Authors: Anuradha Rathod, Neena Sawant, Tushar Bandgar
Categories: Original Article, Diabetes, depressive symptoms, glycemic control, marital satisfaction, sexual dysfunction
Source: Indian Journal of Psychiatry
Authors: Anuradha Rathod, Neena Sawant, Tushar Bandgar
Type 2 diabetes affects 10.5% of adults globally, with sexual dysfunction being one of the complications, of which erectile dysfunction is the most commonly reported one with the prevalence ranging from 35% to 90%. There are a few studies exploring links between sexual dysfunction, depressive symptoms, and marital satisfaction, which is the reason we undertook the study.
To study the prevalence of sexual dysfunction, depressive symptoms, and marital satisfaction in male patients with diabetes and correlation between the three parameters.
A total of 120 male patients with type 2 diabetes were assessed for sexual dysfunction using ICD-10 criteria and International Index of Erectile Function, depressive symptoms using Beck Depression Inventory, and marital satisfaction using Dyadic Adjustment Scale (DAS).
The mean age of patients at diagnosis of diabetes was 42.32 ± 7.48 years, and the mean duration of diabetes was 7.35 ± 3.76 years. Mean HbA1c was 9.05 ± 2.25% with only 22 patients having good glycemic control. Eight-eight patients reported sexual dysfunction with lack of genital response, premature ejaculation, and orgasmic dysfunction being common. Thirty-two patients had depressive symptoms, with borderline clinical depressive symptoms and moderate depressive symptoms in 14 patients each. Marital satisfaction was affected with the total mean DAS score being 93.95 ± 18.34. There was a negative correlation seen between sexual function and depressive symptoms and also between sexual function and increasing age, with a positive correlation seen between sexual function and marital satisfaction. Poor glycemic control was significantly associated with clinically diagnosed erectile and orgasmic dysfunction.
Sexual dysfunctions, depressive symptoms, and marital distress are highly prevalent in patients with type 2 diabetes, warranting timely detection and management. The three parameters are significantly correlated with each other, and poor glycemic control is significantly associated with sexual dysfunction. Psychiatric liaison would improve outcomes.
Diabetes is a chronic endocrine disorder of raised blood glucose levels. Globally, type 2 diabetes affects around 10.5% of adults.[1] It results from reduced pancreatic islet beta-cell function, leading to diminished insulin secretion and acquired insulin resistance.[2] Prevalence rates rise steadily with age.[3] Sexual dysfunction in diabetes can affect all phases of the sexual cycle, with erectile dysfunction being the most widely studied. However, research on sexual dysfunction covering all phases of the sexual cycle is limited.[45] The prevalence of erectile dysfunction in diabetic males ranges widely from 35% to 90% as per various studies.[678] The likelihood of sexual dysfunction increases with age and diabetes duration.[7] Unfortunately, stigma surrounding openness about sex life leads to underreporting, resulting in a significant burden of undiagnosed and undertreated issues, impacting marital satisfaction and overall quality of life.
The prevalence of major depression in diabetes is estimated at around 19.1%.[9] The association between depression and diabetes is bidirectional.[10] The need for constant diabetes management leads to distress and depressive symptoms.[11] Studies also show decreased diabetes-related distress and improved quality of life in patients with good marital adjustment.[12] Widely prevalent but underreported sexual dysfunction may hamper sexual intimacy and the quality of marriage.[13]
Given the limited research in the Indian context, we conducted this study to investigate and assess the burden of sexual dysfunction, depressive symptoms, and marital satisfaction in male patients with diabetes. We also explored the correlation between age and diabetes duration with sexual dysfunction and the association between HbA1C titers and sexual dysfunction based on findings from previous studies.[714151617]
This was a cross-sectional observational study utilizing validated questionnaires, initiated after permission from the institutional ethics committee [IEC Reference EC/74/2020, dated January 8, 2021] and conducted in the outpatient department of endocrinology of a general hospital.
We recruited a total of 120 patients using convenience sampling. Male patients between 30 and 60 years of age, clinically diagnosed by an endocrinologist as having type II diabetes as per American Diabetes Association (ADA) criteria[18] with a minimum duration of 5 years since diagnosis of type 2 diabetes, and those who were married, sexually active, and living with a partner since the past 6 months were recruited for the study.
Patients with known history of mental illnesses on treatment for the same, those receiving any drugs (antihypertensives/antidiabetics/psychotropics) known to potentially cause sexual problems, those with chronic medical or surgical conditions like comorbid hypertension, and those having difficulty to understand and complete the questionnaires due to language difficulty were excluded. Subsequently, their sociodemographic details and clinical variables were recorded. HbA1C titers were graded as per ADA criteria.[19] All patients were evaluated clinically for the presence of sexual dysfunction with a detailed semistructured interview and diagnosed clinically as per ICD-10 criteria.[20]
The interview was of 45–60 min. The self-rated questionnaires were International Index of Erectile Function, Beck’s Depression Inventory, and Dyadic Adjustment Scale.
International Index of Erectile Function (IIEF): It is a standardized self-administered Likert-rated questionnaire consisting of 15 questions that address various sexual function domains. A higher score indicates better sexual function.[2122]Beck’s Depression Inventory (BDI): This is a self-administered tool for screening and assessing possible depressive symptoms in the normal population as well as rating the severity of depressive symptoms in adolescents and adults. It has 21 items rated on a four-point scale ranging from 0 to 3. The maximum total score is 63.[2324]Dyadic Adjustment Scale (DAS): It is a self-administered scale for measuring marital satisfaction. It has 32 items with four empirically verified dyadic satisfaction, dyadic consensus, dyadic cohesion, and affectional expression. The scale has a score range of 0–151. The higher the score, the better is the marital satisfaction.[2526]
All scales which were administered to the patients were translated in vernacular languages by three faculty from the Department of Psychiatry, who were experts in Hindi and Marathi. A validation certificate was obtained for the same.
Sociodemographic variables were studied using means with standard deviation. Descriptive statistics were used to study the presence of sexual dysfunction, depressive symptoms, and marital satisfaction. Correlation of sexual dysfunction with depressive symptoms and marital satisfaction was done using Spearman’s correlation coefficient. Association of HbA1C titers with the presence of sexual dysfunction was done using Chi-square statistics. Two-tailed P values where P < 0.05 were considered significant for all statistical analyses. SPSS-18 was used for statistical analyses.
Sociodemographic variables are described Table 1.
The mean age of patients at diagnosis of diabetes was 42.32 ± 7.48 years with the mean duration of diabetes being 7.35 ± 3.76 years and ranging from 5 to 20 years.
The total mean HbA1c was 9.05 ± 2.25%. Twenty-two (18.3%) patients had good glycemic control (<7% HbA1c), and 26 (21.7%) patients had inadequate control (7–8%), whereas 72 (60%) patients had poor glycemic control (>8%), pointing to vulnerability to diabetic complications.
The prevalence and type of sexual dysfunction as per ICD-10 Criteria, depressive symptoms as per BDI, and marital satisfaction as per DAS are described in Tables 2 and 3.
Eighty-eight (73.3%) patients reported the presence of sexual dysfunction as per the ICD-10 criteria. Lack of genital response was diagnosed clinically in 49 (40.83%) patients, premature ejaculation in 32 (26.67%) patients, orgasmic dysfunction in 24 (20%), and lack of desire in 3 (2.5%) patients. Some patients had more than one sexual dysfunction like lack of desire with premature ejaculation and/or orgasmic dysfunction.
Thirty-two (26.67%) participants were suffering from depressive symptoms with the total mean BDI score being 10.78 ± 8.16. On assessing the severity of depressive symptoms as per BDI, 14 (11.7%) patients had borderline clinical depressive symptoms, 14 (11.7%) had moderate depressive symptoms, and 4 (3.3%) patients had severe depressive symptoms. Seventy-seven patients had normal scores.
The total mean DAS score was 93.95 ± 18.34. When patients were assessed on various domains of DAS for marital satisfaction, the total mean score obtained in the Dyadic Consensus domain was 57.85 ± 8.73; in the Dyadic Satisfaction domain, it was 31.28 ± 7.18; in the Dyadic Cohesion domain, it was 5.86 ± 4.57; and in the Affectional Expression domain, it was 6.93 ± 2.52.
When we studied the correlation between sexual function with depressive symptoms and marital satisfaction, a significant negative correlation was seen between sexual function and depressive symptoms (rs = -0.252, P < 0.022*) and a significant positive correlation was seen between sexual function and marital satisfaction (rs = 0.372, P < 0.001*). Sexual function also correlated negatively with age (rs = -0.502, P < 0.001*), implying that sexual function worsens with increasing age. However, there was no significant correlation of sexual function with the duration of diabetes, though a negative trend was seen as it missed the statistical test of significance (rs = -0.17, P < 0.217). We applied the Bonferroni correction to help prevent any erroneously significant findings [Table 4].
We found a significant association between poor glycemic control and presence of clinically diagnosed lack of genital response (X^2^ = 8.3, df = 2, P < 0.01*) and orgasmic dysfunction (X^2^ = 6.2, df = 2, P < 0.04*). No association was found between HbA1c and premature ejaculation (X^2^ = 0.57, df = 2, P < 0.74) or lack of desire (X^2^ = 0.93, df = 2, P < 0.62).
Our findings of mean age of developing diabetes at 42.32 ± 7.48 years was in keeping with those of other researchers,[27] though a higher mean age at diagnosis of diabetes has also been reported at 54.60 ± 9.48 years.[28] Researchers have also studied a longer duration of diabetes of 16.96 ± 10.55 years[12] as compared to ours. The earlier the age at onset of diabetes, longer is the duration of diabetes and more would be the chances of developing complications, and this is the problem seen in the Indian subcontinent.
Poorer glycemic control was evident in our sample, with mean HbA1c being 9.05 ± 2.25% and 72 patients (60%) having HbA1c > 9.0%. Only 18 patients had good glycemic control, which indicates the need for continued awareness in the general population about maintaining a healthy lifestyle along with a focus on diet and exercise. The reason we had a higher sample of poor and inadequate glycemic control could be that the study sample belonged to a tertiary center, where generally complicated cases with comorbidities like hypertension being managed concurrently are commonly seen rather than uncomplicated cases. Other researchers have found a better HbA1c with mean values of 7.2 ± 1.4%, with 43.4% of the population having HbA1c > 7.0%, 19.0% of the population with HbA1c > 8.0%, and just 9.1% of the population with HbA1c > 9.0%.[29]
Sexual dysfunction has been a widely prevalent but historically underreported complication of diabetes.[13] There is a wide range of prevalence from 45%,[4] 50.7%,[30] and 53.3%[31]. Ziaei-Rad et al.[32] reported a 77% prevalence of sexual dysfunction, which is nearly similar to our findings. A recent review by Gebeyehu et al.[33] gave a global prevalence of sexual dysfunction in diabetics of 61.4%, with type 2 diabetes patients more likely (71%) to have sexual dysfunction, which is also in keeping with our findings.
Forty-nine (40%) of our patients were suffering from lack of genital response, which was earlier undiagnosed. This is in keeping with studies by other researchers who gave the prevalence of erectile dysfunction as 52.5%[34] and 54.3%,[35] respectively. The prevalence of erectile dysfunction in diabetic males ranges widely from 35% to 90% as per various studies.[6836] The other male sexual dysfunction commonly reported in diabetics is premature ejaculation and is seen in 35%–50%[37] of type 2 diabetics. We also found premature ejaculation in 27% of our patients. Lack of desire was seen in only three patients and could be due to the presence of underlying depressive features. Some of the patients had more than one sexual dysfunction like the presence of premature ejaculation with lack of desire and/or orgasmic dysfunction. Most researchers have found erectile dysfunction to be the most common sexual dysfunction in diabetic males as diabetes causes microangiopathy, macroangiopathy, and endothelial dysfunction, which results in limiting the blood flow in the vascular beds. Along with it, there is impairment in the parasympathetic activity which worsens erection. Hence, a good glycemic control in diabetics is advised to prevent sexual dysfunctions.[38]
BDI is universally used for depressive symptoms diagnosis and rating. The relationship between depression and diabetes is interrelated, with either of the two conditions leading to the other.[1039] Similar findings as ours were noted by Dan et al.,[27] who reported a mean BDI score of 10.48 ± 7.37. Several studies have found the prevalence of depression in type 2 diabetes to be 23.01%,[27] 25%,[40] and 29.3%.[41]
Other studies gave a wide range of prevalence depending on study type and criteria used as 38.75%,[42] 40%,[43] and 38%[44]. Mussa et al.[45] found a higher prevalence of 73%.
The majority of our sample had normal mood or mild mood disturbance, which did not satisfy the criteria for depressive episode. Severe depressive symptoms were seen in only four patients with mild and moderate depression each in 11% of patients. Similar findings were reported by Dan et al.[27] Abbas et al.[46] found borderline depression in 13.5% of their study sample, moderate depression in 20.8%, severe depression in 9%, and extreme depression in 4.9%, with mild depressive symptoms in 26.1% and no depressive symptoms in 28% patients. We had not seen a case of extreme depressive symptoms nor anyone expressing suicidal ideations. Depression and diabetes have a cause or effect relationship where lifestyle changes, biological factors, insulin resistance, which is a mood regulator, or presence of inflammation increases the risk of depressive symptoms in diabetic patients.[47]
Dissatisfaction was prevalent in our study sample, with 67 patients (55.8%) scoring below 100, the cutoff for marital distress.[26] There is sparse literature available about domainwise dyadic satisfaction as most researchers have only studied total DAS scores in studies of marital satisfaction.[122748]
Our patients scored low on the Dyadic Cohesion and Affectional Expression subscales, highlighting challenges with shared interests, engaging conversations, affection, and sexual agreement. Conversely, the Dyadic Consensus subscale showed high scores, indicating agreement on family finances, religion, and lifestyle. This could be attributed to sociocultural norms and conservative attitudes in the country, where displays of affection are often considered inappropriate, potentially impacting marital relationships, though consensus on general family matters is intact.
Sexual issues in diabetes, arising from both organic factors and marital maladjustment, can lead to heightened psychological distress and depressive symptoms in diabetic patients.[49] Our findings suggested that sexual function improved with marital satisfaction but was affected with depression and increasing age. Other researchers have also found an association with severity of depressive symptoms and severity of erectile dysfunction.[5051] Researchers have found that patients of sexual dysfunction reported lesser marital satisfaction,[2752] which was contrary to our findings. A similar relationship between age and duration of diabetes, and sexual dysfunction, in which the occurrence of sexual dysfunction in patients with diabetes correlates with higher age and longer duration of the diabetes, has also been found by other researchers.[2951535455]
Significant association between poor glycemic control and lack of genital response and orgasmic dysfunction was seen in our patients. Poorer glycemic control is related to the worsening of complications of diabetes, out of which sexual dysfunction is an important though often overlooked complication.[7] Some researchers found a significantly negative correlation between erectile function score and HbA1c,[71415] whereas others did not find any significant association.[1617]
There was a selection bias in recruiting cases for the study group as only patients seeking medical help at a tertiary care center were included. Tertiary care centers often have complicated, chronic, and poor treatment responders, which could have resulted in our inflated prevalence rates. A larger sample size with a control group would have helped to study the aims and objectives better. Longitudinal studies looking at sexual dysfunction and marital satisfaction in the diabetic population would give more information compared to cross-sectional studies. It is also necessary to look for sexual dysfunction in the female diabetic population and understand similar association with depression and marital satisfaction.
The results of this study imply that there is a high prevalence of sexual dysfunctions, depressive symptoms, and marital distress in patients of type 2 diabetes. Our findings suggested that sexual function improved with marital satisfaction but was negatively affected with depressive symptoms and increasing age. Significant association between poor glycemic control and lack of genital response and orgasmic dysfunction was seen. To elicit these, it is important for the endocrinologist to be aware to enquire about signs and symptoms of any psychological disturbances being experienced by the diabetic patient. Liaison with the psychiatrist would work toward improving the issues of sexual dysfunction, depressive symptoms, and poor social support; improve the quality of life; and thus improve the overall prognosis for the patient.
Nil.
There are no conflicts of interest.