impact on sexual function than others, so they are an optimal second choice. Finally, a variety of useful strategies (such as the addition of sildenafil) are also described where the previous ones cannot be applied, although they may not yield as optimal results.

Sexuality and intimacy among people with serious mental illness: a qualitative systematic review

OBJECTIVE

The aim of this systematic review was to synthesize the best available qualitative evidence on the experiences and support needs of people with serious mental illness (SMI) regarding sexuality and intimacy within hospital and community settings. The objectives were to explore intimate relationship experiences of people with SMI, to uncover potential obstacles to the expression of sexuality and to present recommendations for mental health policy, education, research and practice.

INTRODUCTION

Mental health services worldwide have seen major transformations in recent years through deinstitutionalization programs and more enlightened ways of organizing and providing mental health care. However, in terms of social and emotional wellbeing, issues persist for people with SMI, particularly relating to intimacy and the expression of sexuality. This systematic review may assist service providers to determine ways that they may better support people in establishing and maintaining satisfying intimate relationships and the full expression of their sexuality.

INCLUSION CRITERIA

This review explored the intimacy and sexuality experiences, perceptions and concerns of people over the age of 18 years who were living with a SMI in hospital or community settings. This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

METHODS

The databases MEDLINE, CINAHL, PsycINFO, Embase and Web of Science were utilised in the review. The search included studies published from 1995 up to and including February 6, 2018 and were limited to those in the English language. Each paper was assessed by two independent reviewers for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Any disagreements that arose between the reviewers were resolved through discussion. Data extraction was conducted by two independent reviewers using the standardized qualitative data extraction tool from JBI. The qualitative research findings were pooled using JBI methodology. The JBI process of meta-aggregation was used to identify categories and synthesized findings.

RESULTS

Based on the thematic findings from the 21 studies, three synthesized findings were extracted from 10 categories and 83 findings: 1) the complexity of individual sexual experiences, 2) the clinical constructs of sexuality and 3) family and partner involvement.

CONCLUSIONS

Having fulfilling and satisfying sexual and relationship experiences is a fundamental human right that can enhance an individual's quality of life. Being aware of the potential stresses and challenges that having a SMI can have on a relationship and involving partners in the treatment, may help to promote intimacy and recovery. Practitioners can use these findings to guide future policy, education and developments in practice. Further research is required to develop and evaluate interventions that target the identified barriers and help people with SMI to fulfil their unmet sexuality and intimacy needs.

Sexual health of women with schizophrenia: A review

Women with schizophrenia experience low rates of sexual satisfaction and high rates of sexual dysfunction. They are at high risk for adverse sexual health outcomes including unplanned pregnancies, induced abortions, and human immunodeficiency virus (HIV), and face higher rates of sexual violence and various forms of intimate partner violence. This review explores the complex and intersecting biopsychosocial risk factors that explain these outcomes among women with schizophrenia, including factors related to the illness itself, antipsychotic medications, medical and psychiatric comorbidities, stigma, childhood trauma, and social determinants of health including poverty and housing instability. Sexual health interventions designed to help women with schizophrenia achieve pleasurable and safe sexual experiences, free of coercion, discrimination and violence are few and far between, suggesting opportunities for future development in this area.

Sexual Counseling in Women With Primary Infertility and Sexual Dysfunction: Use of the BETTER Model

The aim of the study was to determine the effect of sexual counseling based on the BETTER model of female sexual health in infertile women with sexual dysfunction. This is an experimental, prospective study carried out in an infertility clinic. The study included 70 women with primary infertility, of whom 35 were in the experimental group and 35 were in the control group. The Female Sexual Function Scale and the Golombok-Rust Sexual Satisfaction Scale were administered at the initial assessment and the final assessment. Two sessions of sexual counseling were given to the experimental group based on the BETTER model. A routine follow-up of the control group was performed. After the counseling, there was a statistically significant improvement in the mean scores for Female Sexual Function Scale and the total scores for the Golombok-Rust Sexual Satisfaction Scale and its subscales in the experimental group compared to the control group. The women who had been infertile for six years and more had less improvement in sexual dysfunction and sexual dissatisfaction. The sexual counseling given in accordance with the BETTER model was found to be effective in improvement of sexual function and sexual satisfaction in the women with one to two years of infertility.

The impact of severe mental disorders and psychotropic medications on sexual health and its implications for clinical management

Sexual dysfunction often accompanies severe psychiatric illness and can be due to both the mental disorder itself and the use of psychotropic treatments. Many sexual symptoms resolve as the mental state improves, but treatment-related sexual adverse events tend to persist over time, and are unfortunately under-recognized by clinicians and scarcely investigated in clinical trials. Treatment-emergent sexual dysfunction adversely affects quality of life and may contribute to reduce treatment adherence. There are important differences between the various compounds in the incidence of adverse sexual effects, associated with differences in mechanisms of action. Antidepressants with a predominantly serotonergic activity, antipsychotics likely to induce hyperprolactinaemia, and mood stabilizers with hormonal effects are often linked to moderate or severe sexual dysfunction, including decreased libido, delayed orgasm, anorgasmia, and sexual arousal difficulties. Severe mental disorders can interfere with sexual function and satisfaction, while patients wish to preserve a previously satisfactory sexual activity. In many patients, a lack of intimate relationships and chronic deterioration in mental and physical health can be accompanied by either a poor sexual life or a more frequent risky sexual behaviour than in the general population. Here we describe the influence of psychosis and antipsychotic medications, of depression and antidepressant drugs, and of bipolar disorder and mood stabilizers on sexual health, and the optimal management of patients with severe psychiatric illness and sexual dysfunction.

Partners in Recovery program evaluation: changes in unmet needs and recovery

Objective Partners in Recovery (PIR) is an Australian government initiative designed to provide support and service linkage for individuals with complex needs living with severe and persistent mental illness. The aim of the present study was to examine whether consumers engaged in PIR programs in two large regions of Sydney experienced: (1) a reduction in unmet needs (either via self- or staff report); and (2) progress in their self-reported mental health recovery. Methods Unmet needs were measured using the Camberwell Assessment of Need Short Appraisal Scale and recovery was measured using the Recovery Assessment Scale - Domains and Stages. For individuals with initial and follow-up data, paired t-tests were used to examine change over time. Results At follow-up, individuals reported an average of two to three fewer unmet needs, and recovery scores increased by approximately 5% across each domain and the total score. At follow-up, the most common unmet needs were in the areas of 'company' and 'daytime activities'. Conclusions The results of the present study suggest that PIR services in these two geographical regions have achieved positive results. Individuals with severe and persistent mental illness engaged with PIR appear to have reduced their unmet needs and enhanced their mental health recovery. What is known about the topic? PIR services were established to support individuals with severe and persistent mental illness by creating service linkages to address unmet needs in order to facilitate recovery. Services were delivered through the new role of 'support facilitator'. What does this paper add? By examining routinely collected outcome measures, this paper shows the success of the PIR program. Individuals engaged with PIR reported fewer unmet needs and enhanced recovery over the time they were involved with the program. However, they still faced serious challenges in building successful social interactions, such as developing friendships, and participating in meaningful activities. What are the implications for practitioners? The support facilitator role developed as part of PIR appears to be a useful method of supporting individuals to reduce unmet needs and enhance recovery. However, further work is required to address the challenges associated with overcoming social isolation and participation in meaningful activities.

An exploratory investigation of sexual health screening in the first 12 weeks of case management in populations with severe mental illness

The sexual health of people with mental illness is commonly overlooked, neglected or inadequately addressed in mental health care, despite evidence showing that people with severe mental illness are more vulnerable to sexually transmitted infections (including HIV), sexual side-effects, and sexual dysfunction than the general population. This article reports a study that investigated sexual health screening in five community mental health clinics within a large a regional health service in Victoria, Australia. The aim of the study was to examine the extent to which sexual health screening is currently undertaken on newly admitted case-managed consumers, and to identify the types of screening undertaken. An exploratory design using retrospective file audit was used in the study. A total of 186 medical records met the study inclusion criteria. The study found that less than 40% of consumers were provided with sexual health screening during their first 12 weeks of case management. The study also found that sexual side-effects, issues of fertility, sexual self-esteem, safe sexual practices, and sexual dysfunction were rarely screened for. Poor sexual health screening has implications for the safety and quality of mental health care and requires targeted research to improve understandings and approaches to care.

Sexual side-effects of antidepressant and antipsychotic drugs

PURPOSE OF REVIEW

Psychotropic-related sexual dysfunction is a quite frequent issue in clinical practice, mainly in chronic treatments affecting both quality of life and compliance.

RECENT FINDINGS

In the last decade fortunately antidepressants and antipsychotic compounds have been deeply screened in order to identify sexual adverse events that were commonly underdiagnosed and previously underestimated by clinicians and perhaps by pharmaceutical companies as well. Some differences in the mechanism of action are the nucleus of this poorly tolerated adverse event. All antidepressants with serotonergic activity can cause mild to severe sexual dysfunction such as decreased libido and delayed orgasm frequently (>60%) or anorgasmia and arousal difficulties sometimes (30%). In contrast, noradrenergic, dopaminergic, or melatonergic antidepressants do not cause sexual dysfunction but perhaps the clinical profile of patients receiving these compounds could be different. Antipsychotics that highly increase prolactin levels and strongly block dopamine receptors could be related to sexual dysfunction as well. Unfortunately, these dysfunctions are present during the long term after the antipsychotic onset to provide continued symptom control and enable recovery. Young patients suffering psychosis and concomitant sexual dysfunction (erectile and/or orgasmic difficulties) tend to show poor compliance in chronic treatments affecting the outcomes.

SUMMARY

The implications of psychotropic-related sexual dysfunction in clinical practice are relevant mainly in patients under long-term treatment with previous satisfactory sexual life. Implications for future research about sexual dysfunction in all new treatments should be strongly taken into account.