Prevalence of Sexual Dysfunction in Patients with Schizophrenia

Introduction

The connection between psychiatric disorders and sexual difficulties is a complex and multifaceted issue that arises from various factors, such as the disorders themselves, co-occurring sexual dysfunctions, and the side effects of treatment ^1,2. Sexual dysfunction is a common issue in patients with schizophrenia and can be caused by several factors, including psychosocial elements, bodily health, medication use, and the disease itself. The most commonly prescribed medication for these patients is antipsychotics, linked to sexual side effects such as decreased sexual desire, anorgasmia, and erectile dysfunction.^3,4 Studies shows  that sexual dysfunction affects 16% to 60% of patients taking antipsychotics, leading to a lower quality of life and reduced medication adherence. This article overviews the relationship between schizophrenia and sexual dysfunction and the available treatment strategies for antipsychotic-induced sexual side effects.^5,6

Schizophrenia and Sexual Functioning

Schizophrenia was once erroneously linked to hormone deficiencies and repressed homosexuality, theories that have since been discredited. While some patients may occasionally experience sexual hallucinations or identity issues, these are rare and often resolved with antipsychotic medication. Individuals with schizophrenia tend to form fewer intimate relationships, with chronic sufferers frequently losing interest in sexual activities. Women generally experience more favorable social outcomes than men, and psychiatric institutions have adapted to accommodate these gender differences.⁷

The Importance of Sexual Complaints: A Viewpoint from Both Physicians and Patients

Patients with schizophrenia frequently encounter sexual side effects that significantly impact their quality of life and adherence to treatment. However, discussions concerning sexual functioning may not always be initiated by patients and clinicians due to discomfort or a lack of knowledge. Surprisingly, studies show that patients are willing and relieved to discuss sexual issues when prompted, and this practice does not destabilize them. Even individuals with treatment-resistant schizophrenia may desire to address these sensitive topics. On the other hand, clinicians may often underestimate the prevalence of sexual dysfunction and its detrimental impact on patients’ lives, primarily due to a lack of knowledge or discomfort. ⁸

One study revealed that only 10% of psychiatrists inquired about sexual side effects despite recognizing their clinical relevance and potential to affect treatment adherence. Studies employing structured interviews or self-report questionnaires tend to report a higher prevalence of sexual side effects related to antipsychotic treatment (30-60%) compared to spontaneous accounts by patients (less than 10%). This highlights the critical importance of direct inquiries about sexual functioning to prevent underestimating their frequency and impact. Sexual issues are highly relevant to patients with schizophrenia and can significantly diminish their quality of life and treatment adherence, reinforcing the need for initiating conversations about sexual functioning. ⁹

Epidemiology of Sexual Dysfunction Induced by Antipsychotics in Schizophrenia Patients

When comparing studies on antipsychotic-induced sexual dysfunction, one must consider several factors, including:

1. Ambiguity in differentiating whether sexual dysfunction is caused by antipsychotic medication or other factors.¹⁰
2. Distinguishing between sexual “problems” and “dysfunction,” the latter being characterized by subjective distress, which may not always be explicitly reported.10
3. A wide array of methodological differences between studies.⁴

A review comparing various antipsychotics concluded that Risperidone induced sexual dysfunction most frequently, followed by typical antipsychotics like haloperidol, olanzapine, and quetiapine. Aripiprazole exhibited the lowest frequency of sexual dysfunction. Another study utilizing a similar design and questionnaire as the former study found a comparable order. A 2022 meta-analysis assessed sexual dysfunction in psychiatric populations among patients taking antipsychotics. Interestingly, it found that different antipsychotics had an incrementally increasing impact on sexual function, ranging from 16% (quetiapine) to 60% (thioridazine). However, the quality of the included studies displayed significant variation, and the findings related to aripiprazole, clozapine, perphenazine, and thioridazine should be interpreted cautiously due to limited replication.¹¹

Shedding Light on Recent Research¹¹

Recent studies have shed light on the prevalence of sexual dysfunction among individuals with schizophrenia. 72 out of 1119 studies conducted in 33 countries on six continents, published from inception to June 2022, were included in the analysis, encompassing 21,076 participants with schizophrenia. The pooled global prevalence of sexual dysfunctions was 56.4%, with men reporting a prevalence of 55.7% and women 60.0%. The most common sexual dysfunctions included erectile dysfunction (44% in men), loss of libido (41% in men), ejaculation dysfunction (39% in men), orgasm dysfunction (28% in women), and amenorrhea (25% in women). Several factors were associated with the heterogeneity of results, including study design, location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and antidepressants and anxiolytics. Furthermore, the type of antipsychotic medication influenced sexual dysfunction, with antidepressants and mood stabilizers being associated with lower rates of erection and ejaculation disorders. These findings highlight the significant impact of sexual dysfunction on individuals with schizophrenia and underscore the importance of addressing this issue in their treatment.

Pharmacological Mechanisms in Antipsychotic-Induced Sexual Dysfunction

Antipsychotic-induced sexual dysfunction is a common side effect that can significantly impact patients’ quality of life. The condition’s mechanism is complex and multifaceted, believed to arise due to the blockade of dopamine receptors and α1-receptors, and the elevation of prolactin levels. ³

Dopamine blockade is the primary factor leading to sexual dysfunction in patients taking antipsychotics. This blockade disrupts the sexual response cycle by reducing dopamine activity, decreasing libido, anorgasmia, and delayed ejaculation. ³

Hyperprolactinemia is the second factor contributing to sexual dysfunction in patients taking antipsychotics. Prolactin, a hormone secreted by the pituitary gland, stimulates lactation. Antipsychotics can increase prolactin levels, leading to side effects such as galactorrhea, menstrual disturbances, and amenorrhea. Increased prolactin levels can also decrease testosterone levels, further exacerbating sexual dysfunction.¹²

Other Pharmacological Mechanisms

Antipsychotics interact with various neurotransmitter systems in the brain and other body parts, including the serotonergic, noradrenergic, histaminic, and cholinergic/muscarinic systems. While the exact effects of central agonism or antagonism of histamine receptors on sexual functioning remain unclear, sedating effects of antihistaminergic medication may indirectly affect sexual function.³

Antipsychotics’ affinity for D2 receptors is a significant pharmacological aspect affecting treatment and side effects. The ability of these medications to cross the blood-brain barrier, undergo liver metabolization, and generate active metabolites also plays a role. Medications with poor blood-brain barrier passage require higher doses to achieve central effects, resulting in elevated peripheral levels. Hydrophilic antipsychotics lead to a considerable increase in prolactin blood levels due to the pituitary gland’s location outside the blood-brain barrier. ¹³

Further complicating the picture is that antipsychotic metabolites with affinities to D2 receptors must maintain a central-to-peripheral ratio comparable to or better than the parent drug. For example, Risperidone’s 9-hydroxy Risperidone increased prolactin levels more than expected. Paliperidone, registered as a separate antipsychotic, also significantly impacts prolactin levels. It’s important to note that antipsychotic-induced sexual dysfunction primarily results from the central-to-peripheral ratio of D2 occupancy, which can overshadow the influence of other pharmacodynamic considerations on prolactin levels. ¹³

Psychosocial Treatment Strategies and General Considerations

Patients with schizophrenia must be educated about how their condition can affect their sexual well-being. Various factors, including primary illness, medication, comorbid disorders, relationship challenges, social competence, and societal consequences, can all influence sexual functioning. Identifying these factors is crucial for devising appropriate treatment strategies. Potential strategies encompass sex education, disorder-specific interventions tailored to patients, and relationship counseling. Furthermore, education about sexual risk behavior, prevention of unwanted pregnancies, abortion, and child-rearing may also be pertinent.⁸

Pharmacological Treatment Strategies for Antipsychotic-Induced Sexual Dysfunction

Clinicians should proactively inquire about any undesired effects of antipsychotic medications on patients, including their impact on sexual performance. An in-depth analysis should encompass psychological, social, symptom-related, and medication-related aspects of sexual performance. Understanding the underlying mechanisms of sexual dysfunction in patients with severe mental illness is essential for providing informed clinical guidance. Strategies to mitigate sexual dysfunction induced by antipsychotics encompass dosage reduction, transitioning to antipsychotics with less detrimental effects on sexual functioning, or introducing adjunctive therapy. Phosphodiesterase 5 (PDE5) inhibitors like sildenafil, lodenafil, and tadalafil have shown promise in improving erectile functioning. Adjunctive treatment with aripiprazole may help lower elevated prolactin levels and restore normal menstruation. ¹⁴

Conclusion

Patients with schizophrenia encounter sexual functioning impairments influenced by psychiatric symptoms, institutionalization, and medication use. Women exhibit more favorable social outcomes, maintain longer-lasting relationships, and have more offspring. An important consideration is that both clinicians and patients often avoid discussing sexual problems, potentially leading to an underestimation of their prevalence. Antipsychotic medications are pivotal in causing sexual issues, including decreased sexual desire. Strategies to manage antipsychotic-induced sexual dysfunction encompass both psychosocial and pharmacological interventions. This comprehensive understanding of the intricate interplay between schizophrenia and sexual dysfunction equips healthcare professionals to address and manage the challenges faced by these patients. ^{3,4,7,8,9,10,11}

Future Research

Antipsychotics’ persistent sexual side effects necessitate effective treatment strategies, including psychosocial and pharmacological approaches. Future research should investigate the potential interaction between sexual side effects and schizophrenia symptoms. To ensure accurate data, future studies on antipsychotic drugs should use validated instruments. Moreover, clinicians must be well-informed and encouraged to initiate discussions about sexual functioning with their patients, ultimately improving the overall quality of care for individuals with schizophrenia and sexual dysfunction. ^1,2,3,4,5,6

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References

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